The surgical war on fat.

Science, technology, and life.
May 26 2009 8:01 AM

The Belly and the Blade

The surgical war on fat.

Illustration by Robert Neubecker. Click image to expand.

Is the war on obesity headed for surgery?

William Saletan William Saletan

Will Saletan writes about politics, science, technology, and other stuff for Slate. He’s the author of Bearing Right.

It's clear that governments are turning up the heat on fat people. The latest weapon is financial incentives. "Congress is planning to give employers sweeping new authority to reward employees for healthy behavior, including better diet, more exercise, weight loss and smoking cessation," the New York Times reported two weeks ago. Agence France-Presse illustrated how such programs operate:

In Varallo, Italy, authorities offered the equivalent of 67 dollars to overweight residents if they achieved a target weight, rising to 268 dollars if they sustained the goal for five months and 670 dollars for 12 months.

But these programs might run into trouble. In the United States, they're constrained by a law that bars "group health plans from discriminating against people because of their health status or medical history," the Times points out. And an ethical analysis by NIH specialists in the May/June issue of Health Affairs says employees may not be penalized for failure to meet goals that are "unreasonably difficult or medically inadvisable" in their circumstances.

"Unreasonably difficult" may turn out to be a fatal problem for reward programs. Studies of weight loss through dieting are showing miserable long-term results.

On the other hand, a different weight-loss strategy is looking pretty good. Last month, the Cochrane Database of Systematic Reviews published an analysis of 26 studies, including six that compared bariatric surgery, such as gastric bypass,

with conventional treatment (such as drugs, diet and exercise). The review found that surgery results in greater weight loss than conventional treatment in people with BMI greater than 30 as well as those with more severe obesity.

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If surgery is more effective than diet and exercise, that shouldn't stop you from trying to exercise and eat carefully. But it might change the way governments approach obesity. Australia is leading the way, as the Herald Sun noted earlier this month:

Thousands more desperately fat Australians would obtain access to lap-band surgery in a radical federal plan to curb obesity. In a significant change in federal policy the morbidly obese would immediately qualify for surgery. A parliamentary inquiry is expected to report in the next week on the need for making bariatric surgery … widely available for those deemed to be unable to lose weight through other means. The scheme would cut waiting lists and provide support services such as nutritionists and mental health experts. It is expected the taxpayer would finance the scheme. … Monash University obesity experts told the inquiry the surgery caused sustained weight loss of up to 60 per cent, while dieters who lost weight often put it back on.

In some ways, this shift in the war on fat mirrors developments in the science of homosexuality. More and more evidence suggests that homosexuality is biologically rooted and impervious to exhortation or willpower. Many gay activists think this evidence will help to end the culture war against homosexuality. I suspect they're right. But maybe that's not the end of the story. If homosexuality is chemical, maybe the war on homosexuality, having ceased to be cultural, will become chemical instead.

Something like that may already be happening to obesity. Homosexuality and obesity are different in many ways. But in one respect, they're similar: Obesity rights activists think the science of intractability is on their side. Lynn McAfee, director of medical advocacy at the Council on Size and Weight Discrimination, makes this point in a recent Reuters story:

"The emphasis has just been 'lose weight and everything will be fine,' and it's becoming really clear that people aren't losing weight," she said. "So we want to shift the emphasis to making us as healthy as we can be at whatever weight we are."

That's not quite true. People on diets aren't losing weight. But people who get bariatric surgery are losing weight. Governments see this difference, and they're increasingly interested in paying for the surgery if, as evidence suggests, it's cost-effective. According to a study published last year in the American Journal of Managed Care, "Downstream savings associated with bariatric surgery are estimated to offset the initial costs in 2 to 4 years."

So look out, fat folks. As we learn more about the intractability of your condition, the good news is that people may stop expecting you to diet or exercise your way to a thinner body. The bad news is, they may start expecting you to go under the knife.

(Now playing at the Human Nature blog: 1. An ad for drinking recycled urine. 2. The swimsuit arms race. 3. Will Obama's CDC director fight obesity by redefining food?)

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