Roughly 300,000 people in the United States die prematurely each year
as result of obesity, and more than $150 billion is spent on
obesity-related health conditions. What can be done to stem the tide
of chronic disease, death and red ink caused by this epidemic? John
Sanford, a writer for Stanford Hospital & Clinics, spoke with John
Morton, MD, MPH, one of the leading weight-loss surgeons in the
country, to find out. Morton is director of bariatric surgery at
Stanford Hospital and associate professor of surgery at the School of Medicine.
What happened to plain old diet and exercise?
Morton: Well, when it comes to a body-mass index over 30, which
generally marks where obesity begins, it's very difficult to lose
weight on your own. If you follow the studies — the longitudinal data
— the evidence for this is pretty compelling. About 95 percent of
patients do not lose weight without some kind of intervention. There
are better treatment programs for crack cocaine than there are for
morbid obesity, meaning a BMI over 39. Those are simply the facts.
It's important to remember that obesity is not caused by a lack of
willpower. As anyone knows, it is hard to stick to a diet. If you look
at the attrition rates of Weight Watchers participants, you'll see
that everyone starts out at 100 percent adherence. After 10 weeks,
however, only 40 percent are still with the program. At 50 weeks, only
10 percent are still sticking with it.
Why is it hard to stick to a diet?
Morton: There are many physiological barriers to losing weight.
If you think about it from an evolutionary standpoint, maintaining
your weight is pretty darn important. Look at the levels of ghrelin,
the so-called hunger hormone, in a person who lost weight on a diet,
and you'll see they are much higher than before. Levels of another
hormone, leptin, which suppresses hunger and speeds up metabolism, are
lower. Your body's not stupid. It knows you have lost weight and will
do everything in its power to get that weight back. This is why you
see the rebound effect — people gaining back their pre-diet weight and
How can weight-loss surgery help?
Morton: I like to say it gives people a hunger holiday. If you
just look at ghrelin levels after gastric bypass surgery, you see they
go down to almost zero. It allows patients a break from all the
"head hunger" and anxiety about weight. You've heard doctors
talk about the golden hour in trauma? Well, bariatric surgery gives
patients a golden year in which they can take time to change their
habits to sustain weight loss. And studies show that it's effective in
the long term. After 10 years, a 2004 study showed that gastric bypass
patients had lost almost a third of their weight. The study showed
that patients who got gastric banding, in which a band is fitted
around the upper part of the stomach to make a smaller pouch, lost
about 15 percent of their weight over that time.
What is also impressive is the reduction of co-morbidities over
time. You see big reductions in hypertension, hypercholesterolemia,
sleep apnea and depression. The real eye-opener is the improvements to
diabetes. A 2001 study showed an 82 percent resolution rate of
diabetes in morbidly obese patients who underwent laparoscopic gastric
bypass surgery. They were able to stop taking medications — no
Metformin, no Actos, no insulin, no Byetta — and that happened very
quickly. This is where bariatric surgery certainly can make a difference.
What about the value of weight-loss drugs and prevention?
Morton: Prevention obviously is a terrific idea. I look forward
to everything that's going to happen there. And it's clearly been
neglected for a long time, but it will take about 20 years before
these efforts really take hold and begin to yield results. You end up
losing a generation. What do you do for people right here, right now?
So, prevention is terrific, but we're not going to see results around
the corner anytime soon.
As for medications, want to venture a guess as to how many there are
on the market today for obesity? Right now, it's one. It's called
Alli, and it's not exactly a blockbuster drug. It works strictly by
decreasing the amount of fat absorbed by the intestines. You lose a
grand total of about 13 pounds at the end of a year. Three other drugs
recently came up for approval, but they were all shot down by the FDA,
which I think is very wary after its experience with fen-phen. [This
anti-obesity drug, which was approved by the FDA but withdrawn from
the market in 1997, was shown to sometimes cause pulmonary
hypertension and heart-valve problems.]
How many people get weight-loss surgery?
Morton: Although roughly 15 million people in the United States
are morbidly obese, only about 1 percent of those who were clinically
eligible had bariatric surgery in 2009 — about 220,000 people. And the
thing is, the surgery is cost-effective. A 2008 study on its economic
impact estimated that the costs of laparoscopic weight-loss surgeries
were recouped in two years by morbidly obese patients who had the
operation. In other words, they got a complete return on investment in
two years, based on not having to pay other medical costs incurred
because of their weight. Patients who had open surgery, as opposed to
laparoscopic surgery, recouped their costs in four years. Bariatric
surgery is also now safer than it's ever been. The New England
Journal of Medicine published findings in 2009 from the
Longitudinal Assessment of Bariatric Surgery Consortium showing that
the mortality rate for 2,975 morbidly obese patients 30 days after
they got laparoscopic gastric bypass surgery was just 0.2 percent. Of
1,198 patients who got laparoscopic banding, the mortality rate at 30
days was zero. So the safety is good, especially compared to the risks
of extreme obesity.