Provincial Variation in Accessibility to Bariatric Surgery

At the Inaugural Diabetes Surgery Summit in Montreal last week, it became apparent that there is significant provincial variation in accessibility to weight loss (bariatric) surgery. As Dr. Nicolas Christou of McGill University pointed out, in Canada in 2008, the number of bariatric surgeries performed in each province was as follows:

- Nova Scotia: 28
- New Brunswick: 17
- Quebec: 802
- Ontario: 579
- Saskatchewan: 23
- Alberta: 272
- BC: 160

The reasons for the provincial variation are complex. One interesting phenomenon that was brought up was that in Ontario, patients had previously been funded by the provincial health care system to have bariatric procedures done in the United States - this was a situation that was unique to Ontarians, as no other province provided funding to do this. Due to the enormous expense of sending patients over the border and the potential savings of having these surgeries done at home, the Ontario government provided funding to build access to the service in their home province, to the tune of many millions of dollars in cost savings. As other provinces never had the situation where patients were funded to go south to have surgery, the same financial pressure does not exist to bring the procedure home.

In the mix of the numbers above, other factors have to of course be considered, including population density and surgical expertise available in each province (though with increased provincial funding for bariatric surgery, the surgical expertise would be likely to follow).

Even in provinces with the most accessibility to surgery, however, there is still an enormous shortage of availability country wide, with an estimated fifteen year backlog of patients who would be appropriate for, and benefit from, the surgery.

What can we do? Get out there and talk about it.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Read more...

Diabetes Treatment - is Weight Loss Surgery the Answer?

Canada, like the rest of the world, is caught in a diabetes epidemic. Over 2 million Canadians are diagnosed with the disease, and by the year 2020, those numbers are expected to rise to 3.7 million. This epidemic is paralleled by the high prevalence of obesity, which currently affects 25% of Canadian adults and 10% of Canadian children. One of the treatment options that is being increasingly considered to treat type 2 diabetes in the setting of severe obesity is weight loss surgery.

I attended the First Canadian Diabetes Surgery Summit in Montreal this week, hosted by McGill University, to discuss this very issue. Over two very intense and productive days, a collection of international leaders in the area presented their research and clinical experience to a diverse group including Canadian surgeons, family physicians, endocrinologists, health care professionals, and policy makers. A wealth of learning, sharing, and ideas were generated from this summit, of which I am going to discuss over the course of several articles in the coming weeks. Here are the highlights.

In short, bariatric surgery is a very effective treatment for type 2 diabetes. The results depend on the type of surgery done, but remission rates of diabetes of over 80% have been documented, and sustained for at least 2 years. Much of this success is related to the impressive weight loss that is seen with bariatric surgery, but gut hormone changes with certain types of surgery (such as gastric bypass surgery) play an important role as well.

It must be emphasized that bariatric surgery is only appropriate for a very select group of people. The current guidelines recommend bariatric surgery as a potential option for patients with a BMI >40, or a BMI >35 with at least one serious medical complication (such as diabetes), who have failed intensive attempts at weight loss with conventional treatments (lifestyle alteration, medications, etc). Bariatric surgery has a long list of potential side effects and complications that must be seriously considered, and which vary depending on the type of surgery performed. On balance, however, bariatric surgery has been shown to decrease mortality by 28-40% in this population, and as such, may be the most appropriate option for some people.

In Canada, we struggle with very limited accessibility to bariatric surgery. As Dr. Nicolas Christou, one of Canada's leaders in bariatric surgery, pointed out:

• Based on very conservative estimates that 5% of the 1 million Canadians who fit criteria for bariatric surgery would actually be appropriate candidates for surgery, 50,000 Canadians would currently be candidates for the procedure.
• Approximately 3,000 bariatric procedures will be done in Canada this year.
• According to these numbers, then, Canada currently has in excess of a 15 year back log of patients who could benefit from these procedures.

What can we do about this? The problem of course, is funding. Funding for bariatric surgery is extremely limited in Canada, though accessibility does vary greatly by province. Cost analyses suggest that for patients with diabetes, the costs of bariatric surgery to the government are recouped by 26-30 months post operatively, and after that, there are only savings to be had by the health care system due to the decreased rate of diabetes related complications, hospitalizations, and medication requirements of these patients. 

On balance, increased accessibility to bariatric surgery in Canada, provided in the appropriate clinical setting by a multidisciplinary, experienced health care team, should be discussed amongst Canadian health care professionals, patients, and the general public.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Read more...

The Dangers of Medical Tourism for Bariatric Surgery

There's no question that the waiting lists for weight loss surgery, or bariatric surgery as it's called, are unacceptably long. The wait list in Canada is well over 5 years, with this number varying across provinces and cities, depending on the availability of local facilities.

In desperation, some Canadians are turning to medical tourism for the answer.

Take the case of a woman who went to Tijuana, Mexico, for bariatric surgery, as per the recent story in the Calgary Herald. Due to leak from her stomach after a sleeve gastrectomy (which reduces the stomach's size), she returned to Canada to endure a prolonged hospital stay, at which point her stomach also had to be stretched out, as the bariatric surgeons in Mexico had made her stomach too small to sustain her.

This lady is not alone: due to the ease of accessibility and short wait times, many Canadians are turning to foreign coutries to have bariatric surgery performed. It costs $,6000 to $12,000, depending on the country (Costa Rica and India are other popular choices) and the procedure performed, which is cheaper than private pay facilities in Canada (eg BC, Ontario), where patients pay $16,000 to $18,000 for comprehensive care. 

But remember - you get what you pay for. Medical tourism outfits may not take the same great care in selecting the appropriate patient for bariatric surgery, nor do they take the time to prepare patients adequately for the dramatic and permanent lifestyle change they are about to undergo. Nor do they do much, if anything, in the way of follow up, which is downright dangerous: ongoing nutritional counseling is crucial, as is monitoring for nutritional deficiency, which occur particularly with gastric bypass surgery, and can be very serious if not managed properly.

Further, one can't help but be wary of an outfit who tries to sell their medical procedure with promises of free nights of hotel accomodation, travel planning, and sometimes with sightseeing opportunities thrown in!

As Canadians, the problem that we need to urgently address is the lack of availability of bariatric surgery within our borders. There are several centres in Canada where bariatric surgery is publicly funded and of no cost to the patient, though the wait times are long. An increase in government funding is desperately needed to improve accessibility to existing centres of excellence for bariatric care, and also to help establish new centres where there currently are none.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Read more...

Weight Loss Surgery

Weight loss surgery, or bariatric surgery as it's called, is one hot topic in the obesity world. And I have lots to say about it, as it is the main focus of my research during my year-long sabbatical here at the University of Copenhagen. Here's a little introduction....


Desperate times call for desperate measures. We exist in a global society that has seen an explosion of obesity in the last few decades. The majority of Canadian adults are overweight at a staggering 59%, with one in four being clinically obese.



The treatment of overweight and obesity must be approached on an individual basis. For most people, obesity has its roots in lifestyle problems, and as such, adopting a new paradigm of lifestyle is the best solution. However, for some people, this seems to be beyond reach. For some people, medications for treating obesity can result in successful weight loss, though they may not be effective for long term weight loss, particularly if not accompanied by lifestyle alterations. For those individuals who are severely overweight, and have not been successful with intensive attempts at lifestyle alteration and/or medical therapy, surgery may be the most appropriate option.

At present, bariatric sugery is a treatment that is reserved for people with very severe, or very complicated obesity.

Commonly accepted criteria for qualifications for surgery include:

• A BMI (body mass index) of 40 or more; or


• a BMI of 35 or more, PLUS either type 2 diabetes, high blood pressure, or obstructive sleep apnea (as complications of obesity)

(You can calculate your BMI using the BMI calculator on my website, in the right hand column http://www.drsue.ca/)

There are several types of bariatric surgery. The most commonly performed currently are Roux-en-Y gastric bypass surgery (RYGB), and laparoscopic adjustable gastric banding (LAGB).

• LAGB involves putting an inflatable ring around the stomach near the top of the stomach, such that it restricts the size of the stomach.



• RYGB is more complex surgery in which the stomach is made smaller, and part of the small intestine is also bypassed, thereby reducing both the amount of food a person can intake, as well as the capacity to absorb that food (diagram displayed above).

There are pros and cons to both procedures. LAGB is a less complicated procedure, and is reversible. RYGB results in greater weight loss and has a higher likelihood of curing diabetes and other cardiovascular risk factors, but has a higher risk of operative complications.

Stay tuned for much more in the coming months.....

Dr. Sue © 2009 http://www.drsue.ca/ drsuetalks@gmail.com

Read more...