The Journal for Nurse Practitioners
Volume 5, Issue 1 , Pages 22-29, January 2009

An Evidence-Based Review of Obesity and Bariatric Surgery

  • Shannon Reedy

      Affiliations

    • Shannon Reedy, MS, CRNP, is a clinical instructor at the University of Maryland School of Nursing in Baltimore. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.

Article Outline

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 

Obesity has reached epidemic levels in the United States. During the 1960s through 1980, less than 50% of American adults were considered overweight or obese.1 In 2003-2004, that number rose to two thirds of the population. Alarmingly, during that same time, 32.2% of adults were actually considered obese.2 Although not a statistically significant increase, that number again rose in 2005-2006 to 34.3%.1 During 2003-2004, the prevalence of extreme obesity or body mass index (BMI) ≥ 40 kg/m2 was approximately 15 million Americans.2

Obesity has been linked to numerous chronic health conditions including hypertension, hyperlipidemia, sleep apnea, type 2 diabetes, and heart disease.3 Obesity-associated conditions significantly increase hospital length of stay, mortality, and overall health care costs.4 A 2003 study found that obesity causes a marked decrease in life expectancy. A 20-year-old white male with a BMI > 45 kg/m2 is estimated to have 13 years of life lost compared to an age and race matched male with a BMI of 24 kg/m2.5 A 20-year-old black male with a BMI > 45 is estimated to have 20 years of life lost when compared to an age- and race-matched male with a BMI of 24.5 Lakdawalla et al6 found that after age 70, Medicare spends 35% more on obese patients than their normal-weight counterparts. It costs an estimated $1400 more per year to care for an obese individual than one of normal weight.7 In addition, there are a multitude of adverse psychosocial aspects of obesity such as alterations in well-being, quality of life, and social stigmatization.8, 9 A leading cause of preventable death, obesity needs to be treated as a chronic health condition by primary care providers.

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Obesity Diagnosis and Management Guidelines 

In May 1995, the National Heart, Lung, and Blood Institute's (NHLBI) Obesity Education Initiative, in cooperation with the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), convened an expert panel to develop evidence-based guidelines for primary care management of obesity. Subsequently, in 1998, the NHLBI published clinical guidelines on the identification, evaluation, and treatment of overweight and obese adults. A systematic review of 394 randomized controlled trials (RCT) was conducted to determine the best evidence regarding obesity management. The panel recommendations were based on evidence that links obesity to increased mortality and evidence that weight loss reduces risk of developing obesity-related disease. The guidelines include an assessment and treatment guide, and are currently being updated, with a proposed publication date in 2009.

According to the guidelines, assessment of the patient should include BMI, waist circumference, and analysis of risk factors. BMI is weight in kilograms divided by height in meters squared, and is routinely used to define obesity. Adults with a BMI > 25 are considered overweight and those with a BMI > 30 are considered obese. Table 1 details the diagnostic classifications for weight based on BMI.10 Waist circumference of > 40 inches in males and 35 inches in females is an independent risk factor for obesity-related complications in patients with BMI of 25 to 34.9.10 In addition, risk factors for potential obesity-related mortality and morbidity should be determined. The presence of disease conditions or risk factors such as type 2 diabetes, sleep apnea, hypertension, and physical inactivity increase the patient risk of obesity-related sequelae. This increased risk status should lower a practitioner's threshold for initiating weight loss treatment. All patients with a BMI of ≥ 30 or patients with a BMI of ≥ 25 with a waist circumference risk factor or ≥ 2 other risk factors should be assisted with developing weight-related goals and treatment.

Table 1. Classification of Obesity
NIH ClassificationBMI (kg/m2)
Underweight< 18.5
Normal weight18.5–24.9
Overweight25.0–29.9
Obesity (Class 1)30.0–34.9
Obesity (Class 2)35.0–39.9
Extreme obesity (Class 3)> 40.0

The treatment algorithm begins with diet therapy, behavioral therapy, and physical activity and includes consideration of pharmacotherapy and bariatric surgery.10 Diet therapy should consist of a 500 to 1000 calorie daily deficit by reduction of both fat and carbohydrate. Physical activity should be initiated in all patients and should progress to reach 30 minutes on most days of the week. Behavioral therapy should ideally be combined with diet and exercise and include strategies for compliance. Pharmacotherapy should be considered in patients with BMI ≥ 27 with risk factors and in those with BMI ≥ 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 ≥ 40 kg/m2 or a BMI of ≥ 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.

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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, 12, 13, 14, 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, 19, 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 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.

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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 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 those search criteria. Articles were excluded if they were any of the following:

1.A commentary or a letter to the editor

2.A review article or an article describing publication elsewhere

3.A survey pertaining solely to attitudes regarding obesity as a disease not bariatric surgery

4.A survey solely of bariatric surgeons' attitudes on types of bariatric surgery

5.A survey of patients' perceptions of provider attitudes

6.A survey of patients' attitude after bariatric surgery

Of the 78 articles retrieved, 70 were excluded. Of the remaining 8 articles, 7 were related to provider attitudes and 1 was related to patient attitudes.

Lynch et al15 published a qualitative study of African American female patient attitudes toward obesity and bariatric surgery. The findings showed that the participants felt that they had lack of time and resources for weight loss, described a feeling of lack of control regarding food, and identified with a larger body image. They had fears and concerns about bariatric surgery and felt that it was too extreme. Patients perceived bariatric surgery as an extreme measure that should only be used in life or death situations.

Avidor et al24 completed a study on 478 physicians in 6 specialty areas. They found that only 15.4% of their sample stated that they prescribed bariatric surgery as a treatment for their morbid obese patients. Seventy-one percent had referred a patient within the last year for bariatric surgery, but 46% of them stated that the referral was typically prompted by the patient. The top 2 reasons that they did refer patients for surgery were to achieve maintenance of weight loss (40.3%) and for reduction of comorbidities (26.9%). Sixty percent of participants listed surgical risk as the major disadvantage of surgery, followed by 25% listing long-term complications such as weight regain, dumping syndrome, and other side effects. Thirty-seven percent of participants indicated that they did not refer patients because they were unacquainted with a local surgeon. The remaining reasons for not referring, listed in order from highest response rate, were lack of patient interest, their morbidly obese patients do not meet the criteria, amount of “legwork,” preference to treat patients themselves, not believing in referral to bariatric surgeons, and that most of their patients meeting the criteria would not benefit from the surgery long-term. The participants believed that bariatric surgery was effective long-term for 49% of their patients who had had bariatric surgery. On a 5-point Likert scale, the respondents averaged 2.9 in regard to their familiarity to the National Institutes of Health (NIH) guidelines. The incongruence between the perceived success rate and the reported prescription of bariatric surgery is noteworthy. Nearly 50% report it as effective for their patients, yet only 15% prescribe it.

In Balduf and Farrell's25 survey of 611 family practitioners and internists, 84% of participants felt they had been unsuccessful at helping severely obese patients lose weight, yet only 76% had referred at least 1 patient for bariatric surgery. Of those 76%, 53% stated that the referral was prompted by the patient. Eight-two percent of the participants had patients who had requested referrals to bariatric surgeons. Thirty-five percent felt that they did not have adequate resources to care for bariatric patients and only 45% felt competent to deal with the medical complications of bariatric surgery. Eighty-five percent had cared for a patient who had had bariatric surgery within the past year. Forty-four percent incorrectly believed that the mortality rates for bariatric surgery were 3% to 4%. Only 12% reported having read the NIH guidelines regarding treatment of obesity. Forty-six percent of the participants completed a CME on bariatric surgery within the past year.

Foster et al26 surveyed 5000 family physicians regarding attitudes on obesity. The survey also questioned the participants regarding whether or not they would recommend evaluation by a bariatric surgeon in patients with a BMI of 40 kg/m2 and comorbidities. Only 23% of the respondents said they would recommend an evaluation.

Of the respondents to a survey of 620 family physicians by Perlman et al,27 85% had referred patients for gastric bypass (GBP). Fear of complications and perceived high death rate were given as the primary reasons for not referring patients for surgery. Thirty-five percent of the participants did not refer patients because they believed that their patients would be unable to follow the postoperative lifestyle. Six percent believed that obesity was best controlled by surgery. Most physicians were able to correctly state BMI criteria for surgery, but many incorrectly stated estimated weight loss by GBP. Seventy-seven percent underestimated weight loss while 8% overestimated weight loss. Sixty-three percent would refer themselves or family members to a bariatric surgeon if needed.

In their survey of 246 internal medicine, family medicine, and obstetrics/gynecology medical staff, Sansone et al28 reported data on attitudes of providers regarding GBP surgery. Eighty-four percent of the participants would recommend GBP for morbidly obese patients and 22% of them felt that it was the only effective means for treating morbid obesity. Female providers were statistically less likely to refer patients for surgery than males. Only 77% of them felt that patients were screened appropriately for surgery and 63% felt that surgery is overutilized in the medical community today. Sixty-nine percent of them believed that GBP patients seem to have a high rate of postoperative complications, but 64% of them felt that GBP saves society money in the long run.

Schuster et al29 surveyed 61 medical students regarding their attitude toward obesity and bariatric surgery. Forty-four percent indicated that they would consider a career in bariatric surgery and 70% stated they would consider performing bariatric surgery as part of their practice. Eighty-nine percent of those surveyed would recommend bariatric surgery to a family member and 77% would have surgery themselves if needed, possibly indicating that current medical education has increased its emphasis on obesity and obesity treatment.

Thuan and Avignon30 examined views regarding bariatric surgery in a survey of 744 French general practitioners on obesity management. Eighty-nine percent of the respondents felt that bariatric surgery should be considered only in exceptional cases. Eighty-seven percent felt that surgery should be restricted to patients who failed other treatments after 1 year of follow-up. Seventy-five percent felt that only a nutrition specialist should indicate whether or not a patient should have surgery. Seventeen percent either strongly agreed or agreed that surgery was the only option possible for obese patients to significantly reduce and maintain weight loss, while 26% strongly disagreed.

A synopsis of the literature shows mixed attitudes toward bariatric surgery. Patients perceive bariatric surgery as dangerous and an extreme measure.15 Between 71% to 85% of providers have referred patients for bariatric surgery, but 45.5% to 53% of the time, patients initiated the referral. Between 63% and 77% of providers/medical students would consider bariatric surgery themselves and between 63% and 89% of providers/medical students would refer a family member for surgery. The numbers of providers who would refer patients meeting criteria for surgery was much broader. Inconsistency was found among the respondents of the surveys and one study posed that this may be due to underlying ambivalence.28 In addition, there was a good deal of misinformation about bariatric surgery and a low percentage of providers had read or received education on bariatric surgery.25

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Use, Safety, and Efficacy of Bariatric Surgery 

The overall attitude of patients and providers toward bariatric surgery is inconsistent with research showing its use, efficacy, and safety. Bariatric surgical procedures include restrictive, malabsorptive, and combination techniques. The most commonly used restrictive procedure is laparoscopic adjustable gastric banding (LAGB). The vertical-banded gastroplasty is another restrictive procedure. Purely malabsorptive procedures are less commonly used and include the biliopancreatic diversion (BPD). The Roux-en-Y gastric bypass (RYGB) is a combination restrictive and malabsorptive procedure.

The most commonly performed bariatric surgeries in the United States are the RYGB and LAGB. Although the RYGB is the most commonly performed 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.

Table 2. Commonly Performed Bariatric Surgeries
Biliopancreatic Diversion with Duodenal Switch (BPD/DS)Laparoscopic Adjustable Gastric Banding (LAGB)Roux-en-Y Gastric Bypass (RYGB)
TypePrimarily MalabsorptiveRestrictiveCombined
DescriptionA 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.

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 ≤ 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 hypertension. 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 12-month follow-up, irrespective of weight loss, diabetes has resolved or improved in 78% of the patients.34

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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 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, 36, 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

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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 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.

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References 

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PII: S1555-4155(08)00401-7

doi:10.1016/j.nurpra.2008.07.017

The Journal for Nurse Practitioners
Volume 5, Issue 1 , Pages 22-29, January 2009

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