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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