2008-09-06 / Columnists

Obesity Will Soon Become the Primary Preventable Cause of Death

Maintaining Your Health on Mackinac
By Yvan Silva, M.D.

The epidemic of obesity and morbid obesity continues to predominate among the concerns in public health care. The incidence is increasing in the United States, and more and more countries are seeing their populations affected. Concerns have heightened. For pediatric and adolescent populations, the co-morbidities of secondary diabetes and abnormal cholesterol levels are further challenges to the prevention and curative measures in these age groups. Most recently, there has been national controversy regarding the recommendations by a national society, that children receive statin drugs for cholesterol control.

Seven years ago, the Surgeon General's report noted that illness associated with obesity had cost the United States $117 billion the previous year. This figure was close to the average annual cost associated with smoking - $150 billion, according to the Surgeon General. As a "fastfood" nation, the daily intake of calories by Americans has jumped by more than 10% over the past two decades. This situation is not unique to the United States. It is increasing visibly in the developed, and some developing, nations.

Obesity has become commonplace all over the United States. Two in three adults are now classified as overweight or obese, compared with less than one in four during the early 1960s. Interestingly, there has been a change in the perception of the general public. More and more people agree that this is more than a cosmetic problem, and recognize the consequences to health when obesity reaches the definition of "morbid."

Some 280,000 deaths per year are now attributable to obesity, which will soon overtake smoking as the primary preventable cause of death, if present trends continue. Although obesity is associated with severe morbidities, health care professionals and public health policy makers have not been able to make substantive inroads into the problem; this epidemic has not yet gotten the kind of deliberate attention received by tobacco use, alcoholism, hypertension, diabetes, and high cholesterol.

Prevention and weight control are receiving greater attention in the field of public health. Programs for children, parental education, and diet modification programs are being presented in schools and other facilities. Widespread identification of caloric content and components in food products are finding their way into labels required by authorities. Yet, obesity rates continue to climb.

The mortality rates in people who are morbidly obese are 12 times higher in men aged 25 to 34 years, and six times higher in men aged 35 to 44 years, compared to men of healthy weight of the same age. It has been observed that even modest weight loss, 10% to 15% of initial weight, usually results in improvement of multiple health-related problems. The costs pertaining to management of obesity, on a national scale, are estimated at $51.6 billion; the annual expenditure on weight reduction is more than $30 billion.

It is important to review current definitions of the terms. The basis is the Body Mass Index (BMI). BMI is calculated based on an individual's height and weight. The weight in kilograms (2.2 pounds per kilogram) is divided by the square of the height in meters (39.37 inches per meter) = BMI.

A BMI of 25 or more is considered overweight, 30 or more is considered obesity, and 40 or more is "morbid obesity."

One other practical way to calculate BMI is to take the weight in pounds, divide it by the height in inches squared, and then multiply that by 703. The calculator is not necessary nowadays, because the formula for BMI is now ubiquitous, and is easily available online and from health care resources in chart form.

Bariatrics is the field of medicine that specializes in treating obesity. Because obesity is so difficult to treat in the long term, several specialties in the medical sciences have begun to come together to help people with this chronic condition. Of these, bariatric surgery, surgery for obesity, is rapidly gaining in popularity.

Bariatric surgery, in appropriately selected patients, appears to be cost-effective by eliminating the need for medications and returning patients to productivity in the workplace, patients who were previous morbidly obese and compromised.

The past 10 years has seen a rapidly escalating demand for obesity surgery, and doctors and hospitals are scrambling to satisfy the demands for surgery that is designed to reconfigure the size of the stomach to restrict and limit intake in severely obese individuals. Several celebrities and public figures have overtly publicized their own successes with surgery. Currently, the number of operations has increased to more than 150,000 annually, approaching more than $3 billion in costs at an average of $25,000 to $30,000 per patient for the surgery, and additional expenses for related therapies.

The procedures have been approved for patients at the upper end of the BMI, defined as "morbid obesity," especially when accompanied by the usually occurring co-morbidities such as diabetes, hypertension, arthritis, and degenerative bone and joint abnormalities. Twenty-four million U.S. adults are living with morbid obesity currently, and may qualify for bariatric surgery, according to guidelines published by the National Institutes of Health. By 2010, it is estimated that 31 million U.S. adults will fit criteria for morbid obesity and may qualify for surgery under these guidelines. Surgery is being increasingly done in selected children and adolescents after careful consideration of risk versus benefit.

Several hospitals are adding special programs for surgical management of obesity - larger beds to support people who are now being called "patients of size," who may weigh up to 1,000 pounds. Specially designed with built-in weight scales that can measure people up to 500 pounds, operating suites are being equipped with larger operating tables and optimal instrumentation. "Bariatric centers" consisting of specially trained surgeons, teams of nutritionists, psychologists, specially trained nurses, special exercise programs, and other health care support services are being built all over the country.

Health care insurers will usually cover the costs only for patients who meet a list of preconditions. Some require proof that patients have spent at least six months in diet and exercise programs supervised by a physician. Many patients are paying costs directly in a serious effort to deal with these problems.

Several years ago, the only surgical procedure used, an intestinal bypass operation, provided patients with early weight loss, but the overall results were poor, and the procedure fell into disrepute. Over the past decade, there have been marked improvements in the design of surgical procedures, and with improvements in the team concept of patient management, bariatric surgery is now accepted as a strong and viable option for many patients with morbid obesity. Along with the expertise of specialists in internal medicine, gastroenterology, nutrition, psychology, and others, the pre- and post-surgical team approach, along with continuing support group interaction, is becoming increasingly popular with overweight Americans. Its popularity is enhanced by the media attention to many success stories.

Patient selection is important. Patients with severe untreated mental disorders such as depression, and those with eating disorders, are not good candidates for surgery. Patients have to be prepared to make drastic changes in their lifestyles. Counseling is an important part of the management plan. Surgical weight reduction is usually recommended to patients with a BMI of 40 or more, or 35 for those with medical complications.

Three types of operative procedures are currently being done. The procedure most commonly done these days is called laparoscopic gastric banding. The abdomen is entered with a laparoscope and a restrictive band is applied to the upper stomach, limiting its capacity to one to two ounces. This minimally invasive procedure has the advantage of rapid recovery and easy reversibility. It is gaining rapidly in popularity, although long-term results are not yet available. A second procedure also greatly reduces the size of the stomach pouch without changes in the small intestine. Commonly referred to as a gastric bypass, it involves the application of staples across the upper stomach, limiting capacity - an outlet to the pouch is provided by joining a limb of small intestine to the pouch. These gastric pouches are fashioned to two ounces or less, allowing ingestion of very small amounts of solid food.

The third, commonly called the Roux-en-Y or Roux-Y (named after Cesar Roux, a long-ago Swiss surgeon), is also popular. It reduces the size of the stomach to a volume of about two tablespoons, narrows the passage between the stomach and the small intestine, and bypasses a long, measured section of the small intestine where the food is absorbed. The restructuring of the small intestine results in the form of a Y-shaped structure, one arm of which carries digestive juices and the other carries food. The combination of restriction and malabsorption has proved more effective in producing long-term weight loss. Proper nutrition needs to be maintained because of the malabsorptive component and potential malnutrition. This procedure is usually preferred for patients with super-morbid obesity, with a BMI in excess of 45 or more.

Success is measured as maintenance of weight loss of 50% or more of excess weight for up to 10 years. The Rouxen Y operation has a long-term success rate to 90%, when combined with intensive counseling, support and nutritional education, and compliance.

There are problems emerging from this rapid expansion. The learning curve of the surgeon and the number of operations of this type performed do relate to the results. Some experts argue that a surgeon needs to do at least 100 cases before mastering the technique. While this seems overstated, it is important to know that any surgeon can perform weight-loss surgery if the hospital will allow it, and although there are professional groups that recommend selection criteria, the guidelines are not binding.

While the costs for the surgery can be $25,000 or more, they can skyrocket if serious complications occur. Within 30 days of surgery, a common period to determine mortality rates, the death rate at one large university medical center was 1.9%. Statistics showed that patients were 4.7 times more likely to die during the surgeon's first 19 procedures than after the surgeon had gained more experience.

Like any major surgery, there are risks. The most common complications include bleeding, blood clots, bowel obstruction, hernias, and infections from leaks into the abdomen from sites where the stomach pouch and intestine has been cut and joined or sealed surgically. According to the National Institutes of Health, 10% to 20% of patients require additional surgery for such complications, and nearly 30% develop nutritional deficiencies that lead to chronic conditions, like anemia and bone loss.

The benefits can be profound. In addition to long-term weight control, surgery can result in excellent improvement, and in some cases, reversal of Type 2 diabetes, improved blood cholesterol, lipid levels, and heart function, correction of breathing problems like sleep apnea, reduction of high blood pressure, and musculoskeletal ailments. Many patients are able to return to their jobs, exercise regularly, and live active social lives. Sexual interest often returns, and there are the important emotional benefits - improved self-image and self-esteem, and correction of depression.

Today, bariatric surgery is definitely an option for certain individuals with morbid obesity. Improvements in the quality of life and lower health care costs, reversal of disabilities, and the risk of premature death are important considerations. Bariatric surgery is an important, needed, and thriving specialty in health care.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.

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