Many insurers don't cover it, and most people who qualify are afraid to get the procedure, but bariatric surgery has proven to be effective.
Natasha Lane, 25 years old and bright-eyed, had a good life by many standards. She had a loving family, a circle of close friends, and a stable nine-to-five job at a call center.
But she also had a problem: at 313 pounds, she was severely obese. In fact, she was nearly double the weight that she should have been for her height. Clothes didn't fit her, walking around left her short of breath, and it was a struggle just to squeeze behind the steering wheel to drive to work. Her health was suffering, too; her blood pressure was too high, and she had developed diabetes.
Natasha made several attempts to diet, but her weight only continued to rise. It reached 320, then 330 pounds. "I felt like I was losing control," she said. "It kept going up and up, and I saw the future: I won't be able to fit into my car, no guy will want to date me, I won't get to do all the things that normal girls do."
Stories like Natasha's are becoming increasingly familiar. Today, a third of Americans are obese, and two-thirds are overweight -- a distressing reality for many reasons. Obesity increases the risk of heart disease, stroke, cancer, and diabetes, all leading causes of death in the United States. Managing the complications of obesity is also extremely expensive. According to the Centers for Disease Control (CDC), obesity accounted for an estimated $147 billion, or 10 percent of the nation's medical costs, in 2008. More recent estimates suggest that annual obesity-related spending could be upwards of $200 billion.
Most efforts to address America's obesity epidemic have emphasized lifestyle changes: better eating habits, more physical activity. First Lady Michelle Obama has introduced a nationwide campaign against childhood obesity. Some states have begun requiring restaurants to post nutritional information (PDF) on their menus. Hospitals, insurance companies, and employers alike have implemented wellness programs that offer education and support.
For those already afflicted by obesity, however, behavioral adjustments alone may not cut it. In a study recently published in the New England Journal of Medicine, patients with obesity were given "lifestyle coaches" to help them lose weight. The result? After working closely with their coaches for two years, patients lost on average five percent of their body weight. But there were no significant changes in blood pressure, blood sugar levels, or cholesterol levels to suggest a change in the risk of obesity-related disease or death. The patients may have looked a few pounds lighter, but they didn't appear much healthier.
Natasha, like these patients, needed a more dramatic change. Obesity was taking over her life -- and threatening to someday take it entirely.
It was time, she decided, to consider bariatric surgery.
* * *
Gastric bypass surgery, the most frequently performed surgical weight loss procedure, was first described in the 1960s. It has been revolutionized by the development of minimally invasive approaches over the last 20 years. Today, almost all operations are performed laparoscopically: this means they're done using cameras and instruments inserted into the belly through tiny ports. Instead of a large incision, the surgery leaves only the port scars, about a centimeter each in length.
The operation itself consists of two steps. The first involves stapling the stomach into a "pouch" the size of a small pierogi. The pouch can only hold a fraction of what the stomach previously held; this limits how much one is able to eat and keep down.
The second step involves "bypassing" a good bit of the gut. Instead of connecting to the small intestine where it begins, the pouch attaches further downstream. The job of the small intestine is to soak up nutrients and calories; by skipping past that initial stretch, food doesn't get absorbed as easily.
Restricting food intake and decreasing absorption both contribute to weight loss, but they may not be the most important mechanisms. Instead, the main driver of weight loss is thought to be a change in the body's hormones. The digestive system secretes hormones that govern appetite as well as how the body responds to food. By changing the anatomy, gastric bypass seems to fundamentally alter the hormone composition. This is perhaps why the weight loss after gastric bypass is so dramatic: patients lose on average 50 to 70 percent of their body weight.
In addition to gastric bypass, two other weight loss surgeries are popular in the U.S.: adjustable gastric band placements and sleeve gastrectomies. An adjustable gastric band works by cinching the stomach like a belt, restricting the movement of food from the small portion of stomach above the band to the rest of the stomach below. Bands are associated with less weight loss than bypass and a greater risk of weight regain afterwards but have the benefit of being reversible. Sleeve gastrectomies, a newer option, remove most of the stomach but don't touch the intestines. Studies suggest the results are similar to those achieved with bypass.
For many patients, what's most remarkable about getting surgery actually isn't the weight loss itself. It's the health transformation that comes with it. Take diabetes, for example. After gastric bypass, more than 80 percent of diabetics cease to be diabetic; essentially 100 percent of pre-diabetics are spared from developing the disease in the first place. Down the road, patients are also more successful at keeping diabetes at bay, according to two studies recently published in the New England Journal of Medicine. One study assigned patients with longstanding diabetes to receive either surgery and medical therapy or medical therapy alone; at two years, diabetes remission had occurred in 75 to 95 percent of the patients who underwent bariatric surgery -- and none of the patients who only received medical therapy. The other study tracked patients' blood sugar levels for a year and similarly found significantly better rates of blood sugar control among diabetics who underwent surgery versus those who received only medical treatment.
Diabetes isn't the only health condition affected by bariatric surgery. Hypertension improves, and in many patients resolves entirely. Obstructive sleep apnea goes away. Cholesterol levels fall; heart disease risk is nearly halved. The list goes on.
With all of these changes, overall mortality decreases, too -- and not just by a little: studies suggest a 40 to 50 percent reduction in the risk of death.
Despite its obvious benefits, bariatric surgery remains a relatively uncommon treatment for patients with obesity. The guidelines set forth by the National Institutes of Health (NIH) state that a patient qualifies for bariatric surgery if he or she has failed conventional weight loss measures and has a body mass index (BMI) above 40 -- this is the threshold for clinically severe obesity -- or a BMI above 35 with a co-existing condition like diabetes. By these criteria, more than 20 million Americans qualify. In reality, however, only about 200,000 undergo bariatric surgery each year. That's less than one percent.
If so many Americans want to lose weight -- need desperately to lose weight -- and if bariatric surgery works so well, then why isn't it more popular?
* * *
To start with the obvious: bariatric surgery involves surgery. And any surgery comes with risks. There's the risk that something might go wrong during the operation: a patient might not tolerate anesthesia, a stapler could misfire, a vessel could bleed. There are risks after the surgery, too; blood clots could form, infections could arise. With gastric bypass and the sleeve gastrectomy, both of which involve surgically fashioning a pouch out of the stomach, there is a risk of the pouch leaking or ulcerating. And, of course, there is the possibility of death; surgeons at major centers cite a rate of one to two in 1,000.
How safe, then, is bariatric surgery? When done laparoscopically, it's actually thought to be just as safe (or just as risky) as other abdominal surgeries, like having a gallbladder removed. Some might argue that any level of risk is too high for an elective procedure. Others would counter that not having surgery is far riskier: many of these patients, without urgent intervention, would very likely die of an obesity-related condition within a few years.
Then again, some patients simply aren't ready for the extreme life changes associated with bariatric surgery. Patients have to relearn eating: what they can or can't have, how often to do it. They have to relearn their self-image, a task that some struggle with emotionally or psychologically. In many cases, they have to reestablish their relationships with others, too. The physical transformation of dramatic weight loss can be a source of tension for patients who come from communities in which everyone is obese. Even dining with friends can be tricky when a meal consists of no more than a few bites, when favorite foods are suddenly forbidden, when breaking these rules would quickly send them running for the nearest bathroom.
"I miss pasta," one patient told me more a year after her gastric bypass. She spoke of it wistfully, the way some women speak of former relationships. She had loved it; it hadn't treated her well; she had moved on. Still, she couldn't help the remembering.
* * *
Setting aside all the patients who aren't willing even to consider surgery, there are still more viable candidates for bariatric surgery than the 200,000 patients who are ultimately getting it each year. So what's stopping the rest?
Dr. Scott Shikora, director of the Center for Metabolic Health and Bariatric Surgery at Brigham and Women's Hospital in Boston, suggested that many patients might not be pursuing the option of surgery because their primary care doctors aren't recommending it. "A lot of primary care physicians see bariatric surgery as the operation it was in the 1960s, not as it is today," he said. "They have an outdated perception of its risks, and they may not be aware of all the clinical benefits." Although the safety and effectiveness of bariatric surgery are well described in the literature, Shikora said, much of the data gets published in surgical journals. "Most PCPs," he surmised, "aren't reading those journals."
Dr. Jason Block, a primary care physician at the same hospital, offered a slightly different perspective. Obesity happens to be Block's area of research; he's been studying the environmental causes of obesity as well as different population-based interventions. "I have a lot of optimism for bariatric surgery helping people," he said. "It's a currently underutilized resource. It can be very successful."
At the same time, he noted, surgery was not something he felt comfortable advocating aggressively. "I discuss it with my patients, but I never push them hard," he said. "More than other interventions, it's something that has to come from within. If patients don't know what they're getting into, they may wake up some day not satisfied."
Block may be more of the exception than the rule -- not only in his openness to discussing bariatric surgery with patients, but also in the extent to which he discusses obesity at all. It's hardly news anymore that primary care doctors are pressed for time. Patients show up to their 15-minute appointments with a bundle of complaints to be unpacked and triaged, from chest pain to athlete's foot, from reflux to mood swings. When weight management does come up, what gets said tends to be rather formulaic (you can probably guess the formula). Other times, it's simply forgotten.
"We need to get obesity on the problem list, and track it as we do other chronic diseases," said Dr. Asaf Bitton, a colleague of Block's. For the last several years, Bitton has been studying and implementing a new model of primary care, the patient-centered medical home. In this model, instead of flying solo, doctors work on multi-disciplinary teams of health care professionals; the idea is to provide patients with comprehensive care for all their medical needs. Obesity and other complex health issues may benefit most from such an integrated approach. After counseling, if a doctor thinks that a patient needs a nutrition consultation, for example, he or she can coordinate what Bitton described as a "warm hand-off" with an in-house dietician.
It's possible that improving how obesity is managed in the primary care setting would in turn facilitate greater adoption of bariatric surgery. Today, before patients can even meet with bariatric surgeons, they need first to have tried and failed traditional weight loss measures. They also need to be evaluated by dieticians, psychiatrists, and a whole host of other specialists to make sure surgery is an appropriate option for them. The process, as it currently works, can be logistically daunting to navigate, even to the point of deterring patients from surgery ("It's a very slow process," warned Block). A system that encouraged doctors and patients to talk meaningfully about obesity might make it easier for doctors to identify the right candidates for surgery -- and for those patients to get referred for surgery in a timely fashion.
Even after referral, however, considerable barriers remain. For many patients, cost becomes the main determinant of whether surgery can happen: a laparoscopic bariatric procedure falls in the range of $17,000 to $25,000, with the amount covered by insurance ranging widely.
All the major U.S. health care payers now include bariatric surgery in their policies. In practice, however, many benefit plans don't cover the option. The medical policy for United Health Care notes, "Most Certificates of Coverage and many Summary Plan Descriptions explicitly exclude benefit coverage for bariatric surgery." Cigna's coverage policy (PDF) includes a similar qualification, as does Aetna's.
Dr. Philip Schauer, director of the Bariatric and Metabolic Institute at Cleveland Clinic, stated that the rates of exclusion are considerable. "At the Cleveland Clinic, more than half of the patients who qualify for and wish to undergo bariatric surgery are unable to do so due to insurance issues," he said.
For patients who do find coverage, there is the additional hurdle of fulfilling various pre-operative criteria mandated by insurers. These include medically supervised dieting programs, often six to 12 months long, with monthly doctors' visits to document their progress. According to Schauer, this delay to surgery offers patients little benefit. "On average, my patients have been on 10 diets before they come to me," said Schauer. "Another diet isn't going to help them." What's more, he noted, the frequency of mandatory doctors' visits imposes considerable hardship on patients, requiring them to find transportation and take half a day off work every month for the better part of a year. If they miss one appointment, they're disqualified. Schauer estimated a 20 to 30 percent rate of attrition from the program as a result.
Shikora, too, cited examples of insurance barriers that have kept patients from surgery, including a stipulation by some insurers that patients prove they've been obese for at least five years. This policy, said Shikora, hurts many younger patients with debilitating obesity. "Patients have died on waiting lists," he said. "The bottom line is insurers don't want to pay."
But should they?
A few years ago, health economist Pierre-Yves Crémieux looked into the business proposition of bariatric surgery. His hypothesis was that since bariatric surgery reduced rates of many costly health conditions, it might actually save insurers money. With funding from Ethicon Endo-Surgery, a division of Johnson & Johnson that makes surgical devices, he studied actual claims data collected over a six-year period for more than 3,600 surgery patients. The analysis, published in the American Journal of Managed Care, estimated that it took two to four years for payers to "save back" what it had cost to cover the surgery.
"Bariatric surgery pays for itself," said Crémieux. He noted that his initial analysis had likely underestimated the time frame for breaking even; a more recent analysis of diabetic patients undergoing bariatric surgery, which he is currently in the process of preparing for publication, suggests that four years may be closer to the average than the upper limit.
According to Crémieux, however, the magic number that insurers are looking for -- the number that has come up repeatedly in his discussions with them -- is not four or even two years: it's 18 months. That is to say, insurers would be enthusiastic about bariatric surgery if the costs of the surgery could be offset within 18 months.
Dr. Carolyn Langer, the medical director of Harvard Pilgrim Health Care, dismissed the notion that return on investment determined reimbursement policies. Harvard Pilgrim's decision to cover bariatric surgery, she said, had been based on an extensive search of the literature on safety and efficacy. "It was pretty clear that patients had better outcomes compared to conventional treatment or no treatment," said Langer. "To the extent that obesity can be controlled through lifestyle changes, that would be much preferred. But we recognize that many habits are embedded, and that there needs to be a concerted effort to address the issue."
* * *
One view that surgeons, primary care doctors, and payers alike seem to share is that there is a subset of patients who stand to benefit disproportionately from bariatric surgery. The problem is that it still isn't entirely clear who these patients are. Are they the youngest? The ones who are most obese? The ones with the most severe co-morbidities? The diabetics? Figuring out how bariatric surgery can be better used will require first identifying this "sweet spot" within the patient mix.
Even for the patients with the greatest promise, however, bariatric surgery is unlikely to be a magic bullet. I recently met a woman in a surgery follow-up clinic who had weighed 300 pounds before undergoing gastric bypass a few years ago. After the operation, she'd dropped down to 150 pounds. But then, gradually, her weight had begun to creep back up. When I met her, she weighed 240 pounds. The weight gain frustrated and confused her, and she was beginning to question the integrity of her stomach pouch. She barely even ate anymore, she told the surgeon who was seeing her. All she consumed each day were six large iced teas from Dunkin Donuts.
Was she using cream in the tea? asked the surgeon.
Yes, the patient admitted, she liked a little cream.
"It's mostly cream," interjected the patient's husband, who had accompanied her to clinic. "It's practically white."
The surgeon looked somber as he explained that no pouch, however small, could keep her from regaining weight if she continued to consume six cupfuls of cream each day. Surgery could change her life, to be sure; but first, her life had to change.
* * *
After carefully weighing the risks and benefits, Natasha decided to proceed with gastric bypass surgery. She completed a professionally-led weight loss program, met with a psychiatrist, and underwent a barrage of testing. She was deemed eligible, and fortunately, her insurer agreed to cover the surgery.
The operation went smoothly. She stayed in the hospital for a few days to make sure her newly routed digestive system was working properly, and then she went home.
The first thing Natasha noticed was that her appetite had changed. "The difference was almost immediate," she said. "I used to think about food all the time. I would snack constantly. After the surgery, I didn't feel hungry anymore." She even started forgetting to eat. "Someone once told me, 'You might have to set an alarm to remind yourself.' I hadn't believed it before, but it turned out to be true."
She also started choosing healthier foods -- lots of vegetables, fruits, and protein. This was partly by choice and partly by necessity: junk food and sweets, previously staples of her diet, now made her sick. "Once, I ate a granola bar and then tried to eat a bowl of sugary cereal," she recalled. "The result wasn't pleasant."
Two months after her surgery, Natasha weighed 286 pounds. By three months, she weighed 265 pounds, and at four months, she was down to 247 pounds -- almost 90 pounds below her highest pre-operative weight. She was still above the normal weight range and had many more pounds to shed, but the change in her health was already dramatic. Her blood pressure had returned to normal, and her diabetes had resolved completely, with her hemoglobin A1c -- a marker of blood sugar levels -- dropped from 7.6 prior to surgery (a number above 6.5 indicates diabetes) to 5.1 (well within the normal range) in just a few months.
"Everything has changed," Natasha said. "I'm going out more with my friends; I'm doing things I never imagined. I used to feel ugly all the time. Now I look at myself, and I like who I am."
"People treat me differently, too," she added. "People are nice in the world, but I guess they weren't so nice to me before. Now they talk to me, they hold doors open ... it feels good."
Asked if there was anything she regretted about the surgery, she thought for a moment before answering. "Without the bypass, I'm pretty sure I would be 400 pounds by now," she said finally. "Getting surgery is the best move I've ever made. It's something I will carry with me for the rest of my life. There is nothing I regret."
* * *
"Fat people don't need surgery," remarked a young doctor -- a surgeon by training -- who had learned of Natasha's operation. "They need to not put food in their mouths."
Implicit in the surgeon's comment was the notion of choice, of individual responsibility. With a little more willpower and a little less food, the comment implied, obesity could be reversed. That made it somehow different from other chronic health conditions like heart disease or cancer.
The stigma attached to obesity may explain why many weight loss interventions have struggled to garner financial and social support in the past -- and may prove to be the ultimate barrier to the expansion of bariatric surgery. As Block put it, "There seems to be a higher threshold that obesity treatments have to overcome." Historically, this has been true for medically based weight loss interventions. Dr. Florencia Halperin, medical director of the Program for Weight Management at Brigham and Women's, observed: "It's extremely difficult to get insurers to pay for obesity-related treatments. Until recently, counseling for obesity wasn't even a billable physician's code. Even now, most weight management programs are out-of-pocket."
Stigma is arguably most dangerous when it distracts from clinical judgment and public health decision-making. In this sense, portraying obesity as an issue of willpower may be just as irresponsible as portraying teenage pregnancy as an issue of promiscuity: it places undue emphasis on an ineffective plea for abstinence. Just don't do it, the plea goes. Don't do it, and you won't have to deal with the problems.
But people are doing it, and the resulting problems aren't just their own anymore. As obesity takes its toll on America -- its families, its work force, its budget -- it gets harder to ignore the suspicion that obesity is now everyone's problem: the skinny and the fat alike, the still-healthy as much as the once-healthy, the rich as well as the poor.
"There's an element of denial," said Crémieux, speaking of the perception of obesity today.
Perhaps it's not denial, though. Perhaps it's just hard to make the leap from recognizing that something drastic needs to be done to doing something drastic. And perhaps before those with obesity can truly change their bodies for the better, we need -- all of us -- to consider changing our minds.