By Francesco Rubino, Professor of Metabolic and Bariatric Surgery at King’s College London
As we mark World Diabetes Day, new figures show that misconceptions and stigma around obesity could be responsible for inadequate provision of metabolic surgery, an effective treatment for type 2 diabetes.
While this is partly due to lack of knowledge of recent evidence among healthcare professionals, as well as inadequate coverage, misconceptions about surgery and the stigma of obesity and diabetes are likely the main barriers.
Surgery can achieve long-term remission of diabetes and decrease risk of cardiovascular disease and other complications. My own research provided the first experimental evidence that gastrointestinal operations traditionally used for the treatment of severe obesity can improve diabetes. These findings are now corroborated by a large body of scientific evidence showing that the gastrointestinal tract is a crucial organ in the regulation of sugar metabolism, hence an ideal target for anti-diabetes interventions.
Large studies have also shown that surgery can reduce overall mortality compared to usual diabetes care. Surgery drastically reduces the need for insulin and other medications to control blood sugar levels, making it is a very cost-effective approach to treating the disease. The evidence is so strong that more than 50 scientific organisations worldwide now back surgery as a therapy for Type 2 diabetes.
Despite that, only 0.1-2% of surgical candidates worldwide currently have access to this type of treatment.
Access is particularly problematic in the UK, where the number of procedures performed every year is between 3 to 10 times lower than in other major European countries.
A common misconception, even among health care professionals, is that surgery would be an alternative to lifestyle interventions. In fact, some argue that diet and exercise rather than expensive surgery should be used to treat diabetes or severe obesity. This argument misses the fact that in the clinical scenarios where surgery is indicated, lifestyle interventions alone, are no longer sufficient to achieve adequate disease control. In these cases it is tantamount to suggesting that one should use lifestyle changes instead of surgery or chemo-therapy to treat cancer.
Another misperception is that high upfront costs of treatment could be an explanation for the low-uptake. In fact, surgical procedures for other chronic diseases are performed far more often despite being similarly or even more costly.
For instance, more than 120,000 surgeries for osteoarthritis (hip- and knee-replacements) are carried out every year in the UK whereas only 6,000-7,000 patients/year undergo bariatric or metabolic surgery – and of these only about 30% have type 2 diabetes.
More than £ 1.2 bn a year is spent in surgical treatment of osteoarthritis compared to only £10-12M for surgical treatment of type 2 diabetes. Also, the cost of treating diabetes with drugs in the UK is about £3bn a year, with £1bn spent just for glucose-lowering drugs and additional £2bn for other drugs needed to reduce cardiovascular risk factors associated with diabetes.
Given the ability of surgery to drastically reduce the need for both these types of drugs in patients with diabetes, and even induce long-term remission of diabetes in at least 50% of patients, increasing costs from greater uptake of surgery would be balanced by the reduced expenditure for drugs.
Prejudice against people with obesity can play a major role in preventing access to surgery. In fact, a recent international study showed that while prejudice against people with obesity is ubiquitous, a gradient exist across countries. If you plot the stigma score from this study against the uptake of bariatric/metabolic surgery, there seems to be a relationship between the level of stigma and the number of bariatric/metabolic procedures being carried out.
More than 90% of the responders in a survey given to the attendees of the recent London conference on the subject, which included healthcare professionals, agreed that stigma and misconceptions are likely the main barriers to surgical treatment, while 100% of them believed that patients with obesity and related diseases are subject to discrimination.
In fact, provision of any treatment for obesity is poor. Despite diabetes and obesity being the world’s biggest health issue, far less research money is spent for these diseases compared to other diseases such as cancer or HIV/Aids
Stigma against this disease is endemic across all areas of society, including with the patients themselves who are often too ashamed to come forward.