Bariatric surgery aids joint replacement outcomes
31 March 2016
Joint replacement surgery is common and obesity is common and obesity is a known risk factor for Osteoarthritis of the weight bearing joints. This study asks the question whether Bariatric surgery (including Gastric Bypass, Sleeve Gastrectomy or Gastric Banding) to help patients to lose significant amounts of weight before undergoing orthopedic surgery has any cost effectiveness associated with it. Obviously public hospitals are most interested in the bottom line of healthcare costs, along with good outcomes for the patients. There are a lot of examples where spending more money up front results in spending less money over the longer term. These sorts of studies are critical in putting that theory to the test. It is hard to convince the financial bods in public hospitals to do more bariatric surgery with the promise of saving more long term unless you have the evidence to back up your claims. But this is one of those situations that performing Bariatric surgery in the first instance may mean fewer patients going on to need joint replacements or better outcomes for those that do have their orthopedic surgery 2 years later and ultimately saving the Public Health System money overall. This is an intelligent way to approach a medical dilemma and looks at treating the whole person and their medical issues rather than just focussing on the joint that needs replacing. I like it!
Two studies at Hospital for Special Surgery (HSS) in New York City have found that bariatric surgery prior to joint replacement is a cost-effective option to improve outcomes after hip or knee replacement. The papers, ‘Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese’ and ‘Cost-Effectiveness of Bariatric Surgery Prior to Total Hip Arthroplasty in Morbidly Obese Patients’ were presented at the annual meeting of the American Academy of Orthopaedic Surgeons in Las Vegas.
"Up to 50 percent of hip replacements are performed in obese patients at some institutions," said Dr Emily Dodwell, an orthopaedic surgeon at HSS and lead investigator. "Obesity is associated with longer hospital stays, higher overall costs and higher failure rates, necessitating costly revision surgery."
It is well-known that obesity takes a toll on one's health. Bariatric surgery and subsequent weight loss reduces the risk of heart disease, diabetes and even some forms of cancer. But the effect of bariatric surgery on joint replacement outcomes was not known, and the HSS investigators set out to determine the costs and benefits of weight-loss surgery prior to knee replacement and the costs and benefits before hip replacement.
"We know that bariatric surgery is a cost-effective intervention for morbid obesity," said Dr Alexander McLawhorn, a chief orthopaedic surgery resident at HSS and study author. "Yet, the cost-effectiveness of bariatric surgery to achieve weight loss prior to joint replacement and thus decrease the associated complications and costs in morbidly obese patients was unknown."
Investigators used a software program to compare the cost-utility of two treatment protocols for patients who were considered morbidly obese and had advanced knee or hip osteoarthritis. One group had joint replacement immediately, without losing weight. The other group had bariatric surgery, followed by hip or knee replacement two years later. Patients typically lose weight during this time period.
Study patients had a BMI 40 or a BMI>35 and at least one other serious obesity-related health problem. For study purposes, researchers assumed that at least one-third of patients having bariatric surgery lost their excess weight prior to undergoing joint replacement.
"Our findings indicate that surgical weight loss prior to joint replacement is likely a cost-effective option from a public payer standpoint in order to improve outcomes in obese patients who are candidates for joint replacement," said Dodwell. "Some health care systems do not include weight loss surgery as a covered benefit, and it is possible that studies such as this will be helpful in re-evaluating whether weight loss surgery may be a reasonable covered benefit."
McLawhorn noted that for some patients experiencing severe knee or hip pain, it may be impractical to hold off on joint replacement. He adds that many times, an orthopaedic surgeon is the first doctor such a patient sees for arthritis pain.
"Ideally, a team approach would be used to treat morbidly obese patients with hip and knee arthritis in which various health care professionals are in place to help a patient lose weight, improve his or her health, and optimise nutrition before joint replacement to maximize its benefits," he said.
Middlemore Hospital Bariatric Television Programme
16 February 2016
Hope you all will be tuning into The Big Ward on television tonight like I will. I work at Middlemore Hospital so have been involved with the filming of this programme over the last year along with Richard Babor and my other colleagues in the department. It is a serious subject but has been a lot of fun. It will be nice to give people an up close and personal look at the Bariatric Journey. The patients have been amazingly generous to allow their lives to be filmed and screened on prime time television. It will certainly generate a lot of discussion and may take away some of the barriers that stop people who would benefit significantly from surgery from coming forwards. Anyway, see what you think!
StephRead more here
Food addiction - craving may be hard-wired in the brain
14 January 2016
This study backs up something that I observe in my clinic regularly. Some of my patients tell me they don't have an 'off switch' when it comes to eating and they feel hungry all the time! This does suggest that there is a brain 'overdrive' going on and contributing to their increased calorie intake. The interesting thing is that following bariatric surgery in the majority of patients, this feeling goes away. Very few patients wake up saying that they feel hungry! Appetite suppression is a well known phenomenon following bariatric surgery and is likely to do with the removal of a large amount of the stomach derived hormones that stimulate appetite. The brain, however, also has a role and this study is investigating that. Imagine if in the future we have a treatment that can assist with weight loss by stimulating or suppressing parts of the brain. The potential for future developments of treatment of obesity are endless but still futuristic. The fact still remains that Bariatric surgery including Lap band, Gastric Sleeve and Bypass operations are the best treatments we have for obesity. But watch this space..!
An international group of researchers have found that food craving activates different brain networks between obese and normal weight patients, indicating that the tendency to want food may be 'hard-wired' into the brain of overweight patients, becoming a functional brain biomarker. The mechanisms associated with the desire to eat are poorly understood, although recent studies are beginning to suggest that the brain mechanisms underlying obesity may be similar to those in substance addiction, and that treatment methodologies may be approached in the same way as other substance addictions, such as alcohol or drug addiction.
"There is an ongoing controversy over whether obesity can be called a ‘food addiction’, but in fact there is very little research which shows whether or not this might be true,” said lead researcher, Oren Contreras-Rodríguez from Bellvitge Hospital, Bellvitge, Spain. “The findings in our study support the idea that the reward processing following food stimuli in obesity is associated with neural changes similar to those found in substance addiction. This still needs to be viewed as an association between food craving behaviour and brain changes, rather than one necessarily causing the other. However, these findings provide potential brain biomarkers which we can use to help manage obesity, for example through pharmacotherapies and brain stimulation techniques that might help control food intake in clinical situations."
Presenting their paper, ‘Brain correlates of the desire to food predict body mass index change in excess weight adults’, at the European College of Neuropsychopharmacology's annual conference in Amsterdam, the researchers from the University of Granada, Spain, and Monash University in Australia, looked for the functional connectivity differences in brain reward systems of normal-weight and obese individuals. In particular, it examined the association between the functional connectivity of the reward-based striatal brain networks during rest and the desire to high calorie food in excess relative to normal weight individuals, and whether such brain correlates predict weight increases in the excess weight individuals.
The study involved 81 participants (participants with overweight/ obesity = 39; normal-weight participants = 42) aged 33.34 years (46.9% women). Ventral and dorsal striatal connectivity were investigated using a validated seed-based multiple regression method. The resulting connectivity maps were compared between the study groups using two-sample models. Moreover, connectivity maps were explored in relation with the desire to consume high-calorie food-items, previously tasted in a previous buffet, and BMI change after a three-months diet using correlation and regression analyses, respectively.
The researchers gave buffet-style food to 39 obese and 42 normal-weight individuals. Later, they were put into functional MRI brain scanners and shown photographs of the food to stimulate food craving. The functional MRI scans showed that food craving was associated with different brain connectivity, depending on whether the subject was normal-weight or overweight.
They found that in obese individuals, the stimulus from food craving was associated with a greater connectivity between the dorsal caudate and the somatosensory cortex, implicated in reward-based habits and the coding of the energetic value of foods, respectively. However, with normal weight individuals, food craving was associated with a greater connectivity between different parts of the brain - between the ventral putamen and the orbitofrontal cortex.
The researchers then measured BMI three months afterwards and found that 11% of the weight gain in the obese individuals could be predicted by the presence of the increased connectivity between the dorsal caudate and the somatosensory cortex areas of the brain.
The researchers say the findings may point the way to using brain scans to diagnose the way some people respond to food, and new drug or brain stimulation treatments for obesity.
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