What about physical activity and exercise medicine?
Editor – Adlan et al lay bare an institutionalised and unbalanced portrayal of obesity treatment and their conclusions appear misleading (Clin Med April 2010 p 206). Obesity and type 2 diabetes are symptoms of pandemic physical inactivity and poor diet making their results far from surprising.1 The authors omit any reference to physical activity preferring to concentrate on diet and medication as the only alternatives to bariatric surgery. Physical activity is of fundamental importance as a primary treatment (along with diet) for obesity, type 1 and type 2 diabetes. It is concerning that they conclude there is a lack of effective alternative treatments, while evidence for physical activity interventions suggests the contrary.2–4
Moreover, recent systematic and Cochrane reviews evaluating surgery for obesity are inconclusive, as long-term data on numerous outcome measures remain unknown.5,6 Recent research suggests that the most obese and those with existing co-morbidities are at the greatest risk of post-bariatric surgery mortality and this could be very relevant to many patients in a secondary care diabetic clinic, when compared to those managed in primary care.7
Admittedly, there is a deficiency of training on physical activity and exercise medicine within undergraduate and postgraduate medical education, a lack of comprehensive physician training to counsel patients effectively on lifestyle modification (and physical activity promotion) and a lack of provision of well-constructed physical activity schemes across the UK for patients with chronic disease.
However, is it not misleading for surgery to be portrayed as the only effective ‘magic bullet’ treatment for obesity and made increasingly available? Lee et al demonstrated in a prospective study, following 21,925 men, that obesity-related health risks are reversed by physical activity even without weight reduction, while the benefits of leanness are lost through physical inactivity.8
When these issues are addressed and considered holistically, perhaps physicians will be better placed to manage patient expectations and treatment with balance and, most importantly, with a sound evidence base.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2010 Royal College of Physicians
References
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- Department of Health
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- Sigal RJ
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- Shugart C
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- Lawton BA
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- Lee CD
What about physical activity and exercise medicine?
We are grateful to Weiler for his response. A close reading of our report would show him that our aim was to demonstrate the high prevalence of obesity qualifying for bariatric surgery in hospital diabetic clinic attendees. In doing so we hoped to highlight the lack of an adequately funded multidisciplinary bariatric surgery service. It was not our intention to make direct comparisons of treatment options for obesity eg exercise versus bariatric surgery. However, there are several points we would like to make.
We do not portray surgery as a ‘magic bullet’. The indications for bariatric surgery in these patients are well defined in National Institute for Health and Clinical Excellence guidelines as quoted and is reserved for those who have failed a trial of diet, exercise and drugs.1
There are numerous studies in well-motivated obese diabetic patients, where increased levels of exercise have made a difference both to risk and to outcome. But we encounter difficulties in motivating our patients (often with multiple co-morbidities such as coronary heart disease, osteoarthritis of weight bearing joints etc) to increase physical activity as a means of achieving and maintaining long-term weight loss.
We disagree with the implied suggestion that bariatric surgery is unsafe in a multidisciplinary setting. The composite end points of death, major thrombosis, reintervention and prolonged hospitalisation were 1% for laparoscopic adjustable gastric banding, 4.8% for laparoscopic Roux-en-Y gastric bypass surgery and 7.8% for open Roux-en-Y bypass surgery, in a multicentre study,2 compared to mortality rates alone for aortic aneurysm of 3.9%; coronary artery bypass surgery of 3.5%, and oesophagectomy of 9% in the USA.
While we agree that further long-term data are needed, current data are encouraging for long-term weight reduction,3 reducing diabetes prevalence4 and reducing mortality.5
However, till more evidence is forthcoming it may be helpful to remember Greenberg and Robinson's views:
In a perfect world, primary prevention through diet and exercise would alleviate the need for any surgical intervention. Unfortunately until we begin to see success with primary prevention…bariatric surgery will remain an important – and reasonably safe – tool in our armamentarium.6
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2010 Royal College of Physicians
References
- National Institute for Health and Clinical Excellence
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