This is the part that I don’t get. I don’t claim comprehensive knowledge of what health insurance policies pay for – maintaining such a database could be a full-time job – but it is my sense that it is already pretty widespread practice for them to pay for interventions, especially surgical ones, if patients meet certain criteria (meaning a BMI over a given number, evidence that their obesity has caused other significant health problems, and failure of non-surgical approaches like diet and exercise). Maybe it’s the part about evidence the patient’s obesity has caused related troubles that could change. Maybe the idea is that insurers would pay for surgery even before those other problems have set in.

What gives me pause, however, is the concern that the push for more and earlier intervention will fail to emphasize behavioral intervention. I work in a health system where there is a lot of surgery for obesity. Surgeons do things to the digestive tract that make it difficult for patients to eat too much or for the GI tract to absorb calories (and important nutrients, too). In the emergency department, of course, we see many patients with complications of surgery, so we get a skewed perspective on this. The patients who have surgery that works well for them and never have any problems don’t come to see us in the ED. That having been said, what I see in my work reinforces my belief that lifestyle changes are a much better approach than surgery, because their side effects (the things that happen besides weight loss) tend to be good rather than bad. When one eats a more healthful diet, reduces caloric intake, and gets regular exercise, the effects on overall health go beyond what can be attributed to weight loss alone.

So try this thought experiment. Suppose we take some people who are quite obese and manage them two different ways. The first group gets “bariatric surgery.” The subjects in the second group are assigned a life coach focused on health with special emphasis on diet and fitness. They have regular meetings with the life coach, are urged to keep a diary of their habits related to eating and exercise, and have frequent phone conversations, text messages, emails, all designed to get them to eat healthier and to get plenty of regular exercise.

My hypothesis: The “life coach” approach would work better, the patient’s overall health would improve more, and just as fast, with no complications (short-term or long-term), with long-lasting benefits. Remember, exercise of the right kind does good things for strength and balance and has been associated with improved cognitive function as age advances. My secondary hypothesis is that the overall cost, especially taking surgical complications into account, not to mention long-term effects on health, would be lower (possibly much lower) for the non-surgical approach.