Letter to the Editor: Obesity Bias Affects Diabetes Management…

| April 15, 2008

Dear Bariatric Times Editor:

On January 23, 2008, the headline on the front page of the New York Times read, “Diabetes Study Favors Surgery to Treat Obese.” With front page news stories in addition to television newscasts reporting the benefit of surgical procedures for the treatment of diabetes, it is logical to assume that the number candidates for these procedures will rapidly increase. Unfortunately, despite the impact of type II diabetes and the cost it imposes on our healthcare system, numerous barriers exist that make it difficult to obtain insurance pre-certification for coverage.

These barriers include requiring patients to undergo a six-month diet supervised by their physicians before being allowed to have a potentially lifesaving surgical procedure. As a result of these barriers, the impact of the important study referenced in the above-mentioned article will be reduced.

The rationale for these preoperative requirements is that not all obese individuals are candidates for surgery, and that preoperative requirements help determine who will benefit from the surgery in terms of patient compliance. The fact of the matter is that data does not currently exist to support this approach. Numerous studies have shown identical weight loss post-surgery with or without a six-month requirement. Additionally, the goal is to provide optimal care to each individual, not ration appropriate procedures.

What is truly perplexing is that similar requirements can be made for many procedures, but are not. Cardiac patients who exercise and change their diet are less likely to have repeat coronary events; however, they are not required to demonstrate behavioral change before having a procedure. Joint replacement patients who attend physical therapy and are compliant perform better than those who do not. Yet they are not required to document compliance before certifying their operative procedures.

The only other area where similar requirements exist are for organ transplant. Alcoholics have been required to remain sober for a period before undergoing liver transplant. However, organs are in scarce supply and we have a responsibility to donors and their families to use this limited resource to the best of our abilities. Laproscopic adjustable gastric bands and staples are not scarce.

So the fact remains that there is a bias against obesity, which affects diabetes management. Now that overwhelming data exist to demonstrate that type II diabetes, which is an epidemic in our country, is preferentially treated with surgery, will this bias change? Or will we allow insurance companies to continue this discriminatory practice? Doctors and bariatric teams need to use their judgement and knowledge to best prepare patients. Needless barriers that create hardship must to be removed. Insurance carriers and their medical staff need to examine data rather than create rules based on unsubstantiated preconceived notions. Additionally, colleagues in other specialties need to acknowledge the data being assembled and realize that type II diabetes is a surgically treatable disease.

Best regards,

Mitchell S. Roslin, MD FACS

Dr. Roslin is Chief of Bariatric Surgery, Lenox Hill Hospital, New York, New York.

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Category: Letters to the Editor, Past Articles

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