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

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.

Have you noticed that your weekly shopping costs seem to be slowly increasing once you reach the checkout? According to Forbes, the federal government and Reserve Bank have forecast that inflation in Australia will peak at 7.75% in the December quarter of 2022. As a patient who has undergone bariatric surgery, it’s important that you continue to eat a healthy diet by avoiding processed foods which will stimulate hunger and make you gain weight.

Today we’re going to give you a few tips on how you can continue to eat healthily every day and maintain your post-bariatric surgery diet, even on a limited budget.

Making larger portions…

After bariatric surgery, one of the main focuses of meals is portion size. You may find now that you are eating much smaller portions than you were before. But you can still make these larger portions, just make use of them in different ways. It’s often cheaper to buy things in bulk and cook meals in bulk. 

• Freezer-friendly meals – freeze meal sizes portions. This will also help during times when you may have no healthy food in the house; rather than ordering a takeaway, simply defrost a healthy meal from your freezer. 
• Lunches – you can always use a smaller portion of your meal for lunch the next day. 
• Re-purposing – be smart with your leftovers, and use them in creative ways. Such as leftover chicken being used in a stir fry or salad the next day. 

Stay away from discretionary foods…

Another very easy way to keep the costs down is to think very carefully about buying discretionary foods that you really shouldn’t be eating anyway (think chips, snacks etc). If you don’t have these sorts of foods in the house then you won’t be tempted by them. They are generally more expensive than buying healthier foods anyway so should be avoided. 

Another quick tip is to avoid going food shopping on an empty stomach! This is not a myth; you are much more likely to succumb to picking up food products that don’t align with your diet if you are shopping when hungry. 

And finally, your liquid diet… 

Really, the only drink that you need to consume when following a post-bariatric surgery diet is water. If you are only consuming water as your drink, you are avoiding spending unnecessary money on juices, coffee, and soft drinks (even if they are sugar-free versions), which can help to lower the total at the checkout. 

As well as creating our own content around the topic of obesity and life-changing treatment, we are constantly exploring others’ ideas and opinions. We discovered an article, A Sad Tale of 2 Bypass Surgeries, that has an interesting way of demonstrating the inequalities of healthcare systems and treatment options for those living with obesity. Treatment that would provide not only a longer life, but better quality of life.

Here’s a quick summary of the article: 

Operation C – More than 200,000 people have these surgeries done every year. Between one and three percent of patients die before they leave the hospital. Typically, they’ll spend a week in the hospital. Recovery usually takes between six weeks and three months.

Operation G – A fraction of those who could benefit – about 41,000 – have this procedure each year. It extends life and reduces the risk of heart attacks, diabetes, and certain cancers. It improves quality of life dramatically. Most patients stay in the hospital for only two or three days. Recovery typically takes three to five weeks. Deaths occur in less than 0.5 percent of patients in the first 30 days after the operation.

You’re asked to guess which procedure is which; “In case you haven’t guessed, Operation C is heart bypass…

The tale of these two bypass surgeries is sad indeed. Blame and shame get in the way of preventive care for obesity that could reduce the need for heart procedures down the road. Fear and a dysfunctional healthcare system lead people to wait until they feel their life is on the line. Then they have a costly and risky heart procedure that offers little or no benefit.” 

Nearly a million Australians (aged 18 and over) had type 2 diabetes in 2017 – 2018 (ABS). This information is only based on self-reported data, so is likely to underestimate the real prevalence of this disease. Type 2 diabetes is a complex condition in which the body becomes resistant to the normal effects of insulin, and the pancreas gradually loses the capacity to produce it. 

Type 2 diabetes develops over a long period of time (many years). As the body’s insulin becomes increasingly ineffective at managing glucose levels in the blood, the pancreas responds by producing more insulin to manage blood glucose levels. Overproduction over a long period of time essentially causes the cells in the pancreas that produce insulin to ‘wear themselves out’. Type 2 diabetes presents itself as a combination of both ineffective insulin and insufficient amounts of insulin. 

If you have type 2 diabetes, are living with obesity and would like to know more about weight loss surgery, and if you are a suitable candidate, then please contact our practice on (02) 9553 1120 to arrange an appointment with one of our specialists. 

If you’ve recently had bariatric surgery or are considering bariatric surgery as a way to lose weight, today we are going to explain the three distinct phases of weight loss following surgery. Each phase requires different advice to ensure that patients are not only going to recover well from their surgery, but also achieve optimal weight loss and health throughout every stage of their journey. 

While every person is different, after surgery we want the focus to be on healthy and sustainable eating and exercise habits. Maintaining weight loss is only possible by the proper management of nutrition by eating healthy food and taking vitamin supplements. Having regular follow-ups with the team helps us meet your health needs more effectively.

Until you have healed internally (typically approximately a month after surgery), eating solid food will be uncomfortable and can potentially cause injury. Therefore nutrition in order of importance is fluid intake, protein, fibre and vitamins. Firstly liquids, then purees, then soft food.  

It is important to keep hydrated so you should be aiming for over 1 – 1.5 litres of fluids per day, including any fluid-like foods (e.g. soup). If you’re consuming any less than this you risk dehydration which will cause nausea, and you will not be discharged from the hospital until you have shown you can drink this much. 

A minimum of 25 grams of protein is needed for health, but aiming for 50 + grams is the aim once you can manage it. Protein supplements can help if you are falling behind. Liquid fibre supplements or gentle stool softeners will prevent constipation and we also start you on chewable multivitamins at this point. But fluid and protein are more important for how you recover at this very early stage. 

Around the 3 – 4 week mark you will be able to start consuming soft foods, but before then you will rely on liquid foods like yoghurt (available with added protein), soups, protein drinks and purees for main meals.  

The habits that you establish during the weight loss phase post-bariatric surgery will assist you in creating the lifelong changes that are needed for long-term weight maintenance in the next phase. 

Key areas contributing to weight loss during this phase: 

Regular meals – sticking to three meals a day (usually two simple and one complex meal). It’s important to establish a meal eating routine that works for you and stick to it, this will help you avoid grazing and snacking which will hinder your weight loss or lead to weight regain in the future. For example if you go to bed late, don’t have your evening meal early, as you are more likely to eat again (snack) before you go to bed. Sticking to regular meals and eliminating snacks leads to significant weight loss. 

Avoiding liquid calories – although liquid calories are important in the weeks immediately after your surgery, once you can consume solid foods again the only liquid foods should be soups or meal replacement drinks. Fizzy drinks, milkshakes, and milky/sugary coffees are all high in calories and low in nutritional value and should be avoided, as they will hinder weight loss. 

Regular exercise patterns – Complex exercise is mostly pointless in the immediate and early post-op period, but daily exercise “activities” such as walking are essential. From 2 weeks post-op it’s ok for most people to do simple treadmill/stationary cycle exercise and light (1-2kg) weights in addition to walking. Aqua aerobics is also ok to start after this time as well. Gradually increasing intensity of exercise and the amount of “resistance” in exercise is appropriate but we generally tell people to stay away from “endurance” or “bulking” regimens until at least 6 months after surgery, otherwise there are risks of injury, excessive loss of body protein and immune function, or risks of interfering with your weight loss trajectory.

Exercise is crucial!

Weight loss will have created a host of exercise opportunities that were not previously available to you. If you are not undertaking a minimum of 2 hours, and preferably around 4 hours every week of exercise activity, above your normal weekly routine then you can expect problems with your weight and health to occur at some stage. We recommend a mixture of aerobic and resistance work. While aerobic exercise such as brisk walks, cycling and swimming are easily available to most people, resistance exercise such as light weights, aerobics/aqua aerobics, yoga and pilates takes more planning so this needs to be an intentional part of your schedule.

After around three years post-surgery the majority of patients will find that they experience some sort of weight gain – this is completely normal. That’s why it’s critical that if you have gained weight, to seek help from the team who will be able to support you with the right tools to get you back on track. Losing weight following bariatric surgery is challenging, but the biggest challenge is creating new lifestyle habits and sticking to them long-term. 

If you’ve visited the weight loss surgery section of our website or followed us on social media, you have probably encountered the promotion of our Bariatric Surgery Information Webinar. If you or a loved one are living with obesity and considering bariatric surgery as an option to help lose weight, this informative webinar is a great place to start. 

The live webinar is split into two main sections; the first is a short presentation (around 30 minutes) given by one of our bariatric surgeons, who will then answer any of your questions during the second part of the webinar (usually another 15 minutes depending on the number of audience questions). 

Here’s a quick insight into what you can expect to learn during our free Bariatric Surgery Information Webinar. 

How does weight loss surgery work? 

Next, we explain how bariatric surgery works. Weight loss surgery can’t change your genes, but it can help you to change your appetite and eating habits. Over time all procedures become less powerful, which is why it is important that we work with our patients to learn new skills, centred around portion size, reducing meal frequency and reducing calorie density. 

Bariatric Surgery Options

The final section of the presentation explains in more detail the different bariatric surgery types; from the most popular sleeve gastrectomy, to the different forms of gastric bypass and the less common gastric band procedure. This helps you to gain a better understanding of each of the procedures, how they work, and potential side effects and risks. 

Q&A Section

After absorbing so much information, you’re sure to have some questions by the end of the presentation. Or maybe you already had some questions in mind and have come prepared beforehand. This is your opportunity to ask one of our bariatric surgeons your own specific questions and get answers straight away. Don’t worry you don’t have to speak up in front of everyone attending, you can simply send a message over the Zoom chat function. 

We run our Bariatric Surgery Information Webinar sessions once a month, at 7.30pm via Zoom on the first Tuesday of the month. If you think that you would benefit from joining our next webinar, you can click here to register and you will be sent the Zoom invite details as well as a copy of A/Prof Talbot presenting the webinar after you attend.

It’s very easy to consume more calories than you may expect throughout the day. Whether you’re picking at your children’s food while you’re preparing their lunches, having a sneaky teaspoon of sugar in your morning coffee or having a nice cool refreshing can of soft drink on a summer’s day. Today we will be exploring the latter; soft drinks. Did you know that a 2-litre bottle of Coca Cola contains around 800 calories and a whopping 220g of sugar? That only takes around 6 – 8 glasses of coke a day… 

Drinking your calories in a day aside (let’s not forget other culprits like creamy or iced coffees, milkshakes or alcohol), there is another reason why you should be avoiding soft drinks when you have had bariatric surgery. 

Early after surgery, soft drinks (or other fizzy drinks like seltzer, beer, and fizzy water) will make it more difficult to consume foods and other liquids (such as water, which is incredibly important for keeping hydrated). Although the aim of bariatric surgery is to reduce the volumes of food, it is important to ensure that you are gaining sufficient nutrition through the smaller volumes of food that you are able to consume, so avoiding fizzy drinks during this time is crucial. If you use fizzy drinks as a way of “pushing” food through your stomach you may cheat yourself out of weight loss.

If you are eating and drinking at the same time, you may fill up to fast and not finish your meal, which can lead to people wanting to graze and snack. Drinking after you eat can push food through and sometimes make it easy to eat more than what you need! If you find yourself both thirsty and hungry at the same time, have a drink (low calorie) first, as drinking with a full stomach may be difficult.

Regular consumption of carbonated drinks also bathes your teeth in acid which will vastly speed up tooth decay, regardless of what else is in the drink.

Try to avoid…

Energy drinks – these are often fizzy drinks and are usually high in sugar. Even if they are ‘sugar-free’ versions they are typically high in caffeine, and the high levels of sweetener will keep you “hooked” on excessively sweet foods. 

Soft drinks – you should avoid soft drinks with sugar altogether as it is an easy way to consume a higher number of calories than you should post-bariatric surgery. Even sugar-free soft drinks should be avoided, as they are often over-carbonated and over sweetened. If you have a craving for fizz, either let the drink go flat or pick up a sodastream ™ machine which can create a non-explosive, and slightly more interesting version of plain or flavoured water. 

Alcohol – check out our blog about Alcohol & Weight Loss for more information. Alcohol is a “triple threat” to weight loss surgery, it’s high in calories, it’s a potent appetite stimulant and it promotes poor (high energy) food choices.

We hope that you have found our blog about soft drinks useful today. If you are interested in bariatric surgery and would like more information please contact our practice to make an appointment by calling (02) 9553 1120.