The disease of obesity and the need for bariatric physicians


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Obesity is probably unique amongst grave medical diseases that it fights with “cosmetic” disorders for attention of public, patients, policy makers, and medical fraternity. Though it is now officially recognized by American Medical Association as a disease, perceptions on the ground remain unchanged and many other national societies are lagging behind. At a time, when world is going through an obesity pandemic, patients suffering with this disease are not recognized as such, do not have a dedicated group of medical specialists looking after them, and find it difficult to get funding for their treatment from both public sector as well as the insurance mechanisms. The response of professional and patient groups, insurance companies, and governments can at best be described as patchy so far. This article makes a case for obesity to be formally recognized in India as a disease and the need for healthcare practitioners in India to develop the specialty of bariatric physicians to look after patients with this disease.

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The disease of obesity and the need for bariatric physicians

  1. 1.                                                                                                   The                                      e disease        of obesit ph ty and the hysicians      e need forr bariatricc
  2. 2. Review Article The disease of obesity and the need for bariatric physicians Kamal K. Mahawar a,b, * a Senior Consultant, Bariatric and Metabolic Surgery, Indraprastha Apollo Hospital, New Delhi, India b Honorary Consultant Surgeon, Sunderland Royal Hospital, Sunderland SR4 7TP, United Kingdom a r t i c l e i n f o Article history: Received 21 April 2014 Accepted 2 May 2014 Available online 27 May 2014 Keywords: Obesity Obesity surgery Obesity in India Bariatric physician a b s t r a c t Obesity is probably unique amongst grave medical diseases that it fights with “cosmetic” disorders for attention of public, patients, policy makers, and medical fraternity. Though it is now officially recognized by American Medical Association as a disease, perceptions on the ground remain unchanged and many other national societies are lagging behind. At a time, when world is going through an obesity pandemic, patients suffering with this dis- ease are not recognized as such, do not have a dedicated group of medical specialists looking after them, and find it difficult to get funding for their treatment from both public sector as well as the insurance mechanisms. The response of professional and patient groups, insurance companies, and governments can at best be described as patchy so far. This article makes a case for obesity to be formally recognized in India as a disease and the need for healthcare practitioners in India to develop the specialty of bariatric physicians to look after patients with this disease. Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction We are living through a pandemic of obesity.1,2 Worldwide, the prevalence of obesity has nearly doubled since 1980 and in 2008, more than 1.4 billion adults, 20 years and older, were overweight. Of these over 200 million men and nearly 300 million women were obese. It is estimated that 65% of the world’s population live in countries, where being overweight and obesity kill more people than being underweight.3 It is undoubtedly the most significant public health issue of this century globally. In some Western countries, more than a third of the population is obese4 and up to 80% of population is either overweight or obese, leaving the “normal” weight peo- ple behind in minority. Modern living with its impact on calorie balance has not spared developing countries like India either.5e8 A recent study of 5 major cities in India9 found that the prevalence of obesity was 6.8% and 33.5% people were overweight. The problem was worse amongst women. In some part of India, authors found that 11%e29% of adoles- cents were either overweight or obese. Authors concluded that, “Obesity, overweight, central obesity and sedentary behavior coexist with under-nutrition, and have become a public health problem in cities of India”. Another recent study10 of 12e18-year-old girls in an urban English medium school found that 28.5% of the girls were overweight and 4.2% were obese. Overweight and obesity are rapidly becoming a major healthcare challenge for the middle and upper classes in urban India.11 * Sunderland Royal Hospital, Sunderland SR4 7TP, United Kingdom. E-mail address: Available online at ScienceDirect journal homepage: a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. American Medical Association has now recognized that obesity is not simply a lifestyle condition, it is a disease12 and living with it has consequences.2,13 At least 2.8 million people die every year globally as a result of being overweight or obese and an estimated 35.8 million DALY (Disability Adjusted Life Year) are lost of being overweight or obese.14 Childhood obesity is a particularly worrying problem.10,11,15,16 Rates of childhood obesity have increased more than threefold in the last 30 years. More than 40 million children under the age of five were overweight in 2011 globally.3 Given the scale of problem, it is indeed surprising that obesity struggles to be recognized as disease, has no dedi- cated medical specialty to look after the patients, govern- ments have largely turned a blind eye to it, and the most effective treatment for some obese patients (bariatric sur- gery) has to fight for the attention of wider medical frater- nity, policy makers and insurance industry. This article reviews how obesity is fighting for attention as a disease and the need to introduce and develop a new specialty of obesity special bariatric physicians in India to look after obese pa- tients who have some very complex needs. We also examine the skill set that such bariatric physicians will need to possess. 2. Obesity: a disease? 2.1. Obesity: not a cosmetic or lifestyle condition For many patients, the serious adverse health consequences of obesity will appear later in life, but the adverse cosmetic effects are present then and there. It is hardly then a surprise that this is the aspect, which worries many patients more than the ill effects of obesity on their health. Apart from its obvious impact on quality and quantity of life, obesity also leads to psychological and social issues, sexual and marital problems, loss of confidence, work place stigma, unemploy- ment, and economic difficulty. The causes of this disease, like many other diseases known to us, may lie in personal lifestyle choices that an individual makes but this cannot be an excuse to not treat these patients. For example, medical fraternity does not think twice before treating patients with diseases that result from other lifestyle choices like smoking, alco- holism, traveling, and sexual choices. T2DM and coronary artery disease, which result from a lifestyle similar to obesity, can also come in the category of so-called lifestyle diseases. But when it comes to obesity, a large number of medical practitioners are happy not addressing the problem and lett- ing patients live with its adverse health consequences. It would have been acceptable, if there were no effective treat- ment available. That is fortunately not the case with obesity and there are good treatments available for patients across the spectrum of this disease. 2.2. Definition of a disease and where obesity stands Before we examine whether or not to call obesity a disease, we must first understand what do we actually mean by “disease”. World Health Organization has defined “health” as, “a state of complete physical, social, and mental wellbeing and not merely an absence of disease or infirmity.” It has, however, not defined disease in such clear terms. That is because it is not easy to define disease.17 History is replete with examples where conditions seen as part of normal living (like osteopo- rosis) are now recognized as disease and conditions treated as diseases in past (like homosexuality) are now accepted as a normal way of living.17 It will not be important to talk about such labeling, if our views and notions did not develop around these labeling. Recognizing an adverse health condition as a disease means that sufferers are recognized, treated, and financially reimbursed for their ill health. It has some very serious implications for these people. It portrays them as the victim of the disease, rather than perpetrators. American Medical Association has defined disease as an impairment of the normal functioning of some aspect of the body. Dictionary definition of “disease” is “a disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors; illness; sick- ness; ailment”.18 Another dictionary19 has defined it as “A disorder of structure or function in a human, animal, or plant, especially one that produces specific symptoms or that affects a specific location and is not simply a direct result of physical injury”. Yet another popular dictionary defines it as “a con- dition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms”. Let us try and examine “obesity” against these definitions. It definitely does not result from injury. Accumulation of excess fat impairs functioning of a number of organ systems in human body, like liver, pancreas, kidney, etc. Though obesity can be asymptomatic in early stages (just like hyper- tension and T2DM), most patients will eventually develop a number of complications in due course and die pre- maturely.19e21 In terms of clinical signs, this is one of those very few diseases where signs of the disease are obvious to anyone who can look at the patients and confirmed by a simple scale. According to the Centers for Disease Control and Preven- tion in United States of America, health consequences of obesity include coronary heart disease, T2DM, hypertension, cancers (endometrial, breast, and colon), dyslipidemia, stroke, liver and gallbladder disease, sleep apnea and respiratory problems, osteoarthritis, and gynecological problems (abnormal menses, infertility). Cost of looking after obesity and its associated problems runs into hundreds of billions of dollars globally.22 It is also the commonest cause of metabolic syndrome and conditions like benign intracranial hyperten- sion, acid reflux etc. However, the important fact to note is that in early stages, many of these adverse health conse- quences can be controlled and even reversed, if obesity is managed successfully. In late stages, when end-organ damage has already taken place, changes may be irreversible and it will shorten the life of the sufferer by a period ranging from years to decades.20,21 Childhood obesity is another worrying aspect of this pandemic. It is associated with a higher chance of obesity, premature death and disability in adulthood. Obese children experience poor self-esteem and adverse psycho- logical effects, breathing difficulties, sleep apnea, increased a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9104
  4. 4. risks of fractures, hypertension, early markers of cardiovas- cular disease, and insulin resistance.3 By not formally recognizing obesity as a disease, we are simply living in denial. It is the biggest healthcare challenge of this century and denying its existence will not make it disappear! 2.3. Obesity: similarity with Type 2 Diabetes Mellitus It is clear from the preceding paragraphs that obesity is truly a disease. In fact, it is a multi-system disease. The closest analogy one can think of in this context would be Type 2 Diabetes Mellitus (T2DM), of which obesity is also the com- monest cause. Like T2DM, diet has a major role to play in its causation and management. Like T2DM, uncontrolled obesity results in a number of complications. Like T2DM, obesity management needs close dietetic support. Like T2DM, patient suffering with advanced obesity needs a number of specialists for management. Like T2DM, it is a significant burden on healthcare resources. Like T2DM, there is currently no “cure” available for it. And finally, like T2DM, surgery is the most effective of all the currently available treatments in inducing prolonged remission. However sadly, unlike T2DM, we don’t have any dedicated physicians looking after these patients. Unlike T2DM, awareness amongst public and healthcare professionals regarding disastrous health consequences of obesity is very low. Unlike T2DM, it does not struggle to be called a disease and unlike T2DM, many healthcare pro- fessionals are happy to let their patients live with it. 2.4. Obesity: bariatric physicians Currently, bariatric surgery is the only dedicated medical specialty that caters specifically to obese patients. It is neither feasible, nor desirable, that bariatric surgeons should deal with the obesity pandemic on their own. Majority of over- weight and obese patients do not qualify for surgery and should be managed by somebody else. Currently, no single health practitioner possesses all the skills and knowledge required to look after patients with this very complex disease. It is hence hardly surprising that patients are not looked after properly and usually allowed to live with their disease and its consequences. There is an enormous need to develop specialist obesity physicians globally and clarify the re- sponsibilities of such a role.23e27 Even though this idea has been going around for a while and gets sporadic mention in scientific literature, there has been little progress in this field and the wider medical community has been rather slow to address this need. United Kingdom has taken lead in this di- rection with Royal College of Physicians now recommending such obesity champions in each and every hospital.28 Table 1 summarizes the recommendations from the Royal College regarding such obesity specialists. Progress in India, under- standably, has been rather slow, as obesity is only now beginning to rear its ugly head here. Endocrinologists are best suited for this role,23,28 but it not likely that they will be able to cope with the demand on their own. In Indian context, many general practitioners already manage less complicated dia- betes patients on their own, with support from endocrinology colleagues. There is no reason why the willing ones could not also take on the role of specialist obesity physicians or bar- iatric physicians. 2.5. Obesity: roles and responsibilities of a bariatric physician Becoming a specialist in obesity management or “Bariatric Physician” is a unique, complex role with challenging needs. Training in this area has been inadequate in the past and there will be need to develop training courses for clinicians wishing to develop this role. A dedicated bariatric physician will need following skills. 2.6. Bariatric physician: able to diagnose obesity and its complications It is obvious that a bariatric physician will need to be able to diagnose obesity. Though there is some debate amongst pro- fessionals regarding the best indicator of an individual’s adiposity and severity of obesity, BMI (Body Mass Index) is by and large the most commonly used indicator for this purpose. Table 2 gives widely accepted World Health Organization and South Asian BMI cut-offs for diagnosis of obesity. Waist Circumference and Waist:Hip Ratio are other useful in- dicators. Men, whose waist circumference is greater than or equal to 94 cm (90 cm for Indians) and women with a waist circumference of greater than or equal to 80 cm, have a higher risk of metabolic complications. Risk is substantially increased for men with a waist circumference of more than 102 cm and women with a waist circumference of more than 88 cm. A Waist Hip Ratio (WHR) of >0.9 in men and >0.85 in women is indicative of significant abdominal fat accumula- tion and substantially increases the risk of metabolic com- plications. Finally, a new system of classifying obesity “Edmonton Obesity Staging System” has been developed (Table 3) to classify patients according to the severity of their disease.29 Bariatric physicians should be able to identify secondary causes of obesity and treat them accordingly. Since obesity is a multi-system disease, bariatric physicians should keep a close Table 1 e Guidance from Royal College of Physicians (UK) on specialist obesity physicians. 1. There is a need to establish a subspecialty of obesity medicine for physicians. The terms ‘bariatric medicine’ and ‘bariatric physician’ are proposed. 2. The subspecialty should be within the umbrella of diabetes and endocrinology, although this does not preclude physicians with other primary specialties from developing subspecialty recognition in bariatric medicine. 3. A core curriculum and relevant experience for accreditation in this specialty is needed. 4. Physicians specialized in bariatric medicine will provide local leadership in the planning, provision, and delivery of obesity treatments, within secondary care, and in collaboration and partnership with primary care. a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9 105
  5. 5. eye on their patients for a number of complications affecting various organ systems that are associated with this disease. Focus should be on diagnosing them early and managing them appropriately. Optimum management of some of these complications may need help from other specialists. 2.7. Bariatric physician: aware of management options Not only do many healthcare professionals not realize that it is dangerous to live with obesity, they also feel that sufferer can easily correct the situation if they had sufficient “will power”. Placing responsibility solely on individuals in this way, when we have a pandemic at our hands is extremely unfair and also ineffective. There is little doubt that diet, ex- ercise, health education, and behavioral counseling play pri- mary role in the prevention and management of obesity. A bariatric physician should have an in-depth knowledge of nutrition and the role of diet and exercise in weight loss. A bariatric physician should know general principles of healthy eating and what constitutes a “good balanced diet”. It is not rocket science to know that one should i) control overall cal- orie intake; ii) limit energy intake from fat, simple sugars, fried snacks, sweets, and liquids (juices, soft drinks, and milk); iii) increase consumption of water, fruit and vegetables, legumes, whole grains, egg white, and lean meat; and iv) engage in regular physical activity (at least 60 min a day for children and 150 min per week for adults) to correct calorie imbalance. Bariatric physician must set “realistic” targets with these in- terventions to avoid discouraging patients. A target of 0.5e1.0 kg weight loss on a weekly basis is widely considered acceptable. It should also be appreciated that developing a healthy lifestyle has a much bigger role in prevention of obesity than its treatment. A number of medical and surgical interventions are available to help obese individuals, who have failed to lose and maintain sufficient weight on conservative management with diet, exer- cise, and behavioral counseling alone. Bariatric physician should be fully aware of the indications, advantages, disad- vantages, complications, and expected results of pharmaco- logical, endoscopic, and surgical interventions available for treatment of obesity. Amongst currently available treatments, pancreatic lipaseinhibitor“Orlistat”isthe onlypharmacological agent and “Gastric Balloon” is the only endoscopic device available for routine use. Gastric Balloon is only licensed to be usedfor a singletreatmentperiod of6 months. Patients typically achieve a weight loss of approximately 15 kg during this period,30 some of which is maintained even up to 5 years later.31 It is, however, not uncommon for patients to remain unsuc- cessful despite optimum conservative, pharmacological, and endoscopic management. For such patients, options are either to undergo surgery or live with their obesity and its conse- quences. It is not always realized that for patients who meet guidelines for surgery,32,33 surgery is not only the cheaper option34e36 butalsomuchsaferandhealthier.37e39 Risksofliving with obesity, for these patients, are much higher and the cost of surgery is recovered as early as within 2e3 years after surgery. There is a deep-rooted misconception that risks of this surgery are higher than living with obesity. Healthcare pro- fessionals don’t think twice before recommending coronary artery bypass surgery for patients with coronary artery dis- ease, which is probably riskier than obesity and metabolic surgery and probably less beneficial, but when it comes to bariatric and metabolic surgery, many patients and health- care professionals consider the risks to be prohibitive. It is not commonly realized that major complication rates and mor- tality with obesity surgery is probably lower than other commonly performed like laparoscopic cholecystectomy, in the hands of high volume dedicated bariatric surgeons.40e45 Perioperative mortality with bariatric surgery is fortunately a very rare event and the benefits in terms of weight loss, co- morbidity resolution, and improvement in quality of life, of bariatric surgery are now firmly established in scientific medical literature. 2.8. Bariatric physician: knows good bariatric surgeons in area Bariatric physicians should be aware of local33 and interna- tional32 guidelines for bariatric surgery (Table 4). For eligible patients, bariatric surgery is the most effective treatment and a bariatric physician should refer these patients to a “good” bariatric surgeon in their area. It should be realized that Table 2 e Diagnosing obesity. International Classification of Obesity BMI 25.0e29.9 (Pre-Obese or Overweight) BMI 30.0e34.9 (Obese Class I) BMI 35.0e39.9 (Obese Class II) BMI 40.0 (Obese Class III) Classification of Obesity for Indians/South Asians BMI 23.0e27.5 (Pre-Obese or Overweight) BMI 27.5e32.5 (Obese Class 1) BMI 32.5e37.5 (Obese Class II) BMI 37.5 (Obese Class III) Table 3 e The Edmonton obesity strategy system. Stage 0 No apparent obesity-related risk factors (e.g. blood pressure, serum lipids, fasting glucose, etc. within normal range), no physical symptoms, no psychopathology, no functional limitations, and/or impairment of wellbeing Stage 1 Presence of obesity-related subclinical risk factors (e.g. borderline hypertension, impaired fasting glucose, elevated liver enzymes, etc.), mild physical symptoms (e.g. dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.), mild psychopathology, mild functional limitations, and/or mild impairment of wellbeing Stage 2 Presence of established obesity-related chronic disease (e.g. hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate limitations in activities of daily living and/or wellbeing Stage 3 Established end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitations, and/or impairment of wellbeing Stage 4 Severe (potentially end-stage) disabilities from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitations, and/or severe impairment of wellbeing a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9106
  6. 6. results of this surgery, like many other interventions, are best in the hands of dedicated, high volume surgeons in high vol- ume centers. Table 5 lists characteristics of what one would describe as a “good” bariatric surgeon. 2.9. Bariatric physician: perioperative care of patients undergoing surgery A bariatric physician will need to work very closely with his/ her surgeon to provide optimum perioperative care to their patients. Looking after a bariatric surgery patients before and after surgery involves careful consideration of a number of things and the bariatric physician should be aware of these aspects of care. 1. They should make an effort to know preoperative, in hospital care, and postoperative protocols of their preferred bariatric surgery center. 2. They should understand the risks, benefits, and com- mon complications of surgical procedures offered by their preferred bariatric surgery centre. They should look out for early symptoms and signs of complications and refer patients back to their surgeon at the earliest opportunity. 3. Patients are prescribed proton pump inhibitors for a variable period after bariatric surgery and Non-steroidal Anti-inflammatory Drugs are usually contraindicated after bariatric surgery (especially gastric bypass). 4. Some surgeons recommend Ursodeoxycholic acid for prophylaxis of gallstones during the early postoperative phase for a variable period. 5. Some patients will need routine mineral and vitamin supplements depending on their surgeon’s protocol. Need is higher with procedures that have malabsorptive component, like gastric bypass and duodenal switch. Table 4 e Local (IFSO-APC) and International (NICE) criteria for obesity surgery. Salient points from IFSO-APC consensus statement 2011 1. Bariatric surgery should be considered for the treatment of obesity for acceptable Asian candidates with BMI 35 with or without co- morbidities. 2. Bariatric/GI metabolic surgery should be considered for the treatment of T2DM or metabolic syndrome for patients who are inadequately controlled by lifestyle alterations and medical treatment for acceptable Asian candidates with BMI 30. 3. The surgical approach may be considered as a non-primary alternative to treat inadequately controlled T2DM, or metabolic syndrome, for suitable Asian candidates, with BMI 27.5. 4. Bariatric/GI metabolic surgery is generally recommended for patients within the ages of 18 and 65. 5. All surgeons who perform bariatric/GI metabolic surgery are properly credentialed and provide a quality bariatric surgical service in accordance with both the required level of skill and experience and the capability of the health service. 6. Surgical treatment of obesity and metabolic disorder need a multidisciplinary approach with a team, which includes surgeons, physicians, psychiatrists, dieticians, counselors, and others as needed. Salient points from United Kingdom’s Nice Guidelines for bariatric surgery 1. Bariatric surgery is recommended as a treatment option for people with obesity if all of the following criteria are fulfilled: They have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight. All appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months. The person has been receiving or will receive intensive management in a specialist obesity service. The person is generally fit for anaesthesia and surgery. The person commits to the need for long-term follow-up. 2. Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate. 3. Surgery for obesity should be undertaken only by a multidisciplinary team that can provide: preoperative assessment, including a riskebenefit analysis that includes preventing complications of obesity, and specialist assessment for eating disorder(s) information on the different procedures, including potential weight loss, and associated risks regular postoperative assessment, including specialist dietetic and surgical follow-up management of co-morbidities psychological support before and after surgery information on, or access to, plastic surgery (such as apronectomy) where appropriate access to suitable equipment, including scales, theater tables, Zimmer frames, commodes, hoists, bed frames, pressure-relieving mattresses, and seating suitable for patients undergoing bariatric surgery, and staff trained to use them. 4. Surgery should be undertaken only after a comprehensive preoperative assessment of any psychological or clinical factors that may affect adherence to postoperative care requirements, such as changes to diet. Table 5 e Characteristics of a good bariatric surgeon. Adequately trained. Perform a range of bariatric and metabolic procedures. Team based practice, supported by dietitians. Has a low mortality and complication rate. Transparently and honestly share data with you. Maintains reasonable volume. Practices evidence based surgery. Only carries out surgery when indicated. Informs patients clearly, if indication is not approved by national guideline/ controversial. Gives patients clear postoperative instructions. Prepared to offer life-long support and follow up to patients. Approachable and works closely with you. a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 0 3 e1 0 9 107
  7. 7. 6. They should keep an eye on the medication usage for other health conditions. Usually, with improvement in co-morbidities need for medications such as anti- diabetic drugs, anti-hypertensives, anti-hyper- lipidaemic, drugs, antacids, painkillers for arthritis, etc. decline 7. Bariatric surgery may variably influence absorption of drugs. For drugs with narrow therapeutic window, pa- tients should undergo careful drug level monitoring in the early phase to titrate the dosage of the drug. 8. Bariatric physician should be prepared to offer regular postoperative follow up to their patients. Follow-up appointments should be alternated in such a way that patient see either the surgeon or the physician at reg- ular intervals. 9. Women in childbearing age should be advised to use regular non-pharmacological contraception to avoid pregnancy for at least 18 months after surgery. 10. Patients should be counseled to avoid smoking as that increases the risk of postoperative complications like marginal ulceration. 3. Conclusion Obesity is a complex multi-system disease with very serious implications for the patients. Currently, the management of these patients is unsatisfactory, as most general practitioners lack the knowledge and resources to treat these patients effectively. There is a vast need to develop and train specialist obesity physicians or bariatric physicians to take care of this unmet need. In this article, we have attempted to define the skill set and role of such a specialist bariatric physician. Conflicts of interest The author has none to declare. r e f e r e n c e s 1. James WP. Obesityda modern pandemic: the burden of disease. Endocrinol Nutr. 2013;60(suppl 1):3e6. 2. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. 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