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Obesity,

Diabetes, and

Bariatric Surgery:
Perception Matters

Professor Kamal Kumar Mahawar

Consultant General & Bariatric Surgeon
Sunderland Royal Hospital

The condition that is not even perceived as
a disease by healthcare professionals and
the public alike seems to be associated with

the most dramatic reduction in quality and
quantity of life. It is difficult to think of any
other disease that wreaks more havoc than
obesity – which many still perceive to be a
lifestyle condition.

he Royal College of Physicians recognised obesity as a disease It delivers sustained, significant weight loss associated with
[1]
last year . American Medical Association did so several years remission of co-morbidities in a large number of patients over the
Tago in 2013. Yet the perceptions on the ground lag behind long-term. It is cost-effective – pays back for itself in the first 24
[2]
and stigma against obesity is all-pervasive , even amongst the months- and is known to reduce certain cancers, as well as overall
healthcare professionals. A disease that affects millions of people mortality. It is carried out in the UK with an exceptional safety of
[6]
on this planet and increases the risk of so many other diseases, like 1:1000 In-hospital mortality and we have the infrastructure to
Type 2 Diabetes Mellitus (T2DM), high blood pressure, coronary carry out many more procedures than the 5000 odd we currently
artery disease, and even cancers, is struggling to be even recognised perform annually. In comparison, most similar-sized European
as a proper medical condition. countries and the United States perform approximately 5 times as
[7]
many procedures per unit of the population .
This is not without its own consequences. This means there are no
proper structures in place to help the individuals suffering from it. It is worth examining why this is the case. In the UK, NICE has
Healthcare funders do not prioritise resources to its treatment and mandated Tier 3 weight management for patients seeking BMS
governments can get away without doing enough for its prevention. and within the Tier 3 services, they are required to lose weight
In the United Kingdom (UK), National Institute for Health and Care to “qualify” for surgery. Patients do lose some weight within Tier
Excellence (NICE) has recommended a stepwise model for obesity 3 services but not because the service itself is very effective but
treatment but in large swathes of country Tier 1, 2, and 3 level because patients need to do so to qualify for surgery. Those who
[3]
obesity management services do not exist . are not able to lose weight within Tier 3 services are not offered
treatment escalation in the form of surgery which is typically
Not only that the evidence for the success of even the most intensive what happens in other areas of medicine when non-operative
Tier 3 medical weight management is at best limited and its cost- managements do not give desired results but are on the contrary
effectiveness in doubt [4]. Long-term data on the effectiveness of discharged from the services to fight the disease themselves.
Tier 3 interventions in achieving significant weight loss are lacking.
We know that very-low-calorie diets lead to weight loss and even Our primary care colleagues know about the efficacy (or lack
[5]
resolution of diabetes in the short term but these benefits are not thereof) of Tier 3 weight management services. That is why very
sustained in the long-term as individuals struggle with homeostatic few of the millions of patients who suffer from overweight or obesity
mechanisms driving hunger and obesity. Diets generally have are actually referred to these Tier 3 services until they seek BMS.
limited success in delivering durable weight loss and long-term For a typical patient, generally, there is no help available in most
benefits in terms of remission of co-morbidities such as T2DM places in the country but the moment they ask for surgery, they are
because they are associated with a rebound increase in hunger. told they have to first "pass-through" Tier 3 weight management
services. If Tier 3 services were successful and value for money,
Yet, there is an intervention called Bariatric and Metabolic Surgery General Practitioners would be fighting to have them for all their
(BMS) that can suppress hunger and reduce appetite significantly. patients who need them and proactively referring them to it. But it
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