Surgical management of obesity and the relationship to cardiovascular disease.

T he World Health Organization estimates that by 2015 the number of adults who are overweight (body mass index [BMI], 25.0–29.9 kg/m 2) or obese (BMI ≥30 kg/m 2) will surpass 1.5 billion. 1 Excess body weight is an independent risk factor for mortality. 2 Among the constellation of weight-related comorbidities that bring the greatest burden for obese patients and their healthcare providers are diabetes mellitus and cardiovascular disease (CVD). Obesity, diabetes mellitus, and CVD cannot be successfully addressed in isolation; therefore , weight loss achieved by any means is a key component of comprehensive cardiovascular care. Obesity prevention is the ideal scenario. However, in the midst of an obesity pandemic, treatment options are essential. The initial approach must always address lifestyle and dietary choices, which contribute so greatly to the current obesogenic environment. A healthy lifestyle is easily prescribed but challenging to maintain. Stalonas et al 5 demonstrated not only that patients who diet usually regain their lost weight within 5 years but also that the average subject was 1.5 lb heavier at follow-up than on entering the program. A recent systematic review of dietary and lifestyle options demonstrated no conclusive evidence for sustainable weight loss. 6 However, it is possible for intensive lifestyle coaching to achieve moderate weight loss, as demonstrated by Appel et al. 7 Of their 392 obese subjects, those receiving in-person support lost a mean of 5.1 kg (P<0.001 for comparison with control subjects) and those receiving only telephone/Internet support lost a mean of 4.6 kg (P<0.001 for comparison with control subjects) at 24 months. The superiority of bariatric surgery over pharmacological and lifestyle interventions in modulating weight, hyperglycemia, and hypertriglyceridemia has been demonstrated by meta-analysis. 8 Few studies have directly compared medical and surgical management of obesity, but 2 head-to-head comparisons highlight the differential impacts. Morbidly obese subjects were assigned to gastric bypass surgery (n=80) or intensive lifestyle intervention (n=66), with the 76 surgical completers and 63 lifestyle completers achieving 1-year weight losses of 30±8% and 8±9%, respectively. 9 Diabetes mellitus and hypertension remission rates were significantly higher in the surgery group (70% versus 33% [P=0.027] and 49% versus 23% [P=0.016], respectively). Andersen et al 10 randomized 57 patients to gastroplasty or a very-low-calorie diet; at 5 years, 8 of 27 gastroplasty patients (30%; 95% confidence interval [CI], 14–50) had maintained >10-kg weight loss compared with 5 of 30 diet-only patients (17%; 95% CI, …