Missing the Big Picture

Above all else, America prizes personal choice. Its people also mirror the glorious contradictions that result from these choices. This country has some of the greatest healthcare resources in the civilized world, but access to them is limited to the insured and the insurable.

Americans enjoy one of the highest standards of living on the planet, but the disparity between the lives of its richest and its poorest is equally great.  Americans buy floor-to-ceiling televisions and struggle to stay active in sedentary workplaces. They track the medal count in the Olympics while they pay for memberships to gyms that they seldom visit.

They patronize supermarkets that stock an assortment of gourmet snacks, but lament the installation of vending machines in public schools. Compounding the effects of these commercial and social influences is a biological imperative to efficiently store energy and retain calories, born of a time centuries ago, when food intake was limited to what could be raised and harvested or caught and killed.

With bodies that are engineered to take on more calories than can be efficiently consumed – Americans’ appetites aren’t telling them to stop. In so many ways, this larger-than-lifestyle existence is causing noticeable tremors in the health industry, and as a society, they are observing the physical aftershocks.

According to the U.S. Centers for Disease Control (CDC), the impact on the U.S. health system from obese and overweight patients may tally at least $80 billion; nearly 10 percent of all U.S. medical expenditures in 1998. That figure includes both direct (“preventive, diagnostic, and treatment services”) and indirect (“income lost from decreased productivity, restricted activity, absenteeism, and bed days”) costs.

But it doesn’t even touch on the tens of thousands of premature deaths brought on by obesity. Although calculations vary famously as to the extent, studies comparing Americans’ body-mass index (BMI), or height-to-weight ratio, at their times of death, report that obesity is the second-leading preventative cause of death in the United States (after smoking).

As of 2007, the CDC reported obesity rates of 20 percent to 30 percent in 46 of the 50 U.S. states. According to the National Center for Health Statistics, 66 percent of Americans older than age 20 are either overweight or obese. Anywhere from 3 percent to 5 percent of Americans are deemed morbidly obese; that is, at least 100 pounds overweight.

These figures increased 25 percent from 2000 to 2005, and are increasing at the greatest percentages among the “super” morbidly obese: those weighing 500 pounds or more. What this means for the imaging world is best summed up in a word: change.

Big Adjustments

“At the rate we are going, 100 percent of American adults will be considered overweight by 2050,” says Nestor de la Cruz-Munoz, MD. De la Cruz-Munoz is the surgical director of the Surgical Weight Loss Institute in Miami. Bariatric surgery involves altering the anatomy of the bariatric patient to limit the intake or absorption of food, so de la Cruz-Munoz spends a great deal of time working with his patients’ radiologists post-operatively to describe these anatomic changes.

But, that’s just one of the myriad ways in which a bariatric patient’s medical history is linked with the imaging field. Caring for obese and overweight patients includes accounting for their secondary disease states and related health risks.

“More and more, we’re calling it metabolic surgery and not bariatric surgery,” says de la Cruz-Munoz. “If you say ‘bariatric,’ people just think about it from a weight-loss point of view. People do not get the surgery because they want to look better,” he says. “They get it because they want to feel better.”

The evidence bears out his point. Obesity sets people up for any number of health problems – some of which are later activated by hereditary triggers – which may include, but are certainly not limited to: hypertension, osteoarthritis, dyslipidemia, diabetes, heat disease, stroke, sleep apnea, gout, and cancer. Relieving the incidence of obesity eliminates these secondary complications in the majority of cases.

According to 20-year studies of bariatric patients published in the Journal of the American Medical Association, the procedure either resolved or improved a number of these obesity-related conditions in 60 percent to 80 percent of patients. As much as bariatric surgery is successful for the patients whose lives are improved by the procedure, decreasing the number of obese Americans will similarly lessen the strain on a U.S. healthcare system charged with treating their ancillary conditions.

“Many, if not all, of these health conditions require imaging throughout the care cycle, from screening and diagnosis through intervention and follow-up,” says John Steidley, vice president of global CT marketing for Philips Medical Systems in Cleveland. “The obesity epidemic will drive the need for a higher number of certain types of imaging procedures for diseases associated with obesity,” he says.

Imaging modalities provide a significant complement to the services provided to bariatric patients. Because the procedure itself requires a lifetime of follow-up, de la Cruz-Munoz finds it imperative to develop a close relationship with imaging professionals. “Morbidly obese patients don’t only get bariatric surgery,” says de la Cruz-Munoz. “They get every other kind of surgery as well, including hip replacements and gall bladder removal.”

By way of illustrating how central radiology is to his specialization, de la Cruz-Munoz points out that reviewers who certify centers of excellence in bariatric surgery spend one-fifth of their facility tour in the radiology department. “Five percent of the men in the United States are morbidly obese,” he says. “I would bet that more than 5 percent of the men who use the imaging centers are obese.”

Workarounds

“I am convinced that imaging departments are hit the hardest with caring for bariatric patients,” says Mark Busceme, RT(R). Busceme is a CT technologist at the Bariatric Center of Southeast Texas at Christus Hospital–Saint Elizabeth in Beaumont. He says that with imaging departments often short-staffed and overwhelmed by normal workflow and volume, bariatric patients are having an effect on the system simply in terms of time consumption.

“Imaging procedures are usually performed by one technologist,” Busceme says. “Technologists are transporting, transferring, and manipulating the bariatric patients to acquire an image of diagnostic quality, and it is getting more difficult to do it alone.”

Apprehension in dealing with bariatric patients is not uncommon, says de la Cruz-Munoz. But, at an average age of 40, he says most bariatric patients are actually younger and more mobile than elderly patients who may be more common visitors to the imaging center. “The first limitation that I’ve seen is the fear of moving that person [post-operatively],” he says.

“They’re very large and they’ve just had surgery. People are afraid that they’re going to have to lift and move them and hurt themselves doing it.”  Beyond questions of physically assisting the patient, many departments have equipment that may not be suited to the needs of large patients. X-ray tables and CT and MRI scanners have weight limits.

Most legacy equipment tops out around 300 pounds, and many enclosures were certainly not originally designed with obese patients in mind. Bariatric patients must be regularly measured and weighed to make sure they will fit the gantries without damaging the machines or themselves.

It can be an awkward proposition, says Busceme, even for someone familiar with the process. “I would find it mortifying as a patient to see someone coming into my room with a measuring tape,” he says, “to see if I even qualify for the procedure that could potentially save my life – and to then be told that I was too obese to be scanned.”

“I’ve had patients who were too large to image,” says de la Cruz-Munoz. “We have had to modify our techniques.”  He describes how many of his fellow bariatric surgeons have had to stand MRI tables upright, remove the floorboards in the imaging suite, and perform the MRI with the patient standing up.

He tells of how he’s broken one CT table and one fluoroscopic table in his career, and adds, “most bariatric surgeons are very conscious about the downtime and expense a broken scanner entails.” In other cases, however, the size of the patient is something that creates problems, even in a more forgiving environment.

When imaging bariatric patients, many procedures can be distorted by artifacts, regardless of whether the dimensions of the patient meet the physical thresholds of the equipment. “In CT angiography of the chest to rule out pulmonary embolisms, the couch, exposures, and contrast bolus have to be exact,” says Busceme.

Furthermore, he says, “If the patient is very large across the chest and upper back, or if the patient is rubbing against the inside of the gantry of the CT unit, artifacts will obscure the small pulmonary vessels, making it very difficult for the radiologist to give a definite diagnosis.”

In a post-operative setting, Busceme says, technologists routinely perform barium swallows and imaging of the upper gastrointestinal tract on bariatric patients. However, positioning obese patients “to accurately image the esophagus and stomach for a precise diagnosis” can be difficult. Morbidly obese patients may also require exploratory or diagnostic imaging when routine physical examinations are insufficient to diagnose their ailments.

As Steidley points out, however, the existent infrastructure may be ill-suited to their needs. ”Insufficient imaging windows in ultrasound and low-power X-ray generators and low table weight limits in cath labs often preclude diagnostic imaging,” he says.

“In fact,” he says, ”in a recent study [in the American Journal of Cardiology, Thomas E. Vanhecke, MD, and colleagues,] surveyed approximately 100 cardiovascular laboratories to determine what they did when patients were too heavy. Seventy percent of respondents could not provide an answer!”

Refining Perspectives

New technology is on the way, however. Steidley points out that the next generation of imaging tables offers reinforced weight limits, roomier dimensions, and higher-intensity beams for penetrating dense tissue. Other modalities that de la Cruz-Munoz mentions as having been useful include digital video recording and digital fluoroscopy.

Yet, the question of accessing larger, more penetrative scanning equipment persists.“Whether it’s a fluoro machine, a [CT scanner], or an MRI, they need to create a bigger space so these patients can fit,” says de la Cruz-Munoz. “I think open MRI is a great thing. Patient comfort and ease has always been a big driver for industry improvement.”

Steidley concurs. “These capabilities certainly add development cost to imaging systems,” he says. “However, the imaging industry is likely to see a relative increase in bariatric procedure volume as clinicians gain improved understanding of the capabilities of new imaging technologies to address these diagnostic needs.”

Busceme puts it more bluntly. “Facilities that have been functioning for the past 10 years have to buy and/or upgrade imaging equipment to accommodate larger patients, and new equipment does not come cheaply,” he says. “More technologists are also needed to care for these patients. It is our job to help the public; it just might take a little longer without help.”

Although obesity is on the radar of decisionmakers and innovators in the healthcare industry as a disease state with its own complications, experts say understanding of the problem in the public consciousness must be cultivated. Obesity is termed “epidemic” in the United States, but experts speculate that the average person does not have an awareness of the problem as anything other than a social issue.

“I think that obesity is one of the few conditions that it is still socially and legally acceptable to discriminate against,” says de la Cruz-Munoz. “It’s not just a willpower issue; really, it’s a physiological difference between different groups of people. It isn’t a one-cause answer.”

Optimistically, a multiphase solution would involve complementary approaches that include preventive care, education, gene therapy, and refinements in public policy. Without additional research into the root causes of obesity, however, everything else is just a stopgap.

“I think the industry has opened its eyes to say the obese population is here to stay,” says de la Cruz-Munoz. “We need to get them the services they need because they are the more frequent users of the healthcare system. Hospitals are turning to the industry and saying ‘this is what we need.’”

— Matt Skoufalos is a New Jersey-based freelancer. Questions and comments can be directed to editorial@rt-image.com.