Patient Safety Leads Issues in Obesity

An epidemic of overweight and obesity is pervading both rich and poor populations, in industrialized as well as developing nations. There are currently more than 300 million obese adults in the world, and the number of overweight children and adolescents is rising. At a Continuing Medical Education program in early July hosted by HMS, leaders in medicine and public health from around the world met to discuss these issues and share ideas on developing best practices for treating the more severe morbid obesity. Topics of the three-day course focused on weight-loss surgery and included lectures on nutritional intervention strategies, medical errors and bariatric surgery risks, standards of care, and patient education.

Morbid obesity is usually defined as a level of overweight 50 to 100 percent above a person’s ideal weight æa BMI typically greater than 39. Clinically, it often manifests as metabolic syndrome with a variety of other comorbidities including type 2 diabetes, hypertension, hyperlipidemia, and sleeping and breathing problems. Scientists believe both genetics and environment play a role in the disorder, and as CDC director of nutrition William Dietz said at the conference, “Genes load the gun and the environment pulls the trigger.”

Treatment Steps
Treatment for obesity usually begins with diet intervention, behavioral therapy, exercise, and sometimes medication. If these steps fail, bariatric surgery may be recommended. The surgery, which involves a major rearrangement of the gut, has often been portrayed as risky by the media. Nationally, the rate of death after any weight loss surgery is about one in 200. Risks increase with patients who are male, smoke, have a BMI greater than 60, have weak or failed organs, or who are older than 50. Yet the benefits are greater than the risks in many cases, according to Walter Pories, professor of surgery, biochemistry, exercise, and sport exercise at the Brody School of Medicine. Five years after bariatric surgery, there is an 89 percent reduction in risk of death for the patient, primarily due to the reduction of BMI and blood pressure, among other health problems, he said.

The majority of the speakers at the conference, however, believe improvements are still needed to reduce mortality rates and increase patient safety. According to Ninh Nguyen, chief of the Division of Gastrointestinal Surgery at the University of California, Irvine, there have not been enough consistent studies to prove the safety and efficacy of bariatric surgery. Citing the exponential growth in both bariatric patients and surgeons, Nguyen argued that more controlled trials are needed to decisively show that the benefits of the surgery far outweigh the complications.

Many of the panel speakers agreed that bariatric centers of excellence should be established across the nation to create standardized surgical procedures and appropriate guidelines for medical staff. Barriers for patients also exist, including hurdles in health insurance coverage of the procedure and proper safety education for patients. “As a surgeon, I believe that education is key to my patients receiving optimal health,” said Brigham and Women’s gastrointestinal surgeon Ashley Vernon.

Surgery is only a first step in weight loss for patients, and this must be clear to the patient prior to the procedure, according to Madelyn Fernstrom, director of the University of Pittsburgh Medical Center weight management center. “Lifestyle after bariatric surgery is 10 times harder than it was before,” she said. Postsurgery patients require a completely new lifestyle, so health care workers place a great emphasis on patients’ commitment. Good nutrition is required after a gastric bypass because the body cannot digest many of the unhealthy foods the patient may have eaten prior to surgery. It is also important for patients to begin physically challenging their body to maintain their weight loss. In addition to the nutrition and physical challenges, the psychosocial trials are what many patients say is the most difficult. “Family support is key, and you have to help the patient identify barriers to success,” Fernstrom said. “Patients have to be 100 percent sure they are doing this for themselves.”

High-tech Help
Since the number of physicians and nutritionists in the world is far fewer than the number of individuals who need help, using the Internet is one solution to the growing problem of overweight, according to Caroline Apovian, director of the nutrition and weight management center at Boston Medical Center. Though computers may be impersonal, the pros of using a Web-based technology overshadow the disadvantages, said Apovian. While patients must be careful to identify reliable information on the Web, using the Internet as a tool for self-education is both cost-effective and beneficial.

Director of advanced medical technology at Beth Israel Deaconess Medical Center James Rosser also believes technology is key in preventing obesity. He said obesity-prevention efforts should focus on children and adolescents, and one way to do this is through technology. “We have to change the way we conduct our curriculum…. The battle actually starts with the children,” he said. So Rosser developed the idea of “edutainment” in the form of an educational video game called “Escape from Obeez City” to teach children physiological facts in a popular, interactive way. Rosser, a patient of bariatric surgery four years ago, has a distinctive perspective on the issue and believes his platform of ideas has great potential.

While discussion of obesity treatment made up a large part of the three-day course, prevention of obesity was a strategy suggested repeatedly at the conference. The speakers agreed prevention must be the ultimate goal of health care providers, and this requires a widespread change in attitude, which international groups like the World Health Organization could help achieve. “The public has to understand they must educate young people in school—they have to take charge themselves,” said Thomas Russell, executive director of the American College of Surgeons, in a speech at the Museum of Science after the first day of lectures. “This is not something only one group can handle—WHO should take the lead.”

—Rachel Patzer

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