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New draft guidance

UK proposes surgery for BMI 30 with diabetes

Draft guidance could see one million people eligible for surgery
Diabetes costs the NHS £14billion a year

New draft guidance by the National Institute of Health and Care Excellence (Nice) has proposed that anyone with a BMI 30 should be considered for the surgery if they have been diagnosed with diabetes in the last decade. This could mean up to a million more people could be offered surgery on the NHS.

Currently, surgery is given to patients on the NHS to those who are morbidly obese with a BMI 40 or to those with a BMI over 35 if they have another condition, such as type 2 diabetes.

“Obesity rates have nearly doubled over the last ten years and continue to rise, making obesity and overweight a major issue for the health service in the UK,” said Professor Mark Baker, director of the Centre for Clinical Practice at NICE. “Updated evidence suggests people who are obese and have been recently diagnosed with type 2 diabetes may benefit from weight loss surgery. More than half of people who undergo surgery have more control over their diabetes following surgery and are less likely to have diabetes related illness; in some cases surgery can even reverse the diagnosis.”

As well as meaning diabetics with a BMI of at least 30 could be eligible, the recommendations state those from an Asian background should be considered even if they are not obese, because of evidence that body fat carries higher risks of diabetes in such populations.

"The first line of attack will be diet and exercise and we would expect clinicians to consider the risks and benefits of surgery for patients,” added Baker.

He said some would not be operated on because of age, concluding: "It would be between 5,000 and 20,000 operations a year, but we haven't done the modelling."

The draft guidance states that there is evidence to suggest that around 60 per cent of morbidly obese diabetics (those with a BMI of 40 and over) could put the condition in remission by having bariatric surgery.

Research indicates that the costs of obesity-associated health issues means the typical cost of an operation is repaid in savings to the NHS within three years, resulting in saved costs of around £4,000 a year per patient in the long-term.

It is estimated diabetes costs the NHS £14billion a year, much of which spent treating debilitating complications such as blindness, strokes, kidney failure and amputations. NICE says evidence shows bariatric surgery helps patients control their diabetes and in some cases effectively resolves the condition.

Diabetes UK estimates that the new criteria mean between 850,000 and 900,000 extra people could qualify to be considered for surgery. Currently, there are only around 9,000-10,000 weight loss procedures funded by local NHS organisations annually.

“Expecting the UK to have the provision to operate on nearly a million people is an unrealistic proposition. The majority of people, their degree of obesity will be corrected by exercise alone,” James Halstead, a bariatric surgeon at Leeds hospital told Radio 4’s Today programme. “The idea that the NHS could deal with 900,000 extra patients with this alone is nonsensical.”

The surgery can cost between £3,000 and £15,000 and the move by NICE has raised concerns that the NHS will not be able to afford the treatment, even if there are savings in the longer term.

“We’ve got a mismatch between what Nice recommended and what the country can afford,” said Tam Fry from the National Obesity Forum. “Clearly there are going to be thousands of people who will look at this and say, I fit that criteria, I want the surgery. We could end up with a situation where clinical commissioning groups say we can’t get the extra midwives we need for the local hospital, we can’t pay for life-saving drugs for people with cancer – because other people have been given the right to have expensive bariatric surgery.”

Current guidelines state that patients must have tried and failed to achieve clinically beneficial weight loss by all other appropriate non-surgical methods and be fit for surgery. This recommendation has not changed.

The updated draft guidelines include additional recommendations on bariatric surgery for people with recent-onset type 2 diabetes. These recommendations include:

  • Offering an assessment for bariatric surgery to people who have recent-onset type 2 diabetes and are also obese (BMI of 35 and over).
  • Considering an assessment for bariatric surgery for people who have recent-onset type 2 diabetes and have a BMI between 30 and 34.9. People of Asian origin will be considered for surgery if they have a lower BMI than this, as the point at which the level of body fat becomes a health risk varies between ethnic groups. Asian people are known to be particularly vulnerable to the complications of diabetes.

The draft guideline also makes recommendations regarding very low-calorie diets (800kcal per day or less). These include:

  • Not routinely using very low-calorie diets to manage obesity.
  • Only considering very low-calorie diets for a maximum of 12 weeks (continuously or intermittently) as part of a multicomponent weight management strategy with ongoing support. This would be for people who are obese and have a clinically assessed need to rapidly lose weight – for example, people who require joint replacement surgery or who are seeking fertility services.
  • Giving counselling and assessing people for eating disorders or other mental health conditions before starting them on a very low-calorie diet. This is to ensure the diet is appropriate for them.

"This raises really important issues, such as the morality [and cost] of giving a surgical procedure for what is essentially a behavioural disease,” Dr Simon Heller from the academic unit of diabetes, endocrinology, and metabolism at the University of Sheffield, United Kingdom, told Medscape Medical News. “This is something that we as a society have really got to think about, and that's true for every country in the world.”

"This is an extremely difficult situation with all kinds of vested interests," he said. "The pharmaceutical industry, for example, presumably doesn't want to see surgery adopted too widely, because these extremely expensive [obesity and diabetes] drugs they have developed are undoubtedly more expensive than bariatric surgery."

The charity Diabetes UK is currently funding the largest study in the UK into this approach, the  Diabetes Remission Clinical Trial (DIRECT) to compare the long-term health effects of current type 2 diabetes treatments with those of a very low-calorie diet, followed by a long-term approach to weight management.

“For most people, losing weight can be very difficult. For some, as well as a healthy diet and physical activity, additional treatments include medication and surgery,” said Simon O'Neill from the charity Diabetes UK. “Although studies have shown that bariatric surgery can help with weight loss and have a positive effect on blood glucose levels, it must be remembered that any surgery carries serious risks. Bariatric surgery should only be considered as a last resort if serious attempts to lose weight have been unsuccessful and if the person is obese.”

To access the full draft guidance document, please click here

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