More than a million Canadians may be morbidly obese — their body mass index (BMI) is 40 or greater, meaning they are at least 45 kilograms heavier than they should be.
Weight loss surgery has proven to be a safe and effective way for many of these patients to lose — and keep off — much of that extra weight. Yet, the waiting list for gastric bypass surgery in Canada can be as long as seven years.
Dr. Arya Sharma is the Scientific Director of the Canadian Obesity Network in Edmonton. He sat down with CBC News to talk about obesity surgery.
Here is a transcript of that interview.
Dr. Sharma, who is a candidate for obesity surgery?
Obesity surgery is currently the most effective treatment for patients who have severe obesity, and we consider someone to have severe obesity when the obesity is clearly impacting their health. We have body mass index cutoffs where we say about a BMI of 40, which is about 100 pounds overweight. But there are also a number of other factors that determine whether or not someone is a good candidate for all obesity surgery.
What might those other factors be?
Those factors, for example, can include things like whether someone has a high risk for surgery. People might have other medical problems that make them high-risk patients to have any kind of surgery. It's also important to remember that sometimes obesity can be a result of things that go on in your head: there is a lot of emotional eating, there are patients who are binge eating, an eating disorder and because obesity surgery is surgery that is done on the stomach and not on your brain, it's important to remember that sometimes you actually have to deal with some of those emotional issues or some of those mental health problems before someone could be deemed a good candidate for obesity surgery.
In your estimation how many people who would be candidates of obesity surgery are there at any give time in Canada?
The number of patients who have severe obesity, which means they have obesity which is clearly impacting their health, their well-being, their ability to work, look after their families, that number is increasing dramatically. And it's probably about a million people across Canada who really have severe obesity and could be considered candidates for surgery based on their co-morbidities, their weight, their body mass index.
However in our experience only about one in four or one in five patients who have the body mass index criteria or their health criteria for surgery are really good candidates, because a lot of these patients may have the wrong expectations [for] surgery, are not able to make the quite drastic lifestyle changes that people who had surgery have to make after they've had the surgery. And as I said there's a lot of patients out there who have emotional problems, mental health problems, history of drug addiction, alcohol addiction, are on medications that promote weight gain, so it's really a very complex heterogeneous group.
So that one million people might sweep done to 250,000 people who you would actually recommend for the surgery?
In our experience, it's probably only one out of four or one out of five patients who are severely obese who will do well with obesity surgery.
So it might squeeze down to 250,000 people?
Yes, but even 250,000 is a large number. We are currently doing about 1,000, maybe 2,000 operations a year in Canada. This means it would probably take us a century to do everybody — so the numbers are just staggering. There are a lot of people out there who could really benefit from obesity surgery, if done properly.
Give us an idea of how these patients are coping before the surgery: describe their health, what is their life like?
Obesity is a condition that affects every aspect of your life. It's not just your body image, your self-esteem, your ability to have a relationship. It's how you live your life. But there are also a lot of medical problems around the obesity. As you get heavier, it becomes more likely that you will develop Type 2 diabetes, but you'll have reflux disease, a lot of patients have sleep apnea, people get high blood pressure. The risk for heart attacks and stroke increases, back pain, osteoarthritis, infertility 7#8212; the list goes on and on and on. There are a lot of complex problems that are medical but there are also a lot of complex mental health problems they can develop as a result of obesity.
Please explain the surgery. Where are we today? How has it evolved?
When it comes to obesity surgery, we know that surgery for obesity is something that's been around for a long time. But over the last decade probably there have been quite dramatic changes in the kind of surgery.
Perhaps the major change that has happened is that we've gone from doing open surgery where you have to cut through 12 inches [30 centimetres] of fat to get to the actual organ that you're operating on, to doing that laparoscopic surgery where we now do all of the operative procedure through a bunch of little holes that you make in the abdomen. This has a huge influence on the morbidity of patients. And you can easily imagine if you're cutting through six inches [15 centimetres] of fat, you're going to have problems with wound healing. The patient has a huge operation.
Laparoscopically, most patient's recovery time is very short. They are back on their feet usually the same day after surgery, and we can discharge patients from the hospital within a few days.
How would you characterize the results of the surgery?
The results of obesity surgery for the majority of patients are actually quite spectacular. We have good data that patients who have obesity surgery will live longer, they will live healthier lives. And we know that the reduction in the rates of diabetes, of high blood pressure and cancer and a lot of the other health problems that patients have with obesity are impressive.
The problem, however, is that it's not just the surgery that's important. The predictors of long-term outcome in patients who undergo obesity surgery, of course, depends on the ability of the surgeon.
But even with a good surgeon, the outcome ultimately depends on doing the operation in the right patient and following up the patient for life to make sure that the patient does not run into problems because, I can tell you, a lot of patients who come seeking surgery are probably not going to do well because they cannot make those lifestyle changes that patients have to make to be successful with obesity surgery.
Can you give us an idea of how long people in Canada are waiting for this surgery?
The waiting times for surgery in Canada are anywhere from two to five years and this differs from province to province to province.
The reason for this is that, so far, the health system has really not been encouraging obesity surgery and we really aren't geared up to deliver obesity surgery to large numbers of patients.
Many feel they cannot wait so instead they go overseas or to the US. Why do you disagree with this?
Surgery is only a small piece in the treatment plan of patients with severe obesity. It's a small technical piece that's important and has to be done well, but it's only a small piece. This is not like going and having your gallbladder taken out. If you don't have the proper preparation, and education that tells you what you're getting into, and teaches you the changes that you're going to have to make once you've had the surgery, you have no one following you out. There's no dietitian, there is no psychologist to deal with the anxiety, the depression that you might get after surgery. There is no one monitoring your food intake, not dealing with any of the nutritional deficiencies that you might develop — then you're going to get problems sooner or later.
The problem we have currently is because so many Canadians are going south of the border for surgery, they come back and there's really nobody looking after them. For some patients it's even embarrassing to have surgery, they don't even tell people. So we've got family doctors who don't know that their patients have actually had surgery. Now that is not a good situation because nobody's looking after these patients.
You agree that waiting too long is also dangerous. Why do you think that?
Having to wait too long when you have a disease that is severely disabling and causing health problems is never a good situation. It's important to remember that when we talk about severe obesity, we're not talking about something that is affecting people when they are in their 60s and 70s and 80s. Most of our most severe patients with obesity are actually quite young. They are in their 20s, they're in their 30s, they're in their 40s and they really should be out there working, raising their families, travelling for pleasure, buying houses, buying cars, contributing to the economy.
And all of that is inhibited by severe obesity. You know people who are so large that they find it difficult to even go out of their house and do the shopping and find jobs and finish their education, find a partner, start a family. All of this is affected by obesity. And if you take the example of a 19-year-old who is 400 pounds, that person cannot wait five or six years to get surgery. If that person does not get surgery today, they are going to lose those five or six years which are absolutely crucial for building their future.
Talk about the public perception of morbid obesity.
The problem that you really have is not so much the policy makers, I think it's the public perception that obesity is largely a self-inflicted disorder. And so when you announce public funding for obesity treatments and for all obesity surgery, I know that there's going to be an outcry from a lot of people saying, 'why is it that we are spending all this money on these obese people who are not taking care of themselves?'
Obesity is typically seen as a self-inflicted, self-indulgent disorder. That's what people on the street think. When you see someone who is large, especially if you see someone who is large and — God forbid — eating in public, you know that perception immediately is, 'well, no wonder this person is so big because look at what they are eating.'
In fact, there are actually a lot of thin people out there who have miserable lifestyles. There are a lot of thin people who eat at fast food restaurants, there are a lot of thin people who don't exercise a lot but the assumption is that if you are big it's something in your lifestyle that's causing that problem. And that's certainly true because we know that lifestyle intervention can be quite effective in helping people manage their weight.
But when you talk about people who have severe obesity, and these are not people who are 20, 30 pounds overweight, we are now talking about people who are 100 pounds, 200 pounds, 400 pounds overweight. These are large people. That is not just lifestyle. It never is just lifestyle. It could be medications that these people are on. It could be genetics in those patients. It could be mental disorders that are causing the problem. They could just be coming from large families where everybody in the family is large. And that is not fully explained by lifestyle.
Could you make an economic case for increasing the number of obesity surgeries in Canada?
We have to provide obesity treatments as we do for other chronic diseases. We're not going to solve this problem by sending people to six-week classes or three-month courses or sending them off to a boot camp for four weeks. None of that is going to make a difference. We have to treat obesity like we address other chronic diseases like diabetes or high blood pressure or people who have asthma or heart failure. And that is what is going to take up the resources.
Now the economics of that are probably not just, again, in reduction of health care dollars. Obesity affects young people and if young people have the problem that is stopping them from working, from raising families, from traveling, from really being part of the society because of obesity, that has a huge economic impact that we can't measure in health care dollars. But we can measure it in other dollars because people are not making the money, they're on disability, we are spending a lot of money on obese people that has nothing to do with health care.
And so I think the economic argument for providing obesity treatments — apart from the social argument or the ethical argument — that you say when people have conditions that affect their health, well, then they require treatment.
So apart from that ethical argument, I think there is a very good economic argument to say that we cannot afford to lose a quarter of the Canadian population into obesity.