What is it going to take for policymakers to increase access to safe and effective therapy, asks Dr Georgia Rigas?
As a nation our waistline is expanding with more than 28% of Australian adults having obesity [BMI>30].
The prevalence of obesity in Australia is expected to continue to increase with an expected 7.2 million people with obesity, or 34% of the projected population, by 2025.
The recently published BEACH data for 2015-16,2 showed that the proportion of Australian adults aged 45 to 64 presenting to GPs with Class III obesity (i.e. BMI>40, previously morbid obesity) has almost doubled in the last 15 years, with a prediction that the numbers will continue to rise.
Embarrassingly however, the BEACH data also indicated that less than 1% of GP consultations centred around obesity management.
Evidently, we appear to be suffering a disconnect between our perception of obesity as a serious condition, and the treatment we offer our patients.
People with obesity suffer significant stigma, discrimination and weight bias, and as a result may be reluctant to access healthcare.
As clinicians, we need to take the lead and initiate the dialogue – however, in a respectful and non-judgemental manner. Numerous resources exist: the NHMRC clinical guidelines, SNAP guidelines as well as other resources scheduled to be released next year by the RACGP.
The RACGP recently recognised obesity as a chronic disease, just as other healthcare professionals in the US and Europe have done.
The goal was two-fold: to give people with obesity a voice and start to chip away at the discrimination, and to highlight the important role that GPs play in the management of obesity and long-term care provided by the primary healthcare team.
So what do we know from the literature so far:
1. People don’t choose to develop obesity; while environment plays a key role there is a strong genetic component being expressed in people with more severe obesity.
2. The body physiologically defends any weight loss, making it very hard for people with obesity to maintain lost weight.
3. For most patients, even a 5% to 10% weight loss is clinically significant and leads to an improved health profile.
4. Long-term follow-up appointments directed at lifestyle improvement leads to sustained weight loss for at least 10 years.
5. In patients who require more significant weight loss, adding more intense therapy as an adjuvant to lifestyle change will improve outcomes.
6. Medications are known to be effective but while there are currently three TGA-approved medications available for weight management, none are on the PBS, limiting accessibility.
7. Metabolic surgery (previously known as bariatric surgery) is the only therapy which leads to significant and sustainable long-term weight loss for the majority of patients with severe obesity or organ threatening co-morbidities, and it is safe.
Obesity not only affects the health and quality of life for the individual and their family, it also impacts on society through direct and indirect costs.
A PriceWaterhouseCoopers report, estimated the total cost of obesity in Australia in 2011-12, to be $8.6 billion (in 2014-15 dollars). Of concern, however, is that those Australian adults who qualify for metabolic surgery by BMI (BMI>35 with weight related comorbidities or BMI>40) only 9.6% seek bariatric surgery.
While acknowledging that not all qualifying patients need or want bariatric surgery, this small percentage is unacceptably low and less than 12% of these operations are being performed in the public healthcare system. This obviously further widens the divide between the haves and the have nots (with respect to health insurance coverage).
The Swedish Obese Study has shown that metabolic surgery results in significant and sustained weight loss for up to 20 years, with a reduction in mortality compared with medical care with diets, exercise and medication.
The benefits of metabolic surgery extend beyond improvements in weight and glycaemic control; patients also exhibit reductions in overall cardiovascular morbidity and mortality rates, as well as a reduction in cancer incidence.
But there is limited access to, and long waiting lists for, public metabolic surgery. And this has significant implications for both the individual and the population.
A recently published review of access and impact of waiting times to the Brazilian public-funded metabolic surgery services, found that delaying surgery, especially in those with T2DM, was associated with greater expense and poorer health outcomes compared with those who received prompt surgery.
This is in keeping with the Swedish study11 which showed that patients with T2DM were more likely to respond to the effects of metabolic surgery if they were treated earlier, rather than wait until their diabetes was more severe.
So what is it going to take for policymakers to increase access to safe and effective therapy?
We know the problem. We have evidence-based solutions. What are the powers-that-be waiting for?
A few weeks ago, there was an announcement12 that a new drug for leukaemia and lymphoma would be listed on the PBS. It is expected the drug will be used by 920 people. The cost to the PBS is expected to be approximately $460 million per year.
Metabolic surgery costs $12,300 to $21,200 per quality-adjusted life year in Australia. With approximately 2800 cases performed per year in the public at $25,000 for each case, public procedures cost approximately $70 million per year. So, for the equivalent money allocated to this cancer drug, about 18,400 patients with obesity could receive metabolic surgery each year in Australian public hospitals.
While I am by no means suggesting that one disease should take priority over another, this could be seen as an example of institutional inequality built on prejudice against people with obesity. Money will only become available to treat people with obesity once they are viewed with the same sympathy as patients with cancer.
To effectively and equitably work towards reducing obesity in our communities, we need a balanced combination of both individual and public-health measures to ensure better health outcomes and quality of life for all Australians.
Dr Georgia Rigas is a bariatric medical practitioner and chair of the RACGP Obesity Management Network
References:
1. Australian Bureau of Statistics. National Health Survey: First Results, 2014-15 Canberra: Australian Bureau of Statistics, 2015.
2. Bettering the evaluation and care of health research into primary care health provision; Sept 2017
3. Clinical Practice guidelines for the management of overweight and obesity in adults and children, 2013
4. Royal Australian College of General Practitioners Red Book 9th edition, Guidelines for preventative activities in general practice
5. Bockelman C et al, Obesity Surgery (2017) 27: 2444-2451; Mortality following bariatric surgery compared to other common operations in Finland during a 5-year period (2009-2013). A nationwide registry study
6. PriceWaterhouseCoopers “Weighting the cost of obesity: A case for action” report October 2015
7. Australian Bariatric Surgery Annual Report 2017
8. Sjostrom L, Narbro K, Sjostrom CD, Karason K, Larsson B, Wedel H et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007; 357: 741–752.
9. Sjostrom L, Peltonen M, Jacobson P, Sjostrom CD, Karason K, Wedel H et al. Bariatric surgery and long-term cardiovascular events. JAMA 2012; 307: 56–65.
10. Sjostrom L, Gummesson A, Sjostrom CD, Narbro K, Peltonen M, Wedel H et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol 2009; 10: 653–662.
11. Sjöström L et al ( 2013), Review of the key results from the Swedish Obese Subjects (SOS) trial – a prospective controlled intervention study of bariatric surgery; Journal of internal medicine, Volume 273, Issue 3 March 2013 Pages 219–234
12. Pharmaceutical Benefits Advisory Committee, October 2017.
