A surgeon waves a white flag on obesity.

As a general surgeon in a community practice, I see a pretty diverse patient population.  Male and female, young and old, healthy and sick, big and small.  In the now over two decades since I graduated from medical school, it has become mostly the big. Or fat, overweight, obese, morbidly obese, body mass index > 25, 30, 35, 40 etc, however you want to label the worlds’ gradually expanding waistlines.  While the medical community argues over the best way to measure obesity (BMI, a ratio of height to weight is inaccurate with high muscle mass in elite athletes, waist circumference differs between males and females, etc) the waistlines of our population continue to expand and the ensuing burden on health care grows. It’s like arguing whether gas or oil started the fire while the house burns down. A lot of that extra weight seems to settle in the areas where I operate- roughly from the clavicles to the groins, most of the time.  Most of the conditions I treat, even electively, are not optional for either myself or the patients- breast cancer, colon cancer, gallbladders and hernias, and often there is some urgency.  Pre-operative weight loss is just not something I ask patients to do the vast majority of the time.  I often ask about whether or not the patient has lost weight with the abdominal complaints they come to me with (a big red flag that something bad is going on), but now the most common answer to the question is “I wish”.  Sometimes this is even from patients whose weight is well within a normal range.   And if they have lost weight, it has often been intentional.

A patient came to see me for routine follow up after gallbladder removal.  While I didn’t bring it up, the patient asked me, while quietly crying, what she should do about her weight.  She was desperate to lose some and viewed having required surgery for her gallbladder to be her line in the sand.  Tears are pretty common, especially from women, when the touchy subject of being overweight comes up in the office. I’m at a loss as to what to recommend to patients at this point.  The weight loss industry, the medical industry, and society at large, must consider our current approach to the obesity epidemic as an abysmal failure.  If the medical intervention of weight loss were a medication, it would have been withdrawn from the market decades ago, not only for lack of effectiveness, but for being dangerous. A recent study done on the contestants of the show “The Biggest Loser” show dangerously dropped metabolic rates.   Article here- https://www.scientificamerican.com/article/6-years-after-the-biggest-loser-metabolism-is-slower-and-weight-is-back-up/  This study gives us some insight into the difficulty people face when trying to lose weight and the roller coaster it becomes.  While there are some success stories of people losing dramatic amounts of weight and keeping it off long term simply with diet, exercise, and willpower, these unicorns are few and far between.  In addition, the older patients get, the less likely they are to have success with weight loss.

What about bariatric (weight loss) surgery?  Obesity is a surgical disease, some of my colleagues will argue.  We need to ramp up dramatically patients’ access to bypass, banding, “stomach stapling” procedures- these are collectively referred to as bariatric surgery.  I see plenty of patients after these procedures, which are no doubt life saving for (I believe) a small group of highly selected patients. Overall though, the results are mixed, with the more aggressive (malabsorptive) procedures much more successful at sustained weight loss than restrictive procedures such as stomach stapling or banding.  I have met some patients who have paid a lot of money and put themselves through the risk of an operation and its complications for very minimal results. One had lost a total of 4 lbs several years after a $15000 bariatric surgery done in another country- maybe the benefit was the surgery has prevented any further weight gain? The patients who do lose weight are often successful at losing some of their excess weight long term, but to me seem to be chronically malnourished and unhealthy when they present with other health problems. Some pretty extreme ideas are now being advanced to allow weight loss, including the FDA in the US approving a tube to partially drain stomach contents after meals (albiet in a selected patient population).  I find it hard to believe this somewhat disgusting device is going to be a magic bullet for weight loss, but you can read about it here-http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm506625.htm.  I just don’t see bariatric surgery as being a viable long term option for the obesity problem.  It should be one weapon in an arsenal.  Preferably that arsenal would contain a whole bunch of effective therapies for weight loss, but at this point it doesn’t.

So what to do?  I have stopped asking patients to lose weight except in very specific circumstances (recurrent hernias being one of the few instances).  After surgery I am simply asking patients to maintain their weight- most North Americans are gaining weight year after year.  I’m going to suggest that in our food inundated society weight maintenance/stability  over the years is a laudable goal once people are through adolesence (and excluding pregnancies). I went to a lecture some years back given by a bariatric surgeon.  He believed that the only way people overcome becoming obese in our society was to use their intellect to overcome the barrage of marketing messages that are thrown at us by the food industry every day.  A person in their 60s who has been 30-40 lbs overweight, but their weight has been stable over decades, is not likely to have much success with weight loss, except to join the rollercoaster of weight loss and regain.  If patients have chronic health conditions related to obesity (sleep apnea, diabetes, hypertension etc), I think absolutely weight loss should be encouraged, but there is a large population of technically obese or overweight people who are quite healthy.  I’m not sure encouraging a medical treatment known to fail 99 % of the time is a logical thing to do.  People often attempt to quit smoking many times before they kick the habit and that’s fine.  But to recommend weight loss to a patient, knowing it is so unlikely to succeed and a lot of the time to lead to a greater amount of weight regain? Is this reasonable?    Specific advice like “eat more fruits and vegetables,” and ” avoid drinks that contain calories”,which can be integrated into the patient’s life on an ongoing basis would be a better plan in my opinion.

I don’t believe my advice on weight loss in the office goes very far and so I am waving a white flag here.  I am not giving up, but I believe we need to have a break in the fight in this ‘battle’ to rethink our strategy- governments, the food industry, and the medical profession.   There is no evidence  and it’s illogical to suggest that investing more money in downstream healthcare (ie healthcare which deals with the adverse health consequences and not the prevention of obesity in the first place), is going to effect change in the expanding obesity problem. Obesity is complex and multifactorial and I think our society is going to have to embrace a widespread, public health approach to this problem. The solutions will have to come at an individual level, but also involve local, regional, and national, and even international approaches to obesity.

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