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Zingmond is quick to point out that laparoscopic weight loss surgery -- a new, minimally invasive technique -- results in far fewer complications. Wolfe agrees and estimates that two out of three weight loss surgeries today use the laparoscopic technique.

Yet nobody yet knows the long-term consequences of offering weight loss surgery to ever larger numbers of patients.

"We know the surgery results in weight loss, lower cholesterol, and resolution of diabetes," Zingmond says. "But we don't know about the changes to the gastrointestinal tract and whether, over a lifetime, this has some impact. We're still looking at what happens."

Surgery the Best Treatment for Morbid Obesity?

Despite the risk of death and other complications, weight loss surgery attracts increasing numbers of patients. The JAMA report by University of Chicago researcher Heena P. Santry, MD, and colleagues chronicles the trend.

From 1998 to 2002, Santry's team finds the estimated number of weight loss surgeries in the U.S. increased from 13,365 to 72,177. As the number of surgeries increased, the rate of complications went down.

Why the increase? Despite the huge number of diet books sold each year, relatively few morbidly obese people manage to lose -- and keep off -- significant amounts of weight.

Weight loss surgery, Santry and colleagues write, "remains the only durable option for weight loss in the morbidly obese." Yet in the U.S., less than 1% of such people undergo weight loss surgery in any given year.

"What is up with that?" Wolfe asks. "There is concern about risk and there are negative perceptions that arise from poor results of operations that have been tried and failed in the past. I believe that risk of complication is the single greatest explanation of why the number of patients is relatively small. As that improves, demand will accelerate quite substantially."

Yet Santry's data reveal a major disparity. Obesity is most common in people with low incomes. Yet weight loss surgery is most common among higher-income people.

"There is still the widespread perception that instead of a disease, obesity is just people's misbehavior and they are not deserving of treatment," Wolfe says. "An unresolved question is to what extent does cost justify withholding access to a treatment. If it is the best treatment for a medical condition, the cost is a problem -- but we cannot deny patients just because it is expensive to give them the proper treatment for their condition. How to sort that out in the long term is a question."

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