Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation

Economic Evaluations of Anti-obesity Interventions in Obese Adults: An Umbrella Review

This umbrella review amalgamates the outcomes of economic evaluations pertaining to bariatric surgeries, pharmacotherapy, and gastric balloon for adult obesity treatment. Six databases were systematically searched. The inclusion criteria were established following the Patient/population Intervention Comparison and Outcomes (PICO) statement. Fifteen reviews met all the inclusion criteria. Eight studies focused on surgical interventions, four on pharmacotherapy, and three on both interventions. No systematic review of the economic evaluation of gastric balloons was identified. The majority of reviews advocated bariatric surgery as a cost-effective approach; however, there was discordance in the interpretation of pharmacological cost-effectiveness. Most of the economic evaluations were conducted from the payer and the healthcare system perspectives. We propose that future economic evaluations assessing weight loss interventions in adults adopt a societal perspective and longer-term time horizons.

Cost-effectiveness of metabolic surgery for the treatment of type 2 diabetes and obesity: a systematic review of economic evaluations

AIM

To systematically identify and appraise the international literature on the cost-effectiveness of metabolic surgery for the treatment of comorbid type 2 diabetes (T2D) and obesity.

METHODS

A systematic search was conducted in electronic databases and grey literature sources up to 20 January 2021. Economic evaluations in a T2D population or a subpopulation with T2D were eligible for inclusion. Screening, data extraction, critical appraisal of methodological quality (Consensus Health Economic Criteria list) and assessment of transferability (International Society for Pharmacoeconomics and Outcomes Research questionnaire) were undertaken in duplicate. The incremental cost-effectiveness ratio (ICER) was the main outcome. Costs were reported in 2020 Irish Euro. Cost-effectiveness was interpreted using willingness-to-pay (WTP) thresholds of €20,000 and €45,000/quality-adjusted life year (QALY). Due to heterogeneity arising from various sources, a narrative synthesis was undertaken.

RESULTS

Thirty studies across seventeen jurisdictions met the inclusion criteria; 16 specifically in a T2D population and 14 in a subpopulation with T2D. Overall, metabolic surgery was found to be cost-effective or cost-saving. Where undertaken, the results were robust to sensitivity and scenario analyses. Of the 30 studies included, 15 were considered high quality. Identified limitations included limited long-term follow-up data and uncertainty regarding the utility associated with T2D remission.

CONCLUSION

Published high-quality studies suggest metabolic surgery is a cost-effective or cost-saving intervention. As the prevalence of obesity and obesity-related diseases increases worldwide, significant investment and careful consideration of the resource requirements needed for metabolic surgery programmes will be necessary to ensure that service provision is adequate to meet demand.

A review on the beneficial effects of bariatric surgery in the management of obesity

INTRODUCTION

Obesity is a chronic disease with a complex interplay of multiple factors such as genetic, metabolic, behavioral, and environmental factors. The management of obesity includes; lifestyle modification, psychological therapy, pharmacological therapy, and bariatric surgery. To date, bariatric surgery is the most effective treatment for obesity by offering a long-term reduction in weight, remission of obesity-related complications, and improving quality of life. However, bariatric surgery is not equally effective in all patients. Thus, if we can predict who would benefit most, it will improve the risk versus benefit ratio of having surgery.

AREAS COVERED

In this narrative review, we explore the question on who will benefit the most from bariatric surgery by examining the recent evidence in the literature. In addition, we investigate the predisposing predictors of bariatric surgery response. Finally, we offer the best strategies in the clinic to explain the potential benefits of bariatric surgery to patients.

EXPERT OPINION

Bariatric surgery is an effective obesity management approach. Despite its efficacy, considerable variation of individual response exists. Thus, it is important to recognize patients that will benefit most, but at present very few predictors are available which can be clinically useful.

Implications of Bariatric Surgery on the Pharmacokinetics of Antiretrovirals in People Living with HIV

Bariatric surgery is increasingly applied among people living with HIV to reduce obesity and the associated morbidity and mortality. In people living with HIV, sufficient antiretroviral exposure and activity should always be maintained to prevent development of resistance and disease progression. However, bariatric surgery procedures bring various gastrointestinal modifications including changes in gastric volume, and acidity, gastrointestinal emptying time, enterohepatic circulation and delayed entry of bile acids. These alterations may affect many aspects of antiretroviral pharmacokinetics. Some drug characteristics may result in subtherapeutic exposure and the potential related risk of treatment failure and resistance. Antiretrovirals that require low pH, administration of fatty meals, longer intestinal exposure, and an enterohepatic recirculation for their absorption may be most impacted by bariatric surgery procedures. Additionally, some antiretrovirals can interact with the polyvalent cations in supplements or drugs inhibiting gastric acid, thereby preventing their use as these comedications are commonly prescribed post-bariatric surgery. Predicting pharmacokinetics on the basis of drug characteristics solely proved to be challenging, therefore pharmacokinetic studies remain crucial in this population. Here, we discuss general implications of bariatric surgery on antiretroviral outcomes in people living with HIV as well as drug properties that are relevant for the choice of antiretroviral treatment in this special patient population. Additionally, we summarise studies that evaluated the pharmacokinetics of antiretrovirals post-bariatric surgery. Finally, we performed a comprehensive analysis of theoretical considerations and published pharmacokinetic and pharmacodynamic data to provide recommendations on antiretrovirals for people living with HIV undergoing bariatric surgery.

Equitability of Individual and Population Interventions to Reduce Obesity: A Modeling Study in Mexico

INTRODUCTION

Modeling studies have estimated the potential impact and cost effectiveness of interventions to reduce obesity; few have focused on their equity across socioeconomic groups. This study aims to compare the equitability of individual- and population-level interventions to reduce obesity in Mexico.

METHODS

Mathematical models were implemented to estimate the expected effect of 2 sugar-sweetened beverage tax scenarios (10% and 20%) and bariatric surgery, pharmacotherapy, and dietary advice as individual interventions to reduce body weight. Individual interventions were modeled using meta-analytical weight change, inclusion and exclusion criteria, and the probability of access to healthcare services. For the tax, investigators obtained the baseline consumption of sugar-sweetened beverages from the National Health Survey 2012 and applied the reduction in sales observed in 2016 to estimate the caloric change and weight reduction. Implementation costs and cost per person, per kilogram, and equity were calculated for all interventions over a 1-year timeframe.

RESULTS

The 20% tax produced the largest estimated increase (4.50%) in normal BMI prevalence, was the most cost effective, and had the largest and most equitable decrease in obesity across socioeconomic categories. Pharmacotherapy and bariatric surgery produced sizable decreases in obesity prevalence (3.68% and 1.18%), particularly among the middle and high socioeconomic groups, whereas dietary advice had the lowest impact on normal and obese categories.

CONCLUSIONS

Individual interventions were effective in reducing obesity; yet, they were more expensive and less equitable than population interventions. Obesity in Mexico affects all socioeconomic groups; available interventions need to be carefully analyzed to tailor a national strategy that is both effective and equitable.

A Meal Replacement Program for the Treatment of Obesity: A Cost-Effectiveness Analysis from the Swiss Payer's Perspective

BACKGROUND

Obesity is a disease associated with high direct medical costs and high indirect costs resulting from productivity loss. The high prevalence of obesity generates the need for payers to identify cost-effective weight loss approaches. Among various weight management techniques, the OPTI (Optifast®) program is a clinically recognised total meal replacement diet that can lead to significant weight loss and reduction in complications. This study's objective is to assess OPTI program's cost-effectiveness in Switzerland in comparison to "no intervention" and pharmacotherapy.

METHODS

An event-driven decision-analytic model was used to estimate the payer's cost savings through the reimbursement of OPTI program over a 1-year period as well as a lifetime in Switzerland. The analysis was performed on a broad population of people with obesity with a body mass index (BMI) higher than 30 kg/m2 following the OPTI program vs two comparators (liraglutide and "no intervention"). The model incorporated a higher risk of complications due to an increased BMI and their related healthcare costs. Data sources included published literature, clinical trials, official Swiss price/tariff lists and national population statistics. The primary perspective was that of a Swiss payer. Scenario analyses - for example, for patients with existing complications (such as myocardial infarction, stroke, type 2 diabetes mellitus) or severe obesity - were conducted to test the robustness of the results.

RESULTS

The OPTI program results in cost savings of CHF 20,886 (€ 18,724) and CHF 15,382 (€ 13,790) per person compared with "no intervention" and liraglutide 3 mg, respectively. In addition, OPTI program led to 1.133 and 0.734 quality-adjusted life years (QALYs) gained respectively against its comparators. Scenario analyses showed similar outcomes with cost savings and QALYs gained.

CONCLUSION

OPTI program is a dominant strategy compared to "no intervention" and liraglutide 3 mg as it leads to both cost savings and QALY gain. Therefore, reimbursing the OPTI program for patients with obesity would be cost-effective for Swiss payers.

Effect of Roux-en-Y gastric bypass on pharmacologic dependence in obese patients with type 2 diabetes

Background

More than half the diabetes-related health care costs in Canada relate to drug costs. We aimed to determine the effect of Roux-en-Y gastric bypass (RYGB) on the use of insulin and orally administered hypoglycemic medications in patients with diabetes. We also looked to determine overall cost savings with the procedure.

Methods

We reviewed the bariatric clinic records of all patients with a confirmed diagnosis of type 2 diabetes mellitus who underwent RYGB between 2010/11 and 2014/15. Percentage estimated weight loss was recorded at 1 year, along with reductions in glycated hemoglobin (HbA1c) level and use of oral hypoglycemic therapy and insulin. We estimated medication costs using Manitoba-specific pricing data.

Results

Fifty-two patients with at least 12 months of complete follow-up data were identified. The mean percentage estimated weight loss was 50.2%. The mean HbA1c level decreased from 7.6% to 6.0%, the mean number of orally administered hypoglycemics declined from 1.6 to 0.2, and the number of patients receiving insulin decreased from 18 (35%) to 3 (6%) (all p < 0.001). The rate of resolution of type 2 diabetes was 71%. Estimated mean annual per-patient medication costs decreased from $508.56 to $79.17 (p < 0.001). Potential overall health care savings could total $3769 per patient in the first year, decreasing to $1734 at 10 years.

Conclusion

Roux-en-Y gastric bypass resulted in significant improvement in diabetic control, with a reduction in hypoglycemic medication use and associated costs in the early postoperative period. Potentially, large indirect and direct cost savings can be realized in the longer term.

A health economic model to assess the cost-effectiveness of OPTIFAST for the treatment of obesity in the United States

OBJECTIVES

Obesity is associated with high direct medical costs and indirect costs resulting from productivity loss. The high prevalence of obesity generates a justified need to identify cost-effective weight loss approaches from a payer's perspective. Within the variety of weight management techniques, OPTIFAST is a clinically recognized and scientifically proven total meal replacement Low Calorie Diet that provides meaningful results in terms of weight loss and reduction in comorbidities. The objective of this study is assess potential cost-savings of the OPTIFAST program in the US, as compared to "no intervention" and pharmacotherapy.

METHODS

An event-driven decision analytic model was used to estimate payer's cost-savings from reimbursement of the 1-year OPTIFAST program over 3 years in the US. The analysis was performed for the broad population of obese persons (BMI >30 kg/m²) undergoing the OPTIFAST program vs liraglutide 3 mg, naltrexone/bupropion and vs "no intervention". The model included the risk of complications related to increased BMI. Data sources included published literature, clinical trials, official US price/tariff lists, and national population statistics. The primary perspective was that of a US payer; costs were provided in 2016 US dollars.

RESULTS

OPTIFAST leads over a period of 3 years to cost-savings of USD 9,285 per class I and II obese patient (BMI 30-39.9 kg/m²) as compared to liraglutide and USD 685 as compared to naltrexone/bupropion. In the same time perspective, the OPTIFAST program leads to a reduction of cost of obesity complications of USD 1,951 as compared to "no intervention", with the incremental cost-effectiveness ratio of USD 6,475 per QALY. Scenario analyses also show substantial cost-savings in patients with class III obesity (BMI ≥ 40.0 kg/m²) and patients with obesity (BMI = 30-39.9 kg/m²) and type 2 diabetes vs all three previous comparators and bariatric surgery.

CONCLUSIONS

Reimbursing OPTIFAST leads to meaningful cost-savings for US payers as compared with "no intervention" and liraglutide and naltrexone/bupropion in obese patients. Similar results can be expected in matching healthcare settings of other countries. Moreover, OPTIFAST has additional clinical and economic advantages through very low complication and adverse events rates.

Oroxylum indicum (L.) Kurz extract inhibits adipogenesis and lipase activity in vitro

Background

Oroxylum indicum (L.) Kurz (O. indicum) is found in Thailand. It has been used for the treatment of obesity. This study aimed to investigate the effects of an O. indicum extract (OIE) on the adipogenic and biomolecular change in 3T3-L1 adipocytes.

Methods

Initial studies examined the chemical components of OIE. The cell line 3T3-L1 was used to establish potential toxic effects of OIE during the differentiation of pre-adipocytes to adipocytes. The inhibitory effect of OIE on lipid accumulation in 3T3-L1 cells was investigated. Moreover, the impact of OIE on pancreatic lipase activity was determined. In further experiments, Fourier Transform Infrared (FTIR) was used to monitor and discriminate biomolecular changes caused by the potential anti-adipogenic effect of OIE on 3T3-L1 cells.

Results

Chemical screening methods indicated that OIE was composed of flavonoids, alkaloids, steroids, glycosides, and tannins. The percentage viability of 3T3-L1 cells was not significantly decreased after exposure to either 200 or 150 μg/mL of OIE for 2 and 10 days, respectively compared to control cells. The OIE exhibited a dose-dependent reduction of lipid accumulation compared to the control (p < 0.05). The extract also demonstrated a dose-dependent inhibitory effect upon lipase activity compared to the control. The inhibitory effect of the OIE on lipid accumulation in 3T3-L1 cells was also confirmed using FTIR microspectroscopy. The signal intensity and the integrated areas relating to lipids, lipid esters, nucleic acids, glycogen and carbohydrates of the OIE-treated 3T3-L1 adipocytes were significantly lower than the non-treated 3T3-L1 adipocytes (p < 0.05). Principal component analysis (PCA) indicated four distinct clusters for the FTIR spectra of 3T3-L1 adipocytes based on biomolecular changes (lipids, proteins, nucleic acids, and carbohydrates). This observation was confirmed using Unsupervised hierarchical cluster analysis (UHCA).

Conclusions

These novel findings provide evidence that the OIE derived from the fruit pods of the plant is capable of inhibiting lipid and carbohydrate accumulation in adipocytes and also has the potential to inhibit an enzyme associated with fat absorption. The initial observations indicate that OIE may have important properties which in the future may be exploited for the management of the overweight or obese.

Systematic assessment of decision analytic models for the cost-effectiveness of bariatric surgery for morbid obesity

Bariatric surgery among patients with morbid obesity is very effective for providing long-term weight loss and remission of obesity-related co-morbidities. However, it is very expensive and its cost effectiveness is commonly argued. Long-term cost-effectiveness evaluations of bariatric surgery have often relied on decision models. A systematic review was performed on the methodologic approaches and their quality, evaluated the quality of reporting, and summarized findings and conclusions in published cost-effectiveness models of bariatric surgery for morbid obesity. A search from different databases with an end date of October 15, 2017 was completed. The initial search for title and abstract screening resulted in 741 articles. A total of 50 articles were included for full-text review and 23 economic evaluation studies were included in the systematic review. The reporting quality scores of most articles were rated as acceptable between 61% and 100%. Most studies (89%) were modeled for adult patients with age range between 25 and 75 years old. Sixty-one percent of studies defined their health states by the existence or absence of different obesity-related co-morbidities. Eleven percent of studies took the societal perspective. Most studies (61%) used a lifetime horizon. Thirty-nine percent of studies identified the extent of weight loss as the most sensitive and influential parameter. Seventeen (74%) did not report a formal model validation. Laparoscopic Roux-en-Y gastric bypass was reported as the most cost-effective strategy most often when it compared with no treatment or medical management. While most had acceptable quality of reporting levels, several gaps in the quality of reporting and quality of methods emerged, which led to recommendations for how to improve quality in future studies.

Cost-effectiveness of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass in two hospitals of Tehran city in 2014

Background: Bariatric surgery with the improvement of obesity-related diseases, increases longevity and quality of life and is more cost-effective when compared to non-surgical Procedures. Objective: The aim of this study is to compare the cost-effectiveness of Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB).

METHOD

This study was performed in two stages. Initially, a cross-sectional study was carried out for costing LSG and LRYGB in Rasoul Akram and Bahman hospitals in Tehran in the year 2014. Direct costs for each surgical procedure were calculated according to the average time of surgery in both the private and public sectors. In the second stage, using Outcome (ΔBMI) collected by means of a systematic review study and cost data; cost effectiveness of two surgical procedures was examined by ICER analysis and compared with threshold limit. The Perspective of this analysis was health system. Results: The direct cost of services for LRYGB was $ 2991.5 (98121659 Rials) in the public sector and $4221.9 in the private sector. In LSG, it was $ 1952.9 (64055468 R) in the public sector and $ 3177.2 in the private sector. ICER for LSG was 720.48(23631855 R) and $716.27 (23493924 R) in private and public sector respectively. Conclusion: In this study, LSG procedure when compared to LRYGB was cost effective. The ICER obtained indicated that LSG surgery in comparison to LRYGB was $716.27 (23493924 R) and $720.48(23631855 R) in the public and private sector respectively. Moreover, per unit change in BMI was less than the threshold.

The Effectiveness of Screening for Obesity in Primary Care: Weighing the Evidence

In response to growing alarm about the increase in the prevalence of obesity in the United States, several organizations have recommended that physicians screen their adult patients for this condition and initiate treatment. Screening can be an effective intervention when the condition is grave and prevalent, when an accurate test exists, when effective treatment exists, when the screening program itself does not pose undue risks, and when early detection and treatment improve outcomes. This article critically reviews the evidence supporting these criteria in the case of obesity in adults. It extends previous reviews by assessing the potential impact that uncertainties in the evidence base may have on the effectiveness a screening program. It also examines the feasibility of such a program. We conclude that following the recommendation to screen all adults for obesity is unlikely to improve outcomes.

Costs and outcomes of increasing access to bariatric surgery for obesity: cohort study and cost-effectiveness analysis using electronic health records

Background

Bariatric surgery is known to be an effective treatment for extreme obesity but access to these procedures is currently limited.

Objective

This study aimed to evaluate the costs and outcomes of increasing access to bariatric surgery for severe and morbid obesity.

Design and methods

Primary care electronic health records from the UK Clinical Practice Research Datalink were analysed for 3045 participants who received bariatric surgery and 247,537 general population controls. The cost-effectiveness of bariatric surgery was evaluated in severe and morbid obesity through a probabilistic Markov model populated with empirical data from electronic health records.

Results

In participants who did not undergo bariatric surgery, the probability of participants with morbid obesity attaining normal body weight was 1 in 1290 annually for men and 1 in 677 for women. Costs of health-care utilisation increased with body mass index category but obesity-related physical and psychological comorbidities were the main drivers of health-care costs. In a cohort of 3045 adult obese patients with first bariatric surgery procedures between 2002 and 2014, bariatric surgery procedure rates were greatest among those aged 35–54 years, with a peak of 37 procedures per 100,000 population per year in women and 10 per 100,000 per year in men. During 7 years of follow-up, the incidence of diabetes diagnosis was 28.2 [95% confidence interval (CI) 24.4 to 32.7] per 1000 person-years in controls and 5.7 (95% CI 4.2 to 7.8) per 1000 person-years in bariatric surgery patients (adjusted hazard ratio was 0.20, 95% CI 0.13 to 0.30;p < 0.0001). In 826 obese participants with type 2 diabetes mellitus who received bariatric surgery, the relative rate of diabetes remission, compared with controls, was 5.97 (95% CI 4.86 to 7.33;p < 0.001). There was a slight reduction in depression in the first 3 years following bariatric surgery that was not maintained. Incremental lifetime costs associated with bariatric surgery were £15,258 (95% CI £15,184 to £15,330), including costs associated with bariatric surgical procedures of £9164 per participant. Incremental quality-adjusted life-years (QALYs) were 2.142 (95% CI 2.031 to 2.256) per participant. The estimated cost per QALY gained was £7129 (95% CI £6775 to £7506). Estimates were similar across gender, age and deprivation subgroups.

Limitations

Intervention effects were derived from a randomised trial with generally short follow-up and non-randomised studies of longer duration.

Conclusions

Bariatric surgery is associated with increased immediate and long-term health-care costs but these are exceeded by expected health benefits to obese individuals with reduced onset of new diabetes, remission of existing diabetes and lower mortality. Diverse obese individuals have clear capacity to benefit from bariatric surgery at acceptable cost.

Future work

Future research should evaluate longer-term outcomes of currently used procedures, and ways of delivering these more efficiently and safely.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. Martin C Gulliford and A Toby Prevost were supported by the NIHR Biomedical Research Centre at Guy’s and St Thomas’ Hospitals. Peter Littlejohns was supported by the South London Collaboration for Leadership in Applied Health Research and Care. The funders did not engage in the design, conduct or reporting of the research.

IV Acetaminophen Results in Lower Hospital Costs and Emergency Room Visits Following Bariatric Surgery: a Double-Blind, Prospective, Randomized Trial in a Single Accredited Bariatric Center

BACKGROUND

Postoperative pain control in bariatric surgery is challenging, despite use of intravenous (IV) narcotics. IV acetaminophen is one pain control alternative.

OBJECTIVE

The aim of this study was to investigate the economic impact of IV acetaminophen in bariatric surgery and its effect on patients' pain, satisfaction, and hospital length of stay.

METHODS

In a randomized controlled trial, Group 1 (treatment) received IV acetaminophen plus IV narcotics 30 min before surgery, then medication plus IV narcotics/PO narcotics for the remaining 18 h. Group 2 (control) received IV normal saline plus IV/PO narcotics. Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (SG). Primary outcomes included direct hospital costs, length of stay, postoperative pain, and patient satisfaction. Secondary outcomes included indirect costs, rescue narcotics dosage, and 30-day outcomes.

RESULTS

Mean direct hospital cost in the treatment group (n = 50) was $3089.18 versus $2991.62 for the control group (n = 50) (p > 0.05). Pain scores did not differ significantly (p = 0.61). After adjusting for surgery type, there was no significant difference in length of stay (p = 0.95). Significantly more control group patients incurred surgery-related indirect costs (10 versus 2%, p < 0.05), with greater presentation to the emergency department (ED) for abdominal pain (5/50 versus 1/50), yielding higher total indirect costs ($39,293 versus $13,185).

CONCLUSIONS

Using IV acetaminophen for postoperative pain management produced notable indirect cost savings and reduced ED visits in the first 30 days postoperatively, with good safety and tolerance. Decreased statistical power may have accounted for certain non-significant findings.

Bariatric surgery outcomes: a single-center study in the United Arab Emirates

BACKGROUND

Bariatric surgery has become an attractive treatment for severe obesity over the last decade, due to its impacts on weight loss and remission of type 2 diabetes and metabolic syndrome. In the United Arab Emirates, a country where the rate of obesity is dramatically increasing bariatric surgery has gained popularity in recent years; however, published data on its outcomes in the Emirati population are lacking.

METHODS

We retrospectively reviewed the medical records of 95 patients who underwent bariatric surgery (ie, laparoscopic Roux-en-Y gastric bypass [RYGB] or laparoscopic sleeve gastrectomy) at the Rashid Center for Diabetes and Research in Ajman, United Arab Emirates. Weight outcomes and metabolic marker data were abstracted at baseline and at 3, 6, and 12 months postoperatively.

RESULTS

Laparoscopic RYGB was the main procedure performed by our bariatric unit. All variables demonstrated postoperative improvement. An average excess weight loss of 68% was observed at 12 months. Fat mass was the body component that decreased the most, with an average reduction of 46%. Additionally, lipid profiles were significantly different (P<0.01) at 12 months, with triglyceride levels improving by 27% and low-density lipoprotein levels improving by 21%. Similarly, glycated hemoglobin (HbA1c) levels decreased significantly (P<0.001) in patients with type 2 diabetes, with an average reduction of 73%.

CONCLUSION

Our results show that a substantial short-term reduction in weight and significant improvements in metabolic markers followed bariatric surgery in severely obese Emirati patients. Our results are consistent with the outcomes of other internationally published studies. Additional studies are warranted to determine whether the favorable impacts of bariatric surgery can be sustained over the long term.

Surgery for weight loss in adults

BACKGROUND

Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009.

OBJECTIVES

To assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities.

SEARCH METHODS

Studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument.

MAIN RESULTS

Twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment.All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data.Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P < 0.00001; 265 participants; 3 trials; moderate quality evidence). Evidence for QoL and comorbidities was very low quality. The LRGYB procedure resulted in greater duration of hospitalisation in two RCTs (4/3.1 versus 2/1.5 days) and a greater number of late major complications (26.1% versus 11.6%) in one RCT. In one RCT the LAGB required high rates of reoperation for band removal (9 patients, 40.9%).Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB.  No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications.Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P < 0.00001; 107 participants; 2 trials; moderate quality evidence). QoL was similar on most domains. In one study between 82% to 100% of participants with diabetes had a HbA1c of less than 5% three years after surgery. Reoperations were higher in the BDDS group (16.1% to 27.6%) than the LRYGB group (4.3% to 8.3%). One death occurred in the BDDS group.One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group.One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group.One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence).  QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation.

AUTHORS' CONCLUSIONS

Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only.  Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.

Cost effectiveness of primary care referral to a commercial provider for weight loss treatment, relative to standard care: a modelled lifetime analysis

BACKGROUND

Because of the high prevalence of overweight and obesity, there is a need to identify cost-effective approaches for weight loss in primary care and community settings.

OBJECTIVE

To evaluate the long-term cost effectiveness of a commercial weight loss programme (Weight Watchers) (CP) compared with standard care (SC), as defined by national guidelines.

METHODS

A Markov model was developed to calculate the incremental cost-effectiveness ratio (ICER), expressed as the cost per quality-adjusted life year (QALY) over the lifetime. The probabilities and quality-of-life utilities of outcomes were extrapolated from trial data using estimates from the published literature. A health sector perspective was adopted.

RESULTS

Over a patient's lifetime, the CP resulted in an incremental cost saving of AUD 70 per patient, and an incremental 0.03 QALYs gained per patient. As such, the CP was found to be the dominant treatment, being more effective and less costly than SC (95% confidence interval: dominant to 6225 per QALY). Despite the CP delaying the onset of diabetes by ∼10 months, there was no significant difference in the incidence of type 2 diabetes, with the CP achieving <0.1% fewer cases than SC over the lifetime.

CONCLUSION

The modelled results suggest that referral to community-based interventions may provide a highly cost-effective approach for those at high risk of weight-related comorbidities.

The economic burden of self-reported and undiagnosed cardiovascular diseases and diabetes on Indonesian households

OBJECTIVES

The goal of this study is: (1) to estimate the current direct out-of-pocket (OOP) and indirect non-communicable diseases (NCD) burden on Indonesian households and (2) to project NCD prevalence and burden in 2020 focusing specifically on hypertension, diabetes, heart problems and stroke.

METHODS

This study relies on econometric analyses based on four waves of the Indonesian Family Life Survey (IFLS).

RESULTS

In aggregate, of the NCDs studied, heart problems exert the greatest economic burden on households, costing Int$1.56 billion in OOP and indirect burden in 2010. This was followed by hypertension (Int$1.36 billion), diabetes (Int$0.81 billion) and stroke (Int$0.29 billion). The OOP and indirect burden of these conditions is estimated to be Int$4.02 billion. Diabetes and stroke are expected to have the largest proportional increases in burden by 2020; 56.0% for diabetes and 56.9% for stroke to total Int$1.27 billion and Int$0.45 billion respectively. The burden of heart problems in 2020 is expected to increase by 34.4% to total Int$2.09 billion and hypertension burden will increase by 46.1% to Int$1.99 billion. In 2020, these conditions are expected to impose an economic burden of Int$5.80 billion.

CONCLUSION

In conclusion, this study demonstrates the significant burden of 4 primary NCDs on Indonesian households. In addition to the indirect burden, hypertension, diabetes, heart problems and stroke account for 8% of the nation's OOP healthcare expenditure, and due to rising disease prevalence and an aging population, this figure is expected to increase to 12% by 2020 without a significant health intervention.

Modelling the economics of type 2 diabetes mellitus prevention: a literature review of methods

Our objective was to review modelling methods for type 2 diabetes mellitus prevention cost-effectiveness studies. The review was conducted to inform the design of a policy analysis model capable of assisting resource allocation decisions across a spectrum of prevention strategies. We identified recent systematic reviews of economic evaluations in diabetes prevention and management of obesity. We extracted studies from two existing systematic reviews of economic evaluations for the prevention of diabetes. We extracted studies evaluating interventions in a non-diabetic population with type 2 diabetes as a modelled outcome, from two systematic reviews of obesity intervention economic evaluations. Databases were searched for studies published between 2008 and 2013. For each study, we reviewed details of the model type, structure, and methods for predicting diabetes and cardiovascular disease. Our review identified 46 articles and found variation in modelling approaches for cost-effectiveness evaluations for the prevention of type 2 diabetes. Investigation of the variables used to estimate the risk of type 2 diabetes suggested that impaired glucose regulation, and body mass index were used as the primary risk factors for type 2 diabetes. A minority of cost-effectiveness models for diabetes prevention accounted for the multivariate impacts of interventions on risk factors for type 2 diabetes. Twenty-eight cost-effectiveness models included cardiovascular events in addition to type 2 diabetes. Few cost-effectiveness models have flexibility to evaluate different intervention types. We conclude that to compare a range of prevention interventions it is necessary to incorporate multiple risk factors for diabetes, diabetes-related complications and obesity-related co-morbidity outcomes.

Clinical factors associated with weight loss outcomes after Roux-en-Y gastric bypass surgery

OBJECTIVE

Gastric bypass surgery is an effective therapy for extreme obesity. However, substantial variability in weight loss outcomes exists that remains largely unexplained. Our objective was to determine whether any commonly collected preoperative clinical variables were associated with weight loss following Roux-en-Y gastric bypass (RYGB) surgery.

METHODS

The analysis was based on a prospectively recruited observational cohort of 2,365 patients who underwent Roux-en-Y gastric bypass surgery from 2004 to 2009. Weight loss was stratified into three major phases, early (0-6 months), nadir, and long-term (>36 months). Multivariate regression models were constructed using a database of over 350 variables.

RESULTS

A total of 12-14 preoperative variables were independently associated (P < 0.05) with each of the temporal weight loss phases. Preoperative variables associated with poorer nadir and long-term weight loss included higher baseline BMI, higher preoperative weight loss, iron deficiency, use of any diabetes medication, nonuse of bupropion medication, no history of smoking, age >50 years, and the presence of fibrosis on liver biopsy.

CONCLUSIONS

Several variables previously associated with poorer weight loss after RYGB surgery including age, baseline BMI, and type 2 diabetes were replicated. Several others suggest possible clinical interventions for postoperative management of RYGB patients to improve weight loss outcomes.

Long-term outcomes of laparoscopic adjustable silicone gastric banding (LAGB) in moderately obese patients with and without co-morbidities

BACKGROUND

Overweight and obesity independently increase cardiovascular risk, while even modest weight loss can result in clinically significant improvements in cardiovascular risk and reduce long-term mortality. Lowering the body mass index (BMI) threshold for bariatric surgery to those with moderate obesity might be one way to lower the burden of this disease. The aim of this study was to evaluate the efficacy and safety of laparoscopic adjustable silicone gastric banding (LAGB) in moderately obese subjects with or without obesity-related co-morbidities.

METHODS

Thirty-four patients with BMI between 30 and 35 kg/m(2) (5 males/29 females, mean age 36 ± 10 years, mean preoperative weight 87.9 ± 7.1 kg, mean BMI 32.6 ± 1.6 kg/m(2) and mean percentage excess weight 48.7 ± 9 %) who underwent LAGB via pars flaccida between June 1, 2002 and August 31, 2010 were included. Good response was defined as BMI <30 kg/m(2) or percentage estimated weight loss (%EWL) >50. Poor response was defined as BMI >30 kg/m(2) or %EWL less than 50 after a minimum of 1 year.

RESULTS

Mean weight, BMI and %EWL were recorded at 1, 3, 5 and 7 years and were 77.4 ± 7.6, 69.9 ± 10.8, 70.9 ± 9.3 and 73.3 ± 12.0 kg; 28.8 ± 2.9, 26.4 ± 3.2, 26.5 ± 3.4 and 27.4 ± 5.0 kg/m(2); and 36 ± 23, 46.1 ± 33.8, 58.6 ± 31.5 and 45 ± 57, respectively (p < 0.01). Co-morbidities were diagnosed in 17/34 (50 %) patients at baseline and underwent remission or improvement in all cases after 1 year.

CONCLUSIONS

LAGB in a safe and effective procedure in patients with a BMI <35 kg/m(2).

The neurologic complications of bariatric surgery

Bariatric surgery has been increasingly employed to manage morbid obesity. Approximately 150000 bariatric procedures are performed in the US annually. Neurologic complications arise in as many as 5% of individuals having this surgery. Although the etiology of some of these complications remains obscure, the majority are the consequence of vitamin (most commonly thiamine and vitamin B12) or mineral (most commonly copper) deficiency and familiarity with these disorders is essential. Their rapid diagnosis and appropriate treatment is essential to avoid long-term, irreversible consequences including, in some instances, death.

Hematological variables and iron status in abdominoplasty after bariatric surgery

BACKGROUND

Abdominoplasty, the treatment for abdominal wall deformity stemming from weight loss after bariatric surgery, can cause postoperative anemia. Moreover, bariatric surgery has been associated with iron deficiency, which by itself can compromise erythropoiesis. The objective of this research is to describe the development of anemia after postbariatric abdominoplasty.

METHODS

The study group consisted of 32 adult women who had received bariatric surgery. Treatment group included 20 patients who were undergoing postbariatric abdominoplasty. Control group included 12 patients waiting for abdominoplasty. Values of hemoglobin, reticulocytes, iron, ferritin, and the transferrin saturation were obtained on the evening before abdominoplasty and during the first, fourth, and eighth postoperative weeks. Hemoglobin was measured at 48 h.

RESULTS

Mean hemoglobin levels for treatment group decreased from 12.98 to 10.8 g/dL after 48 h, increased on day 7 to 11.53 g/dL, but did not increase further after day 7. The reticulocyte number increased in the first week. Serum iron and transferrin saturation index fell during the first week and remained low. Ferritin levels increased non-significantly from 29.77 to 37.24 ng/mL at week 1, then fell until they were decreased (16.44 ng/mL) by day 56.

CONCLUSIONS

As expected, hemoglobin fell after abdominoplasty. However, after a one-third recovery of hemoglobin concentrations by week 1 postoperative, they failed to return to preoperative levels by the eighth week. Additionally, by the eighth postoperative week, 45 % of abdominoplasty patients had developed an iron deficiency and hemoglobin deficit that was higher than that of patients who maintained normal iron stocks.

The cost-effectiveness of laparoscopic adjustable gastric banding in the morbidly obese adult population of Australia

BACKGROUND

To examine the cost-effectiveness of providing laparoscopic adjustable gastric banding (LAGB) surgery to all morbidly obese adults in the 2003 Australian population.

METHODS AND FINDINGS

Analyzed costs and benefits associated with two intervention scenarios, one providing LAGB surgery to individuals with BMI >40 and another to individuals with BMI >35, with each compared relative to a 'do nothing' scenario. A multi-state, multiple cohort Markov model was used to determine the cost-effectiveness of LAGB surgery over the lifetime of each cohort. All costs and health outcomes were assessed from an Australian health sector perspective and were discounted using a 3% annual rate. Uncertainty and sensitivity analyzes were conducted to test the robustness of model outcomes. Incremental cost-effectiveness ratios (ICERs) were measured in 2003 Australian dollars per disability adjusted life year (DALY) averted. The ICER for the scenario providing LAGB surgery to all individuals with a BMI >40 was dominant [95% CI: dominant -$588] meaning that the intervention led to both improved health and cost savings. The ICER when providing surgery to those with a BMI >35 was $2,154/DALY averted [95% CI: dominant -$6,033]. Results were highly sensitive to changes in the likelihood of long-term complications.

CONCLUSION

LAGB surgery is highly cost-effective when compared to the $50,000/DALY threshold for cost-effectiveness used in Australia. LAGB surgery also ranks highly in terms of cost-effectiveness when compared to other population-level interventions for weight loss in Australia. The results of this study are in line with other economic evaluations on LAGB surgery. This study recommends that the Australian federal government provide a full subsidy for LAGB surgery to morbidly obese Australians with a BMI >40.

Bariatric surgery for adolescents

Obesity is no longer just an adult disease. An increasing number of youth are overweight, defined as body mass index (BMI) at or greater than the 95th percentile for age (1). Between 2009 and 2010, 16.9% of children aged 2–19 yr were classified as overweight based on BMI (2), as compared with only 5% of children affected by obesity in 1976–1980 (3). This is a problem of enormous proportion from a public health standpoint, as without intervention these children will grow up to become overweight and obese adults. For an obese child, the risk of becoming an obese adult may be as high as 77%, compared with 7%for a child of healthy weight (4). Morbid obesity is a major risk factor for later complications such as cardiovascular disease, type 2 diabetes, obstructive sleep apnea (OSA), polycystic ovary syndrome (PCOS), and degenerative joint disease (4–10). Obesity is also an expensive problem: the US government spends $147 billion yearly on obesity-related healthcare costs (11). Thus, there is an urgent need to target obesity in the pediatric population, before the expensive and life-threatening consequences of obesity manifest. Unfortunately, the effectiveness of medical treatments for obesity is limited. Behaviorally based dietary and physical activity interventions offer little benefit for pediatric obesity, while pharmacologic therapy is also limited and carries low success rates and recidivism (12–14) (Table 1).

Coding and Reimbursement for Weight Loss Surgery: Best Practice Recommendations

OBJECTIVE

To review the use and usefulness of billing codes for services related to weight loss surgery (WLS) and to examine third party reimbursement policies for these services.

RESEARCH METHODS AND PROCEDURES

The Task Group carried out a systematic search of MEDLINE, the Internet, and the trade press for publications on WLS, coding, reimbursement, and coding and reimbursement policy. Twenty-eight articles were each reviewed and graded using a system based on established evidence-based models. The Massachusetts Dietetics Association provided reimbursement data for nutrition services. Three suppliers of laparoscopic WLS equipment provided summaries of coding and reimbursement information. WLS program directors were surveyed for information on use of procedure codes related to WLS.

RESULTS

Recommendations focused on correcting or improving on the current lack of congruity among coding practices, reimbursement policies, and accepted clinical practice; lack of uniform coding and reimbursement data across institutions; inconsistent and/or inaccurate diagnostic and billing codes; inconsistent insurance reimbursement criteria; and inability to leverage reimbursement and coding data to track outcomes, identify best practices, and perform accurate risk-benefit analyses.

DISCUSSION

Rapid changes in the prevalence of obesity, our understanding of its clinical impact, and the technologies for surgical treatment have yet to be adequately reflected in coding, coverage, and reimbursement policies. Issues identified as key to effective change include improved characterization of the risks, benefits, and costs of WLS; anticipation and monitoring of technological advances; encouragement of consistent patterns of insurance coverage; and promotion of billing codes for WLS procedures that facilitate accurate tracking of clinical use and outcomes.

Bariatric surgery: cost-effectiveness and budget impact

Bariatric surgery is to date the most effective treatment for morbid obesity and it has been proven to reduce obesity-related comorbidities and total mortality. As any medical treatment, bariatric surgery is costly and doubts about its affordability have been raised. On the other hand, bariatric surgery may reduce the direct and indirect costs of obesity and related comorbidities. The appreciation of the final balance between financial investments and savings is critical from a health economic perspective. In this paper, we try to provide a brief updated review of the most recent studies on the cost-efficacy of bariatric surgery, with particular emphasis on budget analysis. A brief overview of the economic costs of obesity will also be provided. The epidemic of obesity may cause a significant reduction in life expectancy and overwhelming direct and indirect costs for citizens and societies. Cost-efficacy analyses included in this review consistently demonstrated that the additional years of lives gained through bariatric surgery may be obtained at a reasonable and affordable cost. In groups of patients with very high obesity-related health costs, like patients with type 2 diabetes, the use of bariatric surgery required an initial economic investment, but may save money in a relatively short period of time.

Economic evaluations of adult weight management interventions: a systematic literature review focusing on methods used for determining health impacts

BACKGROUND

One of the challenges when undertaking economic evaluations of weight management interventions is to adequately assess future health impacts. Clinical trials commonly measure impacts using surrogate outcomes, such as reductions in body mass index, and investigators need to decide how these can best be used to predict future health effects. Since obesity is associated with an increased risk of numerous chronic diseases occurring at different future time points, modelling is needed for predictions.

OBJECTIVE

To assess the methods used in economic evaluations to determine health impacts of weight management interventions and to investigate whether differences in methods affect the cost-effectiveness estimates.

METHODS

Eight databases were systematically searched. Included studies were categorized according to a decision analytic approach and effect measures incorporated.

RESULTS

A total of 44 articles were included; 21 evaluated behavioural interventions, 12 evaluated surgical procedures and 11 evaluated pharmacological compounds. Of the 27 papers that estimated future impacts, eleven used Markov modelling, seven used a decision tree, five used a mathematical application, two used patient-level simulation and the modelling method was unclear in two papers. The most common types of effects included were co-morbidity treatment costs, heath-related quality of life due to weight loss and gain in survival. Only 12 of the studies included heath-related quality of life gains due to reduced co-morbidities and only one study included productivity gains. Despite consensus that trial-based analysis on its own is inadequate in guiding resource allocation decisions, it was used in 39% of the studies. Several of the modelling papers used model structures not suitable for chronic diseases with changing health risks. Three studies concluded that the intervention dominated standard care; meaning that it generated more quality-adjusted life-years (QALYs) for less cost. The incremental costs per QALY gained varied from $US235 to $US56,836 in the remaining studies using this outcome measure. An implicit hypothesis of the review was that studies including long-term health effects would illustrate greater cost effectiveness compared with trial-based studies. This hypothesis is partly confirmed with three studies arriving at dominating results, as these reach their conclusion from modelling future co-morbidity treatment cost savings. However, for the remaining studies there is little indication that decision-analytic modelling disparities explain the differences.

CONCLUSIONS

This is the first literature review comparing methods used in economic evaluations of weight management interventions, and it is the first time that observed differences in study results are addressed with a view to methodological explanations. We conclude that many studies have methodological deficiencies and we urge analysts to follow recommended practices and use models capable of depicting long-term health consequences.

Incorporating indirect costs into a cost-benefit analysis of laparoscopic adjustable gastric banding

OBJECTIVES

The objective of this study was to estimate the time to breakeven and 5-year net costs of laparoscopic adjustable gastric banding (LAGB) taking both direct and indirect costs and cost savings into account.

METHODS

Estimates of direct cost savings from LAGB were available from the literature. Although longitudinal data on indirect cost savings were not available, these estimates were generated by quantifying the relationship between medical expenditures and absenteeism and between medical expenditures and presenteeism (reduced on-the-job productivity) and combining these elasticity estimates with estimates of the direct cost savings to generate total savings. These savings were then combined with the direct and indirect costs of the procedure to quantify net savings.

RESULTS

By including indirect costs, the time to breakeven was reduced by half a year, from 16 to 14 quarters. After 5 years, net savings in medical expenditures from a gastric banding procedure were estimated to be $4970 (±$3090). Including absenteeism increased savings to $6180 (±$3550). Savings were further increased to $10,960 (±$5864) when both absenteeism and presenteeism estimates were included.

CONCLUSIONS

This study presented a novel approach for including absenteeism and presenteeism estimates in cost-benefit analyses. Application of the approach to gastric banding among surgery-eligible obese employees revealed that the inclusion of indirect costs and cost savings improves the business case for the procedure. This approach can easily be extended to other populations and treatments.

Body mass trajectories through midlife among adults with class I obesity

BACKGROUND

Little is known about the body mass trajectories for adults with class I obesity. Our objective was to map the body mass trajectories through midlife for young adults with class I obesity in the United States.

METHODS

Data from the National Longitudinal Study of Youth 1979 was used to generate a cohort of 1058 men and women, aged 25-33 years with class I obesity in 1990. Group-based trajectory modeling was used to identify the number and shape of the body mass index trajectories from 1990 to 2008 for this cohort.

RESULTS

By 2008, about 15% of men and women with class I obesity in 1990 experienced a body mass index increase to >40 kg/m(2). The trajectory analyses showed that roughly one third of the sample were on 1 of 2 body mass index trajectory groups that culminated with an average BMI well above 35 kg/m(2).

CONCLUSION

The large majority of young adults with class I obesity are likely to gain weight over time. For many, the weight gain will be significant and greatly increase their risk of obesity-related co-morbidities and reduced life expectancy. As a result, bariatric surgery or other intensive weight management options might be warranted.

A pathway to endoscopic bariatric therapies

The American Society for Gastrointestinal Endoscopy (ASGE) is dedicated to advancing patient care and digestive health by promoting excellence in gastrointestinal endoscopy. The American Society for Metabolic and Bariatric Surgery (ASMBS) is dedicated to improving public health and well-being by lessening the burden of the disease of obesity and related diseases. They are the largest professional societies for their respective specialties of gastrointestinal endoscopy and bariatric surgery in the world. The ASGE/ASMBS task force was developed to collaboratively address opportunities for endoscopic approaches to obesity, reflecting the strengths of our disciplines, to improve patient and societal outcomes. This white paper is intended to provide a framework for, and a pathway towards, the development, investigation, and adoption of safe and effective endoscopic bariatric therapies (EBT).

A cost-benefit analysis of bariatric surgery on the South Plains region of Texas

The regional economic burdens of obesity have not been fully quantified. This study incorporated bariatric surgery demographics collected from a large university hospital with regional economic and employment data to evaluate the cost of obesity for the South Plains region of Texas. Data were collected from patients who underwent laparoscopic gastric bypass and laparoscopic banding between September 2003 and September 2005 at Texas Tech University Health Sciences Center. A regional economic model estimated the economic impact of lost productivity due to obesity. Comparisons of lost work days in the year before and after surgery were used to estimate the potential benefit of bariatric surgery to the South Plains economy. Total output impacts of obesity, over $364 million, were 3.3% of total personal income; total labor income impacts neared $60 million: the losses corresponded to $2,389 lost output and $390 lost labor income per household. Obesity cost the South Plains over 1,977 jobs and decreased indirect business tax revenues by over $13 million. The net benefit of bariatric surgery was estimated at $9.9 billion for a discount rate of 3%, $5.0 billion for a discount rate of 5%, and $1.3 billion for a discount rate of 10%. Potential benefits to the South Plains economy of performing bariatric surgery more than outweigh its costs.

Comparison of public and private bariatric surgery services in Canada

BACKGROUND

Surgical treatment of obesity is cost-effective and improves life expectancy. Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) are dominant surgical techniques, but RYGB is the only publicly insured procedure in all Canadian provinces. Private clinics currently offer AGB with minimal wait times. We sought to compare RYGB in public facilities with AGB in private clinics in terms of cost, wait times and certain aspects of patient care.

METHODS

We conducted telephone interviews of all bariatric surgery providers across Canada (100% response rate). We asked about various aspects of care, such as wait time, cost, pre- and postoperative care and surgeon experience.

RESULTS

The median out-of-pocket cost for AGB at private facilities is $16,000 (range $13,160-$18,375). Private clinics have much shorter wait times for AGB than public facilities do for RYGB (1 v. 21 mo, p < 0.001). Private clinics provide significantly fewer preoperative visits with multidisciplinary health professionals (2.7 v. 4.3, p = 0.045), and 5 of 12 (42%) private clinics conduct AGB surgeries without on-site critical care for high-risk (based on the respondents' definitions) patients.

CONCLUSION

Private clinics performing AGB offer short wait times, but the cost is high. We found a great deal of variation between pre- and postoperative care among bariatric surgery facilities, and in some cases patient care appears to be less comprehensive. Our findings suggest that further research on obesity treatment is needed to inform policy so that all Canadians can have equitable and timely access to proven, evidence-based care.

Treatment of atherogenic liver based on the pathogenesis of nonalcoholic fatty liver disease: a novel approach to reduce cardiovascular risk?

Nonalcoholic fatty liver disease (NAFLD), which spans a spectrum of conditions ranging from simple steatosis to progressive nonalcoholic steatohepatitis (NASH), is the most common chronic liver disease and a relevant public health issue. The prevalence of NAFLD depends on adiposity, age, gender and ethnicity. The natural history of liver disease in those with NAFLD critically depends on liver histological changes. However, cardiovascular mortality is increased in NAFLD, particularly in middle-aged adults. Against such a background, this review consists of three sections. First, data on NAFLD as a novel mechanism of increased cardiovascular risk via hyperinsulinism, pro-thrombotic potential, and subclinical inflammation are summarized. Next, the role of atherogenic liver in the development of manifestations of oxidative stress and atherosclerosis is emphasized. Finally, whether and how treating NAFLD will mechanistically result in reduced cardiovascular risk through ameliorated metabolic syndrome is discussed.

Improved memory function 12 weeks after bariatric surgery

BACKGROUND

Growing evidence has shown that obesity is associated with poor neurocognitive outcomes. Bariatric surgery has been shown to be an effective intervention for morbid obesity and can result in improvement of many co-morbid medical conditions that are associated with cognitive dysfunction. The effects of bariatric surgery on cognition are unknown.

METHODS

We performed a prospective study total of 150 subjects (109 bariatric surgery patients enrolled in the Longitudinal Assessment of Bariatric Surgery project and 41 obese control subjects who had not undergone bariatric surgery). These 150 subjects completed a cognitive evaluation at baseline and at 12 weeks of follow-up. The demographic, medical, and psychosocial information was also collected to elucidate the possible mechanisms of change.

RESULTS

Many bariatric surgery patients exhibited impaired performance on cognitive testing at baseline (range 4.6-23.9%). However, the surgery patients were no more likely to exhibit a decline on ≥2 cognitive tests at 12 weeks of follow-up than were the obese controls [12.84% versus 23.26%; chi-square (1) = 2.51, P = .11]. Group comparisons using repeated measures multivariate analysis of variance showed that the surgery patients had improved memory performance at 12 weeks of follow-up [λ = .86, F(4, 147) = 5.88, P <.001]; however, the memory performance of the obese controls had actually declined. Regression analyses showed that the surgery patients without hypertension had better short delay recall at 12 weeks than those with hypertension [β = .31, P = .005], although the other demographic and medical variables were largely unrelated to the test performance.

CONCLUSION

The present results suggest that cognitive impairment is common in bariatric surgery patients, although these deficits might be at least partly reversible. Future studies are needed to clarify the underlying mechanisms, in particular, longitudinal studies using neuroimaging and blood markers.

Cost-effectiveness of bariatric surgery for severely obese adults with diabetes

OBJECTIVE

To analyze the cost-effectiveness of bariatric surgery in severely obese (BMI >or=35 kg/m(2)) adults who have diabetes, using a validated diabetes cost-effectiveness model.

RESEARCH DESIGN AND METHODS

We expanded the Centers for Disease Control and Prevention-RTI Diabetes Cost-Effectiveness Model to incorporate bariatric surgery. In this simulation model, bariatric surgery may lead to diabetes remission and reductions in other risk factors, which then lead to fewer diabetes complications and increased quality of life (QoL). Surgery is also associated with perioperative mortality and subsequent complications, and patients in remission may relapse to diabetes. We separately estimate the costs, quality-adjusted life-years (QALYs), and cost-effectiveness of gastric bypass surgery relative to usual diabetes care and of gastric banding surgery relative to usual diabetes care. We examine the cost-effectiveness of each type of surgery for severely obese individuals who are newly diagnosed with diabetes and for severely obese individuals with established diabetes.

RESULTS

In all analyses, bariatric surgery increased QALYs and increased costs. Bypass surgery had cost-effectiveness ratios of $7,000/QALY and $12,000/QALY for severely obese patients with newly diagnosed and established diabetes, respectively. Banding surgery had cost-effectiveness ratios of $11,000/QALY and $13,000/QALY for the respective groups. In sensitivity analyses, the cost-effectiveness ratios were most affected by assumptions about the direct gain in QoL from BMI loss following surgery.

CONCLUSIONS

Our analysis indicates that gastric bypass and gastric banding are cost-effective methods of reducing mortality and diabetes complications in severely obese adults with diabetes.

Does Medicare Have an Implicit Cost-Effectiveness Threshold?

Background. Despite the huge cost of the program, the Centers for Medicare and Medicaid Services (CMS) has maintained a policy that cost-effectiveness is not considered in national coverage determinations (NCDs). Objective. To assess whether an implicit cost-effectiveness threshold exists and to determine if economic evidence has been considered in previous NCDs. Methods. A literature search was conducted to identify estimates of cost-effectiveness relevant to each NCD from 1999—2007 (n = 103). The economic evaluation that best represented each coverage decision was included in a review of the cost-effectiveness of medical interventions considered in NCDs. Results. Of the 64 coverage decisions determined to have a corresponding cost-effectiveness estimate, 49 were associated with a positive coverage decision and 15 with a noncoverage decision. Of the positive decisions, 20 were associated with an economic evaluation that estimated the intervention to be dominant (costs less and was more effective than the alternative), 12 with an incremental cost-effectiveness ratio (ICER) of less than $50,000, 8 with an ICER greater than $50,000 but less than $100,000, and 9 with an ICER greater than $100,000. Fourteen of the sample of 64 decision memos cited or discussed cost-effectiveness information. Conclusions. CMS is covering a number of interventions that do not appear to be cost-effective, suggesting that resources could be allocated more efficiently. Although the authors identified several instances where cost-effectiveness evidence was cited in NCDs, they found no clear evidence of an implicit threshold.

The effect of obesity on health outcomes

The prevalence of obesity has progressively increased globally over the last 30 years. The determinants of this pandemic are many, poorly defined and priorities debated. While public health measures to prevent obesity have largely failed we are presented with a growing burden of disease and disability. Cardiovascular disease, type-2 diabetes, obesity related cancers, osteoarthritis and psychological disturbance generate much of the morbidity and years of life lost associated with increasing levels of obesity. Obesity has a clearly measurable impact on physical and mental health, health related quality of life, and generates considerable direct and indirect costs. The evolving obesity pandemic is exacting a considerable toll on those affected, the treating health services, and on our communities. Weight loss appears to be the most effective therapy for obesity and obesity related comorbidity. As health care researchers and providers we are likely to play a peripheral role in the prevention of obesity, but a central role in effectively treating those afflicted by the obesity pandemic.