9. Know effects and efficacy of surgical approach to obesity

Unit 5 Section 2Exercise 6 Obesity Surgeons' attitudes

Clinical correlate #4
Obesity treatments
Gastric bypass/Lap Banding
Counseling
Chronic care model

Atul Gawande, in his book Complications, describes performing a gastric by-pass on a 54-year old construction contractor who weighed 428 pounds. The story describes the long aftermath of the surgery.

“[After] 3 weeks, he already lost 40 pounds. But at 390, and still stretching his size 64 slacks and size XXXXXXL T-shirts, he did not feel different.”

The patient had been obese most of his adult life, and reached weight where he was unable to function normally. “He hadn’t been on an airplane since 1983, and it had been 2 years since he’d been to the second floor of his own house, because he couldn’t negotiate the stairs…Unable to lie down, he had slept in a recliner ever since.” He also had problems with hygiene, skin infections and a non-existent sex life. He grew too large to operate his machinery or to conduct any aspects of his business that required getting up and about. No amount of dieting had a lasting effect. A serious skin infection and financial disaster finally prompted him to agree to a by-pass. As Gawande comments:

“The history of weight-loss treatment is one of nearly unremitting failure. Whatever the regimen—liquid diets, high-protein diets, or grapefruit diets, the Zone Atkins, The Dean Ornish diet—people lose weight quite readily, but they do not keep it off. A 1993 National Institutes of Health expert panel reviewed decades of diet studies and found that between 90 and 95 percent of people regained one-third to two-thirds of any weight lost within a year—and all of it within 5 years. Doctors have wired patients’ jaws  closed, inflated plastic balloons inside their stomachs, performed massive excisions of body fat, prescribed amphetamines and large amounts of thyroid hormone, even performed neurosurgery to destroy the hunger centers in the brain’s hypothalamus—and still people do not keep the weight off…We are a species that has evolved to survive starvation, not to resist abundance. 169-170.

The patient reached 320 pounds, but was having job trouble because he could still not operate a truck. In addition, the rate of weight loss had slowed, and often he ate more than he could tolerate, which would cause him to throw up. Gawande describes the case of a gastric bypass operation that failed. In that case, the patient ate in spite of the extreme pain it caused. And if eating caused him to vomit, he would just eat more. In fact, by eating constantly, he ended up regaining all of his weight, in spite of the surgery.

After many months, Gawande sees his patient again. “A few day later, he picked me up at the hospital in his rumbling six-wheel Dodge Ram. For the first time since I’d met him, he looked almost small in that outsize truck. He was down to about two hundred and fifty pounds. ..The rolls beneath his chin were gone. His face had a shape. His middle no longer rested between his legs. And, almost a year and a half after the surgery, he was still losing weight. At the Fleet Center, where the Bruins play, he walked up the escalator without getting winded. Our tickets were taken at the gate..and we walked through the turnstiles….He could operate the Gradall without difficulty, and he’d had full-time Gradall work for the past three months. ..At home, he had moved back upstairs.”

“I asked him what had changed since I saw him the previous spring. He could not say precisely, but he gave me an example. ‘I used to love Italian cookies, and I still do,’ he said. A year ago, he would have eaten to the point of nausea. ‘But now they’re, I don’t know, they’re too sweet. I eat one now, and after one or two bites I just don’t want it.’ It was the same with pasta, which had always been a problem for him. ‘Now I can have a taste and I’m satisfied.’

This essay was written in 2002. Gawande writes about gastric by-pass: “Physicians have gone from scorning it to encouraging, sometimes imploring, their severely overweight patients to undergo a gastric-bypass operation…More than 5 million adult Americans meet the strict definition of morbid obesity….So many patients are seeking the procedure that established surgeons cannot keep up with the demand.” 181

Study questions:

1. What is your reaction as you read about Gawande’s patient? What feelings do his entry condition evoke? What is your response to his success? How does this personal narrative influence your reading of the last quotation cited above?
2. Read the following on the costs of caring for obese persons and comment on whether our society should invest in the costs of by-pass surgery.

Kaiser Daily Health Policy Report

      Lifetime health care costs for obese individuals and smokers are lower than those for healthy individuals who live years longer, according to a study Monday on the Web site of the Public Library of Science Medicine, the AP/Boston Globe reports. For the study, led by economist Pieter van Baal of the National Institute of Public Health and the Environment in the Netherlands and sponsored by the Dutch Ministry of Health, Welfare and Sport, researchers developed a model to predict lifetime health care costs for 1,000 individuals in each of three groups -- obese individuals, smokers and healthy individuals. Researchers based the model on "cost of illness" data and disease prevalence in the Netherlands in 2003.

Obese individuals had the highest health care costs from age 20 to 56, and obese individuals and smokers had a higher rate of heart disease than healthy individuals, the study found. However, the study found that obese individuals and smokers had lower lifetime health care costs than healthy individuals because they died earlier.

On average, healthy individuals lived 84 years, compared with 80 years for obese individuals and 77 years for smokers, the study found. Healthy individuals on average had lifetime health care costs of $417,000, compared with $371,000 for obese individuals and $326,000 for smokers, according to the study.

Comments

According to van Baal, the study indicates that government efforts to prevent obesity and smoking can lead to higher health care costs in the long term. He said, "Lung cancer is a cheap disease to treat because people don't survive very long. But if they are old enough to get Alzheimer's one day, they may survive longer and cost more." He said that, although researchers do not recommend that "governments stop trying to prevent obesity" and smoking, they should undertake such efforts to improve the health of residents, rather than to reduce health care costs (Cheng, AP/Boston Globe, 2/4).

Clinical correlate: Questions regarding the long-term outlook and morbidity and mortality benefits of gastric bypass Lap banding Can obese doctors counsel obese patients?