Blog | Wednesday, August 22, 2012

Plain English about ounces, pounds, dollars and sense

One of the arguments for bariatric surgery in principle is that by addressing the problem of often severe obesity effectively, the procedure should alter the entire trajectory of health in a way that saves money. Obesity and its complications are costly; fixing the one and forestalling the others should attenuate those costs.

But such pecuniary hopes attached to weight loss surgery were themselves somewhat attenuated this week with the publication of a new study in the Archives of Surgery. The study, limited to older, male patients in the Veterans Affairs hospital system, showed that costs rise acutely with the surgery itself, as one would expect, but then fail to fall for the three years following. Reasons at this point remain a matter of speculation and debate.

Before following where this leads, I hasten to add that saving money is not the primary reason for bariatric surgery, any more than for coronary bypass. In general, intervening to address severe threats to health carries a cost, often a high cost, and one our society has proven repeatedly it is willing to pay. Bariatric surgery can reverse disease, avert death, and extend life. That it is often the best thing going for the treatment of severe obesity, is well-established by the available evidence currently in hand. I believe strongly it should be available to all who need it.

Our societal problem is letting too many need it in the first place.

As for costs, they don't make or break the case for bariatric surgery once it is needed, any more than they make or break the case for organ transplants, dialysis, burn unit care, or coronary bypass. In general, saving and improving lives in peril costs money. We can let people die for free, that doesn't make it a good idea. In this, as in all things, we tend to get what we pay for.

But it would be one helluva' good idea to prevent so many people from needing medical procedures our society ultimately cannot afford, in the first place. That certainly includes bariatric surgery, which could go away all but entirely, if we did all that it takes to make healthful eating and physical activity every day our prevailing cultural norm, but also extends to coronary care, dialysis, amputations, and more, since so much chronic disease is propagated either directly by obesity, or by the same factors that propagate obesity. We have known for decades that bad use of feet, forks, and fingers represent the leading causes of premature death and virtually all of the major chronic diseases that bedevil our personal fortunes and national economy alike.

Dealing with advanced disease with surgery, or for that matter drugs, like the weight-loss drug Qnexa, just approved by the FDA, carries costs our society cannot bear, even when such interventions work well, which is only sometimes. What would work better for health and vitality, and costs alike, is prevention. Lifestyle as medicine.

While we keep spending vast fortunes on a status quo that, if we are quite blunt about it, covers the expenses of the highly imperfect efforts of all the king's horses and all the king's men, we could spend vastly smaller sums to blaze new trails entirely.

Consider a study in which a group of ordinary people who are lean and healthy in the midst of an obesigenic environment are enrolled. The group should be diverse, younger and older, male and female, richer and poorer, employed and unemployed, in school and graduated, all variations of skin pigment, and so on. They should at first be overfed and underexercised a bit to prove they are as human as the rest of us, and gain weight when that happens. People who are genetically impervious to weight gain would be ineligible. We want people who can gain weight, but don't. For what it's worth, I'd be a perfect study subject so far.

Once we have such a group assembled, we should use readily available research methods to make a systematic audit of their skill sets, and the resources/tools they use as a matter of routine to stay healthy and lean. Using semi-structured survey methods and focus group techniques, this process would be iterative, meaning information is fed back to the group to prime the flow of more information, which would continue until nothing new is disclosed. The audit is done when you know all there is to know.

Then, the inventory of skills and tools could be assembled, and matched against the daily challenges they are used to overcome. And just on the chance you are having doubts that such methods are plausible, we have put them to good use already, although not quite as expansively as I am proposing here.

Once the inventory of skills and tools is identified, the next step would be to figure out how best to get them to everyone. Some tools might be most readily put into people's hands in school, others at work, others at church, others in the supermarket, others still online, and so on. We could create a map linking each resource, tool, or skill to the best means of getting it into everyone's hands.

Maybe this is sounding tough, but consider that just about every baby born in the United States learns to speak English. That's a pretty tall order, really, just ask any adult from elsewhere who doesn't speak it and is trying to learn. Growing up in a culture that surrounds you with exposure to English makes it natural to learn English, something very hard to do later on.

This is directly analogous to prevention, which requires you "grow up in it," but is easy and painless, as compared to dealing later on with what you didn't learn early. That's costly, hard, and painful.

In fact, the way we respond to obesity and related chronic disease in the U.S. is like waiting to send every adult to night school to learn English, painfully, poorly, expensively, and late, rather than having them grow up speaking fluently all along. We should certainly continue offering English-as-a-second-language classes to those who need them, just as we should continue paying for bariatric surgery and coronary bypass operations for those who need them. But not at the expense of routine fluency in either case.

English can be spoken fluently; so, too, can health. The research steps required to learn what the minority who now speak fluent health know, and how everyone else can learn it, are not trivial, but they are not rocket science, either. They are not free, but they are vanishingly less expensive than the status quo, in both dollars, and human costs. Having some experience with this kind of research, a back-of-the-envelope calculation suggests the whole thing could be done for less than the cost of 100 bariatric operations. And we are doing roughly 10 times that many in the U.S. every day!

There is English literacy; and there is health literacy. We could create a culture in which everyone simply acquires health literacy the way they acquire language. It is, if anything, probably a bit less hard!

Applying sense to get at the missing links of science as I've described them may sound as if it entails some heavy lifting. Perhaps. But compared to the crushing weight and unsustainable costs of the status quo, it is as ounces to pounds, as cents to every dollar.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.