The 3rd BOMSS Annual Scientific Meeting 2012, Bristol

The 3rd BOMSS Scientific Meeting, held in Bristol, was a great success with presentations from speakers of national and international renown and a mix of highly informative talks by specialists from across the UK.

The Meeting was preceded by a successful teaching day for trainees which included talks from international speakers, mock MDTs, simulator sessions, input from AHPs and careers advice.

Our partners in industry supported the Meeting generously and with a busy trade exhibition and there were ample opportunities for networking.

The Annual Dinner was held at the Marriot Hotel and was a great success with a very amusing after-dinner speech by comedian and GP Phil Hammond.

 

Scientific programme:

 

Tackling obesity: Future choices
Professor Klim McPherson, public health epidemiologist, Oxford

Professor McPherson began by saying that he wanted to answer the question of whether surgery is the answer for people with high BMIs. He undertook simulation studies using a computer generated selection of the British public and then put in various ‘interventions’ such as operations for those with a BMI of 35+ to see how they affected outcomes over time. He pointed out that as obese people tend to get ill more often than slim people there is a public health interest in studying obesity. His computer model showed that increased surgery will cut numbers of people with diabetes but only massively increased amounts of surgery.

Prof McPherson’s models tended to show a flattening in the upward curve of obesity trends for men aged 30-39, no change for women and a rapid rise for those aged 50-59. It also showed that to effect savings to society there has to be a very large increase in surgery – the cost effectiveness of bariatric surgery falls as the number of cases drop.
Professor McPherson concluded by saying that bariatric surgery is the solution to the problem of obesity but it has to become cheaper and added: ‘If we can’t find some other way of achieving a solution to obesity we are going to be in a terrible mess in 30 years time.”

Commissioning and the White Paper – why so little on obesity?
Professor Philip James, President, International Association for the Study of Obesity

Professor James started his talk by saying: “The question is ‘what is the state of play’ – and the answer is inevitably political.” He added that while there have been several reviews of NHS services, obesity has rarely featured in them. For example, a White Paper in May 2011 referred to obesity as a factor in diabetes and liver disease rather than as a category on its own. He also pointed to the recent dismantling of the independent Food Standards Agency and the loss of mandatory ‘traffic light’ labelling on food as unhelpful in tackling obesity.

Prof James also said: “In this country we have tended as doctors to neglect obesity. It has been seen an as individual responsibility but we are now waking up to the fact that it is a massively rising problem.”

He pointed out that while advertising to children is banned, our brains are not mature until the age of 25. He also pointed to the influence of fast food and soft drink manufacturers plus the alcohol lobby in manipulating food policy.
He posed the question; “How are we going to affect policy?” Prof James said that at the moment surgeons have a high level of interest in obesity but very little influence.

He concluded by saying: “The Prime Minister has said that obesity is a matter of personal responsibility and previously medical care hasn’t focused enough on obesity. GPs feel inadequate to tackle this epidemic. Surgeons must start to take more of a lead, not only in treatment but in influencing policy.”

One third of one per cent of those eligible – is the NHS serious about bariatric surgery?
Mr Mike Lander, specialist commissioner, SE Coast

Mr Lander outlined his role in NHS commissioning: “Put simply, it is the right patient getting the right treatment from the right people at the right time and at the right price.” He discussed the eligibility criteria for bariatric surgery and referred to studies which show that it is cost effective – and indeed the only option at the moment. He said that there are two nationally mandated prices for each surgery.

Mr Lander then displayed a series of maps which showed patchy distribution of bariatric surgery across the UK. He pointed out that while commissioners generally have to follow NICE guidance, obesity is one of the exceptions. He also said that current guidelines are unclear. “What constitutes appropriate non-surgical interventions and clinically significant weight loss?”

Looking to the future Mr Lander said: “We need help to find the solution. We need to focus on all the pathways, not just surgery. Commissioners need to get to grips with these issues and we are beginning to work together. We are serious about bariatric surgery and we need to find ways to better show that we are serious.”

What challenges do we face and what is IFSO’s vision?
Professor Antonio Torres, University of Madrid, President of IFSO

Professor Torres asked for a show of hands in the hall which showed that a majority of conference attendees believed that each patient is different, BMI alone is not enough to decide on surgery and that metabolic disorders can be helped by surgery.

He then pointed out that, historically, in the years 1900-1950 medicine was very focused on infectious diseases and from 1950-2000 on acute illnesses. He said he believed that 2000-2050 would be defined as the era when the focus was on chronic diseases, including COPD, diabetes, hypertension and colon carcionomas – all co-morbidities of obesity.

He said that the close relationship between obesity and diabetes had led him to adopt the term ‘diabesity.’

Prof Torres then spoke of the impact on the economy of people who became too ill to work or died early because of obesity and he said that the cultural challenges included a growing acceptance that obesity is the norm.

He said: “The rate of referral from bariatric surgery is inconsistent and patchy and many people who would benefit from such surgery face barriers, for example, financial barriers.” He also pointed to bias from care providers.

Prof Torres said that IFSO’s role included offering training programmes, making recommendations, highlighting socio/political issues and collaborating with other obesity societies.

What are we going to do about the adolescent obesity problem?
Professor Julian Hamilton-Shield, Professor in Diabetics and Metabolic Endocrinology, Bristol University

Professor Shield opened his talk by posing the question: “What is the public role in improving children’s weight?” He said that latest figures show that 19% of schoolchildren in Year 6 (aged 10-11) are obese and added: “Obesity in children has become so commonplace that people don’t notice it any more.”

Prof Shields also highlighted the particular problems faced by people trying to help obese adolescents compared with younger children, saying: “If we can convince the family then younger children will benefit from intervention – but once they get older adolescents don’t listen to their parents, let alone teachers or doctors. Often they won’t even come into the room when you are trying to talk to them and sometimes they don’t turn up at all.”

He said that simply encouraging teenagers to exercise more was unlikely to help when it would take 105 minutes of continuous skipping to account for the calories in a cheese and coleslaw sandwich.

Prof Shields gave several interesting case studies of obese adolescents with varying results and concluded his talk by saying: “I think that surgery is a good idea in some cases. It is important that the child understands the implications for long-term follow-up and this can be tricky, but it is possible. It is also important that that adolescent is close to physiological maturity.”

The structure of the bariatric MDT – the evidence base
Professor Nick Finer, UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery

Professor Finer outlined the skills he believed needed to be brought into MDTs which would help with the comprehensive management of bariatric surgery patients. These included physicians, nurses, dieticians, exercise specialists, anaesthetist, administrative and management personnel, psychologists and pharmacists. He added: “People working with obese patients needs a whole range of motivational and caring skills and the patients themselves have to be given the skills to look after themselves.”

Prof Finer said that the basic idea behind the MDT would be that teams could work in concert in the interest of the patient – an example of joined-up thinking. “The ideal is a network in which everyone has the same vision and s working towards a common goal.”

Prof Finer then looked at the evidence base for MDTs and said that while he had found good data in other areas, for example, relating to heart failure and MDTS, he hadn’t been able to find a randomised control trial in bariatrics. He went on to give a detailed case study from his own experience.

He also referred to relevant guidelines including NICE, the European association for Endoscopic Surgery and guidelines used by specialist morbid obesity services.

In conclusion he said: “The precise composition and optimal practices for MDTs in this area are currently ill-defined – we have to see to this as a great opportunity!”

What psychiatrists feel that bariatric surgeons should know
Dr Lisa McClelland and Dr Tom Stevens

Dr McClelland and Dr Stevens said they hoped to show how psychiatry can help with bariatric patients by offering a detailed psychological assessment, a psychiatric diagnosis, advising the patient about the psychological risks of surgery and helping with the management of eating disorders.

However, they said that in many areas of the country there are long waiting lists for CBT and that there is also a possibility that a psychiatric intervention could result in a patient subsequently facing discrimination. They also said that it was difficult to predict weight loss post-surgery in patients whether or not they had interventions.

The psychiatrists focused on the historical figure of Henry VIII as a candidate for bariatric surgery at age 50 and with a BMI of 51. He suffered from Type 2 Diabetes and had leg ulcers. He was also said to drink 13 pints of weak beer daily. Under modern-day rules he would quality for surgery under NICE guidance. However, the psychiatrists argued that they would ‘red card’ the King as an unsuitable patient because his violence, chaotic life, history of a head injury and eating habits made it unlikely that surgery would be successful.

They went on to describe a green, amber and red system they are devising to help surgeons better understand which patients might benefit from surgery although they said it couldn’t be considered a failsafe system.

They described three reasons behind excessive weight gain:
– Scavenging: Access to food as a child may be chaotic
– Body armour: People put on weight to hide their body following a traumatic event, for example, sexual assault
– Comfort eating: Eating to forget or because of unhappy situations.

The pscychiatrists said that a good candidate for surgery would show appropriate motivation, a good understanding of the procedure, have appropriate expectations and would be willing to diet.

They also added: ‘We need access to the patient post-operatively to enhance outcomes but there is little funding for this type of work.”

Vitamin deficiencies in bariatric surgery patients
Dr Erlend Aasheim, Research Fellow, Imperial College, London

Dr Aasheim spoke about vitamin deficiencies which become apparent after bariatric surgery and which cause severe complications but said that many of them could be avoided. He went on to discuss the causes and remedies of some vitamin deficiencies and also cautioned medical experts to be aware of the existence of deficiencies which may exist before surgery. He also added: ‘It is important to note that vitamin deficiencies in mothers can be passed to their children.”

He pointed out that vitamin deficiencies can be expressed in different ways which can make diagnosis tricky, for example, it could result in blurred vision in a 15-year-old girl, a twisted ankle in someone in their mid-thirties and could result in someone in their late 30s attacking another person.

He said that complicating factors for treating bariatric patients include:
– Different characteristics and diets between different populations
– Varying methods of supplementation
– The lack of a standard protocol.

Dr Erlend suggested that inflammation might be a cause of vitamin deficiencies in bariatric patients or the fact that vitamins were being stored in fatty tissue. He also said: “Surgery is well-established as a treatment for obesity but we still don’t fully appreciate all the metabolic consequences.”

Hypoglycaemia: the unwanted side-effect
Professor Nick Finer, UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery

Prof Finer gave a detailed case study in support of his discussion about hypoglycaemia and said that patients typically present one to two years after surgery and their hypo episodes typically occur one to three hours after meals. He spoke of the difficulties in identifying hypoglycaemia from other similar conditions and he discussed possible causes.

In terms of treatment he reinforced the need for a low GI diet with frequent small meals plus a medical regime. He concluded by saying: “This is a growing phenomenon and raising awareness among medical professionals is important.”

Gastric Banding long-term – what are the data?
Professor Wendy Brown, Melbourne

Prof Brown said that latest figures show that 30% of Australians are obese and a further 30% are overweight. She said this equated to a cost to society in terms of lost work and health costs of AUS $1.9bn in direct costs and AUS $6.3bn in indirect costs. She said: “It’s time society stopped judging people and started helping them.”

Prof Brown went on to discuss current trials in Australia and spoke about the need to demonstrate durable effect, pointing to the scarcity of long-term bariatric studies. She said she has just completed a long-term study of 3,133 patients with a mean age of 47, an initial mean BMI of 43.8 and a mean initial weight of 121 kg. She said that initial findings pointed to significant weight loss up to 10 years beyond surgery and she called for continued monitoring of bariatric results.

Increasingly obese – is there any hope?
Professor Philip James, President, International Association for the Study of Obesity

Prof James started his talk by outlining the scale of the problem facing the world, saying that WHO figures show an obesity epidemic across the world with developing nations facing the greatest risks. He added that diabetes is set to become completely unsustainable in terms of health costs. He also said that research has shown that even slightly overweight children are doomed to be at a permanently high risk of heart disease as adults and that the fattest children are found in Mediterranean countries. New research shows that a woman’s weight at the point she gets pregnant will partly determine the future size of her children, especially girls.

Prof James then posed the question – “Can anything be done about this?” He said that public health initiatives in some countries are starting to make an impact with examples including Denmark banning trans-fats in 2003, Finland launching a Diabetes prevention programme and France implementing a major plan to reverse childhood obesity. He also cited medical interventions which help people lose weight and said that they can keep the weight off if they are completely rigorous about their diets and prepared to spend years calorie-counting. He also pointed to date that shows that losing 5% of your weight cuts the risk of diabetes by 58%. Prof James also pointed to the role of schools, doctors, dieticians, MDTs and food labelling initiatives as having a a potentially positive impact.

Looking to baraitric care, Prof James said that a co-ordinated approach was important to assess the techniques and protocols and to identify any issues.

He finished his inspiring talk by saying: “Bariatric surgeons can be the creative powerhouse of change.”