“Outside every fat man there was an even fatter man trying to close in.”
— Kingsley Amis (1922-1995), British novelist
One Fat Englishman. Ch. 3 (1963).

In a country where many families eat only once a day, to talk about morbid obesity sounds obscene. On the other hand, there are those who “subsist” on fast food and other high-caloric food to a point that excess weight becomes a problem. There can be too little or too much food. Either way, the body suffers. A very fat person’s family also suffers. My younger brother Vernon died suddenly at 41 last year, diabetic and morbidly obese, and we grieve until now.

Morbid obesity. Most people are in denial about being fat or overweight. That’s understandable. But morbid obesity is something that can’t be denied because all that fat is staring at you. Defined, morbid obesity is 50 to 100 percent more, or 100 pounds above, ideal weight. Using the BMI (body mass index) which is a formula using weight and height to estimate body fat, a value above 39 is considered clinical severe obesity. The normal or healthy weight BMI is between 19 and 24 while an overweight BMI is between 25 and 29.

Causes. The most common cause of morbid obesity is excessive caloric intake – eating like there’s no tomorrow. Lack of physical activity is another obvious cause. A thyroid problem, specifically underactive thyroid (hypothyroidism) can slow down metabolism and pack on the pounds.

Complications. What happens to the morbidly obese reads like the Table of Contents of a Pathology textbook in medical school:

* Diabetes
* Heart disease
* Hypertension
* Stroke (cerebro-vascular accident)
* Cancer (breast and colon commonly)
* Depression
* Osteoarthritis (degenerative arthritis)
* Sleep apnea (breathing stops temporarily during sleep with heavy snoring)

Non-operative treatment. These strategies combine severely restrictive diets, anorectic medications, exercise, behavior modification, counseling, etc. However the long and short of it is, in the morbidly obese, they don’t work. Medical weight reduction trials take about 10 to 12 weeks with an average weight loss of only 2.5 kg (5.5 pounds). One study which lasted for four years and used two drugs (phentermine and fenfluramine) plus diet and exercise, had a one third drop out rate. The final average weight loss was only three pounds! (This means that a 320 pound man may have shrunk to 170 pounds but at the end of the study regained almost all of the weight back).

Bariatric surgery. As a recognized sub-interest of general surgeons, bariatric surgery deals with the operative treatment of the hugely obese. It’s not cosmetic. It’s also not liposuction and can’t be done in your neighborhood “salon with facial/peeling.” Weight loss surgery involves either reducing the size of the stomach and/or bypassing the small intestine where most of the calories from food are absorbed. An example of the first type of surgery is VBG or vertical banded gastroplasty. It is a procedure where the stomach is partitioned into two parts. Usually a surgical stapler divides the stomach into a small upper pouch and a larger lower pouch. A band of non-expandable plastic is also wrapped around the junction of the partition to prevent the opening from stretching. The second type of surgery is exemplified by gastric bypass. Here the stomach is made smaller by stapling. The surgeon then cuts part of the small intestine and sews it directly to the tiny pouch. Food now goes directly to the middle section of the small intestine where absorption is less. Bariatric procedures can also be done laparascopically – by small incisions for the insertion of tubular instruments and guidance with an attached video camera.

The results of bariatric surgery are life-saving and dramatic. Within one to two years after surgery, patients lose an average of 50 percent of the excess weight. However, as in all operations, there can still be immediate complications like pneumonia, blood clots, and infection.

Remember that the fattest people, those who made it to the Guinness Book of World Records, all died before 40. That’s something to think about even if you are not severely obese. And oh, rest in peace dear Vernon. There is no dieting in heaven.

Fact/Factoid. A real Chicago hot dog must have two whole bite-sized green peppers.

Dr Pujalte is an orthopedic surgeon. E-mail jspujalte@yahoo.com webpage http://www.orthopedicspujalte.com