Obesity: role of the attending physician, caution regarding surgery, evaluation of care… the HAS issues new recommendations

The recommendations warn of actions that hurt. PIXABAY – peakSTOCK

A few days before World Obesity Day, March 4, the High Authority for Health presented this Wednesday, February 28, the new contours of the care pathway centered around the attending physician and adapted to the specificities of patients. . In France, 4% of 6-17 year olds and 17% of adults are obese.

"Modeling the route is essential" : the High Health Authority traced this Wednesday, February 28, the new lines of more rational management of obesity, a disease which affects 4% of 6-17 year olds, and 17% of adults. 

And if we only talk about overweight populations: 17% of young people and 49% of adults, according to HAS. Published in February 2023, a study carried out at the initiative of the League Against Obesity, in collaboration with the Montpellier University Hospital, under the aegis of Inserm, made report of an alarming trend: it showed that in 25 years, the obesity figures have quadrupled among 18-24 year olds.    

"The journey could be summarized with 4 D : screen, diagnose, discuss, decide together", summarizes Professor Pierre-Louis Druais. With an attending physician at the center of the care pathway, particular attention to the public concerned. 

The observation: too many failures

The observation which leads the High Authority for Health to clarify the pathways for the management of obesity is clear: the management of obesity, < em>"a complex illness, with medical, psychological, social aspects", insists Professor Pierre-Louis Druais, requires adjustments to gain in efficiency. 

Lack of numerical data that could serve as indicators on this situation, doctors and patients testifying to current inadequacies: "You find yourself in a dietician's waiting room where the seats are made of rattan, or too fragile to support your weight. During the examination, the doctor places his head between your breasts to measure your waist circumference with a two-meter tape, it's very demeaning", testifies a patient. 

"Treating doctors don't even know that their patient is having an operation", adds Professor Pierre-Louis Druais . 

One in two patients is no longer followed up two years after having undergone a bariatric surgery technique. 

Starting this month of March, "questionnaires on the outcome of care perceived by the patient" , the PROMs, will be sent to patients.

Each public has its own care, attending physician and patient on the front line

The High Authority for Health offers two distinct care pathways, for children and for adults for a "just sequence of care, at the right time, by the right professionals". It also distinguishes the public according to their specificity: women, in fragile situations during pregnancy and menopause, but also disabled people or even the most precarious groups, & quot;four times more affected by obesity", as many special cases. 

According to the HAS, the attending physician is the pivot, "a sort of conductor and sometimes a lawyer" , care, a marathon that stretches out "on average over more than ten years of follow-up", which initially involves "a change in habits", diet, physical activity, pace of life, and which must take place "in benevolent neutrality", recalls Pierre-Louis Druais: "The absence of judgment is essential".

It involves co-construction, with the patient and other health professionals, advanced practice nurses, physiotherapists, adapted physical activity professionals… it's not the provision of solutions: "What are the causes of obesity, what happened in the lives of people, what image do they have of themselves ?…"

L'HAS, who wrote "eight sheets defining the role of professionals" specifies that there "tools exist for training& ;quot;, and identify, in his practices, the stigmatization of his patients. "Weighing a person is not trivial", he adds.    

Bariatric surgery: one in two patients lose care two years later, "this is not tolerable"

In 2022, 22,000 bariatric surgery procedures, a practice which consists of shrinking the size of the stomach using different techniques, were performed.

This is not a panacea, recalls the HAS, which "issues new recommendations on pre and post care bariatric" :"When we are in a situation of failure, we will need more radical solutions, such as surgery. The HAS has developed recommendations that position surgery and the use of medications as a last resort. Bariatric surgery is a decision that must be made, within a minimum period of 6 months. The patient must be well informed about the consequences. Nearly one in two people are out of care years after a surgical procedure, this is not tolerable", notes Dr Druais , which also indicates that "15% of patients are re-operated".

"When you have had surgery, you are under surveillance for life", he also specifies.&amp ;nbsp;

"The medicine is not a purpose"

L'HAS shows the same caution regarding the use of drugs, while new molecules are awaiting marketing authorization on the market: "The drug is not an end in the management of obesity, it is a means , a tool.

It is all the more "dangerous that'it is considered as a single method" that'"The Internet sometimes provides answers that escape the medical world".