Why the NHS should do more bariatric surgery; how much should we do?BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1472 (Published 11 May 2016) Cite this as: BMJ 2016;353:i1472
All rapid responses
Responses to this paper illustrate the negative views held about obesity observed in the general population as well as from healthcare professionals (1). Overwhelmingly weight-based discrimination and stigma have been found to leave patients feeling berated and disrespected by their healthcare professional whilst their struggle to manage weight and associated comorbidities feels dismissed; as a consequence, patients are reluctant to address weight concerns (2, 3, 4).
Blaming an individual for weight gain does not foster motivation to change, it instead causes significantly more problems: it is associated with increased risk for maladaptive eating patterns and eating disorder symptoms (5), more frequent binge eating (6), increased calorie intake and decreased perception of control of food (7). It is linked to higher levels of depression, lower self-esteem with anxiety about discrimination compounding exercise avoidance (8).
Of course, simplifying weight loss to a reduction of calories is appealing but the lived experience of obesity is rarely simple. The population of patients within the UK who are eligible for bariatric surgery will have already tried many, many times to ‘just’ reduce their calories.
As providers and policy makers it is our shared responsibility to challenge prejudice about weight within healthcare by increasing our understanding of the complexity of obesity and by demonstrating empathy for the challenges faced (9).
1.Puhl, RM & Heuer CA. The stigma of obesity: A review and update. Obesity 2009: 17(5) 941-964
2.Anderson., DA & Wadden, TA. Bariatric surgery patient’s view of their physicians’ weight-related attitudes and practices. Obesity Research 2004: 12 1587-1595
3.Bertakis, KD & Azari, R The impact of obesity on primary care visits. Obesity Research: 2005 13(9) 1615-1623
4.Brown, I. Nurses attitudes towards adult patients who are obese: Literature Review. Journal of Advanced Nursing 2006: 53(2) 221-232
5.Benas, JS. & Gibb, BE. Weight-related teasing, dysfunctional cognitions and symptoms of depression and eating disturbances. Cognitive Therapy Research. 2008: 32(2) 143-160
6.Ashmore, JA et al. Weight-based stigmatization, psychological distress and binge eating behaviours among obese treatment-seeking adults. Eating Behaviors 2008: 9(2) 203-209
7.Major, B. et al. The ironic effects of weight stigma. Journal of Experimental Social Psychology. 2014:51 74-80 2014
8.Gatineau, M & Dent, M. Obesity and Mental Health. Oxford: National Obesity Observatory 2011
9.Phelan, SM et al Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews 2015: 16 319-326
Competing interests: I work within a weight management and bariatric surgery service and with the lead author of the paper.
Your correspondent Mr. Bollen makes very important points that support the need for continuous medical education in bariatric surgery.
Becoming overweight or obese is a normal response to the prevailing food environment . The World Health Organisation and the American Medical Association both recognise obesity as a disease . There are now more obese people worldwide than malnourished , and no country has a successful strategy for prevention. The resulting burden of type 2 diabetes affects nearly 10% of the world’s population and threatens to overwhelm healthcare resources. Dieting long term does not produce sustained weight loss since basal metabolic rate slows as weight decreases . Dieting also does not induce long term diabetes remission. Bariatric surgery, with behaviour change and long term follow up and support, can do both. Twenty-nine non-surgical diabetes organisations worldwide endorse a new consensus that bariatric surgery should be recommended for diabetics with a body mass index of ≥40 kg/m2 , and commissioning guidance from 10 royal colleges and specialist associations endorses referral pathways to surgery . It is appropriate for all healthcare professionals to work together to improve access to care for patients prepared to make the lifestyle changes for success.
Obesity research is fast moving, and needs to be disseminated to the public and health care professionals. Statements such as “(obesity) is not a disease” or “the only problem these "patients" have is that they eat too much and fail to take responsibility for their own health” are similar to what medical practitioners were saying to patients who had epilepsy at the start of the 20th century. Then, most people did not know this was a complex and chronic brain disease and many suffered under their ignorance. Today epilepsy is controlled by lifestyle treatments, pharmacotherapy and surgery. Similarly, obesity appears to be a complex and chronic brain disease, with more than 80% of the genes associated with obesity from Gene Wide Association Studies pointing to the central nervous system as the cause . Bariatric surgery is helping unravel the mechanisms by showing that altering the appetite and satiety axis from the gut to the brain can achieve long term control of weight and diabetes.
The available operations continue to evolve, we do not know which is the best, and so randomised controlled trials (RCTs) are needed that capture long term follow up data . In the UK a large, pragmatic, multicentre RCT ‘By-Band-Sleeve’ is comparing the three commonest procedures, with 450 patients randomized so far [9, 10]. Many published studies indicate that bariatric surgery is one of the most cost effective treatments that exist, as patients with severe disease incur excess healthcare costs over time without surgery. The quality of life gains after surgery are substantial, even though most do not receive surgery later to remove redundant skin .
Your respondent’s observations illustrate precisely the prejudice that obese patients face amongst healthcare workers unaware of the latest science behind this complex disease. If we focus resources on those that stand to benefit most, bariatric surgery can make a big impact on morbidity, mortality and healthcare costs – making sick patients healthier, more functional, and economically productive. But what individual patients crave more than anything else is for discrimination by uninformed healthcare professionals to cease.
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 Welbourn R, Dixon J, Barth JH, et al. NICE-accredited commissioning guidance for weight assessment and management clinics: a model for a specialist multidisciplinary team approach for people with severe obesity. Obes Surg 2016;26:649-59. doi: 10.1007/s11695-015-2041-8
 Locke AE, Kahali B, Berndt SI, Justice AE, Pers TH, Day FR et al. Genetic studies of body mass index yield new insights for obesity biology. Nature 2015;518:197-206.
 Blazeby JM, Byrne J, Welbourn R. What is the most effective operation for adults with severe and complex obesity? BMJ 2014;348:g1763 doi: 10.1136/bmj.g1763.
 Rogers CA, Welbourn R, Byrne J, Donovan JL, Reeves BC, Wordworth S et al. The By-Band study: gastric bypass or adjustable gastric band surgery to treat morbid obesity: study protocol for a multi-centre randomised controlled trial with an internal pilot phase. Trials 2014;11:15-53. doi: 10.1186/1745-6215-15-53.
 Driscoll S, Gregory DM, Fardy JM, Twells LK. Long-term health-related quality of life in bariatric surgery patients: A systematic review and meta-analysis. Obesity 2016;24:60-70. doi: 10.1002/oby.21322.
Competing interests: No competing interests
Asking this group of doctors to produce an unbiased analysis of the benefits of bariatric surgery is a bit like asking FOREST to produce an analysis of the dangers of smoking. I was unable to access any peer review so can't comment on the rigour with which this was carried out but a lot of dubious spin seems to have been allowed to pass without comment.
Much is made of the NICE recommendations, but as Zoe Harcombe has pointed out, on the NICE committee producing the recommendations, the 4 clinical advisers were doctors making their living from treating obese patients and the 2 patient representatives were enthusiasts, with one running a website promoting bariatric surgery, hardly likely to produce an unbiased, independent report.
Cost analysis of this surgery seems to neatly ignore the high failure rate (eg less than 30% for diabetes remission with a gastric band), the high revision surgery rate (with some studies reporting up to a 40% revision rate within 10 years), the necessity and cost of a lifetime of monitoring and nutritional supplements, the misery for patients and costs of sorting out folds of unsightly redundant skin, the development of gallstones and food intolerance etc etc. If we are harsh about the economics, a body mass index over over 40 reduces life expectancy by about 10 years reducing end of life social costs etc.
All this for a problem that is not actually a disease. The only problem these "patients" have is that they eat too much and fail to take responsibility for their own health. Whichever way you spin it, if you take in less calories than you use, you will lose weight. What does it say about our society, that in a world where hunger kills more people that AIDS, Tuberculosis and Malaria combined, and where nearly 800 million people go to bed hungry at night we have a group promoting the expenditure of scarce health service resources on bariatric surgery. Any funding available ought to be spent on education at primary school level so children learn about sensible eating and nutrition.
Puzziferi N et al Long Term Follow Up after Bariatric Surgery: a systematic review JAMA 2014 934-42
2015 World Hunger Poverty Facts and Statistics by WHES
Competing interests: No competing interests
We enjoyed 'Why the NHS should do more bariatric surgery; how much should we do?' (BMJ 11 may 2016). We are writing to highlight the need for post- bariatric plastic surgery procedures.
After massive weight loss, patients are left with huge abdominal aprons of skin, ptotic breasts, and redundant skin folds on their limbs. These can severely limit mobility and function, and inevitably develop intractable intertrigo and excoriation. The skin redundancy can be as debilitating and restrictive as the fat itself. In addition, the psychological impact and negative impact on quality of life are well recognised. Plastic surgery procedures such as apronectomy (abdominoplasty), body lifting and other techniques for excising redundant skin are not cosmetic only, but should be regarded as an essential part of the weight loss treatment.
If we are to expand bariatric surgery within the NHS, we must make proper provision to ensure a service can be delivered that saves lives whilst maintaining or improving the quality of those lives.
Oliver Sawyer [firstname.lastname@example.org]
STR Plastic Surgery
Consultant Plastic Surgeon
Competing interests: No competing interests
Richard Welbourn and colleagues admirably draw attention to the gross inequality of surgical provision between the UK and comparable developed nations in Europe and North America  and, importantly, the failure to target those subgroups with the greatest potential for individual benefit and cost-utility to the healthcare system, such as patients with type two diabetes (T2D).
It is extremely concerning that T2D is rapidly increasing in prevalence among adolescents, particularly since it has become apparent that, when its onset occurs in childhood rather than in adulthood, T2D is a far more aggressive disease . Pharmaceutical interventions fail earlier in adolescents than in adults and existing therapeutic options are exhausted earlier [2-4]. The 21% rate of failure to maintain glycaemic control across five years in adults  is grossly outstripped by the corresponding rate of 52% among adolescents . Meanwhile, evidence from the growing literature base on adolescent bariatric / metabolic surgery shows excellent safety and effectiveness in the short- to medium-term as a treatment of adolescent severe obesity [5-7], and is beginning to demonstrate impressive effectiveness as a treatment for T2D in adolescents. The most robust report thus far described 94% remission of T2D (17 of 18 adolescents), three years after surgery, in a subgroup of severely obese adolescents with pre-operative T2D .
With limited viable healthcare options available to these vulnerable young people, most of whom are eligible for metabolic surgery on grounds of obesity , the potential benefits of metabolic surgery must surely be considered and formally evaluated within appropriately designed randomised studies. If not, what hope does the individual adolescent with T2D have of remission or improvement of this multisystemic, devastating disease?
1. Welbourn R, le Roux CW, Owen-Smith A, Wordsworth S, Blazeby JM. Why the NHS should do more bariatric surgery; how much should we do? Bmj. 2016;353:i1472.
2. Beamish AJ, D’Alessio DA, Inge TH. When the drugs don’t work, can surgery provide a different outcome for diabetic adolescents? 12. Surgery for Obesity and Related Diseases.
3. Kahn SE, Haffner SM, Heise MA, et al. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. The New England journal of medicine. 2006;355(23):2427-2443.
4. Zeitler P, Hirst K, Pyle L, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. The New England journal of medicine. 2012;366(24):2247-2256.
5. Inge TH, Courcoulas AP, Jenkins TM, et al. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. The New England journal of medicine. 2015.
6. Black JA, White B, Viner RM, Simmons RK. Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis. Obesity reviews : an official journal of the International Association for the Study of Obesity. 2013;14(8):634-644.
7. Olbers T, Gronowitz E, Werling M, et al. Two-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS). International journal of obesity. 2012;36(11):1388-1395.
8. Fried M, Hainer V, Basdevant A, et al. Inter-disciplinary European guidelines on surgery of severe obesity. International journal of obesity. 2007;31(4):569-577.
Competing interests: I work in the field of bariatric and metabolic surgery and research, both in the UK and in Sweden.
We welcome Welbourn and colleagues’ analysis of NHS provision for bariatric surgery (1). Bariatric surgery leads to improved outcomes for appropriately selected obese patients in a supportive environment.
We draw BMJ readers’ attention to the potential role of bariatric surgery in Prader-Willi Syndrome (PWS) for PWS awareness month in May. Since it was first eponymised 60 years ago, PWS has emerged as the most common genetic cause of life threatening obesity occurring in 1 in 13,000 to 1 in 30,000 births. PWS is typically characterised by neonatal hypotonia, lifelong hyperphagia, developmental delay, challenging behaviour and psychosocial disability. The neonatal period of early “failure-to-thrive” is followed by progressive hyperphagia and, if unchecked, morbid obesity.(2) Complications such as high blood pressure, diabetes, and obstructive sleep apnoea (OSA) are common to both PWS and non-genetic obesity, but PWS confers an additional constellation of health risks such as growth hormone deficiency, hypothalamic dysfunction, altered pain threshold and impaired vomiting reflex. Recent advances in early genetic diagnosis, growth hormone intervention, calorie restriction, educational and psychological support have markedly improved the prognosis for PWS patients and families alike, but safe and effective appetite control treatment remains elusive.
Historically, surgical outcomes were poor in PWS patients who underwent legacy bariatric surgery such as biliopancreatic diversion (BPD), intragastric balloon, jejuno-ileal bypass, gastroplasty, gastric bypass, or vagotomy. Complications included recurrent weight gain, revision surgery, post-operative bleeding and death.(3) However, Alqahtani et al (4) recently reported significantly improved long term outcomes in a contemporary series of obese PWS patients who had laparoscopic sleeve gastrectomy (LSG) for refractory weight control. In 24 PWS patients (aged 4.9 to 18 years, average BMI 46 kg/m2, all with obstructive sleep apnoea and none on growth hormone), BMI change at 1-, 2-, 3-, 4-, 5- years’ follow up was -14.7, -15, -12, -12.7, -10.7 kg/m2 with no reported re-operations or deaths, and improvement or remission of OSA, hypertension, diabetes, dyslipidaemia in 95% of cases.
Currently, NICE obesity guideline [CG189] 2014 makes no specific recommendation for bariatric surgery in the obese PWS patient. Modern LSG techniques may have a role in the weight management of carefully selected patients, provided in a multidisciplinary team environment with lifelong food access control and calorie restriction.
Dr Robin Chung
Chair, research working group
Prader-Willi Syndrome Association UK
Derby DE24 8AA
(1) Welbourn R, le Roux C W, Owen-Smith A, Wordsworth S, Blazeby JM. Why the NHS should do more bariatric surgery: how much should we do? BMJ 2016; 353:i1472. doi: http://dx.doi.org/10.1136/bmj.i1472.
(2) Miller JL, Lynn CH, Driscoll DC, Goldstone AP, Gold JA, Kimonis V, Dykens E, Butler MG, Shuster JJ, Driscoll DJ. Nutritional phases in Prader-Willi Syndrome. Am J Med Genet A. 2011 May;155A(5):1040-9. doi: 10.1002/ajmg.a.33951. Epub 2011 Apr 4.
(3) Scheimann AO, Butler MG, Gourash L, Cuffari C and Klish W. Critical analysis of bariatric procedures in Prader-Willi syndrome. Journal of pediatric gastroenterology and nutrition. 2008;46:80-3.
(4) Alqahtani AR, Elahmedi MO, Al Qahtani AR, Lee J and Butler MG. Laparoscopic sleeve gastrectomy in children and adolescents with Prader-Willi syndrome: a matched-control study. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2016;12:100-10
Competing interests: Parent of child with Prader-Willi Syndrome
The prospect of 10% of Britons being candidates for bariatric surgery by 2030 must be worrying for all who work in the NHS. One wonders what the NHS's architect, Lord Beveridge, and its implementer, Aneurin Bevan, would make of this alarming development - and major drain on healthcare resources. Bevan did note in a 1945 speech the 'risk of increasing mental malady which no clinical measures could solve'. (http://www.sochealth.co.uk/national-health-service/the-sma-and-the-found...) Perhaps that is what has come to pass.
Competing interests: No competing interests
Welbourn and colleagues outline the clinical and cost effectiveness of bariatric surgery, with the largest benefit evident among people with type 2 diabetes (1). The article highlights that despite an escalating pool of eligible patients, rates of surgery in the NHS are falling. This mirrors the current situation in the Republic of Ireland where bariatric surgery is severely under-utilised and under-resourced. We have estimated the number of people in Ireland who are eligible and might benefit from bariatric surgery, using a cross-sectional analysis of a population based sample of adults aged 50 years and older (2). Eligibility for bariatric surgery is based on two sets of criteria used to identify those most likely to benefit from surgery: firstly, a BMI greater than 35k g/m² and one or more of the following conditions; type 2 diabetes, hypertension, sleep apnoea and previous myocardial infarction. The second set of criteria are a BMI greater than 35 kg/m², type 2 diabetes and one or more of the following conditions; elevated urine albumin creatinine ratio, retinopathy, neuropathy, previous myocardial infarction and peripheral vascular disease. Prevalence estimates were applied to the most recent Irish census figures (2011) to estimate absolute numbers meeting these criteria. Survey weights were applied to the analysis to adjust for selection bias and to reduce non-response bias. The weight is adjusted to allow for the age and gender distribution of the population. (2) 85,244 (95%CI: 77,113 – 94,233) adults aged 50 years and older were eligible for bariatric surgery under the first set of criteria (7.38%). Under the second set of criteria, 10,891 (95%CI: 8,228 – 14,416) people aged 50 years and older were eligible for bariatric surgery (0.98%).
Welbourn et al report that the UK national registry of patients with diabetes, operated on between 2011 and 2013, shows 65% had acceptable glycaemic control without medication after surgery. By applying these results to Irish patients with complicated type 2 diabetes (criteria 2), we estimated that prioritising bariatric surgery for this cohort could result in an estimated 7,079 patients achieving good glycaemic control, without requiring medication.
These data demonstrate the urgent need to provide clinical and cost-effective interventions for people with type 2 diabetes. Importantly, these figures only include those aged 50 years and older so the overall pool of eligibility is likely to be greater. In Ireland, the provision of bariatric surgery to those in greatest need has the potential to improve both patient outcomes and reduce healthcare expenditure. The barriers to deployment of bariatric surgery identified by Welbourn et al exist in many healthcare systems and need to be tackled urgently. We concur with Welbourn and colleague’s call for a ‘renewed active focus on this large cohort of patients’ and emphasise the ever increasing pool of eligible people and limited treatment options in the Republic of Ireland.
1. Welbourn R, le Roux CW, Owen-Smith A, Wordsworth S, Blazeby JM. Why the NHS should do more bariatric surgery; how much should we do?: Bmj [Internet]. 2016;1472(May):i1472. Available from: http://www.bmj.com/lookup/doi/10.1136/bmj.i1472
2. Barret A, Savva G, Timonen V, Kenny RA. Fifty Plus in Ireland 2011 First results from the Irish Longitudinal Study on Ageing (TILDA) [Internet]. Dublin; 2011. Available from: http://tilda.tcd.ie/assets/pdf/glossy/Tilda_Master_First_Findings_Report...
3. Kearney PM, Cronin H, O’Regan C, Kamiya Y, Savva GM, Whelan B, et al. Cohort Profile: The Irish Longitudinal Study on Ageing. Int J Epidemiol. 2011;40(August):877–84.
Competing interests: No competing interests
Welbourn and colleagues skip somewhat swiftly over the role of primary care, particularly with regards to long-term follow-up. Various primary care audits have shown long-term nutritional deficiency in post-bariatric patients, and an audit in my own practice showed post-bariatric-surgical communication from surgical colleagues to vary from comprehensive to, more commonly, non-existent, demonstrating a need for clear guidance on long-term follow up.
The RCGP Nutrition Group formed a collaborative group with British Obesity and Metabolic Surgery Society, comprising bariatric surgeon, consultant dietician, Tier 3 weight management expert and GPs to produce Ten Top Tips for the Management of Patients post Bariatric Surgery in Primary Care guidance, freely available in the Guidelines in Practice directory https://www.guidelines.co.uk/parretti/obesity
or through the RCGP Nutrition web pages http://www.rcgp.org.uk/clinical-and-research/clinical-resources/nutritio...
We hope you will redress this missed opportunity to encourage primary care engagement by highlighting these links, which outline recommendations for nutritional supplements, micronutrient monitoring, pregnancy advice and medication guidance post bariatric surgery. Thank you.
Competing interests: I recently set up a company called Primary Care Obesity Training Ltd to facilitate obesity training in primary care
There is no doubt in highly selected cases of Morbid Obesity there is a place for selective surgery. However, I have concerns over the authors' question, "how can we increase rates of bariatric surgery?" In my experience, we should be looking at how can we decrease or prevent this Surgery. Any surgeon can operate. Knowing when not to comes with years of experience.
The article misses the fundamental issue of "appetite control". I see initial good results from surgery but then much failure due to inability to control hunger and cravings,with the added problems of dumping, etc.
All patients should have a treatment programme with appetite suppressants.
In my clinic, patients with morbid obesity respond well to phentermine and diethylpropion.These medications are never used preoperatively yet are used to control weight regain after surgery! They are cheap and safer than surgery.
If appetite can be controlled and lifestyle changes implemented surgery rates will drop.
If appetite cannot be controlled then long term weight gain as well as metabolic problems will continue.
Competing interests: No competing interests