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F
ifteen
minutes
R
ev
A
ssoc
M
ed
B
ras
2014; 60(5):395-397
395
Editorial
Fifteen minutes
Q
uinze minutos
W
anderley
B
ernardo
, J
osé
M
aria
J
r
., A
ntônio
S
alomão
, E
dmund
B
aracat
http://dx.doi.org/10.1590/1806-9282.60.05.001
D
escribing
the
importance
of
obesity
today
,
and
the
lack
of
strategies
for
proper
ma
-
nagement
,
can
take
fifteen
minutes
of
rea
-
ding
,
but
the
problem
must
involve
much
more
time
of
your
attention
,
as well
as
gui
-
dance
to
your
patients
.
Epidemic and rising rates of obesity in many parts of the
world are leading to increased suffering and economic
stress. Despite decades of research on the causes of the
obesity pandemic, which does not seem close to a solu-
tion, there is still no clear understanding of the nature of
the problem. This limits creativity and suffocates expan-
sive thinking, which could advance in the field of preven-
tion and treatment, as well as in the scope of the compli-
cations of obesity. Shared decision-making and the
redirecting of policies could remove barriers that prevent
us frommoving forward to solve an urgent public health
issue of the beginning of this century
1.2
.
Overweight and obesity reflect a gain of excess body
fat, including visceral fat, which is a result of initially im-
perceptible cumulative effects of everyday eating, hourly,
with no proper physical activity, creating a surplus of ca-
lories consumed in relation to those expended. Excess
weight gain, gradual and unintended, is accompanied by
the difficulty of reversing the picture and can become per-
manent. Even if all currently obese patients were treated
effectively in the absence of adequate preventive efforts,
there would still be continued growth in the number of
obese people. Many multifaceted interventions to pre-
vent obesity seek to influence the balance of calories, fo-
cusing on energy consumption, or energy expenditure.
While obesity is a priority from an epidemiological and
public health perspective, it becomes even more impor-
tant as it influences other aspects of society. Substantial
direct and indirect costs include discrimination, econo-
mic deprivation, loss of productivity and disability. Thus,
state and local governments end up diverting resources
for prevention and treatment. The country’s health sys-
tem is burdened with the comorbidities of obesity, such
as type 2 diabetes, hypertension, cardiovascular diseases,
osteoarthritis and cancer. It is estimated that the annual
burden of obesity is almost 10% of all medical spending
3
.
There are programs of shared decision-making that offer
surgical treatment modalities for weight loss, including:
Roux-en-Y gastric bypass,
laparoscopic adjustable gastric
banding and laparoscopic sleeve gastrectomy. Patients at-
tend seminars where they are instructed on the differences
in outcomes, follow-up and complications of each procedu-
re. The main information presented at the seminar include:
1. Greater weight loss with Roux-en-Y and sleeve gastrectomy
compared to the use of a gastric band; 2. The gastric band
requires the highest number of post-operative visits (mon-
thly in the first year); 3. The Roux-en-Y and the sleeve gas-
trectomy have a higher rate of life-threatening complica-
tions than the gastric band (fistula); 4. The gastric band has
highest number of delayed complications related to the de-
vice (erosion, migration); 5. The Roux-en-Y has the highest
rate of diabetes remission; and 6. There is a lack of data on
five-year follow-up of weight loss after sleeve gastrectomy.
Fifty-eight percent of patients chose “weight loss” as the
most important result, and 65% chose “fistula” as the most
worrisome complication. A subgroup analysis including pa-
tients with diabetes showed that 58% chose “curing diabe-
tes” as the most important result. Nineteen percent of pa-
tients were unsure about which procedure they wanted, or
changed their decision after consultation with the surgeon
3
.
T
he
choice
for
bariatric
surgery
is
not
easy
,
and
shared
decision
-
making
in
the
manage
-
ment
of
obesity
should
address
both
the me
-
dical
and
surgical
treatment
,
and
preven
-
tion
,
requiring more
than
fifteen minutes
.
In decision-making, patients can choose to be more passive.
That is because they do not know how to feel when they are
more active in decisions. Or, they may fear abandonment or
being labeled “difficult if they seem to defy the doctor’s au-
thority. They may find it difficult to tolerate the doubt, be-
ing satisfied with the first solution, less than ideal, but avai-
lable. In turn, physicians may assume that the patient made
the decision based on correct information and appropriate
assumptions, especially if the professional opinion is natu-
rally favored. It is generally accepted that whenever patients
are well-informed, they canmake the best decisions. Patients
often want more information than expected. Sometimes,
however, the more information is presented, the worse is the
understanding of patients. Patients and physicians need to
consider the right amount. In addition, the number and ty-
pes of suitable options (not all possible options at once) and