Monday, December 28, 2009

Battle of the Bulge

Food portions have tripled in size since the 1950s and so have our waistlines. Worldwide, more than a billion adults are overweight - at least 300 million of them clinically obese. Could obesity surgery offer a comprehensive life-saving solution to this global epidemic?  Eimear Vize talks to pioneering bariatric surgeon T Karl Byrne.

Sporting a Harley Davison t-shirt and pale blue jeans, Professor T Karl Byrne looks no worse for wear despite snatching only a few hours sleep before our interview. One of the top bariatric surgeons in the US, he was back in Ireland for a family gathering. It was his first Irish wedding in many years, he admits over coffee in the hotel lobby, he had forgotten how much the Irish liked to party when he had made the arrangement to meet at 10 am the morning after.
Some things may not have changed in Ireland since Karl emigrated in the 80s, but he has noticed other sizeable differences in recent years.
Us. We’re bigger.
The Irish have been indulging themselves a little too much over the years and it’s beginning to take it’s toll. Alarming results of a new survey of more than 2000 Dubliners, who were taking part in a VHI pilot diabetes screening project, revealed that almost two thirds of respondents were overweight or obese, and it is not a coincidence that a similar number were also identified as being at risk of developing the Type II Diabetes.
“There is a noticeable difference in the size of people here,” Karl says with ominous gravity. “I’ve seen it on the streets and in the restaurants, I’ve seen it even at the wedding here, there are a lot of people who are really dangerously obese. I think it’s because of the affluence maybe, the culture is becoming more Americanised: poor diet, overeating, sedentary lifestyle - That’s a dangerous road to take,” he warns.
Obesity can put people at an increased risk of developing diabetes, hypertension, heart disease, osteoarthritis, stroke, gallbladder disease, sleep apnoea and respiratory problems and even some cancers. The Centers for Disease Control and Prevention recently estimated that obesity costs the US health system as much as $147 billion a year.
“In the US more than 60 per cent of the population are overweight – the estimate right now is that there are probably 15 million people who are morbidly obese, that means they have a body mass index of more than 40kg/M2, which equates to about 7 stone (100lbs) over their ideal body weight.
“It must be a by-product of my surgical speciality, but when I’m out and about and I see a young person who is morbidly obese I think to myself, that person could change their life - could save their life – with a gastric bypass or a sleeve. We spend all this money in the States dealing with the many complications of the disease of obesity without addressing the underlying cause – their obesity.”
An RCSI graduate (class of ’78), Karl developed an interest in weight loss surgery during his residency at The Medical College of Virginia (MCV), under the tutelage of Dr Harvey Sugerman, a world-renowned surgeon in this specialty. He later relocated to The Medical University of South Carolina, as a trauma and critical care surgeon, but seeing a need to provide weight loss surgery to morbidly obese patients in the area, Karl started a small program at MUSC in 1992.  He is now Medical Director of the MUSC’s Bariatric Surgery Centre where he introduced the laparoscopic approach to gastric bypass weight loss surgery procedures in 1999.
“We looked at the admissions in our hospital over the course of a year, and in 10,000 admissions, 2,500 patients were admitted for the complications of obesity, so it’s a huge problem. People are being admitted for the complications of diabetes, hypertension and degenerative arthritis and so on, but the underlying diagnosis is morbid obesity,” he says.
“In the US right now, something like 70 percent of bariatric surgery cases being done are probably gastric bypass, because it’s the most tried and tested, followed by about 25 per cent lap bands, and there’s a small number of bilio-pancreatic bypasses, duodenal switches and gastric sleeves being done, in the grand scheme of things only about 5 per cent.
“We have very clear data on the outcomes in terms of resolution of medical problems such as obesity related type 2 diabetes – an obese patient who has a gastric bypass has an 86 per cent chance of having their diabetes cured permanently. About 93 percent of patients who are hypertensive are cured of their hypertension; people who have degenerative arthritis in their weight bearing joints are often cured of that and don’t need further surgery, such as knee and hip replacements; 95 percent of people with sleep apnoea syndrome will be cured.”

He stresses: “The procedures have been tried and tested over the years, most of them are being done in certified Centres of Excellence so that now the morbidity and mortality rates are pretty damn good really.”
So, why then are the major US health insurance companies not freely encouraging their obese subscribers to seek bariatric surgery when conventional weight-loss treatment fails? Wouldn’t they rather bank those billions of dollars saved on the multiple-medications and surgical interventions needed to manage the chronic diseases associated with obesity?
“Good question,” Karl retorts. “I ask myself that one regularly. You’d think the insurance companies would embrace this as a very effective and low risk, relatively speaking, way to cure the huge medical problems caused by obesity and thereby reduce their expenditure, but they don’t.
“Coverage for procedures such as these, is dictated, to a certain extent, by a Government agency, the Centres for Medicare and Medicaid Services (CMS) and basically the other insurance companies follow along with what they recommend.
“In 2004 Medicare came out with the statement that obesity was a disease - they had never regarded it as that before - and that they would cover obesity surgery for Medicare recipients provided it was done in a Centre of Excellence, so everyone thought: this is it, the flood gates are just about to open because the other insurance companies would follow suit. But they didn’t. Nothing really happened. There was a slight upsurge in procedures for Medicare patients – the toughest patients – statistically the most non compliant and the sickest because they are older and have been on disability for years.”
It is becoming increasingly apparent that Karl, who presents as a relaxed and discerning man, laid back even, is visibly irked by the short-sightedness of the health insurance industry in his adopted country, and their overall reluctance to provide cover for some or all of the five obesity surgeries sanctioned by the American Society for Metabolic and Bariatric Surgery (ASMBS), as identified by the Surgical Research Committee. These are Gastric Bypass, Laparoscopic Adjustable Gastric Banding, Duodenal Switch, Bilio-pancriatric Diversion and Vertical Sleeve Gastrectomy.
“So if you were an insurance company who provided healthcare and you had a population of diabetics and you had a pill that you could give the diabetics that would cure 86 percent of them, wouldn’t you give them the pill?
“Now we don’t have a pill, we have a procedure. Not alone can it cure their diabetes it would also get rid of their hypertension and their sleep apnoea syndrome and a range of other problems. You would think that the insurance companies would 100 percent embrace this and pay for it willingly but they don’t,” he argues hotly.
Why not?
“I don’t know.”
“We are all lobbying for it for years now, perhaps they’re worried that it would open the flood gates but if you look at the cost analysis that shouldn’t be a major issue. The cost of a gastric bypass in the US is about $30,000 but if you have a patient who is on multiple medications for the complications of obesity, the amount of money the insurance company would pay for all those simple pills over the course of the years is way more than the upfront cost of the gastric bypass.
“After two years those lines have been shown to cross, so if you have a patient with multiple medical problems, gastric bypass becomes effective after about two years in terms of finances. When you do a gastric bypass the rapid weight loss is in the first six months, by the end of six months many of them are off all their medications, so they are immediately saving money. Within two years it would be more cost effective to have gastric bypass than to keep them on those medications.”
Karl offers another example of this frustrating misdirection of funds: “If you’re a 300 pound patient with knee problems and your orthopaedic surgeon recommends knee replacements, the insurance company has no problem paying for that. Wait a second now, why has the guy got knee problems - because he is 300 pounds, and incidentally he’s hypertensive. You’re not addressing the underlying problem. What a stupid way to spend money. It’s ridiculous!”
With obesity increasingly evident among children – 22 million children under five are overweight worldwide – this is a global crisis that will only deepen further in the coming years. Thousands of children and adolescents in the UK are using anti-obesity drugs that are only licensed for use by adults, according to a new study published in the British Journal of Clinical Pharmacology. In fact, the number of young people receiving prescriptions for these drugs has increased 15-fold since 1999. Extrapolated across the whole population, the results indicate that around 1,300 young people are now being prescribed off-licence anti-obesity drugs each year.
“They don’t work,” Karl offers flatly. “The statistics are that if you take weight loss medication constantly you can possibly lose 10 percent of your weight, so a 300 pound patient will possibly lose 30 pounds if they are taking them for six months, and there are huge side effects, but once they go off the medication they put the weight back on, so they don’t work.
“Our hospital has a huge transplant centre and I get calls from surgeons who ask if I can do a gastric bypass on a patient who is on dialysis and needs a kidney but his BMI is too high for a transplant. Here’s a patient who has had 20 years of diabetes, 20 years of hypertension and all the other co-morbidities, they are morbidly obese, and because they have had this chronic disease, now they are in kidney failure but they’re too obese to get a kidney, so I have to do a gastric bypass on them so they can get weight off so they can get a kidney transplant. We’re spending money at the wrong end of the problem. Wouldn’t it have made more sense to intervene when this patient was 20 and was morbidly obese? Why don’t we intervene when they’re in their teens?”
Karl isn’t the only one who feels strongly that, when other treatment options fail, obese children and teenagers should be offered bariatric surgery. The number of US children having obesity surgery has tripled in recent years, surging to almost 1,000 in 2007. While the procedures are still far more common in adults, they appear to be slightly less risky in teens, according to an analysis of data on 12 to 19 year olds published in the Archives of Paediatric and Adolescent Medicine in March 2007.
“Thirteen is the youngest I’ve ever done but you can go younger again and I think that’s going to be a big entity eventually, particularly if and when the lap band is sanctioned for use in patients under the age of 18.”
The Endocrine Society's 91st Annual Meeting in Washington, DC in June 2009 heard that lap band surgery significantly improved and even reversed the metabolic syndrome in a study of morbidly obese teens aged between 14 and 17.
“Trials have been done and results are good, so I think that will be something to watch because it has very low morbidity. So we may be slipping lap bands into these pre-teens who are morbidly obese, at some stage,” Karl says.
But why stop there? Why not tackle a person’s obesity before they’re born? It may sound absurd but new research just published has shown that adolescent and young children of obese mothers who underwent weight-loss surgery prior to pregnancy had a lower prevalence of obesity and significantly improved cardio-metabolic markers when compared to siblings born before the same obese mothers had weight-loss surgery. This particular research - published in The Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM) - focused on women who had undergone bilio-pancriatric diversion prior to becoming pregnant.
Karl predicts that the gastric sleeve is going to make a major come back as an effective and lower risk procedure in the bariatric surgery portfolio. “I think it’s going to be a real entity in a couple of years. It’s an old operation that has been re-visited and revamped and the data that we have so far has indicated that it’s as effective as gastric bypass for weight loss in the short term; we don’t really have the long-term data yet.
“It is more effective than the lap band in terms of weight loss but has less complications; there’s less morbidity compared to gastric bypass, so I think it’s going to be an entity. I have done a few but there are certain centres in the US where they are being done almost exclusively.”
Then Karl sighs deeply. “But, of course, there’s a huge insurance issue with this procedure as well.”
It appears that after relentless lobbying by the profession, the CMS finally issued surgeons with a claims payment code for the Vertical Sleeve Gastrectomy.
But they still won’t pay them for it.
“It’s frustrating as hell but we’ll get there.”


  1. Obese individuals spend 36 percent more on health care costs and 77 percent more on medications per year than individuals of normal weight
  1. Approximately 85 percent of people with diabetes are type 2, and of these, 90 percent are obese or overweight
  1. The National Taskforce on Obesity estimated direct costs of obesity in Ireland on a pro-rata population basis at 70 million. Indirect costs were estimated at 73 million
  1. After obesity surgery patients can expect to lose 50 percent of their excess weight within the first one to two years, and to maintain this in the long term.
  1. Research shows insurers recover their costs for bariatric surgery in two to four years depending on the type of surgery performed
  1. Patients consider bariatric surgery for about three years before making their decision to have surgery, according to a 2008 ASMBS / Harris Interactive nationwide survey in the US.
  1. About 220,000 people with morbid obesity in the US had bariatric surgery in 2008.

Bariatric Surgery in Ireland – overview

Bariatric surgery is a relatively new entity in Ireland with some of the first procedures being performed in 2002. However, as the level of morbidly obesity increases in this country, so too does the demand for this treatment option. In recent years, the only public Weight Management Clinic in St Columcille’s Hospital, Loughlinstown, has been struggling to cope with the growing number of seriously obese patients seeking surgery.
Waiting times are in excess of two years, and in 2005 there were almost 450 patients awaiting treatment. Since opening in 2002, at least 12 patients, ranging in age from 22 to 53, have died while on the waiting list. Emergency cases cannot be prioritised because the clinic has reached ‘saturation point’.
Bariatric surgery is also available publicly at University College Hospital Galway. Plans are in the pipeline to open a third public obesity clinic next year offering weight-loss surgeries in Cork in collaboration between Cork University Hospital and the Mercy University Hospital. A fourth public clinic will open on the western side of Dublin on the Tallaght/Connolly Hospital axis at a later date.
Currently bariatric surgery is available privately at the Galway Clinic, the Beacon Hospital in Sandyford, Dublin; Blackrock Clinic, Dublin; Bon Secour Hospital in Cork, and Obesity Solutions in the Auralia Hospital, off the Naas Road.
The three private health insurers in Ireland – VHI Healthcare, Hibernian Aviva Health, and Quinn Healthcare –provide cover for certain bariatric surgeries (procedures and amount of coverage vary between company), however benefit is subject to prior approval and the criteria are quite detailed and specific. These include cover for individual over the age of 18 only. Patients must also have been morbidly obese (BMI over 45) for at least two years.  Surgery must be carried out in pre-approved centres by an appropriately qualified surgeon, who is registered with the individual insurance company.
The supervising consultant is obliged to provide documentation to prove that the patient has received treatment management in a non-surgical obesity programme for at least six months within two years of the proposed surgery.

The Prince’s Trust

Eimear Vize tells the remarkable story of the Irish doctor whose life-long friendship with a tiger-slaying Indian Maharaja helped decorate a tiny church in rural Munster

Inside the beautiful Anglican Church of Ascension in Timoleague, in a quiet corner of West Cork, is an elaborate and unexpected treasure of Byzantine style mosaics that envelop the walls and chancel. On the south wall, among the Indian flower designs, is inlaid a tribute to a local doctor Martin Alymer Crofts, who was a life-long friend and personal physician to the ninth Maharajah of Gwalior, Madhav Rao Scindia.

In the early 1920s, Maharajah Scindia financed the completion of the Timoleague mosaics in memory of this tall and impressively moustached Cork doctor, a member of the Indian Medical Service who was the Maharaja’s tutor and companion from when he was ten.
The pages of history are strewn with accounts of colourful characters, daring deeds and the dedication to their work of many Irish doctors abroad. Medical historians agree that in the 1800s Britain would have been unable to operate its medical services in India and other colonies but for the huge role played by Irish-trained doctors.

In the Indian Medical Service, Irish recruits never fell below 10 per cent and reached a peak of 38 per cent in the 1870s. In fact, during the 1860s and 1870s, Ireland produced proportionately more doctors for the Indian Medical Service than either England or Scotland.
The reality of the time was that Ireland’s medical schools were overproducing doctors. Many elected to emigrate to England or one of the colonies, lured by the prospect of a more comfortable living. It was more attractive for many than the usual career path of an underpaid and mostly part-time post in a dispensary or workhouse in Ireland.
Feasibly, it was with this in mind that the recently graduated Dr Martin Crofts and his older brother James both signed up to the Indian Medical Service in March 1877 aged 23 and 25 respectively after obtaining medical degrees at Queen's College in Cork.

James was appointed Surgeon in the Bengal Medical Establishment, and while he entered the IMS in the same batch, on the same day, he was junior to his younger brother.
The first ten years of Martin’s career with the IMS were spent in military service, when he was for several years medical officer to the renowned 10th Bengal Lancers, ‘Hodson's Horse’ – a cavalry regiment that earned victors’ laurels in successive conflicts and upheld their distinguished reputation in the second Afghan war of 1878-80. During these years Martin served as regiment surgeon with the 10th and faced the Afghans in battles alongside his comrades in the Kandahar and Khaibar field forces.

A year after enlisting in the Indian Medical Service in 1878, the brothers Crofts found themselves among a British force of 40,000 fighting men distributed into military columns which penetrated Afghanistan at three different points – the Khyber, the Bolan and the Kurram passes – in the second Afghan war.
The priority of the British army surgeon was, of course, to treat the wounds and illness of the British and Indian serviceman, but ‘the struggle for hearts and minds’ is not just a modern phenomenon. Medical historians record that, in the aftermath of battle, medical staff would see if anything could be done for survivors of both sides, though this could be dangerous as some ghazis would feign death and shoot at their enemy, or draw a knife and swipe out in a last effort to do their duty under the jihad.

It is known that at least one of the Crofts, James, served in 1878/9 under the famed Anglo-Irish soldier Major General Sir Frederick Roberts, who was one of the most successful commanders of the Victorian era.
General Roberts was given the command of the Kurram Field Force, of which James is credited as one of the regiment surgeons, and Roberts relentlessly advanced into central Afghanistan, meeting and defeating the enemy forces head-on in each encounter, before finally taking Peiwar Kotal in December 1878. 
With British forces occupying much of the country, a deal was struck in May 1879 that relinquished control of Afghan foreign affairs to the British. But that autumn, General Roberts and the Kurram Field Force were summoned into Kabul to suppress an uprising that had been triggered by the slaughter of a British resident and his staff in September that year. The ensuing battle added another victory to Roberts’ extraordinary reputation.
But it was the formation of a force of 10,000 men in Kabul in August 1880, which had to journey hundreds of miles to relieve British troops besieged in the city of Kandahar that brought Dr Martin Crofts under the command of General Roberts. 

Scant documentation makes it unclear if Martin had actually served under Roberts prior to this. Indeed, it is also uncertain if brother James accompanied the relief column on that gruelling 319-mile march from Kabul to Kandahar as his service record makes no reference to him being present for action at Kandahar, the last battle of the second Afghan war.
Martin was certainly one of at least 30 surgeons who made this epic march, and there were many other Irish doctors among the medical compliment. Most notable was General Roberts’ Principal Medical Officer, Irish-born James Hanbury, who was educated in Trinity College Dublin and served with the British Army in China, India and America.
Afghanistan was, then as now, an inhospitable place for visiting armies. Roberts’ troops struggled daily on the march through thick clouds of dust, under a blistering sun and over a hard-baked road from camp to camp. The column would march in the early morning to avoid the full heat of the sun, halting a few minutes every hour. In this way, they managed to cover up to 20 miles a day.
Although the march was unhindered by the Afghans – news of Roberts’ approach had preceded him – it was an historic and remarkable feat of human endurance and organisation.  Finally, on the morning of the 31 August 1880, the relief force reached Kandahar. The inevitable battle was long and bloody but, on 1 September, a decisive victory was claimed for the British.
Martin saw brutal action once again two years later in the Egyptian war of 1882, when he was present in the Battles of Tel-el-Kebir and Kassassin, receiving the campaign medal with a clasp, and the Khedive's bronze star.

In 1886, the princely state of Gwalior was grieving the death of its Maharajah Jayajirao Sindhia, whose sole efforts over the previous three decades had made Gwalior the most advanced city of India. His son and heir, Maharaja Madhav Rao Scindia, was a boy in his tenth year.
As Gwalior held a strategic position between north and south India, the British considered it one of its most important strongholds in the country. It was no small honour then when the young prince was entrusted to 32-year-old Dr Martin Crofts, who was appointed residency surgeon of Gwalior and tutor to the new Maharaja Madhav Rao Scindia.
From a young age, and under the Cork man’s guidance, Madhav Rao threw himself with the utmost keenness into a broad education and the supervision of every detail of State management.
However, during these years, Dr Crofts was still a soldier and military surgeon and as such subject to the call to battle. Promoted to the rank of Surgeon Major in 1889, he served in the Zhob Valley expedition in the same year, on the North-West frontier of India, a long and hotly contested region where many British officers honed their soldiering.
Perhaps it was the Surgeon Major’s war stories from the battlefield that charged the young Prince’s active interest in warfare. Or perhaps it was the emergence of a sovereign spirit in one born to lead that gave the 14-year-old the idea of launching his very own military expedition in 1900. The destination was China where the Boxer movement, a brutal anti-European/Christian organisation, had rebelled with the aim of forcing out colonists.
It seems plausible that the teenage prince’s personal physician and friend of four years may have influenced how such a dangerous journey was undertaken. The mode of transport chosen was a hospital ship and Surgeon Major Crofts accompanied Madhav to China. Once docked, the Maharajah presented the vessel Gwalior to the authorities, at his own expense, for the accommodation of those wounded in the Boxer Uprising. Crofts himself was the senior medical officer of the Gwalior while the now fifteen-year-old Madhav served as orderly officer to General Gaselee in 1901. Both friends were decorated with the Third China War Medal for their efforts.
In 1894 the Maharaja came of legal age and obtained power. He was proudly Western in outlook, a marvellous host and staunchly pro-British. Eager for Western-style progress, he made Gwalior one of the most advanced states in India. He balanced the budget, encouraged local industries, built schools and hospitals and provided honest judges who sent their prisoners to model jails.

At leisure, he enjoyed driving steam engines, crying out to his admiring people “No danger – Sindhia drives.” He also had a passion for tiger shooting, even writing a book about it titled A Guide to Tiger Shooting, which became prescribed reading for the British dignitaries at his hunting parties. Martin Crofts would often accompany the Maharaja on these hunting trips, which were acclaimed for their entertainment value by distinguished foreign guests.
The Irish doctor’s military career was one on the ascension: he was elevated to the rank of surgeon lieutenant colonel in 1897; promoted to colonel in 1908, and to surgeon general three years later.  He was appointed Honorary Surgeon to the King on March 2nd, 1913.
During this time, Martin Crofts became residency surgeon of Kotali and Gialawar in June 1905 and months later, administrative medical officer of the newly created North-West Frontier province.  As surgeon-general he was principal medical officer of the Rawal Pindi division.
Martin maintained contact with his one-time ward and was honoured when Madho and the Indian princes, who presented the hospital ship Loyalty to the Indian Government for service in First World War, expressed a desire that Surgeon General Crofts should be appointed to the medical charge. But Martin’s health would not allow him to accept the post.
Less than a year after he retired, Surgeon General Martin Alymer Crofts died “suddenly of heart disease” in London on 12 March 1915. There was no record that he had ever married or had children.
Days later a brief notice appeared in the Cork Constitution regarding his funeral at Timoleague. It added, simply: “A man who knew how to do a day’s work and who did it”.