Fight obesity through surgery, experts say
Province should cover stomach reductions for 150,000 Ontarians
Joanne Laucius
The Ottawa Citizen
Monday, May 22, 2006
CREDIT: Rod MacIvor, The Ottawa Citizen
Joel Lamoureux, who once weighed 600 pounds, is down to 220 pounds, can take 30-kilometre bike rides and plays hockey.
A panel of obesity experts is poised to recommend the provincial government fund between six and 10 clinics to battle the province's obesity epidemic with surgery.
There are about 150,000 people in Ontario who would qualify for bariatric surgery, colloquially called "stomach stapling," which reduces the size of the stomach. Experts on the panel concluded that surgery is the only solution for some obese patients, most weighing 300 pounds or more and facing debilitating medical conditions if they don't lose weight soon.
Ontario needs to fund about 4,000 of these surgeries a year, according to the advisory panel.
In 2004, Ontario's chief medical officer of health reported that 57 per cent of adult men and 42 per cent of adult women in the province are overweight or obese.
"These are people for whom there are no other options," said Dr. Arya Sharma, co-chair of the Health Technology Utilization Guidelines Committee panel, which advises the provincial government on utilization of new health technologies.
The panel consists of 15 experts on obesity treatment, and the recommendations have been reviewed by a further 20 to 30 more experts.
A few hundred patients a year have been getting clearance through OHIP's out-of-country approvals to get the surgeries in the United States, costing the province between $15 million and $20 million a year, said Dr. Sharma, a professor of medicine at McMaster University who holds a Canada Research Chair in Cardiovascular Obesity Research and Management. He and other experts argue that if clinics were set up in Ontario, the cost to OHIP could be cut at in least half.
Candidates for bariatric surgery have a body mass index of 40, or a body mass index of 35 and other conditions linked to obesity, such as Type 2 diabetes. In order to qualify, a woman five-foot-five would have to weigh at least 240 pounds. A man five-foot-10 would have to weigh 280 pounds.
Patients are candidates for surgery only if they have tried and failed to lose weight through diet and exercise. But less than five per cent of obese people are able to manage their weight on lifestyle management, said Dr. Sharma.
Jennifer Ferguson, 25, is going to Michigan to have a duodenal switch, a surgery in which three-quarters of the stomach is removed.
She has been on several medically supervised diets, once losing 60 pounds, then quickly regaining it, all in the course of a year. She currently weighs about 310 pounds, and her weight causes pain to her knees and ankles.
Many people think it just takes willpower to lose weight. That's not the case, said Ms. Ferguson.
"Of course, these are the people that never experienced how it feels to weigh 300-plus pounds, be discriminated against, laughed at, unable to fit in seats," she said.
Ms. Ferguson has been on a waiting list for about 16 months -- the last time she asked, the waiting list from the Ottawa area stretches to 200 names, and she was number 30.
She said she was worried that some people would see surgery as the easy way out. But people close to her have seen her struggle and her quality of life decline. No one she knows thinks she's taking the easy way out. "This is serious surgery," she said.
"Once you have the disease, you need medical treatment," said Dr. Robert Dent, director of the weight management clinic at the Ottawa Hospital and a member of the committee.
There are about 600 genes, markers and chromosomal regions associated with obesity. Some people can reduce their caloric intake to 500 calories a day and exercise constantly and still not lose weight.
Dr. Sharma said it is "complete nonsense" to believe that the obese can control their weight with diet and exercise alone.
"If you see someone who is diabetic, you don't ask about that person's lifestyle," he said. "When someone is obese, that's the first question that comes to mind. When you have someone who is that obese, it's a chronic disease and it needs treatment."
Meanwhile, many of the patients and even some doctors are ignoring the problems that can be triggered by obesity, said Dr. Dent.
"Time and again, we see people who think of weight as a cosmetic issue," he said. But obesity creates a lot of costly problems for the health care system, including an increased risk of Type 2 diabetes, heart disease and orthopedic problems included overstressed backs and knees that may eventually require joint replacements.
There are two types of bariatric surgeries, said Dr. Dent. "Banding" reduces the size of the stomach while bypass surgery creates a new stomach, then reconnects it about halfway down the small intestine, which ensures some food is not absorbed.
Besides decreasing the volume of food consumed, surgery also has another advantage, said Dr. Dent. Ghrelin, a hormone secreted in the lower stomach that creates the sensation of hunger, is avoided in this way.
Dr. Dent has sent about 100 patients for bariatric surgery to the U.S. in the past few years, mostly to a clinic in Rochester, New York. There only about four surgeons in Ontario who perform the surgery, their numbers have been shrinking and the waiting lists are long, he said.
Dr. Sharma has about 30 patients on a waiting list for bariatric surgery, and a further 500 on a waiting list to see him.
"I don't see people under 300 pounds," he said.
Cheryl Schultz, 55, had bariatric surgery in 2004. Her weight spiraled out of control when she had her second child 26 years ago, going from a low of 112 pounds to 232 pounds on her five-foot frame -- she's considered a "lightweight" in the world of obesity medicine.
By 2003, Ms. Schultz had fibromyalgia, had been diagnosed with Type 2 diabetes and suffered from depression and osteoarthritis.
She has tried repeatedly to lose the weight through diet and exercise and failed. After hearing about bariatric surgery, she tried and failed to convince her family doctor to refer her for the surgery.
"She doesn't believe in it. She weighs about 102 pounds soaking wet," said Ms. Schultz.
She was able to convince another doctor, an internist who sent her for laproscopic bariatric surgery in Rochester.
"I never looked back," said Ms. Schultz, who now weighs 150 pounds. She can eat just about anything, but only in small qualities. She used to be able to consume an entire pizza. Now all she can have is a slice.
Ms. Schultz insists that the surgery saved her life. When she feels hunger now, it's real hunger, not a psychological need.
"I can actually function now. Before I went to Rochester, I was bedridden," she said.
She believes that the surgery, which cost OHIP about $14,000, has saved the medical system money.
"Since I had the surgery, have been to see my family doctor twice," she said. "I used to bounce from doctor to doctor with chronic pain and fatigue. I've saved OHIP a pile of money."
Joel Lamoureux was living in Manitoba and weighed almost 600 pounds when he got approval to have bariatric surgery in London, Ont., in 2003. (The program, the only one west of Montreal, did an average of one bariatric surgery a week. It has since been closed as a cost-cutting measure.)
Mr. Lamoureux once dislocated a knee simply by standing up. "This was my only chance," said Mr. Lamoureux, who attributes his weight to emotional overeating and food addiction. "When you're 600 pounds, you can't even get out of the house."
As a "super-heavyweight," it took him two weeks to recover from the surgery and two years before he shed 380 pounds. Now, at 220 pounds, he can bicycle 20 to 30 kilometres and has started playing hockey for the first time since he was 16.
He believes bariatric surgery is the only answer for some people. And he doesn't believe it's a quick fix.
"The demons are still there and I assume they'll always be there," he said. "I don't want to go back to being an obese person."
Research shows that surgical outcomes are better if the procedures are performed in a high-volume centre, said Dr. Dent. Obese people face greater risks during and after surgery than people who aren't overweight. Last year, the American College of Physicians' clinical practice guideline for obesity management recommended that bariatric surgical patients be referred to high-volume centres because surgeons and their teams in these clinics are able to develop specialized skills.
Dr. Sharma knows of at least two proposals, one in Ottawa and the other in Hamilton, to open a bariatric centre, although there has been no word yet from the province on whether they will be funded.
If surgery is to be successful, it needs to be followed with life-long counselling, he said.
"Surgery is doomed to failure if there is not a program that assesses the patient," he said.
John Letherby, a spokesman for the Ontario Ministry of Health and Long-Term Care, said the provincial government is taking the recommendations, which echo a previous report released in January 2005, "under advisement."
Natalie York, 31, has tried about a half-dozen commercial diets and the prescription drug Xenical, which blocks fat from being absorbed, before she started thinking seriously about bariatric surgery. At 298 pounds and five feet, four inches tall, Ms. York suffers from sleep apnea and asthma.
Ms. York learned that of the 10 or so clinics that did perform the surgery in Canada, most are now closed. She is putting together a package, including medical references and a short essay, to apply for out-of-country OHIP coverage. It would be better to get treatment in Ontario, she said.
"Let's keep us here at home. We shouldn't have to go to another country to have something that could save our lives," she said.
"Maybe it's not like cancer, but it's still a disease."
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