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Lifestyle factors only get you so far. To prevent the children who are obese today from becoming adults who are obese in the next 10 years, you have to offer treatment. It’s the only way.
ACCORDING TO THE latest estimates, only one in every 10 Irish men will not be overweight or obese by 2030.
By 2025, we’re set to be one of the most overweight nations in Europe. Already, six in every 10 people in Ireland are overweight.
The HSE says that the cost of adult obesity in Ireland is estimated to be €1.3 billion per annum, €400 million of which is direct healthcare costs. That figure could rise even further in the future, as the population’s weight increases.
While a number of prevention strategies are essential, some doctors say that for people who are already obese, it is already too late.
As a result, a disparate group of health organisations, including Diabetes Ireland, the Irish Society for Clinical Nutrition and Metabolism and Irish Nutrition and Dietetic Institute, are calling on the government and HSE to introduce a variety of health interventions for overweight or obese people, with surgery one of the main options put forth.
They say that, from a public health and economic point of view, their case is compelling.
“No way of avoiding it”
Dr Grace O’Malley lectures at the Royal College of Surgeons in Ireland and also works at Temple Street Children’s University Hospital.
She told TheJournal.ie that there is a cost-effectiveness in providing surgery for obese people, particularly those with type-2 diabetes, that hasn’t yet been fully explored in Ireland.
O’Malley said that a coordinated approach of GP care, dietitians, chartered physios and clinical psychologists could all play a role, as could surgical interventions.
“The idea of willpower and individual responsibility works to a point,” she said. “When a disease like obesity has ingrained itself in the body to an extreme level, reversing it through lifestyle approaches becomes harder and harder.
Look to the evidence, currently it suggests that bariatric procedures are effective at reducing morbidity and reducing mortality. It’s actually saving money in the long run because you’re not spending on medication.
So what is bariatric surgery? It can take several different forms. The gold standard surgery comes in two forms – a gastric bypass or gastresctomy – and both are minimally invasive. Within a year of treatment, a patient’s excess body weight can be cut in half.
Helen Heneghan, bariatric surgeon at St Vincent’s Hospital and St Columcille’s Hospital in Dublin, told TheJournal.ie that the results for obese patients with type-2 diabetes can be drastic.
She said: “Within 24 hours of a gastric bypass for example, we routinely see patients achieve normal blood sugars by the following morning. At least 80% of patients can achieve that a year after surgery. We know five years after that a patient may need medication, but they don’t go back on insulin.
There’s a strong health and economic argument. If you can reduce the cost of treating a type-2 diabetic overnight, it’s quite clear what we need to do.
Huge savings
Up to now, these surgeries have been performed rarely in Ireland. We do just one of these surgeries per 100,000 population here. It’s 20 times that in the UK. It’s around 80 times that in Sweden.
These doctors, in citing evidence to support their case, mainly draw on international examples but also say that research on the surgeries performed last year in Ireland support their case too.
Taking 15 patients, with hard-to-treat type-2 diabetes, who received bariatric surgery in 2016, a comparison was made between how much they spent on insulin before and how they spent after.
O’Malley said: “Beforehand, they were spending an estimated €8 per day for insulin. After the surgery they were, on average, spending 23 cent a day. And that’s an immediate reduction of 97%. That’s a huge amount.”
Both O’Malley and Heneghan said they wished they could provide more data but, despite hundreds of people on waiting lists, the number of bariatric procedures performed last year was extremely low.
Heneghan said that only being able to provide data from 15 patients was “dismal” while O’Malley said “it’s a shame but that’s all we’ve done”.
Heneghan went on: “No drug treatment can put diabetes into remission like that. It’s a chronic, relentless disease that often leads to damaging, and quite costly, complications.
Things like cardiovascular disease, stroke. It’s hugely costly to our health service.
Funding
The main barrier to more surgeries being done in Ireland at the moment is funding.
The HSE launched a 10-year plan last year to fight obesity in Ireland, and recently appointed the first national clinical lead in this area, Professor Donal O’Shea.
“But the new clinical lead is going to need support,” O’Malley said. “This condition has only really developed over the last 20 years. Financial support is needed to do what needs to be done.”
According to estimates based on figures from the World Health Organisation, the World Bank and an in-depth study of when the surgeries began to be routinely performed in Australia, it would cost about €400 million of investment into providing these surgeries on a wider level nationwide.
“There’s a lot of evidence to show investment will make a difference,” O’Malley said.
Medication savings alone are a really good argument. And that’s not counting the savings from people not requiring treatment for obesity-related conditions. We’ve kicked our heels for too long. For a lot of people, it may already too late.
How many would benefit?
According to figures provided by Diabetes Ireland, there are around 26,000 people in the country with type-2 diabetes who are obese.
“The vast majority of these people would benefit from surgery in the near future,” Heneghan said.
“We want to get to a point of 100 cases a year,” she said. “But we could easily justify 400 cases a year in Ireland.”
Only two publicly-funded hospitals offer such surgeries – in Galway and Dublin – but of the relatively small number of people on the waiting list, some have been waiting a long time for treatment.
“There around 400 people on waiting lists for bariatric surgery in the country right now,” Heneghan said. “And some of those would have been waiting for five or six years.”
“Did it to themselves?”
If the most cost-effective treatment solution is so apparent, then why don’t we offer it routinely in Ireland?
According to the doctors, there are a number of reasons for this and it is partly related to the way society views people with obesity.
Routinely, according to scientific literature cited by the doctors, people who are overweight are told to simply change lifestyle factors and there may be a perception that they “did it to themselves”.
Not so, according to O’Malley. She said: “There are ingrained judgemental attitudes and negative stigma towards people of larger size.
For those of us working in the area, anyone who’s honest would say that when they began working in this field, they’d be quite judgemental too.
She said that it is important to treat obesity as a disease, and approach treatment options to it as such.
“Obesity is now linked with deprivation,” O’Malley said. “Where there is lower socio-economic status, children are twice as likely to be obese. That can’t be ignored.
If we were talking about the management of cancer, or other chronic disease, thankfully we’ve got to a stage where depending on the stage of that cancer, we have different treatments to offer that person. We don’t – and shouldn’t – withhold treatment based on their disease.
Heneghan added that, for these surgical interventions to be the most effective, action must be taken now.
“There may be tens of thousands who could benefit,” she said. “We know that if you delay surgery, not only do the costs of treating patients medically accumulate, the likely benefit of the surgery reduced.”
For its part, the HSE said it is committed to following through on its 10-year action plan.
Taking his new role as the HSE’s clinical lead in obesity, Professor O’Shea cited lifestyle factors as important but said that there was “no magic bullet” to fixing the problems.
He said: “Somehow we have to get this whole of government, whole of industry and whole of society approach to come alive – and take obesity on.”
Heneghan added that, with current trends only going upwards in terms of the number of people in Ireland who are overweight or obese, the time to act is now:
We have a window of opportunity over the next few years. We need to seize it before it’s too late.
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