STIGMA, bias and discrimination are keeping obese patients from getting the treatment they need in the public health system, says an Australian expert.
Professor John Dixon, Head of Clinical Obesity Research at Baker IDI Heart and Diabetes Institute, told InSight+ that public access to bariatric surgeries was “still terrible”.
While globally COVID-19 has caused delays in elective surgeries such as bariatric weight loss procedures, in Australia, the problem isn’t the pandemic — it’s the lack of public access to weight loss treatments.
According to the National Bariatric Registry, there were only 22 public hospitals across the country that reported a bariatric procedure in 2019. Of these, only 10 had a caseload of over 75.
Just 6% of metabolic procedures done in 2019 were performed in public hospitals. The other 94% were in private hospitals.
Bariatric surgery is currently covered by Medicare and most private health insurers also offer coverage. Medicare patients are entitled to subsidised medical services for bariatric surgery, provided they meet the medical criteria requirements – the patient must have clinically severe obesity (ie, body mass index [BMI] of 40 or more, or a BMI of 35 or more with other major medical comorbidities or obesity-related disease). Medicare items 31569 to 31581 and item 20791 provide for surgical treatment of clinically severe obesity and the accompanying anaesthesia service.
Individual private insurers can have differing terms and conditions for weight loss surgery.
“Public access is still terrible,” said Professor Dixon.
“Its impact on the nation’s obesity [levels] is trivial. It’s particularly difficult for regional centres. Most people with clinically severe obesity don’t get any attention at all.
“It’s not [the obese person’s] fault. They could do all the exercise in the world; they could try dozens of diets. They learn it doesn’t work. They float up and down. Yet they still blame themselves and they still feel it’s their fault because they lack willpower,” he said.
“We’ve got to understand we need to treat those with severe obesity with proper treatment like we do every other disease like cancer, diabetes, heart disease etc.
“The main problem with managing obesity today is weight stigma, bias, and discrimination. There is no reason why these very sick people are not treated at public hospitals and other hospitals with appropriate treatment other than those reasons,” Professor Dixon said.
This lack of access is not new. Many studies have detailed the socio-economic inequalities in access to bariatric surgery. However, the fact that there has been little improvement is concerning.
Fortunately, there are a few reasons for cautious optimism.
In late 2020, the Australian New Zealand Metabolic and Obesity Surgery Society (ANZMOSS) created a National Framework to provide clear guidelines for health policymakers, clinical governance boards and health practitioners.
They developed these guidelines with the Collective Bariatric Surgery Taskforce to provide efficient, patient-centred care, sustainable use of resources and provide surgical care to the most appropriate patient populations.
The report gives a detailed analysis on how to determine eligibility for bariatric surgery and then how to triage priority.
It talks about the surgery recommended including gastric banding, biliopancreatic diversion and gastric bypass, although according to Professor Dixon, the current worldwide trend is sleeve gastrectomy.
It also covers the end-to-end service including the importance of patient education and post-operative care, including clinical and annual dietetic reviews.
The first National Framework for Clinical Obesity Services in Australia was developed by the newly created National Association of Clinical Obesity Services (NACOS).
The framework aims to offer practical guidance on how to best provide weight management services for health care professionals, consumers, those working in the health insurance industry, and policymakers.
Approximately 7 million of people have clinically significant weight-related health impairments. In the past, obesity has been blamed on individual risk factors (biological and behavioural).
However, according to the NACOS framework, it’s now recognised that “increasingly ‘obesogenic’ environments and their interactions with individual risk factors most likely explain the rapid worldwide changes in body weight and the differences in obesity rates between countries”.
While frameworks and guidelines have now been developed, progress is slow, mainly thanks to COVID-19.
“It’s hard to get traction at any time but even more now with health being a major issue over the last few months,” Profession Dixon admitted.
According to Dr Evan Atlantis, Secretary and Founding President of NACOS, the guidelines have renewed interest in the area and health ministers across the country have responded positively so far.
“We would welcome the opportunity to work with all state/territory governments to help implement the recommendations in both frameworks,” Dr Atlantis told InSight+.
The seeds are sown for a much better deal in Australia. Hospital and allied health services recognise weight management services in our public hospitals are inadequate and need to change.
It is hoped that with the rollout of the COVID-19 vaccine, there may be an increased focus on improving services for people suffering from obesity.
Professor Dixon hopes the message gets through that obesity is a chronic illness and not an individual’s fault.
“Shaming and blaming is never a way to treat a chronic condition, it just makes it worse,” he concluded.