News | Upper GI Surgery | Bariatric Surgery

Obesity Medication Perspective by A/Prof Michael Talbot

Upper GI Surgery — Tue, 21 Nov 2023 23:00:18 +0000

A counterpoint to the argument for denying effective anti-obesity therapy during a time of medication shortage.

In response to criticism about previous statements that were directly stigmatising of persons with a lived experience of severe obesity, the Therapeutics Goods Association (TGA) and others have appropriately altered their language regarding the use of GLP-1 agonists which have clinical effectiveness for the management of Type II Diabetes as well as clinically significant obesity. They have now asked clinicians prescribing these medications to consider delaying prescription unless other suitable alternatives are not available, rather than seeking to deny patients with severe obesity the opportunity to receive treatment.

While the best of these agents are only approved for use in Australia for the treatment of Type II Diabetes, ample research data and clinical experience are showing excellent results when used for severe obesity, which has subsequently led to widespread “off-label” prescription by Obesity Practitioners in Australia. Some versions of these drugs which are approved as obesity therapies are clinically inferior and more expensive than the newer and potentially scarcer agents.

The widespread success stories of people living with severe obesity who have lost weight with these medications have subsequently been shared on social media support groups set up by patients, which has then led regulatory agencies and the press to be aware of the potential contribution of these prescriptions to medication shortages. Unfortunately, this has potentially trivialised the importance of providing effective anti-obesity therapy to those in need, and it denies the validity of their experiences and health as being important.

While it is obvious that a poorly available therapy should not be used for frivolous purposes, appropriate consideration should be given to the needs of people living with severe obesity before denying them the opportunity to receive appropriate care. Overweight and obesity have skyrocketed in prevalence over the last 40 years and is Australia’s second largest cause of fatal disease and the largest contributor to non-fatal disease.

While substantial increases in the prescription of diabetic and cardiovascular therapies over this time have blunted the effects of obesity on mortality rates, little has been done with regard to managing obesity itself. No one is going to argue about the importance of lifestyle changes in obesity prevention as part of the suite of interventions for those living with obesity-related diseases. However, we have overwhelming evidence that lifestyle change as sole therapy is universally inadequate for those with severe disease, even though its effects in so-called multi-modality or combined therapies are important.

We know enough about obesity to predict, before treatment, the likely outcomes for an individual depending on the treatment prescribed. Patients requiring health improvement and weight stability should therefore be prescribed differing obesity therapies than those presenting with poorly controlled medical conditions, disabilities or diseases likely to become life-threatening soon.

While offering obesity therapies to patients has been made more difficult by the relative scarcity and complexity of treatments until reasonably recently, those treatments that are suitable, successful and cost-effective are rarely offered. The cost of therapy is often cited as a reason, but there appears to be a double standard applied to those seeking or who are eligible for obesity treatment. Therapies for obesity that are known to be more cost-effective than what we currently offer other patients with chronic disease (such as renal failure, osteoarthritis etc) or which are even potentially health-cost neutral, are consistently denied to patients by Federal and State healthcare systems.

Clinically severe obesity is the only major health condition where all healthcare costs are expected to be covered by the person with the disease. Most successful medical therapies for obesity are not approved for use by the TGA and are prescribed “off-label”, and even those that are TGA approved receive no government subsidies, which somewhat negates the point of seeking TGA approval in the first place. Patients presenting for treatment in public hospitals with life-threatening or disabling obesity-related conditions will have their condition treated but are virtually guaranteed to receive no obesity directed care other than documentation of their body mass index (BMI).

It is beyond the scope of this opinion piece to discuss the many complexities of obesity stigma, but for those who are interested, The Obesity Collective provides succinct and easily readable information for the public and lay-press, and the Weight Issues Network, a person-centred support group created by those with a lived experience of obesity, for those with a lived experience of obesity, have created an excellent position statement detailing the experiences of seeking health care when one has obesity. It’s unlikely that anyone reading these documents would come away without increasing their understanding and empathy for those negotiating their lives and the healthcare system with obesity as a front and centre issue.

A more nuanced way of managing the potential conflict between the requirements of those with severe diabetes or obesity is to make decisions based on the clinical needs of the patient. There are multiple drugs known to improve diabetes and prolong survival approved for use in Australia. If a diabetic patient does not require significant weight loss and is being prescribed one of the new GLP-1 agonists that are in short supply, alternatives could be prescribed without sacrificing their care.

Similarly, if a patient is being prescribed a GLP-1 agonist for obesity and is at the weight maintenance part of their therapy, other alternatives are available. Those requiring a lesser degree or slower weight loss have other options as well. This would leave scarce agents available for those patients requiring reliable and consistent weight loss to treat significant illness, and for those diabetics where significant weight loss and lifestyle modification are part of the management of their complicated diabetes associated illnesses.

GLP-1 agonists are part of the first of a suite of anti-obesity medications being released which are effective and well-tolerated when appropriately prescribed. Whether or not these make it into the hands of those in need will depend on our Health system’s re-evaluation of the importance of the needs of those affected by severe obesity, as well as advocacy by patients, clinicians and healthcare institutions.

Dr Talbot is a surgeon working in a multi-disciplinary clinic that provides treatments to patients referred for management of severe obesity. He is a past president of the ANZ Metabolic and Obesity Surgery Society (ANZMOSS) and is on the Board of The Obesity Collective.

Reflux: what is it & how is it treated?

purpleeffect — Wed, 02 Aug 2023 04:01:32 +0000

The oesophagus is like any part of our body, we don’t really think about it until it starts to fail in its function. It is a thin muscular tube about 20 cm long, running from the back of the mouth, through the neck and chest (behind the heart and lungs), and into the abdomen where it joins to the stomach. It functions like a rapid conveyor belt, propelling food into the stomach which pulverises and liquifies it before its long journey through the small then long intestine for digestion and waste management.

The stomach is one of the most toxic environments you can imagine, full of powerful acid and other chemicals that perform a useful function when they are contained in their rightful place, but cause trouble if they escape up the oesophagus.

What is “Reflux”?

The term “Reflux” is used to describe what happens when acid or other gastric content leaves the stomach and moves up the oesophagus. When someone says they have “reflux” (or “acid reflux”) we ask them specific details about their symptoms to get a better idea of what they are experiencing, as many patients labelled as having reflux disease have other conditions. The symptoms that people with reflux experience can include:

Heartburn – the word is used to describe pain felt behind the lower breastbone that feels as if it has a “chemical” or “burning” component.
Regurgitation – this occurs when people feel food or fluid move back up their oesophagus, and it’s quite different from vomiting.
Epigastric pain – patients often struggle to describe this symptom. When pain occurs at the point where the breastbone meets the abdomen it is often hard to figure out where it is exactly.
Chest Pain – this pain is often associated with a feeling of food or liquids getting stuck, chest tightness or pain in the jaw, back, or left arm. Sometimes it occurs when people eat or drink, and sometimes it happens in between meals.
Cough – repetitive coughing can be a symptom of reflux when acid or other toxic chemicals escape out of the stomach and irritate the larynx (voice box).
Asthma/breathlessness – a feeling of chest tightness that limits the ability to take deep breaths or breathe effectively is often called asthma. Some patients get asthma-like symptoms from reflux.
Belching/gas trapping – belching, or discomfort relieved by belching is a common symptom with many oesophageal and gastric disorders.
Bitter taste – some patients with reflux-like symptoms complain of a bitter taste in the back of their throat and in their mouth.

What causes Reflux?

Reflux is not something that is supposed to happen frequently in healthy people, and it occurs only when the pressure inside the stomach becomes greater than the pressure keeping the lower oesophagus closed. The five main causes/drivers of reflux are:

Hiatus hernia
Weak lower oesophageal sphincter (valve)
Weak or abnormal oesophageal function (peristalsis)
Oesophageal sensitivity
Gastroparesis (paralysed stomach)

The large majority of patients with reflux experience symptoms but are lucky enough to avoid significant complications. As reflux, unless treated surgically, is a permanent and usually progressive condition, it is worthwhile to consider for each individual affected the potential long-term consequences of the condition.

Reflux Testing & Treatment

When people develop symptoms of reflux or difficulty swallowing (dysphagia) we want to offer them treatment to improve their symptoms but also do tests to determine what the cause of the problem is. If we treat the symptoms but take no action to treat the underlying condition we may miss the opportunity to treat it effectively.

The majority of people who experience “reflux” symptoms try antacids or acid suppression medication prior to having any tests done. If their symptoms don’t improve quickly, if the person is over 50, has anaemia or symptoms of difficulty swallowing (dysphagia) are present, then investigations to rule out serious conditions are worthwhile. No single test is able to diagnose every condition or its severity, so patients with complex problems can sometimes need to undergo several tests before they get an accurate diagnosis or management plan.

Find out more about Reflux Testing here.

Reflux treatment using medications reduces acid but doesn’t reduce reflux. These medications reduce exposure of acid to the oesophagus, but will not change non-acid or weak acid reflux events. They are usually safe however there are a lot of misunderstandings about how they work. These medications reduce the strength of acid that the stomach produces so that reflux episodes can occur without causing discomfort.

Anti-Reflux Procedures (Reflux Surgery)

Endoscopic Surgical Therapies

These work by correcting/repairing the mechanical causes of reflux. The larger the procedure the more effective, but the larger the procedure the more important it is that accurate tests are done in order to avoid overtreatment and side effects.

Find out more about Reflux Treatments and Anti-Reflux Procedures here.

Laparoscopic Surgical Procedures

These all have a lot in common. General anaesthesia, 1-2 night hospital stay, mostly 5mm incisions, and the ability to correct hiatal hernia which is the greatest driver of reflux in most people with oesophagitis (oesophageal ulcers) or Barrett’s oesophagus.

Hiatus Hernia Repair and Hiatus Hernia Repair with Fundoplication

The aim of this procedure is mostly to restore normal anatomy. Most people with reflux have symptoms that progress over years. This progression is mostly due to a gradually enlarging hiatus hernia with more and more stomach delivering more and more acid up into your chest.

To repair a hiatus hernia, the stomach is first pulled back into the abdomen and then the hiatal muscles are tightened to snug around the oesophagus. In those who are identified to have very weak lower oesophageal valves the upper part of the stomach can be wrapped around the lower oesophagus, a “fundoplication”. Wrapping the stomach around the oesophagus creates an additional clasp around it which helps prevent reflux from occurring.

Benefits of Reflux Surgery

People with reflux and oesophageal symptoms are able, thanks to improved diagnostic testing, to get diagnosis and treatment for unpleasant symptoms, even if they have been present for years and endoscopies are “normal”. Endoscopic and surgical therapies for these conditions are safe and effective, as long as appropriate steps have been taken to confirm the diagnosis beforehand.

At Upper GI Surgery we offer sophisticated reflux testing at our main practice in Kogarah, as well as effective reflux (GERD) treatment options.

VIDEO: A/Prof Michael Talbot Membership Highlight Video from The Obesity Collective

Upper GI Surgery — Fri, 20 May 2022 03:25:56 +0000

The Obesity Collective

The Obesity Collective Australia is a platform for individuals and organisations from across the community to tackle the obesity challenge together. Their collective purpose is “to transform the way society thinks, speaks and acts on obesity”, with a vision to “reduce the impact of obesity in Australia”.

Members come from a range of backgrounds and organisations across Australia, including our own A/Prof Michael Talbot. Here’s a quick video of how Dr Talbot is contributing, or if you want to find out more about other members click here.

World Obesity Day 2022 | Everybody Needs to Act

Upper GI Surgery — Wed, 02 Mar 2022 03:00:04 +0000

Today is World Obesity Day, an annual worldwide event held on the 4th of March each year to raise awareness of obesity and challenge change in society to address this growing problem. 800 million people are living with obesity around the world, and together we can be a powerful voice calling for more respect, better care, bold policies and real action.

Each year World Obesity Day has a theme and this year the theme is ‘Everybody Needs to Act’.

Everybody Needs to Act

The key message for World Obesity Day this year is that obesity is a global problem. That the roots of obesity run deep, and the only way to make progress is by working together to tackle the rising rates of obesity (not just in adults, but children too), reduce the stigma faced by those living with obesity and improve the systems that contribute to obesity around the world. Giving everybody the best chance to live longer, happier, healthier lives.

At Upper GI Surgery our team of bariatric surgeons and practitioners, strongly support World Obesity Day and other initiatives such as WIN (Weight Issues Network), also continuously campaigning for people affected by obesity.

Take Action Today

People living with obesity – call for change

Healthcare professionals – show you care

Employers – end stigma

Policymakers – lead the way

Award-Winning Cause

This year’s World Obesity Day campaign has won the Purpose Award for Best Health Cause Campaign, which is fantastic recognition of the hard work that goes into the campaign each year and the awareness that it is bringing to this increasing issue around people’s health.

VIDEO Blog : Robot Assisted Surgery

Upper GI Surgery — Wed, 10 Nov 2021 03:30:53 +0000

Robotic surgery has been growing in popularity around the world for both patients and surgeons; it is providing very real benefits in complex operations while reducing the number of incisions used in some smaller operations. Robotic surgery is a more modern form of keyhole surgery and it is likely that robotic procedures will gradually replace standard keyhole surgery over the next decade. Watch the video from Da Vinci below or find out more on our Robotic Surgery page on the website.

How to stay safe from COVID-19 if you have a weight problem

Upper GI Surgery — Sun, 29 Aug 2021 23:56:56 +0000

People who are overweight or living with obesity that become infected with Covid-19 have a number of issues that potentially make them more vulnerable to severe illness.

Increased adipose tissue increases how much Angiotensin-converting enzyme 2 (ACE2) your body produces. This enzyme binds to the Covid virus and may therefore increase disease severity.
People with weight problems are more likely to have diabetes, high blood pressure, heart disease, respiratory disease (sleep apnoea, asthma, reflux-related lung disease), kidney disease and other conditions that increase risks of causing severe illness from Covid.
People with weight problems are harder to look after in ICU and are more prone to complications when on a ventilator for a prolonged time.
We now know that people carrying extra weight are also far more likely to die after a covid infection.

So, what can be done about this?

First up, it’s important not to let fear dominate our lives, as that gets in the way of living. It is possible however to use legitimate concerns as a “call to action” to improve not just our health as it relates to Covid but our health overall. Experts have a number of suggestions that will help.

Get vaccinated. Any vaccine is ok for a very large number of people over the age of 20. The risks of the AZ vaccine that everyone is concerned about have been massively blown out of proportion, this has led to people taking bad advice which has led to preventable illness and death.
- If we vaccinated the whole Australian population in 2 weeks with the AZ, we would get around 25 vaccine-related deaths and around 50-100 ICU admissions. In NSW alone we have had a tiny percentage of the population infected with COVID leading to many ICU admissions and an increasing death rate. It’s likely that almost all these ICU admissions and deaths would have been avoided had the people affected had the AZ vaccine.
- 25 people die every week crossing the road in Australia and about 60 people a week from suicide. Clearly, the risks of vaccination need to be understood in this context.
- We should, as adults, be more concerned about our children’s welfare. Every time someone over the age of 50 has a Pfizer COVID vaccine they are effectively preventing a dose from being available for a child or adolescent, and it’s clear that they won’t get their schooling, friends and future opportunities back until they are vaccinated.

Take social isolation and personal hygiene seriously and ensure that those around you do as well. Official government guidelines have been consistently accurate for the last few weeks, and they do a far better job to inform us of the steps we need to take than what may pop up from unofficial sources and armchair experts.

Ensure your medical conditions are optimally controlled. Now is a perfect time to get in touch with your GP and get a check-up.

Work on your fitness. This will improve respiratory health, reduce your blood pressure and help control your blood sugars.

Eat well and avoid snacking. If you are eating more than 3 times a day you are highly likely to be gaining weight. Calorie containing drinks (milky coffee, alcohol, juice etc all count as snacks). Weight gain increases stress on all your body’s vital functions if you are overweight.

Consider short or long-term weight management strategies. While many traditional weight management options are not available during this time there are things you can try that can work well. Losing 5-10% of your weight can have profound effects on many illnesses if you are carrying too many kgs.
- Very Low-Calorie Diets (VLCD) such as Optifast ™. These high protein/low carbohydrate meal replacements can replace 1-2 meals a day to promote weight maintenance, or 2-3 meals a day for rapid and safe weight loss.
- Intermittent fasting. The 5:2 diet whereby you fast 2 days a week or the 16:8 diet where you only eat or have calorie-containing liquids for 8 hours a day are options that may work while our new routine is in “lock-down”.
- Medically supervised options. These are more complex and rely on a mix of exercise, dietary change and VLCD. There are also several new and very effective weight-loss medications available that can help people lose up to 15-20 kg (10-15% of starting weight).

While bariatric surgery has been proven to provide a sustained weight loss greater than 5-10 times what can be achieved with the methods above, there are many people who may not wish to do this during the Pandemic. Now however could be a good time to consider a long-term weight management plan that could help protect you from this and other dangerous health problems in the future. Our offices are open to offering medical advice to people with a weight problem or people who have had previous weight-loss surgery to help keep them safe during this time.

A/Prof Michael Talbot

SCOPE Certified – what does it mean & why is it important in bariatrics

Upper GI Surgery — Thu, 22 Jul 2021 05:50:06 +0000

Recently, Dr Jennifer Matthei joined Dr Georgia Rigas as a SCOPE Certified bariatric practitioner. The SCOPE Certification is the international standard of obesity management expertise, recognising excellence in obesity. The SCOPE Certification is part of the World Obesity Federation, whose mission is to reduce the global burden of obesity and the understanding of obesity as a multifactorial disease. The WOF is also working hard to combat the stigma associated with obesity.

Who is eligible for the SCOPE Certification? The SCOPE Certification is the only internationally recognised certification in obesity management. If a healthcare professional wishes to become certified, they have to meet the following criteria to apply:

Evidence of 6 months practical experience related to obesity management within a medical or allied healthcare professional setting.
Completion of the Core Learning Path (4 SCOPE points).
To achieve certification, 12 SCOPE points are required in total. The remaining 8 points can be achieved through e-learning with SCOPE Schools or other SCOPE Accredited courses.

In addition to their busy days as Bariatric Medical Practitioners here at Upper GI Surgery, both Dr Rigas and Dr Matthei have had to complete additional learning and training in their spare time towards achieving this certification.

The certification is renewable annually, by completing two additional SCOPE modules.

Why is this important?
SCOPE certified practitioners have access to an international community of obesity experts and credible and up-to-date obesity education materials developed by leading experts in the field. Obesity and bariatric surgery is a very specialised area of expertise, and at Upper GI Surgery all of our medical team ensure that they are up-to-date with the latest information to use when treating patients.

Supporting you on your Fresh Start

Upper GI Surgery — Tue, 20 Apr 2021 00:01:16 +0000

At Upper GI Surgery, we want to make sure that you receive as much support as possible after your bariatric surgery. In addition to our already comprehensive after-care program, patients will now be receiving access to Fresh Start Online as part of their surgical package. This is a 2-year support, education and lifestyle coaching program, specifically designed with bariatric surgery patients in mind.

Fresh Start Online includes a wide range of program elements and resources specifically designed to enhance your surgical experience and to help you to to create and sustain a new healthy lifestyle.

Fresh Start is brought to you by an experienced, qualified and professional coaching team, to help you to achieve long-lasting health and weight results.

It’s designed to assist you in:

Getting clear on exactly what you want to create in terms of your health and weight;
Create a new supportive identity for yourself that will support your success;
Break stubborn habits, such as emotional eating, and self-sabotage if they do come up;
Learn smart strategies around stress management, nutrition and movement; and
Feel confident and inspired about the future.

Want to know more? Watch the video below to find out more about the program:

This program is included in the surgical package of all new patients of Upper GI Surgery and past-patients can access it at a significantly reduced price. If you would like to find out more, check out our Fresh Start page or speak to our team today who will be able to help.

Weight Issues Network 2020 Report

Upper GI Surgery — Wed, 10 Mar 2021 02:52:39 +0000

It was in 2019 that we first shared our involvement with Weight Issues Network (WIN), an Australian network created to “provide a strong voice and support for people living with and affected by obesity”. WIN actively seeks participation in their surveys from people affected by obesity, and then share their findings with the public. All of this information comes from members and volunteers who choose to participate.

We have reached out via our blogs, newsletters and social media to encourage those that follow us to participate and join WIN, as we believe the work they are doing is making a difference. WIN recently released their 2020 Report – The Personal Costs of Weight Issues in Australia.

This important report highlights the perspectives of those who are living with the challenges of overweight and obesity. Obesity is much more complex than “eat less and move more” or a simple matter of lifestyle choices. This report is designed to help raise awareness of not only the complexities of obesity but challenges around weight stigma, the impact of the environment and navigating the Australian health system.

Summary of WIN Report Recommendations

Weight stigma needs to stop. The lived experience and perspectives of those living with overweight or obesity to be included in the development of plans and strategies, the design of treatment paths and research, and debates on weight issues in a person-centred approach.
Improve clarity and reduce barriers to better health. Making obesity training mandatory in areas such as health and social care service education. Making effective, evidence-based treatment options affordable and accessible across Australia.
More supportive environments in society. Government making healthy food cheaper and easier to access, particularly in low income and remote areas. Investing in green spaces, education and a regulation in terms of ‘junk food’ marketing, particularly to children and younger people.

In the coming months we will explain each of these areas in more detail in a series of blogs, but in the meantime if you would like to read or download the full report you can here.

World Obesity Day 2021

Upper GI Surgery — Wed, 03 Mar 2021 23:00:44 +0000

World Obesity Day takes place annually on the 4th of March. The global theme this year is:

“Every Body Needs Everybody: Bringing together the global community, we’re working towards building happier, healthier and longer lives for everybody.”

The mission of World Obesity Day is to:

Increase Awareness – raising awareness that obesity is a disease and improving understanding of its root causes and how to address them.

Encourage Advocacy – changing the way obesity is addressed in society, encouraging people to become advocates by standing up and calling for change.

Improve Policies – creating a healthy environment that prioritises obesity as a health issue. Working to change policy to build the right support systems for the future.

World Obesity Day encourages everybody to get involved, from the general public to health professionals. Encouraging people to Learn about obesity (know the facts), Support the campaign (use your voice), Share your story (have your say). Whilst also encouraging health professionals to Share your story (people), Understand obesity (know the facts), Join the community (advocates).

If you’re wanting to learn more about obesity, you can download factsheets to gain a deeper understanding of obesity and its roots, or read real-life stories and experiences that people have shared.

Obesity Advocates

Advocates are encouraged to Share your story (have your say), See what’s happening (events near you), and to Read the declaration (Obesity and COVID-19). Obesity organisations around the world are advocating for national and global policy changes to address the root causes of obesity. The ‘ROOTS’ Framework provides suggestions for obesity policy and advocacy that can be adapted to different national settings. It has been developed with the input of obesity experts and organisations across the globe.

R – Recognise Obesity

O – Obesity Monitoring

O – Obesity Prevention

T – Treatment

S – System Based Approach

For more information about World Obesity Day or to get involved, visit their website World Obesity Day.