News and Trends—October 2016

| October 1, 2016

News from the American College of Surgeons

First Report from Nationwide Bariatric Registry Examines the Outcomes of Common Surgical Techniques Used in Popular Weight Loss Procedures

CHICAGO, Illinois—By analyzing information included in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the largest bariatric-specific nationwide registry, researchers found that laparoscopic sleeve gastrectomy, a newer type of weight loss surgery that reduces the stomach size by about 75 percent, is a safe procedure with a low morbidity rate. But to achieve even better outcomes, common surgical techniques used in this procedure should be examined more closely. Study results are published in the September issue of the Annals of Surgery.

“The MBSAQIP registry is a powerful tool that allows us to look at process measures on a national level so that we can improve the quality of care in bariatric surgery,” said first author Elizabeth R. Berger, MD, a general surgery resident at Loyola University Chicago Stritch School of Medicine, Illinois, and an American College of Surgeons Clinical Research Scholar at the time this study was conducted.  “This resource allows us to do very highly powered studies that we were not able to do before.”

Laparoscopic sleeve gastrectomy is a common bariatric procedure, accounting for 42 percent of these weight loss operations. Growing in popularity, the procedure helps obese patients lose up to 70 percent of their excess body weight during the 12 months following surgery.
While there are a number of studies showing that sleeve gastrectomy is safe and effective, very few look at specific surgical techniques used in this procedure in relation to complications. During bariatric operations, various surgical techniques­­—including the use of a staple-line reinforcement, the bougie size (a tube used to measure where the stomach is divided), and the distance from the pylorus where stapling is initiated—are used to optimize the procedure and achieve better outcomes. But questions remain over the best surgical techniques to use to improve upon the already low complication rates, and to make the procedure even more effective with regard to weight loss.

This issue is important because leaks and bleeding are major postoperative complications that remain a constant concern for bariatric surgeons. Although leaks at the staple line used to divide the stomach and bleeding events requiring a transfusion are rare—occurring in less than 1 percent of the operations—these events can require hospital readmission and a reoperation to fix the problem.

Using data from the MBSAQIP registry, Dr. Berger and colleagues looked at the largest-ever cohort of patients who had undergone laparoscopic sleeve gastrectomy. They compared different techniques used in the procedure on 189,477 cases performed by 1,634 surgeons at 720 centers between 2012 and 2014. In particular, they evaluated staple-line reinforcement (a layer of material that is sandwiched within the staples), oversewing (meaning the surgeon oversews the staple line to make sure it doesn’t bleed or leak) versus stapling alone, as well as bougie size, and stapling distance from the pylorus. The aim of the study was to assess the impact of these techniques on 30-day complication rates, and one-year weight loss.

The results showed that 80 percent of surgeons use staple-line reinforcement, however, staple-line reinforcement was associated with higher leak rates (0.96 percent versus 0.65 percent).  The use of staple-line reinforcement tended to have lower bleed rates (0.75 percent versus 1 percent), but this effect was not statistically significant after taking into account surgeon and patient factors. Not only is staple-line reinforcement associated with higher leak rates, but it also significantly increases the cost of the operation by over $650 per case.

Larger bougie sizes were associated with decreased leak rates, which surgeons would expect, however, larger bougie sizes were surprisingly associated with greater weight loss at one year.  Increased distance from the pylorus was also associated with increased weight loss—again a finding many find to be surprising.

“It is paramount that as professionals, we remain introspective about the work we do and strive to always improve for our patients. While the devil is in the details, this study elucidates some things we can potentially do to get even better results,” said senior study author, Matthew M. Hutter, MD, MPH, FACS, from the Massachusetts General Hospital, Boston.

“The most important takeaway is the fact that staple-line reinforcement is not necessarily better for bleeding and leaking, and it might not always be necessary. As surgeons, we should examine our individual work flow, looking at bleed and leak rates, and decide whether staple-line reinforcement is being appropriately used, because it’s a very costly part of the procedure,” Dr. Berger said. “I think this study is important because it gets at the issue of evaluating process measures in surgery and how very important that issue is.”

The study authors conclude: “Surgeons should consider risks, benefits, and costs of these surgical techniques when performing a laparoscopic sleeve gastrectomy and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.”

Other study participants include Ronald H. Clements, MD, FACS; John M. Morton, MD, MPH, FACS; Kristopher M. Huffman, MS; Bruce M. Wolfe, MD, FACS; Ninh T. Nguyen, MD, FACS; and Clifford Y. Ko, MD, MS, MSHS, FACS.

“FACS” designates that a surgeon is a Fellow of the American College of Surgeons.

About the American College of Surgeons. The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.

News from the American Association of Clinical Endocrinologists

The American Association of Clinical Endocrinologists Applauds Congressional Action on Legislation to Improve Care for Patients with Diabetes and Other Metabolic Diseases

WASHINGTON, D.C.—A pivotal piece of legislation intended to benefit patients with diabetes and other metabolic, autoimmune and insulin-resistant diseases is headed to the floor of the House of Representatives for a vote after its passage today by the House Energy and Commerce Committee.

The National Clinical Care Commission Act, the top legislative priority of the American Association of Clinical Endocrinologists (AACE), calls for the creation of a public/private sector commission that will draw on the expertise of the country’s foremost diabetes specialists, physicians, non-physician health care professionals and patient advocates to improve the communication and coordination among federal agencies and help evaluate current federally administered clinical care initiatives to ensure they are meeting the goal of improving the quality of patient care.
Testifying at a congressional hearing recently on behalf of AACE was AACE President-Elect Dr. Jonathan Leffert.

“Given the upward trajectory of the incidence of diabetes, its related complications and the extraordinary costs incurred by our nation in treating this epidemic,  I am sure you will agree that maintaining the status quo with respect to this disease is not an option” Leffert noted. “A coordinated national response driven by the commission’s expert recommendations will help to reverse the extraordinary burden diabetes and related diseases place on patients, their families and the healthcare system.”

“As long-time advocates of this legislation, we’re extraordinarily pleased that this bill is moving to the House floor for consideration,” said AACE President Dr. Pauline Camacho. “Our appreciation goes to bill sponsors Representative Pete Olson (R-22nd-TX) and Rep. Dave Loebsack (D-2nd-IA) and their colleagues who supported this bill and to the many other diabetes organizations across our nation that joined AACE in advocating for its passage.”

The bill has strong bipartisan support in Congress, with over 226 co-sponsors in the House and 33 Senate co-sponsors, led by Senate bill sponsors Senator Jeanne Shaheen (D-NH) and Senator Susan Collins (R-ME). Additionally, more than 40 organizations representing physicians, allied healthcare professionals, patients, industry and community-based organizations have joined AACE in voicing strong support for the legislation and urging its enactment this year, among them the Diabetes Advocacy Alliance, American Diabetes Association and the JDRF.

About the American Association of Clinical Endocrinologists (AACE). The American Association of Clinical Endocrinologists (AACE) represents more than 6,500 endocrinologists in the United States and abroad. AACE is the largest association of clinical endocrinologists in the world. The majority of AACE members are certified in Diabetes, Endocrinology and Metabolism and concentrate on the treatment of patients with endocrine and metabolic disorders including diabetes, thyroid disorders, osteoporosis, growth hormone deficiency, cholesterol disorders, hypertension and obesity. Visit our site at www.aace.com.

Obesity Medicine Association Releases Groundbreaking Guidelines on Pediatric Obesity Care  
Guidelines Provide Necessary Background Information on Treating Children with Obesity
CHICAGO, Illinois—The Obesity Medicine Association (OMA) today presented a ground-breaking set of guidelines to assist health care professionals when making medical decisions for pediatric patients with obesity. These guidelines were presented to more than 500 obesity medicine clinicians at OMA’s conference, “Overcoming Obesity 2016,” held in Chicago.

September is National Childhood Obesity Awareness Month.
The guidelines, titled the Pediatric Obesity Algorithm, are intended to educate clinicians and help them translate medical and scientific literature into practical approaches that work.

According to the Centers for Disease Control and Prevention, pediatric obesity is a serious public health threat in the United States. It affects 12.7 million or 17 percent of infants, children, and adolescents ages 2 to 19. Treating obesity in children requires an understanding of the patient’s family and cultural background as well as medical and psychological expertise.

“Many health care professionals believe pediatric obesity cannot be treated successfully,” said Dr. Suzanne Cuda, co-author of the Pediatric Obesity Algorithm and associate professor of pediatrics at Baylor College of Medicine. “A well-researched algorithm that guides clinicians through the specifics of age-related health conditions can provide invaluable support for clinicians who treat infants, children, and adolescents with obesity.”
“Many of my colleagues have expressed concern they do not have the resources to provide the kind of support these kids need,” she added.

According to Dr. Wendy Scinta, co-author of the Pediatric Obesity Algorithm and medical director of Medical Weight Loss of New York, this algorithm will give clinicians a clearer idea of current medical research and treatment recommendations.

“Because doctors don’t have the resources to treat kids with obesity appropriately, they end up providing misguided advice or referring them to another provider,” Scinta said. She believes these new guidelines provide reinforcement to clinicians who want to treat patients with obesity and guidance to clinicians about referring children with obesity to specialists or pediatric weight-management centers with comprehensive teams.

Practicing pediatricians and clinicians compiled the Pediatric Obesity Algorithm using scientific evidence, medical literature, and their own clinical experiences. With more than 100 studies referenced, the document covers a diverse and comprehensive section of medical literature.
These guidelines do not replace clinical judgement, but provide an in-depth look at what therapies and approaches work best for infants, children, and adolescents. “Clinicians can compare their approaches to what the medical literature recommends for patients in each age group,” Scinta said.

The Pediatric Obesity Algorithm is available as a free online download at www.PediatricObesityAlgorithm.org.

About the Obesity Medicine Association. The Obesity Medicine Association (OMA) is the largest organization of clinicians dedicated to preventing, treating, and reversing the disease of obesity. Members of OMA believe treating obesity requires an individualized approach comprised of nutrition, physical activity, behavior, and medication. When personalized, this comprehensive approach helps patients achieve their weight and health goals. Visit www.obesitymedicine.org to learn more.

Globally, Increasingly Poor Diets Now Pose a Greater Risk to Health than Unsafe Sex, Alcohol, Drug and Tobacco Use Combined

Rome, Italy—A new report by the Global Panel on Agriculture and Food Systems for Nutrition finds that the burden of malnutrition is equivalent to that of experiencing a global financial crisis every year. An estimated 3 billion people across 193 countries have low-quality diets which contribute to poor nutrition and health outcomes, while also slowing economic and development progress. Food Systems and Diets: Facing the Challenges of the 21st Century outlines the toll that malnutrition takes on individuals, nations and economies today and forecasts the expanding costs and consequences if these trends continue. The report, launched today at the Food and Agriculture Organization (FAO), provides a guide for governments and decision-makers to change course through action and investment to create food systems that promote health and deliver quality diets.

“Nutrition is not about just feeding people, it is about powering life and the growth of individuals, communities and nations,” said the H.E. John Kufuor, former President of Ghana and co-chair of the Global Panel. “If we do not reshape food systems to prioritize nutrition, we are missing an opportunity to create a stronger, healthier and more prosperous future.”
Food systems, which include how food is grown, raised, transported, processed and marketed, play a central role in delivering high-quality diets, but today’s food systems are too focused on quantity and not enough on quality. Low-quality diets are a driving force in increasing rates of overweight, obesity and chronic conditions such as high blood pressure, while also fueling non-communicable diseases, such as diabetes and heart disease.

\Without immediate action, the situation is set to worsen dramatically over the next 20 years as powerful drivers of change such as population growth, climate change and urbanization converge on our food systems. Without significant changes in policies and investments by 2030, the number of overweight and obese people will have increased from 1.33 billion in 2005 to 3.28 billion, or one-third of the projected global population. This is a major concern as no country to date has successfully reversed growth in obesity once it has been allowed to develop.

“Our food systems are failing us,” said Lawrence Haddad, a report author and chair of the project’s Lead Expert Group. “The foods that are produced, are affordable and are chosen have been changing fast and will continue to do so. Now is the time to take action to ensure that food systems and nutrition are helping to power fuel development—not hold it back.”

Data from the report shows that while income growth can help to alleviate hunger, it does not guarantee accessibility to healthier, quality diets. While many people today have better diets than before, the intake of foods that undermine diet quality has increased even faster. For example, the sale of ultra-processed food and beverages rose from one-third of those in high income countries in 2000 to more than half by 2015.

“We must rethink how we look at nutrition and food systems. Nutrition is not just an health and social development issue, but an investment that can spur economic growth,” said Dr. Akinwumi Adesina, President of the African Development Bank and member of the Global Panel. “Nutrition fuels gray matter infrastructure—the minds of the next generation that will drive progress and innovation. If we do not act, we will fail to unleash the full potential of millions of people around the world.”

The report calls on governments, donors and global partners to put food systems at the center of global action, including the Sustainable Development Goals. While policy must be tailored to meet country needs, priority actions at the global and national levels include:
•    Prioritize improvements in women’s diet quality;
•    Develop policies to regulate product formulation, labeling, advertising, promotion and taxes to incentivize production of high-quality foods and inform consumers;
•    Use public sector purchasing power to institutionalize high-quality diets;
•    Improve availability, affordability and safety of fruits, vegetables, pulses, nuts and seeds; and
•    Foster increased collaboration and data access across agriculture, health, social protection and commerce.

“This Report makes clear the enormous challenge posed by malnutrition and poor diets generally to the detriment of many millions of individuals and indeed whole economies,” said Sir John Beddington, former UK Chief Scientific Advisor and co-chair of the Global Panel on Agriculture and Food Systems for Nutrition. “The level of effort required to address this problem is not dissimilar to the sort of effort that has been used by the international community to address the issues of HIV/AIDS, malaria and other pandemic diseases.”

To support a coordinated effort, the report provides a simple decision-making tool to help policy makers identify which actions will help leverage food systems toward improved diet quality. This innovative, six-step tool will help policy makers prioritize realistic actions based on local contexts. The gains from applying this tool, the report argues, could be very substantial toward ensuring better nutrition for all.

News from The Obesity Society

New Therapeutic Treatment Helps People Lose More Weight and Keep it Off
Study shows clear gains from weight-loss treatment aimed at setting goals based on personal life values
SILVER SPRING, MD – A new approach to weight loss called Acceptance-Based Behavioral Treatment (ABT) helped people lose more weight and keep it off longer than those who received only Standard Behavioral Treatment (SBT) – a typical treatment plan encouraging reduced caloric intake and increased physical activity – according to a new randomized controlled clinical trial. Researchers studied the impact of the new ABT method, which ties the effort to a larger personal value beyond weight loss for its own sake, to help people adhere to diet and physical activity goals. The October issue of Obesity, the scientific journal of The Obesity Society (TOS), published both the original article and an accompanying commentary.

“Standard Behavioral Treatments (SBT), which emphasize the importance of decreased caloric intake and increased physical activity, can help individuals lose weight for a period of time, but the strategies taught in such a program are difficult to maintain long-term,” said lead author Evan Forman, PhD, FTOS. “The Acceptance-Based Behavioral Treatment (ABT) method teaches highly specialized self-regulation skills so individuals trying to lose weight can continue making healthful choices long after the program ends. These skills include mindful decision making, identifying and committing to big-picture life values and a willingness to accept discomfort and reduced pleasure for the sake of those values.”

The study, part of the well regarded Mind Your Health trial, is one of the first of its kind. Results showed that participants who received ABT (which includes all behavioral skills taught in SBT) lost 13.3 percent of their initial weight at one year, compared to 9.8 percent weight loss at one year for participants who received SBT only. This difference represents a clinically significant 36 percent increase in weight lost for those in the ABT group. In addition, the likelihood of maintaining a 10 percent weight loss at 12 months was one-third greater for ABT with a rate of 64 percent versus 49 percent for ABT alone. As Thomas Wadden, PhD, FTOS, and Robert Berkowitz, MD, FTOS point out in their accompanying commentary, weight loss with ABT is among the largest ever reported in the behavioral treatment literature without use of an aggressive diet or medication.

“We’re excited to share this new proven therapy with the weight-loss community, and in fact this is one of the first rigorous, randomized clinical trials to show that an alternative treatment results in greater weight loss than the gold standard, traditional form of behavioral treatment” continued Forman.

The ABT sessions emphasized the following principles with the participants to achieve adherence to diet and exercise goals in order to lose weight.
•    Choose goals derived from freely-chosen personal life values, such as living a long and healthy life or being a present, active grandparent.
•    Recognize that weight-control behaviors will inevitably produce discomfort (such as urges to eat, hunger, cravings, feelings of deprivation and fatigue) and a reduction of pleasure (such as choosing a walk over watching TV or choosing an apple over ice cream).
•    Increase awareness of how cues impact eating and activity-related decision making.
In the study, 190 participants with overweight or obesity were randomly assigned to SBT alone, or ABT (which fused both behavioral skills from SBT with acceptance-based skills). Participants attended 25 treatment groups over a one-year period, which consisted of brief individual check-ins, skill presentations and a skill-building exercise. All interventionists were doctoral-level clinicians with experience delivering behavioral weight loss treatments.

“These findings are a boon to clinicians, dietitians and psychologists as they add a new dimension to behavioral therapy that can potentially help improve long-term outcomes for people with obesity,” said Steven Heymsfield, MD, FTOS, a spokesperson for The Obesity Society. “This study is one of the first of its kind, and offers promise of a new tool to add to the toolbox of treatments for overweight and obesity.”

This is the second study of ABT as part of the Mind Your Health trial, and it found an even more pronounced advantage from ABT than the first study. Forman offers several potential explanations, including the use of experienced clinicians and a revised ABT protocol that focuses on general willingness and accepting a loss in pleasure and less on coping with emotional distress, cravings and hunger.

“These are exciting findings for which I congratulate the authors,” said Wadden in an accompanying commentary. “Like all new findings, they need to be replicated by other researchers before ABT can be considered a reliable means of increasing weight loss with SBT,” he added. Wadden noted that treatment comparison studies of different psychotherapies have shown that when researchers feel strongly that their therapy will work best, it can influence outcomes. Future research should be conducted by therapists who did not develop ABT. Additionally, he said, “Future studies of ABT would be enriched by reporting on changes in depression, susceptibility to food cues and motivation for change in both the ABT and SBT groups. Long-term follow-up after treatment would also be beneficial to determine if ABT improves weight-loss maintenance compared with SBT.”

The study and its accompanying commentary are available in the October issue of Obesity, the scientific journal of The Obesity Society (TOS).

About The Obesity Society. The Obesity Society (TOS) is the leading professional society dedicated to better understanding, preventing and treating obesity. Through research, education and advocacy, TOS is committed to improving the lives of those affected by the disease. For more information visit: www.Obesity.org. Connect with us on social media: Facebook, Twitter and LinkedIn. Find TOS disclosures here.

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