Severe Obesity: A Growing Health Concern A.S.P.E.N. Should Not Ignore

Although malnutrition is more commonly associated with starvation, cachexia, or undernutrition, it is more broadly denned than that. The Illustrated Stedman's Medical Dictionary defines malnutrition as "faulty nutrition resulting from malassimilation, poor diet, or overfeeding."1 Even A.S.P.E.N.'s Standards define malnutrition as "any disorder of nutrition status including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or overnutrition."2 It has recently been said that there are as many overweight people in this world as underweight-approximately 1.7 billion each. A.S.P.E.N.'s mission, as stated in its strategic initiative, is to be "the preeminent, interdisciplinary nutrition society dedicated to patient-centered, clinical practice worldwide through advocacy, education, and research in specialized nutrition support."3 Therefore, if obesity is a form of malnutrition and nutrition support is the treatment for malnutrition, and A.S.P.E.N. is to be the preeminent society dedicated to nutrition support, then A.S.P.E.N. must weave obesity and obesity treatment into its fabric.

The Growing Epidemic of Obesity

Despite the popularity of low-fat and fat-free foods, health clubs, home exercise equipment, and nationwide commercial weight loss programs, the incidence of severe obesity in the Western world continues to increase.4 An estimated 97 million adults in the United States are obese, making it one of the fattest nations in the world.5 According to the National Health and Nutrition Examination survey (NHANES III), the prevalence of obesity in the United States has increased from 25% in the 1970s to >35% in 1991, and it continues to rise.6,7 Alarmingly, the prevalence of childhood obesity parallels that of adult obesity. Even more alarming is that fact that obesity in not just an American problem but a worldwide concern. It has been estimated that 1.7 billion people worldwide are overweight.8

Obesity is far more significant than just a social or cosmetic concern. It is associated with an extensive variety of comorbid conditions (Table I) and is estimated to result in >300,000 deaths per year, making it the second leading cause of preventable death in the United States behind smoking.9 Worldwide, it has been estimated to cause over 2.5 million deaths yearly.8 In the United States, these conditions cost over $100 billion of the health care budget.10 With insurmountable evidence of the morbidity and mortality associated with severe obesity and the remarkable rate at which the epidemic is growing, significant interest in its treatment and prevention is not surprising.11

Overview of Weight-Loss Strategies

Nonsurgical strategies for treating extreme obesity consistently fail to achieve meaningful or sustainable weight loss.12 Despite the introduction of structured weight-loss programs both commercial and medical and some new pharmacologie options, the amount of weight loss is either insufficient or there is a high likelihood of relapse. Drugs that decrease or prevent fat absorption (orlistat) or serotonergic drugs that decrease appetite (sibutramine hydrochloride monohydrate) have shown only modest results against placebos in controlled clinical trials and are associated with high rates of recidivism upon discontinuation of the agents.13,14 As with other chronic conditions, only permanent interventions are likely to yield long-term results in treating obesity. This concept underscores the prevalent philosophy behind surgical treatment of obesity.

Surgical strategies for weight loss are more successful in the long term. The field of weight-loss surgery, also referred to as "bariatric surgery," has evolved substantially since the introduction of the intestinal bypass procedure in the 1950s. Operative procedures have taken various forms but generally are safer and more efficacious than their predecessors. In addition to technical advancements, improvements in anesthetic delivery, preoperative medical evaluation and preparation, and preoperative monitoring have dramatically reduced postoperative morbidity and mortality. The development of integrated multidisciplinary team approaches to preoperative evaluation and education and postoperative follow-up have greatly improved the long-term success and quality of life of surgically treated obese patients.

These advances in the field of bariatric surgery, coupled with the successful (and public) experiences of celebrities have led to a dramatic increase in the number of operative procedures performed yearly. In the last decade, the number of surgeries has increased an amazing 644%, making bariatric surgery the fastest growing field in all of medicine.15 It has been estimated that approximately 140,000 bariatric surgery procedures were performed in the United States last year, compared with a mere 10,000-15,000 per year in the early 1990s.15 At many hospitals, bariatric operations are now the most common procedures performed at those institutions.

However, despite its current popularity and successes, surgery has limited applicability. For most obese patients seeking treatment, surgery is not (nor should it be) the initial consideration. Guidelines for patient eligibility are based on the 1991 National Institutes of Health Consensus Statement.16 To be considered for surgery, a prospective candidate must be morbidly obese (body mass index [BMI] =40 kg/m^sup 2^). However, a patient whose BMI is a35 kg/m^sup 2^ can be considered if he/she also suffers from any of the serious obesity-related conditions such as diabetes or hypertension. Even for patients who satisfy the weight requirement, nonsurgical weight loss, including commercial diet programs, self-monitored diets, exercise, and even medications should always be considered first.

Surgical weight loss procedures can be described best by their mechanism(s) of action (Table II). They are designed either to cause nutrient malabsorption or restrict food intake. Some procedures are a combination of both. Currently, there is no universally accepted "best" procedure. The procedures undertaken vary by surgeon preference and geographic differences. For example, in the United States, restrictive procedures, with or without some degree of malabsorption (rouxen-Y gastric bypass [GBP]), are generally the operations of choice for most patients. In Europe, Australia, and Latin America, purely restrictive procedures (laparoscopic adjustable gastric bands [LAGB] and variations thereof) are performed more commonly (although this trend may be changing).

Bariatric Operations: Restricting Nutrient Absorption

Intestinal bypass. Intestinal bypasses, first introduced in the 1950s, were the first true abdominal surgical weight loss operations. These procedures were developed after observations that patients who had shortbowel syndrome lost weight due to inadequate nutrient absorption. The procedures quickly became popular, and different variations were performed (Fig. 1). During the 1960s and 1970s, tens of thousands of procedures were performed. Weight loss was related directly to the length of small intestine bypassed, which was approximately 90%. Patients could eat without restriction, but most complained of frequent foul-smelling bowel movements. Operative mortality was reported to be <3%, which was considered low at the time.17 Perioperative complications were frequent (about 30%), but most were minor in severity.17 Unfortunately, many patients experienced late complications, some of which were very serious.18 More serious complications included liver dysfunction, malnutrition, renal disease, and renal-stone formation. Bacterial overgrowth in the bypassed segment of intestine (the blind limb) was considered to be the cause of complications such as arthralgias and myalgias, which could not be attributed directly to malabsorption. Potentially life-threatening hepatic disease was reported in about 29% of patients who were followed long-term, and the disease progressed to cirrhosis in about 7%.18 Some patients ultimately required liver transplantation for intestinal bypass-related cirrhosis.19 For these reasons, intestinal bypasses are now rarely performed.

Biliopancreatic diversion. In 1976, Scopinaro and colleagues20 developed a variation of the intestinal bypass known as the biliopancreatic diversion (BPD). As depicted in Fig. 2a, the operation involves a partial gastrectomy, with the gastric remnant anastomosed to the distal ileum. The proximal ileum is anastomosed to the terminal ileum, creating a "common" channel approximately 50-100 cm from the ileocecal valve. It is the only "normal" absorptive region of the intestinal tract where food mixes with the digestive enzymes. The partial gastrectomy is believed to initiate the weight loss (nutrient restriction); the intestinal bypassing is believed to maintain the weight loss long-term. Scopinaro and colleagues21 have published results reporting 72% excess weight loss in patients followed up to 18 years. Although the BPD is similar to the intestinal bypass, there is no blind limb, thereby eliminating the detrimental consequences of bacterial overgrowth.

The weight loss achieved by the BPD is considered superior to that of the solely nutrient restrictive procedures, but this loss is accomplished at greater risk. The most serious potential complications include protein malnutrition and severe vitamin deficiencies. Bone demineralization has been reported in up to 15% of patients.21 Ulceration of the ileum at the gastric connection is another common complication due to gastric acid exposure of the ileum.

Duodenal switch. In 1992, Marceau and associates22 described a variant of the BPD, the BPD with duodenal switch, which substantially reduces the risk of ileal ulceration. The BPD with duodenal switch involves a sleeve gastrectomy of the greater curvature of the stomach instead of removal of the distal fundus and antrum (Fig. 2b). The antrum, pylorus, and first portion of the duodenum remain in continuity with the alimentary stream, thereby reducing the incidence of stomal ulceration and the dumping syndrome. Nutrition and metabolic complications are similar to that seen with the standard BPD.

Bariatric Operations: Restricting Nutrient Intake

GBP. Gastric partitioning, commonly referred to as "gastric stapling," was developed to mimic the experience seen with subtotal gastric resections. Most patients lost weight after gastrectomy and were not capable of eating large (or even average-sized) meals. According to these observations, Mason and Ito23 performed the first GBPs for weight loss in 1967. The GBP procedure (Fig. 3) partitions the stomach into 2 chambers: a 15- to 30-mL pouch and the larger excluded fundus and antrum. Both chambers have separate lumens that do not communicate with each other. Although over the years there have been many modifications to the GBP, the tiny pouch is attached directly to the jejunum via a narrow anastomosis. The remainder of the stomach and the duodenum are excluded from contact with the nutrient stream. Weight loss is due to the extremely small pouch capacity, which causes early satiety. Furthermore, the narrow anastomosis to the small intestine delays pouch emptying, thereby maintaining the feeling of prolonged satiety. GBP "forces" patients to only consume small meals and they usually do not snack between meals. Daily caloric intake for the first year after surgery is estimated to be fewer than 900 kcal/d. Despite this massive reduction in nutrient intake, deficiencies (except for vitamins and minerals) are rare, and lean body mass is relatively spared.24

Other mechanisms such as alterations in dietary choices may also play a role in the weight loss achieved with the GBP. Dumping syndrome, a condition seen when hyperosmolar fluids rapidly enter the small intestine, dramatically reduces sugar intake. In addition, many patients cannot tolerate fatty or greasy foods.

Recently, a new peptide hormone, secreted by the stomach and named ghrelin, was discovered and is believed to promote appetite. Ghrelin secretion has been shown to increase in the setting of fasting or weight loss and is thought to enhance appetite.25 It has been suggested that this response is responsible for the recidivism seen with dieting. Recent investigations in patients after GBP have found that despite their weight loss, ghrelin levels have been shown to remain low,25 suggesting another mechanism by which the GBP results in sustained weight loss.

With >20 years of experience, the GBP currently is the most common operative procedure performed in the United States for the treatment of morbid obesity and the procedure against which all others are judged. The operative mortality ranges from 0.3%-1.6%.26'27 Perioperative complications occur in about 10% of patients, Serious complications include thromboembolic events, gastrointestinal leak, and hemorrhage. Wound problems were significantly more common in the open surgery but have been dramatically reduced with the introduction of laparoscopic surgery. Long-term complications include anemia and vitamin and mineral deficiencies. With appropriate patient selection, education, and postsurgical care, 75%-80% of patients lose >50% of their excess weight.28

Gastroplasty. In the mid-1970s, stomach stapling without bypass was introduced. These procedures, called gastroplasties, used the formation of a small gastric pouch while eliminating the intestinal connection. The small gastric pouch was constructed by staple partitioning or division of the stomach and drained into the main body of the stomach through a small gastric channel. The narrow channel functioned similarly to the anastomosis of the GBP by delaying pouch emptying, thereby causing satiety after consuming a small meal. One of the more popular versions, the vertical banded gastroplasty (VBG), was initially described in 1982 by Mason.29 It consisted of a vertically oriented 30-mL pouch that drained through a narrow (1 cm) gastric channel into the gastric fundus (Fig. 4). The pouch outlet was reinforced with a polypropylene band to prevent it from stretching. The VBG has a lower perioperative complication rate than the GBP, and because there is no malabsorption, vitamin deficiencies and anemia are uncommon. However, it has been shown to be inferior to the GBP in many respects. Studies comparing the efficacy of the VBG and the GBP have found that the GBP produces better weight loss.30,31 This may be due to the fact that patients undergoing VBG are still able to tolerate sweets and high-calorie liquids, whereas patients who have undergone GBP do not tolerate those same foods because they experience dumping syndrome. Dumping syndrome seen after GBP functions as a physiologic deterrent to eating foods that are high in sugar and fat. The VBG has proven over time to be inferior in other aspects as well, including a greater incidence of stapleline breakdown, a risk of band erosion, and a significant number of patients experiencing various degrees of food intolerance and vomiting.

Gastric banding. Beginning in the 1970s, gastric banding was offered as an alternative to gastric stapling. The procedures placed tight plastic bands around the upper stomach, creating small proximal pouches. The original concept was developed in Europe and Scandinavia, and the early material used to create the band was similar to that used for vascular grafts. Gastric banding procedures are functionally similar to the VBG. Unfortunately, the initial experience with banding was poor, and significant complications related to the band were seen. These included band migration, band erosion, or pouch dilatation.32 Migration and erosion led to significant vomiting. Pouch dilatation or dietary noncompliance led to weight-loss failure.

In the late 1980s, gastric banding was rejuvenated by Kuzmak33 with the introduction of an adjustable silicone gastric band that had a hollow, expandable collar connected to a saline reservoir by a thin tube. The reservoir was placed below the skin on the abdominal wall. The band could be "tightened" by injection of saline into the reservoir or "loosened" by withdrawal of saline. In 1993, the next major breakthrough in band technology occurred when a modified version of the adjustable gastric band was inserted laparoscopically (Fig. 5). First reported by Belachew and associates,34 the laparoscopic adjustable gastric bypass (LAGB) has become popular in Europe, Australia, the Middle East, Mexico, and other areas outside of the United States. The band is positioned on the upper stomach, just below the gastroesophageal junction, where it limits food intake by constricting the stomach to a shape similar to an hourglass. The upper chamber is a 15- to 20-mL gastric pouch. Similar to the VBG, the LAGB is a purely restrictive operation that causes no malabsorption, thereby dramatically reducing the concern for anemia, vitamin deficiencies, or dumping syndrome. Also similar to the VBG, LAGB mandates a substantial degree of compliance from the patient for success. Studies have documented its safety, with weight-loss results similar to those seen with the VBG.35,36 Given its beneficial characteristics, the LAGB has essentially rendered the VBG obsolete.

The most common complications reported leading to reoperation or removal are slippage, band erosion, or pouch dilatation. Pouch dilatation with or without esophageal dilatation may be related to overfilling of the band. Currently, the risk of erosion is about 1%-2% and slippage is 2%-4%, and the mortality is about 0.05%.37 Overall, there is a 10% complication rate, but most of the complications are minor and related to the reservoir.37 Weight loss is reported to vary from 40%-60% of excess.37

Laparoscopic Bariatric Surgery

The ability to safely perform major abdominal surgery such as bariatric surgery through several small incisions instead of 1 large incision has been a major breakthrough in the field. The major benefits of laparoscopy are related to the wound(s) in terms of infections, hernias, and cosmesis. The risk of wound complications such as hernia or wound infection is reduced from almost 30% with open GBP to <1% with the laparoscopic approach.38 The other well-described perioperative benefits of laparoscopic surgery (eg, less pain, shorter hospitalization, better wound healing, improved cosmesis, and more rapid convalescence) are particularly beneficial to this patient population. In a randomized trial of laparoscopic vs open GBP, Nguyen et al40 reported that extremely obese patients undergoing laparoscopic GBP surgery demonstrated improved pulmonary function compared with patients having open GBP surgery. Currently, all of the procedures described in this article can be and are being performed laparoscopically. Although for some of the procedures the learning curve is steep, numerous recent publications of large laparoscopic series have reported similar complication rates (except for wound complications) to the open procedures.39,41,42

It is estimated that approximately 50% of all bariatric procedures currently are performed laparoscopically (personal communication, American Society for Bariatric Surgery). This percentage should increase dramatically in the near future as more surgeons obtain the requisite training.

Implantable Gastric Stimulation: The Next Horizon in Bariatric Surgery?

All of the currently performed operations for weight loss alter the anatomy and function of the gastrointestinal tract and have the potential for significant operative risk or long-term consequences. This has fueled the recent interest in developing less-invasive and safer technologies, many of which rely on new or novel mechanisms of action to achieve weight loss. One such new technology is the implantable gastric stimulator (IGS). This involves electrical stimulation of the stomach with a pacemaker-like electrical pulse generator. The IGS consists of bipolar leads that are laparoscopically implanted within the stomach wall (Fig. 6). The leads are connected to the electrical pulse generator that is placed subcutaneously in the abdominal wall. The stomach, similar to the heart, has a native pacemaker located along the greater curvature. This electrical activity is responsible for gastric tone, motility, and other functions.43 The concept of "pacing" or altering the intrinsic electrical activity of the stomach first originated in the 1960s and 1970s. Application in humans to affect appetite was proposed initially by Cigaina44 in Italy.

The IGS is being investigated in both Europe and the United States for obese patients who meet standard requirements for surgery and has been shown in clinical trials to be safe.45,46 However, the degree of success for inducing weight loss remains under investigation. Further research is being performed to elucidate the precise mechanism of action, which remains unclear. The original hypothesis was that retrograde pacing induced weight loss by decreasing gastric motility and emptying, but additional mechanisms of action have been supported by ongoing investigations. These include inducing fundic expansion, vagal nerve stimulation, or alterations in gut hormone activity. Because of its relatively good safety profile, the IGS is an exciting modality that warrants further investigation of its long-term efficacy.

Long-Term Considerations

Despite achieving excellent weight loss results after surgery, patients who undergo GBP may present with various problems that can be divided into nutritional and gastrointestinal categories (Table III). Nutritional concerns include malnutrition, dehydration, vitamin deficiencies, and weight-loss failure. The gastrointestinal issues are related directly to the abdominal viscera.

When Perception is Not Reality

Ironically, despite the dramatic increase in the number of bariatric procedures performed yearly and the significant technical advances in the field, bariatric surgery is coming under increasing pressure via negative coverage from the media. There has been unprecedented coverage of adverse outcomes, the like of which are not seen often with mainstream medical interventions. The result has been the perception that the surgeries are too risky, the patients ill advised, the surgeons inadequately trained, and the weight loss outcomes only temporary. However, these perceptions are not reality and are refuted by an abundance of published literature. These reports document that bariatric surgery provides significant and sustainable weight loss. The result of this weight loss is improvement in health and well-being, decreased mortality, and longer life-expectancy. Additionally, the surgery is cost-effective and reduces the annual health care costs for patients who undergo surgery.

Significant and sustainable weight loss. The current group of bariatric procedures has been shown to achieve meaningful and sustainable weight loss. All of the current procedures for weight loss can achieve losses of approximately 40%-80% of excess weight in the short run. Weight loss after GBP is reported to be about 60% of excess weight within the first 2 years and remains stable over time.26'30 Similar findings have been reported with the LAGB.47 Weight loss associated with the very long limb GBP and biliopancreatic bypass often exceeds this amount.21,48 Buchwald et al49 conducted a meta-analysis of published reports of bariatric surgery from the world literature. One hundred thirty-six studies were included, which involved over 22,000 patients. The weight loss achieved by all of the currently popular procedures ranged from 47%70% of excess weight. More significant than the amount of weight loss is the ability to sustain the loss over time. Pories et al26 demonstrated that after 15-year follow-up, his GBP patients maintained a mean excess weight loss of over 49%. Weight-loss sustainability has also been reported by Scopinaro et al21,50 for the BPD and by O'Brien et al47 for the LAGB.

Improved health and well-being. Although the excellent weight loss and its resultant cosmetic benefits are not insignificant, the primary goal of the surgery is to induce sufficient weight loss to ameliorate associated medical problems such as diabetes, heart disease, and respiratory abnormalities. This has been validated in a number of publications. One of the most unique characteristics of bariatric surgery is the ability (with successful weight loss) to improve or even cure such a wide range of health afflictions and diseases with the 1 intervention (Table IV). The Buchwald et al49 metaanalysis and other reports such as that from Schauer et al51 demonstrate >80% improvement or resolution for conditions such as diabetes, hypertension, gastroesophageal reflux, hyperlipidemia, obstructive sleep apnea, etc. It is not too bold to state that there is no other treatment or surgical procedure that can make this claim. There is also a wealth of published studies that have reported the resolution of specific obesityassociated conditions and diseases with successful weight-loss surgery. For adult-onset diabetes mellitus, the seminal paper is by Pories et al.26 Among >500 patients, 82.9% who had preoperative non-insulin-dependent diabetes and 98.7% who had glucose impairment maintained normal levels of plasma glucose, glycosylated hemoglobin, and insulin postoperatively. There are many other papers showing resolution of adult-onset diabetes, including those by Herbst et al,52 Schauer et al,53 and Dixon el al.54 Gleysteen et al55 reported decreased serum triglyc ide levels and improved lipid profiles in 42 morbidly obese patients 1 year after surgery. Alpert and coworkers56 studied ventricular function using echocardiography in morbidly obese patients both preoperatively and after weight loss. They reported significant improvements in left ventricular ejection fraction and lesser improvements in chamber size and ventricular-wall thickness. They also noted improvement in blood pressure. The successful treatment of hypertension also was reported by Foley and coworkers.

Pulmonary manifestations of morbid obesity include the obesity-hypoventilation syndrome and the sleep apnea syndrome. Both problems are life threatening and can occur together (Pickwickian syndrome). Sugerman and coworkers58 found an incidence of at least 1 of these disorders in 14% of their patients. After GBP (mean loss of 45% of excess weight), improvement or cure was documented in most of the patients. Improvements in arterial blood oxygenation, carbon dioxide retention, lung volumes, frequency of episodes of sleep apnea, and resolution of polycythemia vera also were described.

In addition to the improvements in physical health, and in part secondary to it, Boan et al59 demonstrated improvements in quality of life using the SF-36 questionnaire.

Bariatric surgery decreases patient mortality. The morbidly obese patient population is well recognized in the surgical and anesthesia fields to be classified as high risk. This is due to both the associated health conditions and the physical difficulties of operating and anesthetizing the extremely obese. Decades ago, bariatric surgery carried significant perioperative mortality. Most of these deaths were due to intraabdominal sepsis or from thromboembolic events. However, currently, with modern advances in operative techniques (minimally invasive surgery, for example), instrumentation, monitoring technologies, and thromboprophylaxis, the mortality of these procedures has been reduced to incidences remarkably below many other abdominal procedures commonly performed on nonmorbidly obese patients. Buchwald et al,49 in the previously described meta-analysis, found the incidence of early postoperative death to range from 0.1% for gastric banding to 1.1% for the BPDs.

Given the large number of bariatric procedures currently being performed,15 a 0.1%-1.1% mortality rate still represents a significant number of deaths. If 150,000 procedures will be performed this year, at a 0.5% mortality, 7500 patients will die. However, several studies comparing the incidence of death for morbidly obese patients having surgery and those that did not have surgery have found that those not having surgery were more likely to succumb from their obesity than those undergoing surgery. MacDonald et al60 found that the incidence of death was 4.5 times higher for those patients "spared the risk of surgery." Flum and Dellinger,61 using the Washington State Comprehensive Hospital Abstract Reporting System database found that the adjusted hazard for death was 33% lower for patients undergoing surgery than those who did not have surgery. Additionally, Christou et al62 found in an observational study comparing surgical patients with gender-matched controls that the mortality was 0.68% for the surgical patients vs 6.17% for the control group.

Bariatric surgery is cost-effective. In the current health care climate, all surgery is costly. For procedures such as the GBP, the cost could be as high as $30,000-$40,000. Yet, if these procedures improve health, the decrease in medication and medical charges may offset the cost of the surgeries. In fact, this too has been demonstrated. Christou et al,62 in the previously described investigation, found that the cost of weight loss surgery at approximately $8813 in 1996 Canadian dollars was statistically significantly less than the cost of health care for the control group ($11,854, p < .001). Furthermore, surgical patients had fewer yearly hospitalizations (2.75 vs 3.17), shorter hospital stays (21 days vs 37 days), and fewer physician office visits (9.6 vs 17), all of which were statistically significant. Lastly, Monk et al63 found that patients dramatically reduced their monthly medication expenditure after surgery from a mean of $317 per month to $135 (p < .01). This resulted in a savings of approximately $2184 per patient per year. Extrapolating this savings for the 150,000 procedures performed this year would yield as cost savings of over $300,000,000. Because there are approximately 12-15 million morbidly obese adult Americans, the cost savings from the decrease in medications would be incredible.

Weight-loss surgery improves quality of life. Because bariatric surgery dramatically reduces patient weight and size, and improves or resolves the majority of obesity-associated ailments, it is no surprise that it would improve quality of life. Most patients report better body image, new confidence, improved energy levels, and better self esteem. This has been confirmed in several studies. For example, Boan et al59 found that morbidly obese patients had significant improvements in weight-related quality of life and physical activity 6 months after GBP surgery. Furthermore, Nguyen et al64 found that SF-36 scores more quickly improved after laparoscopic GBP surgery than after open GBP.

What Can (Should) A.S.P.E.N. Do?

If A.S.P.E.N. is truly the preeminent clinical nutrition organization in the world, it must therefore incorporate obesity in its organizational fabric. In addition, if it is to be considered the authoritative voice for nutrition support, it must include bariatric medical and surgical treatments along with parenteral and enterai nutrition. Because the obese are one of the only remaining segments of the population that seemingly can be ridiculed and discriminated against with impunity, they need and deserve A.S.P.E.N.'s assistance. Despite the dramatic benefits of weight loss, many insurance carriers are restricting patient access to care. Often the rationale for this is irrational. They proclaim that the high costs of care and the high complication rates of surgery mandate that they limit or even deny access. Yet as described above, the data suggest the opposite.

A.S.P.E.N. can and should include obesity and obesity treatment in its strategic planning and in its various activities.

Advocacy. A.S.P.E.N. can partner with other organizations involved with obesity to present a louder voice for influencing governmental policy making. These include the North American Association for the Study of Obesity (NAASO), American Society for Bariatric Surgery (ASBS), American Society for Bariatric Physicians (ASBP), American College of Surgeons (ACS), American Dietetic Association (ADA), Society for American Gastrointestinal Endoscopie Surgeons (SAGES), etc. In addition, A.S.P.E.N. can use its involvement on the Digestive Disease National Coalition to include obesity-related issues on the council's lobbying efforts.

Clinical practice. A.S.P.E.N. can make an effort to recruit bariatricians to join the organization. This can be facilitated by increasing the content of obesity-related topics in the published materials, such as the Clinical Guidelines. Standards can be established for obesity-related subjects such as the postoperative diet and long-term nutrition assessment and management after surgery. Who would be better equipped to provide these standards than A.S.P.E.N.? In addition, A.S.P.E.N. can encourage the membership to establish a bariatric section. Lastly, the organization could attract more obesity-related topics for publication in the journals.

Education. A.S.P.E.N. can better incorporate obesity-related topics in its educational programs such as Clinical Nutrition Week. Currently, the number of obesity-related topics on the program varies from year to year according to the preferences of the Clinical Nutrition Week planning committee and the presiding officers. A.S.P.E.N. can also continue to convince obesity-based organizations to participate in Clinical Nutrition Week, even if these organizations are not currently interested in co-sponsorship.

Research. This past Clinical Nutrition Week was the first time in my 20 years as an A.S.P.E.N. member that I could recall a bariatric surgery research topic winning a scholarship. A.S.P.E.N., to increase its overall research efforts, can consider reaching out to bariatric researchers. There is currently active research underway to uncover the mysteries of overeating and obesity, and to clarify the mechanisms of action of the various treatment options and why some work and others do not. Maybe A.S.P.E.N. can support some of this work. In addition, A.S.P.E.N. can consider selecting an obesity-related topic for a future research workshop.

CONCLUSION

Obesity is currently one of the most common forms of malnutrition and is extremely costly to society. It is growing at an incredible rate. More and more clinicians of all disciplines are involved in the care of these patients. Nutrition support for this disease involves caloric reduction, or malabsorption, and increased energy expenditure. At this juncture, weight-loss surgery is the most effective treatment for the morbidly obese. It is safe, efficacious, cost-effective, and improves health and well-being. A.S.P.E.N., as the world's preeminent clinical nutrition organization, needs to embrace obesity and bariatric treatment, including surgery, as a service to its membership and to the field at large.

"If you want to be a bariatric surgeon, you have to have it in your blood."

-Douglas S. Hess, MD