Slimming and stomach banding

Slimming is not easy.

We said that yesterday at the start of the article about Chris Oliver’s blog. But it is worth repeating.

Slimming is not easy.

Slimming is made much more difficult by the fact that fat people are stupid.

Britain has been declared the “fat man of Europe”. A quarter of our adults and sixteen percent of our children are now officially deemed to be obese. I have not the slightest doubt that if all the people deemed to be “obese” were to lose weight, their general health would improve. But it is not as simple as that. There is a question of self-respect, of self-esteem. A lot of people who overeat do so not just to “fill a hole” in their stomach, but also to “fill a hole” in their lives. The more the media batters them, the bigger the hole becomes, and that applies particularly to fat teenagers. Next stop anorexia. (from “Fat people are stupid” here)

Chris Oliver writes about his surgery to reduce the size of his stomach. But, from the outset, he is honest about the availability of such surgery:

“I was lucky and could afford to have my surgery privately. The NHS has not really woken up to the merits of Bariatric Surgery.”

Perhaps surprisingly, bariatric surgery is available in Dr Crippen’s PCT area. I have referred two patients for it over the last eighteen months. One was a 31 year old secretary whom we will call Julia.

Julia was always a little overweight as a teenager but, after the birth of her second child when she was 22, she gave up work and devoted herself to childcare and eating. She is now over twenty stone. She has a strong, secure marriage and a supportive husband. Julia has all sorts of issues about self-respect. Does she have an eating disorder? Some of the diet Puritans would say she must have or she would not be the weight she is. I think that is too simplistic.

I have been trying to support her for the last two years. Sometimes she gets a stone off but she soon puts it on again. She is dispirited, fed up, and anxious - but not psychiatrically ill. Fat people may be stupid but we have yet to deem them as being ipso facto mentally ill. But don’t hold you breath on that!

So, after much counselling and discussion, and a medical work up, I concluded that bariartric surgery would be a reasonable option, and referred her to a local surgeon who does it. He agreed. And sent me the following letter:

Dear John

Many thanks for kindly referring this patient to me with a view to laparoscopic gastric banding. I have had a long talk with her, and agree that this is a reasonable option. In order to facilitate her next outpatient visit there are unfortunately a lot of organisational issues, of which the most basic and troublesome one being the PCT funding approval.

In order to minimise delays I have enclosed the PCT guidelines of who will be considered suitable for referral in the future.

Patients have to comply with the listed guidelines.

If the patient is compliant with these NICE guidelines, I would suggest that you write directly to your PCT service purchasers for contract approval.

Finally, in order to facilitate the process so that if approval is available formally from the PCT, if and when I see the patient with the completed investigations (see check list), I will be able to facilitate the process of eventual admission for the banding much more rapidly.

Please feel free to contact me if you have any concerns or queries.

++++++++++++++++++++++

The protocol and guidelines

SURGERY FOR MORBID OBESITY
GP GUIDELINES: WHO WILL BE CONSIDERED SUITABLE FOR REEERRAL?

[Could we not call it "severe" obesity? Morbid is such a morbid word. And in the old days, I decided who was "fit" for referral and duly referred. If the specialist did not agree, he would say so. Now, there is a commissar between me and the specailist, and the commissar, who is not medically qualified, tells us both how to do our job]

We can only consider offering weight loss surgery if patients fulfill these criteria:

[Who is “we”? OK, it is the PCT but in fact it is some unnamed PCT committee composed of anonymous barrier-building bureaucrats. And the use of the word “can” is dishonest. They mean “will”.]

BMI >40 or BMI >35 with co-morbidity

[Arbitrary lines in the sand. Yes, lines have to be drawn but professionals – in this case the family doctor and the specialist surgeon – prefer to have discretion]

Age 18 and over

[Why not 17? Another arbitrary line]

Are not taking oral steroid therapy
No treatable metabolic reason for obesity e.g. Hypothyroidism, Cushing’s Disease
Has been referred to a dietician and has attended dietetic clinics
Has tried other weight loss treatments including either sibutramine or orlistat (as per
NICE guidelines).

[I am uneasy about the need for sibutramine and orlistat. I rarely prescribe either of these drugs. I worry about the safety profile of sibutramine, and orlistat gives you shitty knickers.]

Is committed to losing weight and has demonstrated motivation in previous weight loss attempts with at least 2.5kg weight loss documented at some time.

[OK. All obese patients have played with the dietary yo-yo and can meet this criterion – but it is slightly odd, is it not, to exclude those who genuinely cannot lose weight?]

Understands the need for long term follow up and compliance following surgery

[Egg sucking lesson]

Understands that cosmetic surgery for excess skin following weight loss will not be provided by this NHS service unless in exceptional circumstances where it constitutes a medical problem and will be considered under current criteria for restricted procedures.

[Lunacy. Someone who loses eight stone will find their skin is too big. That can cause serious psychological problems too. So why do we kick them out on the last lap?]

If the patient does not have BMI >35 plus co-morbidity, or BM >40, then they will NOT be considered for surgery.

[See above]

Co-morbidity associated with obesity includes: type 2 diabetes, hypertension, hyperlipidaemia, heart disease, gastro-oesophageal reflux disease, arthritis, sleep apnoea, asthma, incisional hernia, menstrual irregularity.

[Well, yes, OK but a tad silly. If they do not have Type 2 diabetes, it may only be a matter of time. Is this not about prevention. I have never met a woman who cannot conjure up a bit of menstrual irregularity if it is needed.]

The single most important guide to success with surgery is patient motivation. We ask GPs to state clearly that the patient appears motivated and has no psychological problem likely to hinder compliance with diet following surgery, e.g. alcoholism, mental illness, failure to understand the need for long term follow up.

[A cross between egg-sucking and idiocy. All seriously obese patients have psychological problems with their relationship to food. Note I say psychological, not psychiatric.]

Contraindications to surgery include poor compliance, cancer, GI inflammatory disease.

We ask that you document all previous attempts at weight loss.

Please list treatment with anti-obesity drugs and information on compliance, weight loss achieved and any side effects of treatment.

Please send results of fasting blood glucose, full blood count, calcium, liver function tests, lipid profile and thyroid function tests. In addition, any recent endoscopy or upper abdominal ultrasound results (within past year) will prevent unnecessary repetition.

*Guidance on the use of sibutrarnine for the treatment of obesity in adults NICE Y7/tO/2001

[More protocols from the commissariat. I do not agree with NICE on sibutramine, and so I ignore their recommendations.]

Check List of blood tests required:

Full blood count
Urea & Electrolytes
Liver function tests
Thyroid function
Ca/Phosphate/Albumin
Glucose & Lipids fasted
LH
FSH
9. 00 a.m. fasting Insulin
Testosterone
Sex hormone binding globulin
and androgen free index
24 hour urine cortisol and metabolites

[Nothing wrong the list of tests. I had done them all on Julia except for the 24 hour urine cortisol, and it is reasonable to do it, so I did.]

++++++++++++++++++++++++++

This protocol so typifies the modern Stalinist approach to health care. Taken sentence by sentence there is nothing particularly wrong with it. Taken as a whole, it is a disgrace.

Modern bariatric surgery is not hugely expensive. It is not without dangers, and not to be undertaken lightly. But the doctors should be left alone to make a professional assessment. It can be life saving, certainly quality of life saving.

If I see a patient who has smoked thirty cigarettes a day for thirty years I automatically treat his COPD. People who drink too much get their liver disease treated; boxers who hit each other too much get their head injuries treated.

What is so different about people who eat too much?

This protocol is not about economics. It is about blame. It is “your fault” you are fat. Fat people are stupid. Fat people are probably mentally ill. So we are not going to waste money on them unless they are penitent. Unless they admit the error of their ways and promise to behave. Unless they can demonstrate that they “deserve” treatment.

This protocol is about humiliation. Humiliating the patients by making them jump through hoops and humiliating the doctors by telling them how to do their jobs.

Obesity is about energy balance.

If you take in more energy than your body expends, you store it as fat. And vice versa. How many ex-rugby players do you know who were sixteen stone and fit at 25, and then at 50 are eighteen stone and flabby?

Thin as a rake

Take a look at Michael Schumacher since he stopped racing.

Looking more relaxed

That lean, thin, angular pointed face has filled out. Much the same, and more, happened to Chris Oliver

Michael Schumacher is not obese yet, but it is early days. If problems arise, and there is need, he will be able to afford bariatric surgery, Chris Oliver could afford it too.

Most people cannot.

Bariatric surgery performed on suitable patients can transform their life and, on the long term, save the NHS a lot of money. As so often, entry into the NHS "shop" remains free, but once inside, the shelves are empty.