Cardiologists' perspective on obesity and bariatrics: Raising the threat level to "red"

General practitioners are on the front lines when it comes to dealing with the ravages of morbid obesity. They are the recon team, scavengers for the highest-risk individuals, informants warning patients about the path ahead. Cardiologists are at the back of the war zone, taking on acute casualties, acting as triage officers who direct patients into two groups; those who are salvageable by ordinary means and those who are not. The most critical are end-stage patients for whom exercise is nearly impossible and motivation nonexistent and whose support groups have become a well-organized team that aids, abets, and promotes their disease process by providing unhealthy foods and enabling their inactivity. This is a population of patients who have for three decades navigated minefields planted unwittingly by the food and soft-drink industry and whose weight loss efforts have been booby-trapped by lack of parental guidance and knowledge. Our parents grew up in a generation of bicycles, long walks, and after-school chores rather than bus rides and computer activities. Bariatric surgery deals with the aftermath of a generation of parents and children who were mesmerized by cola commercials and happily employed afternoon television programming as babysitters.
 
As a cardiologist, I have offered bariatric surgery approximately 10 times in 18 years, accounting for less than 0.1% of my patient population. As a heart specialist, I intersect with the world of bariatrics far more often from the perspective of providing surgical perioperative risk assessment. (Note that I do not utilize the nomenclature "operative clearance," a term that serves only to artificially situate blame and whet the appetite of malpractice lawyers). We are more often forced to interpret technically difficult tests than we are asked to provide guidance about who actually needs the procedure. I am appalled that our Medicaid system will sooner pay for bariatric surgery than for a YMCA membership with tracking mechanisms for accountability and avenues for dietary counseling. Indeed, some of the patients who have been sent for a nuclear stress exam "for operative clearance for bariatric surgery" have never even considered a Weight Watchers program. I know because I've made it my business to ask.
 
One of my favorite patients required this extraordinary effort to survive. She was 50 years old and required 100 units of insulin twice daily. She stood 5 ft 6 in tall and weighed approximately 375 pounds. Her blood sugar was poorly controlled and her legs were weeping with edema. She developed what she called "asthma" because she wheezed just from the sheer weight of her chest when she was lying supine fueled by diastolic dysfunction. She had blown through five angioplasties and a cardiac bypass surgery and had intermittent episodes of atrial tachycardia. She snored and required [bilevel positive airway pressure] BiPAP to bolster her oxygen saturation even if she napped during the day. Her drug list consisted of around 20 different entities. The last straw that pushed me to recommend bariatric surgery was an admission for cellulitis that involved not only her lower legs but thighs and upper abdomen, not a far reach from a diagnosis of necrotizing fasciitis. Seven years later, she is now almost 150 pounds lighter. Her medication list is shorter and the doses smaller. Most important, she feels well. She has required only medical therapy for her coronary artery disease since her surgery. She has not required an in-patient evaluation for several years, in stark contrast to a nearly monthly admission requirement. Her days are spent getting her grandchildren off the bus, attending family activities, and caring for her significant other. In short, she has been given a life again.
 
However, we must not become mesmerized by the seemingly quick fix of bariatric surgery. An ounce of prevention is better than a pound of cure and certainly better than 150 pounds of fat. We must treat the plague of obesity in our population as we would any invading enemy. Our generals-- ie, our politicians and society presidents--must fuel a revolt against this costly epidemic that begins with the legislation of food labeling and taxation of items most responsible for our demise. We must map a strategy that includes rewarding workplaces that promote healthy lifestyles with tax breaks, thus penalizing those that don't. Mandatory restrictions for school lunches and requirements for physical education must be implemented. Bariatric surgery must be considered in the future as a last resort and the end result of our failure of both prevention and therapy strategies.
 
Only once in the history of homeland security has our national threat level been raised to "red." If as many deaths from terrorism matched the death toll of obesity, we would have already convened a panel to discuss a declaration of war. To put our current threat from obesity into perspective, the [Centers for Disease Control and Prevention] CDC reported over 350 swine flu deaths since January of this year, while the [National Institutes of Health] NIH reported almost 300 000 deaths from obesity in the past 10 months.
 
As with any successful war strategy, victory can be achieved only by initiating a plan from the proper perspective and developing a sense of urgency proportional to the threat. With regard to obesity and its negative impact upon us as a productive and successful society, the threat level has surpassed "red" for over a generation with very little notice until now.

See:

Experts debate bariatric surgery as a cure for diabetes

Your comments

	Cardiologists' perspective on obesity and bariatrics: Raising the threat level to "red"
	# 1 of 4	October 21, 2009 02:16 (EDT)
	sandra jackson	Dear Dr Mellisa  we have just started a bariatric clinic and unfortunately it is in a private hospital and being used as a quick money making venture, unfortunately now days the quick fix is the one in private health care administrators will push for, as it is a revenue builder, hence i am leaving private health care to go back to the more responsible public health care arena. your article said it all
	# 2 of 4	October 22, 2009 09:22 (EDT)
	Frank Kempf	Your words are like poetry...You speak the truth to the blind, the deaf, and the dumb.  The epidemic of obesity and nutritional dysfunction has not yet been fully realized.  Our society has steadily become tolerant of the problem...and there appears to be no groundswell of outrage.  We as physicians are studying bariatric surgery as a cure for diabetes.  Obviously, there is a major problem here...we can offer surgery and study its benefits.  This is incredibly wrong....financially ludicrous...and morally bankrupt!  Obesity is big business.  Our fast food industry and our prepared food corporations make huge profits as feeders to the feedees.  Our health care industry makes big profits from taking care of the consequences.  The pharmacologic industry is wallowing in black ink because statins and oral hypoglycemic agents are immensely profitable and are a ubiquitous need for the general population. Primary prevention is a misnomer that we have conjured to make take care of some of the problems...this isn't primary prevention is it?  Primary prevention starts in education, in information, in fundamentally simple measures that will prevent the problem from advancing to the point that medical intervention is required.  This problem has the capability of single-handedly bankrupting the nascent national health care system!
	# 3 of 4	November 12, 2009 06:13 (EST)
	Alfonso Antequera, MD, FACS	Dear Dr. Melissa:   I appreciate a lot your article. I am sure that Cardiologist are now more interested in the adequate fight against Obesity than Endocrinologis. Now Surgery isthe only effective therapy available against this BIG PROBLEM, but the referrals to Bariatric Surgery Programms are incosistent with the prevalence of Obesity worldwide. I will keep on fighting.   Kind Regards
	# 4 of 4	December 1, 2009 09:18 (EST)
	golftee	Sandra, Frank and Alfonso, Thanks so much for your posts.  I did not realize you had commented until this evening as I must have missed this page.  I apologize because I'm most happy to engage in any conversation that will help us with this terrible epidemic.  Just today I saw a young lady, 5'2", over 200 pounds.  She was referred for a benign issue, but not one single physician had documented anywhere a conversation about her weight.  I told her that though her echo findings were interesting,but they were not life threatening and then asked my nurse practitioners to spend the majority of the visit on the Mediterranean diet.  Her eyes were opened and I think we just might have a chance to save her from the horrible fate that obesity has in store for her if left unchecked. Keep up the good fight folks! Nice to hear from you. Melissa

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