Bariatric Surgery To Lessen The Burden Of Cardiovascular Diseases: It Is An Answer, But Not the Solution
Disclosure: Dr. Fayad has modest relationships with AGA Medical Corporation and the National Institute of Neurological Disorders and Stroke.
Pub Date: Monday, March 14, 2011
Author: Pierre Fayad, MD, FAHA, FAAN
Poirier P, Cornier MA, Mazzone T, et al; on behalf of the American Heart Association Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Bariatric surgery and cardiovascular risk factors: a scientific statement from the American Heart Association. Circulation. 2011: published online before print March 14, 2011, 10.1161/CIR.0b013e3182149099.
Of all future predictions in health care, the anticipated increased excess weight and obesity are rarely doubted. There is no need for convincing statistics or epidemiologic studies, just look around you at work, in the mall, and in the street, to notice the increasing preponderance of excessive weight in all age groups. The most extreme of this epidemic, severe obesity, can be effectively treated with various types of bariatric surgery, as the American Heart Association (AHA) Scientific Statement released this week reveals.
The obesity epidemic represents the cumulative end result of various factors, ranging from economic, commercial, societal, and political ones, to genetic and behavioral factors. The body shows its amazing capability of going way beyond its means to efficiently process and store excess food intake, regardless of the potential extreme consequences. The burden of dealing with obesity falls squarely on the patient; cardiovascular outcomes represent the lion's share of complications. It starts with metabolic derangements in insulin resistance, dyslipidemia, and inflammation and on to sleep apnea, diabetes, hypertension, coronary artery disease, stroke, and premature death. Additionally, obesity is increasingly burdensome in its heavy toll on the health care and societal costs of dealing with it.
In spite of incremental discussions politically and in the lay press about the obesity epidemic, few radical solutions have been identified from a public policy perspective. Some specific initiatives, like the AHA partnership with the William J. Clinton Foundation to fight childhood obesity, target important aspects of the problem. Public policies of the same intensity as tobacco smoking have not yet materialized. In the meantime, how should obesity be addressed on an individual basis? Behavioral treatments alone are rarely effective in the more severe cases. There have been successive failures in discovering an effective medical treatment for obesity. Despite several innovative compounds and approaches, medications aimed at curbing appetite and decreasing weight, have so far shown little improvements, at the cost of serious side effects, which prompted the U.S. Food and Drug Administration (FDA) to decline their approval.
Bariatric surgery is perceived as a harsh solution for a functional physiological disorder, through dismantling parts of normally functioning stomach and intestines, or disabling them. Yet, significant advances have been achieved in refining the techniques, managing the complications and monitoring the outcomes. Poirier et al. thoroughly reviewed the scientific publications covering the topic and concluded: "Bariatric surgery should be reserved for patients who have severe obesity, in whom efforts at medical therapy have failed and an acceptable operative risk is present." Indeed, not only can bariatric surgery be effective at weight reduction, it can also significantly and positively impact the major metabolic and clinical outcomes associated with severe obesity. Understandably, patient selection, type of procedure, and pre- and post-surgical behavioral and nutritional monitoring and therapy are essential at making the benefit-to-risk ratio favorable to the patient.
There is still a lot to be explored and learned on the pathophysiology of obesity and the therapeutic basis of surgery, as the authors discuss in the last section of the manuscript. The problem of obesity, just like many other historical and social situations, shows the human brain in its amazing paradoxical abilities at both extremes. On the one hand, we celebrate the creativity and ingenuity of finding a surgical solution to a health problem that is disfiguring, disabling, and life threatening. Alternatively, our brain's failure is highlighted in its inability to prevent the slippage into such a situation in the first place.
- Astrup A. Drug management of obesity-efficacy versus safety. N Engl J Med 2010;363(3):288-290.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association