Obesity and Eating Disorders – A tale of two reports

In recent months, the Canadian Institute for Health Information (CIHI) has released two very interesting reports.  The first report is on the growth rate of bariatric surgery in Canada and the second is on the use of hospital care for the treatment of eating disorders.  The reports are interesting for what they tell us and what they do not.

Reading the reports together would lead one to think that the need for obesity treatment is ten times greater than the need for eating disorder treatment.  It would seem a matter of fact that obesity is rife with medical problems and that the “cure”, bariatric surgery is safe and improves the health and quality of life for those who access the treatment.  While on the other hand, eating disorders seem rare and rarely lead to the use of urgent care options in our system, such as the emergency department.  We need to analyze the reports very carefully to understand what they are really saying.

First, let us look at the report on bariatric surgery.  Between 2006 and 2013, the number of bariatric surgeries performed increased by 280% (from approximately 1500 to 6000 surgeries) annually.  In the report, CIHI seems to act as both cheerleader and apologist for these surgical procedures.  The assumption that these procedures are beneficial and necessary is never questioned, in spite of the data presented.  It should be concerning that the majority (80%) of patients are middle aged women, but this is explained away by the statement that there are more women with class II and class III obesity (this statement is made despite the fact that BMI of patients undergoing these procedures was not available and so we cannot know if all the patients did in fact fall into those BMI categories).

It is true that in the general population, there are more women in the class II/III obesity categories however, they only make up about 56% of all Canadians in these categories (men make up the other 44%).  Women in class II/III obesity make up about 5.7% of the female population in Canada while men in these categories make up about 4.6% of the male population.  These small differences cannot explain why women make up anywhere from 72-93% (depending on the province) of the surgical patients instead of 50-60%?  If it was simply about health and not about differential appearance and weight expectations based on sex, would the numbers not reflect national percentages for males and females?

A second interesting finding is that the rates of anxiety and depression are lower post-surgery.  At first glance it is somewhat disturbing to simply accept that somehow fatter people should be more anxious and depressed, without considering the underlying reasons.  Reasons such as the stigma that obese people live with every day are to be considered.  I wish the solution was to eradicate stigma rather than cut into bodies?

A woman I work with who had undergone bariatric surgery explained this finding to me in another way.  In her experience, many people undergoing these procedures who struggled with anxiety and depression, were most commonly untreated as they could not access appropriate psychiatric care.  As part of the bariatric program, they were assessed by a psychiatrist and those with mental health symptoms would be treated with medication and/or eight weeks of cognitive behavioural therapy where appropriate.  Over time, their anxiety and depression improved with appropriate psychiatric treatment.  Maybe the actual cause for the success in the reduction of anxiety and depression symptoms is the psychiatric treatment and quite possibly NOT the surgery.  Maybe overweight Canadians should have access to mental health treatment without having to sign up for surgery.

Another concerning finding is the low rate of co-morbid conditions such as sleep apnea, hypertension and diabetes in people undergoing this major operation ostensibly to treat these medical issues (that are thought to be directly related to obesity).  All of these illnesses individually occurred at a rate of 15% or less.  This data along with the finding that two years after surgery, patients had about twice the number of elective and urgent care hospital visits as they did two years before the surgery is disturbing.

Taken together (and remembering that 80% of the patients were middle aged women) it appears that any of these surgical patients were people who were reasonably healthy (albeit overweight) and that after surgery they used our health care system twice as often as they did prior to surgery.  I wonder whether bariatric surgery should be reconsidered by our health care system?  The whole system seems suspect.  Let’s stop letting our prejudiced beliefs influence our health care.

Stay tuned for part 2 of this blog, where I discuss the CIHI report on eating disorders.