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patients reached 100 percent within a few years of dieting. Traci Ma nn, PhD, Universit y of Minnesota Department of Psychology, has spent much of her career studying obesity and fi nds that any combination of diet, exercise, counseling and medical inter- ventions leads to more or less the same results. " B a s e d o n my qua ntitative reviews of the litera- ture, for the majority of people, diets don't lead to long-term weight loss," Mann says. "Weight slowly returns. It does not appear to be helped by counseling and other interventions." Into the Gap: Bariatric Surgery By contrast, many studies have found bariatric surgery, including gastric band- ing, gastric sleeve and gastric bypass procedures, to be effective at promoting long-term weight loss. One review of the literature found bariatric surgery to be effective up to 10 years after surgery. A Cleveland Clinic study that followed bariatric surgery patients for an average of six years after their procedures found typical patients had lost 60 percent of their excess weight. As a result of this and similar research, physicians are prescribing weight-loss surgery earlier, says Ninh Nguyen, MD, FACS, President of the American Society of Metabolic and Bariatric Surgery. "I think physician attitudes are chang- ing and more are suggesting bariatric surgery earlier and more frequently for their patients, based on the scientifi c evidence that has been accumulated over many, many years," he says. "Primary care providers have taken notice. The American Heart Association, American College of Cardiology and The Obesity Society released obesity guidelines com- missioned by the National Institutes of Health that recommend doctors diagnose and treat obesity at every clinic visit 'the way they would any other chronic disease.' In addition, the guidelines specifi cally state patients who meet the criteria should be referred for bariatric surgery evaluation." Like other people who desire to lose weight, bariatric surgery patients must follow healthful diet and exercise pat- terns. However, Dr. Nguyen says, those lifestyle changes produce more satisfac- tory results when made by people who have undergone surgery. "Adhering to proper nutrition and exercise may be more successful after bariatric surgery," he says, "because the surgery limits the amount of food the stomach can hold." Dollars and Sense Not only has bariatric surgery proved effective, but it may also be fi nancially advantageous. While a recent study in JAMA Surgery did not find long-term overall healthcare cost savings related to bariatric surger y, a study in The American Journal of Managed Care found that costs for bariatric procedures were recouped within two to four years, in signifi cant part because of savings related to reduced comorbidities. However, many patients lack the fi nan- cial means to undertake bariatric surgery. Many insurance plans — including about two-thirds of employer-sponsored plans — do not cover the surgery, Dr. Nguyen says. Those that do often require psychological evaluations and detailed evidence of failed dieting attempts. "We are making progress, but much work still has to be done so patients have greater access to what, for many, could be a lifesaving procedure," he says. "Severe obesity is vastly undertreated, resulting in shorter life spans, proliferations of other diseases including diabetes, heart disease and certain cancers, and greater long-term costs to the healthcare system. Yet less than 1 percent of the eligible patient population has bariatric surgery each year." Dr. Nguyen predicts that will change, however, as physicians recognize the value of bariatric surgery and advocate for more insurance coverage. "Bariatric surgery is a safe and effective long-term treatment for chronic disease," he says. "This is particularly true for patients with obesity and metabolic diseases, including hypertension, dys- lipidemia and Type 2 diabetes." W hen do you refer patients for bar- iatric surgery? Join in the discussion at www.mdnews.com. ■ A DVO C AT ES FO R T H E O B ES E SO MANY PEOPLE have struggled to obtain bariatric surgery that a branch of legal practice — termed obesity law or obesity advo- cacy — has evolved to assist them. Obesity advocates may work for patients or physician practices to obtain insurance approval for bariatric surgery. Obese Society, M D N E W S . CO M ■ MD NEWS Greater Boston | 1 3

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