1. About AOA
2. Medicare Policy and Obesity
3. The Role of Evidenced-Based Medicine
4. About Obesity and Morbid Obesity
5. Evaluation of Bariatric Surgery
6. Applicability of Bariatric Surgery in the Elderly Population
7. Recommendations for Medicare Policy
8. References

Executive Summary

Morbid obesity is a major public health problem and bariatric surgery has superior outcomes for this population compared to other interventions. Bariatric surgery has been extensively researched and reviewed. Recent studies have confirmed that this surgery has a powerful effect on reducing mortality (Christou) and resolving several intractable chronic conditions (Buchwald) making it one of the most powerful interventions in modern medicine. The various surgeries have been reviewed by numerous governmental and non-governmental experts and found useful and valuable when employed by experience surgeons in comprehensive programs in the population for which intended. AOA would like to see zero adverse outcomes in all obesity interventions but at the present time the risks of bariatric surgery appear outweighed by the benefits. The Centers for Medicare and Medicaid Services (CMS) should continue coverage of these procedures and encourage continuing quality improvements.

1. About AOA

The American Obesity Association (AOA) is pleased to have this opportunity to address the Medicare Coverage Advisory Committee (MCAC) on the review of bariatric surgery for the treatment of morbid obesity.

AOA is a non-profit tax-exempt educational and advocacy organization with approximately five hundred members, both professional and lay. Our financial support comes principally from pharmaceutical research and development companies as well as other companies in the weight management field including Abbott, Amylin, Aventis, Bristol Myers-Squibb, Ethicon-Endo Surgery, Eli Lilly, Glaxo Smith-Kline, Pfizer, Merck, Regeneron, Roche, Sanofi-Synthelabo, Weight Watchers Intl. Inc. and Wellspring Camps. I also serve as a consultant to the American Society for Bariatric Surgery and as a member of the Scientific Advisory Board of Ethicon Endo-Surgery Inc.

2. Medicare Policy and Obesity

This is our second appearance before MCAC. Our first appearance on March, 2000 focused on the now-eliminated language in the Medicare Coverage Policy Manual Section 35-26 which stated the obesity was not an illness and on the need to evaluate medical technologies for their effectiveness in persons with obesity. We heartily applaud the decision by Secretary Tommy Thompson to remove the Coverage Policy Manual language and to recognize obesity as a disease. We are pleased to see the Centers for Medicare and Medicaid Services begin the process of evaluation of interventions for the treatment of obesity.

As you know, the Medicare Coverage Policy section approving of gastric bypass procedures for controlling the comorbid conditions of obesity, Section 35-40, has not been changed and is not formally open for review. Best available information indicates that gastric bypass surgery is used primarily for the non-elderly disabled Medicare beneficiaries. As almost all persons with morbid obesity have a comorbid condition, this limitation is not in question either.

The Medicare Coverage Advisory Committee Executive Committee Recommendations for Evaluating Effectiveness asks panels to examine two questions:

1. whether the scientific evidence is adequate to draw conclusions about the effectiveness of the intervention in routine clinical practice in the population of Medicare beneficiaries, and,
2. how does the magnitude of effectiveness of the new medical item or service compare to other available interventions?

Specifically, these Recommendations state:

Historically, many randomized controlled clinical trials excluded older men and women. An increasing number of randomized trials now include elderly men and women. However, simply enrolling older people in proportion to their number in the general population may not be sufficient to determine whether the results of the trial apply to Medicare patients. If the study has too few elderly participants, it might not have the statistical power to detect a clinically important effect in Medicare patients. Clinical trial populations might also differ from the clinically relevant population of Medicare beneficiaries because the trials exclude individuals who have significant comorbid illness or who take many medications. If the study population in the available trials is not the same as the general population of Medicare beneficiaries who would be candidates to receive the intervention, the Panel must state whether the results of the trials apply to typical patients and explain it reasoning. Issues of external validity also apply to the interventions. For a drug or device, the intervention is the same when used in different settings. But other interventions may differ from one site to another. For example, the outcomes of a complex surgical procedure can depend heavily on the skills of the surgeons and other staff caring for the patient. If available trials only include sites where surgeons have the best outcomes, the outcomes might be considerably better than what is possible in a typical practice setting. The Panel must state whether the results are likely to apply to the general practice setting and explain its reasoning.

As to the first question, we believe the panel will see that there is more than adequate scientific evidence to conclude that bariatric surgery is effective for Medicare beneficiaries. Bariatric surgery is complex surgery in very complicated patients who have multiple health problems and are often taking multiple drugs. Randomized controlled clinical trials are extremely difficult in bariatric surgery as surgery is the standard of care for qualified patients and there are no other real alternatives. As a practical matter, it would be extremely difficult to enroll morbidly obese patients in a long trial to only receive a placebo. Therefore, there are few such studies in the field.

Some of the opponents of bariatric surgery imply a bias by surgeons reporting on their own patients. We would like to address that. While bias may sometimes be a factor, it should be noted that research on persons with morbid obesity and on the elderly obese is in a relative state of infancy. Funding for such research by the National Institutes of Health has historically been extremely low and little of it is devoted to morbid obesity. It is only in the last year that NIH has expanded research on bariatric surgery. Likewise, the broader medical community has poorly served persons with morbid obesity. Many bariatric surgeons have devoted their careers to this unpopular population and have carried out important and valid research with little institutional support. Their work should be accepted or rejected on its merits rather than on the basis of innuendos and stereotypes of both the patients and their caregivers. An old adage reminds us that The Perfect is the Enemy of the Good. Requiring perfect studies or a perfect intervention is only going to harm the many people whose lives can be saved and their quality of life improved through bariatric surgery.

The second question is perhaps the easier for there is really no other intervention for persons with morbid obesity. As numerous studies and literature reviews have determined, persons with morbid obesity lose too little with other interventions to make a clinically significant improvement in their health. There will be some advocates who mistakenly believe that diet and exercise are adequate for persons with morbid obesity to lose large quantities of weight. The view that obese persons can simply ameliorate their condition by eating less and exercising more is at odds with overwhelming scientific facts. The hereditability of obesity is equivalent to that of height, which most people readily accept as genetically driven. It is greater than for almost every other condition, including breast cancer, schizophrenia and heart disease. (Allison) The average human consumes hundreds of thousands calories per year. Yet, for most people, weight changes very little. Energy balance is regulated to a level of exactness of about 99.5%, far exceeding the level at which calorie intake can be effectively monitored. (Friedman) Current scientific insights into obesity are focusing on pivotal hormonal mechanisms which regulate appetite control. For example, grehlin which is secreted in the stomach and intestine increases hunger signaling time for a meal. Researchers have recently established that grehlin levels are higher in patients with morbid obesity and rise even under diet conditions, thereby significantly stimulating appetite. Grehlin levels after gastric bypass surgery are very low, correlating with the reduced appetite these patients experience. (Cummings)

3. The Role of Evidence-Based Medicine

Evidence-based medicine can be an extremely powerful tool. However, with regard to bariatric surgery, we have seen that while it takes many well-controlled studies to justify coverage, stereotypes, assumptions and unfounded innuendos are acceptable for non-coverage decisions. If evidence-based medicine is to achieve acceptance it must apply to the goose as well as the gander.

In the last few years, insurers have imposed more and more stringent requirements on patients seeking bariatric surgery. Some of these restrictions impose additional time burdens on the patient, meaning they become sicker before receiving the surgery. Others require the patients be sicker than the NIH Guidelines require. Any restrictions should be required to meet the same evidence standards as the surgery itself.

4. About Obesity and Morbid Obesity

Obesity is the most prevalent, fatal, chronic disease of the 21st Century. The World Health Organization (WHO) has identified obesity as one of the ten leading health risks in the world today; one of the top five in the developed world. WHO reports that over one billion people are overweight in the world out of a population of 6 billion and that 300 million persons (5%) are clinically obese. WHO projects 3 million deaths annually worldwide from obesity rising to 5 million by 2020.

Approximately 4.7% of the United States population (about 9 million persons) is classified with morbid (sometimes called severe or class III) obesity. For comparison purposes, this is over twice the size of the countryıs population with Alzheimer’s disease (4 million). The total number of persons considered eligible for the surgery under the 1991 NIH Guidelines may be as high as 20 to 25 million.

Morbid obesity is one of the most complex and intractable conditions faced by modern medicine. Morbid obesity is understood as a complex biological process involving genetics, the environment and behavior. There is a very strong genetic component in morbid obesity. (Bouchard, Perusse, Thirbly)

Women, and especially minority women, have the highest prevalence of morbid obesity. Approximately 15% of African-American women are morbidly obese. Overall, 6.3% of women have morbid obesity while 3.1% of men have the condition. Only 1.2% have 4 years of college or more. Between 15% and 30% of all women have been sexually abused as children. Obesity is one of the adult manifestations of this abuse. (Roberts) Physical abuse and verbal abuse are strongly associated with body weight and obesity. (Williamson) Sexual abuse, in one study, was found to be significantly higher in women with obesity than in women with eating disorders (Koop)

Obesity and, particularly morbid obesity, pose social, marital and sexual problems. Obese people are frequently ridiculed, shunned, and considered inferior to persons of normal weight. Discrimination against this group is socially permissible, the last socially acceptable discrimination. This discrimination is manifest in employment discrimination, restriction of educational opportunities and the refusal or exorbitant expense of health, life or disability insurance. Maternal morbid obesity carries a higher risk of preeclampsia, antepartum stillbirth, cesarean delivery, instrumental delivery, difficult delivery, fetal distress, early neonatal death and large-for-age births than normal weight mothers. (Cedergren, Rosenberg) Severely obese children and adolescents have lower health-related quality of life than children who are healthy and have a similar quality of life as those diagnosed with cancer. (Maher) Obesity has negative impact on treatment of infertility. (Al-Azemi)

The effects of morbid obesity, known as comorbidities, are numerous, affecting virtually every organ system including cardiovascular (e.g. hypertension, coronary heart disease), respiratory (e.g. sleep apnea, asthma); metabolic (e.g. diabetes); musculoskeletal (e.g. osteoarthritis of knee and hip); gastrointestinal (e.g. cholelithiasis, cirrhosis of the liver); endocrine and reproductive (e.g. cancers of the uterus and breast and reproductive disorders); neurologic (e.g. pseudotumor cerebri); dermatological (e.g. dermatitis); and psychological, (e.g. depression).

Many studies have established that mortality increases with higher weight levels. (Bender, Peters, Rogers, Seidell) In one such study morbidly obese men age 25 to 34 had a 12-fold increase in the risk of mortality over their non-obese peers. The risk was 6-fold in the 35 to 44 year old group and declined steadily. Cardiovascular disease was the primary cause a death. (Drenick)

All too often, discussions about obesity seem to focus on normal weight persons at risk for becoming obese or persons with just borderline obesity. The population which is overweight has not changed all that much over the last 30 years. The population which is considered obese and especially the population with morbid obesity (approximately 100 pounds or more over ideal weight) is where the greatest growth is occurring. While the population with a BMI over 30 has doubled in the last twenty years, the population with a BMI of over 40 has tripled and the population with a BMI of over 50 has increased 400%. Obesity-driven mortality, morbidity, health care costs and health care utilization are driven to a large extent by persons with morbid obesity.

For these reasons, obesity has become recognized as a major, perhaps the major, pubic health problem of the 21st Century. The federal government has repeatedly pointed to the enormous human suffering, adverse health effects, and effect on health care costs and utilization from obesity. Examples are Healthy People 2010, Dietary Guidelines for Americans and the Surgeon General’s Call to Action 2001. These profound concerns have led Secretary of Health and Human Services (HHS), Tommy Thompson, to require the major components in HHS develop plans to combat obesity. The major agencies involved are the Food and Drug Administration (FDA), the National Institutes of Health (NIH), and the Centers for Disease Control and Prevention (CDC).

5. Evaluation of Bariatric Surgery

Since 1991, bariatric surgery studies have received numerous reviews by governmental and non-governmental panels of experts. These include:

2004

2003

2002

2000

1998

1996

1991

We would like to quote some of the conclusions reached by these groups:

United States Preventive Service Task Force (USPSTF)

"There is fair to good evidence to suggest that surgical interventions such as gastric bypass, vertical banded gastroplasty, and adjustable gastric banding can produce substantial weight loss (28kg to > 40kg) in patients with class III obesity. Clinical guidelines developed by the National Heart, Lung, and Blood Institute Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults recommended that these procedures be reserved for patients with class III obesity and for patients with class II obesity who have at least 1 other obesity-related illness. The postoperative mortality rate for these procedures is 0.2%. Other complications include wound infection, re-operation, vitamin deficiency, diarrhea, and hemorrhage. Re-operation may be necessary in up to 25% of patients. Patients should receive a psychological evaluation prior to undergoing these procedures. The long-term health effects of surgery for obesity are not well characterized." (USPSTF)

Agency for Healthcare Quality and Research, Department of Health and Human Services, Diagnosis and Treatment of Obesity in the Elderly, January 15, 2004.

"In the younger population (under age 65), surgery can promote large degrees of weight loss among those with extreme obesity. Its complications are infrequent, but can be severe, including death (p.vi)....Surgical intervention, among the very obese, can produce substantial weight loss and marked improvement in blood pressure, lipid profile, glycemic control (including reversal of diabetes), and quality of life measures. Surgical data, though, are of lesser quality than counseling studies, and adverse events, while uncommon, can be serious, including death.'(p.14)

NIH Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. 1999

RECOMMENDATION: SURGICAL INTERVENTION IS AN OPTION FOR CAREFULLY SELECTED PATIENTS WITH CLINICALLY SEVERE OBESITY (A BMI >40 OR >35 WITH COMORBID CONDITIONS) WHEN LESS INVASIVE METHODS OF WEIGHT LOSS HAVE FAILED AND THE PATIENT IS AT A HIGH RISK FOR OBESITY-ASSOCIATED MORBIDITY AND MORTALITY.

"Weight Loss Surgery: Weight loss surgery is one option for weight reduction in a limited number of patients with clinically severe obesity, i.e. BMIs > 40 or >35 with comorbid conditions. Weight loss surgery should be reserved for patients in whom efforts at medical therapy have failed and who are suffering from the complications of extreme obesity. Gastrointestinal surgery (gastric restriction, vertical gastric banding or gastric bypass [Roux-en-Y]) is an intervention weight loss option for motivated subjects with acceptable operative risks. An integrated program must be in place to provide guidance on diet, physical activity, and behavioral and social support both prior to and after surgery."(p.xx-xxi)

NIH Consensus Development Conference March 25-27, 1991, Gastrointestinal Surgery for Severe Obesity Summary:

The National Institutes of Health Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity brought together surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals as well as the public to address: the nonsurgical treatment options for severe obesity, the surgical treatments for severe obesity and the criteria for selection, the efficacy and risks of surgical treatments for severe obesity, and the need for future research on and epidemiological evaluation of these therapies. Following 2 days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement. Among their findings, the panel recommended that (1) patients seeking therapy for severe obesity for the first time should be considered for treatment in a nonsurgical program with integrated components of a dietary regimen, appropriate exercise, and behavioral modification and support, (2) gastric restrictive or bypass procedures could be considered for well-informed and motivated patients with acceptable operative risks, (3) patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise, (4) the operation be performed by a surgeon substantially experienced with the appropriate procedures and working in a clinical setting with adequate support for all aspects of management and assessment, and (5) lifelong medical surveillance after surgical therapy is a necessity."

The American Medical Association "Roadmaps" publications on the treatment of obesity. The AMA publication on surgery for obesity states:

"What are the expected benefits and risks from surgery?
Mean weight loss following VBG (vertical banded gastroplasty) and RYGB (Roux-en-Y gastric bypass) is approximately 30% to 35% of the preoperative weight, respectively, and is reached between 12 and 18 months post operatively. The RYBG is currently the preferred method because weight loss is superior to that typically achieved after other gastric restrictive operations. Weight loss following malabsorptive procedures is reported to be greater than with gastric restrictive procedures but with a greater incidence of metabolic complications.

Multiple studies have demonstrated complete resolutions or improvement of obesity-related comorbid conditions following surgery-most notably, Type 2-diabetes, obstructive sleep apnea, obesity hypoventilation, gastroesophageal reflux disease (GERD), and peripheral edema. Often, medications for diabetes and cardiovascular disease may be reduced or eliminated entirely. Although there is an immediate reduction in the incidence of hypertension, these benefits may diminish over time.

Risks from the operation are related to both the complications of any gastrointestinal procedures in a high-risk population and the complications specific to the bariatric procedure. Data from the International Bariatric Surgery Registry - a registry of more than 20,000 patients ­ reveals a 30-day mortality rate of 0.3%.

The most common complications tend to be related to the underlying obesity and include respiratory complications, venous thromboembolic events, and wound infections. The most serious complication following bariatric surgery is peritonitis from an anastomotic or staple-line leak.

Post-operative complications. Following hospital discharge, the most common surgical complications include stomal stenosis or marginal ulcers (occurring in 5% to 15% of patients) that present with prolonged nausea and vomiting after eating or inability to advance the diet to solid foods. These complications are typically treated with endoscopic balloon dilatation and acid suppression therapy, respectively. Abdominal and incisional hernias (occurring in approximately 15% to 20% of patients with the open incision) necessitate an operative repair, the timing of which is determined by symptoms and stabilization of body weight.

Long-term post-surgical complications. A surgically induced effect of the RYGB procedure is the dumping syndrome. This syndrome represents a constellation of vasomotor and neuroendocrine events that collectively serve as negative re-enforcers to the consumption of simple sugars. The syndrome, which is initiated by rapid emptying of food into the jejunum, results in a variety of unpleasant and distressing symptoms, including nausea, abdominal cramping, diarrhea, lightheadeness, tachycardia, flushing, and syncope. Although the symptom-induced intolerance to sugar-containing foods is a powerful incentive to dietary changes after surgery, the dumping syndrome often disappears within 12 to 18 months in many patients." (AMA)

The Blue Cross Blue Shield Association TEC:

"Gastric bypass with Roux-en-Y anastomosis has been considered the bariatric surgery of choice in the United States, and this is supported by a substantial body of literature. Roux-en-Y gastric bypass achieves greater weight loss and can be performed with low rates of morbidity and mortality.

There is sufficient evidence to conclude that surgery improves health outcomes for patients with morbid obesity as compared to non-surgical treatment. The best evidence is from the Swedish Obese Subjects (SOS) intervention trial, which has reported to date of several hundred patients in each group with up to 8 years of follow-up. This trial shows that surgery results in large amounts of weight loss compared with usual care (16% decrease in total body weight at 6 years, versus an increase of 0.8% for usual care.)"

The SOS intervention trial also shows that some comorbid conditions and quality of life are improved following surgery. The most compelling evidence for an improvement in comorbid conditions exists for diabetes. The SOS trial reported a large reduction in diabetes over a 5.5 year mean follow-up for the surgery group (3.6% vs. 18.5%, p=0.0001). Decrease in proportion of patients with hypertension was observed 2 years after surgery, but was not sustained with longer follow-up. The SOS trial also found 56% and 48% decreases in the number of patients meeting the criteria for depression and anxiety for surgery. The results of 1 randomized controlled trial (n=60) and 11 single-arm studies corroborate the findings of the SOS study." (Blue)

Most of these reviews, although following different methodologies, seem to center on a consensus that surgically induced weight loss remarkably improves comorbid conditions and that both laparoscopic gastric bypass and laparoscopic gastric banding are safe and effective procedures similar to open procedures but with less risk of complications.

The recently published meta-analysis published in the Journal of the American Medical Association makes a powerful case for extraordinary power of this surgery to resolve not only excess weight but several long-term chronic diseases. This meta-analysis reviewed over 130 studies that included more than 22,000 patients. The analysis showed that type 2 diabetes was eliminated in 76.8% of patients and improved in 86%. Hypertension was eliminated in 61.7% of patients and resolved or improved in 78.5%. Obstructive sleep apnea was eliminated in 85.7% of patients and high cholesterol or hyperlipidemia was decreased in 70% of patients. Mortality was similar for other major surgeries: .1% for purely restrictive procedures, 0.5% for gastric bypass procedures and 1.1 % for biliopancreatic diversion or duodenal switch procedures. (Buchwald)

A recent study in Canada comparing over 1,000 patients who had gastric bypass to over 5,000 persons with morbid obesity who did not, found that bariatric surgery reduces by 89% the relative risk of death for people who underwent the surgery and a 5.4% reduction in absolute mortality between the operated and non-operated patients. Thus, this paper demonstrated a real effect of bariatric surgery in reducing mortality in an extremely high-risk population. Regarding the comorbid conditions, only 4.7% of the people who underwent the surgery had cardiovascular disease while nearly 6 times as many, 26.7%, developed cardiovascular disease. (Christou)

6. Applicability of Bariatric Surgery in the Elderly Population

As stated above, the overwhelming application of bariatric surgery is likely to be in the Medicare non-elderly disabled population. A few studies indicate it could be very useful in the elderly. One study performed laparoscopic adjustable gastric banding in 18 patients over age 60 and found BMIs dropped from 44.2 to 30.5 and diabetes was resolved in 71% of the patients, hypertension in 33% and sleep apnea in 100%. (Abu-Abeid) Other studies showed similar results. (Sugarman, Murr) There is no evidence that bariatric surgery in elderly patients would be unsafe or ineffective.

7. Recommendations for Medicare Policy

Given the evidence of the safety and effectiveness of bariatric surgery, AOA believes the current Coverage Policy Manual section does not need to be changed but should be interpreted to include the procedures discussed today by the committee. The panel should recommend that CMS and NIH participate in developing a research program for the elderly obese population, encompassing both better understanding of the disease process. Likewise, the panel should recognize that this is a dynamic field which new technologies and procedures under development. CMS must avoid freezing the field by taking a snapshot in time. The panel needs to appreciate that bariatric surgery is one of the most powerful interventions in medicine. If this was a therapy for cancer or heart disease or HIV/AIDs, we would be meeting to address the problems with the fact that only .04% of eligible patients are receiving it. There are important issues to be dealt with. It appears that higher rates of mortality are associated with surgeon inexperience and/or low-volume hospitals.(Nguyen) Programs to raise hospital credentialing, create centers of excellence, increasing fellowships and other training are important and are being pursued by the leadership in the American Society for Bariatric Surgery. We recommend that the Panel urge the Centers for Medicare and Medicaid Services to vigorously support these and similar efforts.

8. References

• Allison,D, et al, The heritability of body mass index among an international sample of monozygotic twins reared apart. Int.J.Obes 20,;501-506 See also, Stunkard AJ, Harris, JR, Pedersen NL et al. The body-mass index of twins who have been reared apart N. Engl. J. Med. 322;1483-1487. and Stunkard, SJ, Foch TT, et al, A twin study of human obesity. JAMA 256;51-54 (1986).
• Al-Azemi M, Omu FE, Omu AE, The effect of obesity on the outcome of infertility management in women with polycystic ovary syndrome. Arch Gynecol Obstet. 2003 Aug. 29.
• American Medical Association, Roadmaps for Clinical Practice, Assessment and Management of Adult Obesity: A Primer for Physicians Surgical Management 7.November, 2003.
• Bender R, Jockel KH, Trautner C, et al. Effect of age on excess mortality in obesity. JAMA, 1999, Apr. 28;281(16):1498-504.
• Allison,D, et al, The heritability of body mass index among an international sample of monozygotic twins reared apart. Int.J.Obes 20,;501-506 See also, Stunkard AJ, Harris, JR, Pedersen NL et al. The body-mass index of twins who have been reared apart N. Engl. J. Med. 322;1483-1487. and Stunkard, SJ, Foch TT, et al, A twin study of human obesity. JAMA 256;51-54 (1986).
• Blue Cross Blue Shield Association Tech Assessment, TEC Bulletin June 3, 2003.
• Bouchard C, The Genetics of Human Obesity;recent progress. Bull Mem Acad R Med Belg 2001;156(10-12)455-462.
• Buchwald H, Braunwald E., Avidor Y., Jensen MD, Poires, W., Fahrbach K, Schoelles, K, Surgery Decreases Long-Term Mortality in Morbidly Obese Patients, JAMA, October 13, 2004.
• Cedergren MI, Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol. 2004 Feb;103(2):219-224.
• Christou, NV, Sampalis JS, Lieberman M, et al. Surgery decreases long-term mortality in morbidly obese patients. Canadian Newswire April 16, 2004. Paper in publication, Annals of Surgery Sep/Oct 2004.
• Cummings DE, Weigle DS, Frayo RS, et al. Plasma grehlin levels after diet induced weight loss or gastric bypass surgery. N. Engl J Med 2002;346:1623-30.
• Drenick EJ, Bale GS, Seltzer F, et al. Excessive mortality and causes of death in morbidly obese men. JAMA, 1980 Feb.1;243(5):443-5.
• Friedman JM, A War on Obesity, Not the Obese, Science 7 Feb 2003, 299:856-858.
• Koop W, The incidence of sexual abuse in women with eating disorders. Psychother Psychosom Med Psychol 1994 May;44(5):159-62.
• Maher E. Health-related quality of life of severely obese children and adolescents Child Care Health Dev. 2004 Jan;30(1):94-5.
• Murr, MM, Siadati, MR, Sarr, MG, Results of Bariatric Surgery for Morbid Obesity in Patients Older than 50 Years. Obesity Surery 5: 399-402.
• Nguyen NT, Paya M, Stevens M, Mavadadi S, Zainabadi S, Wilson SE, The Relationship between Hospital Volume and Outcome in Bariatric Surgery at Academic Medical Centers, Ann. Surg 2004;240:586-594.
• Peters A, Barendregt JJ, Willekens F, et al. Obesity in adulthood and its consequences for life expectancy: a life-table analysis. Ann Intern Med. 2003 Jan 7;138(1):24-32.
• Perusse L, Chagnon YC, Bouchard C. Etiology of massive obesity: role of genetic factors. World J Surg 1998 Sep;22(9):907-12.
• Roberts SJ, The sequel of childhood sexual abuse: a primary care focus for adult female survivors. Nurse Pract. 1996 Dec;(21)(12 PT 1):42, 45, 49-52.
• Rogers RD, Hummer RA, Krueger PM. The effect of obesity on overall, circulatory disease and diabetes specific mortality. J. Biosoc Sci. 2003 Jan;35(1):107-29.
• Rosenberg TJ, Garers S, Chavkin W, Chiasson MA, Prepregnancy weight and adverse perinatal outcomes in an ethnically diverse population. Obstet Gynecol 2003 Nov;102(5Pt1): 1022-7.
• Seidell JC, Verschuren WM, van Leer RM et al. Overweight, underweight, and mortality. A prospective study of 48,287 men and women. Arch Intern Med. 1996 May 13; 156(9):958-63.
• Sugerman, HJ, DeMaria EJ, Kellum JM, et al, Effects of Bariatric Surgery in Older Patients, Ann Surg 2004;240:243-247.
• Thirbly RD, Randall J. A genetic "obesity risk index" for patients with morbid obesity. Abes Surg 2002 Feb;12(1):25-9.
• USPSTF, Screening for Obesity in Adults: Recommendations and Rationale, Annals of Internal Medicine, Dec. 2003, 139;11:930-932.
• Williamson DF, Thompson TJ, Anda RF et al, Body weight and obesity in adults and self-reported abuse in childhood. Int J Obes Relat Metab Disord. 2002 Aug;(26)(8):1075-82.