Management of obesity and politics

There was a recent national conference in Atlanta that addressed the issue of obesity in this country. Portions of the discussions were reported on the front page of the ACS Surgery News (01/20/14) under the byline: “Politics, bias drive obesity treatment costs.”

The statistics are staggering; obesity possibly afflicts one third of the adult U.S. population and an estimated 15 percent of children. Every day television and newspapers remind us of this “modern day plague” while the same media wallow in cash from selling products purported to treat the problem.

Who is obese?

In clinical practice, “weight problems” are classified according to the BMI [Basal Metabolic Index, a mathematical calculation based on body weight in kilograms (kg) and height in meters squared (m2)]. An individual is clinically classified as underweight if the BMI is <18.5; Overweight = 25 to 29.9; Obese = 30 to 34.9; Morbid obesity = greater than 35 with comorbidities or >40; Super Morbid Obesity >50. The candidates for bariatric surgery are those with BMI >35 who have comorbidities such as hypertension, diabetes mellitus, sleep apnea and depression and those with BMI >40 even in the absence of comorbidities.

In today’s health care environment, obesity is considered a tremendous drain on our health care resources because of the associated complications, which can become chronic illnesses that are very expensive to take care.

Ten years ago, the estimated overall medical care cost related to obesity alone was about $100 billion* and this continued to rise! Today, CMS spends “$1.5 billion dollars a day or $900 billion yearly on healthcare.” Although these unimaginable figures may not totally refer to obese patients, it is believed that 25 percent of patients with chronic problems such as the comorbidities of obesity comprise 85 percent of the health care cost.

Possible solutions to this national health problem have been discussed in numerous forums, but there seems to be no final answer. In the process, there are accusations that the issue is politicized and patients are being discriminated against.

According to the recent symposium on obesity reported on the January issue of ACS Surgery (the official newspaper of the American College of Surgeons), there are three factors that might undermine the ability to meet the challenges caused by obesity and these are: “politics, prejudice and inconsistent health insurance policies.”

For instance, it is cited that obese individuals in their 20s will have BMIs of 40 kg/m2 before they reach their 40s and then when they get to their 60s, they will develop obesity related comorbidities. Therefore, it is strongly suggested that early intervention in the form of bariatric surgery would prevent the future complications that are cost prohibitive to take care!

However, leaders of the American Society for Metabolic and Bariatric Surgery (ASMBS) claim that CMS limits the coverage for bariatric surgery. For instance, CMS would cover surgery only if a patient has undergone behavioral intervention that most bariatric surgeons claim to be ineffective.

Another lamentable observation is that “people are prejudiced against the obese.” To paraphrase Dr. John Morton of Stanford University, “Obesity is often described in exclusionary terms by third party payers” – referring to insurance plans – despite the language in the Affordable Care Act that prohibits discrimination on the basis of health condition.

There is a universal agreement that there is no single solution to this problem. Surgery alone is not the answer; common sense suggests that diet and exercise also play an important role in controlling this malady. Still there is that question of “who pays for all these?”

Reference: ACS Surgery News. Vol.10. No.1 January 2014

*The China Study, by T.Collins Campbell, PhD. 2006

Dr. Cabasares is a board certified general surgeon and Fellow of the American College of Surgeons; he practices in Perry.

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