Obesity Knows No Borders: Notes from an International Practice

by Steven R. Hendrick, MD, FACS; Julie M. Janeway, BBA, MSA, JD; and Karen Sparks, BBA, MBEd

INTRODUCTION
The Bariatric Surgery Center at Henry Ford Wyandotte Hospital (HFWH) is part of the world renowned Henry Ford Health System in Detroit, Michigan. Henry Ford Health System is a regional and national leader in bariatric surgery offering various gastric bypass options and the Lap-Band™ procedure. As Michigan is consistently in the top few states named as the “fattest” states in America, HFWH maintains a steady influx of patients from the metro Detroit area, as well as from all over Michigan, northern Ohio, and Ontario, Canada.
Detroit is one of the busiest international border entry points on the North American continent. Along with the Sarnia/Port Huron border, also located in southeast Michigan/southwest Ontario, they represent nearly 50 percent of the traffic volume crossing the US/Canada border each year.1

Being located near such a friendly and open border means that determining who hails from either side of that imaginary border line is no small feat. Certainly the general health, eating habits, BMIs, and comorbid conditions of the two populations are not distinguishing features. In fact, if you were to stand obese Canadian and American patients next to each other in a line, the only thing that would really distinguish their nationality is their accents.

HFWH is a practice that actively seeks and treats a large percentage of Canadian patients. The authors and the staff of HFWH are privileged to have the opportunity to observe the differences and similarities between the two patient populations as far as general health statistics, behaviors, attitudes, compliance, access to and involvement in follow-up care, and other relevant factors. This article is intended to report our preliminary qualitative, ethnographic2 data gathered through our observations over the last several years.2

STATISTICS
• American population: 300 million as of October 2006.3
• Canadian population: 32.8 million as of January 2007.4
• Michigan population: 10.1 million as of December 2006.5
• Ontario population: 12.7 million as of January 2007.4
• Percentage of Americans who are overweight and obese: 65% Overweight; 30% Obese.6
• Percentage of Canadians who are overweight and obese:
59% Overweight; 23% Obese.7
• Number of American obesity related deaths annually: 400,000 per year.8
• Number of Canadian obesity related deaths annually: Unreported9

American requirements for weight loss surgery. Record of previous failed attempts at weight loss; BMI of 40 or greater, or 35 or greater if accompanied by a comorbid condition.10 Many practices also add no smoking; no recent myocardial infarctions or strokes; no acute mental illness; no current substance abuse; more than five years out from certain types of cancer.

Ontario requirements for weight loss surgery. Must have a BMI of 40 or greater, with an accompanying comorbid condition; record of previous failed attempts at weight loss; recommendation from an attending physician (family or specialist); can go out-of-country for surgery if one meets these requirements as well; patient must have written authorization from the Ministry of Health and Long-Term Care prior to obtaining out-of-country bariatric treatment; the treatment proposed must be generally accepted in Ontario; it must be shown that the person must travel outside of Canada to avoid a delay that would result in death or medically significant irreversible tissue damage.11

ACCESS TO CARE
As HFWH generally deals with patients from Ontario, all of whom are insured under the Ontario Health Insurance Plan (OHIP—the provincial socialized medicine program), all references to this article’s observations will be reflective of that population. The information may or may not be able to be generalized to patients from other provinces in Canada that are insured under their respective provincial health plans.

Estimates state that 15.3 percent of Americans have no healthcare coverage.12 A significant number of Americans with health coverage still have trouble accessing treatment for their weight and weight-related issues.13 Although the access to care is slowly easing in the US, the same cannot be said for Canadian patients. Canadian socialized medicine has been a wonderful gift for many in various situations, but has provided little assistance with regard to getting Canadian citizens the treatment they need for their obesity-related issues.

In February, 2007, the Ontario Ministry of Health and Long-Term Care reported that the Ontario government pledged an additional $3.7 million investment in Ontario bariatric programs that will increase the number of surgeries offered in the province by approximately 225 each year. Although that is a good start, it truly is not even a drop in the bucket of patients seeking surgical obesity treatment.14

Access to care is an issue because patients simply outnumber surgeons by a very significant factor. In fact, combined Ontario and Quebec surgeons registered with bariatric organizations total only seven bariatric practices or programs, not all of which accept provincial health insurance because some only provide Lap-Band™ services.15 All of Canada reports only 49 bariatric surgeons.15 Comparatively, Michigan has more bariatric surgeons than are in all of Canada, providing services through approximately 30 practices offering a variety of surgical options from Roux-en-Y gastric bypass to Lap-Band™, from the gastric sleeve to biliopancreatic diversion (BPD) and duodenal switch (DS), as well as others.16

HFWH’s Ontario patients and affiliated physician’s and surgeons informally report up to an eight-year wait to undergo weight loss surgery in Ontario, although the wait time could not be confirmed through OHIP, as the provincial insurance program is currently implementing a program to decrease wait times. The Medical Advisory Secretariat for the Ontario Ministry of Health and Long-Term Care reports that OHIP pays for about 508 combined in-province and out-of-country bariatric surgeries per year, and estimates that it needs to be providing approximately 3,500 per year.11

OHIP will pay for Ontario patients to have Roux-en-Y gastric bypass procedures, whether open or laparoscopic, as well as for some of the other related procedures, such as mini-pouches. OHIP will not pay for patients to have an adjustable gastric band procedure because it still considers the procedure “experimental.”17 Although there are two very prominent practices in Toronto that primarily perform Lap-Band™ surgeries, patients of these practices are paying out-of-pocket for the procedure.18 As of February, 2006, Medicare is now covering the Lap Band™ in the US. It is no longer considered an investigational procedure in the US. Although Medicare will now pay for Lap-Band™, many private insurers still will not cover adjustable gastric band surgery.

Generally speaking, it is easier for Ontario patients to get approval for surgery, unless placement of an inferior vena cava (IVC) filter is requested. In those instances, approvals are slowed considerably while OHIP decides whether the filter should be placed by the bariatric surgeon located out of the country or by a surgeon in Ontario prior to the bariatric procedure. Sometimes approvals are slowed because of similar problems concerning whether a Canadian or American therapist should perform the behavioral assessment. It seems to be dependent upon the desk on which the application lands—not unlike many American insurance companies. OHIP prioritizes bariatric surgery candidates by the same BMI criteria used in the US by organizations such as ASMBS. The only additional caveat is that the patient must also have a documented comorbidity even if the BMI is over 40.

Americans, conversely, tend to have a much harder time getting approvals for surgery. Documentation of previous attempts at weight loss tend to be especially difficult, and many insurance companies throw in additional requirements, such as documenting failure of a medically managed weight loss program within the previous year or six months. American insurance companies tend to pay for 90 days of follow-up postoperative care, as does OHIP. OHIP patients must also pay out-of-pocket for office visits and assessments with the dietitian, exercise physiologist, or behaviorist. Both sides tend to pay for their respective patients’ blood work and additional studies, with the caveat that Ontario patients have all, or the majority of those procedures and tests, done in Ontario.

Ontario patients who meet the OHIP criteria and are approved to have surgery out of the country can generally go anywhere for treatment, but the problem becomes the logistics of getting to the practice for visits and returning for required follow-up appointments. In addition, Ontario patients must return to their side of the border after surgery, and should a complication arise, or a patient needs immediate medical attention, many of the Canadian family and emergency physicians are unfamiliar with the various bariatric surgeries, their complications, and related issues, or how to handle or properly treat them. Generally, Ontario patients must also return home to virtually no support groups and limited access to other necessary resources.

At HFWH, the program sets in place communications and relationships with local physicians, surgeons, emergency room physicians, therapists, and other pertinent medical professionals in the lower Ontario area from which patients travel. HFWH seeks to make Ontario patients’ experiences more like American patients’ experiences by training and fostering support group leadership and development in Ontario, and constantly locating new resources, such as supplements and vitamins that are available by internet sale.

Not all American programs, however, are as involved in their Canadian patients’ success once they re-cross the border. Many still simply take the OHIP payment, perform the surgery, and hope for the best for the Canadian patient. They do not reach out to the other side of the border to work with the physicians and medical professionals in the related communities to assist patients in succeeding in their weight loss program. They encourage patients to return following surgery, but know that logistics may prevent the necessary follow-up and support care. It is unfortunate, but it is happening. Much worse things are happening, however, to patients who choose to go to countries other than the US for treatment, but that is information for another article.

PATIENT PROFILES
The average patient seen at HFWH is a 40-year-old woman. The same holds true for both American and Canadian patients. Both patient populations present overall with similar BMI ranges and similar common comorbid conditions. Canadian patients, however, seem to present more often with undiagnosed comorbid conditions than American patients. Patients attribute this to less access to specialty care in Ontario under the socialized healthcare program. Additionally, Canadian patients seem to present with severely underdiagnosed sleep apnea, and there is a significant lack of sleep study centers in the lower part of Ontario. Finally, it appears that Canadian patients are also presenting with less aggressively treated hyperlipidemia than are American patients.

Patients from both sides of the border tend to tell remarkably similar tales of living with the ramifications of being heavy in a thin society, as well as of the multitude of weight loss and diet programs they have tried in the past. Given the prevalence and accepted nature of holistic and alternative medicine practices as mainstream medicine in Ontario, we expected to see more patients who had tried treatments, such as acupuncture, hypnotherapy, reflexology, and natural medicine therapies as treatments for their obesity, but were surprised to find that not to be the case.

BEHAVIORS AND ATTITUDES
With regard to the attitudes and behaviors toward weight loss surgery, the differences between American and Canadian patients becomes more distinct. For example, we have observed that Canadian patients tend to arrive at the practice having done more research about the procedures, the complications, the requisite lifestyle changes that must be made to facilitate success, and other related issues. This is not to say that American patients come unprepared or ignorant of what they are seeking, but they simply tend to do less hard research, and more “day-time talk show type” research. American patients tend to rely on reports in the mainstream media, more than Canadian patients who tend to go to more science or professionally based sites and resources for their information.

Although Canadian patients may come prepared with more general information about the procedure and program, they tend to present with approximately the same “desperation factor” for surgery as Americans. The difference here is that many Canadians never expect to have an opportunity for surgery, and when the light appears at the end of the tunnel, they run toward it with enthusiasm, not worrying if it might be an oncoming train. On the other hand, Americans are more acclimated to the fact that surgery is accessible, at least to some Americans, and they feel less of a need (although they still feel a distinct need) to jump through the hoops and secure the prize in case the opportunity disappears.

More American patients than Canadian present for treatment expecting it to be a magic cure-all. As well, Americans tend to harbor this idea for longer than Canadians. Again, due to the “thrill” factor, or the “I won the lottery” mentality of Canadians, they tend to orient themselves faster toward compliance with program requirements than do Americans. Additionally, Detroit tends to see a lot of Medicare patients seeking bariatric surgery, and they generally present with more entitlement issues than do Canadian patients.

American patients seem to be more likely to try and short-cut or circumvent the steps necessary to gain approvals or to complete the process prior to surgery, especially if the wait time seems too long in their minds. Canadian patients tend to engage in this behavior less, but when it comes to small “fudging” about things like weight loss, cheating on preoperative fasts or food programs, or severity of comorbid conditions, they are equal in every way to American patients in their desperation factor.

Desperation factor is not the only interesting behavioral attribute for these patients. The general and overall fear of the surgery, the outcome, the changes, the lifestyle, and other related issues tend to differ a bit as well. American patients show the general fears and apprehensions with which many of the readers of this article have become familiar. Canadian patients, however, have a little higher anxiety level as they constantly worry about complications and ancillary medical issues once they return home. The constant worry surrounds things like “Who will take care of me if something happens and I can’t get to my bariatric surgeon?” and “How will I pay for it?”

Americans tend to have a culturally engrained belief in the general medical system, and are usually quite confident that if a complication or emergent situation arises, trained medical personnel will be able to attend to the issue until such time as the patient’s bariatric surgeon can be called, or another bariatric surgeon is located. They are generally confident, appropriately or not, that bariatrics is a commonly understood practice area, and that their condition can be properly handled.

Confidence in patients’ respective medical systems underlies another issue: Willingness to contact the bariatric practice with questions or concerns. It has been our observation that Canadian patients are far more willing to contact the practice with questions and concerns, especially during the 6-month postoerative period. This may again be an outcropping of the “who will care for me if something happens” phenomenon, and an attempt to stay on top of issues as they may arise so that the bariatric surgeon can be in the loop from the beginning.

Staying in touch with the bariatric surgeon and the staff at the practice is not limited to questions and concerns for Canadian patients. Observations of the Canadian patients at HFWH show a very good compliance rate of attendance at follow-up appointments, as well as with maintaining the set schedule for follow-up appointments. In fact, Canadian compliance may actually exceed American compliance. Again, this may be attributed to the “thrill” factor that they actually were given the opportunity to have surgery, as well as to the “who will take care of me” phenomenon. This observation, as noted earlier, is not necessarily the norm in all practices treating Canadian patients. Perhaps this observation is due in part to the general ease with which the Ontario patients can return across the border for follow-up care.

American patients, on the other hand, tend to have slightly less overall compliance with follow-up visits, and tend to blur the edges when it comes to following the set schedule of visits. The 3-month visit tends to become the 5-month visit, and the 6-month visit tends to become the 10-month visit, etc. Perhaps this is again due to the general confidence that the American healthcare system will always be there when it is needed. Canadians may just be more worried that they have to take advantage while they can.

The situation is reversed, though, when it comes to support group attendance. American patients tend to participate in more support groups than do Canadian patients. To be fair, it must be noted that Canadians have far less access to support groups than Americans. Bariatrics as a practice field is barely established (although growing) in Canada, and thus the attendant infrastructure among ancillary professionals is barely in existence at this point.

Canadian patients of HFWH are welcome to attend any of the support groups that are offered by the practice free of charge, but few opt to do so. Perhaps it is the expense and logistics related to crossing the border for something that is not considered necessary, or perhaps it is just inconvenient. The Canadian patients that do attend support groups monitored or offered by HFWH tend to participate more in the daytime groups rather than the evening groups. This may be attributable to the fact that the evening groups are offered at 6:00pm, and traffic at the border crossings at that time is particularly onerous.

Another thing that is considered particularly onerous in equal amounts by Canadian and American patients is involvement in exercise. There seems to be no difference in the universal dislike for exercise. Additionally, there exists no difference in their universal distaste for the word exercise. Both patient populations must be prodded and educated about the necessity of movement in a successful weight loss program.

ACCESS TO PRODUCTS AND SERVICES
American patients have the significant upper hand when it comes to access to products and services. There is a much larger selection of foods, supplements, gyms, activity centers, classes, and the like from which to choose in the US. Americans, with their love of convenience, have a multitude of prepared and pre-packaged products and programs to help them with their eating programs, vitamin regimens, and daily movement requirements. Although it may be a challenge to teach American patients how to find these resources and how to use them, American patients at least have options available.

Canadian patients, however, have a harder time overall. It is very hard for them to find appropriate protein and dietary supplements because many companies do not ship to Canada, or do so at a premium rate. Additionally, sugar-free and high-protein products are harder to find, and the convenience-based products so prevalent in the US are very scarce in Canada. Canadian and American foods that may appear to be of the same brand name may have entirely different formulations and nutritional contents—some better, some worse. Lack of access to convenience foods and appropriate supplements does have an effect on actual compliance (if not on attempted compliance) with food and nutritional protocols.

Canadians do have some pluses in their column. They have better access to natural foods and to higher quality foods than most Americans because Canadian food standards are generally higher than US food standards. Patients must learn to be more resourceful in order to get what they need for their success, and they have to learn to hone their food preparation skills in order to make the types of foods necessary for that success. Some patients attempt to buy convenience packaged foods or buy additional foods and supplements to increase variety when they cross the US border for appointments or for other purposes. Having increasing variety, conveniently packaged foods, and access to dietary food supplements, such as protein bars and other items, does tend to increase dietary protocol compliance; however, patients are urged not to become dependent on these types of foods and learn to use the food preparation and nutrition skills taught by the program dietitian. Although these foods can be helpful, many foods are prohibited from being brought across the border into Canada. In addition, the currency exchange, plus the border tolls, and the fuel cost for driving to the US for groceries makes it an exercise in diminishing returns.

FAMILY SUPPORT ISSUES
The final note on observations of these two patient populations concerns the support or lack of support of family members and members of patients’ personal support circles. American patients tend to report experiencing a more extreme range of experiences with family, friends, and coworkers. Canadians, conversely, do not seem to report much about the subject. Perhaps this is due to the more reserved nature of Canadian culture, or to the “thrill” factor experienced because a relative, friend, or loved one has had the opportunity for treatment in the US, When family and friends realize that the patient will not have to endure the extensive wait times in Canada in order to receive surgical bariatric treatment, thereby potentially saving a patient’s life due to advanced comorbid conditions, friends and family may not manifest their personal feelings of fear, trepidation, frustration, helplessness, or other issues relating to the surgery and the impedning process. The fewer issues belonging to the members of the patient’s personal support circle, the fewer issues the patient has to deal with over all, and the fewer issues that are reported.

CONCLUSIONS
The Bariatric Surgery Center at Henry Ford Wyandotte Hospital will continue to reach out to the Canadian patient population, as well as to its medical colleagues across the border. Continued collaboration and affiliation will only improve bariatrics in both the US and Canada, and will ultimately improve access to care for all patients who seek it. It is the hope of HFWH that this article will spark some discussion of how Canadian patients are being cared for by American practices, as well as practices from other countries, and that the discussion will elevate the care being afforded our good neighbors to the north.

References
1. Project Needs and Feasibility Background Study. The Canada-US-Ontario-Michigan Border Transportation Partnership. 2005. Available at: www.partnershipborderstudy.com/stage1/background.htm. Accessed March 30, 2007.
2. “An ethnography is a description and interpretation of a cultural or social group or system. The researcher examines the group’s observable and learned patterns of behavior, customs, and ways of life. Ethnography involves prolonged observation of a group, typically through participant observation in which the researcher is immersed in the day-to-day lives of the people, or through one-on-one interviews with members of the group.” Creswell JW. Qualitative Inquiry and Research Design. Thousand Oaks, CA; Sage Publications. 1998.
3. Statistical Abstract of the United States. US Census Bureau Web site. 2007. Available at: www.census.gov/prod/2005pubs/06statab/pop.pdf. Accessed March 15, 2007.
4. Canada’s Population Estimates. Statistics Canada Website. 2007. Available at: www.statcan.ca/Daily/English/070329/d070329b.htm. Accessed March 15, 2007.
5. Estimated Populations of States. State of Michigan Website. 2007. Available at: www.michigan.gov/hal/0,1607,7-160-17451_18668_41233-158963–,00.htm. Accessed March 28, 2007.
6. NIH News. National Institutes of Health Website. 2005. Available at: www.nhlbi.nih.gov/new/press/05-10-03.htm. Accessed March 15, 2007.
7. Trends in Weight Change Among Canadian Adults. Statistics Canada Website. 2007. Available at: www.statcan.ca/english/research/82-618-MIE/82-618-MIE2006005.htm. Accessed March 15, 2007.
8. Mokdad AH, Marks, Stroup DF, et al. Actual Causes of Death in the United States, 2000. JAMA 2004; 291:1238–64.
9. Despite in-depth and exhaustive research to find these statistics, all references made by the Canadian government and Canadian medical journals are to American death rates per year as caused by obesity and related conditions.
10. Rationale for the Surgical Treatment of Morbid Obesity. ASMBS Website. 2005. Available at: www.asbs.org/html/patients/rationale.htm. Accessed March 20, 2007.
11. Medical Advisory Secretariat Report on Bariatric Surgery. Ontario Ministry of Health and Long-Term Care Website. 2006. Available at: www.health.gov.on.ca/english/providers/program/mas/tech/reviews/sum_baria_010105.html. Accessed March 30, 2007.
12. US Census Bureau News, March 23, 2007. US Census Bureau Website. 2007. Available at: www.census.gov/Press–Release/www/releases/archives/health_care_insurance/009789.html. Accessed March 26, 2007.
13. Insurance Introduction. Obesity Action Coalition Website. 2007. Available at: www.obesityaction.org/resources/insurance/introduction.php. Accessed: March 24, 2007.
14. McGinty Government Increases Access to Bariatric Surgery. Ontario Ministry of Health and Long-Term Care Website. 2007. Available at: www.health.gov.on.ca/english/media/news_releases/archives/nr_07/feb/nr_020207.html. Accessed March 21, 2007.
15. Canadian Bariatric Surgeons. Obesity Help.com Website. 2007. Available at: www.obesityhelp.com/morbidobesity/professionals/find-professional.php?type=46. Accessed March 31, 2007; Membership Directory. Canadian Obesity Network Website. 2007. Available at: www.obesitynetwork.ca/members/search.aspx?pti=experts. Accessed March 31, 2007.
16. Canadian Bariatric Surgeons. Obesity Help.com Website. 2007. Available at: www.obesityhelp.com/morbidobesity/professionals/find-professional.php?type=46. Accessed March 31, 2007; Membership. ASMBS Website. 2007. Available at: www.asbs.org/cgi-bin/membertest3.pl. Accessed March 30, 2007.
17. OHTAC Recommendation. Ontario Health Insurance Plan Website. 2005. Available at: www.health.gov.on.ca/english/providers/program/mas/tech/recommend/rec_bar_012105.pdf. Accessed March 25, 2007.
18. Toronto Laparoscopic Band Center; Surgical Weight Loss Center of Mississauga.

Address for correspondence:
Julie M. Janeway, BBA, MSA, JD, Little Victories™ Medical/Legal Consulting & Training, 4371 Kinneville Road,
Suite 200, Onondaga, MI 49264;
Phone: (517) 589-5535;
E-mail: [email protected].

Category: International Perspective, Past Articles