Weight-Loss Surgery Cost-Effective Even for Mildly Obese (Oh, Really?)
According to this article in MedPage Today, weight loss surgery (WLS) is cost-effective even for the mildly obese (people with a BMI of 35 to 40). Excuse me while I laugh my ass off.All righty then, I’m done laughing, now it’s time to get down to brass tacks. The full report can be found here.
Treatments for overweight and obesity include dietary therapy, exercise/behavioral interventions, weight loss medications, and bariatric surgery. Yet studies have shown that all of these options except surgery have been ineffective in long-term weight control. In addition to sustained weight loss, surgical treatment provides additional benefits to people with ORDs and reduces relative risk of death.
Well, I have to disagree with, just from personal experience. Risk of death? Yeah, that one’s interesting, and one reference can be found here. In one place, it says that the impact of surgically-induced, long-term weight loss on mortality is unknown. Elsewhere, this study shows that weight-loss surgery significantly decreases overall mortality, as well as the development of new health-related conditions in morbidly obese patients. So which is it? They either don’t know if you live longer with WLS, or you do live longer with WLS. Can’t have it both ways (now do you see why I’m so skeptical when studies say they’ve proved something?).
However, surgery for obesity has shown remarkable results in helping patients to achieve significant long-term weight control. In addition, it is associated with improvement and often resolution of co-morbid conditions, including type 2 diabetes mellitus, systemic hypertension, obesity hypoventilation, sleep apnea, venous stasis disease, pseudotumor cerebri, polycystic ovary syndrome, complications of pregnancy and delivery, gastroesophageal reflux disease, stress urinary incontinence, degenerative joint disease, and non-alcoholic steatohepatitis.
Ummm… yeah, not so much. My WLS caused my venous stasis disease, gastroesophageal reflux, stress urinary incontinence (sorry for TMI), and a few other things not even listed. Remarkable results? Yeah, if you think it’s remarkable that I’m worse off now than I was 14 years ago before I had WLS. Seeing as how I didn’t have type 2 diabetes, hypertension, or high cholesterol before I had my WLS, maybe I should consider myself lucky that I don’t have any of those now, either (/sarcasm).
Now comes the part where they talk about the costs of WLS (I can guarantee you they left out some very important costs, but we’ll get to those in a bit).
Along with substantial health benefits, weight loss surgery has its costs. First of all, like all other surgeries, there are risks of mortality, complications, and side effects, e.g., food intolerance and micronutrient deficiencies. Secondly, it is an expensive procedure. The average cost of surgery exceeds US$13000, with additional costs possible in years following surgery.
According to one reference here costs were $19,794 to $25,355, depending on the type of surgery done (in 2002, and I don’t even want to think what it would cost now with the price of health care today). According to the other reference, and the math I did (0.6% of 11.5 million divided into $948 million costs of WLS), that comes out to $13,739 for 2002. Quite a difference between the two studies, I’d say.
Those “additional costs possible in years following surgery”? They aren’t really addressed in any of the abstracts or full studies I read. I can tell you what the possible additional costs are though, just from reading the Yahoo! group I belong to, OSSG-gone_wrong. Revision surgery (to have the original surgery undone, if possible), taking supplements for the rest of your life, protein shakes for the rest of your life, additional tests for deficiencies, shots for those deficiencies if pills don’t work, surgeries to have twisted intestines/bowels/blockages fixed, hernia repairs, feeding tubes, and the list goes on and on and on.
None of that is inexpensive and all of that is a direct cost of WLS that no one hears about. And that doesn’t even begin to count the cost of treating the complications of WLS (which this study doesn’t even begin to address). Let alone the cost of a WLS patient dying and therefore not being a contributing member of society anymore, let alone the cost to hir family. Those are the invisible costs of WLS, that no study will ever address.
I’m not a researcher, I admit that. This is the first research paper I’ve read in-depth, and I’m finding it interesting, frustrating, and rage-inducing. The assumptions that are so rage-inducing to me are that coronary heart disease, hypertension, type 2 diabetes, stroke, and dyslipidemia, as well as endometrial, breast, and colon cancers, are only obesity-related diseases. That anyone who has a BMI of less than 25 doesn’t get these diseases and, if they do, they don’t die from them (or not in the vast numbers that fat people do). Give me a fucking break. Just because people have a BMI less than 25 doesn’t mean those people are never going to have any of those diseases and are never going to die from one of them (may or may not, life is a crap shoot, depending on genetics, availability of health care/food, lack of stress, and more factors than I care to name right now).
On to the meta-analyses, which I found interesting. One of the doctors who was involved in two of the studies was the surgeon who did my vertical banded gastroplasty (VBG). This is why I question how valid the follow-up of his patients is (he also did both VBGs on my best friend, who died from her WLS). He doesn’t have a clue how I’m doing with my VBG, since he hasn’t seen me since he took the staples out of my incision six weeks after my surgery (that would have been in November 1997).
He didn’t know Pat had died (six months after her last VBG) until I called him and told him. From everything I had seen of his patients, the only ones he followed for any length of time after their WLS were the ones who were successful at keeping the weight off for three or more years (those were the ones he had come in and talk to prospective WLS patients, the cheerleaders who said how wonderful WLS was, how WLS saved their lives, how they could actually live their lives now that they were thin, etc., etc.). He also taught other surgeons how to do WLS. If he’s an example of how weight loss surgeons follow their patients after surgery, it’s no wonder that there aren’t many studies with results for WLS survivors past five years (and most studies don’t have any results past two or three years).
They searched PubMed using the search terms obesity and surgery for the time frame June 1, 2003 to Nov 1, 2010. After they reviewed those results, they did a second PubMed search, using the search terms obesity, bariatric surgery, weight loss surgery, gastric banding, or RYGB, and the same search timeframe in order to identify as many potentially relevant studies as possible.
They had two levels of screening. The first scanned abstracts for their exclusion criteria, which yielded 11,289 articles. After multiple exclusion screenings, they then retrieved full articles, screened them at the second level for exclusion and inclusion criteria, and data were extracted from 170 articles, which included 53 on weight loss, 50 on mortality, and 27 on comorbid conditions. The mean patient age was almost 45, mean BMI was 46, and 80% of participants were female.
A total of 280315 patients were included in our analysis… Among the studies that had information about obesity-related comorbidities, 21.27% of the patients had type 2 diabetes, 36.17% had hypertension, 15.65% had dyslipidemia, 9.19% had cardiovascular diseases, and 0.47% had strokes.
It’s interesting that they quote percentages for co-morbid conditions, but don’t say if any of those conditions overlap (for example, did a person with type 2 diabetes also have hypertension and/or stroke, therefore being counted 2 or 3 times in those percentages). Notice also how 80% of the patients were female (I’m not even going to get into what this says about our society and its obsession with the female form).
They looked at 27 studies for the meta-analysis of co-morbid conditions. And what did they do with people like me? When I had my WLS, the only co-morbid conditions I had were arthritis and mobility issues due to severe lower back pain that had no diagnosed cause (blood pressure was normal, blood sugar was normal, cholesterol was normal, heart worked fine, lungs worked fine, no heart disease at all).
And I know I’m not the only DEATHFATZ person who was referred for WLS who had good numbers, but was told WLS was a dire necessity or else I’d either die in five years without it (that Vague Future Health Threat) or that no surgeon would replace my arthritic knees because I was too fat. Want to bet that those of us who had good numbers were conveniently left out of the calculations (yeah, yeah, I know, I’m a cynic).
Operative mortality was relatively low in general. Sixty-one studies reported operative mortality rates. The simple pooling across studies estimate for all reported operative mortality was 3.487 deaths per one thousand patients (rounded up to 0.35% in Table 3). The FE and RE estimates were 4.693 and 4.694 deaths per one thousand patients, respectively.
I couldn’t find anything that showed how they figured operative mortality. Was that patients who died on the operating table? Patients who died while in hospital, before discharge? Patients who died within a month of discharge? What about patients who died within six months, a year, two years of their surgery? I’m betting if they counted WLS patients who died within two years of their surgery, that percentage would be a lot higher (and if they counted the patients who died of complications after 5, 10, 15 years, the number would be so high that people would think long and hard before having this surgery, if they knew what that number was, that is).
Fifty studies and 52 cases contributed to meta-analyses of post-operative complication and reoperation rates. Of these studies, the complication rates ranged from 12% to 14% for weighted mean, FE, and RE estimates. Reoperation rates varied across studies. The reoperation rate was 2.45% when equal reoperation rates between cases were assumed, while the FE and RE estimates were 10.89 and 10.87% respectively.
I still want to know how they can justify WLS as being cost-effective when 12 to 14% of patients have complications that have to be treated (not cheap, see above), at least 2% to 3% of patients require second operations (also not cheap). How do they justify spending an initial $14,000 to $26,000 over treating any possible diseases that a fat person may have? I’m sorry, but $14,000 to $26,000 will pay for a boatload of statins, hypertension meds, etc. Not to mention all the money spent on treating complications that would never have happened had one not had WLS. That money would better be spent on actual health instead of trying to make fat people thin and therefore “healthy.”
Weight and BMI changes were reported in one-third of the studies from which we extracted data. Only studies that reported yearly changes in BMI and their pooled standard deviations or from which pooled standard deviation could be computed were incorporated into our meta-analysis. As shown in Table 3, 57, 34, 12, 8, and 13 cases provided information with regard to first-year (1-y), second-year (2-y), third-year (3-y), fourth-year (4-y), and fifth-year (5-y) change of BMI (ΔBMI), respectively. Both FE and RE estimates showed that the BMI loss after surgery was very persistent within the range from 12 to 17 kg/m2. Two articles based on The Swedish Obese Subjects Study reporting BMI change 10+ years after surgery were excluded from our meta-analysis. The BMI reduction 10 years and 15 years after surgery was still approximately 6.48 and 7.12kg/m2 on average.
This is the part that had me laughing my ass off. “After surgery, BMI decreased by 12 to 17 points.” Yeah, you know why they can say that? I’ll tell you why. When I had my WLS, I weighed 350 lb. at my doctor’s office the day before my surgery. I spent that whole day in the bathroom, getting rid of everything in my system after drinking a gallon of GoLYTELY (yeah, you don’t go lightly at all; to be blunt, you’re shitting your brains out for almost 24 hours).
When I got to the hospital and they weighed me, they said I weighed 370 lbs (yeah, I gained 20 lbs overnight after eating nothing for two days and spending all of one day on the crapper). When I was discharged from the hospital five days later, they said I weighed 300 lbs. Somehow, I had miraculously lost 70 lbs in five days.
So, at 5′ 8″ and 370 lbs. (according to them), I had a BMI of 56.3, and at 300 lbs, I had a BMI of 45.6. That’s a difference of 10.7 BMI points in five days. It’s a miracle, I tell you! (and you wonder why I’m skeptical of this kind of shit?)
If the hospital fudged my numbers to make it look like I weighed more than I actually did and lost more weight than I actually did, how many other people has this happened to? The really sad thing? My surgery was done at the University of Minnesota Medical Center, which you’d think would have more integrity (evidently not when it comes to WLS and statistics).
“The bottom line is that bariatric surgery is cost-effective for at least the mildly obese with or without obesity-related co-morbidities and even cost-saving for the co-morbidly super obese (BMI 50 or higher),” they stated.
It’s funny that they can say this with a straight face, after saying that they omitted the study from Sweden that said WLS patients at 10 and 15 years out had only a BMI loss of 6.48 and 7.12 on average, instead of the initial 12 to 17 BMI loss (means those WLS patients gained back some weight or didn’t lose as much as was expected, no?).
Cost-saving? Is it cheaper to treat the so-called co-morbidities of obesity or to treat the many and varied complications of WLS? The following is a list of complications, and I’ll leave it to you to figure out which is cheaper to treat: dehydration, chronic vomiting and nausea, stroke, heart attack, arrythmia, kidney stones, kidney failure, liver failure, anemia, deficiencies (B-12,potassium, iron, B-1, B-6, etc.), malabsorbtion of supplements (calcium, minerals, nutrients from food), blurred vision, muscle and bone pain, loss of teeth, bleeding gums, rotting teeth due to vomiting requiring root canals, hypoglycemia, headaches, blackouts/seizures, lactose intolorance, injury to spleen during surgery, coma, paralysis/blindness after coma, osteoporosis, burst pouch, lupus, auto-immune disease, looped intestines, ruptured esophagus from vomiting, misfired stapler during surgery, ulcers, pneumonia/lung problems, arthritis, weakness and fatigue from malnutrition, overall pain, metabolic bone disease, food blocking stoma causing severe pain, stoma needing stretched repeatedly, neuropathy, beriberi, put on feeding tubes/PICC lines, fibromyalgia, chronic fatigue, fistulas, atrophy of muscles, hair loss, hernias, blood clots, leaks, peritonitis, heart burn/GERD/acid reflux, bowel obstructions, gallstones and gallbladder removal, severe depression, anxiety, loss of memory, poor concentration, irregular blood pressure, diarrhea, constipation, opening of outer incision which requires packing until healed from the inside out, insomnia/sleep disorders, unforced anorexia and bulemia, gas, silent stroke, vertigo, malnutrition which is the cause of many of the above problems, many end up becoming invalids, and then there is death.
This list continues to grow.
These complications can happen right after surgery, or days, weeks, months, or many years, even when taking all the required supplements.
Besides physical complications there is financial hardship and families who are devastated.
And this study doesn’t even begin to address the quality of life of a WLS survivor. If I were going by my quality of life before WLS and my quality of life after WLS, believe me, I’d take the before for quality purposes, hands down.
That list of complications up there? I can tell you from personal experience that living with some of them sucks dirty ditch water and I wouldn’t wish that on my worst enemy (not even screaming MeMeMeMe Roth).
So that $25,000 that Medicaid spent on my WLS was totes wasted. I’m fatter now than I was before I had WLS, I have had 19 of the complications listed above (before WLS, I only had 2 of them: arthritis and depression).