The Morbid Obesity Dilemma and Governor Christie
March 15, 2013As a physician that specializes in the treatment of morbid and severe obesity, the recent exchange between Governor Chris Christie and Dr. Connie Mariano, made me contemplate many of the misunderstood and misappropriated issues and perceptions that surround obesity in our society. Governor Christie decided to appear on The Late Show with David Letterman. To demonstrate his humor and humility, he pulled a doughnut from his pocket and began to eat while Letterman chuckled. The following day, a former White House physician, Dr. Connie Mariano declared that the Governor’s weight was no laughing matter. Furthermore, she stated that he was a ticking time bomb, and if elected president, could die in office. To some, these comments may represent the honest opinion of a famous physician. From my perspective, they demonstrate how unique obesity is over every other medical condition.
The difference in our collective perception and beliefs regarding obesity and other chronic medical issues can be shown by comparing the medical history of Governor Christie to that of former Vice President Richard Cheney. Dick Cheney was 59 years old when he was elected, with George W. Bush, to serve as Vice President. As Vice President, he was barely one medical event or disaster away from becoming Commander in Chief. While Dr. Mariano may believe that Christie is a ticking time bomb, Cheney was alive in 2000 because of timely medical care and the incredible advancements made in his lifetime in the management of coronary artery disease. Before, during, and after office, Cheney has been the recipient of virtually every new procedure and technique to treat heart disease. He had his first major heart attack at the age of 37. Prior to becoming Vice President he had four heart attacks, a cardiac arrest and underwent open-heart surgery. While in office, he had multiple angioplasties and stents placed, as well as an implantable defibrillator to treat a potentially fatal arrhythmia. After leaving office, he underwent heart transplantation. While many would not describe Cheney as an empathetic figure, his medical condition was handled with respect and compassion. Despite the multiple cardiac events that occurred, his capacity to serve - based on his medical condition -was rarely questioned. Where it was fair to debate his policies and positions, he was never attacked and/or viewed as being incapable because of the severity of his heart disease.
During hurricane Sandy and its aftermath, we all saw Governor Christie climbing through rubble and traveling throughout the state of New Jersey. Appearing with President Obama, he was vibrant and full of energy. Appearing on television regularly, his size could not be missed. However, he never appeared to be limited or impacted by his girth, nor was he hospitalized or treated for any medical issue during this stressful period.
The contrast and irony is startling. Christie, who has never had a major medical issue in office, is labeled to be a ticking time bomb. Yet, little attention has been paid to Cheney’s extensive medical condition and complex cardiac history. In fact, you could say that his bomb had already detonated. The difference? Christie’s obesity is not transparent. Everyday, every second, all can see his girth. In contrast, the blockages in Cheney’s heart cannot be seen. While intellectually, we can understand their significance, an angiogram or a map of his circulation is not shown by his side.
Much more is also taking place. It is with trepidation and even fear of legal implications that one questions whether someone can or cannot perform their professional tasks secondary to a medical condition. Yet, the implication of Dr. Mariano’s statement is that corporeal weight and body habitus can be implicated in the determining whether someone is qualified for employment. She questioned whether Governor Christie would be able to perform the duties of national office. Thus, on the basis of size, he may not be the right man for the job. If we extrapolate this thought, it would mean that all employers could believe that a person of ideal weight many be better able to work in their establishment than a severely obese individual. Thus, when it comes to obesity, it is acceptable to discriminate. Unfortunately, this is not new news. To protect individuals that have other medical conditions, we have even passed laws such as HIPAA to preserve their privacy. It certainly can be argued that if you are an employer, you would not want to hire someone with a similar cardiac history as Vice President Cheney. Individuals, such as Mr. Cheney, are more likely to miss work time and cost more to employers and tax payers to provide sufficient health care, regarding their dire conditions. That is why, for most positions, your medical record is kept private. In contrast, in the case of morbid obesity, there is no anonymity and a test is not needed to diagnose. It is physically and socially self-evident. Imagine someone of Dr. Mariano’s status commenting on an issue of race, religion, sexual orientation, or even other any other status of adverse medical condition. Her comments would be treated with outrage. It seems that obesity is the last bastion of accepted prejudice. In a world were we have become socially and legally evolved enough to understand and accept all divergent issues, whether they be diverse in ethnic, religious, economic, racial and sexual identifications, obesity still endears itself to cultural stereotyping and profiling.
It may be my prejudice, but I think Dr. Mariano was saying much more with her comments: if you are not able to balance your caloric intake, do you have the self-control to balance our budget? Can a person who is morbidly obese be a proper role model to be Commander In Chief? If you do not have the discipline to manage yourself, how can you manage our country? Also if you are not potentially in denial, would you not seek treatment and accept responsibility for creating then solving your own medical problem that would impede you from such?
All such simply continues to add to the misperceptions and misappropriations regarding obesity. They also explain why surveys and studies have shown that people would rather be dead than severely obese. No matter how ridiculous this sounds, when you are obese, society looks at you with scorn. You are responsible for your condition. As a result, little compassion is expressed. Besides having a strong family history for heart disease, Vice President Cheney smoked heavily for 20 years prior to his first heart attack. Although, this certainly contributed to his heart disease, his heart disease was viewed as a medical condition, and not equated with character flaws. Obesity is not viewed with such largesse toward any individual.
Another unspoken message was that Governor Christie was in denial or should be actively working to lose weight. The truth, in my opinion, is that he struggles everyday and is very much aware of the issue and frustrated by it. It has been my experience that people who are successful and severely obese wonder: ‘how can I succeed in most everything else and still fail this battle?’.
So what have we learned about obesity? Is there truth to Dr Mariano’s comments? Is this just another essay that states that no one should be held accountable or have personal responsibility?
Severe and morbid obesity combined with a sedentary lifestyle is the biggest medical issue that people, and de facto, our country faces. Despite medical innovation, life expectancy is expected to decline, only seconded to the epidemic of obesity and diabetes. Thus, clearly, someone that is as obese as Governor Christie is at a substantially increased risk of significant heath detriment than someone of similar age, who has a normal body mass. His statement that he is the healthiest fat person is one that I hear commonly. It usually means that he requires no medication for hypertension, diabetes and hypercholesterolemia. Obesity is representative of an energy imbalance. The causes are multifactorial and the impact variable. Not all severely obese individuals are diabetic or prone to heart disease. Those such propensities depends on the distribution of the adipose or fat tissue. Those that have central obesity, especially with fat in their abdominal cavity, are much more likely to have metabolic disease. When the majority of fat resides in the subcutaneous tissues these co-morbidities are less likely. However, their excess adiposity has other consequences. There are only few people that I have cared for that are Governor Christie’s size that do not have sleep apnea. Sleep apnea is a condition that generally results in patients awakening at night to get adequate oxygen, due to the stress on the body of excess weight. The blood vessels in the lungs contract and this puts strain on the heart. As a result, the heart is more likely to have rhythm disturbances. In addition, excess corporeal weight causes undue and substantial wear on joints and the lower extremities.
It is a misnomer that Gov. Christie does not care about his physical state or is in denial about such. Besides surgery, there is absolutely no documented or successful treatment option. Laymen watch popular television shows like the Biggest Loser or daytime talk shows and think that weight loss is easy. Unfortunately, the majority of people that lose large sums of weight – regardless of whatever method - suffer cataclysmic recidivism. Intuitively, most believe that we can be trained or be taught to change our behavior and maintain weight loss. However, science contradicts these widely-held beliefs. The body resists weight loss. When caloric intake is curtailed, we respond by becoming more efficient and reducing our metabolic rate. A registry is kept of people that have lost substantial sums of weight and maintained the weight loss for five or more years. On average, to preserve their weight, at the new loss state, they eat less than 1200 calories and exercise more than an hour per day.
The story of Dr. Stuart Berger is typical of the weight loss struggle. Dr. Berger was perhaps the first famous television diet doctor. While in medical school at Tufts University, he weighed in excess of 400 pounds. He lost a substantial sum of weight and authored The South Hampton Diet. His diet book was widely-publicized and he became a weight-loss guru. He died from heart disease at the age of 42. At the time of his death, his weight was again 400 pounds.
With the development of minimally invasive techniques, bariatric surgery has become safer than virtually any other abdominal or weight-loss operation. Despite these improvements, surgery is a frightening proposition. Family and friends who believe that all that is needed is further education and more willpower discourage many people. This circle also differentiates obesity. In most every other condition when you reach a threshold, treatment is mandatory. In obesity, the desperation of the patients and their desire to seek options determines who gets treated.
The differences in how obesity is handled and viewed continue when the decision to pursue treatment occurs. Rather than have a physician decide when a patient is ready or qualifies for a specific procedure, insurance companies require a detailed pre-certification process. This typically includes documentation of a recent diet that is supervised by a physician and includes monthly medical visits. For people like Governor Christie, this means that their life-long struggle is unimportant. Instead, they need to duplicate and relive their frustrations to obtain treatment. Such an approval process exists in no other area of medicine. Dick Cheney did not have to document his gym regimen before one of his many heart surgeries was approved.
When proper treatments are met with such difficult fiduciary remuneration, it is not surprising that there are few new remedies. It is estimated that 36% of the American population is now obese. At current growth rates, by the year 2050 the entire population will be obese. Thus it would seem that products that effectively treat obesity would have a large market and a priority for ambitious entrepreneurs. Yet, this is not the case. There has been only one medical device and one pharmaceutical product approved by the FDA in the past ten years. The reasons are multifold. There is no agreement about who should be treated for obesity. There is no agreement as to what constitutes successful or meaningful treatment. Additionally, obtaining insurance reimbursement for obesity treatments is an obstacle. The approval process for surgery is arduous. Less than 30% of insurance plans cover weight-loss pharmaceuticals. In comparison, look at the new products and procedures that were developed for heart disease during Dick Cheney’s life. They include stents, defibrillators, as well as surgical procedures such as coronary artery bypass grafting and cardiac transplantation. All benefited from widespread public acceptance and a clear path for reimbursement.
More than 20 years ago, former Surgeon General, Dr. Everett Koop, wrote Shape Up America. He became the first public health figure to recognize the significance of the obesity epidemic. Regardless of the dangers of obesity that have been published since its publication, the emphasis has been placed on education rather than cure. Hence, the epidemic has continued. We must realize that behavioral modification techniques that have not even succeeded in halting the rise in the prevalence of obesity are unlikely to be successful as a treatment for morbid obesity. Stated succinctly, prevention and treatment are different. We prevent bacterial infections by washing hands and avoiding contact with infected sources. We treat people, de rigeur, with surgical debridement and medications such as antibiotics. It is possible that if Vice President Cheney never smoked, he would not have had a heart attack at 37 years of age. However, no one would treat his heart disease by only having him stop smoking and change his diet. While an important component, such efforts would be combined with medications. Yet, in obesity, we still want to believe that the same techniques that are used to prevent weight gain will result in successful treatment.
It is time to address the obesity epidemic. Just as we check blood pressure, we need to measure body-mass index. At a young age, those with a mildly elevated BMI need to be referred for treatment. There needs to be reimbursement for these treatments. If initial approaches are not successful, a different approach is warranted. At the end of the line will be surgical procedures. The combination of a mandatory treatment threshold and reimbursement will stimulate the search for better solutions. Coverage should be mandatory. Only with mandatory coverage will insurance companies take preventive efforts seriously.
We also need to face that combatting the obesity epidemic will require difficult decisions that will limit personal choice. I am not sure that Mayor Michael Bloomberg’s sugar tax will be successful or the correct approach. But, I highly commend his attempt to bring awareness to this issue. It is naïve to continue to rely on nutritional education. We need to be bold and explore even unpopular options. These may include higher prices for items such as soda and other simple carbohydrates. An emphasis has to be placed on physical fitness. Each week, I see people in their early twenties that are permanently disabled secondary to medical issues caused by morbid obesity. Our society cannot afford for this trend to continue.
What about Governor Christie? We should judge him based on his ability to govern and the record he has assembled. Should he ever feel his obesity is interfering with his public duties, effective surgical treatment exists. In all probability he could return to his normal duties in 7 to 10 days. With current surgical techniques, his obesity is far easier to treat than Vice President Cheney’s heart disease. What we also have to realize is that Dr. Mariano was talking about a lot more than the medical implications of obesity. What I heard was a fat man does not appear to be presidential. Additionally, by not addressing his obesity he has character flaws that she does not find acceptable. However, looks can be deceiving. FDR led us through WWII, and The Depression from a wheelchair. What should not be questioned is Christie’s determination and inner strength. As a leader, as a person. Despite constant ridicule and jokes about his weight, he has risen to become a national leader and is being urged to run for president. To survive the discrimination he has faced, he probably has had to perform better than those who merely look the part.
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