Being fat is not a choice
The story of a young man who went public last week to describe losing 74kg following weight-loss surgery attracted dozens of negative comments when it appeared online. His surgeon, Richard Flint, has been moved to respond.
Last week, Stuff described a young man whose life had been changed. After numerous failed attempts to turn his life around he summoned courage to ask for help. A year later he has an exciting new life ahead of him and keen to tell his story.
Such an upbeat tale would surely be enjoyed by those wearied by articles of crime and injustice. But the young man was obese and the life-changing event was weight-loss surgery. His story was disparaged and his character (and that of his parents) was maligned as lacking discipline.
For those of us who know him it is hard to read the ill-informed comments that have been blogged about the article. He is an ordinary kid who did not ask to be fat. His parents are intelligent, caring people who never daydreamed that their son would be obese.
Furthermore, their plight must parallel other families as many of the children and adults in New Zealand have a weight problem. Therefore I feel it necessary to respond to these blogs in the hope that my advocacy may gain some respect for this young man and others like him.
Fatness is not a choice
There is indisputable proof that some people are prone to becoming fat. The strongest evidence comes from hereditary studies such as the Swedish twin study that followed 25,000 pairs of twins.
The researchers found that identical twins who had been separated at birth had similar weights when they reached adulthood. Likewise studies from the Danish adoption register show a strong correlation between the weight of adopted children and their biological parents but not their adoptive parents.
Genetic studies have identified up to 32 genes that contribute to obesity (including FTO, MC4R, and POMC) and the best-known inherited disorder of obesity, Prader Willi syndrome has been attributed to mutations of chromosome 15q11-q13. This body of evidence suggests that some people are born to a life where they will constantly battle their weight.
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We live in a fat-making environment
Most people will focus on fast food and sugary drinks as the cause of obesity. However this is overly simplistic.
There is strong evidence to implicate infections as a cause of obesity. Both viral (AD-36 and SMAM-1) and bacterial (C. pneumonia) infections will cause some people to gain weight.
Likewise studies of the normal bacterial flora of the gut have shown changes in the ratio of gut Firmicutes and Bacteroide will predispose to obesity. Environmental pollutants have also garnered attention.
Bisphenol A that is used to make hard plastics has been linked to obesity in large population studies and confirmed in laboratory testing. Other pollutants implicated as a cause of obesity include DDE (the metabolite of the pesticide DDT), PCB (used in coolant fluids and as an electrical insulator) and PBDE (a flame retardant).
Even the recent drive for warmer housing has been shown to be a cause of obesity. Those people exposed to real-world temperatures weigh less than those who live in an air-conditioned environment. Presumably this is because a reduction in heat from 25 degrees C to 16 deg will increase energy expenditure by 160kcal/day as the body tries to keep itself warm.
There are numerous other environmental factors that have been linked to obesity such as cigarette smoke, work-place hours that lead to sleep deprivation, and common pharmaceuticals just to mention a few.
The examples are many but the message is simple. For people who are prone to obesity their life can be likened to an alcoholic being asked to live in a brewery.
They should eat fruit and go for a run
Most comments that were blogged in the last week offered "sage" advice. This young man should eat better and exercise more. It may be some comfort, therefore to these bloggers that this young man (and many like him) are very adept at dieting.
Indeed it has been estimated that people seeking weight loss surgery have lost a total of four times their body weight with prior attempts at dieting.
However the norm is for limited weight loss that cannot be maintained. A recent scientific review of 48 trials of dieting programs (over 7000 patients) reported an average weight loss of just 8kg at six months that had diminished to 7kg at 12 months.
A 10-year Swedish observational study revealed a group that attempted dieting not only regained their weight at two years but also had put more on.
Laboratory studies have provided a clue on why dieting is so difficult. A reduction in calories leads to a significant drop in their metabolic rate as their body adapts to a starvation mode. When food is reintroduced there is a variable period of overeating but no restoration of the metabolic rate.
In essence the body is ingesting more energy but burning less. If the person is able to counter this period of overeating and maintain the diet they are wracked with hunger, as many of the hormones that control appetite, such as ghrelin, remain elevated for up to two years after dieting down to goal weight.
Adding exercise to a diet program will limit the extent of weight regain, presumably by reducing the amount of muscle lost during dieting. However, it has yet to be shown to add dramatic results to dieting. This is because exercise only accounts for 10 per cent of the daily energy requirement (most calories are used just to stay alive!) and the fatigue induced by exercise usually offsets any gains – eg, people are less likely to take the stairs if they have sore legs from a run around the park.
There are no fat cows in a concrete paddock
The first argument against surgery (and often the most fervent) is that obesity is just a product of free will and money should not be spent to surgically correct gluttony.
Although I hope I have convinced readers that the cause of obesity is more complex than simple over-indulgence, I must agree that few are forced to eat.
But whilst it is true that food is taken willingly it is also true that factors promoting obesity are not experienced by choice. The ethics of denying patients the chance for treatment because they have been too weak-willed to resist in a fat-inducing environment must be questioned.
What difference would there be in denying patients treatment for melanoma because they failed to use sunscreen regularly, treatment for AIDS sufferers because they failed to adopt safe sexual practises, emergency surgery for the drunk driver who crashed, or oxygen therapy for emphysema because they used to smoke?
Most modern healthcare is focused on conditions that could be prevented by healthy life choices, but it is disturbing that obese patients are judged on a premorbid sense of "discipline" that is never debated as a prerequisite to treatment for other conditions.
Why is one group of people judged on deservedness yet everyone else on need? This prejudice must surely disturb those with any sense of fairness and justice.
Patients puree up Mars bars after surgery
A further argument against weight loss surgery is that it doesn't work. Anecdotal tales of a patient pureeing up Mars bars to sabotage their operation are often volunteered as proof. However, this conclusion is not supported with scientific evidence. Randomised controlled trials and cohort studies have shown weight loss surgery to be vastly superior to dieting.
Compare an expected average weight loss of 30kg after surgery to 8kg after dieting. Weight reduction after surgery is maintained for over a decade and this has been shown to not only improve ailments but also increase life expectancy. Furthermore it is a relatively safe procedure with a mortality rate of less than 0.1 per cent.
However, if we are to accept that the single anecdote of a nameless patient can be used to reject the weight of evidence supporting weight loss surgery, then why is no one questioning therapies for other conditions?
Why do we not deny cardiac stents when we know that 10 per cent of patients will fail to continue their medication that will prevent the stent from occluding? Why should we maintain liver transplantation when up to 38 per cent of patients fails to take their anti-rejection medication? Is it because it is not acceptable to deny people an effective treatment when their survival is at risk?
How much more inappropriate can it be to decline weight loss surgery that has been shown to improve annual survival by 80 per cent?
I am not paying to stop fat people eating
The final argument against weight-loss surgery is that it is unreasonable to spend tax dollars on fat people when so many other people have health needs.
Let us not get distracted by irrelevant examples of tax dollars willingly being squandered (a boat race comes to mind), or moral arguments regarding prejudice against fat people. I would argue that not offering weight loss surgery has an inherent cost that will eventually limit healthcare at any rate.
Obesity raises the cost of inpatient and outpatient care by 36 per cent, the cost of medication by 77 per cent, and accounts for 2.5 per cent of New Zealand's health spending. This can be extrapolated to $344 million a year, yet the true cost can only be greater as this estimate is based on 1990 data that does not account for the recent rise in the rate of obesity.
In the face of such sums it seems ironic that avoiding surgery will actually cost the health system even more. Numerous studies have indicated that weight loss surgery leads to long-term savings with the cost of surgery being recouped within two years. In recognition of such data the Ministry of Health published a business case in 2008 for New Zealand to publically fund weight loss surgery.
Its initial recommendation of offering surgery to just 0.5 per cent of the morbidly obese population was based on unavailability of enough skilled surgeons, rather than a foolish financial notion.
Who will identify with fat people?
It is peculiar that few people identify with being fat when most people have a weight problem. It is stranger still that those who try to do something about it are vilified.
The weight of scientific evidence indicates that a group of people are born prone to obesity and the modern world has changed into a pro-fattening environment. This renders it near impossible for these people to avoid being fat.
Those oblivious to the evidence may glibly state that they just need to stop eating but those seeking surgery have already tried this, many times. This young man has found an answer and wanted others to know. His courage for speaking out should be admired and his experience should make people pause to think.
Surgery may not be for everyone, but for those that need it, it can be a life-saver.
Richard Flint is a consultant surgeon at Christchurch Hospital and lecturer in surgery at the University of Otago, Christchurch. He recognises a conflict of interest in championing weight loss surgery, but says he has a duty to advocate for his patients, and eagerly awaits an independent person to take up the cause.
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