Drugs Physical Activity Surgery and other Treatment for Overweight and Obesity - Surgery

Weight-loss surgery is considered a treatment option only for persons for whom all other treatment methods have failed and who suffer from clinically severe obesity—BMI of 40 or greater or BMI of 35 or greater in the presence of comorbidities. (Clinically severe obesity was formerly known as morbid obesity, indicating its potential to cause disease.) Two types of surgical procedures have been demonstrated effective in producing weight loss maintained for five years: "restrictive" techniques, which restrict gastric volume, and "malabsorptive" procedures, which not only limit food intake but also alter digestion. An example of the first type is banded gastroplasty, in which an inflatable FIGURE 6.5
Surgical weight loss procedures band that can be adjusted to different diameters is placed around the stomach. The Roux-en-Y gastric bypass is an example of the second type. (See Figure 6.5.) On average, patients maintain a weight loss of 25 to 40 percent of their preoperative body weight after these procedures.

An NIH review of five randomized clinical trials (studies in which participants are assigned by chance to separate groups to compare the outcomes of different treatments to determine which is most effective) found that patients who received obesity surgery lost 10 to 159 kg (22.05 to 350.53 lbs) over twelve to forty-eight months; however, the surgeries are not without risk, so health-care professionals generally recommend surgery only when the risks of obesity far outweigh the risks associated with the surgery. According to the National, Heart, Lung, and Blood Institute, surgical complications vary depending on the weight and overall health of the surgical patient. Young people without comorbidities and BMI equal or less than 50 have the lowest reported mortality rates—less than 1 percent. Not unexpectedly, those with BMI equal to or greater than 60 with comorbidities such as diabetes or high blood pressure have mortality rates of 2 to 4 percent.

Persons who undergo weight-loss surgeries require lifelong medical monitoring. After surgery they are no longer able to eat in the way to which they were accustomed. Those who have undergone gastric bypass experience "dumping syndrome" with symptoms such as sweating, palpitations, lightheadedness, and nausea when they ingest significant amounts of calorie-dense food, and most become conditioned not to eat such foods. Patients who have had gastric restriction surgery are unable to eat more than a limited amount of food at a single sitting without vomiting, and must eat several small meals per day to maintain adequate nutrition. Those who do not adhere to a prescribed regimen of vitamins and minerals may develop vitamin and iron deficiencies. There also are postoperative and long-term complications of surgery such as wound infections, problems such as hernias at the incision site, and gallstones. Generally, however, patients fare extremely well, experiencing dramatic improvement and even complete resolution of diabetes, hypertension, and infertility, as well as improved mobility, self-esteem, and overall quality of life.

In "Surgery for Obesity: Demand Soars Amid Scientific, Ethical Questions" (Journal of the American Medical Association, vol. 289, no. 14, April 2003), Mike Mitka noted that ethical and scientific questions about obesity surgery remain unanswered. Mitka observed that a 1991 Consensus Statement by the NIH that established criteria for eligibility for surgical treatment of morbid obesity opened the door for insurance coverage and precipitated an explosive increase in its use. About 47,000 surgeries for treatment of morbid obesity were performed in the United States in 2001, approximately 63,000 surgeries were performed in 2002 and about 98,000 in 2003. He noted that by 2003 the demand for the surgery was so great that many hospitals had yearlong waiting lists of hundreds of patients.

Mitka questioned whether the science is keeping pace with the popularity of the procedures, observing that fundamental questions about the surgery and its long-term consequences are unanswered. These include a complete understanding of the precise mechanisms whereby surgical treatment results in weight reduction; mechanisms underlying improvement in comorbid risk factors or disease; safety and efficacy of surgery in defined patient subgroups; safety and efficacy of different surgical procedures; and the impact of surgery on subsequent pregnancy. Issues such as the maintenance of weight loss and the long-term effects of altering nutrient absorption also remain unresolved.

Troubling questions about reimbursement and payment for the surgery also remain. With some surgeons performing as many as 400 surgeries per year for fees as high as $4,000 per procedure, the practice is extremely lucrative. In light of the increasing number of obese adults in the United States and the willingness of many to pay cash if they do not have insurance or they have been denied coverage, some surgeons may be motivated by financial interests to perform increasing numbers of procedures. This ethical issue is heightened by the proliferation of print and electronic media advertising of the surgery by physicians and hospitals along with endorsement of the procedure by celebrities. Carnie Wilson of the band Wilson Phillips, and daughter of Beach Boy Brian Wilson, has been the most outspoken celebrity proponent of gastric bypass surgery since undergoing the procedure in 1999 and slimming down from 300 to 150 pounds. Today Show weather reporter Al Roker had gastric bypass surgery in March 2001, and comedian Roseanne had gastric bypass surgery in 1998. Although some industry observers feel that celebrity success stories have raised the visibility of gastric bypass surgery and reduced the stigma associated with seeking treatment for obesity, others fear that media fanfare will prompt increasing numbers of people who are obese to forgo less drastic treatment options in favor of the surgery that media celebrities endorse.