'Palliative care not surgery' for the most obese

Thermograms of an obese woman. Pic Tony McConnell/SPL Surgery is needed before you get too fat

Britain is in the grip of an obesity epidemic, with more than a million severely and morbidly obese.

Surgery is available. But in this week's Scrubbing Up, Dr David Haslam, from the group Experts in Severe and Complex Obesity (ESCO), warns the wrong people are getting it and says some of those who are biggest should just be offered "palliative care" for their obesity.

Weight-loss - bariatric - surgery is a rare and precious resource that has the capacity to permanently induce major weight loss, and 'cure' diabetes in 90% of cases, sometimes within days.

It is cost-effective, with gastric bypass paying for itself within three-and-a-half years due to reduced drug costs and hospital admissions, and this is before we take into account the individual's renewed productivity, and benefit - rather than burden - to the economy.

Even the most cynical, fat-phobic taxpayer should rejoice in the benefits of bariatric surgery.

According to the National Institute of health and Clinical Excellence (NICE), of the 1,010,000 severely and morbidly obese population in the UK, there are currently 230,000 people both eligible and willing to have surgery.

However, this year fewer than 2% of these patients will actually receive treatment.

Start Quote

Some people are just too big for any constructive cure to be countenanced”

End Quote Professor David Haslam
Wrong people

The availability of surgery is limited, as relatively few surgeons perform laparoscopic techniques within a limited number of designated centres, with a substantial initial financial outlay, so it should be used carefully and offered only for those who will benefit most.

Like anything precious, bariatric surgery should be rationed. But the wrong people are currently benefiting.

NICE guidelines are well-considered and based on clinical-effectiveness and cost-effectiveness, deeming surgery appropriate in anyone with a BMI (Body Mass Index) of 40+, or 35+ if they have other illnesses.

However current barriers, set out by administrators rather than clinicians, ration access to surgery and are discriminating against deserving patients and reducing the number who benefit - and promoting surgery for the wrong people.

How gastric bands work

Graphic: how gastric bands work
  • Gastric band fitted around the upper end of the stomach
  • This restricts flow of food into the lower stomach
  • Band can be adjusted via the access port

Here are a couple of examples of the kind of cases that occur.

Doris is 62, with a BMI of 72. She has been housebound for 10 years in her fourth floor flat and has complaints including heart disease and chronic leg ulcers.

She smokes 40 cigarettes a day and sleeps in front of the television, as severe osteoarthritis prevents her from moving. She lives just one street from the sea, but can't get there.

Sean is 38, married with two young children and has suffered from type 2 diabetes for 10 years.

He is insulin resistant, on 300 units of insulin, has retinopathy (damage to the retina), burning feet and erectile dysfunction as a result of diabetes. He has depression and is gaining weight rapidly due to insulin, with a BMI of 35.

His prognosis is dreadful. He can look forward to a future of weight gain, blindness, heart disease and the prospect of an early death, leaving his wife to support their children alone.

Shocking concept

Doris will be granted surgery because she has sleep apnoea and weighs enough to fulfil local guidelines, despite the risk, and has limited potential gain in health, longevity and productivity.

Start Quote

The current route to treatment means that the most needy and deserving individuals often go without”

End Quote Professor Haslam

Sean will be denied surgery, and will resort to gaining weight for a few more years before becoming eligible.

If both could have surgery, all well and good, but if only one can, clearly Sean is the more deserving.

What then should become of Doris? Physical activity is out of the question, dietary interventions won't scratch the surface, and most anti-obesity drugs have been removed from pharmacies.

Like anyone else with incurable, terminal diseases, she can be offered palliative care. The concept is a shocking one, and recognises that some people are just too big for any constructive cure to be countenanced. There are times when palliative care is appropriate for obesity: enough is enough when there is no chance of effective treatment.

Doris will then fulfil her ambition to see the ocean, by moving into warden-controlled accommodation by the beach, receiving pain management for arthritis, smoking cessation advice from the district nurse, psychotherapy from the community mental health team, while remaining irreparably obese.

Sean, having undergone surgery, will return to work as a security guard, feed his family and pay his taxes.

It's inevitable that bariatric surgery is rationed, but the current route to treatment means that the most needy and deserving individuals often go without.

Your comments

As a cynical, fat-phobic, taxpayer, I wholly disagree with the notion that there are more or less deserving individuals for this surgery. No-one is deserving of this surgery or any medical support for a self-induced condition, unless they have a legitimate reason for gaining the weight. It is all very well to say this is a more cost-effective way of dealing with this 'epidemic' than drugs etc, but the most cost effective way would be to decline medical assistance to these people. Of course, this will be seen as a rather right-wing notion, but I am a firm believer that the taxpayer should not be burdened by other peoples' poor lifestyle choices.

Matthew Maycock, Old Buckenham, Norfolk

I'm 52, with two children aged 6 and 10. I'm overweight, diabetic and have kidney complications. I had a gastric band fitted a year ago and have lost over 20 kg so far. As a consequence I've reduced my insulin from 120 units daily to just 40 and expect to reduce it further still. It's not easy, but it's worth it. I agree that Sean is more worthy, because bariatric surgery has the potential to radically change his life for the better. Doris on the other hand, shouldn't be considered until she stops smoking at least, otherwise bariatric surgery will have less of an effect.

Les Litwin, Ellesmere Port, Cheshire

I live in South wales, I'm 49 with diabetes, angina, fibromyalgia, depression, PCOS, and high blood pressure. My BMI is around 60. I'm now classed as disabled and had to give up work because of ill health. Ten days ago I went to my GP to be referred to Bariatric surgeon, her words to me were that all the people she has put forward for this type of surgery have been refused, No, not by the surgeon or medical staff, but by the welsh assembly administrators who in my eyes are "playing god" with other peoples' lives. So the question I'm asking myself is "what are my chances". Slim chances I expect (excuse the pun). All I'm doing is asking for some help with my weight problem as I can't afford to go private. I just want to live a healthier and longer life. I guess what I'm really saying is "please", The Welsh Assembly think of the person who you are saying NO to, think of me as a person, as an individual, as a wife, a sister, a daughter. Don't just think of me as drain on NHS money. Please help me live my life to the full.

Pam, South Wales

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