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Two papers in this issue of the NZMJ serve as reminders of the many complexities of managing the real and perceived problems of excess body fatness, and that an overarching strategy, including public health initiatives, is essential for the management of this global epidemic.In October 2013, the BMJ published a systematic review and meta-analysis of the 11 randomised controlled trials of bariatric surgery with at least 6 months of follow-up, versus non-surgical treatment for obesity.1 Those allocated to surgery lost more body weight (mean difference -25 [95% confidence interval -31, -21] kg) and had a higher remission rates of type 2 diabetes (relative risk 22.1 [3.2, 154.3]) and the metabolic syndrome (relative risk 2.4 [1.6, 3.6]) after a maximum of 2 years, compared with those receiving nonsurgical treatment.Information regarding long-term outcomes is not available from randomised controlled trials and can only be derived from case series. Variable findings regarding remission and relapse rates for type 2 diabetes mellitus (T2DM) have emerged from such reports2–4 so the findings of Lam and colleagues, in this issue of the Journal,5 are of considerable interest. They report on their experience of 126 patients who had been followed for at least 4 years following gastric bypass surgery (GBP) at Waitemata District Health Board (WDHB), one of the few centres in New Zealand offering publically funded bariatric surgery.After about 5 years average weight loss was around 45 kg having achieved a postoperative nadir around 55kg. Twenty-nine of the 33 subjects with preoperative T2DM fulfilled the criteria for complete remission at some stage postoperatively. At a mean follow-up of 63 months, 59% were regarded as full remitters. Short duration of diabetes and not being treated with insulin were the only predictors of full remission.While the mechanism for the improvement in glucose metabolism is yet to be fully understood,6 these results provide some reassurance that in the context of routine publically funded care, bariatric surgery offers clinically meaningful outcomes for these patients who fulfil the currently agreed stringent criteria for surgery.Given the absence of pharmacotherapy of proven benefit,7 lifestyle modification is the only other therapeutic option. While some individuals do manage to achieve and maintain weight loss and some dietary patterns and weight loss programmes appear to confer special benefit, the vast majority of patients tend to regain some or all of the weight lost after a few years.Furthermore weight loss regimes or dietary patterns (e.g. the high fat, low carbohydrate diet) which have been shown in the short-term to promote more weight loss than other approaches, generally appear to have lost their advantage by 12 to 18 months after initiation.8Against this background, the findings of Leong and colleagues9 in the second NZMJ paper are of relevance. Nearly 40% of women participating in a cross-sectional mail survey reported that they were trying to control their weight—and among those who were not, almost 70% were trying to prevent weight gain. Fewer than half reported use of appropriate measures such as reduction of portion sizes and cutting down of fats and sugars.However rather alarmingly nearly a quarter said they were using exercise in what was described as a compulsive or driven way and 14% were smoking as a method of assisting weight control. Smaller numbers were using intermittent fasting, laxatives, diuretics, self-induced vomiting and drugs.Equally concerning findings were that nearly one-fifth of women who were underweight (BMI<18.5) and 9% of those in the lower healthy age range (BMI 18.5–<22) were attempting weight loss whereas 10–14% of those who were overweight or obese were not. Clearly these findings do not provide encouragement that ‘dieting' as currently practised by women in New Zealand is an appropriate approach to weight management in the population at large.Among adults aged 15 years and over, 27.7% of women and 27.8% of men are classified as obese10 and excess body fatness is a major driver of rates of T2DM, an important risk determinant for cardiovascular disease, and some of our commonest cancers, colorectal cancer and postmenopausal breast cancer. Yet we still have no overarching national strategy in New Zealand for dealing with the epidemic proportions of obesity and its comorbidities.Appropriate services for advising and supporting those appreciably overweight, especially those who have already developed comorbidities such as prediabetes and T2DM, are woefully inadequate or absent in some parts of the country. Indeed, national criteria for bariatric surgery need to be adopted and implemented by all District Health Boards.Most important of all, we need a raft of public health measures to alter an environment which promotes unhealthy weight gain. Re-establishing a programme supporting healthy eating in schools may be a good place to start.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Jim I Mann, Director; Edgar National Centre for Diabetes and Obesity Research (ENCDOR), Department of Human Nutrition and Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Kirsten J Coppell, Senior Research Fellow; Edgar National Centre for Diabetes and Obesity Research (ENCDOR), Dunedin School of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

Professor Jim Mann, Edgar National Centre for Diabetes and Obesity Research, Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand. Fax: +64 (0)3 4747641

Correspondence Email

jim.mann@otago.ac.nz

Competing Interests

Nil.

Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934. http://www.bmj.com/content/347/bmj.f5934 Chikunguwo SM, Wolfe LG, Dodson P, et al. Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2010;6(3):254-9.DiGiorgi M, Rosen DJ, Choi JJ, et al. Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up. Surg Obes Relat Dis. 2010;6(3):249-53.Pournaras DJ, Aasheim ET, Sovik TT, et al. Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders. Br J Surg. 2012;99(1):100-3.Lam A, Kim D, Cutfield R, et al. Long-term outcomes in gastric bypass patients with and without type 2 diabetes Waitemata District Health Board experience. N Z Med J. 2013;126(1386). Lingvay I, Guth E, Islam A, Livingston E. Rapid improvement in diabetes after gastric bypass surgery: is it the diet or surgery? Diabetes Care. 2013;36(9):2741-7.Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA. 2013;14(10):281-361.McAuley KA, Smith KJ, Taylor RW, McLay RT, Williams SM, Mann JI. Long-term effects of popular dietary approaches on weight loss and features of insulin resistance. Int J Obes. 2006;30(2):342-9.Leong S, Madden C, Gray A, Horwath C. A nationwide survey of weight control practices among middle-aged New Zealand women. N Z Med J. 2013;126(1386). http://journal.nzma.org.nz/journal/126-1386/5909 University of Otago and Ministry of Health. A Focus on Nutrition: Key findings of the 2008/09 New Zealand Adult Nutrition Survey. Wellington: Ministry of Health; 2011.

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Two papers in this issue of the NZMJ serve as reminders of the many complexities of managing the real and perceived problems of excess body fatness, and that an overarching strategy, including public health initiatives, is essential for the management of this global epidemic.In October 2013, the BMJ published a systematic review and meta-analysis of the 11 randomised controlled trials of bariatric surgery with at least 6 months of follow-up, versus non-surgical treatment for obesity.1 Those allocated to surgery lost more body weight (mean difference -25 [95% confidence interval -31, -21] kg) and had a higher remission rates of type 2 diabetes (relative risk 22.1 [3.2, 154.3]) and the metabolic syndrome (relative risk 2.4 [1.6, 3.6]) after a maximum of 2 years, compared with those receiving nonsurgical treatment.Information regarding long-term outcomes is not available from randomised controlled trials and can only be derived from case series. Variable findings regarding remission and relapse rates for type 2 diabetes mellitus (T2DM) have emerged from such reports2–4 so the findings of Lam and colleagues, in this issue of the Journal,5 are of considerable interest. They report on their experience of 126 patients who had been followed for at least 4 years following gastric bypass surgery (GBP) at Waitemata District Health Board (WDHB), one of the few centres in New Zealand offering publically funded bariatric surgery.After about 5 years average weight loss was around 45 kg having achieved a postoperative nadir around 55kg. Twenty-nine of the 33 subjects with preoperative T2DM fulfilled the criteria for complete remission at some stage postoperatively. At a mean follow-up of 63 months, 59% were regarded as full remitters. Short duration of diabetes and not being treated with insulin were the only predictors of full remission.While the mechanism for the improvement in glucose metabolism is yet to be fully understood,6 these results provide some reassurance that in the context of routine publically funded care, bariatric surgery offers clinically meaningful outcomes for these patients who fulfil the currently agreed stringent criteria for surgery.Given the absence of pharmacotherapy of proven benefit,7 lifestyle modification is the only other therapeutic option. While some individuals do manage to achieve and maintain weight loss and some dietary patterns and weight loss programmes appear to confer special benefit, the vast majority of patients tend to regain some or all of the weight lost after a few years.Furthermore weight loss regimes or dietary patterns (e.g. the high fat, low carbohydrate diet) which have been shown in the short-term to promote more weight loss than other approaches, generally appear to have lost their advantage by 12 to 18 months after initiation.8Against this background, the findings of Leong and colleagues9 in the second NZMJ paper are of relevance. Nearly 40% of women participating in a cross-sectional mail survey reported that they were trying to control their weight—and among those who were not, almost 70% were trying to prevent weight gain. Fewer than half reported use of appropriate measures such as reduction of portion sizes and cutting down of fats and sugars.However rather alarmingly nearly a quarter said they were using exercise in what was described as a compulsive or driven way and 14% were smoking as a method of assisting weight control. Smaller numbers were using intermittent fasting, laxatives, diuretics, self-induced vomiting and drugs.Equally concerning findings were that nearly one-fifth of women who were underweight (BMI<18.5) and 9% of those in the lower healthy age range (BMI 18.5–<22) were attempting weight loss whereas 10–14% of those who were overweight or obese were not. Clearly these findings do not provide encouragement that ‘dieting' as currently practised by women in New Zealand is an appropriate approach to weight management in the population at large.Among adults aged 15 years and over, 27.7% of women and 27.8% of men are classified as obese10 and excess body fatness is a major driver of rates of T2DM, an important risk determinant for cardiovascular disease, and some of our commonest cancers, colorectal cancer and postmenopausal breast cancer. Yet we still have no overarching national strategy in New Zealand for dealing with the epidemic proportions of obesity and its comorbidities.Appropriate services for advising and supporting those appreciably overweight, especially those who have already developed comorbidities such as prediabetes and T2DM, are woefully inadequate or absent in some parts of the country. Indeed, national criteria for bariatric surgery need to be adopted and implemented by all District Health Boards.Most important of all, we need a raft of public health measures to alter an environment which promotes unhealthy weight gain. Re-establishing a programme supporting healthy eating in schools may be a good place to start.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Jim I Mann, Director; Edgar National Centre for Diabetes and Obesity Research (ENCDOR), Department of Human Nutrition and Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Kirsten J Coppell, Senior Research Fellow; Edgar National Centre for Diabetes and Obesity Research (ENCDOR), Dunedin School of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

Professor Jim Mann, Edgar National Centre for Diabetes and Obesity Research, Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand. Fax: +64 (0)3 4747641

Correspondence Email

jim.mann@otago.ac.nz

Competing Interests

Nil.

Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934. http://www.bmj.com/content/347/bmj.f5934 Chikunguwo SM, Wolfe LG, Dodson P, et al. Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2010;6(3):254-9.DiGiorgi M, Rosen DJ, Choi JJ, et al. Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up. Surg Obes Relat Dis. 2010;6(3):249-53.Pournaras DJ, Aasheim ET, Sovik TT, et al. Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders. Br J Surg. 2012;99(1):100-3.Lam A, Kim D, Cutfield R, et al. Long-term outcomes in gastric bypass patients with and without type 2 diabetes Waitemata District Health Board experience. N Z Med J. 2013;126(1386). Lingvay I, Guth E, Islam A, Livingston E. Rapid improvement in diabetes after gastric bypass surgery: is it the diet or surgery? Diabetes Care. 2013;36(9):2741-7.Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA. 2013;14(10):281-361.McAuley KA, Smith KJ, Taylor RW, McLay RT, Williams SM, Mann JI. Long-term effects of popular dietary approaches on weight loss and features of insulin resistance. Int J Obes. 2006;30(2):342-9.Leong S, Madden C, Gray A, Horwath C. A nationwide survey of weight control practices among middle-aged New Zealand women. N Z Med J. 2013;126(1386). http://journal.nzma.org.nz/journal/126-1386/5909 University of Otago and Ministry of Health. A Focus on Nutrition: Key findings of the 2008/09 New Zealand Adult Nutrition Survey. Wellington: Ministry of Health; 2011.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Two papers in this issue of the NZMJ serve as reminders of the many complexities of managing the real and perceived problems of excess body fatness, and that an overarching strategy, including public health initiatives, is essential for the management of this global epidemic.In October 2013, the BMJ published a systematic review and meta-analysis of the 11 randomised controlled trials of bariatric surgery with at least 6 months of follow-up, versus non-surgical treatment for obesity.1 Those allocated to surgery lost more body weight (mean difference -25 [95% confidence interval -31, -21] kg) and had a higher remission rates of type 2 diabetes (relative risk 22.1 [3.2, 154.3]) and the metabolic syndrome (relative risk 2.4 [1.6, 3.6]) after a maximum of 2 years, compared with those receiving nonsurgical treatment.Information regarding long-term outcomes is not available from randomised controlled trials and can only be derived from case series. Variable findings regarding remission and relapse rates for type 2 diabetes mellitus (T2DM) have emerged from such reports2–4 so the findings of Lam and colleagues, in this issue of the Journal,5 are of considerable interest. They report on their experience of 126 patients who had been followed for at least 4 years following gastric bypass surgery (GBP) at Waitemata District Health Board (WDHB), one of the few centres in New Zealand offering publically funded bariatric surgery.After about 5 years average weight loss was around 45 kg having achieved a postoperative nadir around 55kg. Twenty-nine of the 33 subjects with preoperative T2DM fulfilled the criteria for complete remission at some stage postoperatively. At a mean follow-up of 63 months, 59% were regarded as full remitters. Short duration of diabetes and not being treated with insulin were the only predictors of full remission.While the mechanism for the improvement in glucose metabolism is yet to be fully understood,6 these results provide some reassurance that in the context of routine publically funded care, bariatric surgery offers clinically meaningful outcomes for these patients who fulfil the currently agreed stringent criteria for surgery.Given the absence of pharmacotherapy of proven benefit,7 lifestyle modification is the only other therapeutic option. While some individuals do manage to achieve and maintain weight loss and some dietary patterns and weight loss programmes appear to confer special benefit, the vast majority of patients tend to regain some or all of the weight lost after a few years.Furthermore weight loss regimes or dietary patterns (e.g. the high fat, low carbohydrate diet) which have been shown in the short-term to promote more weight loss than other approaches, generally appear to have lost their advantage by 12 to 18 months after initiation.8Against this background, the findings of Leong and colleagues9 in the second NZMJ paper are of relevance. Nearly 40% of women participating in a cross-sectional mail survey reported that they were trying to control their weight—and among those who were not, almost 70% were trying to prevent weight gain. Fewer than half reported use of appropriate measures such as reduction of portion sizes and cutting down of fats and sugars.However rather alarmingly nearly a quarter said they were using exercise in what was described as a compulsive or driven way and 14% were smoking as a method of assisting weight control. Smaller numbers were using intermittent fasting, laxatives, diuretics, self-induced vomiting and drugs.Equally concerning findings were that nearly one-fifth of women who were underweight (BMI<18.5) and 9% of those in the lower healthy age range (BMI 18.5–<22) were attempting weight loss whereas 10–14% of those who were overweight or obese were not. Clearly these findings do not provide encouragement that ‘dieting' as currently practised by women in New Zealand is an appropriate approach to weight management in the population at large.Among adults aged 15 years and over, 27.7% of women and 27.8% of men are classified as obese10 and excess body fatness is a major driver of rates of T2DM, an important risk determinant for cardiovascular disease, and some of our commonest cancers, colorectal cancer and postmenopausal breast cancer. Yet we still have no overarching national strategy in New Zealand for dealing with the epidemic proportions of obesity and its comorbidities.Appropriate services for advising and supporting those appreciably overweight, especially those who have already developed comorbidities such as prediabetes and T2DM, are woefully inadequate or absent in some parts of the country. Indeed, national criteria for bariatric surgery need to be adopted and implemented by all District Health Boards.Most important of all, we need a raft of public health measures to alter an environment which promotes unhealthy weight gain. Re-establishing a programme supporting healthy eating in schools may be a good place to start.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Jim I Mann, Director; Edgar National Centre for Diabetes and Obesity Research (ENCDOR), Department of Human Nutrition and Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Kirsten J Coppell, Senior Research Fellow; Edgar National Centre for Diabetes and Obesity Research (ENCDOR), Dunedin School of Medicine, University of Otago, Dunedin

Acknowledgements

Correspondence

Professor Jim Mann, Edgar National Centre for Diabetes and Obesity Research, Department of Medicine, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand. Fax: +64 (0)3 4747641

Correspondence Email

jim.mann@otago.ac.nz

Competing Interests

Nil.

Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934. http://www.bmj.com/content/347/bmj.f5934 Chikunguwo SM, Wolfe LG, Dodson P, et al. Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2010;6(3):254-9.DiGiorgi M, Rosen DJ, Choi JJ, et al. Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up. Surg Obes Relat Dis. 2010;6(3):249-53.Pournaras DJ, Aasheim ET, Sovik TT, et al. Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders. Br J Surg. 2012;99(1):100-3.Lam A, Kim D, Cutfield R, et al. Long-term outcomes in gastric bypass patients with and without type 2 diabetes Waitemata District Health Board experience. N Z Med J. 2013;126(1386). Lingvay I, Guth E, Islam A, Livingston E. Rapid improvement in diabetes after gastric bypass surgery: is it the diet or surgery? Diabetes Care. 2013;36(9):2741-7.Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA. 2013;14(10):281-361.McAuley KA, Smith KJ, Taylor RW, McLay RT, Williams SM, Mann JI. Long-term effects of popular dietary approaches on weight loss and features of insulin resistance. Int J Obes. 2006;30(2):342-9.Leong S, Madden C, Gray A, Horwath C. A nationwide survey of weight control practices among middle-aged New Zealand women. N Z Med J. 2013;126(1386). http://journal.nzma.org.nz/journal/126-1386/5909 University of Otago and Ministry of Health. A Focus on Nutrition: Key findings of the 2008/09 New Zealand Adult Nutrition Survey. Wellington: Ministry of Health; 2011.

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