Why are so many health insurers willing to pay for the extremely high cost of surgery to reduce food intake, and not for the considerably cheaper intervention of diet foods and nutrition counseling?
Dr. Rena Wing posed this question in an editorial in the October 27 issue of the Journal of the American Medical Association. She compared the cost of bariatric surgery, which ranges in cost from $19,000 to $29,000, to the $1,600 cost of a 12-week commercial weight-loss program that provides prepackaged, prepared, low-calorie food and weekly nutritional counseling. Dr. Wing suggested that if health insurers covered such programs, more people might be willing to stay with them until their weight goals were attained.
Her optimism that such commercial programs might succeed if their cost did not limit the time someone stayed on the program was based on a study published in the same issue of the journal. Dr. Cheryl Rock and her colleagues compared weight loss and the maintenance of weight loss between two groups of obese women.
The test group received prepackaged diet foods from a commercial weight-loss company for a year and needed only to supplement these foods with fresh produce and dairy products. At the end of the first year, they made the transition to their own foods. They also received weekly nutritional counseling, either in person or by telephone for two years, along with support in following an exercise program. The control group was given printed dietary and exercise guidelines and a minimal amount of personal counseling over the same time period.
At the end of two years, about 59 percent of the women who were given the food, nutritional and behavioral support maintained their weight loss of about 12 to 14 pounds. In contrast, most of the women who received very little support were only about four pounds thinner than they were at the start of the study.
The results of this study confirm the discouraging fact that if dieters are not supported in their weight-loss efforts, there is little chance they will succeed. On the other hand, it also revealed that after a year of free diet food and two years of continual counseling, only 12 to 14 pounds were lost.
Perhaps the reason that health insurers pay for surgical techniques that severely limit food intake is that they work, at least in the first year or so after the surgery. Rapid weight loss occurs and some underlying medical problems, such as diabetes, become more manageable fairly quickly, sometimes within weeks. Although the goal weight of the patient is often not achieved, enough weight is lost to enable the patient to resume a normal life style.
Furthermore, unlike conventional diet programs, such as those providing food and diet counseling, it is not easy for the patient to gain back the weight. It can be done but in order to consume enough calories to gain weight or stop losing, small amounts of highly caloric soft or liquid food (like ice cream or milkshakes) have to be consumed again and again in very small quantities. If too much food is put into the stomach the consequences are very unpleasant and can be dangerous.
The problem with programs supplying prepackaged, prepared diet foods is that no such barrier to overeating exists. Boredom and temptation may cause the dieter to abandon the prepared foods altogether or eat them as an appetizer before going onto the foods that are craved. If participants don't buy vegetables, fruit and dairy products to eat along with the prepared meals, they may not be obtaining adequate nutrients. Few programs offer personal support in developing and sustaining an exercise program and the quality of the nutritional and behavioral counseling may vary.
However unlike surgery, the risks are small. Bariatric surgery is risky, patients need substantial medical support in the early days after the surgery and the patients must be vigilant about obtaining essential nutrients such as protein, vitamins and minerals because so little food can be consumed and absorbed into the body. And like the commercial weight-loss programs, patients may not receive sufficient behavioral counseling and exercise training.
A client who had bariatric surgery after years of struggling unsuccessfully to lose weight through conventional diets told me that the first post-surgical year is considered the "honeymoon."
"The weight came off so fast, it seemed almost magical," she told me. "If I had a problem, there was a team of people I could call on for help. But after the first year I was on my own and that is when I had to fight to keep myself from overeating. I went to Christmas dinner at the home of a relative and it was painful to see others eating the special foods she made and knowing that I couldn't eat any of them. And now, every day, I am tempted to give in and eat the foods I used to crave even though I know I will be sick if I do."
This patient described what is so well known to all of us, thin or obese: A small stomach full of food does not turn off the desire to eat. (Anyone who eats dessert after claiming to be too full to eat another bite is aware of this.) And although the reasons for wanting to eat beyond fullness may be as simple as a special Christmas dessert, more often situational or psychological distress, what is generally termed "emotional overeating," is what's motivating the need to continue to eat.
Increasing the effectiveness of bariatric surgery and commercial weight-loss programs requires identifying clients whose overeating is generated by emotional overeating and giving them the psychological as well as nutritional support to stop. Many years ago we carried out a study at MIT that identified a subgroup of obese individuals who used carbohydrates as a form of self-medication. These carbohydrate-cravers felt less stressed after consuming sweet or starchy foods, presumably because carbohydrate consumption allowed their brains to increase serotonin production, the brain's mood- regulating neurotransmitter.
Based on these observations and further studies showing that increasing serotonin increases satiety, we developed a weight-loss program for emotional overeaters that used specifically-timed consumption of carbohydrates to improve their mood and decrease their appetite.
If any weight-loss program is going to succeed, not just in removing the weight but preventing it from being regained, it is necessary to understand what drives the overeating. The size of the stomach of an emotional overeater is not going to prevent her brain from insisting that she eat to feel better. Twelve months of packaged diet food is not going to prevent someone driven to eat out of anger, depression, fatigue or serotonin-linked premenstrual syndrome from putting the diet food back in the freezer and going out to get a pizza.
Programs as the one Dr Rock tested are effective in decreasing weight, albeit very slightly. And certainly more effective than no support at all. Perhaps health insurance coverage for such programs should be contingent on results: dieters are reimbursed if they are able to keep their weight off a year after the program has ended. Such a policy might motivate the commercial programs to modify their approach so that those dieters who overeating is not caused by hunger but by their psychological state will be helped to lose and keep off their weight.