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Many Should Bypass Gastric Operation

Posted on: Thursday, 19 January 2006, 21:00 CST

By Kevin Lamb

With New Year's dieters falling off wagons like leaves on a windy day, all those local ads for gastric bypass surgery might start to look like a tempting treat.

It's not. Of every 1,000 people having bariatric surgery to essentially shrink the stomach or intestines, 46 die within a year, the Journal of the American Medical Association

reported in October. Even in the 35-to-44 age group, more than five percent of men and nearly three percent of women don't survive the next year.

They were pretty sick even before the surgery, though. Wasn't their health a lot better afterward? Well, no. They were hospitalized twice as often in the three years after bariatric surgery as in the three years before, at four times the cost.

Even before leaving the hospital, six percent to nine percent need more surgery for complications from rearranging their digestive systems. The difference in three-year hospital costs was nearly half the average $33,672 cost of the gastric bypass itself, the main bariatric surgery.

"We can treat about 10 people for the cost of one surgery," said dietitian Richard Cohen, director of Greene Memorial Hospital's HMR Weight Management Program in Beavercreek. Yet, "many insurances pay for surgery, while few pay for behavioral treatment. This increases health-care costs for all of us."

Listening to the debate over insurance for weight loss, you'd think the only alternative to risky and expensive surgery was staying fat and sickly. Coverage for expert advice in nutrition, exercise, behavior, metabolism and psychology barely comes up. But losing weight is far more complicated than reducing one's capacity for food consumption.

"Obesity is a medical problem, not a cosmetic disorder," said Dr. David Westbrock, who directs New Profile Weight Management Center in Washington Twp. "Obesity is not curable. There's no magic pill. You must work to make meaningful, consequential lifestyle changes to lose weight, keep it off and be healthy."

Even while JAMA spelled out the downside of bariatric surgery in several articles, the physicians' association kept putting surgery atop the social order. One article cited "greater and more durable weight reduction than behavioral and pharmacological interventions."

"The best proven treatment is a nutritious diet and regular exercise," said Medicare director Mark McClellan in November, about ceasing Medicare's coverage of bariatric surgery for anyone older than 65. But it will continue for the 91 percent of Medicare's bariatric surgery patients who are younger than 65 and on disability.

There was no mention of nutrition, exercise or behavior counseling, despite Dr. George Bray's well-documented conclusion that "behavior modification can affect both eating and physical activity," in Contemporary Diagnosis and Management of Obesity and the Metabolic Syndrome. "People who exercise and modify their behavior are more likely to keep their weight off."

But everyone who ever cringed at a scale is well aware that eating well and exercising are good ideas.

"Insurance companies' expecting people to make lifestyle changes without coaching and support is like expecting people to learn how to play a musical instrument on their own," Cohen said.

Nor does insurance typically cover doctors' visits, diagnostic tests or analysis of body fat, metabolism or anything else that might impede weight loss unless the patient already has a chronic illness. They're the only hope of bypassing human defense mechanisms that conspire against starvation, but not excess weight.

Bariatric surgery does have a role. One in 20 U.S. adults need to lose at least 25 percent of their weight just to reach the border between overweight and obese, and some of them truly find nothing else works. lf they're young enough and their surgeons are experienced enough, gastric bypass is more apt to save their lives than end them. New techniques are even making it less costly and dangerous.

But it's far from the only option worth an insurance dollar. Cohen doesn't blame hospitals. They're in the "sick-care business," he said, because it brings in more money than keeping people healthy.

"I guess it's like the old commercial for oil changes," Cohen said. "Pay $20 now or $500 later for the engine overhaul. Our system not only doesn't emphasize the $20 oil change, it seems to be promoting the engine overhaul."

Contact health and medical writer Kevin Lamb at klamb@DaytonDailyNews.com or 225-2129. His column appears every other Tuesday.

Source: Dayton Daily News

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