Obesity in the News

Published in July 2013 Issue             

Medicare and Certification...Diabetes Remission and Gastric Bypass...Celebrity Chef Has Gastric Sleeve...Metabolic or Bariatric Surgery?...Healthgrades Comes Out with Report...Living Longer, But Not Necessarily Healthier...New Findings from NIH Study on Cardiovascular Health...Curing Obesity with Surgery...How Much Weight is from Genetics?

Medicare May Scrap Certification for Bariatric Surgery Centers
(Clinical Endocrinology News)

In an interview with Clinical Endocrinology News, Dr. Jaime Ponce discusses the importance of retaining the certification requirement under CMS for hospitals performing metabolic and bariatric surgery. Dr. Ponce states that ASMBS plans to fight the "dangerous" CMS proposal to drop certification completely. "We do believe that this could be very harmful for Medicare patients because if a patient that is very sick shows up in a community hospital that doesn’t have the right structure to take care of obese patients... accidents are going to start happening again." Dr. Ponce cites studies supporting accreditation including the 2011 Annals of Surgery study that evaluated mortality among Medicare patients before and after the certification requirements took effect showing mortality, readmission, and reoperation rates all declined after the coverage decision was implemented. He notes the ASMBS, along with the American College of Surgeons, is working to create a single, unified program that will include a lower volume threshold for certification, dropping from a minimum of 125 cases a year to 50. Dr. Ponce also addressed potential detriments in safety and cost-effectiveness that could result from the removal of the requirement, noting without clear requirements in place, “hospitals will be unlikely to make the investments they are making today in equipment, personnel, and training.”

Gastric Bypass Patients Often Relapse After Diabetes Remission
(Gastroenterology & Endoscopy News)

A study in Obesity Surgery found that, of patients who initially experienced complete remission, 35.1 percent redeveloped diabetes within five years. When the patients who never remitted and those who relapsed were added together, more than half of the patients (56%) did not have durable remission of diabetes. However, there was evidence that patients who received earlier surgical intervention for their diabetes might have better outcomes. “What’s new and different [about this trial] is that we focused on relapse of diabetes after patients have remitted,” said Dr. David E. Arterburn, associate investigator, Group Health Research Institute, Seattle, and lead researcher on the study. “We followed them longer—beyond their initial remission—and found that by five years, 35 percent of patients had redeveloped diabetes. No prior studies have examined this question on this scale.”

The study included 4,434 adults. Overall, 68.2 percent (95% confidence interval [CI], 66%-70%) had complete diabetes remission within five years postsurgery. Among these, 35.1 percent (95% CI, 32%-38%) redeveloped diabetes within five years. The median duration of remission was 8.3 years (3,019 days; 95% CI, 2,507-3,281 days). Factors significantly associated with higher relapse rate included longer diabetes duration, insulin use and poor preoperative glycemic control (hemoglobin [Hb]A1c ≥6.5%).

Dr. Ponce commented, “The biggest message is early intervention in diabetic patients with obesity.” Evaluate them for bariatric surgery at BMI of 35 [kg/m2], and at 30 to 35 with diabetes requiring more medications.” Limitations of the study noted by Dr. Ponce included not looking at results per variations in technique of bypass, and not having sufficient data to analyze differences in outcomes by race or ethnicity. Dr. Philip Schauer noted the low five-year retention rate of 67.8 percent of the study. “They’re missing a lot of patients at the five-year mark,” he said. “We would like to see retention rates of 80% to 90%.”

Additionally, Dr. Schauer said, “Because patients who had earlier disease achieved a higher percentage of long-term remission, physicians and patients should consider earlier intervention”—within five to 10 years of diagnosis. If they wait until their diabetes is more advanced, they’ll have less of a chance for long-term remission.” He added, “the real value of surgery is not just in achieving remission in some patients, which is remarkable, but its ability to substantially improve even those patients who don’t achieve remission.”

Graham Elliot Undergoes Weight Loss Surgery (People Magazine)

MasterChef TV show judge Graham Elliot, 36, had a sleeve gastrectomy after hitting nearly 400 pounds. In an interview with PEOPLE, the reality TV star commented, "Weight is something I've battled all my life. It's hard to get in and out of a car, tie my shoe or play with my kids. This is what I need to do for my family.” Elliot explained that he’s mulled over having some form of weight loss surgery since 2005, but ultimately made the decision after speaking with his doctor earlier this year, saying "it was a relief that somebody was helping me make this decision and stick with it. It's like I'm somebody who is way past their prime and that shouldn't be the case at 36. Throw in gout and high blood pressure and the history of strokes and heart attacks in my family... this is something that has to happen… What's going to make me healthy is the most important thing right now." Elliot also explained that prior to surgery he met with a nutritionist and psychologist, and switched to a daily 1,000-calorie diet consisting mostly of broth and protein shakes. He added that his culinary career was a major consideration in his choice of bariatric procedure, "Because of my line of work, the doctor specifically thinks this is the surgery best suited for me. With gastric bypass and other surgeries, there's some ingredients you can't eat because it will cause you to get sick. This procedure will allow me to still taste and try everything.”

Metabolic Therapy or Bariatric Surgery: What’s in a Name? (General Surgery News)

Dr. Francesco Rubino is proposing the creation of a new surgical specialty called gastrointestinal (GI) metabolic surgery – an operation with the primary intent to treat diabetes and metabolic disease – separating the procedure from bariatrics, which would be reserved for patients who require surgery to address physical complications of excess weight but have no metabolic disease. The suggestion is based on results of Dr. Rubino’s study, published in the Annals of Surgery, which showed billing a surgical procedure as a metabolic therapy rather than as a weight loss surgery attracted patients who were markedly different from typical bariatric surgery candidates. At New York’s Weill Cornell Medical College, where two departments offer bariatric surgery, patients treated in the metabolic program were older by four years (45.8 vs. 41.8), had a lower BMI (42.4 vs. 48.6) and were more likely to have diabetes (62% vs. 35%), hypertension (68% vs. 52%), dyslipidemia (48% vs. 31%) and cardiovascular disease (14% vs. 5%). Additionally, men accounted for 42 percent of the metabolic surgery population compared with 26 percent of the bariatric cohort. Dr. Rubino noted that the term “bariatric surgery” significantly influenced the selection of surgical candidates, “a result, perhaps, of the fact that the name and focus on weight loss results is more attractive to relatively healthy young females than older men.”

Dr. Stacy Brethauer, of the Cleveland Clinic, who was not involved in the study, noted that many programs have adopted both terms. “Over time, some programs may remove ‘bariatric’ from their title. We have to remember that many obese patients don’t have diabetes or metabolic disease and are pursuing the surgery for weight loss. Using both terms is the most inclusive approach and will attract both types of patients.”

Healthgrades Bariatric Surgery Report 2013 Evaluates Hospitals Performing Obesity Surgery in the U.S. (PR Newswire)

Healthgrades, an online resource that helps consumers search and compare physicians and hospitals, released its “Bariatric Surgery Report 2013: Your Choices Influence Your Outcome,” which assesses the performance of hospitals performing surgery in the U.S. The survey examined hospitals performing vertical sleeve gastrectomy, LAGB and LGB in an effort to provide consumers with information that better ensures the “likelihood” of them having a “safe bariatric surgery experience.” The report analyzed clinical outcomes of 204,069 bariatric surgery discharges from 467 hospitals in 18 states from 2009 through 2011 to develop its analysis on each hospital’s performance in relations to risks and complications. The report noted out of the hospitals evaluated, 120 (25.7%) received a five-star rating and these hospitals had a 71 percent lower complication rates than 1-star hospitals. If all hospitals had performed at the level of hospitals with five-stars, 6,417 patients could have potentially avoided a major in-hospital complication.

Americans Living Longer But Not Necessarily Healthier
(The Wall Street Journal, ABC News)

According to a new report published in Population Health Metrics, University of Washington's Institute for Health Metrics and Evaluation researchers found Americans are exercising more, but that has not done much to slim their waistlines, “underscoring the immense challenge confronting health advocates fighting the nation’s obesity crisis.” In more than two-thirds of the nation’s counties people became more physically active over the last decade, with women making “notable progress nationwide, with the percentage who got sufficient weekly exercise jumping from 46.7% to 51.3%.” The percentage of physically active men ticked up a point to 57.8 percent. But researchers concluded these improvements have done little to reduce obesity, reporting that between 2001 and 2009, obesity rates for men or women fell in just nine counties. National rates climbed throughout the decade, although some recent evidence suggests obesity rates may no longer be rising. ”There has been a lot of progress on physical activity,” said Dr. Christopher Murray, lead author of the research. “To tackle obesity, we need to do this. But we probably also need to do more… Just counting on physical activity is not going to be the solution.”

Large NIH Trial Finds No Cardiovascular Benefits For Weight Loss And Exercise In Type 2 Diabetics (Forbes, The Wall Street Journal, CBS News)

NEJM published results of the “Look AHEAD” (Action for Health in Diabetes) study, presented recently at the American Diabetes Association meeting, which demonstrated intensive lifestyle intervention was no better than standard nutrition and exercise counseling in reducing cardiovascular events in obese patients with Type 2 diabetes. However, weight loss from both methods resulted in a decrease in the development of chronic kidney disease, a risk of having Type 2 diabetes.

Weight-Loss Surgery: A Cure for the Morbidly Obese? (US News)

The benefits of bariatric surgery are touted in this article reporting on the various methods of surgery. One of Dr. Brethauer's patients is featured in the story. After surgery, the patient's asthma, sleep apnea and blood pressure problems have all disappeared. "All of my health issues have completely reversed, every single one of them." Dr. Brethauer comments that surgery is a tool and that, "you can't just do the surgery alone and expect to have good long-term outcomes." As Dr. Brethauer explains, only once patients have the surgery can they then get healthy through diet and exercise. "Once people reach a certain point in terms of their weight and comorbidities," or related disorders, "diet and exercise alone is ineffective," he says. ASMBS fact sheets on the safety and effectiveness of surgery are referenced throughout the article.

New Genes IDd in Obesity: How Much of Weight is Genetic? (TIME)

A new study published this week examined genetic factors that could explain weight gain in some people. The discoveries add to the growing body of knowledge about the biology behind weight, and according to TIME, the results confirm that weight is the complex combination of a multitude of different metabolic processes. A study conducted by researchers at Boston Children’s Hospital examined a genetic mutation in mice that can cause weight gain without overeating by preventing the body from burning off fat calories. When the gene, Mrap2, was “silenced” in mice, their food intake had to be reduced by 10 to 15 percent to keep weight gain as low as normal mice. The results of the study were published in the journal Science, where the authors noted an analysis of 500 people found the equivalent human gene mutation in four people with severe, early onset obesity. The study suggests the body’s mechanisms for energy use and weight gain among some obese people may be different than among skinnier peers.

A team based at University College London reported in Journal of Clinical Investigation that a specific form of a gene previously linked to obesity, FTO, can increase craving for high-fat foods. In a study of nearly 400 men, 45 had mutations of the FTO gene, which may result in greater appetite and caloric consumption. FTO gene mutation was shown to be associated with higher levels the “hunger hormone ghelin” and men with the mutated form of FTO did not show the same drop in ghelin levels, which signifies a felling of fullness.