By Prue Salasky, email@example.com | 757-247-4784
7:39 AM EST, December 10, 2012
Bariatric surgeon David Salzberg can reel off a list of life-threatening problems associated with morbid obesity. They include diabetes, hypertension, high cholesterol, sleep apnea, joint pain, depression and elevated rates of cancer.
"Twenty percent of the population is morbidly obese, or 75 to 100 pounds over their ideal weight," he said. "Their problems are life-threatening. The increase in the rate of early death is up to 55 percent and that equates to 10 to 15 years off the typical human life span."
Salzberg, who practices at the 1-year-old Riverside Medical & Surgical Weight Loss Center in Newport News, is not alone in calling obesity an epidemic and the nation's greatest health crisis. Orthopedic surgeon Colin Kingston with Tidewater Orthopedics believes obesity will surpass all others as the No. 1 health issue in the U.S. in the next 10 years. "It's a real disease, and it's not being treated as disease," he said.
The American Association of Clinical Endocrinologists has determined that obesity is not attributable solely to poor lifestyle choices and this year called for its designation as a primary disease with specialized medical training for its treatment.
The associated costs are massive — in the impaired health of the almost 50 percent of U.S. adults who are overweight, in associated chronic diseases and early mortality — and also in financial burdens on the health system.
At Riverside Regional Medical Center, four of the rooms in its new 72-bed wing are specially equipped for patients weighing 500 pounds or more. The doors are wider, the beds are larger, and there are special lifts installed. In the Orthopaedic Hospital at Sentara CarePlex, special accommodations include extra-wide wheelchairs and reinforced toilet stands; when needed, it rents extra-large beds for patient rooms at a cost of $145 per day. It has also invested in a new 3T MRI machine, scheduled to arrive in December, that can accommodate larger patients. Likewise, Hampton Roads Orthopaedics & Sports Medicine advertises its open multi-positional MRI as able to "accommodate virtually any size patient."
In the operating room at Sentara CarePlex, Hercules beds allow for any necessary width and length extensions. "There's definitely a degree of difficulty standing across a 350-pound patient," said bariatric surgeon Tom Clark, medical director of the decade-old bariatric surgery program at Sentara and the Center for Weight Loss Success in Newport News. To compensate, he uses extra-long implements — about 5 to 8 centimeters — which are now readily available. In the past, he said, "we almost had to make them ourselves." Likewise, more expensive special scales have to be used to get accurate weight measurements.
After surgery, nurses can inflate a Hovermat on the operating room bed in order to move patients to gurneys. The procedure that once took 10 people can now be done by two, said Ruth Fowler, RN, manager of surgical services. She noted, however, that an extra person is routinely assigned to the surgical team for bariatric surgeries.
Obesity and surgery risks
For anesthesiologists, large patients pose greater risks as the fatty tissue around the trachea tends to collapse, said Clark. In 2010, Sentara invested in a video tube for the operating room to help with intubation of bariatric patients. "The length of surgery is key. The longer it takes, the higher the risk," said Clark.
Orthopedic surgeon Kingston agreed. "At 500 pounds, you're at high risk for infection. There are three or four inches of adipose, fat, tissue. The leg is heavier, it's harder to bend the knee upward to get the appropriate orientation, it can add 10 or 20 minutes to a knee replacement. That can be the difference between infection and blood clots."
While obese patients used to have to lose weight before orthopedic surgery, many doctors now feel it's more important to get patients moving. The downside is that replacement joints don't last as long, the weight and force across the polyurethane wears out faster. "At 100 pounds overweight you're already looking at a second operation in 15 years even from a perfect result," said Kingston. He also cited gallstones and gallbladder issues in addition to higher pre- and post-operative risks for infection among the morbidly obese.
The knees take the brunt of the wear and tear. The Arthritis Foundation reports that for every pound gained, it exerts four pounds more pressure on the knees. Citing "The Biggest Loser" TV show Kingston observed that the biggest eye-opener for participants is when they attempt to run while carrying the hundreds of pounds they've lost. "It's really difficult," he said.
How weight gain happens
Clark, Kingston and Salzberg all point to environmental factors in the obesity epidemic. Fast foods, portion sizes and sedentary lifestyles all contribute, as do lack of education about nutrition and physical fitness.
As people gain weight it becomes increasingly difficult to reverse course. "They're in pain. They can't exercise, their lean body mass decreases and muscle diminishes, and their metabolism slows down," said Deb Vaccaro, Sentara's bariatric program coordinator.
She added, "People think about surgery for a while. You don't just go 100 pounds overweight. Sometimes, it's a scare, a heart attack, or the doctor has told them they have five years to live. Some want to get off meds or play with their grandchildren."
Some want to get off reliance on help from others for toileting and showering. Others want to be able to forgo using a seatbelt expander.
For Newport News resident Veleka Sawyer, 40, the weight accumulated when she became depressed after the death of her third child shortly after birth. She was closing in on 300 pounds, taking medication for her blood pressure and she needed a repair of a torn meniscus in her knee. In July, after three years of thinking about it, Sawyer opted for a gastric sleeve operation. She has already lost 57 pounds and is off her blood pressure medication and pain meds for her knee. "I needed a permanent solution," she said. "I love it."
Surgical weight loss
The three most common procedures are the gastric bypass, the sleeve gastrectomy and the adjustable gastric band, or "lap-band" surgery. The hardest thing for people is making the decision for surgery, said Salzberg. "They see it as a drastic step." However, he said, it now has wide acceptance, a change from a few years ago.
Currently, bariatric or weight-loss surgery for the morbidly obese is covered by Medicare and Medicaid, most government employee plans, most large group plans, and some plans that have bariatric riders. Under the "essential health benefits" proposed by the Virginia Health Reform Taskforce for the state's health exchange (which is currently on hold), bariatric surgery would also be mandated for individual and small-group plans. The taskforce estimated costs for this benefit between .75 percent and 1.5 percent.
Salzberg likens the costs of obesity for patients to "buying a new car every year" in medications, health care, food, and so forth. He describes the surgery as "liberating — they're not thinking about food all the time. It's a brand-new life."
Bariatric surgery works
Experts agree that it takes lots of pre- and post-counseling to make the surgery effective.
"When weight gets to be high enough, diet and exercise alone are almost universal failures. The amount of food they need is so little, the sensation of hunger is intolerable," said Salzberg.
With surgery, the rate of weight loss is typically 85 percent of excess body weight over one to two years. "If someone weighs 350 pounds, they're going to lose 175 pounds comfortably," he said.
With that loss, come cures for chronic conditions. "Half of diabetics no longer need insulin; people come off high blood pressure medication after three months and cholesterol medication after six months. It doubles or triples the efficacy of orthopedic surgery. We're truly finding cures for long-term chronic problems," said Salzberg.
Clark is more cautious, stating that the surgery itself is not the cure. "It's a tool. They still have to do the right things. The surgery is just one hour out of their life. Education and compliance are key."
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