Overeating is a behavioral problem, not a surgical one

Overeating is not a surgical problem.

This may seem to be a statement of the obvious, but the solution to a behavioral problem is not surgery. Overeating is not a surgical problem — it is a behavioral one. The problem is not because the stomach is too big and needs to be made smaller. It is a function of how much food is put into the stomach. Surgical “solutions” should be the absolute last resort measure.

The company that makes lap band devices (used in bariatric lap band surgery) has applied to the FDA to lower the obesity threshold at which surgery can be performed. According to the New York Times, if successful, this application would double the number of people who would “qualify” for surgery. An FDA panel has supported the application and now it awaits a final decision.

Another FDA panel is about to consider the merits of a weight loss drug, which narrowly meets the criteria for effectiveness but has heart related side effects.

The thresholds are based on the body mass index (BMI). This is a useful but flawed indicator of obesity. It is not a predictor of future health problems in a given individual. Bariatric surgery has been an option for people who are classed as morbidly obese. Initially the main candidates were those with a BMI of over 40, or 35 if the person has other health problems. The new application would include people with a BMI of 35 (without other problems) and 30 (with other health problems).

The cut off for overweight versus obese is 30. Yes these people are carrying more weight than might be ideal but not by that much. Critically studies have shown that people with a BMI between 25 and 30 live longer than those with a “normal” reading of 20 to 25.

The makers of the device and the surgeons doing the operation have a legitimate commercial interest in doing more procedures. The Times report stated sales were down 4% this year. The real question is whether these are the right people to be driving the agenda?

In Australia lap band surgery continues to “grow.” Figures show Western Australia has the highest rate in Australia. This prompted the local Australian Medical Association president to opine that this was because the state had  ”leaders in the field.” Another view may be that there is just a greater willingness to operate.

There is no long-term safety data on surgery as it has not been around long enough. One thing is certain. Nothing happens in isolation in the body. Interfere with the gut and other things will happen. Already it is emerging that there are higher rates of kidney stones and bone fractures eight to ten years post surgery. Who knows what may happen after 20, 30 or 50 years?

Furthermore we do not actually know the risk benefit equation or if indeed the procedure” works” long term. We know that some people lose weight in the first few years. Not all keep it off.

In all of this it remains the case that there is promotion of a surgical solution by those who perform the surgery or make the devices for a problem, which is not fundamentally a surgical problem. This is happening without any knowledge of whether there is long term benefit and certainly without knowledge of long-term complications.

There is no need to increase the market for bariatric surgery by including those who are moderately obese. Neither do we need more weight loss pills, which cause more problems than they solve.

Eating less and moving more is side effect free and inexpensive.  Why on earth is so much effort devoted to other so-called “solutions”?

Joe Kosterich is a physician in Australia who blogs at Dr. Joe Today.

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  • buzzkillersmith

    Psychosis is not a pharmacologic problem, it is a behavioral problem. Acute appendicitis is not a surgical problem, it is an infectious problem. Trauma is not a surgical problem, it is an anatomic problem.
    The author’s first paragraph is absurd. His later paragraphs are more reasonable. Clearly long term studies are important.

  • Finn

    Why? Because
    1. Losing weight is hard work
    2. People want a quick fix
    3. Insurance will pay for pills and surgery but not for gym memberships, personal trainers, cooking classes, or education about nutrition

    • stitch

      Bingo, and especially regarding point number 3, why? Kickbacks, maybe?
      It should be the other way around.

  • http://brent.kearneys.ca Brent Kearney

    It is depressing to see doctors blaming their patients instead of educating themselves. There is plenty of science explaining why adipose tissue grows, shrinks, and what causes the hormonal releases that drive all animals to eat more or less.

    The latest book by science journalist Gary Taubes summarizes relevant studies.

    • Family Doctor

      Sorry man, can’t go with you in this one. People are obese simply because of their own behavioral inability to control their diet. And refusal to exercise. Call it a psychiatric problem if you like, but obesity, and I mean the BMI’s over 30 are no ones responsibility, or fault but the person who is obese. This is clearly a multi-factorial problem but the solution still lies FIRST in the individual admitting his/her 100% responsibility in the problem weight. Finding the best solution after needs to be patient tailored. As a family doc I work w obesity a great deal in my practice w excellent results (believe it or not), but it takes work, on both the patient & doctors behalf. The first job of the patient is accepting responsibility. This isn’t blame. But we do a great disservice to our patients when we allow them to not accept responsibility. That is why some, probably many, fail in their quest for weight loss, & maintenance of weight loss- they never accepted that it was their behavior that got them there. Their claim which I often hear “But doctor, I can’t lose weight, it’s impossible” is rarely true (except for some uncommon disorders like hypothyroidism).

      For those of you with a high BMI reading my comment: yes, you have made poor choices before but that can change. Try Nutrisystem for 4 weeks like a RELIGION & walk only 30 minutes a day 5x/wk. In 4 weeks you will lose 4-8 lbs. I promise. Imagine 24 weeks on that same successful regimen? Much lighter.

      Don’t have time to exercise? Don’t complain about your weight.

      Full disclosure: I exercise at least 5x/wk, one hour to one & half hours a session. I eat 5-6 SMALL meals a day, and my BMI is less than 25. Yes, I walk my talk. But my family is quite large due to bad eating & no exercise. That could be me if I let it.

      Good luck everyone!!

      • http://brent.kearneys.ca Brent Kearney

        I hate to sound like a salesperson for the book (“Why We Get Fat, and What To Do About It”), but in it, your anecdotes are all debunked as myth, and backed up by numerous scientific studies in major journals. These studies are somehow largely ignored by the medical establishment.

        What works, then? Changing the type of foods consumed. Generally, remove the carbohydrates which did not exist for 99.9% of human history. Several myths connecting heart disease to fat consumption are also debunked by large, randomized controlled studies cited in the book, which also seem to be mysteriously ignored by the medical authorities.

        There is clearly a problem of epidemic proportions, so the advice on offer now — to eat less, exercise more — is obviously not working. Maybe we should revisit our commonly held beliefs and look at the actual evidence.

        • http://fertilityfile.com IVF-MD

          I used to have only mild interest in my patients’ body fat composition. Over the years, that has evolved to having great interest and great success in lifestyle modification that can result in great loss of body fat.

          Body fat composition and fertility are closely related, especially in patients who are insulin-resistant. I concur with you regarding the evolutionary significance of carbs. Many PCOS patients are descended from a line of people who are precision-engineered by evolution to be resistant to starvation. That type of body, while great for enduring the famines of the past, is not suited for the high fructose corn sweetener temptations that are ubiquitous nowadays.

          I’m seen some consistently good results in patients (and friends) who can adhere to strict carb-restriction (legumes/beans OK) without any need for fat-restriction. Daily monitoring of weight and energy level, supplemented by food diaries play an important role as well. When they cheat on their diet, the precision monitoring helps teach and convince them what their body can get away with and what it can’t get away with.

    • http://www.drjoe.net.au Dr Joe

      And we can only ponder who puts the food into the mouths of adults who are overweight.It is not about blame ,it is about responsibility for ones actions.There is no obesity where there is a shortage of food.

      • stitch

        “There is no obesity where there is a shortage of food.”

        However, if you measure many parameters for obese people, obesity is a condition of malnutrition. And obesity does increase in areas where there is a shortage of good food, such as cities where there are plenty of fast food joints and few groceries that carry fresh fruits and vegetables. Documented extensively.

        Add to that the fact that calorie dense but nutritionally poor foods such as those found at fast food places are much less expensive, especially per calorie, than fruits and vegetables and you have another addition to the problem, not to the solutions.

  • BladeDoc

    The reason is that your first line therapy is ineffective. Less than 10% of morbidly obese people who are entered into even the most resource intensive physician supervised weight loss plan including exercise and behavioral therapy have sustained weight loss at 5 years. Even fewer have resolution in any of the sequellae of morbid obesity. As a matter of fact, most patients who attempt a low-calorie diet initially lose weight just fine and then breakthrough and end up weighing 10% more than their starting weight 1-2 years after the weight loss attempt. Come up with a therapy that actually works be it diet or a pill or hypnosis or whatever and the need for surgery will go away. Until then just telling the obese patients to stop eating has proven a failure.

    • Justin

      I think fat people need more physically demanding jobs. It’s not normal for humans to be trapped inside a cubicle all day. Of course they’re getting fat, they’re not using any energy. It’s not a matter of needing surgery to fix the problem. The problem is our sedentary lifestyle in the modern age (Along with easy access to high calorie food, and an unfortunately progressive acceptance from society that it’s okay to be fat).

      • stitch

        Get up, roll out of bed, walk to the car in the attached garage, drive to work (hit the drive through on the way in,) park as close as possible to the door to the office, sit at desk all day long, walk back out to car, drive home to attached garage, eat frozen meal or call for pizza, sit in front of TV (which actually has been shown to reduce the basal metabolic rate,) go to bed.

        Yep. Our physiology has not caught up with that, and our taste buds are still geared towards “fat equals flavor.”

        There are multiple systems in human bodies to cope with starvation but only one hormone deals effectively with the fed state. Evolutionarily we are still designed to be ever in search of food.

    • pcp

      “most patients who attempt a low-calorie diet initially lose weight just fine”

      As you indicate, the therapy works as long as the patient is compliant. When the patient is no longer compliant with the therapy, it (of course) does not work. The problem is not with the therapy; the problem is that there is no support in the society that we have created for the patient to comply with it.

    • gzuckier

      Exactly. Telling 10% of the population they aren’t up to snuff is one thing; telling more than half the population they are severely sub-par is hard to swallow. Similarly, I wouldn’t expect Olympic caliber athletes to tell me or the rest of us the only reason we can’t compete with them is we don’t have the willpower.

  • http://drpullen.com Dr Pullen

    Obesity is so much more complex than just a behavioral problem. Surgery may or may not pan out to be a good option, but to flatly state it’s a behavioral problem is not uniformly true.

    • http://www.drjoe.net.au Dr Joe

      Part of the problem is that we make simple things complex. People can only be overweight when they consume more energy than they expend.This is a law of physics and is remarkably simple.

  • Angela Caffaratti, MD

    Obesity is a long term problem and it needs a long term solution. Weight Watchers is always what I recommend. It is smart and once you get to your goals, they expect you to stay a life-long member. I just don’t believe in diets/pills/surgery. If you don’t approach it from a lifestyle factor, you will fail. I see many people that put the weight back on years after any bariatric procedure. Society needs to change. People need more flexibility/ more activity/ better food/ sick leave/ healthier transportation/ maternity leave/ more sleep/ healthy school lunches/outdoor recreation, etc… We are working ourselves to an early grave and aren’t living a quality lifestyle.

  • Muddy Waters

    Obesity results solely from laziness and apathy, which consequently are the same traits that are leading to the devolution of our species. People no longer have personal responsibility or accountability. Our future is concerning…

    • gzuckier

      The fact that enormous corporations devote huge sums to having us overconsume so that they can enhance profits has absolutely nothing to do with it. And all the studies the companies do internally to optimize their marketing are just flawed.

  • http://fertilityfile.com IVF-MD

    So there are a group of people (O) who are obese and they wish to have another group of people (S) work to do surgery on them (in exchange for money). Sometimes, this involves another group (M) who make money manufacturing devices that are used in the surgery. Some of the folks in Group O are willing to work in order to earn enough to pay Group S and Group M. Others want the surgery, but only if it is free. However, it’s not really free. It’s being paid for by taxpayers (T) who have no say in whether this happens or not. Instead, the decision is made by politicians (P). So Group S and Group M spend money to pay lobbyists (L) who have a purpose in life that does not generate any true product or service, but instead involves expending life energy trying to sway Group P to take the fruits of group T’s labor to pay to Group S and Group M. By the way, don’t forget the junk food manufacturers (F) who are advertising heavily to get kids (and adults) to develop eating habits that will help them join the ranks of Group O.

    Does everybody think this is a great set of rules under which a nation of people live together? Yes, I can anticipate the answer of many of you. “It’s not a perfect system, but it’s the only system we have”. Hmm, does that make it excusable then?

    • http://www.drjoe.net.au Dr Joe

      Great comments.Maybe it means the first step to changing it is to recognize what we are doing.

    • gzuckier

      Nothing new. Rather than make an effort to keep carcinogenic substances out of our lives, as a society we prefer to try and cure cancer.

  • soloFP

    For the bariatric surgery or lap band surgery, the patient must see a psychiatrist, dietitian, and demonstrate the ability to lose some weight across 6 months. These are requirements on most insurance plans. Around 20-25% of my patients who do the 6 month preparation are encouraged that they can lose weight without surgery and do not do the surgery. The ones who do the surgery and the ones who do not both lose weight, but the ones without the surgery do not have the forced eating limits. After the surgery, the patient is limited to small portions long term, which helps maintain weight loss. Likely the weight is a psychological problem that can be treated with physical modifications. Even if the patient does not exercise, simply having smaller portions allows the patient to lose weight.

  • sharon a. wander M.D.

    The lap band and or bariatric surgery are the greatest. I have seen obese people who have tried everything and nothing works except lap band/bariatric surgery. They lose 100 lbs in short of 2 months, they never felt better and looked better. Sure they suffer from vomiting if they eat too much, but they have more strength to move about. The only problem is after a few years they might get anemia, low iron so they must take iron supplements for life. They fit into clothes like never before. The get back their self esteem. But there is still the problem of weight gain after they are feeling super. Their appetites are still there and they must learn to curb it and do exercise or they will gaitn back their weight, but not all of it. Their appetite is still their biggest problem.

    • http://www.myheartsisters.org Carolyn Thomas

      Sharon, it’s hard to tell if you are joking or not.

      If all patients have to learn to “curb their appetite and do exercise” after surgery or else they’ll regain that “100 pounds they lost in 2 months”, why not just curb your appetite and exercise FIRST so you don’t need the surgery? Your comment merely confirms Dr. Joe’s observation that this is a behavioral problem, not a surgical one.

      Describing lap band/bariatric surgery as “the greatest” because patients will “fit into their clothes like never before” is truly disturbing, coming from somebody with the letters MD after their name. Please tell me that you ARE joking….

      • gzuckier

        Reminds me of those diet milkshakes that say, “just have one of these for lunch and eat a sensible dinner”
        Hey, if people could eat a sensible dinner they wouldn’t be buying your product.

  • http://www.myheartsisters.org Carolyn Thomas

    As a gastric surgeon at the University of Texas Southwestern School of Medicine once wrote:

    “These operations clearly help some people, but the lap-band manufacturer Allergan is trying to sell it as a solution for everybody. If you follow the rules, it works. But most people who get to be 400 pounds aren’t very good at following rules.”

    And in answer to Dr. Kosterich’s question: ” Why on earth is so much effort devoted to other so-called “solutions?”, well, simply FOLLOW THE MONEY!

    More on this at “How Doctors Are Selling Weight Loss Surgery To Teens” at:
    http://ethicalnag.org/2011/02/16/stomach-banding-teens/

  • Claudia

    There is a lot of research that shows that the problem is not “simply calories in > calories out”.

    Complicated endocrinological factors contribute to the body’s storing and releasing fat, and stress and lack of sleep is a major contributor.

    I see so many young mothers, for example, forced to go back to work weeks after delivery, juggling employment, child care, household, and years of nights with interrupted sleep and never a waking hour of rest to themselves.

    Even reduction of calorie intake to starvation levels will not help them lose weight, but it will make them nervous, easily angered, frazzled, unconcentrated, and in the long run severely depressed.

    Likewise, being poor, in uncertain employment situations with hourly pay and no health insurance or long-term safety of any kind, is an extremely stressful situation, and cheap high-carb foods, mixed with irregular food intake and many skipped meals (12% of the population regularly go hungry) will, ironically, make you fat, not slim.

    It is therefore often not the lazy but the ones who are overburdened with work, worry, and responsibility for others, who end up obese.

  • Dorothy Green

    The US eating culture has become a public health problem

    What each of us put into our mouths is

    individual responsibilty

    and what is out there to put into our mouths is

    90% processed food – 10% natural food

    Neither one can be absolved of causing obesity.

    The COST of the related PREVENTABLE conditions (diseases if you like) such as CV and diabetes type II is UNSTAINABLE and IS the primary reason why health care costs are and will continue to be out of control.

    The following are the ways only ways that will start to reverse this epidemic, start to reduce health care costs and NOT punish the individuals who 1) take care of their body and 2) and who develop a disease not related to an unhealthy diet.

    STOP THE SUBSIDIES TO AGRIBUSINESS for CORN and SUGAR AND CORN FED ANIMAL MEAT AND DAIRY.

    Subsidize local organic farms – a good place to increase jobs

    Tax the sugar, fat and salt in processed food. Forget sin, fat, soda and other names – call it R.I.S.K. – reduction in sickness kitty and make the message and the RISK clear on the packages,. Nutritional FACTs are not enough.

    Food subsidy programs must not allow high RISK foods.

    The revenue can be used many programs that keep Americans healthy as well as a healthcare tax credit to taxpayers (since they are the ones who pay for Medicare and Medicaid).

    The tobacco tax worked and is still working.

  • http://www.facebook.com/people/Natalie-A-Sera/743004321 Natalie A. Sera

    After reading your column, and even more, some of the responses that follow, I am horrified. I attended 2 interesting presentations at the AADE (American Association of Diabetes Educators) last week on “Food, Fat and Satiety”, and “Fructose and Cardiovascular Disease: A Not So Sweet Connection”.  A salient point in both presentations was that obese people eat because they are hungry, exactly the same reason that thin people eat. And because of inborn energy-storage tendencies, and function of the hypothalamus, some people are driven to move, and others find it unpleasant and even painful. In other words, the urge to move makes athletes, not the other way around. And who wants to move if it hurts? There are at least 6, probably more, hormones in the stomach and foregut that are found to modulate hunger, satiety, and energy storage, and new research is finding abnormalities in obese Type 2 diabetics AND non-diabetics. No wonder they’re hungry!

    So it’s time to stop the blame game. These people are suffering from a disease, not a lack of willpower or willful neglect of their bodies. While exercise is good for the vascular system, and muscle tone, it does NOT cause weight loss. Only diet does that, and what are you going to advise a person who is hungry all the time? Dietitians are beginning to understand that sugary sodas are a big contributor to weight gain, because of the fructose content of table sugar (50%) and the supposedly “healthy” agave syrup is 100% fructose, which goes straight to the liver to be converted to blood lipids and fat. However, they have not yet recognized the role of carbohydrates, which, if converted to glucose in excess, are also further processed into triglycerides and body fat, and stored viscerally, which is the worst place.

    But if you’re going to reduce carbs, what can the patient eat? The answer is more protein, which is what causes satiety. The reason poor people get fat is that they eat cheap processed carbs, and not enough expensive meat, eggs and cheese. But those are what would make them full, and if eaten first in a meal, make them desire less of the unhealthy carbs, particularly bread, rice, potatoes, cereal, pasta, corn and peas. By reducing carbs and fructose which leads to losing weight, moving becomes easier, and although its health benefits do not include weight loss, it does help weight maintenance.

    So quit the blame game, and do your research — you medical professionals are in the business to HELP people, not to scorn them and offer them oversimplified, ineffective cliches such as “eat less, move more”.

    And, as mentioned in another post, Gary Taubes’ Good Calories, Bad Calories is an eye-opening read.

  • http://www.facebook.com/people/Natalie-A-Sera/743004321 Natalie A. Sera

    After reading your column, and even more, some of the responses that follow, I am horrified. I attended 2 interesting presentations at the AADE (American Association of Diabetes Educators) last week on “Food, Fat and Satiety”, and “Fructose and Cardiovascular Disease: A Not So Sweet Connection”.  A salient point in both presentations was that obese people eat because they are hungry, exactly the same reason that thin people eat. And because of inborn energy-storage tendencies, and function of the hypothalamus, some people are driven to move, and others find it unpleasant and even painful. In other words, the urge to move makes athletes, not the other way around. And who wants to move if it hurts? There are at least 6, probably more, hormones in the stomach and foregut that are found to modulate hunger, satiety, and energy storage, and new research is finding abnormalities in obese Type 2 diabetics AND non-diabetics. No wonder they’re hungry!

    So it’s time to stop the blame game. These people are suffering from a disease, not a lack of willpower or willful neglect of their bodies. While exercise is good for the vascular system, and muscle tone, it does NOT cause weight loss. Only diet does that, and what are you going to advise a person who is hungry all the time? Dietitians are beginning to understand that sugary sodas are a big contributor to weight gain, because of the fructose content of table sugar (50%) and the supposedly “healthy” agave syrup is 100% fructose, which goes straight to the liver to be converted to blood lipids and fat. However, they have not yet recognized the role of carbohydrates, which, if converted to glucose in excess, are also further processed into triglycerides and body fat, and stored viscerally, which is the worst place.

    But if you’re going to reduce carbs, what can the patient eat? The answer is more protein, which is what causes satiety. The reason poor people get fat is that they eat cheap processed carbs, and not enough expensive meat, eggs and cheese. But those are what would make them full, and if eaten first in a meal, make them desire less of the unhealthy carbs, particularly bread, rice, potatoes, cereal, pasta, corn and peas. By reducing carbs and fructose which leads to losing weight, moving becomes easier, and although its health benefits do not include weight loss, it does help weight maintenance.

    So quit the blame game, and do your research — you medical professionals are in the business to HELP people, not to scorn them and offer them oversimplified, ineffective cliches such as “eat less, move more”.

    And, as mentioned in another post, Gary Taubes’ Good Calories, Bad Calories is an eye-opening read.

  • http://www.facebook.com/people/Natalie-A-Sera/743004321 Natalie A. Sera

    After reading your column, and even more, some of the responses that follow, I am horrified. I attended 2 interesting presentations at the AADE (American Association of Diabetes Educators) last week on “Food, Fat and Satiety”, and “Fructose and Cardiovascular Disease: A Not So Sweet Connection”.  A salient point in both presentations was that obese people eat because they are hungry, exactly the same reason that thin people eat. And because of inborn energy-storage tendencies, and function of the hypothalamus, some people are driven to move, and others find it unpleasant and even painful. In other words, the urge to move makes athletes, not the other way around. And who wants to move if it hurts? There are at least 6, probably more, hormones in the stomach and foregut that are found to modulate hunger, satiety, and energy storage, and new research is finding abnormalities in obese Type 2 diabetics AND non-diabetics. No wonder they’re hungry!

    So it’s time to stop the blame game. These people are suffering from a disease, not a lack of willpower or willful neglect of their bodies. While exercise is good for the vascular system, and muscle tone, it does NOT cause weight loss. Only diet does that, and what are you going to advise a person who is hungry all the time? Dietitians are beginning to understand that sugary sodas are a big contributor to weight gain, because of the fructose content of table sugar (50%) and the supposedly “healthy” agave syrup is 100% fructose, which goes straight to the liver to be converted to blood lipids and fat. However, they have not yet recognized the role of carbohydrates, which, if converted to glucose in excess, are also further processed into triglycerides and body fat, and stored viscerally, which is the worst place.

    But if you’re going to reduce carbs, what can the patient eat? The answer is more protein, which is what causes satiety. The reason poor people get fat is that they eat cheap processed carbs, and not enough expensive meat, eggs and cheese. But those are what would make them full, and if eaten first in a meal, make them desire less of the unhealthy carbs, particularly bread, rice, potatoes, cereal, pasta, corn and peas. By reducing carbs and fructose which leads to losing weight, moving becomes easier, and although its health benefits do not include weight loss, it does help weight maintenance.

    So quit the blame game, and do your research — you medical professionals are in the business to HELP people, not to scorn them and offer them oversimplified, ineffective cliches such as “eat less, move more”.

    And, as mentioned in another post, Gary Taubes’ Good Calories, Bad Calories is an eye-opening read.