This month: The State of Obesity and Bariatric Surgery in Spain

An Interview  with Dr. Antonio J. Torres  Bariatric Times. 2014;11(7):14.

Dr. Torres is Professor of Surgery, Department of Surgery, Hospital Clínico San Carlos, Facultad Medicina Universidad Complutense, Madrid, Spain.

The state of obesity and bariatric surgery varies from country to country. In this series, authors from around the world 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 Spain today?

Dr. Torres: I became a bariatric surgeon out of the necessity for our endocrinologists treating those superobese patients on whom other colleagues did not want to operate. It was the time of open surgery (late 1980s), and the most common implemented surgical procedure was the vertical banded gastroplasty (VBG) for patients who were not considered “superobese.” Our group began to perform open biliopancreatic diversion (Scopinaro’s technique).
There are about 325 members in our Spanish Society for Obesity Surgery (SECO). So, we can assume that there are around 500 bariatric surgeons in Spain.

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

Dr. Torres: From a legal or administrative point of view, one does not need special certification to conduct bariatric procedures. During the last five years, however, we have implemented a program for certification and re-certification within SECO. This certification is now widely accepted as recognition of competence and expertise.

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

Dr. Torres: Again, there is not a specific official or administrative accreditation program to which the different units have to apply. At present, some administrations are trying to concentrate obesity treatment in those centers with more experience and with a larger number of treated patients (i.e., high-volume center). Those centers provide multidisciplinary care teams that includes endocrinologists, surgeons, internists, diabetologists, nutritionists, psychologist, and psychiatrists.

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

Dr. Torres: Obesity is a great problem in Spain. The last epidemiological studies have shown that it is exponentially increasing. At present, the prevalence of obesity (BMI 30–35kg/m2) in the adult population (25–64 years) is around 22.9 percent (24.4% among men and 21.4% among women). In addition, class III obesity (BMI ≥40kg/m2) has increased sharply, from 0.18% to 0.61%. Regarding children and adolescents, it is estimated that 12.6 percent of children aged 8 to 17 have obesity (with a further 26% overweight).

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. Torres: In my opinion, there is no any specific cause of obesity in Spain. I think that the cause is multifactorial, and despite our classical mediterranean cuisine with a great variety of food offerings, still citizens become obese. To me, one of the most important factors causing obesity in Spain is the dramatic decrease in physical activity, especially in children.

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

Dr. Torres: In Spain, the estimated yearly number of bariatric surgical procedures in 2011 was 6,000. Since then, the number of surgeries has increased, but so too has the growing prevalence for morbid obesity, even faster than the number of performed surgeries.

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

Dr. Torres: Without any doubt, sleeve gastrectomy (SG) is the most popular procedure, followed by Roux-en-Y gastric bypass (RYGB). I estimate that SG comprises 35 percent of all the bariatric surgical procedures performed in Spain. Spanish surgeons also perform duodenal switch (DS), single anastomosis duodenal ileal with sleeve (SADI-s), and BPD. I have observed that the number of laparoscopic gastric banding procedures has decreased dramatically during past couple of years.

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

Dr. Torres: In my department, we perform a wide range of surgical procedures as follows: 1) 40 percent RYGB; 2) 30 percent SG; 20 percent SADI-s; 10 percent revisional surgery.

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

Dr. Torres: In Spain, the healthcare system is public; however, about 25 percent of the population choose to use private health assistance. Bariatric surgery is performed in both systems. Those patients operated on under the public system do not have to pay as everything is covered. Those patients undergoing bariatric surgery in the private sector have to pay a percentage of the bill, which depends on the different conditions of their insurance policies.

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

Dr. Torres: I believe that bariatric surgery will be acquiring more and more relevance in the global surgical scenario. The number of patients is increasing, as well as the number of better trained bariatric surgeons. Also, the number of multidisciplinary teams is evolving very nicely in both public and private healthcare systems.
In my opinion, another very important positive issue is that the private insurance companies are much more aware of this situation and they are now offering new policies to their clients.

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

Dr. Torres: My choice of procedure would be dependent on my indivual case and clinical data. If my BMI was over 50kg/m2 and I had some comorbidities (e.g., type 2 diabetes mellitus, hypertension, dyslipemia), I would prefer to undergo the SADI-s procedure in one or two steps, undergoing SG first and then waiting on the results. If my BMI was lower than 50kg/m2 with comorbidities, I would prefer to undergo RYGB. If my BMI was around 40kg/m2 with no comorbidities, I would prefer to undergo SG.

References
1.    European Association for the Study of Obesity. Obesity policymaker survery 2013. http://easo.org/wp-content/uploads/2013/09/C3_EASO_Survey_A4_LowRes.pdf. Accessed July 1, 2014.
2.    J.J. Sánchez-Cruz et al., ‘Prevalence of child and youth obesity in Spain in 2012. Rev Esp Cardiol. 2013;66(5): 371–376: http://www.ncbi.nlm.nih.gov/pubmed/23375996. Accessed July 1, 2014.
3.    Runkel N, Colombo-Benkmann M, Hüttl TP, Tigges H, Mann O, Sauerland S. Dtsch Arztebl Int. 2011; 108(20): 341–346.

Funding: No funding was provided.

Disclosures: The author reports no relevant conflicts of interest.

Tags: bariatric surgery, obesity

Category: International Perspective, Past Articles