The State of Obesity and Bariatric Surgery in Italy

This month: The State of Obesity and Bariatric Surgery in Italy
An Interview with Dr. Mirto Foletto

Bariatric Times. 2014;11(5):12–13.

Introduction
The state of obesity and bariatric surgery varies from country to country. In this series, authors from around the world will discuss obesity and bariatrics in their country, answering questions on the most recent trends, most frequently performed procedures, access to care, health coverage, requirements, accreditation, and cultural considerations.

This series is dedicated to providing updates on the global state of obesity.

How did you become a bariatric surgeon? How many bariatric surgeons are there in Italy today?

Dr. Foletto: During my residency in General Surgery at Padua University Hospital, Padua, Italy, I happened to be in the operating room with Dr. Franco Favretti. It was around 1990. I assisted some Mason and McLean vertical banded gastroplasty (VBG) and found it to be really amazing and much different from the surgical oncology procedures that I was used to. The clinics were also different and I found them impressive as people were seeking relief from weight-related problems that were involving daily life. The general mood was, again, much different. Though the efforts (the fight against obesity) were strong, I found that they were usually unsteady and most people were young.

I was a little bit fed up with desperate oncological cases and I wanted something more lively. I asked to enter a bariatric program, even though it was not so well established in Italy at that time.

Padua University Hospital was one of the first centers to implant gastric banding laparoscopically in the early 1990s and that was my starting point, as I could practice minimally invasive surgery. I really loved the procedures and also taking care of patients with obesity.

The surgical units where bariatric surgery is conducted in Italy are shown in Figure 1. There are about 350 Italian Society for the Surgery of Obesity and Metabolic Disorder (SICOB)-affiliated surgeons, and at least 150 bariatric surgeons among these units.

Do you need a special certification to conduct bariatric procedures in Italy?

Dr. Foletto: At the moment, there is no need for a special certification to perform bariatric procedures in Italy, although some Universities introduced specific bariatric programs and classes during surgical residency.

Are centers that perform bariatric surgery accredited by any society in Italy?

Dr. Foletto: In 2013, the SICOB promoted a strict national accreditation program for bariatric centers willing to partcipate, although it is not yet compulsory to conduct bariatric surgery. Moreover, three centers in Italy achieved The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO)-European Accreditation Council for Bariatric Surgery (EAC-BS) accreditation privileges.

What is the obesity rate in Italy? Is it increasing or decreasing? How about in children?

Dr. Foletto: In Italy in 2011, more than one-third of the adult population (35.8%) was overweight, and 10 percent were obese. Therefore, it was estimated that 45.8 percent of the Italian population 18 years of age and older were burdened by excess weight. In 2001, the prevalence of overweight and obesity was 33.9 percent and 8.5 pecent, respectively. Therefore, these data confirm the increasing trend of overweight and obesity prevalence in Italy between 2001 and 2011. There are considerable differences between different regions. The southern regions have the highest prevalence of overweight and obesity. The percentage of the Italian population in a condition of excess body weight increases with age and is more prevalent among men. In Italy, 45.5 percent of men and 26.8 percent of women are overweight, and 10.7 percent of men and 9.4 percent of women are obese.

A survey conducted in Italy on more than 40,000 children aged 8 to 9 years confirmed the alarming levels of excess weight: 22.2 percent of infants were overweight and 10.6 percent were obese, with higher rates in central and southern regions.

Is there anything unique about the country culture/lifestyle that may contribute to the obesity rate (e.g., extreme cold or heat, dominant occupations, access to food and drink)?

Dr. Foletto: There is an inverse correlation between parents’ education and childhood obesity rates. Trends show an increased sedentary way of life during adolescence and later in life. In this setting, “western-like” globalization habits and recent economic constraints play an important role, shifting common people from healthy mediterranean lifestyle and diet to fat-rich, cheap diets and sedentary daily life.

What percentage of the obese population actually undergo bariatric surgery? Are those numbers increasing or decreasing?

Dr.Foletto: The trends of bariatric procedures in the last five years are reported in Figure 2. Given a current resident population of 60 million and obesity rates around 10 percent, about 1:1360 obese patients undergo bariatric surgery. Therefore, there is a lot of unmet demand. It is important to note that obesity awareness is not that high among Italian people.

What are the current trends in bariatric surgery in your country? Meaning what are the most popular procedures?

Dr. Foletto: The most common bariatric procedures performed in Italy are listed in Figure 3.

What procedures do you perform at your center—order from most frequent to lease frequent with statistics, if available.

Dr. Foletto: The most common performed procedure in our bariatric unit is sleeve gastrectomy (80%), followed by gastric bypass (10%) and staged biliopancreatic diversion with duodenal switch (BPD-DS [10%]). Revisional surgery accounts for 40 percent of clinical practice, as for any referral center. Moreover, we are now implanting very few bands and we quit a gastric plication program that began in 2010 due to the high rate of revisional surgery.

What is the healthcare/ insurance system like in your country? How do patients pay for weight loss surgeries?

Dr. Foletto: In Italy, there is a National Healthcare Systems (NHS) that is public and granted for all residents and citizens. Bariatric surgery is covered by NHS for patients with morbid obesity.

What is your prediction for the future of bariatric surgery in your country?

Dr. Foletto: Although at the moment we are reaching less than 1:1000 of potential candidates to bariatric surgery, given the present economic situation, I do not foresee a significant increase in bariatric procedures in the near future, at least within the NHS framework. Government policies are usually not far-sighted and are mostly focused to contain debts and publlic expense in the short term, not taking the pay-off of bariatric surgery in the long run. Moreover, the emotional yield on tax-payers community is much less compared to transplant and oncological surgery.

If you would have to choose a bariatric procedure for yourself or a relative of yours, which one would you choose?

Dr. Foletto: Definitely sleeve gastrectomy as it is much more physiological than gastric bypass and allows, if necessary, further surgery.

FUNDING: No funding was provided.

DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Tags: bariatric surgery, obesity

Category: International Perspective, Past Articles