Obesity The Great American Health Problem Reality is something you rise above. -Liza Minelli One of the most basic of human activities has been the pursuit of food. In its most primitive form, this involved hunting wild animals or searching for edible plants. Throughout the millennia, finding enough to eat has often been difficult. Wars have been fought over fertile tracts of land or abundant hunting grounds, often on empty stomachs. The story of Joseph in the Book of Genesis typifies the struggles man has experienced throughout recorded history. Joseph was a servant who was elevated to second in command of all Egypt because he was able to interpret the pharaoh's recurring dream. In that dream he saw seven fat cows and seven thin cows, which Joseph correctly interpreted as a sign that there would be seven years of plentiful crops followed by seven years of drought and failed crops. This information was used by Joseph, the pharaoh's chosen overseer of the entire nation, to store up grain for future use and avoid the cycle of famine that was common in those days. This story obviously revolves around food, and it speaks volumes about the relationship between food, political power, and social status. The domestication of livestock and raising of crops are a hallmark of our modern civilization. With the Industrial Revolution came improved farming techniques with more abundant crops and larger herds of cattle and other livestock, raised specifically as food. Just as important was the development of a transportation system capable of bringing that food to a hungry market. The benefits of these advances were obvious. Compared with just 100 years ago, U.S. industry has achieved an unprecedented command over the feeding of an entire population. At no time in recorded history, except perhaps in the Garden of Eden, has food been more plentiful, at a lower cost. In the 1970s, the stated objective of our society was to wipe out world hunger. That is not only an admirable goal, but today it even seems achievable. However, in recent years we have witnessed a serious side effect of the pursuit of that goal. This "land of plenty" has become a nation of overweight and obese individuals. While many are quick to point a blaming finger at the "fat" man or woman on the street, the problem is much more complex. Obesity is a disease with its roots in human physiology and is greatly influenced by our environment. Our Relationship with Food G. Dick Miller, Psychologist If you look at recent history, my parents, the World War II generation, had a garden no matter what. Because for them as kids, the thing they had to have was food. They stored potatoes and apples for winter, and my Dad still does that, even though he can buy whatever he wants. Our attitude as a society has changed. We fast, we feast. We no longer think of food as a necessity. Few people in this country know anyone who is going hungry. But we know a lot of people who have weight problems. Part of the reason is that our lifestyle no longer demands physical labor to get the food we eat. But it's more than abundance without exercise. We're pressured socially. Most places I visit, I'm asked, "Can I get you something?" Or they'll say, "You've got to be hungry, you've traveled all this way." People find themselves uncomfortable with me if I don't eat their food. If I don't eat, I hear, "Is something wrong with the food? Do you want to go someplace else? Why didn't you eat all of it?" In addition to social pressure, we're enticed. Look at what advertising agencies do to attract us by associating food with music. I met a guy who works for the company that developed the drink Fango Tango. No one could remember the first Fango Tango jingle, but I did. After I sang the song for him, I could taste Fango Tango. Think about how powerful that is, especially knowing I first heard the song in 1954-a whopping 52 years ago. Movie theaters have done something similar using smell. I hardly ever eat popcorn except in a movie theater. But once I'm there and get a whiff of popcorn, even though I know I'm going to eat after the movie, I get uncomfortable and feel I must have some. It's common to use the word "love" when we talk about provisions. A few generations ago people talked about "sweet-tasting" corn. Now we "love" the corn. We talk about food the way characters talk about each other in a romance novel, in hushed tones, with great anticipation. I said all that to say we have a love/hate relationship with food, and it's affecting our waistlines. The human body is designed to allow excess food energy to be stored as fat for later use. It is our safety net in the event of famine. This process has helped preserve our species throughout the ages when the availability of food was in question. However, when a shortage never comes, the fat stores continue to increase. Obesity has been known to exist throughout history, even in ancient times, but prior to the last half of the twentieth century it was actually quite rare. Today obesity is an epidemic in the United States and, to a lesser extent, throughout Western civilization. It affects all ages, without regard to gender, race, ethnic background, or socioeconomic status. In 2004, approximately two-thirds of U.S. adults were overweight. What's more, we know it. Dieting has become "the great American pastime," and is a multibillion-dollar industry. We are also told how important it is to exercise. Fitness centers are everywhere these days and will gladly get you started, with or without supervision. The "home-gym" is also a hot seller, especially around the first of the year, when we ceremonially vow to start working out to shed those unwanted pounds. Despite all these efforts, the problem is actually getting measurably worse. We must be missing something. What can be done to successfully combat this nemesis? To begin to answer the question of obesity, it is important first to quantify the problem. While most Americans are overweight, the term "obese" is actually a medical term that implies a specific degree of excess weight. But weight alone doesn't tell the whole story. An individual's height obviously must be taken into consideration. A person who is 6 foot, 6 inches and weighs 250 pounds is not particularly overweight, but someone at the same weight who is 5 foot, 3 inches is morbidly obese. Both height and weight are used to calculate what is called the Body Mass Index, or BMI. A BMI is calculated by taking the person's weight in kilograms divided by their height in meters squared (BMI = kg/m2). A normal BMI is between 20 and 25 kg/m2, while obesity is defined as between 30 and 40 kg/m2. If the BMI is over 40 kg/m2, the condition is known as morbid obesity. Morbid obesity is widely defined as being 100 pounds or more overweight. For purposes of simplicity throughout the remainder of this book I will drop the kg/m2 and just use the designation BMI when referring to Body Mass Index. In my example, the 6-foot, 6-inch person weighing 250 has a BMI of 28.9, while the 5-foot, 3-inch person has a BMI of 44.9. There is a Body Mass Index table in the Resources chapter (page 262) at the end of the book for your convenience in determining your own BMI. Below is a table showing the BMI categories along with the related risk of other disease for each BMI range and associated waist size. Obesity is clearly a major healthcare problem because of its direct causative relationship to a number of serious health problems, including Type 2 diabetes, hypertension, heart disease, and cancer. The incidence of adult onset diabetes has skyrocketed in the last decade, and the healthcare costs associated with diabetes have jumped as well. The American Diabetes Association estimated that the direct and indirect expense associated with diabetes in the United States was $123 billion in 2002. That was an increase of 27 percent compared with just five years earlier. Despite the obvious relationship between obesity and a number of major health problems, medical science has had little to offer the obese patient other than medications designed to curb the appetite. Some of these drugs have shown promise, but most have been plagued either by significant side effects or a lack of effectiveness. There is currently some optimism surrounding emerging hormone therapies and even genetic manipulation, but these experimental technologies have yet to be proven. In the absence of effective treat ments for obesity, physicians are currently left with a variety of medications designed to treat merely the chronic symptoms of the disease, such as diabetes, hypertension, and high cholesterol. While generally effective at controlling these secondary problems, the medications are often expensive, and most have side effects. More important, they don't do anything about the basic cause, obesity. In keeping with our fast-paced lifestyle, many obese people are seeking a "quick fix" to their problem. After all, the "makeover" programs on television take the process of totally changing your appearance and make it look so simple. It all takes place in about an hour. What better way to get rid of those unwanted pounds than to have them surgically removed? Uninformed patients often consider liposuction and other body contouring procedures as weight management tools and are shocked to find following such procedures that they have lost only a few pounds. Such cosmetic procedures were never intended to achieve weight loss. There are surgical operations designed specifically to promote weight loss. These procedures, known as bariatric surgery, typically rearrange the gastrointestinal tract and can have dramatic results. In recent years, bariatric surgical procedures have received tremendous media attention as treatment for morbid obesity. The National Institutes of Health (NIH) reported in their 1991 consensus statement that the only treatment shown to be effective in the treatment of morbid obesity long-term is surgery. But the risks of the surgical procedures in use at the time the NIH made that statement are high, and recurrent weight gain has been more common than had been hoped. The numbers indicate that 1 in 100 gastric bypass surgery patients will die within a month of surgery. Five out of 100 will die within a year, and another 20 percent or more will be rehospitalized for complications related directly to their surgery. Despite the risk, the number of obesity operations has increased dramatically in recent years. The lack of a safe and effective treatment option has many obese individuals feeling trapped. Dieting and exercise have not worked for them, and the risk of bariatric surgical procedures has made that option unacceptable to the majority of potential patients. Their frustration is usually compounded by the fact that most morbidly obese people are also suffering from one or more associated health problems. The perpetual treatment of their diabetes; high blood pressure; knee, hip, and back problems; acid reflux; or other weight-related conditions is not only exasperating but also costly. Stephen's Story (Left) Stephen pre-op, 568 pounds. (Right) Stephen, 17 months post-op, 362 pounds. In the beginning, I was against band surgery. I kept telling myself I can do this, I can do it on my own. I was afraid of being put to sleep for surgery because, in my case, the odds were pretty good I would never wake up. I had no idea how much I weighed before I came to Dr. Sewell because most doctors' scales went up to only 350 pounds. When I weighed in at 568, I just cried and cried. What changed my mind about the surgery was watching my sister and my mom, who both have the band-especially my sister. She started at close to 400 pounds and lost 80 with the band. Initially, Dr. Sewell told me I had to lose weight before he'd do the surgery. I lost some, but I couldn't lose the amount needed. Then he told me there were other people with a higher BMI than mine who got the band, and he thought he could do it. He expected to be three to four hours in surgery, but after 45 minutes he was done. I was the first of his patients to get the larger 9cc band. That was May 12 of 2004. Now, 17 months later, I've lost 206 pounds. It's the greatest thing I've ever done. I love it that Dr. Sewell says this is permanent and it'll be there the rest of my life. I work out hard with weights and I do cardio. I realize the band is not going to be the cure-all, and you've got to add some exercise. I've heard every pound you lose is 2 pounds of pressure off your joints. I have very bad knees-no cartilage in one knee, and I've had two knee surgeries. Now with my weight loss, my knees feel so much better. I see other changes already. We've gone to Disney World three years in a row, and usually I had to park myself somewhere and watch the world go by. One of the hardest things was when people used to ask to have their pictures taken with me because I'm so big. I noticed this time I walked past a group of kids and they didn't all turn around. Some did, but not all of them like they used to. And I was step for step with everyone during the three days. In addition, I recently did a 5K walk and passed people on the course. I feel great that I can put on a seatbelt in a car. As for living with the band, I'm a firm believer in not drinking for two hours after I eat. I used to go into a restaurant and tell the waiter to bring me a pitcher. Not now. I've been real lucky. Even at 568, I had people who supported me and could see positives in me. My older sister, who doesn't have a band, is my workout buddy along with her husband. She has always seen in me what I couldn't see in myself, and she told me I'd find a way to get the weight off. Where I work, two people died after the gastric bypass. I work with only 200 people, so two deaths is a lot. In my family, three people have been banded, and we're all doing fine. With severe sleep apnea, I sleep with a machine. But I notice my breathing is easier. I don't snore at all, and I don't wake until my alarm goes off. I used to wake up 30 to 40 times each night. The worst thing for me in the beginning was people's perceptions. At six weeks after surgery, people were saying, "Are you still eating all that?" or "You've only lost 12 pounds?" I didn't put this on overnight, and I'm not going to take it off overnight, either. My wife is my support. She loved me at my worst in my life. I cannot wait to be the husband I always wanted to be for her. I used to be very athletic, and I want to be that way again. I've been sterile, but I want to be able to have children. There's a chance I could be sterile because of my weight. We checked into adoption, but no agency will consider someone who is 35 years old and weighs over 500 pounds. They just don't think I'll live long enough to see the child grow up. My next goal is to get to 250. When that happens, my wife says she's going to buy me a motorcycle. The focus of this book is an innovative treatment that combines a much lower-risk, minimally invasive surgical procedure with a diet and exercise program. The adjustable gastric band was introduced in Belgium in 1992 and has enjoyed considerable popularity in the management of morbid obesity throughout the world. It received approval by the Federal Food and Drug Administration for use in the United States in June of 2002, following several years of clinical trials. By the end of 2003 more than 100,000 bands had been placed worldwide, with about 25,000 in the United States. While the adjustable gastric band is providing considerable help to a number of morbidly obese individuals, it is not a panacea. Subsequent sections of this book endeavor to offer as much information as possible about this treatment, so anyone who is contemplating weight-loss surgery can make an educated and fully informed decision.