Weighing the Options

Canadians are getting fatter. Depending on which day you turn on the television or open the newspaper, you’ll hear varying statistics: half of Canadians are overweight, a third of us are obese, child obesity is rising at catastrophic rates… It’s difficult to sort through the numbers, but any way you slice it, in the early years of the 21st century, our country is heavier than it has ever been.

According to a Statistics Canada article by Michael Tjepkema, the Canadian Community Health Survey in 2004 found that 23.1% of adult Canadians had a Body Mass Index (BMI) of 30 or more, making them obese. An additional 36.1% were overweight (defined by a BMI of 25 or more). (BMI is a person’s weight in relation to height. According to Canadian guidelines and in step with World Health Organization guidelines, a “normal” BMI is between 18.5 and 24.9. Anything less is considered underweight, anything more, overweight.)

Tjepkema goes on to show that in 1978/1979, the Canadian Health Survey found that the adult obesity rate was 13.8%, much lower than it is today. Since the late ’70s, the percentage of obese people between the ages of 25 and 34 more than doubled (8.5% increased to 20.5%). There are, of course, myriad reasons why this is happening: proliferation of fast food, unlimited access to cheap, nutritionally void and calorically rich groceries, and sedentary lifestyles, to name a few.

So what’s the big deal if the average Canadian is a few pounds heavier than he or she was thirty years ago? Unfortunately, there are negative aspects to extreme weight gain that go beyond vanity issues.

“Patients who are overweight or obese are at increased risk for diseases associated with increased weight including Type 2 diabetes, hypertension, sleep apnea, arthritis, elevated lipids, cardiovascular diseases, non-alcoholic fatty liver disease and certain cancers among other diseases,” says Dr. Daniel W. Birch, medical director of the Centre for the Advancement of Minimally Invasive Surgery (CAMIS), a Capital Health regional program based at the Royal Alexandra Hospital in Edmonton. Birch is a minimally invasive gastrointestinal surgeon and has worked with a lot of overweight patients. “For these reasons,” he says, “patients in these categories should seek medical attention for management of their overweight and obesity and associated diseases.”

Obesity, says Janet Stewart, director marketing, Ethicon-Endo Surgery, a Johnson & Johnson company, is a major health challenge. “Not only can obesity kill, but there are a number of co-morbid conditions that are aligned to obesity,” she says, adding stroke and depression to the list of associated conditions Birch provides. She specifies Type 2 diabetes as especially worrisome. “Most health regions across the country would suggest that they have a significant diabetes problem.”

Laurel Toth, registered dietitian, certified diabetes educator and coordinator of the diabetes program at the Manitoulin Health Centre in Little Current, Ontario, sees the relation between obesity and diabetes in her work on Manitoulin Island in Northern Ontario. “Obesity, specifically abdominal obesity — fat stored around the abdomen and waist — is a risk factor for developing Type 2 diabetes because it causes insulin resistance,” says Toth. “Insulin resistance is a condition in which the body’s cells and tissues do not respond properly to the effects of insulin: a hormone produced by the pancreas that controls the amount of glucose in the blood.” Type 2 diabetes, although controllable and often preventable, does not have a cure, and is irreversible at this time, says Toth. If left untreated it can lead to heart attack, stroke, eye and kidney disease, and damage to the nerves in hands and feet.

To treat obesity, there are the obvious solutions. Diet and exercise, when possible and when done properly, is the safest choice. But the long road from obesity to health can be extremely difficult to navigate successfully. More and more Canadians are turning to bariatric surgery, also known as weight-loss surgery. There are different types of weight-loss surgery, but in general, bariatric surgery means that the gastrointestinal tract is changed or modified to manipulate nutrient intake.

Typically, only morbidly obese patients (those with a BMI of 40+) qualify for bariatric surgery, and wait times can be extremely long. For example, according to a cbcnews.ca story posted Feb. 2, 2007, out of 20,000 morbidly obese people in southern Ontario, about 4,500 were applying for bariatric surgery every year, but less than 300 of them actually had their surgery in Canada.

Some relief is in sight. The Ontario government announced this year that the number of bariatric surgeries will increase to 2,085 a year by 2011/2012. In total, the province announced that they will invest $75 million into bariatric surgeries over three years. The government of Quebec has done something similar, announcing that the province will spend $30 million to fund bariatric programs.

The money invested into weight-loss surgery will ultimately relieve pressure on other parts of strained provincial health-care systems. “There is excellent evidence to demonstrate that bariatric surgery leads to sustainable weight loss in the majority of patients, producing profound improvements in co-morbid disease associated with obesity,” says Birch. “These changes after bariatric surgery are beginning to save lives, and there is also good evidence for an overall savings in health-care costs after approximately three years.”

A proactive approach to obesity management is important in every part of the country. “In Alberta we are developing a provincial strategy for obesity management,” says Birch. “We hope to lead the country in developing a model that is appropriate and supports patients seeking obesity treatment.”

In terms of specific treatment, Birch says there are basically two surgical options: gastric bypass and gastric banding. “The two procedures have many differences and may be best suited for different patients,” he says. “Gastric bypass is much more complex, involving dividing the bowel and stomach and creating new connections from stomach to small bowel.” Both procedures are done laparoscopically (small incisions are made into the abdomen, through which the operation is performed, also known as minimally invasive surgery), but gastric bypass takes two hours compared to gastric banding’s 30-40 minutes, and patients will be in hospital longer (two to three days).

“The risks after bypass are greater and the complications can be serious and life threatening,” says Birch. “Bypass has evolved over thirty years and is now a very sophisticated and successful procedure, but requires advanced surgical skills to complete routinely.” In terms of overall weight loss, bypass may have an edge on banding. “The bypass procedure produces impressive early weight loss — over 100 pounds in the first year,” says Birch, “and may produce a greater extent of weight loss on average as compared to the band.”

Banding is a less complicated procedure, as it doesn’t actually change the patient’s anatomy. Birch says the band is “closed like a belt” on the patient’s stomach. The recovery after banding is relatively short: patients are released from hospital the next day, and although they will experience mild discomfort and fatigue, could return to regular life within days.

The Realize Adjustable Gastric Band from Johnson & Johnson is one of the banding options available in Canada. It features the REALIZE Injection Port and Applier which is the only sutureless tissue anchor system. “What makes the velocity port different from other ports in the banding market is that it can be attached to the fascia in less than one minute,” says Shauna Dagnone, product manager – bariatrics, Ethicon-Endo Surgery. “The surgeon doesn’t have to take time suturing it… It can save up to ten minutes in a surgical case.”

But it’s the support program that accompanies the Realize Band that might be the biggest key to patients’ success. REALIZE mySUCCESS™ is an interactive website that provides support to the patient before and after surgery. “It’s really important to know that surgery is a small part,” says Dagnone. “It’s the patient’s effort post surgery that plays a large role in their overall success.”

One difficulty that often arises after surgery is patients’ inability to visit with their health-care team. Perhaps the patient travelled for the surgery, and is now consulting with a local GP. REALIZE mySUCCESS™ allows patients to remain constantly connected to their health-care providers, who also have access to the site. “It really bridges the patient to the practice, and when I say practice, I mean the team that’s looking after the patient — that’s the nutritionist, dietitian, surgeon, it could be a physical therapist, occupational therapist, anybody who’s looking after the patient will have this interactive access,” says Dagnone.

REALIZE mySUCCESS™ is available to Realize Band patients, but also to anyone who undergoes a gastric bypass or gastric sleeve procedure using Ethicon Endo-Surgery products. As well as fostering a lot of healthy communication between doctors and patients, the site also contains a wealth of useful information: recipes; info on nutrition, exercise and caloric value; meal planning and goal-setting tips; and guidance on what to do when you’re struggling and who to reach out to for help. Patients can also input their nutritional intake into a food diary, which their nutritionist can monitor remotely. “It’s a journey to health for these patients, and it’s a long journey,” says Stewart. “They’re looking at 18 to 24 months or longer, depending on their weight-loss goal.”

The decision to undergo bariatric surgery is one that should be given ample thought. “Patients who meet the criteria outlined by the National Institutes of Health for bariatric surgery are candidates for the adjustable gastric band,” says Birch. He adds that patients also need to be assessed in a program dedicated to obesity management before they consider an operation at all. “Obesity is now recognized as a chronic disease, therefore a chronic disease model should be used for [it]: multidisciplinary evaluation and care, careful patient selection for various treatment modalities and long-term follow-up,” he says.

But when it comes to bariatric surgery in general, Birch has seen a lot of positive results. “Our program has achieved excellent success in many patients that have been treated with the adjustable gastric band, gastric bypass and sleeve gastrectomy,” he says.

The team from Johnson & Johnson is determined to see continued progress in patients. “This is a patient population that is growing way too quickly… We want to do what we can to help stem the tide and help these patients be successful,” says Stewart. “We’re not focused on cosmetics as our primary goal; we’re focused on the individuals that have health-care concerns that go beyond how they look, and more to how they feel.” •

Johnson & Johnson Medical Products, a division of Johnson & Johnson Inc., has provided funding to CAMIS and Dr. Birch for research and development projects and/or consulting.