For obese, surgery more effective than drugs

By Nanci Hellmich, USA TODAY

Expensive weight-loss surgeries such as gastric bypass are by far the most effective options for severely obese people who want to lose a lot of weight, according to a new analysis.

The report suggests that prescription diet drugs combined with diet and exercise provide modest weight loss for the overweight or moderately obese. But for those who are 100 or more pounds too heavy, the researchers say, these weight-loss tools may not be enough.

While these findings might not seem surprising, this analysis is important because it was financed by the government — the U.S. Agency for Healthcare Research and Quality — and may be a factor as insurance companies and government agencies debate whether to pay for weight loss, or bariatric, surgeries.

Currently, Medicare covers bariatric surgery only if the obese patient has other life-threatening conditions, such as diabetes and heart disease. Benefits for Medicaid patients vary by state.

Scientists from several medical institutions reviewed 225 studies on diet drugs and bariatric procedures, including gastric bypass and adjustable gastric banding. Among the findings reported in today's Annals of Internal Medicine:

• Severely obese people who have procedures such as gastric bypass surgery lose and keep off an average of 44 to 66 pounds for up to 10 years. The average cost for gastric bypass, which creates a much smaller stomach and rearranges the small intestine, is $26,000.

• Overweight people who take prescription diet drugs while dieting and exercising lose an average of 8% to 10% of their starting weight, about 15 to 20 pounds, in the first year. This research did not cover as many years as did the bariatric-surgery studies.

• Weight-loss surgery helps improve or eliminate diabetes, high blood pressure, sleep apnea and high cholesterol for most patients.

• The mortality rates from all the bariatric procedures is under 1%. Overall, about 20% of people had some complications such as intestinal leaks and nutritional abnormalities. Deaths and complications were significantly higher when performed by surgeons who had done fewer than 50 such surgeries.

• The medications have some side effects. Studies on sibutramine, which works on brain chemistry to enhance the feeling of fullness, have documented cases of increased heart rate and blood pressure. Study participants who took orlistat, which blocks some dietary fat from being absorbed by the body, have reported gastrointestinal problems.

"We've concluded that bariatric surgery is better than diet and medications for severely obese individuals who are willing to undergo surgery," says Paul Shekelle, a study author and acting chief of General Medicine for the Greater Los Angeles Veterans Affairs Healthcare System. He's a staff member of RAND Health, a non-profit research institution.

Also, the American College of Physicians releases its obesity guidelines in this issue of the Annals of Internal Medicine. The group recommends medication and bariatric surgeries only for obese patients who are not otherwise able to lose weight.

Thomas Wadden, director of the Weight and Eating Disorders Program at the University of Pennsylvania in Philadelphia, calls for more emphasis on obesity prevention. "This will require a major public health campaign similar to those developed for smoking cessation, drunken driving and AIDS prevention."