Martin Patriquin is a Montreal-based journalist.
The patient lies arms outstretched, his massive body spilling over the operating table. With a scalpel, Michel Gagner makes an incision just above the navel, then inserts a camera through the hole. He then makes four incisions in the surrounding abdomen and inserts what look like metal straws that will serve as conduits for laparoscopic instruments. We watch on the screen as they pierce the stomach wall and come into the camera’s view.
For the next 80 minutes at his private clinic in downtown Montreal, Dr. Gagner navigates within the confines of the patient’s belly by way of these instruments. We see the pinkish liver, the gelatinous spleen, the webs of veins and arteries.
And everywhere, there is fat. It clings to vital organs and swims in the cavities between them.
A custard-yellow slab of the stuff, up to 15 centimetres thick in some places, lines the abdomen between his skin and muscle wall. Left to its own devices, this fat will condemn the patient, a 41-year-old, six-foot-one male weighing 340 pounds, to a life of obesity-related ailments – and, quite possibly, an early death.
Puffs of smoke rise as Dr. Gagner, a gastrointestinal surgeon, cauterizes the fat and detaches it from the stomach. He then inserts a linear stapler that cuts and seals from the top of the stomach to where it meets the small intestine, reducing the stomach’s size by 90 per cent. Dr. Gagner then pulls the orphaned bit of gut from the hole above the patient’s navel, as though he were unpacking a particularly stubborn sleeping bag. He places it on the table. It’s the colour of uncooked sausage.
Exactly why this relatively straightforward surgery, known as a “sleeve gastrectomy,” should be the country’s (if not the world’s) answer to its looming obesity crisis will become evident in the months and years after the patient leaves the operating table. You’d think his radically reduced stomach would force him to eat less – and it does. But the surgery also reduces the body’s production of ghrelin, the so-called “hunger hormone,” meaning his urge to eat will be reduced as well.
As a result, studies say, he will likely lose about 30 pounds in the first month, an additional 30 after three months and a total of about 100 pounds after six months. He will plateau at somewhere near 220 pounds after a year to 18 months. By shedding 120 pounds – nearly a third of his presurgery body weight – he’ll likely avoid a host of illnesses including heart disease, stroke, diabetes, sleep apnea, high blood pressure and several types of cancer.
Most importantly, and in sharp contrast to the diet-and-exercise model of weight reduction, he’ll likely keep the weight off for the rest of his life. He paid $13,500 for this privilege. It might be the best money he’ll ever spend.
It’s time to admit what is patently obvious: The western world’s approach to reducing the ever-burgeoning size of its citizens has been a colossal failure. With its emphasis on diet and exercise, this approach has been utterly ineffective in controlling our expanding waists.
Worse, it has essentially shamed the hundreds of thousands of people who are unable to lose weight or fail to maintain weight loss. And fail they do: According to a 2015 study in the Lancet medical journal, up to 90 per cent of patients on a diet-and-exercise regime regain any weight they lost within five years. Yet we continue to offer trite advice and ineffectual platitudes, along with a stern wag of our collective finger at the obese.
This notion is quietly being put to rest in Quebec, home to the largest per-capita number of bariatric surgeries in the country. One in 90 obese people get bariatric surgery in the province, more than double the national average. As home to some of the skinniest people on the continent, and among the lowest per-person health spending in the country, Quebec might seem an odd place to be at the forefront of bariatric surgery research and practice.
Two surgeons, Rae Brown and Lloyd MacLean, were among the first to perform earlier, far more invasive versions of bariatric surgery, at McGill University in the 1970s and 1980s. Most of the advancements in the surgery, including the sleeve gastrectomy and the laparoscopic duodenal switch, were developed in Quebec. Dr. Gagner was the first to do both.
Today, the vast majority of bariatric surgery procedures in Quebec are performed in the private sector, in large part because the stigma against the overweight has become institutionalized within the province’s health bureaucracy.
Quebec is the only province that has paid for all types of bariatric surgeries. Yet, even now, bariatric surgeons have difficulty getting operating time for their patients. “They’ll give a liver transplant to an alcoholic before they let me operate on an obese person,” Nicolas Christou, one of the world’s leading bariatric surgeons, told me recently.
Past health crises have spurred government action. Cancer, among other diseases, has its own society and myriad hospital and governmental research facilities dedicated to its treatment and avoidance. Yet there are no such initiatives with obesity, even though the condition will affect some 34 per cent of Canadians over the age of 18 by 2025, according a 2018 World Obesity Federation report. Instead, we stubbornly believe that the obese are such because of their own failings and overindulgence.
This country’s approach to obesity has been a genteel take on this harsh axiom. In the early 1990s, Health Canada instituted its Vitality Program, which emphasized “healthy eating, active living and positive self- and body image.” Among other initiatives, the Vitality Program birthed Body Break, those two-minute, synth-driven odes to regular exercise, healthy eating and questionable Spandex.
These wonderful slices of Canadiana saw Hal Johnson and Joanne McLeod canoe, skip, jog, snowshoe, bike and ski across the land, happily telling us that reaching and maintaining a healthy weight was but a matter of eating well and staying active.
It hasn’t worked. Twenty-eight per cent of the country’s population is obese – nearly three times the rate 30 years ago. Instances of Type 2 diabetes, which are closely associated with obesity, increased by 26 per cent between 2009 and 2016.
In this age of conspicuous lethargy, where a swipe of a smartphone screen can bring a box of empty calories to one’s doorstep, it is easy to suggest we simply haven’t followed Body Break’s advice. Yet there is a growing body of evidence that suggests one’s waistline is less determined by appetite and physical activity than by a person’s genetic makeup.
In 1990, the New England Journal of Medicine published a landmark study analyzing 673 pairs of twins, roughly half of whom were reared apart. It showed that those twins who grew up separately, like those who stayed together, had maintained nearly the exact body type.
“We conclude that genetic influences on body-mass index are substantial, whereas childhood environment has little or no influence,” the study reported. Translation: We are skinny or fat or somewhere in between based largely on our parent’s genes, not on what they stuff in our mouths or how often they drag us to soccer practice.
Researchers have since determined several reasons behind this conundrum. In 1995, another study published in the New England Journal of Medicine noted how, in the face of increased exercise and resulting weight loss, the body slows its metabolic rate, thereby negating any further benefits of exercise. This makes maintaining weight loss difficult and further weight loss near-impossible.
Meanwhile, a 2007 study published in the journal Science found one genetic culprit behind obesity – a gene variant named rs9939609, one of more than 100 thought to determine body weight. When present, it is associated with increased food consumption and a related increase in the likelihood of Type 2 diabetes in children and adults. The adverse effects of this gene are further exacerbated by lower physical activity. In other words, lethargy doesn’t cause obesity, but it certainly makes it worse.
In North America, particularly in Canada, bariatric surgery remains an outlier in the treatment for obesity. Only one in every 183 obese people in the country have access to it, according to a 2017 Canadian Obesity Network report.
This is in part because the surgery used to be far riskier. Today, though, it is about as safe as gallbladder surgery, according to a 2014 Cleveland Clinic report. Governments have also been loath to cover the surgery’s higher upfront costs, preferring instead drugs and treatment of the obese, which are less expensive in the short term.
The other, more insidious reason as to why it remains so underused? A stubborn, pervasive belief that the overweight and obese are authors, not victims, of their own girth. “The public and the medical community still overwhelmingly believe obesity is the fault of the individual,” Dr. Christou says.
At $13,500, the surgery is expensive. Yet the stigma against obesity is demonstrably costlier to the healthcare system – about $7.1 billion a year, according to a 2015 Senate report. That’s roughly $5,000 a year for 1.6-million obese people for whom treatment often means a miserable stasis of pain, ailments and disease. The obese are largely left to a lifetime of suffering when the answer is 80 minutes on an operating table – a procedure that effectively pays for itself in less than three years. It’s a particularly cruel joke.