Preventive Medicine Column

Dr. David L. Katz

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 3 years following– for reasons as yet unclear.

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 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.

While we keep spending vast fortunes on a status quo which, 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 ordinary people who are lean and healthy in the midst of an obesigenic environment are enrolled.  The group should be diverse- and we would want people who CAN gain weight, but don’t.

The 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.  Then, the inventory of skills and tools could be assembled, and matched against the daily challenges they are used to overcome.

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 on-line, 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.

The way we respond to obesity and related chronic disease in the US 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, would be 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 ten times that many in the U.S.…every day!

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.




Dr. David L. Katz;