Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Cardiologists' perspective on obesity and bariatrics: Raising the threat level to "red"Oct 12, 2009 21:59 EDT
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.