Bariatric Surgery PICO Question

PICO Question: Bariatric Surgery
As the obesity rate continues to be an issue of great concern in America, the question arises as to the best ways to reduce the BMIs of individuals already suffering from the condition, as well as how to enact preventative means. Although the ideal is for people to never become obese at all, the fact remains that there is a need to develop proactive measures to facilitate weight reduction. For most patients, modifications in diet and exercise is recommended but, as even people who have attempted casual weight loss know, deploying such techniques in an effective and consistent fashion is far easier said than done.
PICO Question
The PICO question for the purpose of this study is, from the perspective of a family nurse practitioner, when treating patients with type 2 diabetes and obesity, can bariatric surgery be more effective than standard medical therapy at increasing the probability of remission of diabetes? The patient population in question is obese females with type 2 diabetes, the intervention is bariatric surgery (or other types of weight loss surgery), the current standard medical care is that of diet and exercise, the desired outcome is weight loss and diabetes management. Surgical intervention always poses at least some risk to patients and is not something to be undertaken lightly, hence the significance of this question to nursing, particularly for practitioners who are dealing with an increasingly large population of patients suffering from obesity-related conditions.
Systematic Review One: The Benefits of Surgical Intervention
According to a systematic review of 7 randomized control trials (RCTs) involving bariatric patients conducted by Colquitt (et al. 2014), all studies found benefits for surgery in terms of weight loss combined with non-surgical control groups. Improvements included health-related quality of life outcomes and control of diabetes. No deaths occurred during any of the studies and serious adverse events ranged from 0-37% in the group which experienced the surgical intervention versus 0-25% in the groups which eschewed surgical intervention. This was deemed to be a statistically significant difference. Across the studies which kept track of such data, 2%- 13% of participants required reoperations. The authors noted, however, that adverse effects across all of the studies were poorly reported in general. Most studies only followed up with patients for a year or two. Three of the studies found gastric bypass to foster greater weight loss versus with laparoscopic adjustable gastric banding, suggesting the more intensive intervention was beneficial for patients.
Overall, the authors concluded, based upon the study, that for patients that meet current criteria regarding the BMI for bariatric surgery, the surgery fosters more positive health outcomes than dieting and exercise alone. There was limited data on patients whose body mass indexes fell outside of such criteria, though. The authors concluded that recommending a bariatric intervention would be warranted, weighing the potential risk factors against the benefits of both weight loss and quality of life improvement but also cautioned that the quality of evidence within all the RCTs was relatively weak. It should also be noted that although the focus of the PICO study is upon female obese patients with diabetes, the Colquitt (et al. 2014) study focused upon both male and female patients in the randomized control studies chronicled in the review.
Systematic Review Two: Surgical Intervention for Younger Patients
Surgical intervention is often only prescribed for older patients, after other options for weight loss have been repeatedly exercised. But there is an argument for earlier intervention, given the extent to which diet and exercise habits are established earlier in life. Also, long-term treatment for chronic obesity-related conditions has a physical, psychological, and economic cost for both the patient and society. A study by Ells (et al. 2015) tackled the even more controversial of whether obese children and adolescents should be prescribed gastric surgery. Finding studies which focus on children proved to be difficult and the study’s authors only could find one study of 50 participants which met their criteria. This meant that 25 were in the experimental group; 25 in the control group. Slightly less than half of the participants in the control group reported adverse events, but quality of evidence was judged to be low.
The relatively small number of patients who go through bariatric surgery and other forms of weight control surgery may in part explain the relatively few studies on the subject. The risks of performing surgery on young people may also partially explain the limited sampling. The study’s conclusions suggest that there is no clear evidence-based benefit for early surgical intervention. Although the focus of the PICO question is on adult patients, the conclusions of the study are still relevant, given that the age of the patient may still be a factor in deciding how to prescribe and treat appropriate lifestyle interventions versus surgery.
Systematic Review Three: Female-Specific Studies
There are relatively few female-specific studies on the benefits of weight loss surgery, although a number of the studies in all of the systematic reviews had slightly higher percentages of female patients. But one review by Kitson (et al., 2018), specifically focused on endometrial cancer, a cancer that has been found to be unusually prevalent in overweight and obese women. Two randomized controlled studies were used, featuring 161 overweight and obese women with endometrial cancer. Unfortunately, no lifestyle-based interventions were found to reduce the risk of reoccurrence of the cancer or of general mortality rates the patients, including intervention involving weight loss, both surgical and diet-related. In short, there was no quality evidence to indicate that significant weight loss, as occurs with bariatric surgery, should be recommended as part of a treatment for endometrial cancer.
Still, this does not necessarily mean that the findings of this study were applicable for all obesity-related conditions. For obesity-related conditions such as diabetes, reduction in BMI may be more effective. The study does act as a caution in anticipating too broad and sweeping an improvement regarding the patient’s health, although obesity has been linked to certain specific cancers.
Conclusion
Overall, the evidence suggests that weight loss surgery can hasten BMI reduction, compared with non-surgical methods and existing studies did not find a significantly heightened risk regarding the use of surgery for weight loss. But the quality of evidence in all the studies was poor, despite the use of RCTs. The relative novelty of the use of bariatric surgery in weight loss may in part explain this lack of data and future research is clearly needed to firstly establish its efficacy in a long-term fashion as well as its safety based upon a cost-benefit analysis. The lack of long-term data is especially worrisome, given the extent to which most studies only focused on patients for a year or two. Weight loss is a constant lifelong struggle for most individuals struggling with the condition and also side effects from surgery may only be evident later on. There was no discussion of the significance of medical support and therapeutic counseling for patients post-intervention. Finally, little emphasis was placed upon any specific challenges women might struggle with in regards to weight loss surgery.
References
Colquitt J.L., Pickett, K., Loveman, E., & Frampton, G.K. (2014). Surgery for weight loss in
adults. Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD003641. DOI: 10.1002/14651858.CD003641.pub4. Retrieved from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003641.pub4/full?highl ightAbstract=bariatr&highlightAbstract=bariatric
Ells L.J., Mead, E., Atkinson, G., Corpeleijn, E., Roberts, K., Viner, R., Baur, L.,
Metzendorf, M.I., & Richter, B. (2015) Surgery for the treatment of obesity in children and adolescents. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD011740. DOI: 10.1002/14651858.CD011740. Retrieved from:
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011740/full?highlightA bstract=bariatr&highlightAbstract=bariatric
Kitson, S., Ryan, N., MacKintosh, M.L., Edmondson, R., Duffy, J.M.N., & Crosbie, E.J.
(2018). Interventions for weight reduction in obesity to improve survival in women with endometrial cancer. Cochrane Database of Systematic Reviews 2018, Issue 2. Art. No.: CD012513. DOI: 10.1002/14651858.CD012513.pub2. Retrieved from:
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012513.pub2/full?highl ightAbstract=bariatr&highlightAbstract=bariatric