Freakonomics in the Times Magazine: The Stomach-Surgery Conundrum

For their Nov. 18, 2007, “Freakonomics” column, Dubner and Levitt revisit a favorite topic: unconventional weight loss. In September 2005, they wrote about Seth Roberts, who shed 40 pounds with a diet he crafted through years of meticulous self-experimentation. This week’s column digs into the risks and benefits of using surgery to combat obesity. This blog post contains additional research materials.

  1. There are two main types of bariatric surgery: gastric bypass, and laparoscopic adjustable gastric banding (Lap-Banding), which is less invasive than a full bypass. This paper, from the journal Archives of Surgery, describes Lap-Banding, and reports it to be both effective and safe.
  2. Bariatric surgery is often the most effective treatment for the morbidly obese, and with a mortality rate of around one percent, it isn’t terribly risky, according to this paper by Bennet Omalu et.al. (abstract only without subscription). The highest risk is faced by patients who undergo the procedure at the hands of an inexperienced surgeon. This Washington State study, by David R. Flum and E. Patchen Dellinger, shows a strong correlation between survival rates and surgeon experience (abstract only without subscription).
  3. Bariatric surgery can be costly, ranging from $15,000 to more than $30,000, depending on the procedure. But the surgery tends to pay for itself, according to several studies, including this one from the journal Medical Clinics of North America (abstract only without subscription).
  4. The column features Dr. Marc Bessler, a prolific bariatric surgeon and an innovator in the field. More information about Dr. Bessler is available here.
  5. One of the risks of bariatric surgery, for people who are addicted to eating, is what psychologists call “addiction transfer.” According to this Wall Street Journal article, a significant fraction of bariatric patients pick up other addictive habits afterward, like gambling or smoking, or fall into alcoholism.
  6. But that risk is far outweighed by the benefits of the surgery, which include significant health cost savings over the long term, according to this article in Surgery News.
  7. In the column, Dubner and Levitt discuss commitment devices, which are strategies people use to lock themselves into a particular course of action. Levitt defined it more fully last year in the Freakonomics blog.
  8. Short of surgery, one commitment device might be to leave an anatomically correct blob of fake human fat in your kitchen. To see what a disgusting pet fat glob looks like, click here. Fake fat usually comes by the pound, but, for the calorie-conscious executive, MyPetFat.com sells an office-ready 1-ounce version.
  9. Annual gym memberships are another purchase on the commitment device shopping list for those trying to lose weight. Except that people overestimate by 70 percent how much they will use them, as Dubner and Levitt wrote in their Jan. 7, 2007 column, “The Gift Card Economy.” The column references Stefano DellaVigna and Ulrike Malmendier‘s paper Paying Not to Go to the Gym.
  10. The popular new weight-loss pill Alli, which partially blocks the body’s absorption of fat, is a commitment device with real consequences: a person who takes Alli and then eats too much may experience a bout of oily diarrhea. (Among the initiated, this is known as an Alli-oops.)
  11. But commitment devices don’t get much more real than the one used by the legendary Chinese general Han Xin. Before battle, Xin was known to arrange his troops with their backs to a river, so they knew retreat wasn’t an option. More on his story here.

ef

Stomach-Surgery helps advance science. I think that is a good thing. experidato65@gmail.com

john

To Paul Bowers:

Obese people most definitely eat more than their bodies need. That is no myth. It's how they got to be obese in the first place. It's called the First Law of Thermodynamics - one of the most fundamental law of physics in this universe. If you eat more than your body burns, all those extra energy has to go somewhere. Guess what? They got stored as fat. Hence you gain weight.

If you *consistently* eat less than your body burns, you *will* lose weight. Again, that's the First Law of Thermodynamics. If you believe "insulin control" or some other pseudoscience can circumvent the First Law of Thermodynamics, you might as well start building a perpetual motion machine...

Anonymous

Actually there is at least one nonsurgical solution for weight loss (Stephen J. Dubner and Steven D. Levitt Nov. 18) that has been extremely effective for food addiction. Compulsive Eaters Anonymous, a 12-step program for food, operates on the same principles of Alcoholics Anonymous. Like alcoholics, many compulsive overeaters battle a physical allergy coupled with an obsession of the mind. In the 12-step rooms, addiction whether to alcohol, food, debting, gambling, sex, narcotics and so on is treated as a disease which may explain why other addictions pop up after patients undergo bariatric surgery.

This procedure seems like yet another opportunity for the medical industry to make a profit on the illusion of the quick fix. Isn't that what this is about anyway? The quick fix. How many people are out there taking antidepressants prescribed by their gynecologists? Do these medical professionals ever bother to suggest psychotherapy first and/or inquire to the amounts of alcohol and marijuana their patients are consuming? On another note, does filing for bankruptcy alleviate the problem of debting for the compulsive debtor?

There are many people in Compulsive Eaters Anonymous who have lost well over 150 pounds and have kept the weight off without drugs and dieting, while gaining the gift of serenity in the process. Furthermore, for those who have found themselves continuing to gain weight after having had bariatric surgery, this program has been "their last house on the block." There are no dues or fees to be a member, only a desire to stop eating compulsively one day at a time. Clearly, this is not a program for people who need it. It is a program for people who want it. http://www.ceahow.org

Anonymous,
Santa Monica

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Rita

"Much criticism of OA has been posted here."

Actually, OA has received many accolades here, so I wanted to present an alternative view, one that honors the fact that OA is NOT right for everyone (and, as I said, OA not working does not have to do, necessarily, with being "unwilling" to change). I *did* say that OA has helped many.

However, many also find their own way out of the binge mentality *without* it. OA can be cultish, repressive and controlling. People should know about the downside of OA, too. To the idea that: "it only works if you work it", I would say: "it only works if it's right for the person who works it". If not, say goodbye without guilt and move on.

Zebee

Are you sure about that mortality figure?

To quote from http://junkfoodscience.blogspot.com/2007/10/jfs-special-latest-research-on-actual.html

"We also estimated the long-term mortality for individuals who had undergone surgery many years ago. For the 1995 cohort who had at least 9 years of follow-up, 13.0% had died. From the 1996 cohort with 8 years of follow-up, 15.8% had died, and from the 1997 cohort with 7 years of follow-up, 10.5% had died. For the 1998-1999 cohorts with 5 to 6 years of follow-up, the total mortality was 7.0% to 2004."

That's from a very comprehensive study of all patients in Pennsylvania, they can't all have been worked on by hacks can they?

Brad

I think that's the difference between a long-term mortality rate and the mortality rate as an immediate result of the surgery.

With 5-9 years before the follow-up, there's plenty of time to die from other things!

Mark

Here's my method: If I don't lose 10 pounds by the New Hampshire primary, I will have to donate $250 to the political campaign of Rudolph Guiliani. I can't think of anything more motivating. If I lose, the whole world will know due to public disclosure. A friend is holding the check to prevent me from backing out.

Substitute politician's name as needed...

rini

The solution to obesity may sound simple....eat less.

Doing it is impossible for obese people. They have different hormone levels of several hormones, including leptin and ghrelin, that regulate appetite. I suspect that for them not to eat an entire cake takes more will power than for a thin person to avoid nibbling on a cookie. Sure, years of overeating has probably caused this disregulation. But some people are more susceptible than others.

Why blame the individual, who will fast, starve and diet or even commit suicide to end the misery of obesity? I blame the screwed up junk food environment and the culture of fast food that has been created by industry and advertising. Why should a three year old be subjected to ads beckoning them to ignore their parents and eat crap? We didn't evolve for this and many people CAN'T deal with it.

PS. I am lucky to have thin genes but have sympathy for those who don't.

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rini

BTW

If I weighed a two hundred pounds, instead of one hundred pounds, I would get a gastric bypass in a second.

percy

As a RN on a GI floor I do believe that if gastric bypass is done for medical necessity do it, but unfortunately it is being done for body image. Stop eating. If not move to an underdevelop country for six months.

Amanda Itzkoff, MD

Dear Messrs Dubner and Levitt,

I would like to point out that in your excellent article about bariatric surgery you mention that the procedure "often produces complications -- physiologic ones, to be sure, but also perhaps psychological ones." I think you may have reversed the vector of causality here, and, in my humble opinion, the use of "perhaps" was also superfluous. As a psychiatrist, there is no doubt in my mind that a morbidly obese patient without other medical cause for obesity (ie thyroid disease) already has a severe psychiatric problem that has produced the complication known as obesity. Such a person overeats when they know it makes them unhappy, to say the least, as well prone to other life threatening diseases, but it literally unable to stop. Without treating the psychiatric compulsion to harm oneself that underlies such behavior, it is no wonder that patients who have surgery but no psychiatric treatment develop "new" psychiatric symptoms, like gambling, compulsive shopping and alcoholism, as you've mentioned. All patients considering bariatric surgery and all physicians recommending it should consider psychiatric consultation for those patients who are open to it, so that they can maintain the health benefits that they achieve through sugerry without acquiring a potentially more dangerous psychiatric ailments.

In a way, there is a simple economics to it. The patient who undergoes surgery, perhaps even covered by insurance, does not pay the psychological price, never mind the opportunity cost of couch time and the true cost of paying for therapy, that would be required to come to understand why he thwarts himself so. And so the psychological problem, having not received it's due sum, returns in a new form.

Amanda Itzkoff, MD
Department of Psychiatry
Mount Sinai Hospital

Dr. Itzkoff is a psychiatrist at Mount Sinai Hospital and winner of the Adele Zinberg Award for Women's Leadership in psychiatry

amanda.itzkoff@gmail.com

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Robin

While the actual procedure deaths are fairly low, deaths afterwards from later complications, malnutrition, and even suicide are far higher than in comparable morbidly obese patients who do not lose the weight. Even the weight loss of bariatric surgery is not always permanent

Gastric bypass does not force one to eat a healthy diet or else. It forces one to eat an unhealthily small amount of food and supplement that rigorously as the body is no longer capable of absorbing certain nutrients.

As for the diabetes reduction, that happens almost immediately, within the first few days following surgery. It has nothing to do with the weight loss, but something to do with the digestive mechanisms that have been altered. While this is encouraging knowledge as far as diabetes treatment is concerned, it bears more investigation of what exactly has changed and if there are ways to do this for diabetic patients short of a risky and life-altering surgical procedure.

For those who say stop eating? Research has shown that in those who have been very overweight for a long period of time, this is FAR easier said than done. Many of them already eat far less than one imagines. Whether or not that is the case, a calorie restriction leads to a starvation response. In order for most obese people to take weight off and leave it off, it requires living in a state of starvation for the rest of one's life.

Perhaps there are ways to prevent obesity. I do not think dieting - forcing one's body into a state of starvation and lowering one's metabolism - is one of them. After all, this increase in obesity has occurred concurrently with the rise of the diet industry and how many overweight people have not already tried several diets? It is not willpower in resisting eating a whole cake we are talking about. It is pushing aside hunger, a basic physiological urge more akin to deciding one is only going to go to the bathroom once a day or only breathe every thirty seconds.

Do I know the answer? No. I am lucky enough to have thin and fit parents and have eaten healthfully (neither overeating nor dieting) my entire life. But it horrifies me when we as a society focus on beating down those who have not been so lucky, encouraging them to mutilate their stomachs and hurt themselves. The truth is we don't know much at all about human weight regulation and turning people into pariahs for a state most can no longer permanently control is certainly not the answer.

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Susan

Dr Itzkoff is quite correct. Many if not most of the obese use eating and food as a coping mechanism. Most are unaware and may be unwilling to explore the etiology.

Alli is the equivalent of Antabuse for alcohol. You pay a (nasty) price for a bad decision. Gastric bypass makes you abide by portion control whether or not you want too.

As medical insurance will not reimburse for therapy that focuses on that coping skill, so too a refusal to fund the treatment needed to change those automatic choices (unlike the advertisement, your baby isnt going to slap you when you choose the french fries). The studies that demonstrated the efficacy of "lifestyle modification" in weight loss, diabetes prevention, heart disease usually included intense intervention - weekly then gradually decreasing frequency over a 3-4 month period. This usually includes work with a nutritionist and a physical therapist or trainer.

Instead, insurance would rather pay a single larger sum for a single "procedure" with its "universal reproducible" effect.

More importantly, how many choose this option for cosmetic reasons rather than for future health status? What is the perceived "value?"

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Rupert Pupkin

I can just imagine an obese NY Times Magazine reader on Sunday morning: "Oh my God. Eat less??? [slaps his forehead] Wow, those Freakonomics guys really are smart! Why didn't I think of that? Eat less ... wow ... I'm going to try that."

Stephen M (Ethesis)

You ought to quote some studies about the general time it takes for people to go from start, to weight loss, to regaining the lost weight with several of the surgical techniques.

A Member of Overeaters Anonymous

The people you describe in this article are compulsive overeaters. Addicted to overeating the same as an alcoholic is addicted to alcohol. Would you suggest that an alcoholic where a stinky scarf to cure their disease? Just as I can never trully understand the urge to drink excessively, I cannot expect non-compulsive overeaters to understand my urge to overeat.

But I have found a solution in the twelve-step program of recovery -- Overeaters Anonymous. By working this program daily, I have been free from the compulsion to overeat for over three years.

I hope that you'll at least mention this program when you write about the hopelessness of the obesity epidemic. There is hope. If just one person experiences the recovery I have received, you'll have done a great service.

swifty

While there are some statistics and quotes published in this article, it is an opinion - plain and simple. The authors, like in most of society, wrote this piece under the presumption being fat is bad, unhealthy and unacceptable. But moreover, the generalizations are being made that fat people themselves are bad, unhealthy and unacceptable - as well as lacking any knowledge or discipline.

As usual, there is a judgment upon those of us who are fat, about our choices, what our lifestyles might be like. I particularly enjoyed the part about how, thanks to these surgeries, fat people can, "Now people can eat all they want for years and years and then, at the hands of a talented surgeon, suddenly bid farewell to all their fat". What an ignorant statement - and one that indicates a sad truth about our culture. This is SURGERY that seriously alters a MAJOR ORGAN of one's body. I know people who have opted to have this surgery and I respect their decision to do so. However, it should be said that such a thing is not an easy decision - never mind the expense, the recovery - there are a lot of risks involved during the procedure, after and then in the long term.

I want to call attention to a statement in this article, a quote by Marc Bessler who talked about his father being fat and developing colon cancer. Marc says: "...He died at age 54 from colon cancer. It may have been picked up late because of his obesity." With respect to Mr. Bessler and his father (whom clearly I do not know the specifics of his case), I must reject the last part of this quotation - that because of his obesity the colon cancer was not found. Fat people often have mis-diagnosis given to them by Doctors who simply dismiss their symptoms, because they are fat. I recall an acquaintance, who at 35 was finally diagnosed with ovarian cancer after longstanding symptoms - which had been dismissed because she was fat. By the time she was diagnosed she had stage 4 cancer and a very low survival prognosis. I reject that fat is the lone reason for these mis-diagnoses. It is the assumption on the part of many doctors that whatever the problem is is simply because the person is fat, they need to lose weight - case closed. I say this understanding that sometimes losing some weight may help, depending on the medical situation, but I am speaking specifically about the dismissal of another possible diagnosis other than "fat" or "morbidly obese".

I wish for there to be more understanding about the assumptions made, and are encouraged to be made about fat people. It is, contrary to general belief, very possible to be fat and healthy. I wish there to be more questioning of our assumptions that thin = healthy. Our culture produces more processed foods than ever before, not to mention all of the engineering that goes into low-fat and non-fat foods. How about questioning what those foods do to prevent the absorption of nutrients into our bodies - and so perhaps they are not really "healthy" after all? Asking more questions to get better answers, that is what I hope for.

I encourage anyone who read this article, to also read the following article, which talks about the largest and longest study about food, nutrition, weight loss which was conducted and it's surprising results. These results weren't widely published because it did not support the agendas of the larger medical establishment. This article is written by Sandy Szwarc, BSN, RN, CCP on 10/15/07 and is on her blog, Junkfood Science: http://junkfoodscience.blogspot.com/2007/10/junkfood-science-exclusive-big-one.html

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Marilyn

Please cite the studies showing that people can lose weight and keep it off long term through using a commitment device. Most overweight or obese people would love to lose weight. In fact, many have done so, only to gain it back.

If dieting worked, Jenny Craig and Weight Watchers would have long ago gone out of business.

For most people, focusing on regular exercise will do more for their health (and self esteem) than dieting.

stjoe56

Actually, I once went to long-term weight loss clinic. After a month there, I walked away with the following lessons: (1) I really could live on eating a lot less food; (2) eating primarily steamed vegetables will not kill me; and (3)a piece of fruit can taste just as good as a chocolate cake.

The end result is that I lost 125 pounds on the eat less diet.

Julius Kusuma

When I lived in Switzerland, going to the farmers market meant losing 120m in elevation. That means that whatever I bought, I had to haul back up the 120m of elevation that I lost to get to the food. And going to the supermarket meant losing an additional 80m or so in elevation.

So see, the "economics of food gathering" prevented me from gaining any weight at all. In fact, transferring there from the US always made me lose 15-20 pounds, without even trying.

Unfortunately, in most of the US nowadays one has to drive everywhere, since we are stuck in our islands of subdivisions. Perhaps this can be thought of as a long-term failure of city planning and policy, a very INELASTIC infrastructure.

Come to think of it, how about taxing food by the caloric content?