3/13/05njm

Summary of Discussion

SURGICAL TREATMENT OF OBESITY:

PRIMARY CARE ASPECTS

-Should the majority of your obese patients receive bariatric surgery
now, before they develop diabetes complications, or arthritis and
require multiple joint replacements?

-Is it time for Obesity Surgery in the IHS?

-How are primary care providers addressing the obesity epidemic now?

-Would non-surgical programs to address this issue be safer? easier?
more effective?

-Cost effectiveness\... what\'s cheaper? What about results?

-How is your facility going to be able to pay for all these bariatric
surgery procedures, and their complications?

**Here are some examples:**

32 yo mother of twins 10 days s/p Gastric bypass presents to her primary
care provider complaining of hiccups, feeling anxious, heart rate 105,
history of anxiety attacks and depression, has been unable to swallow
her Zoloft.

**How do we help her?**

You referred a 27 yo hypertensive diabetic male with a BMI of 41for
obesity surgery which he successfully underwent 7 months ago. He returns
to you having lost over 80 lbs. but now can hardly eat, he has daily
bouts of epigastric pain that can last for hours.

**What diagnostic test might be helpful?**

AG is a 39 y.o. American Indian diabetic female who weighed 450 lbs.
.....after bariatric surgery she developed chronic diarrhea and is now
taking several oral mineral supplements a day...

**How do we help her?**

**Other Background at end of document\* and online here**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SurgObes12705.doc>

and

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SumObe22805.doc>

**Discussion**

**Ann Racehorse <aracehorse@ABQ.IHS.GOV>**

**Wednesday, February 02, 2005 11:13 AM**

I am a social worker at the Albuquerque Indian Health center, having
worked with the development of an intervention program for the morbidly
obese. I receive referrals from physicians, nurses, clients or their
family members.

After an assessment and evaluation is completed, a treatment plan is
developed which includes University of New Mexico Hospital's (UNMH) Wt.
Loss class, stress management class, and walking class presented by the
Pt. Education Dept., referrals to private organizations or an assessment
of other health insurance programs for weight reduction. Our remaining
dietitian is now in the Diabetes program and I staff cases with her for
approval before I make referrals to her.

I have met with the nutritionist who worked with the gastric bypass
patients at UNMH several times to discuss patient issues. The UNMH
gastric bypass surgery is no longer offered due to the death rate and
ensuing lawsuits. There are several bypass patients who are seen at our
facility and have been successful with the surgery and weight loss, but
this is not always the case. I am also working with patients who were on
the waiting list for the surgery and are willing to wait for the
surgery. There are patients who do not want the surgery under any
circumstance and are successful working with a dietitian and an exercise
program. Mental health has agreed to work with patients around the
issues that impact weight and obtaining a healthy lifestyle.

On the pueblos that I provide service to, the Tribal diabetes programs
are the most helpful in developing and maintaining exercise programs,
healthy eating and weight loss. If this resource is used wisely it could
help Indian Health employees identify individuals who could benefit from
case management, mental health intervention, and wt. loss interventions.

To answer your questions:

No, not all obese Indian patients should be offered a surgical
intervention. From my understanding, in the long run, it is not as
expensive to have the gastric bypass surgery when successful as it is to
manage long term diabetes, cardiac issues, sleep apnea, and other
co-morbidities.

I am encouraging the primary care providers to make referrals to me
since we no longer have a nutritionist for patients unless they are
diabetic, I assist with referrals to Physical Therapy, Mental health,
patient education programs. There is also a 12 step program that was
started at our facility much along the lines of AA which is at no cost
to the participant, is a support group and has a food plan.

**Hope M Baluh (<Hope.Baluh@MAIL.IHS.GOV>**

**Wednesday, February 02, 2005 7:04 PM**

I\'m so glad to hear your area has a system in place. The publicity of
surgery as the treatment for obesity can be a disservice, if we do not
offer the basics of sound nutrition, exercise, and emotional support to
our patients. Many surgeons will mandate that patients lose a certain
amount of weight prior to surgery ( to demonstrate compliance). Surgery
has not been demonstrated as a safe option for our pediatric patients
who have now been recognized as a marked at risk group.

In the Oklahoma Area we are fortunate to have a fitness program called
'Wings\'. Many of the services you describe are not universally
available but contracting with such programs or developing such options
would seem to me to take priority over funding surgical programs without
such team support. One thing I think we as health care providers need to
do is set an example by participating\.....

**Erik Johnson <Erik.Johnson@MAIL.IHS.GOV>**

**Wednesday, February 02, 2005 8:23 PM**

The last time this surgery was being done, everyone stopped, and
excellent surgeons I know said things like any reputable surgeon no
longer does them, as there were so many problems with it. As far as I
can tell, the current fad is no different than the previous techniques?
Just like the previous Adkins craze faded and there were problems, and
Dr. Adkins then went back to treating breast cancer with calcium pills
until he lost his license\....Is it going to be like all the people who
were given Phen-Fen, and now the ones who had prescribed it have not
done follow-up echocardiograms on all of them?

**Hope M Baluh <Hope.Baluh@MAIL.IHS.GOV>**

**2/3/2005 10:57:15 AM**

I think the current \"FAD\" is only in regards to the \'come-latelys\'
who want to add this to their armamentarium - there are ,however, many
established devoted , yes, surgeons who have helped many obese pts.
through surgery. I think what has evolved is newer techniques to an old
problem. It has become obvious that committed teams do better than
individual surgeons who may be just trying to get in on a \'market
share\'. The previous surgeries were different- beginning with the
jejunal / ileal bypass (abandoned now for metabolic reasons) followed by
the vertical banded gastroplasty now being replaced by a multitude of
procedures. Surgery can be a good thing\...\...\.....hb

**Myriam J. Curet <mcuret@STANFORD.EDU>**

**Fri 2/4/2005 4:53 PM**

Roux-en-Y gastric bypass has clearly been shown to decrease mortality
due to morbid obesity and is the most effective treatment currently
available to treat morbid obesity and its related co-morbidities.
Patients have to meet the NIH criteria ( BMI \>40 or 35-40 with
co-morbidities, relationship with PCP for 1 year, psychological
screening). In addition, a good surgical program will also have patients
see a nutritionist pre-op, attend a support group, have a thorough
medical work-up including labs, EKG, CXR, EGD, and cardiac and pulmonary
work-up as needed etc and many programs have patients lose 5-10% of
their weight preoperatively. The good programs will also see their
patients postoperatively on a regular schedule for at least a year.

These programs should be able to demonstrate that on average patients
lose 65-75% of their excess body weight, that mortality rates are \<
0.5%, leak rates are \< 2% and stricture rates are \<10%. In general,
surgeons who have done a laparoscopic surgery fellowship or have done
\>100 laparoscopic gastric bypasses have better results. I think the
patient and PCP need to carefully pick the surgeon and work closely with
him or her, but with those caveats in mind, surgery is definitely the
right treatment for selected morbidly obese patients.

**Michael Wilcox <Michael.Wilcox@IHS.GOV>**

**Mon 2/7/2005 8:09 AM**

I agree with Drs. Baluh and Curet that the most effective treatment for
the obese (those with BMI\>40, and those with BMI\>35 with related
health problems) is bariatric surgery. This doesn\'t mean that all obese
Indian patients should be offered a surgical intervention. The surgical
procedure should be a small part of a comprehensive bariatric surgery
program. Successful programs are multi-disciplinary, and require
intensive nutritional, medical, and psychological assessments and
treatment prior to the surgical procedure. This often means an
evaluation and treatment period of several months prior to the surgical
procedure. During this time, the patient must demonstrate a commitment
to the goals of the program, an understanding of both the operative
risks and benefits and the post-operative regimen required, and
demonstrate compliance with treatment. The patient must also meet the
medical and psychological requirements of the program. There are many
patients who may be candidates for bariatric surgery by BMI criteria who
are non-compliant, are not medically stable, etc., and should not be
offered a surgical intervention. How do you identify which patients
might be good candidates for surgery? By referring them for evaluation
in a good bariatric surgery program.

One of the challenges we face in the Indian Health Service in this
regard is that most of our patient's live long distances from bariatric
surgery programs. I recently attended a bariatric surgery meeting where
a bariatric surgeon from Chicago stated that he would not operate on
patients who lived outside the Chicago area. He does not feel that
patients who have to travel long distances are able to meet the
requirements of his program, and distance makes post-operative follow-up
difficult. How do we resolve this problem for our patient population? A
possible solution is to develop a relationship with a good bariatric
surgery program in your area. Research the requirements of the program,
their results, etc. When you are satisfied that it\'s a good program,
work with them to develop the same pre-operative assessments and
treatment at your institution, and the same post-operative treatment
regimen. Become \"Bariatric Surgery South,\" (or North . . .) without
the surgical part of the program. In this way, our patients will have
access to critical aspects of the program, and if they are felt to be
good surgical candidates, they can get the surgery at the bariatric
surgery center. This approach would have several other benefits. For
example, it would probably be the most cost-effective way for us to
provide the service. It would also be a good way for those IHS
institutions that are interested in doing the surgery to get their
program started.

**Myriam J. Curet <mcuret@STANFORD.EDU>**

**Mon 2/7/2005 3:12 PM**

We work with a lot of patients who live far away. The only requirements
that have to be done at our institution are a preliminary evaluation and
a support group meeting - we coordinate both of those on the same day.

Otherwise, everything else can be done with their home institution/PCP -
we have given talks to these various MDs and clinics and sent handouts
explaining what needs to be done and we are always available for
questions.

I think your suggestions are good ones and very viable.

**Maureen Longworth <maureenl@SEARHC.ORG>**

**Mon 2/7/2005 8:46 AM**

Two of my patients were diagnosed with cancer less than a year out from
their surgeries for weight loss\...one abdominal non-Hodgkin's lymphoma,
another metastatic (to lymph axilla) breast. Do you think this is
coincidence?

Has anyone seen long term studies looking at immune system allowing
cancers with higher frequency in these pts?

**Hope M Baluh <Hope.Baluh@MAIL.IHS.GOV>**

**Mon 2/7/2005 10:46 AM**

Gastric bypass is not offered through the IHS in Oklahoma however we do
care for complications of the surgery (by default).

We currently have a gastric-cutaneous fistula in house. I agree, surgery
is just one part of care of the obese patient- it is hard to justify
starting programs when we often can not even get a dietary consult much
less the other multidisciplinary consults. But are we discriminating
against the obese? And now with the upsurge of pediatric obesity/
diabetes/ hypertension where should funding go?

 

The question about secondary malignancies is interesting; I have not
seen data on this issue other than the difficulties with diagnosis after
a roux-en-Y procedure. One could imagine that the anemia associated with
malabsorbtion post op might be written off to the surgery resulting in a
delay in diagnosis. hb

**Myriam J. Curet <mcuret@STANFORD.EDU>**

**Mon 2/7/2005 11:09 AM**

I am not aware of any correlation, but will check with my colleagues and
in the literature. We do require that patients have a thorough medical
evaluation pre-op including Pap and mammogram for women. Any reason to
think these were missed in the work-up rather than occurred post-op?

**Neil Murphy <nmurphy@SOUTHCENTRALFOUNDATION.COM>**

**Sunday, February 06, 2005 7:46 AM**

 There was a recent article in the NEJM that concluded

*\....*As compared with conventional therapy, bariatric surgery appears
to be a viable option for the treatment of severe obesity, resulting in
long-term weight loss, improved lifestyle, and, except for
hypercholesterolemia, amelioration in risk factors that were elevated at
baseline.

Sjostrom L, et al Lifestyle, diabetes, and cardiovascular risk factors
10 years after bariatric surgery. N Engl J Med. 2004 Dec
23;351(26):2683-93.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15616203>

>  

There was an Editorial in the same NEJM

\.....The demonstration of long-term benefits of bariatric surgery is
encouraging but must be viewed in a broad context. The increasing
prevalence of obesity not only in adults but also in children and
adolescents - indeed, bariatric surgery is now being considered a
potential pediatric intervention- indicate the urgent need to implement
effective preventive interventions, beginning early in life, to improve
dietary habits and increase physical activity. Bariatric surgery is
currently the most successful approach to \"rescuing\" patients with
severe obesity and reversing or preventing the development of several
diseases associated with obesity. It would be an even greater success to
make these procedures unnecessary.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15616210>

>  

There was also a recent systematic review and meta-analysis that
concluded

CONCLUSIONS: Effective weight loss was achieved in morbidly obese
patients after undergoing bariatric surgery. A substantial majority of
patients with diabetes, hyperlipidemia, hypertension, and obstructive
sleep apnea experienced complete resolution or improvement

Buchwald H, et al Bariatric surgery: a systematic review and
meta-analysis. JAMA. 2004 Oct 13;292(14):1724-37.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=1479938&dopt=Abstract>

>  

My understanding is that the initial procedure alone can cost as much as
\$40,000 in some cases, without the extensive pre-op evaluation and
lengthy post-op f/u.

>  

I wonder, how many IHS facilities offer bariatric surgery on site? By
contract health funds?

\...and how many Indian Health facilities should offer this on site? or
by contract health funds\....

>  

Can the IHS afford this procedure now?

Can the IHS afford NOT to offer this procedure widely eventually?

Should we have a national Indian Health guideline for proper pre-op
evaluation to choose the correct pts and post-op f/u guideline to insure
good outcomes?

**Charles North <CNorth@ABQ.IHS.GOV>**

**Tue 2/8/2005 3:53 PM**

Dr. Murphy has highlighted the best research on bariatric surgery
published recently and raises some important health policy questions for
Indian Health as well as the rest of the nation other developed nations
who share our obesity epidemic.  Ann Racehorse, Hope Baluh and Myriam
Curet have pointed out the value of a comprehensive approach to the
evaluation and management of the morbidly obese patient before even
considering the appropriateness of bariatric surgery.  Since Ann and I
initiated the case management of our patient population, rudimentary as
it is, I have read that Kaiser, Health Partners of Minneapolis and just
recently Cigna have developed programs to case manage this population. 
Despite the lack of evidence on the efficacy of case management,
integrated health systems feel a need to act. My anecdotal experience is
that we have reached a tipping point and for the first time in my 28
years of practice, I feel like I am having an impact on obesity.  Using
the same techniques that empower primary care physicians in smoking
cessation and problem drinking we can have a much larger influence than
we imagine.  I encourage you all to tackle obesity with brief
intervention and motivational interviewing techniques. 

Orzano and Scott published an evidence based review of the literature
entitled Diagnosis and Treatment of Obesity in Adults: An Applied
Evidence-Based Review (J Am Board Fam Pract 2004;17:359-69)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15355950>

...where they recommend:

 

1.  Manage obesity as a chronic relapsing disease

2.  Use BMI as a vital sign to screen for overweight/obese patients and
    to decide treatment (PPV=97%)

3.  Modest weight loss (10%) positively affects prevention/treatment of
    hypertension (NNT=3), diabetes (NNT=9) and hyperlipidemia

4.  Effective treatments exist for overweight/obese patients and a
    combination of diet and exercise provides the best results (NNT=7)

5.  Counsel patient to achieve a goal of 10% reduction in weight (500 to
    800 kcal/day decrease to affect 1-2 pound loss/week)

6.  Counsel patient to exercise to achieve a goal of any increased
    energy expenditure

7.  Weight loss has an impact on important disease states and risk
    factors.  Effective strategies exist for the management of obesity
    when viewed as a chronic relapsing disease.

 

The single digit numbers need to treat (NNT) are remarkable statistics
and should spur us on.  Dr. Murphy asks rhetorically how we can afford
the cost of disease and treatment for morbid obesity and what our role
should be in our loosely integrated national Indian Health program. 
These questions are being answered now locally in our clinical practices
daily.  What we desperately need is the integration of our services to
prevent and treat obesity at all ages through our community health and
clinical programs.  Contracts with regional centers for morbid obesity
and appropriate pre-operative and post-operative care should be
considered seriously by our clinical leadership.  Criteria for
evaluation may vary with the centers but bariatric surgeons and primary
care physicians can agree that the time to act is now.

**Hope M Baluh <Hope.Baluh@MAIL.IHS.GOV>**

**Wed 2/9/2005 7:40 AM**

Prevention at the pediatric and young adult level is pivotal- what do
the pediatricians and family physicians do now (BMI as a screen at the
time of vital signs is one easy thing we do in surgery clinic)? One of
our pediatricians has developed a program for kids highlighting
nutrition and exercise but is literally swamped. Wouldn\'t it be great
if the IHS could develop a model and be funded via grants etc to impact
this life threatening problem? hb

**Hope M Baluh <Hope.Baluh@MAIL.IHS.GOV>**

**Sunday, February 13, 2005 9:00 PM**

This month\'s Journal of the American College of Surgeons addresses the
issue of cost with bariatric surgery\.... interestingly it is expected
that obesity will replace tobacco as the leading cause of preventable
mortality. Health related costs associated with obesity and the
overweight are estimated to be over \$92 billion a year. A recent
analysis for the US Preventive Services Task Force found that \'no
nonsurgical interventions provide sustained and significant weight loss
beyond 1 year\'.

There is a paucity of data on the cost effectiveness of bariatric
surgery- but of the studies out there most note a cost effectiveness at
least as good (if not superior) to other common interventions our
society has accepted such as dialysis.

It would seem that since most of the established obesity surgery
programs are multi-disciplinary, as noted by Dr. Wilcox, that the IHS
could start with good foundation programs in nutrition, exercise,
psychological evaluation, and support groups and provide these services
both for treatment and prevention\...and then as time, funding, and
needs dictate expand to surgical options. hb

**Charles North <CNorth@ABQ.IHS.GOV>**

**Monday, February 14, 2005 10:06 AM**

Does anyone have a local or regional bariatric surgeon or surgery center
on IHS contract to provide the services described? Has there been an
attempt to develop such a program at any of our medical centers?

**Hope M Baluh <Hope.Baluh@MAIL.IHS.GOV>**

**Wed 2/16/2005 10:30 AM**

No contract funds have been available for patients in the Oklahoma Area
for obesity surgery- patients have sought referrals but have had to be
responsible for funding on their own. I have made referrals and been
involved with a well- established surgery program (scrubbed with and
observed their procedures) and we have done some of the preoperative
scopes and post op metabolic follow-up. I think the establishment of
such programs would be feasible but only with an administrative or
facility commitment and some funding above what is received now. hb

**William Calder William.Calder@MAIL.IHS.GOV**

**Wed 2/16/2005 1:18 PM**

Here in Wyoming\'s Wind River IHS we follow this discussion with
philosophic interest, and we too have referred a few self-insured
patients to regional centers for surgical intervention. However, for our
uninsured patients, our CHS program cannot even afford funding for
oncology care for known palpable obvious cancers, never mind the worried
diagnostic workups. We cannot fund cardiac workups for angina, or for
revascularization for known and symptomatic ischemic heart disease. Our
CHS can no longer support GPRA mandated cancer screening goals. The
shortage of CHS funds here is truly life threatening. Our patients and
their medical providers face a grim reality that leaves uninsured
bariatric surgery in the realm of abstract fantasy. We marvel and wonder
how anyone in IHS can afford to contemplate funding for any elective
surgeries at all. We are tempted to ask (but because we are so
politically correct we won\'t) whether the apparent uneven distribution
of already under-allocated CHS funds reflected in this discussion, all
valid intellectual discourse aside, is attributable to a policy-wonking
or bomb-building obesity somewhere out there beyond the Rockvillian
horizon of our humble service unit that should be offered a surgical
procedure instead. We\'ll have another bake sale to help fund it, just
as we do locally for patient care nowadays. Anybody out there care to
trade an elective bariatric procedure for care of my patient\'s
untreated cancer? Bill Calder

**Angela M Erdrich <angela.erdrich@MAIL.IHS.GOV>**

**Wed 2/16/2005 1:51 PM**

Dr. Calder - thanks for the reality check. We all complain about lack of
funds for our service units, but perhaps we should be aware of the
relativity of the situation. I have worked as a pediatrician for the
Indian Health Service for 7 years and I have never been unable to get a
child a service that was truly Priority One.

I do believe that when a service unit puts money and support into
benefits coordinator positions, millions of dollars can be saved for
Contract Health Services. Perhaps your service unit is already on this
track. Angie Erdrich, MD Pediatrician

**Hope M Baluh <Hope.Baluh@MAIL.IHS.GOV>**

**Wed 2/16/2005 6:57 PM**

I agree\.... there \'seems\' to be a marked disparity in health care
even within the IHS and even among different services within one service
unit.

For example, I recently saw a patient for a surgical problem who had
been treated at another IHS service unit in another state. She came with
copies of her chart, lab, etc. which interestingly included genetic
studies. Genetic studies, a luxury\...

Our waiting list in the surgery clinic has surpassed the 2000 mark. How
many service units live in this quiet desperation? hb

**The Summary and analysis is posted here:**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SumObe22805.doc>

**\***

**More Background**

Obesity is now the most common chronic health problem in the United
States and effects Native Americans and Alaskan Natives in epidemic
proportions. Surgical treatment may be indicated in patients who have
failed multiple attempts at weight loss and have a BMI (body mass index)
greater than 40 kg/m2 or co-morbid conditions with a BMI greater than 35
kg/m2. As noted at the 1991 NIH Consensus Development Conference Panel
there are multiple co-morbid conditions which include diabetes,
hypertension, sleep apnea, asthma, reflux, congestive heart failure
,joint disease, dyspnea on exertion, and urinary incontinence. The
emotional and economic tolls on patients can be tremendous. Many of
these problems not only improve but can totally resolve with weight
loss.

One surgical expert, Dr. M. Gagner predicts that within the next ten
years surgery for the treatment of obesity will become one of the most
frequently performed procedures in our country.

The role of the primary care provider will become increasingly important
as this health care problem escalates.

-   Appropriate referrals in well selected patients can be life saving

-   Knowledge of potential complications in the peri-operative period
    and beyond can be instrumental in early recognition and treatment

-   Long term consequences of weight loss unique to each procedure must
    be factored into the ongoing care of these patients

-   Adjustment of medications during the rapid weight loss phase is
    important to prevent such complications as hypotension and
    hypoglycemia

-   Recognition of and sensitivity to the needs of obese patients will
    enhance care

Regardless of whether a facility offers surgical treatment options for
obese patients, clinicians everywhere will be called upon to treat
patients with this condition.

**More cases**

A 38 yo establishes her care with your group. She complains of fatigue
and shortness of breath on mild to moderate exertion. She had some type
of obesity surgery 8 years ago but doesn\'t know the name of the
procedure. She lost over 100 lb., but now has leveled off at 150% ideal
body weight.

**What next?**

44 yo female 3 wks s/p roux- en- Y Gastric bypass with persistent
vomiting. BMI 52. Heart rate 88.

**Management?**