25th November 2011, Volume 124 Number 1346

Richard Flint, Steven Kelly

It is incredulous that New Zealand is still debating the merits of public funded bariatric surgery, when it is close to 40 years since it was introduced.1,2 Back in the 1970s surgery was freely offered with little data justifying its efficacy.

Fortunately our surgical predecessors were right as we now know the perils of obesity; it reduces life expectancy (by 30% for every 5 kg/m2 above normal BMI),3 increases the risk of cancer,4 is responsible for an alarming rise in diabetes,5 reduces worker productivity,6 and is destined to burden the health budget by over $300 million dollars per year.7

Furthermore we now know that bariatric surgery can result in significant, long-term weight loss;8reduce comorbidities;9 improve quality of life;10 improve mortality;11 and improve health economics;12whilst maintaining a very safe perioperative profile.13 So why is there now a hesitancy from the non-surgical community to adopt bariatric surgery as a viable option for those who are obese?

The first argument against surgery (and often the most fervent) is that obesity is just a product of free will and resources should not be spent to surgically correct a self-inflicted condition.14 Whilst it is true that most food is ingested willingly, it is also true that factors promoting obesity are not experienced willingly.

Widespread obesogens like bisphenol-A (BPA),15 prenatal factors such as poor maternal diet that increases the risk of future obesity,16 socioeconomic status17 and heavy commercial marketing of poor quality foods are all involuntary factors that have been implicated in the development of obesity.

The ethics of denying patients the chance for surgery because they have been too weak-willed to resist in a pro-obesogenic environment must be questioned. Even if this argument is accepted then it must surely raise a perturbing precedent.

What difference would there be in denying patients treatment for melanoma because they failed to use sunscreen, retrovirals for AIDS because they failed to adopt safe sexual practises, angioplasties for coronary artery disease because they failed to exercise 30 minutes a day, or oxygen therapy for COPD because they used to smoke? Most of healthcare is focused on conditions that could be ameliorated by healthy life choices, but it is disturbing that obese patients are judged on a premorbid sense of ‘discipline’ that is never debated as a prerequisite to treatment for other conditions.

A further argument against bariatric surgery is that it does not work. Anecdotal tales of a patient pureeing up Mars (chocolate) bars to sabotage their weight loss surgery are often garnered as proof (does anyone know who this patient really is?) However, this conclusion is not supported with scientific evidence.

Randomised controlled trials18,19 and cohort studies8,20 have shown bariatric surgery to be vastly superior to dieting. Weight loss is maintained for over a decade21–25 that not only improves comorbidities but guarantees an increased survival.8,11,26 However, if we are to accept that the single anecdote of a nameless patient can be used to reject the weight of evidence supporting bariatric surgery, then why is no-one questioning therapies for other conditions.

Why do we not deny drug-eluting cardiac stents when we know that over 10% of patients will fail to continue thienopyridine therapy within the first month so increasing stent thrombosis and subsequent mortality by a factor of 10.27

Why should we maintain solid organ transplantation when up to 38% of patients will fail to take their anti-rejection medication.28 Is it because it is not acceptable to deny people an effective treatment when their survival is at risk. How much more inappropriate can it be to decline bariatric surgery that has been shown to improve annual survival by 80%!29

But maybe the main reason that bariatric surgery is resisted is the concern that health resources may be overwhelmed. Estimates that a quarter of adult New Zealanders are obese30 correlated to United States data showing rising popularity of bariatric operations31 can cause concern over cost blow-outs unless surgery is withheld. Yet not doing anything has an inherent cost.

Obesity increases the cost of inpatient and outpatient care by 36%, the cost of medication by 77%,32 and accounts for 2.5% of NewZealand’s health spending.7 This can be extrapolated to $344 million a year, yet the true cost can only be greater as this estimate is based on 1990 data that does not account for the recent rise in the rate of obesity. In the face of such sums it seems ironic that withholding surgery will actually cost the health system even more. Numerous studies have indicated that bariatric surgery leads to long-term savings33–36 with the cost of surgery being recouped within 2 years.37

In recognition of such data the Ministry of Health published a business case in 2008 for New Zealand public funded bariatric surgery.38The recommendations that 0.5% of the morbidly obese population be offered surgery (equating to 915 operations over a 5-year time period) became closer to reality in October 2010 with the introduction of specific funding earmarked for bariatric surgery on a nationwide basis with geographical equality.39 Despite being an admirable first step toward an effective treatment for obesity, it is uncertain to guarantee the adoption of bariatric surgery as a mainstream option. The funding is temporary and reliant on District Health Boards to pick up the future costs.

Furthermore, it is difficult to see how District Health Boards will be ‘convinced’ on the utility of bariatric surgery when the results of just 13 operations a year in cities such as Christchurch are expected to influence the adverse effects of the 90,000 obese people in their district. So it is unsurprising that some have intimated that the restriction of bariatric surgery is prejudicial rather than based on a reasoned evaluation of the evidence.40

In a time when obesity has increased to near epidemic proportions, New Zealand has progressed from readily available bariatric surgery to a position of near impossible access. And this is despite the overwhelming evidence that extol the merits of such surgery. Must it take another 40 years to get back to the position we enjoyed in the 1970s?

Author Information

Richard Flint, Steven Kelly, Bariatric Surgeons, Department of Surgery, Christchurch Public Hospital, Christchurch

Correspondence

Richard Flint, Surgery and Cancer Medicine, University of Otago – Christchurch, PO Box 4345, Christchurch, New Zealand.

Correspondence Email

richard.flint@otago.ac.nz

Competing Interests

Both authors are bariatric surgeons.

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