‘Things need to change’: diabetes clinics have few options for severely obese patients

Specialist diabetes clinics in public hospitals are dealing with patients who are mostly obese and yet have no access to effective treatments, endocrinologists in NSW say

A three-year study, conducted from 2017 to 2019, showed that almost half the 700 patients who attended the specialist outpatient clinics for type 2 diabetes at a western Sydney hospital had a BMI of at least 35kg/m2, meeting criteria for bariatric surgery, and less than a quarter of them an HbA1c level of under 53 mmol/mol.

Four out of five of the obese T2D patients at the clinics were not offered referrals to weight loss management services or bariatric surgery despite meeting the criteria under national and international guidelines, a study has found.

There was also scope for increased use of GLP1 agonists and SGLT2 inhibitors with weight-loss effects that would benefit obese patients with T2D, the study found.

“In spite of frequently meeting the criteria for bariatric surgery and not achieving glycaemic targets, people with T2DM received limited medical or surgical management of their obesity,” the authors concluded.

Care could be improved on several levels, said lead investigator Dr Milan Piya, a diabetes specialist based in western Sydney. He said long waiting lists, medication costs and insufficient multi-discipline obesity services worked as barriers for obese patients in the public health system.

As the study authors noted, obesity was a well-known risk factor for T2DM, and 11% of adults in Australia lived with severe obesity.

“Beyond the major health challenge, the additional annual total health cost, in comparison to those with a normal weight without diabetes, is 26% for obesity alone and 46% for those with obesity and diabetes,” they wrote.

Dr Piya said people with high BMIs needed a lot of additional support to regain their health, lose weight and achieve better glycaemic control.

“We have a multi-disciplinary team in Camden, whereas in Campbelltown we have just a standard diabetes clinic. We know patients have better outcomes when they have multi-disciplinary support.”

A 2018 study identified only 16 specialist obesity services in the public health system in Australia, of which eight were in NSW.  Along with more services, more emphasis should be put on allied health, including psychologists and dieticians, he said.

“Quite a few things need to change,” Dr Piya said. “I think a cultural shift needs to happen in terms of treating obesity as a disease.”

With only five to 10 percent of primary bariatric surgeries performed in the public health system, the cost of private treatment was not an option for many, which could help explain the low rate of referrals, he added.

The same problem applied to existing obesity clinics.

“We have massive waiting lists to get into our clinic, and I am sure other clinics are the same. Because of the long wait list people tend not to refer to these services because they’re waiting too long.  If they were more accessible, specialists would be doing those referrals. “

Dr Piya said medications that can help obese people lose weight should attract PBS subsidies to the same degree as medications that licensed for diabetes.

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