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

Weight-loss surgery is considered a treatment option only for people 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 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 6.4.) On average, patients maintain a weight loss of 25% to 40% 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 kg to 159 kg (22.05 to 350.53 pounds) 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 FIGURE 6.4 Surgical weight loss procedures "Figure 5. Surgical Procedures in Current Use," in The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, National Institutes of Health, National Heart, Lung, and Blood Institute, North American Association for the Study of Obesity, October 2000, http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm (accessed January 12, 2006)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 to or less than 50 have the lowest reported mortality rates—less than 1%. 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%.

People 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 9, 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 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 $10,000 per procedure, the practice is extremely lucrative. In 2005 the cost of surgery and related care ranged from $20,000 to $50,000. 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.

Number of Surgeons and Surgeries Soars

The American Society for Bariatric Surgery (http://www.asbs.org/) reports that its membership has risen steadily from 162 in 1992 to 1,364 in 2005. In 1992, 16,000 bariatric procedures were performed; in 2005 the number was estimated to be in excess of 150,000. For thousands of patients, the weight-loss surgery has eliminated debilitating diseases and improved the quality of life. With the number of candidates for bariatric surgery increasing, the number of procedures is expected to continue to grow, even in view of data that reveals that the risks are greater than previously believed.

One study reported that one in five patients suffered complications after surgery. For one in twenty patients, the complications were serious, including heart attacks and strokes. Another recent study said the mortality rate for the most common type of bariatric surgery, gastric bypass, was one in 200-higher than for coronary angioplasty, a procedure to open blocked heart vessels. Because bariatric surgery is increasingly common, there may be more complications and deaths overall, even if the risk associated with each individual procedure decreases (Robert Steinbrook, "Surgery for Severe Obesity," New England Journal of Medicine, vol. 350, no. 11, March 11, 2004).

One survey found that even the risk of death does not dissuade many patients from undergoing bariatric surgery (Christina Wee et al., "Assessing the Value of Weight Loss among Primary Care Patients," Journal of General Internal Medicine, vol. 19, no. 12, December 2004). In an effort to quantify the value people place on modest weight loss, researchers at Harvard Medical School interviewed 366 patients at a large hospital-based primary care practice, one-third of whom were obese. The subjects were asked to imagine a treatment that would guarantee them effortless weight loss of varying amounts of weight. For each amount, they were asked, would they be willing to accept a risk of death to achieve it? If so, how much of a risk of death?

Willingness to risk death or trade years of life to lose weight significantly increased with higher BMI, and the more weight the subjects imagined they could lose, the greater the risk they would take to achieve it. Nineteen percent of overweight and 33% of obese people said they would risk death for even a modest 10% weight loss, compared with just 4% of normal weight subjects willing to risk death to lose 10% of their weight.

Many of the overweight and obese participants in the Harvard survey also said they would give up some of their remaining years of life if they could live those years weighing slightly less. Thirty-one percent of obese patients and 8.3% of overweight patients said they would trade up to 5% of their remaining lives to be 10% thinner. The researchers concluded that many people, especially those who are obese, value modest weight loss and they exhorted physicians to emphasize the benefits of modest weight loss when counseling their patients.