Surgery and sugar-bans: How are health boards fighting fat?
More than 30 per cent of New Zealand's adult population is obese, with a further 35 per cent over weight. We wonder how are district health boards fighting the fat?
Dr David Schroeder thought he could cure diabetes with a scalpel.
At his peak, Schroeder performed 13 surgeries a week - two gastric bypass surgeries on a Monday, four on a Tuesday and seven gastric bands on a Friday.
He was operating on patients who would die from diabetes. At about $27,000 per surgery, it was cost-effective for district health boards and patients were ditching their insulin before leaving the hospital.
"We became aware a very long time ago that you could apparently cure diabetes by doing a gastric bypass on people," Schroeder said.
"It was just an amazing thing to see them go home off their insulin. And we thought, this is fantastic.
"So I said to the diabetic department, 'it's probably more cost effective if you let me do a gastric bypass on your patient and then it'll take away a lot of the medications and the follow ups'.
"They looked at the literature and the literature looked great. So they then started sending me their worst patients, the patients that were going to die if they didn't get their diabetes under control."
But it only worked for a short time. After a year, Schroeder's patients had regained the weight and were back on the insulin. He said he and his team failed to look at why their patients' diabetes were out of control. It was more complicated than picking apart their diet.
"What we were seeing was people with poor self care, poor social support. We saw poverty and the inability to buy good food. So these people would have the surgery and lose weight for a year and because nothing else in life had changed," Schroeder said.
"[After the surgery] they would go back to their same diet, they would go back to not taking their supplements. They wouldn't do what they were asked to do. Probably because it was not financially, socially [viable] and not within the realm of what they were trained, I guess, to do.
"That is the limitation of obesity surgery, it's different to every other operation I do - the hernias, the gall bladders. I do those operations because we fix them, that's what surgeons are meant to do."
Schroeder works in a private practice but also does publicly-funded surgeries. His patients are referred to him by Justina Wu, the director of the diabetes service and head of the adult weight management programme at the Waikato DHB. Schroeder, Wu, and their team have worked together over the past several years to design a programme more apt to help patients who have surgery. The weight management programme is for patients with obesity-related illness - type 2 diabetes is the most prevalent disease among those in the programme.
In 2014, there were 889 weight-loss surgeries performed in New Zealand. In the same year, the government earmarked $10 million for at least 480 bariatric surgeries over the following four years. But it's not as easy as signing up and booking in for surgery - you have to first prove you can lose weight and keep it off for a period of time.
Wu says losing weight in the current environment is extremely difficult so the programme is not just about nutrition and diet, it's about managing the weight when the patient leaves hospital.
"The patients learn how to exercise properly and learn about their health, about healthy eating and the impact of unhealthy eating, so they gauge the impact of their choices. And we also look at the diseases and how to manage them and how to lessen the effects," she said.
"The core thing that we also educate on is psychological skills because a lot of the difficulty is having a lifestyle in an environment which is not healthy. It's not easy."
Surgery is only one way to battle the obesity epidemic. According to the 2015/16 New Zealand Health Survey, almost one in three adults aged 15 years and over were obese, with a further 35 per cent overweight. A Ministry of Health spokesperson said the ministry had several initiatives to battle the bulge.
District health boards have stopped selling fizzy and sugar-laden drinks. The key person behind the initiative to get rid of the fizz was Dr Rob Beaglehole, principal dental officer at Nelson-Marlborough DHB. His mission to get sugary drinks out of DHBs was prompted by sitting in the hospital canteen with his hand in ice because it was so sore from pulling out children's teeth. He looked out of the window to see a Coca Cola truck dropping off a delivery to the hospital.
The National Healthy Food and Drink Policy is in full effect, with a number of DHBs now working with their local councils to improve the food and drink environments at council facilities.
In October 2015, the Government launched the Childhood Obesity Plan, which includes a range of initiatives to prevent and manage obesity in children and young people. A total of 22 separate initiatives were announced which include referring more overweight children for dieting and exercise interventions from the age of 4.
A number of DHBs have developed their own obesity plans including Northland DHB and Toi Te Ora (Lakes/BOP DHBs). These plans have identified priority issues within their local communities.
The Auckland DHBs have partnered with other local organisations and council to form Healthy Auckland Together to integrate nutrition and physical activity into programmes and initiatives across Auckland.
Project Energize, a programme which teaches children to be healthy and encourages them to be fit, is school-based and only available in three regions, Counties Manukau, Waikato and Northland.
The Green Prescription initiativeis funded by DHBs nationwide. It provides support for adults, children and families who are referred by their GP or nurse. A support person provides the patient or family with ongoing nutrition and physical activity advice and support. Over half of the nearly 50,000 Green Prescriptions issued in 2015/16 were for people with weight problems and almost half lost weight as a result of increased activity and improved nutrition.
The Ministry is also working with all DHBs and the sector to implement Living Well with Diabetes. The plan builds on the work already underway and aims to improve outcomes for people with diabetes.
By the numbers
* Almost one in three adults aged 15 years and over were obese.
* A further 35 per cent were overweight.
* 47 per cent of Māori adults were obese. 67 per cent of Pacific adults were obese.
* Adults living in the most deprived areas were 1.7 times as likely to be obese as adults living in the least deprived areas
* The adult obesity rate increased from 27 per cent in 2006/07 to 32 per cent in 2015/16.
Source: 2015/2016 New Zealand Health Survey
LEARNING THE LINGO
GASTRIC BANDING: Involves placing a band (commonly known as a lap band) around the stomach to turn a two-litre pouch into a 30 millilitre pouch. The band can be adjusted for each person and the procedure is reversible.
GASTRIC BYPASS: The stomach is stapled to create a small pouch, with the surgeon carrying out some "innovative plumbing" to bring the small intestine up to the new stomach.
SLEEVE GASTRECTOMY: The newest of the three surgeries available in Christchurch, but increasingly popular. In a sleeve gastrectomy, part of the stomach is removed to turn it into a narrow tube.