With approximately 100 million inhabitants, Egypt is the 14th-most populated country in the world, and the third-most populated in Africa. Bariatric News spoke with Professor Mohamed Hany from Alexandria University and Madina Women’s Hospital, Alexandria, Egypt, about the increasing rates of obesity and the status of bariatric surgery in the country...
What the current levels of obesity in Egypt?
From a study published in 2021, according to “100 million health” survey, which was conducted in Egypt in 2019 and screened 49.7 million adult Egyptians (≥18 years old), 39.8% of adult Egyptians suffered from obesity (BMI ≥ 30 kg/m2). Obesity was more prevalent in adult females than adult males, with 49.5% of Egyptian adult females suffering from obesity compared to 29.5% for males.
References:
Aboulghate M, Elaghoury A, Elebrashy I, Elkafrawy N, Elshishiney G, Abul-Magd E, Bassiouny E, Toaima D, Elezbawy B, Fasseeh A, Abaza S, Vokó Z. The Burden of Obesity in Egypt. Front Public Health. 2021 Aug 27;9:718978. doi: 10.3389/fpubh.2021.718978. PMID: 34513789; PMCID: PMC8429929.
What are the drivers of obesity rates?
From the literature, we observe that missing or infrequent intake of breakfast at home; frequent consumption of snacks; low servings per day of fruits and vegetables coupled with frequent consumption of sweets, and fried foods; eating while watching TV; and sedentary behavior were all identified as predictors of obesity and overweight among the current sample.
In our practice, we have noticed a pattern of infrequent eating throughout the day, with a cultural preference for carb-rich foods, including bread and rice. Additionally, cultural practices such as consuming the main meal late at night (around 00:00 am) contribute to disordered eating rhythms.
References:
Hassan NE, Wahba SA, El-Masry SA, Elhamid ER, Boseila SA, Ahmed NH, Ibrahim TS. Eating Habits and Lifestyles among a Sample of Obese Working Egyptian Women. Open Access Maced J Med Sci. 2015 Mar 15;3(1):12-7. doi: 10.3889/oamjms.2015.005. Epub 2014 Dec 28. PMID: 27275190; PMCID: PMC4877769.
In your opinion, what can be done to reduce obesity rates?
Reducing obesity rates demands a multifaceted and multidisciplinary approach, underscoring the complex interplay between dietary habits, mental health, and lifestyle choices. A cornerstone of this strategy involves the collaboration between dietitians and psychiatrists. Dietitians provide essential guidance on nutrition, helping individuals understand and implement healthy eating patterns and manage diet-related aspects of obesity. They offer personalized dietary plans that consider individual health needs, preferences, and lifestyles, aiming to achieve and maintain a healthy weight through balanced nutrition.
Concurrently, psychiatrists address the psychological dimensions of obesity, including emotional eating, body image issues, and any underlying mental health conditions that may contribute to weight gain, such as depression or anxiety. By integrating mental health support, individuals receive comprehensive care that addresses both the physical and emotional barriers to weight loss, fostering a holistic approach to obesity management.
In cases where lifestyle modifications and psychological support don't achieve the desired outcomes, bariatric metabolic surgery emerges as a viable option. For individuals facing severe obesity. These surgical interventions consider a last resort can significantly reduce weight and mitigate obesity related health conditions, offering a new lease on life for those struggling with obesity. However, it's imperative that candidates for surgery receive complete preoperative evaluation and ongoing post operative support, including nutritional counselling and mental healthcare, to ensure long term success.
How many bariatric centres and surgeons are there in Egypt?
In Egypt, the landscape of bariatric surgery centres and surgeons is quite distinct. The only accredited centre is the Madina Women's Hospital (Professor Hany’s centre). Currently, this centre's accreditation status is under renewal. Beyond this, bariatric surgeries are predominantly carried out in the private sector. Additionally, patients have access to designated governmental hospitals that offer bariatric metabolic surgery services in a limited manner.
Most surgeons who practice bariatric surgery are general surgeons who perform bariatric surgery. Currently, there are no named consultants of bariatric surgery or any organisation in Egypt that has accreditation to state that a surgeon is a bariatric surgeon.
Approximately, how many procedures are performed each year in Egypt?
This is difficult to estimate since we don’t have a clear registry in place. We estimate around 35,000 procedures a year and LSG is the main procedure performed with approximately 80-85% of all the procedure performed. As most are general surgeons, I believe that LSG is seen as a much easier procedure compared to the bypass etc.
Approximately how many procedures do you perform each year?
We started bariatric surgery in 2002 at a high-volume University Hospital and private hospitals that serves serves 5 large governments in our country with around 30 million nationals. Our Surgeons had their MD in bariatric surgery and had training with senior surgeons who started the field of bariatric surgery in our country. Also, surgeons attended workshops in European bariatric centres in Spain (Hospital Clinico Universitario San Carlos), Switzerland (St Claraspital), The Netherlands (Franciscus Gasthuis & Vlietland Rotterdam), and in the USA (Scripps Memorial Hospital La Jolla).
Also, one of our private centres has been accredited as an IFSO Center of Excellence (European Chapter) since 2020. The volume of cases has evolved, starting with around 400 cases in 2002 and increasing to around 800 cases per year in recent years. In the early years, RYGB was the main operation performed in around 80% of the cases, with the other 20% being revisional surgeries mainly for failed VBG and laparoscopic adjustable gastric banding (LAGB) with few cases of one-anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG). Over time, the percentage of RYGB has decreased in favour of SG and OAGB.
The following chart shows our case volume for different bariatric procedures at our centers over time. The drop in the years 2020 and 2021 is due to the Covid-19 crisis.
Regarding insurance coverage or healthcare coverage does exist in Egypt for private surgery is there any government funding or is it all from is it all paid by the patient?
Currently, 80% of cases are private and 20% are covered by government services. Previously, we adopted the NIH guidelines for bariatric surgery and now we follow the more recent IFSO/ASMBS 2022 guidelines.
And what about bariatric tourism? Does that play an influential role in the number of procedures in Egypt?
Yes. In our clinic, we observed that approximately 9% of our patients per year come from bariatric tourism. This reflects our clinics contribution to and participation in the global trend of seeking specialised medical treatments such as bariatric surgery, outside one's home country for various reasons, including costs, accessibility and the availability of specific medical expertise. Typically, patients come from Northern Africa, the Middle East or also Europe.
At the recent 19th annual conference of the Egyptian Society for Bariatric Surgery (ESBS), president of the congress, Professor Khalee Gawdat, highlighted that the need for a comprehensive national Egyptian Bariatric Surgery Registry is something important and challenging. What are the benefits of establishing such registry?
Establishing a comprehensive national Egyptian Bariatric Surgery Registry would offer significant benefits for various stakeholders in the healthcare system. For surgeons, we can enhance patient outcomes by accessing a rich database of patient outcomes, surgeon can analyse trends, refine surgical techniques and adopt best practises. A registry also allows surgeon to benchmark their performance against national standards and identify areas for professional growth and training. Finally, access to the comprehensive dataset facilitates clinical research enabling surgeons to contribute to the body of the knowledge on bariatric surgery and outcomes. This is for surgeons for hospitals and clinics. Ultimately, a registry would improve the quality of care, patient safety and outcomes.
For hospitals and clinics, a registry would aid quality improvement as they can use the registry data to monitor and improve the quality of care, patient safety, and outcomes for bariatric surgery patients. Insights from the registry can help optimize resource allocation, patient flow, and overall operational efficiency in delivering bariatric care. In addition, participation in a national registry can enhance a hospital or clinic’s reputation, potentially leading to higher patient volumes and assisting in accreditation processes.
For our national society, it can use registry data to develop and update bariatric surgery clinical guidelines, standards and best practices. Furthermore, with comprehensive data, societies can advocate more effectively for policy changes, funding, and resources to support bariatric care. The registry can identify trends and gaps in care, informing the development of targeted educational and training programmes for healthcare professionals.
Governments can use the registry data to inform public health policies and strategies aimed at managing and reducing obesity, including allocation of resources for bariatric care. Also, the data can inform government on healthcare planning, ensuring the facilities and services are appropriately distributed. Understanding the outcomes and long term benefits for bariatric surgery can help allocate healthcare budgets more effectively, potentially reducing the burden of obesity related health conditions for patients themselves. The registry also provides with patients with access to information about outcomes and the safety for bariatric procedures, helping them make informed decisions about their care. Knowing that their care is part of a nationally monitored and analysed programme can enhance patients confidence in the quality and safety of bariatric surgery.
A comprehensive national Egyptian Bariatric Surgery Registry would serve as a valuable resource for improving surgical outcomes, enhanced mission care, informing public health policies and achieving research in the field of bariatric surgery.
What are some of the hurdles or some of the difficulties in establishing a national registry?
Established a national bariatric surgery registry in Egypt faces several challenges. A primary difficulty lies in ensuring that surgeons and clinics understand and appreciate the value and necessity of systemic data collection. It's crucial to foster a culture where data sharing and collaboration are seen as contributing to the greater good. Aiming towards a shared goal of improving patient outcomes and advancing the field of bariatric search rather than perceiving these efforts as individual or competitive endeavours.
Additional challenges include setting up a comprehensive registry requires robust IT infrastructure, standardized data collection tools, and secure data management systems, which may require significant investment and expertise. Ensuring the privacy and security of patient data is paramount. Establishing trust and compliance with data protection regulations can be complex and requires careful planning.
Clinicians and administrative staff need training in data collection and entry processes to ensure high-quality, consistent data. Overcoming resistance to new procedures and ensuring widespread participation is essential.
Securing sustainable funding for the registry's development, maintenance, and ongoing operation can be challenging. Financial support is needed not just for the technical aspects but also for educating stakeholders and promoting the registry’s use. Shifting the mindset of healthcare providers towards a more collaborative and data-driven approach involves changing deeply ingrained cultural and professional practices.
In addition to the whole of the have said now also the registry also faces the issue of data fraud. With the potential of fraud, financial incentives and pressure to show successful outcomes, there is a risk of inaccurate or manipulated data being entered into registry. It's essential for a registry to implement stringent checks and balances and frequent audits to ensure the validity and accuracy.
For the registry to be successful, it is essential to address these challenges through strategic planning, stakeholder engagement, and the provision of necessary resources and training. Only by overcoming these obstacles can we fully leverage the potential of a national bariatric surgery registry to improve patient care and outcomes in Egypt
What kind of data would you want to collect?
To ensure that the National Bariatric Surgery Registry is as practical and informative as possible, it should collect a wide range of data encompassing the patient's journey, preoperative, perioperative and post-operative phases. This comprehensive data collection is critical for answering critical hypothesis, and identifying and understanding previously unrecognised confounding factors. This holistic approach allows for the exploration of outcomes and processes, facilitating the high quality position and potential development of new treatment guidelines and standards.
Achieving such comprehensive data collection necessitates robust teamwork and collaboration among all stakeholders involved in bariatric care, including surgeons, nurses, dietitians, psychologists, and patients themselves. Engaging with these stakeholders to identify and include variables beyond the standard scope is crucial for the registry’s success. This collaborative approach ensures that the registry not only serves as a tool for monitoring and improving patient care but also as a rich resource for academic research, capable of generating insights that advance the field of bariatric surgery.
How would such a registry be funded?
Funding a national bariatric surgery registry requires a diverse range of funding resources including government grants, partnership with healthcare organisation and industry stakeholders, and support from social organisations and individual donors. By leveraging these resources, the registry can continue to provide valuable data and insights to support improvements, research and improve patient outcomes. A collaborative and multifaceted approach would ensure its sustainable development, maintenance and expansion. The registry's funding model should leverage contributions from a wide range of stakeholders, reflecting the collective benefit of the registry to the healthcare system, research community, and patient populations.
This comprehensive funding strategy ensures a diverse revenue stream, reducing dependency on any single source and fostering a sense of ownership and commitment among all stakeholders. By investing in IT systems, research coordinators, and data collection processes, the registry can enhance bariatric surgery outcomes and advance research in the field in Egypt.
For the registry to be successful, it's essential to address the challenges through strategic planning, stakeholder engagement and provision of necessary resources and training. Only by overcoming these obstacles, we can fully leverage the potential of National Bariatric Surgery Registry to improve patient care and outcomes in Egypt.