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An Evidence-Based Review of Obesity and Bariatric Surgery
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Continuing Education
An Evidence-Based Review of Obesity and Bariatric Surgery Shannon Reedy
ABSTRACT Obesity has reached epidemic levels in the United States. In 1998, the National Heart, Lung, and Blood Institute published guidelines on the identification, evaluation, and treatment of overweight and obese adults. Despite these guidelines, health care providers are still doing a poor job of treating obesity. Millions of Americans meet the weight criteria for bariatric surgery, yet few actually undergo it. Many factors may contribute to this, including patient and provider attitudes regarding obesity and bariatric surgery, cost, and insurance coverage. Recently, numerous publications have described the safety and efficacy of bariatric surgery. Keywords: Attitude, bariatric, cost, evidence, guidelines, obesity
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PREVALENCE AND IMPACT OF OBESITY identification, evaluation, and treatment of overweight Obesity has reached epidemic levels in the United and obese adults. A systematic review of 394 randomized States. During the 1960s through 1980, less than 50% of controlled trials (RCT) was conducted to determine the American adults were considered overweight or obese.1 best evidence regarding obesity management.The panel In 2003-2004, that number rose to two thirds of the recommendations were based on evidence that links population. Alarmingly, during that same time, 32.2% of obesity to increased mortality and evidence that weight adults were actually considered obese.2 Although not a loss reduces risk of developing obesity-related disease. statistically significant increase, that number again rose in The guidelines include an assessment and treatment 1 2005-2006 to 34.3%. During 2003-2004, the prevaguide, and are currently being updated, with a proposed lence of extreme obesity or body mass index (BMI) ⱖ publication date in 2009. 2 2 40 kg/m was approximately 15 million Americans. According to the guidelines, assessment of the patient Obesity has been linked to numerous chronic health should include BMI, waist circumference, and analysis of conditions including hypertension, hyperlipidemia, sleep risk factors. BMI is weight in kilograms divided by 3 apnea, type 2 diabetes, and heart disease. Obesity-associheight in meters squared, and is routinely used to define ated conditions significantly obesity.Adults with a BMI > increase hospital length of stay, 25 are considered overweight Diet therapy should consist mortality, and overall health care and those with a BMI > 30 are costs.4 A 2003 study found that considered obese.Table 1 details of a 500 to 1000 calorie daily obesity causes a marked decrease the diagnostic classifications for deficit by reduction of in life expectancy. A 20-year-old weight based on BMI.10 Waist both fat and carbohydrate. white male with a BMI > 45 circumference of > 40 inches kg/m2 is estimated to have 13 in males and 35 inches in Physical activity should be years of life lost compared to an females is an independent risk initiated in all patients and should age and race matched male with factor for obesity-related comprogress to reach 30 minutes on 5 a BMI of 24 kg/m2. A 20-yearplications in patients with BMI most days of the week. old black male with a BMI > 45 of 25 to 34.9.10 In addition, risk is estimated to have 20 years of factors for potential obesitylife lost when compared to an age- and race-matched related mortality and morbidity should be determined. male with a BMI of 24.5 Lakdawalla et al6 found that The presence of disease conditions or risk factors such as after age 70, Medicare spends 35% more on obese type 2 diabetes, sleep apnea, hypertension, and physical patients than their normal-weight counterparts. It costs inactivity increase the patient risk of obesity-related an estimated $1400 more per year to care for an obese sequelae.This increased risk status should lower a practi7 individual than one of normal weight. In addition, there tioner’s threshold for initiating weight loss treatment.All are a multitude of adverse psychosocial aspects of obesity patients with a BMI of ⱖ 30 or patients with a BMI of such as alterations in well-being, quality of life, and ⱖ 25 with a waist circumference risk factor or ⱖ 2 other social stigmatization.8,9 A leading cause of preventable risk factors should be assisted with developing weightdeath, obesity needs to be treated as a chronic health related goals and treatment. condition by primary care providers. The treatment algorithm begins with diet therapy, behavioral therapy, and physical activity and includes OBESITY DIAGNOSIS AND MANAGEMENT GUIDELINES consideration of pharmacotherapy and bariatric surgery.10 In May 1995, the National Heart, Lung, and Blood Diet therapy should consist of a 500 to 1000 calorie daily Institute’s (NHLBI) Obesity Education Initiative, in deficit by reduction of both fat and carbohydrate. Physicooperation with the National Institute of Diabetes and cal activity should be initiated in all patients and should Digestive and Kidney Disease (NIDDK), convened an progress to reach 30 minutes on most days of the week. expert panel to develop evidence-based guidelines for Behavioral therapy should ideally be combined with diet primary care management of obesity. Subsequently, in and exercise and include strategies for compliance. Phar1998, the NHLBI published clinical guidelines on the macotherapy should be considered in patients with BMI
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Table 1. Classification of Obesity NIH Classification Underweight
BMI (kg/m2) < 18.5
Normal weight
18.5 - 24.9
Overweight
25.0 - 29.9
Obesity (Class 1)
30.0 - 34.9
Obesity (Class 2)
35.0 - 39.9
Extreme obesity (Class 3)
> 40.0
ⱖ 27 with risk factors and in those with BMI ⱖ 30 with no risk factors. Sibutramine (Meridia) and orlistat (Xenical) are FDA-approved prescription drugs available for long-term treatment of obesity. Orlistat is also available in a lower dose over the counter as Alli.The recommendations only include medications approved for long-term use due the chronic nature of obesity. Phentermine is an FDA prescription drug approved for short-term use. Weight loss medications must be used in select patients and need to be monitored closely by providers. Based on the 1998 NHLBI guidelines, patients meet weight criteria for bariatric surgery if they have a BMI of ⱖ 40 kg/m2 or a BMI of ⱖ 35 kg/m2 with comorbidities. Surgery should be considered and reserved for patients who have failed medically supervised weight loss attempts and have complications from obesity. CURRENT TRENDS IN OBESITY AND BARIATRIC SURGERY There are multiple studies investigating patients’ knowledge of healthy body weight, obesity, nutrition, exercise, and the effect of body weight on their heath.11-15 Unfortunately, a 2006 study asking patients what they would like to weigh showed that desired body weight is on the rise.16 Studies have shown that patients have an altered perception of their body weight, but that obese patients typically identify themselves as obese and are aware of the health risks.17 Despite the growing concern over the health consequences of obesity, there is an abundance of documentation about lack of knowledge and failure of primary care providers to identify and treat obesity.18-20 Physicians only identified obesity in 38% of their obese patients and only 36% of those patients were counseled on weight loss, according to data from the National Ambulatory Medical Care Survey.20 Galuska et al18 showed
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that only 42% of adults recall getting advice regarding diet from a health care provider. In a 2003 study on the knowledge and attitudes of internal medicine residents on obesity, 60% did not know the BMI criteria for diagnosing obesity and 69% did not recognize waist circumference as a measurement tool for obesity. Less than one third of the residents in the study reported success in treating obesity and nearly half incorrectly reported their own BMI.21 A 2004 study shows that providers are still remiss in recommending weight loss to their morbidly obese patients but those who recommended weight loss surgery were more likely to have previously recommended other weight loss interventions.22 Despite a large increase in the use of bariatric surgery, the number of surgeries performed is still dismal compared the number of morbidly obese patients.23 In 2006, an estimated 180,000 bariatric surgeries were performed in the United States.2 Accounting only for patients with a BMI of 40 kg/m2, this means that less than 1.5% of the patients who qualified for bariatric surgery actually had surgery. Many factors contribute to the low use of bariatric surgery as a method for weight loss.The factors include patient attitudes and knowledge of obesity or bariatric surgery, provider attitudes and knowledge of obesity or bariatric surgery, cost of bariatric surgery, and insurance coverage of bariatric surgery. LITERATURE REVIEW OF ATTITUDES OF PATIENTS AND PROVIDERS TOWARD BARIATRIC SURGERY Patient and provider knowledge and attitudes toward obesity are well documented, but studies related to patient and provider attitudes toward bariatric surgery are few. In November and December of 2007, a literature review was conducted to examine the research available on patient and provider attitudes regarding bariatric surgery. A search was performed using MEDLINE, CINAHL, the Cochrane Library databases, Psychology and Behavioral Sciences Collection, Social Sciences Citation Index, ScienceDirect, and Academic Search Premier.The main search terms were obesity surgery, gastric bypass, bariatric, and/or weight loss surgery.The results were combined with the term attitude.The search was limited to the English language.The table of contents’ of Surgery for Obesity and Related Diseases, Obesity Surgery, and Obesity Research were manually searched for articles. Seventy-eight articles were obtained meeting
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those search criteria. Articles were excluded if they were referring, listed in order from highest response rate, were any of the following: lack of patient interest, their morbidly obese patients do 1. A commentary or a letter to the editor not meet the criteria, amount of “legwork,” preference 2. A review article or an article describing publicato treat patients themselves, not believing in referral to tion elsewhere bariatric surgeons, and that most of their patients meet3. A survey pertaining solely to attitudes regarding ing the criteria would not benefit from the surgery obesity as a disease not bariatric surgery long-term.The participants believed that bariatric sur4. A survey solely of bariatric surgeons’ attitudes on gery was effective long-term for 49% of their patients types of bariatric surgery who had had bariatric surgery. On a 5-point Likert scale, 5. A survey of patients’ perceptions of provider the respondents averaged 2.9 in regard to their familiarattitudes ity to the National Institutes of Health (NIH) guide6. A survey of patients’ attitude after bariatric surgery lines.The incongruence between the perceived success Of the 78 articles retrieved, 70 were excluded. Of rate and the reported prescription of bariatric surgery is the remaining 8 articles, 7 were related to provider attinoteworthy. Nearly 50% report it as effective for their tudes and 1 was related to patient attitudes. patients, yet only 15% prescribe it. 15 Lynch et al published a In Balduf and Farrell’s25 surqualitative study of African vey of 611 family practitioners American female patient attiand internists, 84% of particiIn 2006, tudes toward obesity and pants felt they had been unsucan estimated 180,000 bariatric surgery.The findings cessful at helping severely obese bariatric surgeries were showed that the participants felt patients lose weight, yet only performed in the that they had lack of time and 76% had referred at least 1 resources for weight loss, patient for bariatric surgery. Of United States. described a feeling of lack of those 76%, 53% stated that the control regarding food, and referral was prompted by the identified with a larger body image.They had fears and patient. Eight-two percent of the participants had patients concerns about bariatric surgery and felt that it was too who had requested referrals to bariatric surgeons.Thirtyextreme. Patients perceived bariatric surgery as an five percent felt that they did not have adequate resources extreme measure that should only be used in life or death to care for bariatric patients and only 45% felt competent situations. to deal with the medical complications of bariatric surAvidor et al24 completed a study on 478 physicians in gery. Eighty-five percent had cared for a patient who had 6 specialty areas.They found that only 15.4% of their had bariatric surgery within the past year. Forty-four persample stated that they prescribed bariatric surgery as a cent incorrectly believed that the mortality rates for treatment for their morbid obese patients. Seventy-one bariatric surgery were 3% to 4%. Only 12% reported percent had referred a patient within the last year for having read the NIH guidelines regarding treatment of bariatric surgery, but 46% of them stated that the referral obesity. Forty-six percent of the participants completed a was typically prompted by the patient.The top 2 reasons CME on bariatric surgery within the past year. that they did refer patients for surgery were to achieve Foster et al26 surveyed 5000 family physicians regardmaintenance of weight loss (40.3%) and for reduction of ing attitudes on obesity.The survey also questioned the comorbidities (26.9%). Sixty percent of participants participants regarding whether or not they would recomlisted surgical risk as the major disadvantage of surgery, mend evaluation by a bariatric surgeon in patients with a followed by 25% listing long-term complications such as BMI of 40 kg/m2 and comorbidities. Only 23% of the weight regain, dumping syndrome, and other side effects. respondents said they would recommend an evaluation. Thirty-seven percent of participants indicated that they Of the respondents to a survey of 620 family physidid not refer patients because they were unacquainted cians by Perlman et al,27 85% had referred patients for with a local surgeon.The remaining reasons for not gastric bypass (GBP). Fear of complications and perceived
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high death rate were given as the primary reasons for not seven percent felt that surgery should be restricted to referring patients for surgery.Thirty-five percent of the patients who failed other treatments after 1 year of folparticipants did not refer patients because they believed low-up. Seventy-five percent felt that only a nutrition that their patients would be unable to follow the postopspecialist should indicate whether or not a patient erative lifestyle. Six percent believed that obesity was best should have surgery. Seventeen percent either strongly controlled by surgery. Most physicians were able to coragreed or agreed that surgery was the only option posrectly state BMI criteria for surgery, but many incorrectly sible for obese patients to significantly reduce and stated estimated weight loss by maintain weight loss, while GBP. Seventy-seven percent 26% strongly disagreed. underestimated weight loss while A synopsis of the literature The most commonly 8% overestimated weight loss. shows mixed attitudes toward performed bariatric surgeries Sixty-three percent would refer bariatric surgery. Patients perin the United States are the themselves or family members to ceive bariatric surgery as danRYGB and LAGB. a bariatric surgeon if needed. gerous and an extreme measIn their survey of 246 interure.15 Between 71% to 85% of nal medicine, family medicine, providers have referred patients for bariatric surgery, but 45.5% to 53% of the time, and obstetrics/gynecology medical staff, Sansone et al28 reported data on attitudes of providers regarding GBP patients initiated the referral. Between 63% and 77% of surgery. Eighty-four percent of the participants would providers/medical students would consider bariatric surrecommend GBP for morbidly obese patients and 22% gery themselves and between 63% and 89% of of them felt that it was the only effective means for providers/medical students would refer a family member treating morbid obesity. Female providers were statistifor surgery.The numbers of providers who would refer cally less likely to refer patients for surgery than males. patients meeting criteria for surgery was much broader. Only 77% of them felt that patients were screened Inconsistency was found among the respondents of the appropriately for surgery and 63% felt that surgery is surveys and one study posed that this may be due to overutilized in the medical community today. Sixtyunderlying ambivalence.28 In addition, there was a good nine percent of them believed that GBP patients seem deal of misinformation about bariatric surgery and a low to have a high rate of postoperative complications, but percentage of providers had read or received education 64% of them felt that GBP saves society money in the on bariatric surgery.25 long run. Schuster et al29 surveyed 61 medical students USE, SAFETY, AND EFFICACY OF BARIATRIC SURGERY regarding their attitude toward obesity and bariatric The overall attitude of patients and providers toward surgery. Forty-four percent indicated that they would bariatric surgery is inconsistent with research showing consider a career in bariatric surgery and 70% stated its use, efficacy, and safety. Bariatric surgical procedures they would consider performing bariatric surgery as include restrictive, malabsorptive, and combination part of their practice. Eighty-nine percent of those surtechniques.The most commonly used restrictive proveyed would recommend bariatric surgery to a family cedure is laparoscopic adjustable gastric banding member and 77% would have surgery themselves if (LAGB).The vertical-banded gastroplasty is another needed, possibly indicating that current medical educarestrictive procedure. Purely malabsorptive procedures tion has increased its emphasis on obesity and obesity are less commonly used and include the biliopancreatic treatment. diversion (BPD).The Roux-en-Y gastric bypass 30 Thuan and Avignon examined views regarding (RYGB) is a combination restrictive and malabsorptive bariatric surgery in a survey of 744 French general procedure. practitioners on obesity management. Eighty-nine perThe most commonly performed bariatric surgeries cent of the respondents felt that bariatric surgery in the United States are the RYGB and LAGB. should be considered only in exceptional cases. EightyAlthough the RYGB is the most commonly performed
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Table 2. Commonly Performed Bariatric Surgeries Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Laparoscopic Adjustable Gastric Banding (LAGB)
Roux-en-Y Gastric Bypass (RYGB)
Type
Primarily Malabsorptive
Restrictive
Combined
Description
A portion of the stomach is removed. The remaining stomach is directly connected to the last section of the small intestine, bypassing the upper part of the small intestines.
An adjustable band is placed around at the upper portion of the stomach.
A stomach pouch is created out of a small portion of the stomach. It is attached directly to the small intestine, bypassing a large part of the stomach and duodenum.
surgery, the LAGB is gaining in popularity in the United States and is the most commonly performed procedure in Europe.31 The RYGB involves creating of a restrictive 30-ml gastric pouch and bypassing a portion of the small intestine, causing mild malabsorption.The procedure can be performed laparoscopically or as an open procedure. LAGB involves laparoscopic placement of an adjustable silicone ring around the upper portion of the stomach, causing a restriction in the amount of food intake.The BPD, an open or laparoscopic procedure, involves a bypass of the majority of the small intestine, causing malabsorption.Table 2 describes the 3 most commonly performed procedures. A 2005 meta-analysis by Maggard et al31 reviewed the safety and efficacy of bariatric surgery in 147 studies.The meta-analysis showed that bariatric surgery is more effective than nonsurgical weight loss treatments for patients with a BMI of 40 kg/m2 and results in 20 to 30 kg weight loss that is maintained for up to 10 years. Similar findings were found for patients with BMIs of 35 to 39.9 kg/m2, but could not be considered conclusive.The study also found that current bariatric procedures in use have a mortality of less than 1%. A 2004 meta-analysis by Buchwald et al32 examined 136 studies and included a total of 22,094 patients.They found that the overall percentage of excess weight loss (% EWL, the amount of weight lost expressed as a percentage of the patient’s weight in excess of his or her ideal weight) for bariatric procedures was 62.1%. Gastric bypass weight loss was 61.6%, while gastric banding weight loss was 42.7%. In addition, the ⱕ 30-day mortality was 0.1% for restrictive procedures and 0.5% for gastric bypass.A total of 76.8% of patients had resolution of diabetes and 61.6% of patients had resolution of hyper-
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tension. Obstructive sleep apnea resolved in 85.7% of patients and hyperlipidemia resolved in 70% of patients. The Cochrane Collaboration performed a systematic review of bariatric surgery in 2007.Twenty-six studies, of which 23 were randomized controlled trials (RCTs), met the inclusion criteria and were reviewed.The review indicated that bariatric surgery “results in greater weight loss than conventional treatment, and that the results are maintained at least up to 8 years.”33 Data showed that at 8 years follow-up, bariatric surgery patients had lost 21 kg, where the nonsurgical patients had gained weight.33 In addition, patients had improvement in quality of life, diabetes, and hypertension.33 Patients were at increased risk of gall bladder disease, heartburn, vomiting, wound infection, and death.33 In addition to its efficacy in the treatment of obesity, variations of bariatric procedures are being researched as a treatment for Type 2 diabetes in nonmorbidly obese patients. In 2007, there were 2 case reports of patients with BMIs of 29 and 30.3 undergoing duodenal-jejunal bypass procedures as treatment of type 2 diabetes.The patients both returned to normo-glycemia with no weight loss. Currently, nearly 40 patients with BMI between 22 and 34 have had duodenal-jejunal bypass procedures for treatment of Type 2 diabetes.At 9- to 12month follow-up, irrespective of weight loss, diabetes has resolved or improved in 78% of the patients.34 INSURANCE COVERAGE AND COST Cost containment, health insurance, access to health care, and health care disparities are concerns for all health care providers. Cost effectiveness modeling has been completed for bariatric surgery. Craig and Tseng35 used a deterministic decision model to compare lifetime
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expected cost and outcomes of bariatric surgery versus no treatment.The patients had a BMI of ⬎ 40 kg/m2.and no comorbidities.Their study and other studies have found bariatric surgery to be cost-effective.35-37 Insurance coverage for obesity treatment and bariatric surgery has long been debated. Societal stigma and prejudice related to obesity are still present in health care, particularly in the arena of health insurance coverage.38 A 2007 study at a bariatric surgery center showed that of 1054 patients evaluated for surgery, nearly half underwent surgery. Of the half that did not undergo surgery, almost 30% were due to insurance reasons (19.9% were denied by their insurance company and 9.8% had unattainable insurance prerequisites).39 The Center for Medicare and Medicaid Services (CMS) issued its decision regarding national coverage for bariatric surgery on February 21, 2006, deciding that Medicare would pay for bariatric surgery.40 This decision had implications for patients, providers, and insurers. Patients covered by Medicare will have increased access to bariatric surgery. Providers will likely see a related increase in discussion about bariatric surgery. In addition, commercial insurers typically follow behind CMS and, therefore, coverage of bariatric surgery will likely increase.40 Flum et al41 noted that there is a great deal of racial and financial disparity in bariatric surgery.They found that while African Americans, Hispanics, and the poor are more likely to be obese, they are less likely to have bariatric surgery.41 In addition to racial inequities, they found that the significant gender and age disparities offer an ethical and public health dilemma as well.41 IMPLICATIONS, ROLES, AND RESPONSIBILITIES OF THE NURSE PRACTITIONER Familiarity with clinical practice guidelines better prepares nurse practitioners for diagnosing and managing obese patients.A comprehensive assessment and treatment plan based on standardized guidelines will provide patients with the best possible outcomes.There is compelling evidence in favor of bariatric surgery as a treatment for morbid obesity.32 Up-to-date knowledge of current statistics on use, safety, efficacy, and trends for bariatric surgery place nurse practitioners in an optimal role of educating both patients and fellow colleagues. Because patient attitudes toward health and health care are often driven by the attitudes of the health care profession, it is important 28
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that health care providers assist each other in examining their attitudes toward treatment of obesity.Advocating for policy change and insurance coverage for obesity treatment is the task of nurse practitioners and the entire health care team. In conclusion, recognition of obesity and the associated health consequences, along with initiating patient discussion regarding evidence-based management options, is a responsibility that nurse practitioners must be prepared to address. References 1. National Center for Health Statistics. Health, United States, 2007. (With chartbook on trends in the health of Americans.) Hyattsville, MD: U.S. Government Printing Office; 2007. DHHS Publication No. 2007-1232:40-41, 104. Available at: http://www.cdc.gov.proxy-hs.researchport.umd.edu/nchs/ data/hus/hus07.pdf. Accessed July 17, 2008. 2. Ogden C, Carroll M, Curtin L, McDowell M, Tabak C, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549. 3. Must A, Spadano J, Coakley EH, Field AE, Colditz G, et al. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523-1529. 4. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8-27. 5. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003;289:187-193. 6. Lakdawalla DN, Goldman DP, Shang B. The health and cost consequences of obesity among the future elderly. Health Aff. 2005;24:W5R30-41. 7. Wee CC, Phillips RS, Legedza AT, et al. Health care expenditures associated with overweight and obesity among US adults: importance of age and race. Am J Public Health. 2005;95:159-165. 8. Jia H, Lubetkin EI. The impact of obesity on health-related quality-of-life in the general adult US population. J Public Health. 2005;27:156-164. 9. Tyler C, Johnston CA, Fullerton G, Foreyt JP. Reduced quality of life in very overweight Mexican American adolescents. J Adolesc Health. 2007;40:366368. 10. National Heart, Lung, and Blood Institute. National Heart, Lung, and Blood Institute: Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults: Executive summary. Rockville, MD: National Institutes of Health; 1998. Available at: http://www.nhlbi.nih.gov. proxy-hs.researchport.umd.edu. Accessed November 20, 2007. 11. Fuemmeler BF, Baffi C, Mâsse LC, Atienza AA, Evans WD. Employer and healthcare policy interventions aimed at adult obesity. Am J Prev Med. 2007;32:44-51. 12. Andersson P, Sjoberg RL, Ohrvik J, Leppert J. Knowledge about cardiovascular risk factors among obese individuals. Eur J Cardiovasc Nurs. 2006;5:275-279. 13. Burton S, Creyer EH, Kees J, Huggins K. Attacking the obesity epidemic: the potential health benefits of providing nutrition information in restaurants. Am J Public Health. 2006;96:1669-1675. 14. Irani J, Abell R. Awareness of body weight status among family medicine clinic patients. J Okla State Med Assoc. 2007;100:139-143. 15. Lynch CS, Chang JC, Ford AF, Ibrahim SA. Obese African-American women’s perspectives on weight loss and bariatric surgery. J Gen Intern Med. 2007;22:908-914. 16. Maynard LM, Serdula MK, Galuska DA, Gillespie C, Mokdad AH. Secular trends in desired weight of adults. Int J Obes. 2006;30:1375-1381. 17. Little P. GP documentation of obesity: what does it achieve? Br J Gen Pract. 1998;48:890-894. 18. Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? [see comment]. JAMA. 1999;282:1576-1578. 19. Simkin-Silverman LR, Gleason KA, King WC, et al. Predictors of weight control advice in primary care practices: patient health and psychosocial characteristics. Prev Med. 2005;40:71-82. 20. Stafford R, Farhat J, Misra B, Schoenfeld D. National patterns of physician activities related to obesity management. Arch Fam Med. 2000;9:631-638. 21. Block JP, DeSalvo KB, Fisher WP. Are physicians equipped to address the obesity epidemic? Knowledge and attitudes of internal medicine residents. Prev Med. 2003;36:669-675.
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22. Anderson DA, Wadden TA. Bariatric surgery patients’ views of their physicians’ weight-related attitudes and practices. Obes Res. 2004;12:15871595. 23. Trus TL, Pope GD, Finlayson SR. National trends in utilization and outcomes of bariatric surgery. Surg Endosc. 2005;19:616-620. 24. Avidor Y, Still CD, Brunner M, Buchwald JN, Buchwald H. Primary care and subspecialty management of morbid obesity: referral patterns for bariatric surgery. Surg Obes Relat Dis. 2007;3:392-407. 25. Balduf L, Farrell T. Attitudes, beliefs, and referral patterns of PCPs to bariatric surgeons. J Surg Res. 2008;144:49-58. 26. Foster G, Wadden T, Makris A, et al. Primary care physicians’ attitudes about obesity and its treatment. Obes Res. 2003;11:1168. 27. Perlman SE, Reinhold RB, Nadzam GS. How do family practitioners perceive surgery for the morbidly obese? Surg Obes Relat Dis. 2007;3:428433. 28. Sansone RA, McDonald S, Wiederman MW, Ferreira K. Gastric bypass surgery: a survey of primary care physicians. Brunner-Mazel Eating Disorders Monograph Series. 2007;15:145-152. 29. Schuster R, Morton JM, Liu GY, Alami RS, Curet MJ. Attitude of prospective surgical residents regarding surgery for morbid obesity. Obes Surg. 2006;16:1464-1468. 30. Thuan JF, Avignon A. Obesity management: attitudes and practices of french general practitioners in a region of france. Int J Obes. 2005;29:11001106. 31. Maggard M, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547-559. 32. Buchwald H, Avidor Y, Braunwald E, Jensen M, Pories WJ, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-1737. 33. Colquitt J, Clegg A, Loveman E, Royle P, Sidhu MK. Surgery for morbid obesity. Cochrane Database of Systematic Reviews. 2007;1-75. 34. Cohen R. Controlling type 2 diabetes through surgery in non-morbidly obese patients. Obes Care News. 2008;2(2):22. 35. Craig BM, Tseng DS. Cost-effectiveness of gastric bypass for severe obesity. Am J Med. 2002;113:491-498. 36. Clegg A, Colquitt J, Sidhu M, Royle P, Walker A. Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation. Int J Obes Relat Metabolic Disorders. 2003;27:11671177. 37. van Gemert WG, Adang EM, Kop M, Vos G, Greve JW, et al. A prospective cost-effectiveness analysis of vertical banded gastroplasty for the treatment of morbid obesity. Obes Surg. 1999;9:484-491. 38. Bell SE. Current issues and challenges in the management of bariatric patients. J Wound Ostomy Continence Nurs. 2005;32:386-392. 39. Sadhasivam S, Larson CJ, Lambert PJ, Mathiason MA, Kothari SN. Refusals, denials, and patient choice: reasons prospective patients do not undergo bariatric surgery. Surg Obes Relat Dis. 2007;3:531-535. 40. Elmore BL, Phillips WT. Bariatric surgery coverage decision: opportunities and limitations. Health Care Financ Manage. 2006;60:52-54. 41. Flum D, Khan T, Dellinger EP. Toward the rational and equitable use of bariatric surgery. JAMA. 2007;298:1442-1444.
Shannon Reedy, MS, CRNP, is a clinical instructor at the University of Maryland School of Nursing in Baltimore. She can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/08/$ see front matter © 2009 American College of Nurse Practitioners doi:10.1016/j.nurpra.2008.01.017
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Continuing Education
An Evidence-Based Review of Obesity and Bariatric Surgery Shannon Reedy
ABSTRACT Obesity has reached epidemic levels in the United States. In 1998, the National Heart, Lung, and Blood Institute published guidelines on the identification, evaluation, and treatment of overweight and obese adults. Despite these guidelines, health care providers are still doing a poor job of treating obesity. Millions of Americans meet the weight criteria for bariatric surgery, yet few actually undergo it. Many factors may contribute to this, including patient and provider attitudes regarding obesity and bariatric surgery, cost, and insurance coverage. Recently, numerous publications have described the safety and efficacy of bariatric surgery. Keywords: Attitude, bariatric, cost, evidence, guidelines, obesity
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PREVALENCE AND IMPACT OF OBESITY identification, evaluation, and treatment of overweight Obesity has reached epidemic levels in the United and obese adults. A systematic review of 394 randomized States. During the 1960s through 1980, less than 50% of controlled trials (RCT) was conducted to determine the American adults were considered overweight or obese.1 best evidence regarding obesity management.The panel In 2003-2004, that number rose to two thirds of the recommendations were based on evidence that links population. Alarmingly, during that same time, 32.2% of obesity to increased mortality and evidence that weight adults were actually considered obese.2 Although not a loss reduces risk of developing obesity-related disease. statistically significant increase, that number again rose in The guidelines include an assessment and treatment 1 2005-2006 to 34.3%. During 2003-2004, the prevaguide, and are currently being updated, with a proposed lence of extreme obesity or body mass index (BMI) ⱖ publication date in 2009. 2 2 40 kg/m was approximately 15 million Americans. According to the guidelines, assessment of the patient Obesity has been linked to numerous chronic health should include BMI, waist circumference, and analysis of conditions including hypertension, hyperlipidemia, sleep risk factors. BMI is weight in kilograms divided by 3 apnea, type 2 diabetes, and heart disease. Obesity-associheight in meters squared, and is routinely used to define ated conditions significantly obesity.Adults with a BMI > increase hospital length of stay, 25 are considered overweight Diet therapy should consist mortality, and overall health care and those with a BMI > 30 are costs.4 A 2003 study found that considered obese.Table 1 details of a 500 to 1000 calorie daily obesity causes a marked decrease the diagnostic classifications for deficit by reduction of in life expectancy. A 20-year-old weight based on BMI.10 Waist both fat and carbohydrate. white male with a BMI > 45 circumference of > 40 inches kg/m2 is estimated to have 13 in males and 35 inches in Physical activity should be years of life lost compared to an females is an independent risk initiated in all patients and should age and race matched male with factor for obesity-related comprogress to reach 30 minutes on 5 a BMI of 24 kg/m2. A 20-yearplications in patients with BMI most days of the week. old black male with a BMI > 45 of 25 to 34.9.10 In addition, risk is estimated to have 20 years of factors for potential obesitylife lost when compared to an age- and race-matched related mortality and morbidity should be determined. male with a BMI of 24.5 Lakdawalla et al6 found that The presence of disease conditions or risk factors such as after age 70, Medicare spends 35% more on obese type 2 diabetes, sleep apnea, hypertension, and physical patients than their normal-weight counterparts. It costs inactivity increase the patient risk of obesity-related an estimated $1400 more per year to care for an obese sequelae.This increased risk status should lower a practi7 individual than one of normal weight. In addition, there tioner’s threshold for initiating weight loss treatment.All are a multitude of adverse psychosocial aspects of obesity patients with a BMI of ⱖ 30 or patients with a BMI of such as alterations in well-being, quality of life, and ⱖ 25 with a waist circumference risk factor or ⱖ 2 other social stigmatization.8,9 A leading cause of preventable risk factors should be assisted with developing weightdeath, obesity needs to be treated as a chronic health related goals and treatment. condition by primary care providers. The treatment algorithm begins with diet therapy, behavioral therapy, and physical activity and includes OBESITY DIAGNOSIS AND MANAGEMENT GUIDELINES consideration of pharmacotherapy and bariatric surgery.10 In May 1995, the National Heart, Lung, and Blood Diet therapy should consist of a 500 to 1000 calorie daily Institute’s (NHLBI) Obesity Education Initiative, in deficit by reduction of both fat and carbohydrate. Physicooperation with the National Institute of Diabetes and cal activity should be initiated in all patients and should Digestive and Kidney Disease (NIDDK), convened an progress to reach 30 minutes on most days of the week. expert panel to develop evidence-based guidelines for Behavioral therapy should ideally be combined with diet primary care management of obesity. Subsequently, in and exercise and include strategies for compliance. Phar1998, the NHLBI published clinical guidelines on the macotherapy should be considered in patients with BMI
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Table 1. Classification of Obesity NIH Classification Underweight
BMI (kg/m2) < 18.5
Normal weight
18.5 - 24.9
Overweight
25.0 - 29.9
Obesity (Class 1)
30.0 - 34.9
Obesity (Class 2)
35.0 - 39.9
Extreme obesity (Class 3)
> 40.0
ⱖ 27 with risk factors and in those with BMI ⱖ 30 with no risk factors. Sibutramine (Meridia) and orlistat (Xenical) are FDA-approved prescription drugs available for long-term treatment of obesity. Orlistat is also available in a lower dose over the counter as Alli.The recommendations only include medications approved for long-term use due the chronic nature of obesity. Phentermine is an FDA prescription drug approved for short-term use. Weight loss medications must be used in select patients and need to be monitored closely by providers. Based on the 1998 NHLBI guidelines, patients meet weight criteria for bariatric surgery if they have a BMI of ⱖ 40 kg/m2 or a BMI of ⱖ 35 kg/m2 with comorbidities. Surgery should be considered and reserved for patients who have failed medically supervised weight loss attempts and have complications from obesity. CURRENT TRENDS IN OBESITY AND BARIATRIC SURGERY There are multiple studies investigating patients’ knowledge of healthy body weight, obesity, nutrition, exercise, and the effect of body weight on their heath.11-15 Unfortunately, a 2006 study asking patients what they would like to weigh showed that desired body weight is on the rise.16 Studies have shown that patients have an altered perception of their body weight, but that obese patients typically identify themselves as obese and are aware of the health risks.17 Despite the growing concern over the health consequences of obesity, there is an abundance of documentation about lack of knowledge and failure of primary care providers to identify and treat obesity.18-20 Physicians only identified obesity in 38% of their obese patients and only 36% of those patients were counseled on weight loss, according to data from the National Ambulatory Medical Care Survey.20 Galuska et al18 showed
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that only 42% of adults recall getting advice regarding diet from a health care provider. In a 2003 study on the knowledge and attitudes of internal medicine residents on obesity, 60% did not know the BMI criteria for diagnosing obesity and 69% did not recognize waist circumference as a measurement tool for obesity. Less than one third of the residents in the study reported success in treating obesity and nearly half incorrectly reported their own BMI.21 A 2004 study shows that providers are still remiss in recommending weight loss to their morbidly obese patients but those who recommended weight loss surgery were more likely to have previously recommended other weight loss interventions.22 Despite a large increase in the use of bariatric surgery, the number of surgeries performed is still dismal compared the number of morbidly obese patients.23 In 2006, an estimated 180,000 bariatric surgeries were performed in the United States.2 Accounting only for patients with a BMI of 40 kg/m2, this means that less than 1.5% of the patients who qualified for bariatric surgery actually had surgery. Many factors contribute to the low use of bariatric surgery as a method for weight loss.The factors include patient attitudes and knowledge of obesity or bariatric surgery, provider attitudes and knowledge of obesity or bariatric surgery, cost of bariatric surgery, and insurance coverage of bariatric surgery. LITERATURE REVIEW OF ATTITUDES OF PATIENTS AND PROVIDERS TOWARD BARIATRIC SURGERY Patient and provider knowledge and attitudes toward obesity are well documented, but studies related to patient and provider attitudes toward bariatric surgery are few. In November and December of 2007, a literature review was conducted to examine the research available on patient and provider attitudes regarding bariatric surgery. A search was performed using MEDLINE, CINAHL, the Cochrane Library databases, Psychology and Behavioral Sciences Collection, Social Sciences Citation Index, ScienceDirect, and Academic Search Premier.The main search terms were obesity surgery, gastric bypass, bariatric, and/or weight loss surgery.The results were combined with the term attitude.The search was limited to the English language.The table of contents’ of Surgery for Obesity and Related Diseases, Obesity Surgery, and Obesity Research were manually searched for articles. Seventy-eight articles were obtained meeting
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those search criteria. Articles were excluded if they were referring, listed in order from highest response rate, were any of the following: lack of patient interest, their morbidly obese patients do 1. A commentary or a letter to the editor not meet the criteria, amount of “legwork,” preference 2. A review article or an article describing publicato treat patients themselves, not believing in referral to tion elsewhere bariatric surgeons, and that most of their patients meet3. A survey pertaining solely to attitudes regarding ing the criteria would not benefit from the surgery obesity as a disease not bariatric surgery long-term.The participants believed that bariatric sur4. A survey solely of bariatric surgeons’ attitudes on gery was effective long-term for 49% of their patients types of bariatric surgery who had had bariatric surgery. On a 5-point Likert scale, 5. A survey of patients’ perceptions of provider the respondents averaged 2.9 in regard to their familiarattitudes ity to the National Institutes of Health (NIH) guide6. A survey of patients’ attitude after bariatric surgery lines.The incongruence between the perceived success Of the 78 articles retrieved, 70 were excluded. Of rate and the reported prescription of bariatric surgery is the remaining 8 articles, 7 were related to provider attinoteworthy. Nearly 50% report it as effective for their tudes and 1 was related to patient attitudes. patients, yet only 15% prescribe it. 15 Lynch et al published a In Balduf and Farrell’s25 surqualitative study of African vey of 611 family practitioners American female patient attiand internists, 84% of particiIn 2006, tudes toward obesity and pants felt they had been unsucan estimated 180,000 bariatric surgery.The findings cessful at helping severely obese bariatric surgeries were showed that the participants felt patients lose weight, yet only performed in the that they had lack of time and 76% had referred at least 1 resources for weight loss, patient for bariatric surgery. Of United States. described a feeling of lack of those 76%, 53% stated that the control regarding food, and referral was prompted by the identified with a larger body image.They had fears and patient. Eight-two percent of the participants had patients concerns about bariatric surgery and felt that it was too who had requested referrals to bariatric surgeons.Thirtyextreme. Patients perceived bariatric surgery as an five percent felt that they did not have adequate resources extreme measure that should only be used in life or death to care for bariatric patients and only 45% felt competent situations. to deal with the medical complications of bariatric surAvidor et al24 completed a study on 478 physicians in gery. Eighty-five percent had cared for a patient who had 6 specialty areas.They found that only 15.4% of their had bariatric surgery within the past year. Forty-four persample stated that they prescribed bariatric surgery as a cent incorrectly believed that the mortality rates for treatment for their morbid obese patients. Seventy-one bariatric surgery were 3% to 4%. Only 12% reported percent had referred a patient within the last year for having read the NIH guidelines regarding treatment of bariatric surgery, but 46% of them stated that the referral obesity. Forty-six percent of the participants completed a was typically prompted by the patient.The top 2 reasons CME on bariatric surgery within the past year. that they did refer patients for surgery were to achieve Foster et al26 surveyed 5000 family physicians regardmaintenance of weight loss (40.3%) and for reduction of ing attitudes on obesity.The survey also questioned the comorbidities (26.9%). Sixty percent of participants participants regarding whether or not they would recomlisted surgical risk as the major disadvantage of surgery, mend evaluation by a bariatric surgeon in patients with a followed by 25% listing long-term complications such as BMI of 40 kg/m2 and comorbidities. Only 23% of the weight regain, dumping syndrome, and other side effects. respondents said they would recommend an evaluation. Thirty-seven percent of participants indicated that they Of the respondents to a survey of 620 family physidid not refer patients because they were unacquainted cians by Perlman et al,27 85% had referred patients for with a local surgeon.The remaining reasons for not gastric bypass (GBP). Fear of complications and perceived
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high death rate were given as the primary reasons for not seven percent felt that surgery should be restricted to referring patients for surgery.Thirty-five percent of the patients who failed other treatments after 1 year of folparticipants did not refer patients because they believed low-up. Seventy-five percent felt that only a nutrition that their patients would be unable to follow the postopspecialist should indicate whether or not a patient erative lifestyle. Six percent believed that obesity was best should have surgery. Seventeen percent either strongly controlled by surgery. Most physicians were able to coragreed or agreed that surgery was the only option posrectly state BMI criteria for surgery, but many incorrectly sible for obese patients to significantly reduce and stated estimated weight loss by maintain weight loss, while GBP. Seventy-seven percent 26% strongly disagreed. underestimated weight loss while A synopsis of the literature The most commonly 8% overestimated weight loss. shows mixed attitudes toward performed bariatric surgeries Sixty-three percent would refer bariatric surgery. Patients perin the United States are the themselves or family members to ceive bariatric surgery as danRYGB and LAGB. a bariatric surgeon if needed. gerous and an extreme measIn their survey of 246 interure.15 Between 71% to 85% of nal medicine, family medicine, providers have referred patients for bariatric surgery, but 45.5% to 53% of the time, and obstetrics/gynecology medical staff, Sansone et al28 reported data on attitudes of providers regarding GBP patients initiated the referral. Between 63% and 77% of surgery. Eighty-four percent of the participants would providers/medical students would consider bariatric surrecommend GBP for morbidly obese patients and 22% gery themselves and between 63% and 89% of of them felt that it was the only effective means for providers/medical students would refer a family member treating morbid obesity. Female providers were statistifor surgery.The numbers of providers who would refer cally less likely to refer patients for surgery than males. patients meeting criteria for surgery was much broader. Only 77% of them felt that patients were screened Inconsistency was found among the respondents of the appropriately for surgery and 63% felt that surgery is surveys and one study posed that this may be due to overutilized in the medical community today. Sixtyunderlying ambivalence.28 In addition, there was a good nine percent of them believed that GBP patients seem deal of misinformation about bariatric surgery and a low to have a high rate of postoperative complications, but percentage of providers had read or received education 64% of them felt that GBP saves society money in the on bariatric surgery.25 long run. Schuster et al29 surveyed 61 medical students USE, SAFETY, AND EFFICACY OF BARIATRIC SURGERY regarding their attitude toward obesity and bariatric The overall attitude of patients and providers toward surgery. Forty-four percent indicated that they would bariatric surgery is inconsistent with research showing consider a career in bariatric surgery and 70% stated its use, efficacy, and safety. Bariatric surgical procedures they would consider performing bariatric surgery as include restrictive, malabsorptive, and combination part of their practice. Eighty-nine percent of those surtechniques.The most commonly used restrictive proveyed would recommend bariatric surgery to a family cedure is laparoscopic adjustable gastric banding member and 77% would have surgery themselves if (LAGB).The vertical-banded gastroplasty is another needed, possibly indicating that current medical educarestrictive procedure. Purely malabsorptive procedures tion has increased its emphasis on obesity and obesity are less commonly used and include the biliopancreatic treatment. diversion (BPD).The Roux-en-Y gastric bypass 30 Thuan and Avignon examined views regarding (RYGB) is a combination restrictive and malabsorptive bariatric surgery in a survey of 744 French general procedure. practitioners on obesity management. Eighty-nine perThe most commonly performed bariatric surgeries cent of the respondents felt that bariatric surgery in the United States are the RYGB and LAGB. should be considered only in exceptional cases. EightyAlthough the RYGB is the most commonly performed
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Table 2. Commonly Performed Bariatric Surgeries Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Laparoscopic Adjustable Gastric Banding (LAGB)
Roux-en-Y Gastric Bypass (RYGB)
Type
Primarily Malabsorptive
Restrictive
Combined
Description
A portion of the stomach is removed. The remaining stomach is directly connected to the last section of the small intestine, bypassing the upper part of the small intestines.
An adjustable band is placed around at the upper portion of the stomach.
A stomach pouch is created out of a small portion of the stomach. It is attached directly to the small intestine, bypassing a large part of the stomach and duodenum.
surgery, the LAGB is gaining in popularity in the United States and is the most commonly performed procedure in Europe.31 The RYGB involves creating of a restrictive 30-ml gastric pouch and bypassing a portion of the small intestine, causing mild malabsorption.The procedure can be performed laparoscopically or as an open procedure. LAGB involves laparoscopic placement of an adjustable silicone ring around the upper portion of the stomach, causing a restriction in the amount of food intake.The BPD, an open or laparoscopic procedure, involves a bypass of the majority of the small intestine, causing malabsorption.Table 2 describes the 3 most commonly performed procedures. A 2005 meta-analysis by Maggard et al31 reviewed the safety and efficacy of bariatric surgery in 147 studies.The meta-analysis showed that bariatric surgery is more effective than nonsurgical weight loss treatments for patients with a BMI of 40 kg/m2 and results in 20 to 30 kg weight loss that is maintained for up to 10 years. Similar findings were found for patients with BMIs of 35 to 39.9 kg/m2, but could not be considered conclusive.The study also found that current bariatric procedures in use have a mortality of less than 1%. A 2004 meta-analysis by Buchwald et al32 examined 136 studies and included a total of 22,094 patients.They found that the overall percentage of excess weight loss (% EWL, the amount of weight lost expressed as a percentage of the patient’s weight in excess of his or her ideal weight) for bariatric procedures was 62.1%. Gastric bypass weight loss was 61.6%, while gastric banding weight loss was 42.7%. In addition, the ⱕ 30-day mortality was 0.1% for restrictive procedures and 0.5% for gastric bypass.A total of 76.8% of patients had resolution of diabetes and 61.6% of patients had resolution of hyper-
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tension. Obstructive sleep apnea resolved in 85.7% of patients and hyperlipidemia resolved in 70% of patients. The Cochrane Collaboration performed a systematic review of bariatric surgery in 2007.Twenty-six studies, of which 23 were randomized controlled trials (RCTs), met the inclusion criteria and were reviewed.The review indicated that bariatric surgery “results in greater weight loss than conventional treatment, and that the results are maintained at least up to 8 years.”33 Data showed that at 8 years follow-up, bariatric surgery patients had lost 21 kg, where the nonsurgical patients had gained weight.33 In addition, patients had improvement in quality of life, diabetes, and hypertension.33 Patients were at increased risk of gall bladder disease, heartburn, vomiting, wound infection, and death.33 In addition to its efficacy in the treatment of obesity, variations of bariatric procedures are being researched as a treatment for Type 2 diabetes in nonmorbidly obese patients. In 2007, there were 2 case reports of patients with BMIs of 29 and 30.3 undergoing duodenal-jejunal bypass procedures as treatment of type 2 diabetes.The patients both returned to normo-glycemia with no weight loss. Currently, nearly 40 patients with BMI between 22 and 34 have had duodenal-jejunal bypass procedures for treatment of Type 2 diabetes.At 9- to 12month follow-up, irrespective of weight loss, diabetes has resolved or improved in 78% of the patients.34 INSURANCE COVERAGE AND COST Cost containment, health insurance, access to health care, and health care disparities are concerns for all health care providers. Cost effectiveness modeling has been completed for bariatric surgery. Craig and Tseng35 used a deterministic decision model to compare lifetime
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expected cost and outcomes of bariatric surgery versus no treatment.The patients had a BMI of ⬎ 40 kg/m2.and no comorbidities.Their study and other studies have found bariatric surgery to be cost-effective.35-37 Insurance coverage for obesity treatment and bariatric surgery has long been debated. Societal stigma and prejudice related to obesity are still present in health care, particularly in the arena of health insurance coverage.38 A 2007 study at a bariatric surgery center showed that of 1054 patients evaluated for surgery, nearly half underwent surgery. Of the half that did not undergo surgery, almost 30% were due to insurance reasons (19.9% were denied by their insurance company and 9.8% had unattainable insurance prerequisites).39 The Center for Medicare and Medicaid Services (CMS) issued its decision regarding national coverage for bariatric surgery on February 21, 2006, deciding that Medicare would pay for bariatric surgery.40 This decision had implications for patients, providers, and insurers. Patients covered by Medicare will have increased access to bariatric surgery. Providers will likely see a related increase in discussion about bariatric surgery. In addition, commercial insurers typically follow behind CMS and, therefore, coverage of bariatric surgery will likely increase.40 Flum et al41 noted that there is a great deal of racial and financial disparity in bariatric surgery.They found that while African Americans, Hispanics, and the poor are more likely to be obese, they are less likely to have bariatric surgery.41 In addition to racial inequities, they found that the significant gender and age disparities offer an ethical and public health dilemma as well.41 IMPLICATIONS, ROLES, AND RESPONSIBILITIES OF THE NURSE PRACTITIONER Familiarity with clinical practice guidelines better prepares nurse practitioners for diagnosing and managing obese patients.A comprehensive assessment and treatment plan based on standardized guidelines will provide patients with the best possible outcomes.There is compelling evidence in favor of bariatric surgery as a treatment for morbid obesity.32 Up-to-date knowledge of current statistics on use, safety, efficacy, and trends for bariatric surgery place nurse practitioners in an optimal role of educating both patients and fellow colleagues. Because patient attitudes toward health and health care are often driven by the attitudes of the health care profession, it is important 28
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that health care providers assist each other in examining their attitudes toward treatment of obesity.Advocating for policy change and insurance coverage for obesity treatment is the task of nurse practitioners and the entire health care team. In conclusion, recognition of obesity and the associated health consequences, along with initiating patient discussion regarding evidence-based management options, is a responsibility that nurse practitioners must be prepared to address. References 1. National Center for Health Statistics. Health, United States, 2007. (With chartbook on trends in the health of Americans.) Hyattsville, MD: U.S. Government Printing Office; 2007. DHHS Publication No. 2007-1232:40-41, 104. Available at: http://www.cdc.gov.proxy-hs.researchport.umd.edu/nchs/ data/hus/hus07.pdf. Accessed July 17, 2008. 2. Ogden C, Carroll M, Curtin L, McDowell M, Tabak C, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549. 3. Must A, Spadano J, Coakley EH, Field AE, Colditz G, et al. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523-1529. 4. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8-27. 5. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003;289:187-193. 6. Lakdawalla DN, Goldman DP, Shang B. The health and cost consequences of obesity among the future elderly. Health Aff. 2005;24:W5R30-41. 7. Wee CC, Phillips RS, Legedza AT, et al. Health care expenditures associated with overweight and obesity among US adults: importance of age and race. Am J Public Health. 2005;95:159-165. 8. Jia H, Lubetkin EI. The impact of obesity on health-related quality-of-life in the general adult US population. J Public Health. 2005;27:156-164. 9. Tyler C, Johnston CA, Fullerton G, Foreyt JP. Reduced quality of life in very overweight Mexican American adolescents. J Adolesc Health. 2007;40:366368. 10. National Heart, Lung, and Blood Institute. National Heart, Lung, and Blood Institute: Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults: Executive summary. Rockville, MD: National Institutes of Health; 1998. Available at: http://www.nhlbi.nih.gov. proxy-hs.researchport.umd.edu. Accessed November 20, 2007. 11. Fuemmeler BF, Baffi C, Mâsse LC, Atienza AA, Evans WD. Employer and healthcare policy interventions aimed at adult obesity. Am J Prev Med. 2007;32:44-51. 12. Andersson P, Sjoberg RL, Ohrvik J, Leppert J. Knowledge about cardiovascular risk factors among obese individuals. Eur J Cardiovasc Nurs. 2006;5:275-279. 13. Burton S, Creyer EH, Kees J, Huggins K. Attacking the obesity epidemic: the potential health benefits of providing nutrition information in restaurants. Am J Public Health. 2006;96:1669-1675. 14. Irani J, Abell R. Awareness of body weight status among family medicine clinic patients. J Okla State Med Assoc. 2007;100:139-143. 15. Lynch CS, Chang JC, Ford AF, Ibrahim SA. Obese African-American women’s perspectives on weight loss and bariatric surgery. J Gen Intern Med. 2007;22:908-914. 16. Maynard LM, Serdula MK, Galuska DA, Gillespie C, Mokdad AH. Secular trends in desired weight of adults. Int J Obes. 2006;30:1375-1381. 17. Little P. GP documentation of obesity: what does it achieve? Br J Gen Pract. 1998;48:890-894. 18. Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? [see comment]. JAMA. 1999;282:1576-1578. 19. Simkin-Silverman LR, Gleason KA, King WC, et al. Predictors of weight control advice in primary care practices: patient health and psychosocial characteristics. Prev Med. 2005;40:71-82. 20. Stafford R, Farhat J, Misra B, Schoenfeld D. National patterns of physician activities related to obesity management. Arch Fam Med. 2000;9:631-638. 21. Block JP, DeSalvo KB, Fisher WP. Are physicians equipped to address the obesity epidemic? Knowledge and attitudes of internal medicine residents. Prev Med. 2003;36:669-675.
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22. Anderson DA, Wadden TA. Bariatric surgery patients’ views of their physicians’ weight-related attitudes and practices. Obes Res. 2004;12:15871595. 23. Trus TL, Pope GD, Finlayson SR. National trends in utilization and outcomes of bariatric surgery. Surg Endosc. 2005;19:616-620. 24. Avidor Y, Still CD, Brunner M, Buchwald JN, Buchwald H. Primary care and subspecialty management of morbid obesity: referral patterns for bariatric surgery. Surg Obes Relat Dis. 2007;3:392-407. 25. Balduf L, Farrell T. Attitudes, beliefs, and referral patterns of PCPs to bariatric surgeons. J Surg Res. 2008;144:49-58. 26. Foster G, Wadden T, Makris A, et al. Primary care physicians’ attitudes about obesity and its treatment. Obes Res. 2003;11:1168. 27. Perlman SE, Reinhold RB, Nadzam GS. How do family practitioners perceive surgery for the morbidly obese? Surg Obes Relat Dis. 2007;3:428433. 28. Sansone RA, McDonald S, Wiederman MW, Ferreira K. Gastric bypass surgery: a survey of primary care physicians. Brunner-Mazel Eating Disorders Monograph Series. 2007;15:145-152. 29. Schuster R, Morton JM, Liu GY, Alami RS, Curet MJ. Attitude of prospective surgical residents regarding surgery for morbid obesity. Obes Surg. 2006;16:1464-1468. 30. Thuan JF, Avignon A. Obesity management: attitudes and practices of french general practitioners in a region of france. Int J Obes. 2005;29:11001106. 31. Maggard M, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547-559. 32. Buchwald H, Avidor Y, Braunwald E, Jensen M, Pories WJ, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-1737. 33. Colquitt J, Clegg A, Loveman E, Royle P, Sidhu MK. Surgery for morbid obesity. Cochrane Database of Systematic Reviews. 2007;1-75. 34. Cohen R. Controlling type 2 diabetes through surgery in non-morbidly obese patients. Obes Care News. 2008;2(2):22. 35. Craig BM, Tseng DS. Cost-effectiveness of gastric bypass for severe obesity. Am J Med. 2002;113:491-498. 36. Clegg A, Colquitt J, Sidhu M, Royle P, Walker A. Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation. Int J Obes Relat Metabolic Disorders. 2003;27:11671177. 37. van Gemert WG, Adang EM, Kop M, Vos G, Greve JW, et al. A prospective cost-effectiveness analysis of vertical banded gastroplasty for the treatment of morbid obesity. Obes Surg. 1999;9:484-491. 38. Bell SE. Current issues and challenges in the management of bariatric patients. J Wound Ostomy Continence Nurs. 2005;32:386-392. 39. Sadhasivam S, Larson CJ, Lambert PJ, Mathiason MA, Kothari SN. Refusals, denials, and patient choice: reasons prospective patients do not undergo bariatric surgery. Surg Obes Relat Dis. 2007;3:531-535. 40. Elmore BL, Phillips WT. Bariatric surgery coverage decision: opportunities and limitations. Health Care Financ Manage. 2006;60:52-54. 41. Flum D, Khan T, Dellinger EP. Toward the rational and equitable use of bariatric surgery. JAMA. 2007;298:1442-1444.
Shannon Reedy, MS, CRNP, is a clinical instructor at the University of Maryland School of Nursing in Baltimore. She can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/08/$ see front matter © 2009 American College of Nurse Practitioners doi:10.1016/j.nurpra.2008.01.017
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