What's pretty funny is that if you look at any research that's been done on weight less programs involving reduced calorie consumption and regular exercise--regardless of type of exercise--the overwhelming majority of obese subjects fail to attain non-obese status and maintain it long-term.

There's something metabolic going on with obesity, and doctors are increasingly recognizing this. Watching your diet and exercising appear to be a good way to lose some weight and avoid becoming obese, but they appear to rarely actually reverse the problem.

There appears to be something in human metabolism that makes most fat people--not all, but most--have to work harder and harder just to maintain a healthy weight over time.

Rosemary, I agree totally. If I contracted HIV through my own fault, you can bet that it would be covered by my insurance. Morbid obesity, on the other hand, is viewed as nothing more than a moral failing--even though it's mostly out of the control of the sufferer. Insurers can skate by on paying for treatment because of the prevailing societal attitudes toward the obese.

Several years ago I was in exactly the same spot you were in, and found the same solution (though my bariatric surgery was laparoscopic). Thank God that at the time I had good insurance, since the surgery basically gave my life back to me. Good luck on the gallbladder. On balance, it's worth it, isn't it?

I agree that there are people with different natural trends as far as their bodies go. Some smokers die of cancer when they are 35 while other lifelong smokers are never effected and puff away well past 90. Medicine is a science but there is so much unknown.

I'm not convinced obesity should be a disease but hey, everything else is becoming one. Honestly, I cannot share your plight...I am a high-metabolic person. It meant I got shoved in alot of lockers in Jr. High and High School, but I do still weigh the same as I did back then, 15 years ago. But I do see how my wife eats 1/4 of what I do and still gains.

Dean,

I'd be interested in seeing the research that says you can get obese while consuming 2000 calories a day and engaging in regular, vigorous exercise. I was always under the impression that gaining weight, by definition, meant that you were consuming more calories than you're taking in.

The metabolism issue is of course dead-on, but that's not purely a heritable condition. After all, we don't see obese people running around Africa during famines (unless one counts Sally Struthers). The main reason many Americans have such a slow metabolism is our crappy diets, notably our addiction to processed carbohydrates.

I've always had one question about weight-loss surgeries such as gastric bypass: What happens when you reach a weight that would be considered "normal" and don't need to lose any more weight? Does the surgery eventually have to be reversed so you don't become dangerously underweight?

The obesity research I've seen acknkowledges that caloric restriction + exercise is effective for weight maintenance. What is probleatic is that, so far, there is no research proving that overweight past a certain point can reliably or permanently be reversed by such regimens. Every controlled study done on the matter has shown abysmal success rates with such programs.

There is no disputing that caloric restriction can maintain a weight level. There is also no disputing that in extreme starvation conditions, people will of course lose weight. But some will lose it faster than others, some will die faster than others, and some will rebound their weight much more quickly once starvation is alleviated.

There is, in fact, much speculation that people who are obese are those with a genetic inheritence that would make it much easier for them to survive famines, because their metabolisms slow down more than most people when caloric intake is restricted, and their fat-storage mechanisms kick into overdrive as soon as caloric restriction is ended.

It is important in these discussions to separate people who are 10-20 pounds overweight from the obese, by the way.

The most damning study I saw was from the 1990s, the first serious attempt to study diet+exercise+lifestyle changes to cure obesity. It involved taking a large group of obese persons, giving them regular consultations with dietitians and physical trainers, group counseling sessions, and putting them on a moderate, medically healthy regimen of caloric restriction and regular exercise.

After two years, only a third of the group could be listed as successfully maintaining any significant weight loss at all. 2/3rds utterly failed on the program. More damning, if you looked more closely at the figures, of the 33% "success" group, "success" was defined as taking off 5% of their excess weight and maintaining at least that much loss over two years. For most obese persons, while losing 5% of their overweight is healthy, that's a pretty damning indictment, because it amounts to a small weight loss and would leave most obese persons still obese. The study's conclusion was that diet + exercise and all the conventional advice was only effective for weight maintenance, not long-term loss, and not a solution for obesity in most patients.

Higher-protein, lower-carb diets are increasingly being shown to be more effective for weight loss for many people, although we're still in the early stages of research on that. The fact is that we don't understand obesity anywhere nearly as well as most people think we do, and there's a crushing need for more research and for alternative treatements. Because this problem is killing people, and making their lives miserable.

Tom:

The answer to your question is no. There is a weightloss window of 2-3 years. Basically, your weightloss progressively slows down until it stops. Then if you gain weight or you decide that you haven't lost enough, you basically have to put yourself on a diet. There are weight maintenance techniques that you learn about. The surgery is not fool proof - you could in theory gain back your weight. If you consistently overeat you could blow out your stomach and get fat again.

One thing that many surgeons require that you do before surgery is undergo a psychological evaluation. They don't want to take on patients that will not follow instructions and kill themselves.

After reading that, I realize that my answer was a bit vague.

The weightloss window occurs because the stomach is reduced to 30 cc about the size of a golf ball - initially. But over time (2-3 years) the stomach will eventually stretch a little. Naturally, slowing your weightloss until it stops.

As a person who has been in the "obese" demographic for most of my life, I'm not certain that weight loss products should be covered by health insurance. But then, I only know my own story. I think that the vast majority of people who are overweight - the VAST majority - are so because of lifestyle issues. I know that was the way for me, as well. I had been fat all of my life. At age 24, I had gotten to about 280 pounds.

One day, I went shopping for pants and notice that the size 41 pant I found was beginning to get very tight. Then and there, I decided to make a lot of changes. See? I wasn't the guy who went to McDonalds and ordered a Big Mac Combo. I was the guy who order that AND two burgers AND an apple pie AND supersized it...EVERY DAY. I also drank about 3 liters of Coke a day.

I haven't had a Coke in nearly ten years. And I rarely ever eat fast food.

I've learned to live a very healthy lifestyle. Breakfast every day - no exceptions. And three or four small meals a day - which I usually make up on Sunday. Plus, I go to the gym every weekday. As a result, I have lost 100 pounds and kept it off for about 9.5 years now. Every day is rough. Especially around Thanksgiving and Christmas. But I do it because I know where I'll end up if I don't.

$29.95 a month for a gym membership. And regular $$ for groceries - less because I don't eat crap anymore.

Granted, I think there are people who have problems that simple lifestyle changes will never help. But I believe in almost all cases, people have to make a choice. If you don't change anything about yourself, nothing changes.

Just my two cents! Great discussion!

I'm not certain that weight loss products should be covered by health insurance.

What about AIDS?

I think that obesity *is* a disease, regardless of whether it's metabolic or behavioral. If it's metabolic, you will retain more fat and burn calories more slowly than the average human, regardless of what or how much you eat. If it's behavioral, it's practically indistinguishable from any other addiction, including nicotine or heroin. Someone who keeps on eating and maintaining a dangerously high weight, despite the obvious and incontrovertible evidence that this will decrease the years and quality of his or her life, is unwell.

I say this as someone who has struggled with his weight for his entire life, and who, contrary to popular opinion, finds men with a few extra pounds rather attractive. On the one hand, I think that as a culture we need to recognize that there are a wide variety of body types -- from Ryan Seacrest to Drew Carey -- that can be attractive. On the other hand, we have to recognize that whatever investment we, as a society, make in eliminating morbid obesity will be repaid to us hundreds of times over.

Rosemary:

One has nothing to do with the other. AIDS is always a disease. Obesity is not always a disease. In most cases, becoming "not obese" is simply a lifestyle change.

There is no comparison. Quite frankly, I think it could be construed as quite insulting by many dying people and friends of them to compare AIDS, a fatal disease that cannot be cured, to another potentially fatal condition that can be cured in most cases by exercising and eating properly.

I didn't say I definitely think weight loss products should be covered. I said I am not sure. Obviously, in your case, it was a good thing, and I am very happy for you that it made such a wonderful difference in your life.

But I think that obesity can be looked at like some of us have looked at abortion. I think abortion should be paid for only in the most extreme cases (like your weight loss.) However, like you I think, I never want abortion to become a birth control method that's convenient for women and men who screw around. I want people to realize that there are consequences to actions. Whether a woman is pregnant or not is something she can (except in obvious cases) control. So, if a woman decides say, in late term to get an abortion, I would ask why. If she says "because I've thought about it an I don't want it now", I would tell her that this was a decision she should have responsibly made a LONG time ago - a decision, like mine to lose weight, that I made before it bacame too late.

When I realized the pants didn't fit, I knew I was about to cross a very dangerous line. I changed my lifestyle, and I am happy I did.

But you are definitely right. There are extreme cases. As I said, I only know my own story.

Michael:

My point is that AIDS is behavioral driven disease. As is obesity. As is skin cancer. As is cirrhosis, lung cancer...

Rosemary:

I don't have much to add right now because I am still thinking it through, but I do have one observation on the AIDS-Obesity comparison. AIDS is the result of a virus. This is a foreign pathogen that is not naturally found in the body. Obesity is a result of the natural functioning of the body (arguably a malfunctioning, but natural nonetheless). Although I have yet to form an opinion about how this impacts the larger issue of declaring obesity a disease, it is a difference that needs to be noted.

StumpJumper:

Okay, but what about the other behavior diseases that i mentioned. Also, respectfully, AIDS can be avoided if dangerous lifestyle choices are avoided. No, I don't mean being gay. But by not engaging in risky sexual behavior, not practicing safe-sex or sharing needles. My point is virus or not behavior influences getting the virus.

My sister recently had this surgery and is looking great. I guess her husband thinks so too: she two months pregnant with their fourth.

Rosemary:

I agree with you that behavior influences both situations but that isn't the complete issue.

Let me explain where I am coming from. As a personal responsibility advocate my knee-jerk reaction is to oppose declaring behaviors to be diseases. As a health/fitness advocate my knee-jerk reaction is to declare obesity a state that can be addressed by behavioral modification. Hence, I currently feel that obesity should not be declared a disease. Your comparison of obesity to AIDS and skin cancer based on behavior has given me a new perspective from which to approach the issue. This is why I said that I am still forming an opinion - you haven't convinced me yet but you have made me re-think my position, which is a start.

One stumbling block for me right now is the issue of the pathogenic nature of AIDS. In order for us to declare that something is a "disease" we must first have some objective way to determine what a disease is. With AIDS and skin cancer we have a clearly objective standard by which they can be declared diseases. Based on your statements so far I see no such objective standard for declaring obesity a disease. I will grant you that obesity is a situation that can lead to health problems, but so is snowboarding (broken wrists and concussions being the most common). I don't consider myself to be "diseased" because I hit the slopes once or twice a week in the winter.

Simply put, I'm open to the possibility that obesity could be declared a disease, but I need to be convinced that there is an objective standard. So far your argument seems to be based primarily on subjectivity.

skin cancer is not strictly behavior driven, and neither is lung cancer (Andy Kaufman, anyone?) Just as obesity is not strictly behavior driven. AIDS has not always had a behavior-only transmission pattern, and in some parts of the world, it is still contracted through transfusions. The cancer comparisons sort of work, because not all (skin and lung) cancers are behavior-derived.

health insurance coverage is usually for preventative care, or emergent care, and sometimes (if you're lucky) both. If you're VERY lucky, you get long-term care coverage, as well. Some companies will take care of weight-related issues, and some will not, regardless of what the underlying problem is. Some would rather deal with future problems. In the future, it may be cheaper to supply joint & heart replacement than it is now, and some companies are hedging their bets rather than ok'ing bariatric surgery or a lifetime diet, exercise and medication program for an obese patient. It all depends on the carrier.

A lot of obese people are obese because of glandular imbalances (thyroid and pituitary problems). Some have no internal switch to tell them they aren't hungry anymore. Some obese people eat horrible food and never get off the couch, and that can be a terrible downward spiral once it starts. Depression can lead to weight gain, which can lead to more depression... and the underlying depression goes unnoticed and untreated. Even medications used to treat depression and other maladies can pack pounds on.

There is no easy answer. The "Big and Beautiful" backlash of overweight people during the 80s fitness craze, i think, also had something of a hand in today's problem. It was ok to be overweight, they said.. but just how overweight? 10 lbs? 50 lbs? 150 lbs?

Rosemary,

The difference between obesity and behavior driven diseases is that the cure for obesity is constantly available: exercise and diet control. Once you have AIDS or lung cancer there is no lifestyle change to control the disease.

Certainly, controlling obesity is much more difficult for some than others, so the level of exercise and diet control differs significantly between people. I have been overweight since I graduated high school and stopped playing sports (in the 80's). I am also an avid reader and sports fan, which means my relaxation activities don't help either. I know what I have to do if I want to slim down, but I don't do it. I'm ok with this, it's my choice.

I don't want to talk about your personal situation, because I don't know anything about it. But the vast majority of overweight people are like me. In a perfect world we'd be thinner. But in reality we're not willing to make the sacrifices.

I also think your post is somewhat contradictory. You claim that dieting and exercising didn't work for you, then claim you wouldn't have had to have surgery if weight loss programs were covered by insurance. By claiming weight loss programs would have worked, you're admitting that exercising and dieting is sufficient. That's all that weight loss programs are.

You may be right that it's in the insurance industry's interests to cover weight loss programs. But obesity isn't a disease.

Two quick sidenotes:

1) I wonder if the fact that insurance coverage changes impacts their decision not to cover. If they pay for weight loss, maybe it saves another company those future charges since the beneficiary may change carriers. My pet cause is to end employer-paid health insurance. I bet in that case the incidence of change significantly decreases.

2) I'm open to the idea of a heretofore undiscovered disease causing certain people obesity. I'm sure there are already certain diseases which include weight gain as a symptom. But aren't these already covered? By extension wouldn't discovery of said unknown disease lead to covery of the symptoms?

3) I'm only discussing run-of-the-mill obesity, not anything related to a pathogen or a symptom of a recognized physical disease.

"Two quick sidenotes:

1)...
2)...
3)..."

The sad part is that I'm an accountant.

Has anyone read obesity series featured on TechCentralStation? I found it rather interesting.

I also think your post is somewhat contradictory. You claim that dieting and exercising didn't work for you, then claim you wouldn't have had to have surgery if weight loss programs were covered by insurance. By claiming weight loss programs would have worked, you're admitting that exercising and dieting is sufficient. That's all that weight loss programs are.

Actually, my point may not have been clear.

Obesity for some is behavior driven and for others metabolic. The point I was trying to make is that weightloss programs work for some, weightloss drugs (prescription) work for some, and surgery is necessary for other. But if we ignor the people that are current only a little overweight today - they become surgical candidates tomorrow.

For me personally - my problem was a long dead thyroid gland and a destroyed metabolism. At 350lbs, I was gaining weight on 1100 calories and maintaining my girth at 950-1000cals.

Had my thyroid been discovered when my parents begged the doctor to help me - my life may have been different. Instead, the pediatrician blamed my heritage, my mother and me. Never tested me for anything. Treated me with no compassion and my mother with no respect.

2) I'm open to the idea of a heretofore undiscovered disease causing certain people obesity. I'm sure there are already certain diseases which include weight gain as a symptom. But aren't these already covered? By extension wouldn't discovery of said unknown disease lead to covery of the symptoms?

Only if your doctor can prove it. And, if they care enough to look that far.

I had a great doctor. She was tireless in her efforts to help me and it was her appeal to my insurance that got my surgery covered.

Too bad for me and many others that it has to get that far gone for treatment.

Society didn't look at me and think that I had a medical problem that made me fat. They looked at me like I was a lazy beast with no self-control.

Ok, if it's just about 'diet and exercise' how about this: I weigh 300 lbs. but am very fit and can walk most people under the table. I have *normal* blood sugar and pressure (doctors *hate* that!). I've been dieting since I was 12 (I was just 'chubby' then). I lived (live) on a farm, guys. I was outdoors for hours after school and just about 24/7 during the summer. My current regimen: mow 5, count'em, 5 acres, by hand, with a push mower (no self-propelled). That works out to 17 hours of pushing a lawn mower per week. Where we live, that's for 9 months a year. All our neighbors wonder what's wrong with us that we don't have a riding mower. It's what I do to keep from being even *fatter*. All my life society has told me I was morally weak (no guts! no willpower! No character!) Now my poor joints are giving out and what the hell am I supposed to do? And before you ask, no, I don't spend the rest of the weekly hours eating. I've been to every endocrinologist in our region. But yeah, diet and excersize will do it. I defy those who maintain that to try and keep up with me during my 'slothful' lifestyle.

Rosemary,

The difference is, of course, that if I knew a guy had AIDS, I wouldn't have sex with him.

I learned a lesson. If I keep stuffing my face, I get fat (he says while guzzling a beer! :-)    )

Both are cause by behavior, yes. But in most cases, the person who gets AIDS doesn't know that's going to happen. The person, like me, who stuffs his face every day with big mac combos and coke knows what's going to happen.

There's this article.
Scientists Find Obesity Gene
For what it's worth.

Michael:

But that doesn't happen to everybody. I'm sure we all know that guy/girl that can't seem to gain weight...

The difference is, of course, that if I knew a guy had AIDS, I wouldn't have sex with him.

Well sure. But some people are like me. I played sports in school. I ate very little. I wasn't a binge eater or closet eater. I was always active as a child and I steadily gained large amounts of weight.

It baffled my parents. They took me to many different doctors - they(the doctors) refused to believe it was a medical problem. I dieted from the age of 12. My childhood sucked. Do you know how it sucked watching kids eat ice cream while munching on celery and always feeling hungry and gaining weight. Always being told that youd be so pretty - if only you lost weight. Puberty sucked for me. I fought my weight forever.

My parents cried when I found out my weight was due to my thyroid and bad metabolism. See, if the doctors had tested me at 11 they would have discovered it and it could have changed my entire life. Since, none of them believed that obesity was a medical problem - I was never diagnosed.

Note: If anyone thinks I am in any way trivializing AIDS, cancer or anything else. I apologize. That isn't my intent. I was just hoping to make people realize that obesity is more than lack of self control and laziness.

Had a vertical-banded-gastroplasty in 1985. They didn't have the laser equivalent back then, so I have a nasty scar from my chest to my belly button.

It did create some challenges when I had my children (low calorie consumption often leads to low birthweight babies), but other than that, no problems. I throw up about 4 times a month (took me years to get used to it and not throw up 4-5 times a week). I have acid reflux problems, but it seemed like a small price to pay.

I remember lying in the hospital (9 day recovery) in incredible pain, unable to move, thinking, "is this enough pain and pennance to payback society for burdening them as a fat person?" MAN! I had no idea I felt guilty about being fat until that thought went through my head.

It does eventually "wear off." It's been nearly 20 years for me now and the weight gradually has come back--not all of it, of course, and I have no idea how much I'd weigh if I hadn't had it, so still no regrets.

Good thing is, I don't care anymore. Actually, better thing is, Kim doesn't care, and prefers the real me.

Where was this man in 1985????

All obesity is behavior-driven. This is a biochemical fact. It is literally impossible to non-surgically gain body mass, regardless of your metabolism, if you burn more calories through activity than you ingest. If it were, we could recruit reconnaissance patrols staffed only by low-metabolism soldiers and send them behind enemy lines for months with only a bag of ammunition, a bottle of vitamin tablets and a water purifier.

Metabolism plays a large part in determining how extreme the consequences of overeating are, but almost all Americans overeat. Metabolism doesn't create intake calories where no intake calories exist.

I don't particularly care whether overeating is categorized as a disease or not, so long as I don't have to subsidize the bad health choices of anyone else via my raised insurance rates, or subsidize anyone's air travel by paying the same price for my seat as someone for whom the airline incurs twice the marginal cost to serve. Let me offer to take huge deductables for the treatment of behavior-related diseases, as my commitment to the insurance company that I'm willing to take responsibility for my health and reduce their real cost to insure me.

Rosemary:

1) If you were only eating celery, you'd be dead of starvation now. Bare celery requires more calories to ingest than it brings to the system.

2) Everyone has crosses to bear. Mentally deficient people have to study harder than us in order to learn the same material. Unattractive people can't attract as many or as attractive suitors. Either you believe in striving very hard to overcome relative challenges and deficiencies (capitalist model) or you believe in rewarding the ignoring of deficiencies (communist model). You'd always struck me as the capitalist/accountable type, until this thread.

Misery: try swimming 2K meters or so a day. It's the only form of aerobic exercise available to me when I broke my foot four years ago, and it worked phenomenally well.

Obesity Apologists in General: it doesn't matter if you're "outdoors," and/or you're "in sports" (technically bowling, baseball, golf and field events are all "sports"). If you aren't sustaining a lifestyle aerobic enough to maintain your medically-appropriate weight, your intake vs. exercise equation is out of balance. Which is your decision, as it should be.

Jonathan:
Give me a break...

Celery in lieu of ice cream - in the summer. I didn't think I had to spell it out that far.

I'm not an apologist. I had surgery to repair what was deficient in me. It worked.

Not to be insulting but you haven't a clue what I went through or anyone else. You are making assumptions and generalizations based on prejudice. I worked my ass off to lose weight for years. And you know something - I still am. The difference is now my body is functioning as it should. So I am successful at it.

Would you tell a mentally retarded person that he wasn't trying hard enough if he couldn't master Calculus?

Because that is what you are saying to me.

As a doctor who is just passing by, I'd like to make a couple of comments.
First, there are a grand total of about two pathologic conditions that cause weight gain- hypothyroidism, and cushing's disease (steroid excess). To these three conditions, you could add puberty, pregnancy and menopause. These are all readily diagnosed by some simple tests (Rosemary's history notwithstanding) or observation. However, even in these conditions, the calories going in still exceed the calories being burned off. It's just that the body is conspiring in A MAJOR WAY to throw off the metabolism or increase the appetite.

There are other, more subtle ways to tip the balance. Some people eat more than others. Some have a naturally slow metabolism. Some are sedentary. Some take drugs that change the metabolism (beta blockers, cigarettes) or appetite (prednisone, anitdepressants). It still boils down to basic physics. Calories in>calories burned=weight gain.

That some people are predisposed to obesity cannot be denied. Yet, our country is so prosperous that few of us do physical labor, and food is so cheap and plentiful that our sense of what constitutes a portion size is utterly distorted. We don't know what real exercise is. I went to medical school in San Diego and residency in Iowa. Despite the higher rate of smoking, the average weight of an Iowan was obviously higher than a Californian (and statistics bear this out-actually Colorado has the skinniest people since they have to work so hard to breathe, I guess!)- and indeed, bariatric surgery was pioneered in Iowa.

Now, these are all ordinary Americans. Their only difference was lifestyle. The Californians, to a great extent, were either more motivated to be one of the "beautiful people," and/or had more opportunities to exercise. Iowa is a different place (one I actually liked better than CA) with different priorities and a different climate. A lot of farmers or former farmers still eating farmstyle cooking. A nasty climate for exercise.

Life is not fair. Indeed, I went from a skinny active person to a medium-weight flabby person (with time to read blogs) because of rheumatoid arthritis with its attendant drugs and inactivity. However, right before I retired, I saw a long-time patient of mine- a nearly wheelchair-bound arthritis patient with steroid-induced osteoporosis and obesity. She can barely walk, much less do step aerobics. She lost 50 pounds through weight watchers, because was motivated to try to stay out of the wheelchair. If she can do it, so can I or any of the rest of us.

There is a culture of victimhood in this country. Labeling obesity as a disease just makes the companies who make diet drugs richer because they hope insurance will then pay for it. We'll see. Insurance companies don't pay for smoking cessation, either, and that is also a matter of addiction, but to tobacco, not food. But have a daughter tell a mother- "You can't be around your grandbaby because you smoke," and watch the cigarettes go out the window. Permanently.

Yes, weight control is difficult. But it isn't impossible. Treating HIV without drugs is impossible. Treating cirrhosis without a liver transplant and drugs is impossible. In an ideal world, we'd have endless dollars for the treatment of illnesses with a behavioral base- but we don't have endless dollars. We have to prioritize. The BEST and SAFEST route to weight loss is still exercise and caloric restriction.

If we go too far with classifying everything that has a treatment as a "disease" the insurance companies will simply refuse to treat certain diseases. We're already half way there. There are treatments that have become prohibitively expensive--you can have your gall bladder removed, but not a heart transplant, etc.

Insurance Companies are a business and the free market should determine what they will or will not cover. If someone sues an insurance company for failure to cover a particular disease, which they clearly specified as "not covered" in their policy, it should be thrown out of court.

Your current insurance company doesn't care if you die 40 years from now, from preventable illnesses (onset by obesity) because it's more than likely you'll be with a different carrier by then. What could or might happen (as a long term prevention) shouldn't be (and isn't) an issue for them. They aren't health care providers, they're legalized gambling organizations.

Everyone dies. Even thin people. The insurance company has no incentive to keep you alive longer, unless you're already healthy.

I know you weren't thinking of this as a "the state must make this happen thing" Rosemary, and it seemed like common sense that insurance carriers would do that, but that's the wrong advice---well, good advice, but directed to the wrong group. It is in the PATIENT's best interest to have the procedure for long term health benefits, not the insurance company.

If we all paid for our own medical care (instead of insurance) we'd either make it a priority to save the money for the optional (long term benefit) surgeries we need, or we'd die sooner. Our choice. That's the bottom line. It doesn't matter what the American Medical Association decides is a disease or not, what matters is what where we place our priorities (by backing them up with our dollars).

The BEST one was when Kim got preapproval from his insurance company to have the snip-snip. They later tried to deny the claim stating that it was a "pre-existing condition." I should HOPE so.

To the retired Doctor (and a few others)...You are virtually 100% correct in everything you wrote. Down the line I agree with virtually every point and recommendation.

But...

I disagree with your conclusion and the statements of a few others. Here's why...

The summary of the causes of obesity is woefully incomplete. There are far more variables that lead to obesity. Some individuals can make a lifestyle change and permanently return to a normal weight. This is the exception (based on the high failure rate of weight loss programs). Here are some other variables:

HUNGER! Many are far more *hungry* than 'normal' people. This isn't do to weakness, this is due to genetics. One cause has been identified: Gherlin (http://www.healthscout.com/static/news/8006417.html).

Another cause may be leptin (http://www.hhmi.org/genesweshare/d130.html).

At last count, over 20 genes (http://obesitygene.pbrc.edu/cgi-bin/ace/mainMenu.cgi) have been found that are involved in regulating appetite and body weight. One gene, Nhlh2, seems to have a key role in regulating body weight AND ACTIVITY! It's time to lay to rest the myth that ALL overweight people got that way due to being 'weak'.

For the record, my birth-mother had the gastric bypass surgery and it saved her life.

I am old enough to remember when seeing really fat people was really rare.

Now it is commonplace.

Common sense tells me that it is life style - no slopping the hogs, milking the cows and chopping cotton all day - a diet that says light breakfast, light lunch and heavy dinner, when it should be the reverse - more alcholic beverages consumed and ready to cook dinners loaded with fats and sugars...

Excuse me, gotta go...my milkshake is ready.. now if I can just find the whipped cream and strawberries

Celery in lieu of ice cream - in the summer. I didn't think I had to spell it out that far.

If you're trying to give an example of one uncomfortable experience you had, I suppose that's okay.

Not to be insulting but you haven't a clue what I went through or anyone else.

What do you know about about what I know?

You are making assumptions and generalizations based on prejudice.

I'm making statements based on medical fact.

I worked my ass off to lose weight for years. And you know something - I still am. The difference is now my body is functioning as it should. So I am successful at it.

Fair enough. Congratulations!

Would you tell a mentally retarded person that he wasn't trying hard enough if he couldn't master Calculus?

Because that is what you are saying to me.

I would leave that decision to the mentally retarded person. I don't feel the need to judge anyone. You're the one who appears to demand that the rest of us--via the insurance premiums that we pay--adhere to your view of obesity and subsidize its impact in your life.

This is a subject that will take time. This is not something we can dismiss and make claims just yet that we know for sure either way.

If we skip back into an era or two we can look at a man named Bill W. Bill W. had a serious drinking problem. He did not grow up that way. He, like so many of us, came from a depressed era and background. Change the family, change the time frame. Bill W. started drinking more and more and went through his tale of woes. In time, Bill W. formed an organization called, Alcoholics Anonymous.

It took many years for society and the medical profession to accept alcoholism as a disease.

I also look at mental illness and the word we use that so many people get turned off to called, depression.

Once again, step back a few eras and look at a few writers and composers that come to my mind: Mozart, Beethoven, Hemingway, F.Scott Fitzgerald.

How many years did people suffer in silence and fear society's harsh cruelty on these that suffered. In time society and the medical profession accepted depression as an illness.

Now these are just two diseases that I am so very familiar with, and know the devastation either of these diseases has on the person suffering the disease and the family and friends who dearly love them endure.

Are they lifestyle? Are the inherited?
Can they be helped with the intervention of medical science and family support and counseling? You bet they can.

We are finding out more and more about autoimmune diseases. Aids is a virus/autoimmune disease and it can be transmitted to precious newborn babies. It is passed through bad blood transfusions and of intercouse.

I too have an autoimmune disease that comes from a virus called rheumatoid arthritis. 70% of women get this disease. I ask myself. Did I do something in my past? Did I not eat or drink or not exercise enough, or walk on the right side of the road or say hi to the right people? Not according to the doctors. Is it because I took hormone pills?
Is it?

Rosemary, those of us that have known you and Dean through this wonderful world of blogging, know you are coming from your heart.

...Society's acceptance is a very bitter pill...I know this from my Mother and Father and the maladies they suffered in silence. We can look back to Grandparents in older eras and there again wonder.

The beauty of modern science and people today is society is becoming more accepting, more understanding Rosemary.

Time...society and the medical profession will take a seious look at obesity and will insure those that need help.

Great compassionate post.

James Joyner touched on a very important point earlier in the discussion: "The main reason many Americans have such a slow metabolism is our crappy diets, notably our addiction to processed carbohydrates."

I'm seeing a lot of "calories in minus calories burned" talk going on... when talking about calories, it's important to realise that your body doesn't react to all calories the same way.

A calorie of carbohydrate is not treated the same as a calorie of protein or fat. Simple carbohydrates trigger the release of massive amounts of insulin, which is very good at converting sugar in your blood into fat for storage.

Too many people say "you just need to eat right and exercise" meaning you should stay away from fat and load up on carbs... they don't realize that you are not what you eat. You could take in zero fat or cholesterol, but your body could still easily produce both.

If someone wants to lose weight and actually keep it off, they need to start by looking at simple carbohydrates with the same contempt that most people have for saturated fat. Exercise is always a good idea, but people who workout need to lose the misconception that carbs are an almost magical source of energy.

Jonathan:
What do you know about about what I know?

I'm a psychic. ;-)

I don't feel the need to judge anyone. You're the one who appears to demand that the rest of us--via the insurance premiums that we pay--adhere to your view of obesity and subsidize its impact in your life.

But aren't you judging. I understand your complaint about premiums. I have similar complaints. I resent being taxed against my will and using my tax dollars for dumb crap and entitlement programs. I resent the fact that I am paying for lung cancer treatments for people that wouldn't quit smoking. I resent paying for people that can't control their drinking and develop liver problems. We pay all the time for illnesses that are a result of reckless behavior.

Studies continue show that obesity is more than calories in and calories out. Sure there are fat people out there that made themselves fat all by themselves. But not 100% of them and the more obese they are the higher the chance that it is more than just self infliction.

I respect your opinion. I disagree with it but I respect it. My history is a big influence on my attitude. I can't help that. It doesn't mean I am trying to avoid accountability. I've spent most of my life trying to fix a problem that refused to get fixed. I blamed myself, even when doctors told me that I wasn't to blame. I did not want to be fat - I hated being fat. I hated myself so much that I contemplated suicide more than once. I decided that it would the ultimate act selfishness and cowardice to do so.

So I found a way to fix it. I work hard everyday to make sure it stays fixed and I remain healthy.

One particularly valuable thing I learned from therapy is the futility of trying to explain yourself to those who can not or will not understand.

After all, Rosemary, you're obviously a self-deluded idiot who could have solved your problem with a little discipline. Your experience is worthless in the light of superior wisdom from the fucking know-it-alls.

Calories in/calories out is fine if you're a bomb calorimeter. Not so simple if you're an adaptive organism. Most of us are, I think.

How comforting, how inspirational to hear the familiar preamble, "Why don't you just ..." Just what? Snap out of it? Eat a little less? Exercise a little more? Think cheerful thoughts? Grin and bear it? Buckle down and finish the task? Toughen up? Say no?

If it were so simple and easy, almost everyone would do it.

I hate the saying, "If I can do it, anyone can." That is patently absurd. A better formulation was spoken by Anthony Hopkins in a wilderness survival movie: "What one man can do, another can do." Not every other, but some other. So, what works for one will work for others, but not for everyone.

As for insurance, I don't want any. The last thing I want is for some bastard to prolong my life for the sake of billable procedures or, worse, out of some sense of dedication. If my credit card won't cover it, let me die. But then, nobody ever accused me of excessive joie de vivre.

Dave B. I agree that there is a great deal we do not know about the causes of obesity. Yes, things like leptin (and its opposite, cachectin) do exist. These "stack the deck" so to speak, regarding weight and are some of the causes which tip the balance one way or the other. However, the fact that there are genetic predispositions to manageable conditions makes the management harder, but not doomed to failure.

Watcher- I agree that not all calories are treated the same way in the body, but in the end, if carbs are converted to fat or if you just eat fat, it doesn't make a lot of difference. Unless you are diabetic, then stability of blood glucose is much better without carbs, and people on the Atkins diet do get a geat positive boost (in the beginning) from losing the water that goes with metabolizing carbs. I think medical science has pretty much realized the key to health is just to lose weight, no matter what diet you chose to follow. And weight watchers (good old calorie counting) has, over and over again, been shown to be the only program that works in the long run, because you learn how to eat in the real world. Not in the world of no-carbs.

Finally, Janelle, rheumatoid arthritis has not been shown to be caused by a virus, that theory has been looked at and there's no proof for it (yet). Also, 70% of women don't get RA, only 2% do (but for me and you, that's 2% too many). Are you thinking of another virus, say EBV or CMV? These can cause fatigue and joint aches. The Arthritis Association has a very fine website if you want to know more.

A mentally handicapped person cannot learn calculus. But all people can lose weight- even though it can be very, very hard, it isn't physically impossible. The playing field is not level, but I could point to a hundred other areas in which it isn't, either. When, exactly, do we say that we as a society cannot fix every bad deal life hands our citizens? People are literally dying to leave some parts of our big cities- $30,000 could get an entire family out of a hellhole. Why not? It's not their fault that they were born into such a situation. We all know they have an uphill climb out of poverty. But, we also know that it IS possible and that it is done every day, and that sometimes, life is just not fair.

I guess I feel strongly about this issue, because I see so much unmet need in health care, where there MUST be money spent for a cure, but there's no money to be had. Insurance premiums are spiralling out of site, people are going without insurance and care, and now bariatric surgery is to be added to the list of covered procedures?

I once took care of a lady with heart failure caused by anemia caused by heavy menstrual bleeding, caused by abnormal hormones, caused by obesity, caused by thyroid disease that could have been cured by a twenty-five cent thyroid pill. But they didn't have the money or insurance to find out what the hell was wrong. Good God, what is wrong when we can't come up with $0.25 for prevention but $30,000 for treatment? That, I guess, is a question for another day.

Danielle, I'm sorry to say this, but your being an MD doesn't make you an expert on obesity. In fact, most physicians know very little about the condition, and a retired physician (which you describe yourself as) would obviously even less qualified than a bariatric specialist.

I'm afraid you've said several things which are completely incorrect about the current state of obesity research. The most wrong of all is your claim that " And weight watchers (good old calorie counting) has, over and over again, been shown to be the only program that works in the long run, because you learn how to eat in the real world."

This statement is, categorically, false-to-fact. In truth, no such research that's ever been done has shown that such programs are effective on the majority of obese patients. In fact, the failure rate of most such programs is so bad that it would have to be considered quackery if it were being used to treat just about any other condition. Indeed, groups like Jenny Craig and Weight Watchers have now, for years, refused to release verifiable figures on the results they've gotten, and most of us suspect that the reason is that almost none of their obese customers actually wind up attaining and maintaining normalweight status.

Furthermore, your comments about low-carb plans are, frankly, behind on the research. While it's well-documented -- and fully explained by almost all low-carb diet books and physicians who use these approaches -- that there is some fast weight loss in the beginning of these programs due to water weight loss and loss of glycogen in the liver and muscles, the fact is that several peer-reviewed studies in the last few years have demonstrated that these diets do work for some patients for real fat loss, and that indeed many patients actually lose weight faster on the low-carb plans than on higher-carb plans even if caloric intake is higher on the low-carb plan.

Quite simply, there is a serious dearth of research into the causes and solutions for chronic obesity. There is some evidence of a viral connection to some obese patients--are you aware of that? That's been in the peer-reviewed literature the last few years. There's evidence of genetic predisposition. There's evidence that hyperinsulinemia plays a role, and indeed there's been much progress in showing that drugs which simply reduce insulin levels reduce weight.

The fact is that we don't know, and I'm afraid a big part of the problem for a while now has been physicians such as yourself who act as if you "know" what the cause and cure of obesity is, and who state flatly that there are "no" medical causes other than a few rare conditions. No, we do not know any such thing. Your being a physician doesn't make you an expert on a pathology that is under-researched and poorly understood--I'm sorry, it just doesn't. And you've got a condition here that, time after time after time, has been proven to be almost impossible to treat with "eat less and exercise more."

There's a serious problem here, and while the cause may be rooted in sedentary lifestyles and easy caloric intake in part, it's extremely irresponsible to generalize.

In fact, I used to have a doctor just like you. I fired her and got one who actually treated obesity as a medical condition, and didn't pretend that there were simple answers like handing me a diet, referring me to a dietician, and telling me to exercise more. You know what? I tried that for years, and it wasn't until I got with a physician who treated the condition a little more seriously, and actually aggressively stayed on top of the current medical literature on obesity--which I'm sorry to say, it's apparent that you haven't--that I started getting better control of my problems, and stopped feeling like I was some sort of pathetic loser. Ditto for my wife.

Dean-
I am sorry that you took such offense at my posting. However, you're calling yourself a pathetic loser, I'm not. I fully appreciate what you and Rosemary have been through, well, as much as a non-obese person can.

I am afraid, however, that you have misjudged my qualifications considerably. I retired in May and have spent the past ten years helping women, most of whom struggle with their weight. I am well aware of the new research on low-carb diets, and, in my previous post, pointed out situations in which they work very well. But, they are notoriously hard to stay on, and people often relapse. There are no long-term studies on their benefits. Keep in mind, Dean, that people who write books want to sell them. I would take what you read with a grain of salt. And always, always, wait until two or three studies find the same connection before accepting something as true.
A couple of years back, a peer-reviewed study showed that good old-fashioned low carb/low calorie diets do work, and this led to federal legislation allowing people to use medical spending account money on programs like Jenny Craig and weight watchers at about that time. If I am wrong, then a whole bunch of federal advisors are wrong, too.

At first I was skeptical about bariatric surgery, but have been a major supporter of our fledgling program, because I have seen the surgical horrors generated by bad programs. Our program treats patients as whole people, and tries very hard to work with diet and medication, before referral to our specially trained surgeons. Since my premature retirement from the surgical arena, I have, in fact, been asked to work in this very program.

Less than a year ago, I had a patient who wanted to postpone her surgery for UTERINE CANCER (a complication of morbid obesity) to have bariatric surgery done. I got her cancer surgery and bariatric surgery approved and she had them done within a month of each other. How could I not be touched by this patient who would risk her life for a chance at weight reduction? I regularly prescribed anti-insulin drugs to combat obesity and dysmetabolic sundrome X and all the side effects of that syndrome, which likewise is poorly understood. I am sorry I did not lay my resume out for you, but I did not expect to be attacked when I attacked no one.

My sympathy extends, however, to other patients as well as heavy ones. I was an "in-the-trench" doc who did not have the luxury of limiting my study or care to obese patients. Of course the bariatric specialists all want this area paid for by insurance- no one can afford their services now! Our best and well-regarded weight-loss doc had tremendous success- but time and time again my patients said "he's great, i can't afford him."

My point was, and is, simply this: Our health care system is about to implode. My other patients will suffer if we adopt expensive treatments for which there are alternatives. Not all patients will exhaust the alternatives like you and Rosemary did. They will bypass the hard path and find nice doctors like me who'll get the surgery approved. I was not only a private-practice doc, I still sit on the hospital board of directors. I know this system is not sustainable. You say there are no alternatives, I say there are and my basis comes from seeing patients who have succeeded. We are drawing on our own experiences, both of which are valid.

My perspective is just a bit wider than yours, Dean. I have to worry about a townful of people. You have to worry about your family. Hard choices are going to have to be made in the near future about what we can and cannot afford to provide, and these questions need to be asked. Don't vilify me for asking them.

I didn't think I was attacking you, Danielle. But I was pointing out what has been my experience, which is that a disturbingly large number of physicians generalize irresponsibly about obesity, and say things which were the common wisdom of 15 or more years ago but which are simply not true. I've also heard many horror stories from patients who were treated horibly by physicians spouting the "you just need to exercise more and eat better" mantra.

It may surprise you to learn that while I am certainly not a physician, I'm more up to speed on the medical literature than most people, and I've spent an inordinate amount of time talking to physicians and other professionals who treat obesity for a living.

I would also urge you to look closely at any literature which closely examines the Jenny Craig or other programs--which you'll have a hard time doing, since those folks are very reticent to give out their data. Yes, studies showing that "eating less causes you to lose weight" do exist, and have existed for years, and these are often (way too often) held out as "proof" that such programs work. But the long-term success rates of such programs are abysmally bad. The problem is that you need to look at the data--and don't even get me started on what the government will accept as scientific proof of something.

I've written more on this subject here, inspired by this conversation.

By the way, I would agree that our health system has profound problems. On the one hand, and not to be dismissive, I've been hearing that our health system is imploding for almost 20 years, and so far it has not imploded. However, I would agree that we have profound issues to work out, and I don't know where it will all lead.

Rosemary, you asked:

"Do you know how it sucked watching kids eat ice cream while munching on celery and always feeling hungry and gaining weight. Always being told that youd be so pretty - if only you lost weight. Puberty sucked for me. I fought my weight forever."

Yep. I know exactly how you feel. (Well, except I would only eat celery if it was plastered in CheezWhiz or Peanut Butter.) Like I said, I was the fat kid, too. I was made fun of. I was beaten up, when I walked down the school corridor, people stared at me. I did everything I could to fit in: Drugs, Drinking, Smoking. Never worked. I was the big old tub of lard - just like you right? Thankfully, I'm over that now - although if I ever met one of my old school mates who used to tease me, I wonder what I would say to them now?

Also, try being fat AND GAY! LOL! :-)

It does suck, and I don't mean to trivialize fat any more than you mean to trivialize AIDS. I've been in both situations. I've known people who have AIDS, and I've actually become friends and regularly talk back and forth with a high-profile journalist, who has it as well.

My point is not to say that obesity is a disease or is not a disease. I was just commenting on what worked for me.

Personally, I think our government doesn't give a flying shit about the number of fat people in the country. If they did, they'd take that "useless as hell" food pyramid (scheme) and toss it on a fire somewhere. It basically tells people they have to gorge on grains n order to be healthy!!! Guess what? Gorging on grains makes you fat!!! But the grain lobby has a lot of money. I'm not an adovcate of conspiracy theories, but I smell a rat! :-)

We've started our kids out on the wrong foot. They scarf down sugar-laced cereal in the morning. They eat sandwiches and pudding cups and coke for lunch. We feed them burgers and fries for dinner!

Like I said in an atricle I wrote: SlimFast is neither fast, nor slimming! Here's a list of food. Which ones are good for you?:::

Apple Juice
Special K
Strawberry Jam
Potatoes
Orange Juice
Fat free oatbran blueberry muffin
Wheat Bagel

If you answered "None of the Above. They're all Horrible!" you would be right! Human beings were NEVER meant ot eat so much grain. We were meant to eat meat - no matter what PETA tells you.

And THAT'S the biggest problem obese people face in the West. People lie to them constantly.

P.S.: I love your email address!!

Michael:

I agree with you. The food pyramid is EVIL!!!!

Dean and I did something a little "radical" with our son in his first 3 years. We fed him a low carb diet. No processed crap. Meat, veggies and fruit. All juices were 100% no sugar added (I watered them down by 50%)

We knew we wouldn't be able to keep it up forever but we wanted to give him a headstart on healthy eating.

Why wouldn't we keep it up for ever? We didn't want him to feel abnormal around other kids. We trained him to eat protein first, non-starchy veggies second, then fruit and carbs if needed.

Now, I have a lean 6 year old that has been nicknamed T-Rex by some of his friends. My son eats a normal diet. But, if you offer him a cookie,candy, cake or a treat - he will more often say "I'm not hungry for that" than he will say "Yummy, yes please".

I can keep cookies in the cupboard and one box can last months. He doesn't have to ask to have one - if he wants them they are available. I wanted to make food a minimal influence in his life. He needs to eat for energy and health but that is it. So far, it is working.

P.S.

My email address is a very literal personal joke related to pregnancy...if you know what I mean.

Hey Rosemary:

But aren't you judging.

No, I really am not. I am making no judgment in the affirmative or the negative. All I'm asking is that I not be forced to subsidize anyone else's behavior.

I understand your complaint about premiums. I have similar complaints. I resent being taxed against my will and using my tax dollars for dumb crap and entitlement programs. I resent the fact that I am paying for lung cancer treatments for people that wouldn't quit smoking. I resent paying for people that can't control their drinking and develop liver problems. We pay all the time for illnesses that are a result of reckless behavior.

Why should we? The central prescription of micro-economics is to internalize externalities. And for some reason most of the people on this blog seem cool with that until we get around to this obesity discussion.

In a free market, I should be able to buy insurance which precisely addresses my risk profile at the cheapest possible price, and insurance companies should be allowed to cut me a deal based on the deductibles I want to take for treatment of all elective diseases. I don't have sex with people whose last names I don't know, so I'd take a high deductibe for STDs. I exercise and eat pretty healthily, so I'd take a high deductible for heart disease. I don't smoke, so I'd take a high deductible for lung disease.

No judgment of my behavior is required or asked for. I simply choose my risk profile based on my behavior and the insurance company decides what kind of risk I pose. This kind of "buffet-style" insurance is consistently opposed by members of high-risk-behavior groups who want to pro-rate the consequences of their health choices across people who make better health choices. That is fundamentally unjust.

Studies continue show that obesity is more than calories in and calories out.

True, there are other mitigating factors. But obesity is never NOT about calories in and calories out. This is the biochemical, thermodynamic truth.

It doesn't mean I am trying to avoid accountability.

It really does, though. To the extent you continue to support health insurance restrictions which prevent everyone from choosing their own coverage buffet-style in a free market, you are forcing us to subsidize your health care. That's medical communism, and it's no more moral than any other form of communism.

I do applaud your ambition and your determination, though. I recently had my metabolism downshift and I, too, miss the nice deserts. It was more fun before.

Off to the squash court . . .

I have struggled/refused to struggle with my weight all my life, hitting my high point four years ago at 245. What really hit me though was that after progressing up to a size 24, I was at the point where the 24s were getting too tight. I just could not stand the thought of having to wear size 26 or going over 250 pounds, so I decided I had to do Something.

However, I have no stomach (pun intended) for wieght-loss diets. I just can't stand being On A Diet. It seems so incredibly stupid to cut down on food by making food the total focus of your life.

In addition, study after study (plus my personal experience) shows that quick weight loss (including the so-called "safe" two pounds a week touted by most "sensible" plans) is never permanent.

I also remember quite vividly reading a study in Consumer Reports when I was a teenager (1970s), that compared various weight loss plans' cost and effectiveness. The second cheapest and second most effective was Weight Watchers, back in the days when it was $2 a week and before they got into food merchandising. The most cheap and most effective were regimens that individuals designed for themselves - CR concluded that when individuals took charge of their own weight loss, they were more highly motivated and also able to fine-tune whatever they were doing to their own situation. And of course, you don't have to pay yourself a weekly fee.

I don't have any apparent medical condition, other than an incredibly efficient metabolism. (That is the doctor's diagnosis; my metabolism is very efficient, and utilizes calories very effectively, saving the excess for next week's famine.) I have been on the world's slowest weight loss plan, six pounds a year. However, in four years, that means that I am at 221 pounds right now, and more importantly, comfortable in size 20 clothing. It is extremely frustrating because there is absolutely no apparent evidence that I am losing weight - except for a steady downward trend measured on annual visits to various doctors, the consistency with which I can fit into smaller sizes, and an absence of lower-back pain. Oh, and my butt doesn't stick out quite as far as it used to.

I would love to be at 160 and in a size 14 (I have modest goals) tomorrow, but I would rather be there and able to stay there in 10 years than be bouncing all over the weight/body mass landscape for the rest of my life.

Rosemary,

It's not just related to pregnancy, I'm afraid! :-)

I don't know what to say.

When I knew you, Rosemary, I would never have guessed that you would end up in the situation you're now in. I must have known you in the really skinny phase.

I applaud your forthrightness. While there are aspects of your position I don't agree with in the abstract, I refuse to condemn you for your suffering or act as your personal critic. So I will refrain.

Blessings to you and your family, and best of luck in any future surgeries.

I have some strong feelings about doctors, which I'll post to the other thread.

I, too, applaud your honesty in discussing this issue.

Of three children, I have one struggling with obesity. I don't think those who haven't dealt with this issue, especially when manifested at an early age, can understand the emotional and physical toll.

It really is not as simple as calories in = calories out. There are a plethora of significant factors contributing to this condition.

Have you thought about starting a blog dedicated to this issue? I think your experience and expertise would be of great value. If nothing else, a clearing house of literature/physicians would be of inestimable value.

Jeff:

You met me after my surgery. I'm much,much thinner now.

Seriously, much thinner!!!! About 60lbs thinner.

MW:

I haven't given it much thought. Perhaps, Dean and I will discuss it.

I'm not convinced that obesity is a disease.  I think that TV journalist John Stossel and his guests made some excellent points during Stossel's addiction special a few months ago.  The hour-long program was called, "Help Me, I Can't Help Myself".

Here's an excerpt from an ABC News web page related to the show:

Celebrities tell us that overeating is an addiction.  Oprah Winfrey has said, "It's like a crack addict going to crack."

Today Show weatherman Al Roker has the willpower to get up at 4:30 in the morning and freeze in the cold, but to lose weight he had to get his stomach stapled so it's the size of an egg, because, he says, he's addicted to food.  "People will look at this and say, 'Oh, what a crock, but it's true," Roker says.

Jeffrey Schaler, author of Addiction Is a Choice, disagrees:  "These people are playing or pretending to be helpless.  If they want real help, they need to confront the fact that they're lying when they say they can't do something that they can do."

Schaler says we're stronger than we think, and that overeating, smoking and other so-called addictions are all things we can choose to control.  Our genes are not in charge, he says, we are.

Schaler says people may process food differently because of their genes.  But, he says, "The activity of eating is not controlled by a gene."

Winfrey has demonstrated that she recently lost 33 pounds.

"It's a myth that we have no control over our body weight," says JoAnn Manson, an obesity expert and chief of preventive medicine at Boston's Brigham & Women's Hospital.  She says genes do partly determine body shape, but not mostly.  "Maybe a third is genetic and the remainder is lifestyle-based," Manson says.

The whole article can be found here (if you hold down the "Shift" key when you click on the link, the page will open up into a new window):

http://abcnews.go.com/sections/2020/Living/2020_fattwins030418.html

"If you admit you're responsible, you may have to admit you're irresponsible."

-Stephen R. Covey

I believe at some level most of the comments are correct. The main problem I see is that we like to generalize everyone in a category. Because we see people who are obese lose weight, we assume that it should be that easy for everyone.

Because the vast majority of Americans are overweight, we assume that most people are simply lazy if they become grotesquely overweight. We can not differentiate between those that are self-made obese and those that are metabolically challenged.

However, it really should not matter. We as a culture and a country need to spend more time helping to solve most of our ills together. If my insurance rates balloon because my kids are lazy then that is my fault. If they balloon because they have a disease, I help them fight it.

On another note, I am a smoker. If I could quit tomorrow I would. But that is one of the most difficult things to do in the world, and I do it only 20x a day for a matter of minutes. However, eating would be considerably harder to give up if I was addicted. There is nothing we take for granted more than having something to eat. Almost everybody eats until they are satisfied. But what does satisfaction mean? I would think different amounts for different people.

Whether or not we want to call a disease or just a physiological or psychological deficiency, it is worth it for us as a people to try to help those that we can lose the weight.

Ah, but you can quit tomorrow.  Better yet, quit today.  Estimates vary, but most sources agree that about half the people who have ever smoked have succeeded in quitting.

Oh, I should have pointed out that I myself quit smoking in April of 2000.  Haven't had a single cigarette since then.

Carlton:

Insurance should exist to mitigate the effects of unforeseeable disasters. If insurance is health insurance is forced to pay for the cost of discretionary diseases, it becomes just another societally-destructive tax on those who make an effort to live their lives so as to minimize risks, rewarding those who seek out avoidable risks.

If I have to pay for your obesity, then I should have control over what you eat and drink. It's only fair. The consequences and benefits of any given decision should always ride on the decider.

But I don't want to control anyone else's behavior or subsidize the consequences of peoples' bad behavior. If we leave the natural rewards and punishments in place, the problems will correct themselves automatically.

I too have had this surgery and unfortunately I do not share in some of your theories. I was heavy for many years and most of the reason was because I was taking in more than putting out. I would love to blame genetics however I believe now it was poor self control. The surgery yes helped me become a thin person on the outside however the old heavy me was still within. It has been 6 years since my surgery and I have not had a day go by that I haven't regretted it. I have had numerous stomach problems including ulcers, esophegal erosions and hernias. I would rather have the heaviness than the pain of being thinner. It has taken years for me to realize how that alot of my emotional issues were keeping me from handling my weighty issues. I have managed to keep the fat off because frankly I still can't eat much...but I will say that in as much as I have kept my weight off,resolved old issues and exercised more I wish I had done it without the havoc of such drastic measures. This surgery is dangerous and should only be undertaken by the severely obese....my daughter also underwent this surgery and is anemic now and has suffered miscarriages, and premature birth...so please advocate the surgery but only to those who cannot get support in other forms...