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      Organization of future training in bariatric gastroenterology

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          Abstract

          A world-wide rise in the prevalence of obesity continues. This rise increases the occurrence of, risks of, and costs of treating obesity-related medical conditions. Diet and activity programs are largely inadequate for the long-term treatment of medically-complicated obesity. Physicians who deliver gastrointestinal care after completing traditional training programs, including gastroenterologists and general surgeons, are not uniformly trained in or familiar with available bariatric care. It is certain that gastrointestinal physicians will incorporate new endoscopic methods into their practice for the treatment of individuals with medically-complicated obesity, although the long-term impact of these endoscopic techniques remains under investigation. It is presently unclear whether gastrointestinal physicians will be able to provide or coordinate important allied services in bariatric surgery, endocrinology, nutrition, psychological evaluation and support, and social work. Obtaining longitudinal results examining the effectiveness of this ad hoc approach will likely be difficult, based on prior experience with other endoscopic measures, such as the adenoma detection rates from screening colonoscopy. As a long-term approach, development of a specific curriculum incorporating one year of subspecialty training in bariatrics to the present training of gastrointestinal fellows needs to be reconsidered. This approach should be facilitated by gastrointestinal trainees’ prior residency training in subspecialties that provide care for individuals with medical complications of obesity, including endocrinology, cardiology, nephrology, and neurology. Such training could incorporate additional rotations with collaborating providers in bariatric surgery, nutrition, and psychiatry. Since such training would be provided in accredited programs, longitudinal studies could be developed to examine the potential impact on accepted measures of care, such as complication rates, outcomes, and costs, in individuals with medically-complicated obesity.

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          Most cited references 44

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          Annual medical spending attributable to obesity: payer-and service-specific estimates.

          In 1998 the medical costs of obesity were estimated to be as high as $78.5 billion, with roughly half financed by Medicare and Medicaid. This analysis presents updated estimates of the costs of obesity for the United States across payers (Medicare, Medicaid, and private insurers), in separate categories for inpatient, non-inpatient, and prescription drug spending. We found that the increased prevalence of obesity is responsible for almost $40 billion of increased medical spending through 2006, including $7 billion in Medicare prescription drug costs. We estimate that the medical costs of obesity could have risen to $147 billion per year by 2008.
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            Quality indicators for colonoscopy and the risk of interval cancer.

            Although rates of detection of adenomatous lesions (tumors or polyps) and cecal intubation are recommended for use as quality indicators for screening colonoscopy, these measurements have not been validated, and their importance remains uncertain. We used a multivariate Cox proportional-hazards regression model to evaluate the influence of quality indicators for colonoscopy on the risk of interval cancer. Data were collected from 186 endoscopists who were involved in a colonoscopy-based colorectal-cancer screening program involving 45,026 subjects. Interval cancer was defined as colorectal adenocarcinoma that was diagnosed between the time of screening colonoscopy and the scheduled time of surveillance colonoscopy. We derived data on quality indicators for colonoscopy from the screening program's database and data on interval cancers from cancer registries. The primary aim of the study was to assess the association between quality indicators for colonoscopy and the risk of interval cancer. A total of 42 interval colorectal cancers were identified during a period of 188,788 person-years. The endoscopist's rate of detection of adenomas was significantly associated with the risk of interval colorectal cancer (P=0.008), whereas the rate of cecal intubation was not significantly associated with this risk (P=0.50). The hazard ratios for adenoma detection rates of less than 11.0%, 11.0 to 14.9%, and 15.0 to 19.9%, as compared with a rate of 20.0% or higher, were 10.94 (95% confidence interval [CI], 1.37 to 87.01), 10.75 (95% CI, 1.36 to 85.06), and 12.50 (95% CI, 1.51 to 103.43), respectively (P=0.02 for all comparisons). The adenoma detection rate is an independent predictor of the risk of interval colorectal cancer after screening colonoscopy. 2010 Massachusetts Medical Society
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              Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement.

               V Moyer,   (2012)
              Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for obesity and overweight in adults. The USPSTF reviewed new evidence on the benefits and harms of screening and primary care–feasible or referable nonsurgical weight-loss interventions. The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index of 30 kg/m(2) or higher to intensive, multicomponent behavioral interventions (B recommendation).
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                Author and article information

                Contributors
                Journal
                World J Gastroenterol
                World J. Gastroenterol
                WJG
                World Journal of Gastroenterology
                Baishideng Publishing Group Inc
                1007-9327
                2219-2840
                21 September 2017
                21 September 2017
                : 23
                : 35
                : 6371-6378
                Affiliations
                Center for Advanced Laparoscopic General and Bariatric Surgery, MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, United States. timothy.r.koch@ 123456medstar.net
                Center for Advanced Laparoscopic General and Bariatric Surgery, MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, United States
                Professor Emeritus, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
                Author notes

                Author contributions: Koch TR, Shope TR and Gostout CJ outlined and wrote the manuscript.

                Correspondence to: Timothy R Koch, MD, Professor of Medicine (Gastroenterology), Georgetown University School of Medicine, Center for Advanced Laparoscopic General and Bariatric Surgery, POB South, Suite 301, MedStar-Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010, United States. timothy.r.koch@ 123456medstar.net

                Telephone: +1-202-8777788 Fax: +1-877-6808198

                Article
                jWJG.v23.i35.pg6371
                10.3748/wjg.v23.i35.6371
                5643262
                ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.

                This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

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