Fighting Obesity: Surgery or Lifestyle Modification?

An increasingly popular response to morbid obesity affecting both adults and adolescents lies with bariatric surgery—gastric-restrictive and intestinal-bypass procedures. With the widespread public awareness of bariatric surgery, there has been a near explosion in the number of practitioners in the community who perform these operations. Similarly, the number of major academic centers with bariatric surgery programs has dramatically increased in the past several years.

We readily, even enthusiastically, acknowledge that with careful patient selection and fine operation performed in a first-rate center, some morbidly obese patients with significant medical co-morbidities may lose hundreds of pounds and recover an otherwise lost life.

Brittle diabetes may be brought under control; hypertension may virtually disappear; and an ever-present wheelchair may be disregarded. But all too often, unhappy overweight and obese patients may choose to undergo bariatric surgeries either prematurely or seemingly in the absence of meaningful efforts at prescriptive social and behavioral weight-loss programs.

Bariatric surgery is arguably in its infancy, and, with a variety of operations and the plethora of settings, outcomes and morbidity have simply not yet been fully studied. It is not unreasonable to suggest that informed consent itself for these procedures is a dubious proposition.

In clinical practice, a disproportionately large number of bariatric patients appear to suffer from chronic and severe dumping syndrome, other sequellae of malabsorption and malnutrition, acid reflux, blood pressure and body temperature instability, and loss of the usual sensations of taste, cravings, and satiety.

Despite the change in body habitus and improvement in global medical condition, it is not uncommon for physicians and health care providers, including nutritionists, to hear patients express regrets as often as satisfaction in the wake of bariatric surgery. Erratic and incomplete reporting may well be clouding perceptions of the basic safety and wisdom of obesity surgery.

This observation is particularly disturbing in light of multiple studies, especially in the pediatric population, that demonstrate the efficacy of family-based programs of dietary intervention, exercise, and other evidence-based behavioral modification strategies. At a recent Academy for Eating Disorders meeting, Marsha Marcus of the University of Pittsburgh reviewed multiple studies in obese children that have shown sustained weight reduction a decade after treatment: 30% of subjects were no longer obese.

We know that intensive counseling by health care professionals is effective in increasing the level of physical activity in previously sedentary individuals’ physical activity alone. We also know, from the Physicians’ Health Study and the Harvard Nurses’ Health Study, that physically active obese individuals have a lower incidence of many chronic diseases than unfit obese counterparts and that physical activity independent of obesity lowers the risk of both diabetes and coronary events. These observations are certainly in line with what is known about the physiology of exercise and promotion of endothelium-dependent vasodilation, reversal of insulin resistance, and increase in lipoprotein lipase activity.

In the realm of food and nutrition, we know that caloric reduction, i.e., dieting in conjunction with properly adjusted and meaningful aerobic exercise, generally leads to weight loss. Why is it that we as a nation are in such nutritional trouble when our fund of knowledge and our level of technology have never been greater? It seems to us that it is time to revisit questions about the adequacy of our collective professional efforts to help the morbidly obese eat better, live better, and lose weight more safely.

Have we done studies that compare socioculturally appropriate environment-focused interventions with individual behavioral approaches to control obesity? Have we looked at innovative public health/education approaches to collaboration with mass media, the insurance industry, social support networks, religious groups, and “big business”? Have we fully explored and exploited opportunities to deliver smaller, healthier portion sizes in cafeterias and vending machines? We are pleased to see that current trends indicate that food portions are declining while offering a variety of healthful choices, school cafeterias are modifying their menus, and vending machines are providing alternative food choices for a healthy lifestyle.

If we are to stem the tide of what may well be an excess of serious surgeries often associated with unacceptable morbidity, let us re-examine our commitment to developing and studying nutritional intervention for this complex and difficult public health problem.

by Roger Clemens, Dr.P.H.,
Contributing Editor 
Director, Analytical Research, Professor, Molecular Pharmacology & Toxicology, USC School of Pharmacy, Los Angeles, Calif. 
[email protected]

by Peter Pressman, M.D.,
Contributing Editor 
Attending Staff, Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif.
[email protected]