Obesity: A heavy burden

By RUTH HILL - The Dominion Post

One in five Kiwis are medically obese and their care places a hefty strain on the public health service. Surgery is an option - but should taxpayers cough up for people who can't stop eating?

Former trade union heavyweight Ken Douglas is half the  man he used to be thanks to  weight-loss surgery that saw  him shrink from 151kg to 83kg.

The Capital and Coast District Health Board deputy chairman, who paid $20,000 for his gastric bypass in 2003, describes it as the best investment he has made - and one that saved the taxpayer thousands.

Health Ministry figures have put the direct cost to the health sector from obesity at about $460 million a year.

Complications from type-2 diabetes kill 2000 Kiwis a year, while heart disease, cancer, kidney failure and a host of other obesity-related problems add to the weighty burden on the health system.

Having seen the health benefits himself, Mr Douglas has become a staunch advocate for more publicly funded bariatric, or weight-loss, surgery.

"As far as I'm concerned, it's a no- brainer - putting money into this now will save millions of dollars in the long run. It's unfair that those who are most badly affected by obesity - Maori and Pacific people - have the least access to it."

Figures obtained by The Dominion Post under the Official Information Act show the number of publicly funded weight-loss operations more than tripled in the past two years, to 233 in the year to June. Another 400 patients a year pay to go private.

However, widespread regional inequities remain. More than half the operations (139) were done by Counties Manukau District Health Board, while six regions have performed none in the past five years.

The ministry is still considering recommendations made a year ago from its national service and technology review advisory committee, which said DHBs should be funded to surgically treat 0.5 per cent of the morbidly obese population annually.

This would translate to about 915 operations a year and cost about $17m in the first year, declining to about $11m within five years because of the money saved on other services to treat the complications of obesity.

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Nutrition expert Jim Mann, professor of human nutrition and medicine at Otago University and a member of the ministry's advisory committee, says he was initially sceptical about the value of weight-loss surgery. "But I've been persuaded that, for some patients, it's the only answer. We treat cancer in smokers - so why not treat the morbidly obese?"

Many weight-loss drugs available have so far turned out to have serious side- effects: "This problem is not going to go away by itself."

The fact that there are regional inequities is unfair, he says. "In Tairawhiti, for instance, the need is phenomenal."

Medical ethics professor Grant Gillett says many people assume morbidly obese people have only themselves - and their lack of self-control - to blame.

"Slim people, often educated, middle- class people, feel somehow morally superior about this. But not everyone has the same meaningful choices in life . . . obesity is a life-threatening disease and it's our social duty to treat those individuals who need help."

Paradoxically, obesity is now associated with poverty. "Fast food is the cheapest food and it's also ideal for people with low self-esteem because it makes you feel good. Surgery is a late response to a situation which has got out of control and it's not an adequate response to the social problem of obesity. But we can't just abandon those caught in the trap."

A clinical trial at Auckland's Middlemore Hospital is investigating the use of wrap-around services (counselling and support) to boost the long-term success of weight-loss surgery. The hospital is doing 100 weight-loss operations a year, funded out of its existing elective surgery budget.

Lead researcher Brandon Orr-Walker is passionate about its potential to transform lives. Some people have lost up to 70kg and seen a huge improvement in their diabetes and other health problems.

But he is under no illusions that surgery is the answer for everyone. In Counties Manukau alone, there are 110,000 obese people. "That's not just overweight; they are morbidly obese."

An estimated 30,000 of them could benefit from weight-loss surgery, assuming they do not have other factors that could disqualify them, such as a weak heart. At current rates, it would take roughly 300 years to operate on everyone who needs it.

"That's even if no-one else joins the queue," Dr Orr-Walker says

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Obesity is determined by several factors, including genetics, demographics, culture and environment, and therefore a "multi-pronged" approach is needed.

By scrapping healthy eating/healthy action programmes, the Government has "dropped the ball" on the biggest public health issue facing the country, he says. "The prime minister may be interested in cycle lanes, but that's a Remuera solution for an Otara problem. A kid who's given $2 for breakfast and walks past the dairy on the way to school is not going to exercise personal responsibility."

The latest ministry figures show Maori are 1 1/2 times more likely to be obese than the average New Zealander, while obesity rates among Pacific people are 2 1/2 times higher. Based on the percentage of obese Pacific people in South Auckland, researchers had expected about 40 per cent of trial participants would be Pacific Islanders.

In fact, only about half that number are involved. Possibly the results were too dramatic for some. "We've heard comments like 'I don't want my wife to get that skinny.' "

In Pacific culture, being bigger is traditionally associated with status and wellbeing, and so obesity has been normalised. However, it's not just a problem for one group, he says. "Pacific  people are our canaries in the coalmine.  The fact this environment is making  them sick is telling us that it's not a  healthy environment for anyone."

Obesity Action Coalition head Robyn Toomath sees obesity's impact every day in her job as director of clinical support services at Capital and Coast Health.

The morbidly obese are challenging patients, not just because of their co- existing health problems, but also because the standard diagnostic tests are often unsuited to them.

Some people do not fit inside scanners and lab results have to be interpreted in different ways.

"As humans, we have evolved to seek out high-energy food. In the past few decades, our environment has changed, but those powerful genetic drivers are still there. We are punishing people who are effective food-seekers.

"The ultimate solution is to re-engineer society and introduce environmental controls to make it easier for people to make the right decisions, but meanwhile, I'm totally convinced that surgery is the only effective option for a minority of people."

However, some still question the push toward surgical interventions for the masses and "pathologising" fat.

Eating Difficulties Education Network co-ordinator Maree Burns says surgery does not fix the underlying problem for most people, which is "disordered eating".

For some people, overeating - especially of comfort foods - is their only coping strategy for dealing with stresses in their lives.

For others, surgery could cause eating disorders by "disrupting their natural relationship with their bodies".

There are still considerable gaps in our understanding of - and ability to predict - who will benefit and who will be harmed by these "incredibly invasive procedures".

"There is some evidence that post- operative mortality rates are quite high, not just from complications, but from suicide.

"The problem is that surgery doesn't fix the underlying problem for most - the reasons why they had disordered eating in the first place."

Those who undergo weight-loss surgery face a hugely modified lifestyle.

"I've heard of people having to carry around plastic bags because they don't know when they might sick up their food."

Furthermore, rates of post-operative suicide are relatively high, she says. "People could be just replacing one set of health problems with another."

More information is needed on the long-term psychological and physical effects of weight-loss surgery, and meanwhile, more resources should be invested in alternatives to surgery to treat mood disorders, eating disorders, social stigma and discrimination, she says.

"The key message should be that fitness, not fatness, should be the measure of health."

Policy analyst Christy Parker, from Women's Health Action Trust, says weight-loss surgery is invasive and expensive, and prevention and early intervention are preferable.

"Ultimately we are concerned that we are living in a social context which pathologises and stigmatises fatness, and that it is this which is overly influential in people's decisions to undergo this surgery - particularly women who tend to be more affected by the slenderness ideal.

"Women's susceptibility to fat stigma is reflected in the DHB statistics on the uptake on bariatric surgery, which is highly gendered."

Ms Parker is concerned at obesity being categorised as a disease. "The relationship between body size and health is at best poorly understood."

BRIAR'S MOTHER KNEW BEST

Maree Allely has given life to  her daughter twice - once when  she gave birth to her 26 years  ago, and again 18 months ago  when she paid for her weight-loss  surgery.

Mrs Allely knows the life-changing potential of weight-loss surgery. She was about the same age as daughter Briar Stockley when she had her operation in 1981. She shed 45kg - and gained a new personality.

"Before I lost weight, I would sit in a corner . . . afterwards I became a loud mouth."

After struggling to walk, she took up squash and soccer. "If I hadn't had surgery, I don't think I would have made old bones."

She also had subsequent surgery to remove her "fatty apron".

"I always thought that was vanity, till I was zipping up my jeans and felt something wet, looked down and it was all bloody. I had zipped up my loose skin. That's when I realised it was a health issue."

Within two years of her operation, Mrs Allely became pregnant with Briar, the first baby born to a New Zealand woman after a gastric bypass. Unfortunately, history was to repeat itself.

Briar Stockley started putting on weight in her teens, and tried everything to lose it, joining Weight Watchers at 16 and taking appetite suppressants.

During her pregnancy with twins, her weight topped 170kg and she was admitted to hospital.

After Lucian and Coen were born three years ago, she was unable even to lift her sons out of their car seats without help and struggled to breathe when lying down. Her asthma deteriorated and she was depressed.

Her mother and stepfather, Craig, had considered giving her a deposit for a house.

"But they figured there was not much point in getting me a house if I was going to die before I turned 30, so they offered to pay for surgery."

She had a gastric sleeve operation last April.

Before surgery she weighed 157kg; she is now 76kg.

"I went swimming the other day for the first time in 10 years. I'm not skinny, but I feel normal. When I was fat, people stared at me all the time, they couldn't help it . . .

"I feel lucky that I had a chance to have this operation when I'm young. So many people have to wait till their 40s or 50s when they already have bad health problems and they've wasted all those years.

"My mum saved my life."

GREAT TRAUMA BUT NO REGRETS

Allison Doody has had three  weight-loss operations, the first  when she was just 14 - making  her New Zealand's youngest  patient and the second youngest in the  world at the time.

"I desperately wanted it. I was three times the size of anyone else in my class . . . my life was made a misery by my PE teacher, the few friends I managed to make were teased for being friends with me, I believed I would never get asked to parties, never have a boyfriend."

It was 1984, and the latest operation on offer was the vertical banded gastroplasty, which reduced her stomach volume to just 15ml.

She lost 10kg, but as she had weighed 120kg before the operation, she was "still huge".

Unable to eat meat, bulky vegetables or fruit, she subsisted on fizzy drinks, icecream, chocolate and high-calorie junk food. At 18, she ended up in hospital with malnutrition, despite being grossly overweight. By 22, she was so desperate that she pleaded with her surgeon to perform a drastic type of operation no longer routinely done.

Both Mrs Doody's aunt and mother had the operation in the mid-1970s and had dramatic weight-loss. Her aunt died two years ago from kidney cancer, while her mother suffers massive "staghorn" kidney stones, which need to be surgically removed every couple of years.

The operation fell into disrepute because of its serious complications, including diarrhoea, gallstones, uncontrollable pain, arthritis, liver cirrhosis and death.

But for Mrs Doody, it was "a licence to eat. I could eat whatever 'crapola' I liked and I didn't gain weight".

But in 2004, she started gaining weight again and suffered crippling stomach pains. Despite joining WeightWatchers and walking the dog for an hour a day, her weight kept creeping up until she was more than 100kg again.

She was told she needed the original operation reversed and a new gastric bypass. Her husband, Jim, cashed in his superannuation to pay for the $20,000 operation in 2006.

Doctors said there was a 50 per cent chance she could die on the operating table. "But I knew there was a 100 per cent certainty I would die without it, so I had no choice."

Mrs Doody now weighs about 80kg and wears a size 16, but that is mainly because of excess skin.

"I'm a size 12 inside a shar-pei body," she jokes, referring to the dog breed with fleshy folds of skin.

She is trying to help her younger sister, Bronwyn, get the money to have a second operation after her first gastric band burst while being refilled.

Mrs Doody says obesity does not only have physical effects, but also has mental, social and even economic impacts, as overweight people are discriminated against in the job market.

"A friend who's in a wheelchair told me if she was given the choice between walking and being skinny, she would ask to be skinny because being fat is more of a disability. People think fat people are stupid and unmotivated, but I've always been motivated and hard-working."

Despite the trauma that surgery has caused her, she has no regrets.

"I don't think 14 is too young, but it was too young for the kind of surgery I had . . . But at least I didn't get any bigger. I believe I would be dead by now if I hadn't had it."

DIABETIC'S TRANSFORMATION 'NOT INSTANT FIX'

Athena Gavriel's doctor first  recommended weight-loss surgery six years ago because her  diabetes and blood pressure were  getting worse.

"But with three kids and a mortgage, I just couldn't afford it," the Wellington woman says.

Last year, she was one of five people in Wellington to get surgery courtesy of the taxpayer. At 125kg, she was not considered grossly obese, but after 20 years of being overweight - not helped by yo-yo dieting - her health was becoming seriously at risk.

Despite using two doses of insulin and 12 tablets a day for diabetes, high blood pressure and to counter the risk of stroke, high cholesterol, kidney or heart problems, she could not get on top of her diabetes. Some of the medication also had weight gain as a side-effect.

"My kids were afraid I was going to drop dead."

Eighteen months on from her operation, she has lost 56kg, and needs only two diabetes tablets and a multi-vitamin pill a day. Other medical concerns are resolved and her blood pressure is at the low end of the normal range.

She has recently taken up belly-dancing for exercise and walks regularly.

At 52, her life is transformed, but she cautions it is "not an instant fix". She is paying for counselling to deal with the psychological aspects involved.

"Your body changes, but your head and emotions take a while to catch up.

"You still have to work at it, exercise and eat properly. You've got to be extra careful to eat the right things because you can't eat much."

It has taken time to learn new ways of eating.

If she eats too quickly, food can get stuck, and some sweet or fatty foods cause "dumping" - nausea, sweating and a racing heart.

Ms Gavriel carries nuts and other snacks with her to avoid the temptation to graze on sweets when her energy is low.

"I don't want to have gone through all this for nothing and end up where I was.

"I'm so grateful, privileged even, that I have had this chance . . . and also think that I have a responsibility to succeed, not just for myself and my family but also for the taxpayers, because our taxes allowed me to have the operation."

'MOST COMMON SURGICAL PROCEDURE IN THE US'

RICHARD STUBBS has performed  about 1000 gastric bypasses in the past 20 years and hopes one day  to do himself out of a job. The Wellington specialist says that, for now,  bariatric, or weight-loss, surgery offers  the best and only hope for many with  type-2 diabetics.

With one in five Kiwis medically obese, it seems highly unlikely it will ever be possible to operate on everyone who needs it - but Dr Stubbs says that is debatable. "Back in the 1960s, when heart surgery was first being done, no-one ever thought it would become a commonplace intervention.

"Bariatric surgery is now the most common surgical procedure in the United States - 200,000 patients a year, and growing 20 per cent per annum."

He welcomes recommendations to increase the number of publicly funded operations in New Zealand: "They've got to make this a priority."

Gastric-band operations are the simplest and cheapest - about $17,000 - but about 10 per cent of patients require repair surgery each year, he says. His speciality is the Fobi pouch gastric bypass, which reduces the stomach to about the size of a walnut. It is more expensive - $25,000 to $28,000 all up - and requires a longer recovery time, but patients rarely need a repair job and it works for 90 per cent of cases.

There are other challenges for the public sector: sometimes patients who are getting an operation free are not as "motivated" to make the necessary lifestyle changes, he says.

"Private patients are typically highly motivated, but I've had to turn some people down in the public system because I didn't think they would be able to cope."

His biggest patient weighed 360kg, but some people are simply too obese for obesity surgery.

"I've had to turn people down because they would never have got off the ventilator, and they have to be able to lie flat on an operating table."

Hamilton-based surgeon Rowan French says gastric bands have the advantage of being adjustable - and reversible. "Also, you lose weight over a couple of years so don't have the same problems with loose skin or gallstones, and they're good for women who want to get pregnant later because their nutrition needs will be different.

"We can't just 'set and forget'. . . but it's not just about weight loss, it's about quality of life."

FOR WALNUT-SIZED STOMACHS

Up to three small cups of food a day is the maximum intake for a person with a gastric bypass, which reduces the stomach to the size of a walnut.

For the first couple of days after surgery, patients consume only clear liquids, progressing to pureed food for a month, then easy-to-chew foods for eight weeks before graduating to a "normal" - though radically reduced - diet.