He ain't heavy, he's my brother

Plump, full figured, overweight, obese, fat... Americans are overweight and the problem is getting worse. As a child in the 50's, I remember that there being very few heavy kids. They were called "husky". We rarely ate food not prepared by our mothers. We played outside after school and even had outdoor recess in elementary school. There were few channels on the black and white TV. In the 21st century children have lots of electronic distractions. Parents are so protective, that children are only allowed outdoors under adult supervision. Fast food and abundant junk foods contain more calories, sugar, and fat. The statistical evidence is confirmed by personal observation, patients of all ages are getting larger.

Type 2 diabetes is now a pediatric disease. Bariatric surgery is a growth industry. Equipment has to be supersized. Wheelchairs wider than my couch, scanners that have to have augmented gantry motors. Even our 450 lb scanner is sometimes not adequate. Simple IV access can become a time consuming and sometimes impossible process. CPR is ineffective as chest compresses are insufficient to give useful circulation. Our colleagues in veterinary practice have made their large animal CT and MRI machines available for our largest patients.

Obseity has deleterious effects on many body systems. The joints and bones cannot enlarge to support the extra bulk. Arthritis, compression fractures and ruptured ligaments and tendons are more common. I treated a 400+ lb man who ruptured his patella tendon in a simple fall. My PA tried to find a long leg immobilizer to stabilize his knee. The patient was unable to do non-weight bearing because of his size and even the largest knee immobilizer was to small to fit around his leg.

The early onset arthritis makes it difficult for the motivated obese patient to exercise effectively. Morbidly obese patients have restrictive lung disease from their own body weight crushing the chest cavity. Obesity is closely linked to sleep apnea.

Diabetes and hypertension are markedly increased with increased body weight. The risk of heart disease and stroke is similarly elevated. Entubation, IV access, anesthesia and skin care are all more difficult and may lead to more complications.

The ER, as the first line of medical care for many people, is attempting to cope with the needs of our ever "expanding" patient population. Ultrasound for assisting in IV insertion and lumbar puncture is available and helpful. Fiberoptic entubation can be life saving. Mechanical chest compressors are more effective than all but the strongest human CPR providers. Having a second, heavyduty CT scanner extends our ability to evaluate larger patients. Most of our wheelchairs are "double wides".

I have mentioned 2 of the possible causes of weight increase in the US; increased intake of high caloric foods and decreased physical activity. Other factors have been tentatively identified including increased use of hormones in farm animals and contaminates in our foods that may imcrease weight gain. The solution to weight loss is simple to state but extremely hard to accomplish. One needs to take in less calories than they expend, eat less and exercise more.

After many attempts at dieting with weight loss and rebound weight gain, a person can get desperate. The solution is bariatric surgery; at least according to the American College of Surgeons. There are three main types of weight loss surgery. The earliest surgeries involved "stomach stapling". A large portion of the stomach was stapled closed. Only a small tract of the upper stomach remained. Overeating would lead to vomiting. Weight loss was dramatic and rapid. The stomach remnant could only hold 1-3 ounces of food. Complications could be dangerous as infections and bleeding in an obese and often diabetic patient made management more difficult.

Gastric bypass was the second major variation of baritric surgery. The
"roux-en-y" gastric bypass is more complicated than a stomach stapling. A loop of intestine is closed at one end and the other end is attached to the closed off area of the stomach. Again, weight loss is impressive. There are also significant complications. Bleeding and infections are the most serious. Gall bladder disease, chronic diarrhea, and obstruction are more frequent but less deadly.

The newest and least invasive technique is the gastric or "lap" band. An adjustable ring is placed at the upper part of the stomach. This leaves a very small volume for food. Too tight a ring leads to vomiting, and too loose a ring can lead to inadequate weight loss. The ring can slip, and can cause erosion throught the wall of the stomach.

When a bariatric surgery patient has problems and calls the surgeon's office they are advised to go to the ER. If your hospital has surgeons who perform bariatric procedures, their patients will end up being your patients. A recent case is illustrative. The local bariatric surgeon was called by an ER doc from out of town. The surgeon's patient had a complication of the roux-en-y gastric bypass. This was confirmed by CT. When called by the ER doc at the out of area hospital, the surgeon instructed the ER doc to send the patient to me. The surgeon got to sleep and skillfully repaired the problem the next morning. I was only too happy to act as the hired help for the surgeon. The patient, being my first priority, was given pain medication and kept stable until the surgeon arrived the next morning.

I would be remiss if I didn't address the work related injuries that the obese patient can cause to the ER staff. Having to move, tranfer and turn hundreds of pounds of patient is not good for the backs of the nurses, aides, PA's or docs.

No easy solutions is available for the epidemic of obesity in the US. Taxes on junk food, listing BMI (body mass index, a measure of obesity) on childrens report cards, and public campaigns have all been proposed or instituted. I will admit that my BMI is 21. I am thin. I exercise daily and limit my caloric intake. I have maintained the same body weight my entire adult life. Much credit goes to good genes. My parents are both of normal body weight for their height.

A few simple suggestions: shut off the TV, computer, and video gamer. Put on you MP3 player and take a walk. Remember that eating fried anything is not a good idea for someone trying to lose weight. French fries are not a vegetable. When asked, "would you like to supersize that", say no thank you. Even modest weight loss in the severely obese can improve their overall health.