There is no longer a question about the incidence of obesity: we are in the midst of a global epidemic. According to current estimates more than 1 billion adults are overweight, with over 3 million who are obese. The numbers are indeed staggering: 35 percent of women and 31 percent of men are considered seriously overweight. A phenomenon rarely encountered not long ago, childhood obesity can now be considered a developing disaster, at least to our health care expenditures. Some of the latest figures reveal 15 percent of children between the ages of six and 19 are overweight.

Granted, these figures are based on BMI, specifically ‘body mass index’, which is recognized to be a noticeably imprecise measure of obesity, although easily the most frequently used measure. Far more telling, and more impactful, is the body adiposity index, abbreviated to BAI. This is a method of determining body fat in humans, although it does not use weight (unlike the body mass index). Instead, it uses the size of the hips compared to the person’s height. Turns out hip size provides a much more accurate predictor of negative health consequences.

So what’s the big deal concerning obesity? The consequences to an individual go beyond the medical effects; we must also look at the psychological dangers, as well as quality of life changes. Referring to someone as fat is tremendously derogatory and carries significant emotional baggage. The stigma of being overweight, especially in this culture, in which physical appearance carries such tremendous importance, produces predictable changes to self-esteem.

The repercussions to one’s health are better understood, although treating the disease which is morbid obesity is another matter. It is well-accepted obesity makes one much more susceptible to high blood pressure, aka hypertension. In turn, this makes one more likely to suffer a heart attack or stroke, or to develop kidney disease. Obesity is also known to encourage the development of type II adult-onset diabetes. The extra physical stress to the body means joints have to do more work, and so are more susceptible to osteoarthritis, and various degenerative joint problems.

We have definitively concluded obesity is a significant and growing problem, with clear heath risks. Our attention must then turn to treatment of the disease. This has proven to be a much more difficult proposition, at least partially because so many disparate reasons that exist as to why someone is obese. Obviously, this will not be a “one size fits all” therapy.

Dieting remains the most frequently prescribed method of weight loss, although the specifics of what to remove from your diet, exactly what you should eat and how much, all these questions and more continue to elude our grasp. The number of different diets that have been attempted to lose weight is staggering, and has filled many a book. Unfortunately, we have few answers. The difficulty in performing conclusive studies on weight and nutrition are huge. Most diet studies are short term, and therefore are unable to provide long term, ‘big picture’ conclusions about the benefits and drawbacks to a specific diet. Another relevant question in all these studies is whether the participants actually adhere to the prescribed plan, which is impossible to definitively ascertain.

Research is ongoing in our search for a weight-loss medication. It’s an attractive concept when applied to weight loss: simply pop a magic pill and lose weight. This is one of the “holy grails” of the pharmaceutical industry (right up there with curing baldness). The currently available prescription medications to treat obesity work in different ways. Some of them help you feel less hungry or full sooner. Other medications may make it harder for your body to absorb fat from the foods you eat. There is much for a physician to consider before writing for one of these drugs, such as the health benefits and possible side effects. Also, it is abundantly clear that diet drugs don’t negate the need for exercise, contrary to popular belief.

A more recent tool in the battle against obesity is the performance of various surgical procedures designed to restrict the amount of food the stomach can hold. Strangely, it has become clear these procedures have other effects resulting in various changes, some of these consequence being unintended, yet still beneficial. One is the decreased absorption of nutrients, which means the body will tend to burn a higher percentage of calories consumed. Unfortunately, this can also lead to vitamin and mineral deficiencies, including those of calcium, vitamin D, iron, zinc, and copper.

Like every surgical procedure, gastric by-pass procedures have potential risks and complications. The use of minimally invasive techniques have reduced some of these, but these don’t always work as well as intended. For one thing, although rare, something during or after the procedure itself may go wrong. Because one of the more common techniques utilizes a band which encircles the stomach, the adjustable band may fail to work properly or may move out of position. Another possibility is that the individual may not lose sufficient weight.

Some serious health problems can also develop. As with any major surgery, gastric bypass procedures pose some potential health risks, both in the short term and long term. Short term risks include excessive bleeding, infection, blood clots and breathing problems. Some of the long term complications are the development of gallstones, low blood sugar, malnutrition, a perforated stomach, ulcers, and others.

The question epidemiologists ask is whether bariatric surgery is cost-effective for our health care system. Evidence suggests that outpatient costs are reduced after this type of surgery. However, long term costs due to inpatient care are increased. The net result appears to be no long term net cost benefit. Yet to someone who has undergone the procedure and seen positive results, it is worth every penny.

Randomized control trials have clearly demonstrated bariatric surgical procedures are more effective in the short term than medical or lifestyle interventions for producing weight loss, even in those who are just moderately obese. Long term conclusions are difficult to reach since most of these studies do not go beyond two years. Yet some observational studies show a reduction in cardiovascular disease, as well as an initial remission of type 2 diabetes. It appears bariatric surgery is probably more effective than lifestyle changes or drugs for long-term weight loss. But the cost savings, over time, remains a hotly debated topic.

But does it need to be more cost-effective than the typical recommendations? Or should there be a higher standard, one of long term cost savings in hand with the benefits to their well-being? This, as well as an associated reduction of expenditures for the long term care of heart disease and the complications of diabetes. It is likely we will need to answer this question in order to see insurance coverage on a broad and routine level. Until that occurs, as with so many therapies and treatments, bariatric surgery will be out of reach for many individuals who might benefit. The alternative approach remains diet and exercise, an approach that, although healthy, seems to benefit some people very little. Until we have better answers as to why there is an obesity epidemic, none of the available options provide a definitive, reliable solution to the dangers of obesity.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.