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Obesity in the Middle East

The scale of the Middle East’s obesity threat has reached such a point that only one thing is certain: without new thinking and definitive action, it will only get worse

A global issue of pandemic proportions

The need to tackle obesity – both in healthcare and society in general – is the message from experts across the region who are discussing ways to effectively address a health emergency that will not be solved by continuing to focus on prevention alone.

Obesity is a healthcare challenge of global reach, with recent evidence highlighted in the McKinsey Global Institute report, showing that 2.1 billion people (approximately 30 per cent of the world’s population) are overweight or obese; however the statistics for the Middle Eastern region alone, are equally as staggering.  According to one study[i], 51 million people in the Middle East are classed as obese, crystallizing the scale of the issue. In the same study, Qatar is reported to have the highest incidence of obese men (44 per cent) in the Middle East and North Africa region, followed by Kuwait (43 per cent) and Bahrain (31 per cent), while the prevalence of obesity among women exceeded 50 per cent in three Middle Eastern countries; Kuwait (59 per cent), Libya (57 per cent) and Qatar (55 per cent).

Solutions to this growing epidemic were top of the agenda at a recent obesity roundtable meeting held by Johnson & Johnson at its offices in Dubai Healthcare City.  Sabine Dandiguian, Company Group Chairman for the Global Surgery Group of Johnson & Johnson Medical across Europe, the Middle East and Africa, was joined by Professors and Medical Experts from across the region to discuss the role of bariatric surgery in easing the increasing burden of obesity on the region’s patients and healthcare systems.

A growing economic and societal burden in the Middle East and North Africa

Not only does obesity carry serious consequences for people’s health, it carries a global cost of $2 trillion, consuming 2.8 per cent of global Gross Domestic Product and demanding approximately 15 per cent from the healthcare budgets of developed countries, according to the authors of the McKinsey report.

Researchers have produced the startling forecast that if current obesity rates continue, almost half of the world’s adult population will be overweight or obese by 2030.

The roundtable discussion highlighted how the demand for bariatric surgery is increasing by 20 per cent annually in Gulf countries, however in many cases it is out of necessity rather than choice. Bariatric surgery is proven to reduce the risk of serious health complications associated with obesity such as cardiovascular disease, sleep apnea, certain cancers and perhaps most pressing for the region, type 2 diabetes.

According to experts, it is pivotal to dispel the notion held by many, that obesity is self-inflicted or a lifestyle choice, rather than a critical health issue.

It is these damaging perceptions which have led to widespread criticism of bariatric surgery, which can cost between $8,000 and $15,000, as many claim that the procedure is becoming a substitute for a lifestyle overhaul.  It is from this viewpoint that a serious stigma has emerged.

The alternative perspective, shared by the thought leaders in attendance at the roundtable discussion, is that surgical intervention for obesity can have health benefits for patients, many of whom suffer from two or more associated diseases by the time they are eligible for surgery. 

An increase in bariatric procedures could also realize financial savings for governments and healthcare systems alike, as patients who have undergone surgery, are more likely to avoid life-threatening and costly conditions such as heart disease and diabetes, which currently affects approximately one in ten adults in the Middle East and North Africa region.

The shift from lifestyle disorder to disease state

In 2013, the American Medical Association voted for obesity to be recognized as a chronic disease and the World Health Organization has said obesity is one of today’s most blatantly visible – yet most neglected – public health problems.  However, the idea that obesity is a lifestyle disorder lingers in the public consciousness.

Dr Mohammad Ahmad Al Jarallah – GOSS President and Consultant in Bariatric & Metabolic Surgery

“As a company operating within the Middle East and North Africa region, we are seeing the stigma associated with obesity first-hand," said Ms Dandiguian.  "It is a belief that obesity is purely cosmetic and those patients are just lazy; there is a perception they should just go out and exercise. Our message is that this is a life-threatening issue. As a company, it is our responsibility to change the way obesity is viewed and treated. We are dedicated to collaborating with pioneering experts to help bring obesity under control before it is too late.”

Dr Mohammad Ahmad Al Jarallah, the former Minister of Health in Kuwait and former Chief of the Military Medical Services Authority in the Kuwait Ministry of Defense, agrees. 

"There are these views that if you are obese, go and get a bike. There is no doubt, that we need to start by encouraging patients to control their diet and address their lifestyles, but we also need an end-point.”

Professor Fahim Bassiouny, Professor of General Surgery in Cairo University, Egypt believes that, “obesity by itself is a disease," and evidence shows investing in surgical intervention for obesity saves not just costs, but lives.

There has definitely been some success over the last decade in shifting the long-held perception of obesity as being related simply to poor lifestyle choices and lack of exercise, in the opinion of Dr Haitham Al Falah, Hospital Director for King Saud Medical City in Riyadh, the largest Ministry of Health (MOH) hospital in Saudi Arabia. 

However, he feels more education is needed if its true severity is to strike a public chord. 

“Ten years ago, we were fighting to prove that obesity is a disease,” he said. “Nowadays, we are reaching that point where people realize obesity is one of the biggest health problems in society. It is recognized in the medical community, still, we need to raise awareness of its status as a true disease state among clinicians, and that it can really impact a patient’s health and well-being.” 

The importance of providing access to treatment

An increase in awareness however, can also create its own challenges as the rise in obesity means demand for multidisciplinary services and bariatric surgery is already outstripping supply in the public sector.

"The number of people treated versus the number of people who deserve to get access to treatment is very low – not only here in the region, but all over the world," said Ms Dandiguian. "We need to know what we can do to increase access to the right type of care."

Dr Abdelrahman A Nimeri - Head of the Division of General, Thoracic, and Vascular Surgery at Sheik Khalifa Medical Center

Saudi Arabia provides an example of the variance between what is required and what is available in terms of bariatric surgery. 

The number of eligible candidates in the Kingdom far outnumbers the number of procedures performed annually, according to Dr Al Falah, and eligible candidates often go without surgery – with waiting lists stretching into years, as opposed to months.

"The main issue is manpower," he explains. To address this, he believes future efforts in fighting obesity should focus on closing these gaps in care, and increasing the number of skilled surgeons and accredited centers.

Understanding the necessary guidelines

If you are eligible for bariatric surgery, sleeve gastrectomy and gastric bypass procedures are considered safe and effective options which can have a positive impact not just on weight loss, but also on diabetes and other serious conditions caused by obesity.

To undergo a sleeve gastrectomy or gastric bypass procedure, international guidelines state a patient must have a Body Mass Index (BMI) of at least 40, or if they are suffering from a weight-related illness such as diabetes, at least 35.

In rare cases, patients with a BMI between 30 and 35 can also be considered if they are at risk of serious illness, but Dr Abdelrahman A. Nimeri, Head of the Division of General, Thoracic, and Vascular Surgery at Sheik Khalifa Medical Center – Cleveland Clinic in Abu Dhabi, believes cosmetic reasons often drive obese patients to seek surgery.  “Patients come to us for cosmetic reasons," he said. "I think there are milestones that need to be reached for us to be able to actually make patients understand we are not doing this so they can just look better; we are doing this to help them become healthier.”

The message from Dr Al Nimeri is that a patient whose BMI falls below the agreed criteria will not be operated on, due to the risk of potential complications outweighing the benefit.

Dr Haitham Al Falah - Hospital Director for King Saud Medical City in Riyadh

Whatever the intention for a patient seeking surgery, the most important factor, says Dr Al Falah, is simply to get them through the door of their doctor’s consulting room in the first place. “Even if they are initially seeking intervention for a cosmetic purpose, it is a good thing because we know operating on eligible patients will positively impact their health.  Nevertheless, it is our continued responsibility to ensure awareness is raised around obesity as a disease state and surgical intervention as a viable treatment option for the right patients.”

While bariatric surgery is a safe and cost-effective treatment for obese patients, as with any major operation, it does not come without potential risk to short and long term health. Procedures are performed under general anesthesia and can lead to complications such as infection and blood clots.  "Patients must be completely informed when opting for bariatric surgery," said Dr Al Nimeri. “They must know it works, but also that there is the potential for complications.”

According to Dr Al Nimeri, patients must also be aware that surgery is not a quick fix, and that aftercare is a vital part of treatment. To ensure adequate post-surgical care and monitoring, Ms Dandiguian also believes further guidelines should be applied. “It is not only about surgery, you have to have a comprehensive approach to patient follow-up. The question for the future is how can we collaborate to secure the clinical outcome?”

One of the key aspects of any advancement in bariatric surgery is the framework in which it operates.  More guidelines are required to standardize the procedure, according to Professor Bassiouny, including which patients are eligible for surgery, which surgeons should perform the operation and to which centers patients should be referred.

Professor Fahim Bassiouny – Professor of General Surgery at Cairo University

This will act as a safety net for post-operative patients, with Dr Al Jarallah saying: "In our society, although the government has budget, the administration needed to manage such major health problems still needs to be defined.

"The plan and the strategy are there, the program is there, and implementation is vital. You need the manpower and the education. In our community, we are currently focusing on prophylactic; treatment first, then education.

A long, yet achievable, road ahead

Even if the journey involved in tackling obesity may seem long, significant steps have already been taken.

“About 20 years ago, we had this discussion and discovered there was nowhere to physically walk in Riyadh," said Dr Al Falah. "Now there are places to walk everywhere.  At the beginning, the idea of simply walking was rejected by society. It is much more accepted now and common to see people walking. There is a social awareness about the problem of obesity, and that it is not healthy to be an obese person.”

Sabine Dandiguian – Company Group Chairman for the Global Surgery Group of Johnson & Johnson Medical (Europe, Middle East & Africa)

Enhanced awareness has been mirrored by increasing recognition regarding the safety of bariatric surgery. In the past, negative media scrutiny following unsuccessful bariatric surgery deterred eligible patients. "The media can magnify things, and so there have been opinions that bad things can happen in surgery and people have had bad experiences. Now it is considered by the public as a safe method of treatment for obesity," said Dr Al Falah.

Despite the definite sense of optimism around the table at Johnson & Johnson’s offices in Dubai, there is also the realization that a challenge as great as obesity will not be solved by one society alone.

Progress can be made, says Dr Al Nimeri, but this will only be through collaborative action between government, industry and society and that means the Middle East must act in partnership and unison.

"One opportunity we have in the region is to increase connectivity between surgical teams," he said. “We have a lot of talent in different regions, in different countries, but we do not always share that talent. We do not share our successes and failures together. I think if we were able to do that, we would benefit tremendously.  "We need an annual meeting across the Middle East, North Africa, the Gulf; a singular bariatric surgery meeting once a year. This is the ultimate goal."

Professor Bassiouny likens the current structure of the Middle East’s approach to addressing obesity to “operating like islands”.  The scale and complexity of the issue means countries cannot hope to succeed if they work in isolation; teamwork, and the sharing of expertise and knowledge is vital to preventing the region’s health systems becoming overwhelmed by obesity and the serious related conditions.

Said Haddad – Managing Director for the Global Surgery Group of Johnson & Johnson Medical (Middle East, Egypt & Pakistan)

One step towards creating unity within the field is the establishment of the Gulf Obesity Surgery Society’s (GOSS) annual meeting, which aims to become the region’s premiere educational platform in the field of bariatric surgery, and a platform for experts across the region to share their learnings. The second annual meeting will take place in Dubai this month, endorsed by IFSO and supported by Johnson & Johnson.

The need for collaboration chimes with the need for ongoing, transparent, peer-to-peer discussion on how to tackle the obesity pandemic. The roundtable discussion was one forum for achieving this aim, and Ms Dandiguian feels such think tanks can open the door to further progress, building the foundations for tangible action on major health issues and setting an example for the rest of the world to be guided and inspired by. "With attention on this region, and by collaborating with experts and strong leaders, we can show the world what is best for obese patients.”

References

[i] “Global, regional, and national prevalence of overweight and obesity in children and adults during 1980—2013: a systematic analysis for the Global Burden of Disease Study 2013”, The Lancet, May 2014

Press Contact:

Dawn Trail, Director, Public Affairs & Communication Johnson & Johnson
Email: dtrail@its.jnj.com
Tel: +49 6209 796 8906

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