The miniature Stone Age statue of the Venus of Willendorf (circa 25,000 B.C.) is one of the earliest records of morbid obesity (Figure). If the Venus of Willendorf were alive today, she would certainly be interested in Obesity Surgery. This is not a textbook but, rather, an eminently readable, timely, and concise overview of the disease, in which the authors detail the physiological interactions of brain, gut, and fat cells and medical, metabolic, and psychological complications of obesity and their resolution. Like Venus, many other historical figures might have been interested in this surgery. Obesity has been with us throughout recorded time. One example is an Egyptian statue (circa 3500 B.C.) that depicts the classical "apple" and "pear" fat distribution in a prosperous farmer and his wife. We may be more familiar with images of corpulent Henry VIII, reflecting prosperity, and Rubens's The Three Graces, reflecting beauty. The National Library of Medicine's 1885 cinematic stills show a morbidly obese woman rising from the prone position who would be commonplace today in a bariatric outpatient center or lying on an oversized operating-room table. During the past 10 years, the prevalence of obesity in the United States has increased from 23 percent to 31 percent of the country's 280 million people. The latest National Health and Nutrition Examination Survey shows that some 127 million people are overweight (which is defined as having a body-mass index [BMI, the weight in kilograms divided by the square of the height in meters] of 25 to 30), 60 million are obese (BMI >30), and 10 million have life-threatening morbid obesity (BMI greater/equal 40). Current trends indicate that obesity will increase to 39 percent by 2010 and with it morbid obesity. Obesity is not only an American phenomenon. The World Health Organization's figures are even more depressing. Thus, the decision by the Department of Health and Human Services in July 2004 to elevate obesity to an illness is a fitting recognition of the disease's emergence from a personal social stigma to an international epidemic. This status crowns humankind's unprecedented era of progressively and unrelentingly enlarging girth, whose scourge spares no social, ethnic, sex, or age group but tends to single out unfairly Hispanic and black children and females, along with Pima Indians, Samoans, and other aboriginal and national communities recently immersed in a new lifestyle. Although morbid obesity is defined as a weight of 45.5 kg above ideal body weight or a BMI of 35 or more, a weight increase that is only 20 percent above the ideal body weight results in a 20 percent decrease in life expectancy. Relative to normal weight, morbid obesity is associated with a several-fold increase in such chronic debilitating conditions as type 2 diabetes, hypertension, stroke, heart disease, dyslipidemia, arthritis, degenerative musculoskeletal diseases, gallstones, certain types of cancer, asthma, sleep apnea, and socioeconomic and psychosocial impairment. Obesity and its coexisting illnesses cost an extra $117 billion in health care and 300,000 deaths annually. The goal of obesity therapy is weight reduction by inducing negative energy balance to consume endogenous fat stores, involving dieting and exercise. A modest weight loss of 10 percent or less is associated with a substantial improvement in coexisting illnesses. Unfortunately, our current urbanized, sedentary lifestyle and supersized portions of food (characterized by our culturally oriented, chronic overconsumption of easily obtainable energy-dense liquids and foods) leads to fat storage, to which our hunter-gatherer species is genetically predisposed. Thus, achieving and maintaining long-term weight loss is difficult for the overweight or obese. Even with the use of approved drugs, a weight loss of only 5 to 10 percent typically occurs in one year, and weight is commonly regained. However, the morbidly obese patient has lost "the battle of the bulge" multiple times and as a last resort is referred to the surgeon. Obesity Surgery describes the historical development of bariatric surgery and the operative options, including restrictive and malabsorptive limitations of the gastrointestinal tract. For example, a Roux-en-Y gastric bypass incorporates both aspects of food restriction and leads to an initial weight loss of 25 to 30 percent, with subsequent sustained weight loss and amelioration of coexisting metabolic illnesses. Other operations are discussed in similar detail, including adjustable silicon gastric banding. Along with providing information about preoperative and postoperative care, the book emphasizes the critical need for support facilities (both office and hospital) and staff to care for such patients. Given the magnitude of the obesity problem and the nearly 200,000 procedures that are performed annually, the authors refer to policy guidelines jointly formulated by the American Society for Bariatric Surgery and the Society of American Gastrointestinal Endoscopic Surgeons to train and credential future laparoscopic bariatric surgeons. This book is essential reading for enlightened medical students and residents, whose future is inescapably linked to the obesity epidemic; for pediatricians and family physicians, who struggle daily with the care of the morbidly obese adolescent and with the adult patient's sensitivities and denials; for hospital administrators and third-party payers, who require a working understanding of obesity; for surgeons, who are expected to provide competent care; and above all, for morbidly obese patients, who are exuberant at the prospect of an improved image and quality of life after surgery, but whose interests are best served by being well read and informed. Michael M. Meguid, M.D., Ph.D.
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