Monday, May 14, 2018            

The following is a summary/brief analysis of the obesity and surgery stories making news this week:

Lack of Insurance Coverage Restricts Access to Bariatric Surgery in States with Highest Prevalence of Obesity…Bariatric Surgery May be Linked to Mental Health Issues in Some Teens…More Obesity Medicine Specialists, Bariatric Surgery Centers Offering Behavioral Therapy…Bariatric Surgery Beats Meds for Treating Teens’ T2D…One Woman’s Gastric Bypass Success Story…Treat Obesity Just Like Other Chronic Diseases…People with Diabetes and Obesity More Prone to Stress, Study Suggests…Obesity Increases Risk of Heart Rhythm Disorder

Metabolic and Bariatric Surgery in the News…

The Obesity Cure Is Out of Reach in the Heaviest States (The Atlantic)

Mississippi, the state with the second highest prevalence of obesity in the U.S., is one of two states, along with Montana, that doesn’t cover bariatric surgery in its Medicaid program. Even though bariatric surgery has been shown to halve the risk of death for people with obesity, insurance companies treat the procedure “less like a life-saving treatment and more like a nose job: frivolous and optional.” According to ASMBS, the article notes, many states don’t cover the procedure in their employee, Obamacare, or Medicaid plans, including South Carolina where there is no coverage for Obamacare enrollees or state employees, and Arkansas, the state with the third highest prevalence of obesity, where there is no coverage for Obamacare enrollees. “Even in a state where there’s technically coverage, there are so many barriers to getting surgery, it’s like not having coverage at all,” says Scott Kahan, the director of the National Center for Weight and Wellness in Washington, D.C. In some states, surgery candidates must lose weight before they qualify, while in others, the weight loss is recommended, but optional. Other states require a six-month waiting period. According to ASMBS, Aetna requires bariatric surgery candidates not to gain any weight during the three-month preoperative phase—something that’s challenging for individuals whose biggest problem is that they gain weight uncontrollably. In part because of these hurdles, only a small number—about 1 or 2 percent— of people who qualify for bariatric surgery actually get the operation. John Scott, MD, a bariatric surgeon in Greenville, South Carolina and the Access to Care chairman at ASMBS, says many people in his state go to Mexico for bariatric surgery, where the procedure is thousands of dollars cheaper but is sometimes performed poorly. “We’ve had patients come back from Mexico with leaks and infections from poorly performed surgery. The state washes their hands, from an insurance perspective, and the patient is on the hook for whatever expenses [arise] from the complication,” added Dr. Scott. “The interests of surgeons and patients align, from a medical perspective,” the article notes. To Dr. Scott, the lack of bariatric surgery coverage suggests that outdated ideas about obesity—like the notion that people bring it on themselves—die hard. “Obesity is the last acceptable bastion of discrimination in this country, and people who deal with obesity get treated like dirt,” Dr. Scott says. “That’s reflected in these insurance plans.”

Some Teens May Have Mental Health Issues After Weight-Loss Surgery

Adolescents may develop new or worsening mental health problems after weight loss surgery, particularly those who already had symptoms at the time of the procedure, according to a study published online in the Journal of Adolescent Health. Researchers followed the psychological health of 139 adolescents with severe obesity undergoing bariatric surgery and 83 similar teens treated without surgery, and found that after two years, roughly one in three kids had some mental health problem, such as depression, anxiety or behavioral disorders. About 9 percent of the surgical patients had worsening of their psychological symptoms from the start of the study period compared with about 6 percent of nonsurgical patients. However, for nearly 19 percent of surgery patients and 25 percent of nonsurgical patients, mental health symptoms were reduced after two years. The results suggest that a “notable minority” of adolescents do have mental health issues and, like any condition that doesn’t go into remission after bariatric surgery, such as high blood pressure or blood fats, continued monitoring and treatment is “warranted,” the authors wrote. While bariatric surgery is safe and effective for adults, adolescence is normally a tumultuous time, says John Morton, chief of bariatric and minimally invasive surgery at Stanford University Medical Center and Past President of the ASMBS, who wasn’t involved in the study. “We’re very careful about the adolescent patients we pick and are careful with their follow up. They have to be mature enough to give consent and have to have a very stable and supportive home situation. If not, it makes things more difficult.” When adolescents lose weight, they might have adjustment problems because they haven’t been socially accepted by their peers before, Morton notes. “When someone is obese they’re ostracized and don’t fit in.” They’ll need resiliency and coping skills to eat well and socialize “otherwise these kids may fall into bad habits,” he adds.

Should You Try Therapy for Weight Loss? (U.S. News & World Report)

Obesity medicine specialists and other healthcare providers are increasingly focusing on the link between weight and mental health, encouraging patients to develop healthier thought patterns through cognitive behavioral therapy (CBT), a form of talk therapy that emphasizes how thoughts drive behavior. According to the article, weight loss facilities, including bariatric surgery centers, are also increasingly adding licensed clinical psychologists to their staffs, and dedicated binge eating, and emotional eating therapy practices have opened throughout the country. Recently, the American Diabetes Association and the American Psychological Association partnered to build the ADA-APA Mental Health Provider Diabetes Education Program to teach mental health professionals how to best care for patients with diabetes. Jennifer Shapiro, a licensed clinical psychologist, says, "Many people who are overweight or obese also experience depression, low self-esteem, binge eating disorder and other psychological disorders." Between 15 and 25 percent of patients receiving bariatric surgery suffer from binge eating disorder, according to Shapiro. Weight stigma is another threat to mental health in those who have overweight or obesity, adds Dr. Jennifer Seger, an obesity medicine specialist at the Bariatric Medical Institute of Texas, which is among the majority of bariatric surgery centers that require patients undergo psychological testing to be approved for weight loss surgery.

Is Bariatric Surgery the Best Option for Diabetic Teenagers? (Medical News Bulletin)

When comparing the progression of type 2 diabetes in teenagers with obesity treated with either medication or bariatric surgery, researchers found that surgery improved the control of diabetes better than medication alone, in a study published in JAMA Pediatrics. The study compared 30 teenagers who had bariatric surgery, and 63 teenagers who were treated non-surgically. Overall, the glycated hemoglobin decreased in the group of teenagers that had surgery and the glycated hemoglobin of patients who didn’t have surgery actually increased, demonstrating a deteriorating control of their type 2 diabetes. Additionally, the patients who had bariatric surgery showed more improvement in other complications that can occur with type 2 diabetes, such as high blood pressure. The researchers say it is becoming apparent that teenagers with type 2 diabetes show a faster progression of disease than adults and as a result bariatric surgery should be performed sooner rather than later to slow down the progression of the disease and the associated complications.

Woman Shares How Bariatric Surgery Helped Her Become a Marathoner
(Sleep Review)

Story profiles Shirley Bearden, a nurse who once had trouble walking even short distances because of her weight. Bearden had a BMI of 48, diabetes, high blood pressure and sleep apnea when she had gastric bypass surgery in 2010. In the process of losing 160 pounds, Bearden wanted to get in better physical shape. Two years after surgery, she was running in races and to date has completed almost 30 half marathons and eight marathons. “To go from being short of breath after walking to my mailbox to running 26.2 miles in a marathon is amazing,” says Bearden. “I cried so hard after I finished my first half marathon and first marathon because they are accomplishments I never saw in my future before
bariatric surgery.”

Obesity in the News…

Obesity Is a Disease, Not a Choice, Experts Advise (Medscape)

Effective weight management requires a paradigm shift in the way healthcare professionals treat obesity, according to Lee Kaplan, MD, PhD, director of the Obesity, Metabolism and Nutrition Institute at Massachusetts General Hospital in Boston. In his presentation at the Pediatric Academic Societies 2018 meeting, Dr. Kaplan told delegates, “obesity is a disease,” and must be treated with pathophysiologic processes, just like type 2 diabetes and other chronic diseases. Like diabetes, obesity is never "cured," patients can "still have the disease of obesity, even though they no longer meet the definition of obesity by our measurements," Dr. Kaplan explained. Physicians who treat obesity often take a history to identify triggers for eating, exercise patterns, stress levels, sleep patterns and related circadian rhythm imbalances, and any drugs that can promote obesity. "We take that history in detail and then we say to the patient, 'eat less and exercise more'," with little understanding of the biologic basis of obesity or its heterogeneity. The body defends a fat mass just like it defends a mass of red blood cells, Dr. Kaplan explained. Since obesity is a pathophysiologic state, the treatments used to modify this state need to be physiologic in nature to drive down the elevated fat-mass set point that propels people to overeat, Dr. Kaplan explained. Currently, treatments for obesity include a healthy diet, exercise, stress reduction, improved sleep health and the re-establishment of normal circadian rhythms, antiobesity medications that promote weight loss, and bariatric surgery. However, there is an enormous variability each antiobesity intervention, according to Dr. Kaplan, who, along with his team, is exploring the potential of a genetic risk score to help determine the likelihood of an individual's response to a particular therapy.

Are People with Diabetes, Obesity Predisposed to Stress? (Medical News Today)

Insulin resistance may contribute to rendering people with obesity and diabetes more prone to stress, according to a new study published in Psychosomatic Medicine. Researchers analyzed 331 adults participants’ "startle response," which is defined as an involuntary defensive reaction to a stimulus that is automatically perceived as potentially dangerous. Each study participant was shown a series of images with negative, positive, or neutral content, with the aim of triggering an emotional response. At the same time, researchers tested the participants’ involuntary responses using an electroencephalogram (EEG) to measure activity in the central nervous system. People with diabetes had more intense startle responses than people without diabetes. Those with type 2 diabetes or prediabetes also had more activity in the right half of their brains – an overactive right hemisphere has been associated with depression and negative moods – and had low cortisol levels, which is a possible sign of chronic stress.

Obesity Might Raise your Risk for A-fib (HealthDay via Medical Xpress)

People with obesity have a 40 percent higher risk for the heart rhythm disorder atrial fibrillation (A-fib), according to a study published in the American Journal of Cardiology. The study included more than 67,000 U.S. adults with an average age of 44; half of the participants had obesity. During the eight-year follow-up, 2.7 percent of the participants with obesity developed A-fib compared with 1.8 percent of those didn’t have obesity. "If you have both atrial fibrillation and obesity, treating obesity will go a long way in treating and managing your atrial fibrillation," says study author Dr. Andrew Foy, assistant professor of medicine at Penn State College of Medicine. "And if you have obesity, and lose weight through diet, exercise, or even surgery, that will help reduce your risk of developing chronic conditions like atrial fibrillation." Dr. Foy suggests the added strain in hearts of patients with obesity may be the reason they're at an increased risk for A-fib.