The Doctor's Guide to Weight Loss Surgery: How to Make the Decision That Could Save Your Life Reprint, Subsequent Edition

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OBESITY: AMERICA’S DISEASE

“I’ve been fat since I was a baby. My entire family is fat. Who knows if it’s our genes or our eating habits or a combination of both. I just know that being fat is a horrible way to have to live.”

Sara P., 43, 360 lbs. pre-op; 200 lbs. 2 years post-op

“When I walk around at the mall with my kids, I have to admit that I look at people who are obese. It reminds me of how I looked and felt before the operation. It’s amazing how many people there are out there suffering from this when there is something that can be done about it.”

Tim W., 50, 400 lbs. pre-op; 230 lbs. 18 months post-op

Disease (noun)-a specific illness or disorder characterized by a recognizable set of signs and symptoms, attributable to heredity, infection, diet, or environment. (Mosby’s Medical, Nursing, and Allied Health Dictionary, Fifth Edition)

Contrary to popular opinion, obesity is not a personality disorder

resulting from a lack of individual willpower or self-control. Rather, it is a chronic disease characterized by the accumulation of excess body fat, which can be detrimental to health. Obesity is distinguished from overweight, which does not take body composition into consideration. Many athletes are overweight, but because their excess weight is predominantly comprised of muscle, not fat tissue, they are not obese.

SOME FACTS ABOUT OBESITY

The worldwide incidence of obesity is increasing. In 1998, the World Health Organization published Obesity: Preventing and Managing the Global Epidemic, which classified obesity as a growing epidemic. In the United States, obesity is the most common chronic disease, affecting one-third of all Americans, including children, and its prevalence has been steadily increasing for the past twenty years. In Europe, Australia, New Zealand, the Middle East, and the remaining portions of the Americas, the occurrence of obesity appears to be increasing and is now between 10 and 20 percent. The prevalence of obesity is still fairly low in China, Japan, and many countries in Africa.

During the 1970s, the National Center for Health Statistics found that approximately 45 percent of all adult Americans were overweight and 14 percent were obese. These figures stayed relatively constant for over a decade. Armed with this information at the beginning of the 1990s, the Department of Health and Human Resources published Healthy People 2000, a policy statement outlining our national public-health priorities and goals as we entered the new millennium. The initiatives recommended included: reducing the incidence of overweight and obesity by 20 percent; improving the diagnosis and treatment of several obesity-related conditions, such as diabetes, coronary artery disease (hardening of the arteries), hypertension (high blood pressure), and hyperlipidemia (elevated serum cholesterol and blood lipids); and increasing the amount of regular aerobic exercise engaged in by adults and children.

When the National Center for Health Statistics repeated its survey in the mid-1990s, it found that the prevalence of overweight had increased from 47 percent to 54 percent (57 million people), with the prevalence of obesity increasing from 15 to 22 percent (40 million people). Moreover, the prevalence of severe obesity rose from 4.5 percent to 8 percent of the population (Table 1-1). In 1995, the Institute of Medicine, in its publication Weighing the Options, referred to obesity as an epidemic. It is currently estimated that there are approximately 127 million overweight or obese adults in the United States. Of these, 30 million are obese with a Body Mass Index of 30 to 34, 23 million are severely obese, with a Body Mass Index of 35 to 39, and 10 million suffer from morbid or clinically severe obesity, with a Body Mass Index above 40. (We will discuss the Body Mass Index, or BMI, in Chapter 2.)

Among American youth, the prevalence of obesity has sky-rocketed during the past two decades, from just under 4 percent in children (six to eleven years) and 6 percent in teenagers (twelve

to nineteen years) to 15 percent in children and 15 percent in

adolescents. The prevalence of overweight is also extremely high among youth, being 40 percent in Native Americans, 30 percent in African Americans and Hispanics, 25 percent in whites, and 20 percent in Asian-Americans. As with adults, obesity in youth is associated with a number of medical problems, including type II diabetes, hypertension, asthma, sleep apnea, orthopedic problems, psychological problems, and negative social stigmata.

The exact cause of obesity remains unknown, but multiple factors, genetic and environmental, appear to contribute. Afflicting individuals of all ages, genders, races, and ethnic groups, obesity is associated with numerous medical problems and can have a relatively benign or malignant course. Obesity increases steadily with age in both men and women, and it is more common in women than men. It affects African-American and Mexican-American women more than Caucasians or Asian-Americans. A strong genetic linkage exists among the Pima Indians, who live in the Southwestern United States.

Children born to obese parents are more likely to become obese than children born to thin parents. Studies of adopted children have shown that their tendency toward obesity is more related to the weight of their birth parents than their adoptive parents. Furthermore, in studies of twins who were raised separately, the ultimate weight of each sibling tended to be more similar to each other than to that of their nonbiological, adopted family members. Nevertheless, it is likely that these genetic factors merely predispose individuals to obesity but do not guarantee its development. The disease becomes manifest only in the presence of the proper environmental triggers, which are related to several factors, including culture, diet, and physical activity.

Over the past few centuries, Western industrialized societies have placed a progressively greater value on thinness. Television and magazine advertisements equate beauty with thinness. By contrast, the robust bodies of the women glorified in masterpieces throughout the Middle Ages and Renaissance would be considered obese by our standards. On the other hand, in poorer, underdeveloped cultures, where famine is common, obesity is perceived as a sign of wealth and is therefore associated with greater sexual attractiveness.

Diet and exercise also affect the onset and development of obesity. High-fat diets, which are prevalent in wealthier, Western cultures, increase the prevalence of obesity. Modernization of society and the development of ever more advanced technology have led to a progressive decrease in physical activity. Inventions such as the automobile, elevator, escalator, remote control, and wireless communication all decrease the amount of physical activity we perform daily. Similarly, children reared on television, video games, and computers are more likely to become obese than those who exercise regularly.

Table 1-1: Increase in the Prevalence of Overweight and Obesity

in the United States

Weight                          Number

Category*       1976-1980       1988-1994       1999-2000       Americans

Overweight      32 percent      32 percent      34 percent      64 million

Obese   10 percent      14 percent      16 percent      30 million

Severely Obese  3 percent       5 percent       9 percent       23 million

Morbid Obesity  2 percent       3 percent       5 percent       10 million

Total Population        47 percent      54 percent      64 percent         127 million

* Classification based upon World Health Organization

American Obesity Association: www.aoa.org/subs/fastfacts/obesity_US.shtml

THE HIGH COST OF OBESITY

The economic cost of obesity is enormous. An estimated $70 billion is spent annually in the United States on the treatment of obesity and its related conditions. This sum represents about 8 percent of the total health-care budget, or one out of every twelve dollars spent on health care. In addition, another $33 billion is expended on commercial weight loss programs each year, despite the fact that there is no available evidence suggesting that they are effective in producing long-term weight loss. Annually, the cost of obesity treatment exceeds $100 billion. At any given time, an estimated 40 percent of women and 25 percent of men are trying to lose weight, with an additional 30 percent involved in weight maintenance.

The significance of obesity as a public-health problem is related to its association with a number of complicating (or co-morbid) medical conditions. Obesity alone is a risk factor for premature death, with risk increasing in direct proportion to weight. Furthermore, obesity is causally related to diabetes, hypertension, coronary artery disease, stroke, sleep apnea, venous disease, gallstones, gastroesophageal reflux (heartburn), osteoarthritis, urinary stress incontinence, menstrual irregularity, infertility, depression, and several types of cancer. Many of these health problems improve or completely resolve with weight loss. Ironically, many insurance carriers and the federal government continue to refuse to pay for obesity treatments (diets, drugs, behavior modification, and surgery) but willingly expend funds to treat diseases that result from obesity.

Obesity takes a social and psychological toll on its victims. Obese individuals face discrimination in school, the workplace, the media, and in the health-care system. Many health-insurance plans do not cover obesity treatment or, if they do, the benefits are severely reduced or restricted. The decisions of insurance and managed-care companies in this regard are often arbitrary and ignore established medical evidence. No other group of individuals is stigmatized to the same degree as the obese and forced to jump through so many hoops in order to receive authorization for the care of a chronic debilitating disease. Morbidly obese people seeking weight loss surgery have to document every diet they have ever been on in addition to undergoing psychological screening to make sure they will comply with the dietary requirements after surgery. Smokers suffering from coronary artery disease in need of open-heart surgery do not need to present letters from their physicians verifying that they have stopped smoking nor do they need to undergo psychological screening to ensure that they will modify their diet and engage in a cardiac rehabilitation program after surgery. Physicians and other health-care practitioners involved in the treatment of obesity are also stigmatized, still often referred to as “quacks.”

Recently, inroads have been made into the causes and treatment of obesity. Identification of several genes and their corresponding hormones, such as leptin, that are in part responsible for obesity have confirmed that it has a biological basis, helping to reduce the misconception that obesity is a behavioral or psychological disorder. Several promising new drugs and drug classes have been introduced to treat obesity. However, these medications face severe hurdles before they can become available to the general public. They have strict restrictions against long-term use, often based on misconceptions rather than scientific evidence that they are addictive. Safe and effective surgical techniques have been devised that produce long-term weight control for the most severely obese individuals and result in significant improvements in associated medical problems. The beneficial effects of surgery in severe obesity have been evaluated, confirmed, and endorsed by the National Institutes of Health, the World Health Organization, the American Obesity Association, and Shape Up America! Nevertheless, much still remains to be done to improve the treatment of obesity and access to treatment.

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ARE YOU OBESE?

“The first time I saw the word obese used to describe me was when I sneaked a look at my medical chart when my doctor walked out of the room. I was shocked. I knew I was fat-but it was hard to accept the fact that I was that far gone.”

Maggie L., 54, 384 lbs. pre-op; 265 lbs. 3 years post-op

“I never saw the term morbidly obese until I read it in a magazine. It didn’t take me long to understand what it meant. If I didn’t begin to take care of my health-I was not going to live to a ripe old age.”

Karen K., 38, 288 lbs. pre-op; 179 lbs. 1 year post-op

The medical, psychological, social, and economic consequences of obesity are directly related to body size. The greater the degree of obesity, the greater the health risk. In order to more accurately predict the increased health risk associated with obesity, it is necessary to accurately describe the degree of obesity.

BODY MASS INDEX, OR BMI

Obesity can be defined in several ways. In the past, people referred to height-weight tables (such as those published by the Metropolitan Life Insurance Company) to determine if their weight was appropriate for their height. The weights were often corrected for “frame size” (small, medium, large). In recent years, height-weight tables have fallen out of favor within the medical and scientific communities and have been replaced by a method that more accurately accounts for the relative contributions of height and weight-called the Body Mass Index, or BMI. (BMI is generally expressed as kg/m2, but for the sake of simplicity we will omit the kg/m2 notation in the remainder of the book.)

To calculate your BMI:

Multiply your weight in pounds by 705.

Divide that number by your height in inches.

Divide that number by your height in inches again.

You can also calculate your BMI by using the accompanying Table 2-1.

IDEAL AND EXCESS BODY WEIGHT

Although BMI is the preferred method for describing one’s health risk as it relates to weight, the concepts of Ideal (or Desirable) Body Weight (IBW) and Excess Body Weight (EBW) are simple ones. The notion of an IBW, which is the ideal amount that a person should weigh, arose from the use of height-weight tables. Several formulas to estimate IBW exist, but the simplest is:

IBW (Women) = 100 lbs. for the first 5 ft. of height, + or

– 5 lbs. for each inch above or below. (For example, a woman 5 ft. 2 in. tall has an IBW = 110 lbs.)

IBW (Men) = 106 lbs. for the first 5 ft. of height, + or – 6 lbs. for each inch above or below. (For example, a man 5 ft. 2 in. tall has an IBW = 118 lbs.)

EBW, which is the amount that one is overweight, is calculated as follows:

EBW = Actual body weight (ABW) minus IBW

In addition to estimating how much a person “should weigh” and how much he or she is overweight, IBW and EBW are most useful in estimating how much weight an individual can reasonably expect to lose following WLS. You can reasonably expect to lose at least 50 percent of your EBW following WLS.

ASSESSING THE RELATIONSHIP BETWEEN WEIGHT

AND HEALTH RISK

A normal BMI is between 19 and 25, and beyond this level, health risks increase steadily. In 1998, the World Health Organization, in its report Obesity: Preventing and Managing the Global Epidemic, proposed a new classification for health risk related to BMI. Individuals with BMIs between 20 and 25 are considered normal. Those with BMIs between 25 and 30 are classified as overweight, with only a mild to moderate increase in health risk. The risk increases as the BMI rises above 30 (obese), 35 (severe obesity), and 40 (morbid or clinically severe obesity). Individuals with a BMI greater than 50 are often referred to as super obese and carry the greatest threat to health. There is also a health risk associated with being too thin, with a BMI less than 19. (See Table 2-2.)

People with morbid or clinically severe obesity are at greatest risk for the various associated health problems. In the past, these labels were used when someone was 100 pounds above ideal body weight or twice his or her ideal weight. With more widespread use of BMI to describe health risk, this corresponds to a BMI greater than 40 or greater than 35 in the presence of life-threatening complications. In general, co-morbid medical conditions are most common in patients with severe and clinically severe/morbid obesity.

When describing the effects of obesity treatment, it is necessary to evaluate weight loss and its impact on associated health risks. A better and more scientifically accurate approach would probably be to estimate how many BMI units one would have to lose in order to lower overall health risk and reach a “healthier weight.” However, it is much more understandable to express weight loss in pounds (“I lost 100 pounds”) than in BMI units (“My BMI went from 50 to 27”).

The various formulas describing weight discussed so far are summarized in Table 2-3.