HEALTH CARE/Joan Retsinas

Battling Fat in America

Take this quiz. Imagine you are obese. For a chunk of the population, that is not much of a stretch. You physician has warned you of the perils: every extra pound raises your risks of heart disease, diabetes, arthritis, and some kinds of cancers. Cowed by the statistics, you decide to lose weight. How? Choose one answer.

1) you slash your caloric intake to subsistence, substituting fruits and vegetables for the large quantities of sugary carbohydrates you used to gulp down.

2) you jog, cycle, swim, power-walk. You join a gym, working out on Marquis de Sade machines. You substitute hours of physical activity for hours of sedentary spectatorhood.

3) you undergo bariatric surgery, where surgeons staple your stomach into a shot glass-sized receptacle. Physically unable to eat vast quantities of anything, you spend the rest of your life munching on tiny portions.

What do you choose?

Astoundingly, an increasing number of Americans are opting for surgery. In 1998, 13,386 Americans went under the knife to lose pounds; in 2004, 121,055 did -- a nine-fold increase. (Source: Statistical Brief 23, Agency for Healthcare Research and Quality, January 2007). Patients ran the age-gamut. Although most were ages 55-64, a swathe (349) of teenagers sought the surgical solution. Patients stayed an average of 3 days in the hospital, and cost their insurers an average of $10,000.

The risk of dying from the procedure, which requires general anesthesia, has dropped from 0.89% to 0.19%. Yet this is no simple panacea. Patients are at risk for vitamin deficiencies (food doesn't just make us fat -- it gives us nutrients), flabby pouches of skin (calling for cosmetic surgery), and re-hospitalizations. On the plus side, patients may be quickly freed from type 2 diabetes, joint pain, sleep apnea, and cardiovascular problems. On the negative side, patients discover that they can no longer take joy in eating -- even though many social rituals are built around food. And, of course, for long-term success, patients still must modify their lifestyles to eat healthier foods, exercise regularly.

The intriguing question is: Why the popularity of an inpatient operation, one that may keep a patient out of work for up to six weeks -- and one with little data on long-term sequelae? Diet and exercise have no calamitous side-effects, cost little, do not keep a person out of work.

For severely obese patients who have tried diet and exercise, the surgery is the last resort. Yet the soaring statistics suggest that more people are embracing it not as the last resort, but as the best resort. Why?

One plausible explanation -- call it the capitalism-as-bogey one -- points to an avaricious industry. Federal researchers calculated the total cost last year of bariatric surgeries at $1.26 billion, up from $147 million in 1998. For the vast majority of patients, insurers pay. This market is strong. According to this explanation, the "bariatric" industry is trying to "grow" its clientele. In time, the "recommended body mass index" for the operation may drop from 40 to 35 to 30.

Yet it is too tempting to blame an industry. Perhaps clever advertising can convince consumers to buy high-definition televisions, or Jacuzzis. But the patients who sign up for this surgery sign "informed consent" papers that spell out the risks.

As Cassius told Brutus, the fault may lie in ourselves.

Judging by the populace's expanding girth, few people are avidly dieting and exercising. The reason: they don't want to. Call it the self-denial-is-not-fun theory. Carrots don't taste as yummy as chocolate mousse; and it is hard to give up the latter for the former. It is equally hard to forego watching the home-team play its penultimate game for an afternoon jogging. Surgery offers an easy way out: you can lose the fat quickly, without going through the rigors of a strict regimen.

Dieting and exercise generally work. But they take time, and require life-style changes that can be both onerous and dreary. We are a populace unaccustomed to sacrifice. We want to arrest global warming, but not trade in our SUVs. We want wars without casualties, social programs without taxes, clean air without controls. And now it seems we want to slim down without stepping on a treadmill, or giving up doughnuts.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, March 1, 2007

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