The news that there may be two million people in England eligible for obesity surgery will come as no surprise to those of us working in the field. Despite armies of NHS dieticians and any number of government-sponsored public health initiatives, the proportion of those with serious weight problems in the population continues to rise.
Well meaning public health specialists keep banging the same old drum about the need for a holistic approach to treatment; reducing energy intake and increasing energy expenditure through physical activity. Unfortunately this approach doesn’t work. We have had almost five decades of trying to get (almost) the entire nation to lose weight and become more active and five decades of abject failure. Drawing a parallel between the success of smoking cessation initiatives and getting 60% of the population to lose weight, is simply naive. Smoking is a discretionary activity, eating is not.
Unpalatable though it may be to some, the only effective long-term treatment for chronic obesity, is surgery. Historically, the National Institute for Health and Clinical Excellence (NIHCE) has offered surgery to patients who have certain Body Mass Index (BMI) criteria, in combination with so-called “co-morbidities” – hypertension, arthritis etc. The problem with this approach is that BMI discriminates unfairly on the basis of age, ethnicity and gender. It is, quite simply, a very poor indicator of risk, yet NIHCE persists in using it to the detriment of many who would benefit from surgery.
We need to increase the number of surgical procedures offered to obese patients most at risk of premature death and disability. If the government wants to spend whatever money it is willing to allocate to this problem as cost-effectively as possible, I would suggest they focus on obese patients with type 2 diabetes. Among other things, it is a disease which afflicts a large number of people who are in regular employment and are economically productive.
Weight loss surgery has been shown to improve diabetic control, reduce the need for diabetic medication and, in many cases, completely cure the disease. It reduces the risk of diabetic complications such as blindness, nerve damage and kidney disease and, in the longer term, reduces the risk of premature disability and death. There are plenty of excellent studies to show that concentrating resources on this group is a “best buy” in terms of prevention.
So my advice to the government is to wake up to the problem and to stop wasting time and money on treatments that are obviously useless. Increase the number of surgical procedures, but in the first instance prioritise the (around 100,000) diabetics within the obese population. If we could build up to 20,000 procedures a year over the next 5-years, it would make a huge difference to a group of people at very high risk. Furthermore it will probably more than pay for itself in terms of a reduced use of expensive diabetic drugs and treatments for kidney failure and heart disease. The time for hand-wringing is long over. It’s now time to do something that works.
Dr David Ashton MD PhD
17th January 2014