Obesity is an international epidemic that has invaded every corner of the globe. In the last two decades, the spread of obesity has shown indifference for race, culture, country, or continent. While it has indeed shown predilection for lower socioeconomic class, affluence and education do not confer immunity. Civic leaders and physicians have waged a combined legislative and medical battle, but education to date has been expensive and ineffective.1 Advancements in technology, the overt availability of food, and the expansion of carbohydrate and sugar rich diets throughout the globe have proven too effective against all efforts to restore balance to societal nutrition.
The effects of societal obesity have been well documented in the United States. The growth in bariatric surgery has paralleled society's awareness of morbid obesity. Over the last decade, the medical landscape of the United States has been populated with innumerable specialty centers and centers of excellence for the surgical treatment of obesity. These centers have shown significant and durable efficacy regarding individual control of obesity. When their results are taken cumulatively, they represent our only effective treatment.2 Bariatric surgeons within the United States, in general, utilize Roux-en-Y gastric bypass and gastric banding for surgical management of morbid obesity, and have shown permanent weight loss, effective resolution of obesity related disease, and significant savings in medical costs as compared to medical management.3
In 1995, Wolff and Colditz documented an annual expense of nearly $100 billion dollars annually in direct and indirect costs of obesity in the United States.4 Despite their observations, comparatively little emphasis was placed on obesity policy by lawmakers, and no organized medical effort to combat the problem was generated. Fewer than 5000 bariatric surgery procedures were done in 1995 in the United States.5
Twelve years later, the American healthcare system is now struggling to keep up with the astronomical direct and indirect costs of obesity. As well, we are forced to engage the underlying problem: morbid obesity. Multiple studies by both university and private groups, have documented the cost savings of bariatric surgery, as well as its efficacy in weight loss, resolution of co-morbidity, and improved survival (Fig. 1).3 Currently, over 100 000 bariatric surgery procedures are done annually in the United States.5 This translates into an increase of nearly 900% between 1990 and 2000. A separate investigation documented an increase in the annual rate of bariatric surgery procedures from 6.3 procedures per 100 000 patients to 32.7 procedures per 100 000 patients between 1998 and 2002 alone.6 The expense of these procedures, coupled with the costs of maintaining a population overwhelmed with obesity, threatens medical funding.
American society has now accepted bariatric surgery as an effective measure for weight control, and it continues to expand throughout the country. However, we are just trying to catch-up. The current American populace has an obesity rate of 66%, with 34% of those being morbidly obese. This epidemic has also targeted our children, as they grow up surrounded by obese adults. Adolescent children are now commonly diagnosed and treated as patients simply because of their body weight.7 A new cycle of social disease has established itself within our country. This will take generations to break.
The European continent is now experiencing the obesity epidemic. In the United Kingdom, it is currently estimated that 17% of men and 21% of women are clinically obese.8 Loosely estimated, approximately 11.5 million Britons maintain a body mass index (BMI) that effectively reduces their quality of life, and their quality and quantity of work. Recently, a paper published in Obesity Surgery created an economic model for three industrialized European countries, one of which was the United Kingdom. They estimate an added cost of £932 per clinically obese individual annually as compared with their non-obese counterparts.9 This sum only represents the direct medical cost of obesity. It does not include the inevitable reduction in work days, work product, quality of work, etc. (i.e. the indirect costs of obesity). Projected costs from this population represent a current annual expenditure of £10.8 billion. This expense does not address the underlying problem of obesity. It merely treats the co-morbidities created by it.
Unlike their American counterparts, the British medical community finds itself in the position to attack obesity before it becomes firmly established. The United Kingdom's current per capita expenditure on obesity related co-morbidities is profound, but nowhere near what the United States is currently facing. The greatest expense of morbid obesity is the treatment of Diabetes mellitus type II. Recent clinical studies show that surgical exclusion of the foregut (as is done in roux-en-Y gastric bypass, biliopancreatic diversion, vertical banded gastroplasty, and gastric banding) effectively resolves DMII in over 80% of patients, regardless of weight lost.10 As well, significant resolution of other co-morbidities occurs in direct proportion to weight loss. This data, coupled with the explosive expansion of morbid obesity throughout the world, strongly favors employment of bariatric surgery Table 1.
It is imperative that the United Kingdom addresses the problem of obesity urgently and deliberately. It is estimated that the National Health Service will fund treatment for at least 50% of the morbidly obese patients in Great Britain, while the remainder will be funded by private insurance carriers.11 Currently, this will add approximately £5.4 billion of expenditure to an already taxed National Health System, and this expenditure will only address symptoms of the problem, rather than the problem itself.
Plastic surgery will play a significant role in the treatment of morbid obesity. As morbidly obese patients regain physiologic body mass indices, a new patient population will be created: the post-bariatric surgery body contouring candidate. These patients now present without significant co-morbidity, but have tremendous skin redundancy. While they no longer consider themselves ‘fat’, they still harbor an inadequate body image. It is estimated that body contouring will cost the National Health Service approximately £100 000 per individual patient.11 Early development of comprehensive, multidisciplinary obesity management infrastructure will allow the National Health Service to manage this epidemic more effectively than waiting for an inevitably obese population.
The United Kingdom has the ability to limit the direct and indirect costs of obesity and its financial burdens before it becomes overwhelming. By adopting an aggressive stance of surgical management against obesity, the United Kingdom can improve the work and lives of its citizens, and prevent an inevitable financial crisis. The plastic surgery community must play a pivotal role in combating obesity. Plastic surgeons must support comprehensive surgical care of obese patients through both patient education and post-bariatric body contouring.
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