Smoking and Weight – It’s Effects on Your Body and Weight

For years, people have noted that when they quit smoking they gain weight. Is this a legitimate weight gain? Does the average person who quits the habit increase their number of consumed calories, or do other factors come into play?

An article published in the medical journal Clinics of Endocrinology and Metabolism may have put some credence into the fact that tobacco smokers do have a metabolic reason for their weight gain when they quit. According to research performed, the individual who has recently quit smoking does have a significantly increased sense of hunger and appetite leading to a increase in their intake of calories. This is, however, not caused by the psychological factors which for many years have been blamed for this insidious weight gain.

With careful research and testing, it has been determined that the average smoker has a metabolism that is between 3-4% higher than that of an equivalent individual who is a non-smoker. This boils down to an average ten pound weight difference between the smoker and non-smoker.

When a smoker quits, it takes approximately ten months for their metabolism to stabilize. the bodies hunger mechanism is affected by the lack of tobacco constituents and there is an increase in the number of calories consumed.

A sensible diet during the year following smoking cessation is the best method to both prevent and control the weight gain that is metabolically caused by “kicking the habit” Your bariatric physician has the tools and knowledge to help with medications and dietary guidance to assist you in your successful control of smoking cessation weight gain.

Location of Fat – A Health Risk

In a recent published medical journal, researchers have gone somewhat further in specifying the correlation between fat location on the body and the increased incidence of systemic disease.

A Swedish study recently revealed that a waist/hip ratio (abdominal) ratio of 1.0 in men and .8 in women increases mortality rates. This ratio is also shows an increase in stroke, cardiovascular disease, and diabetes.

Of further interest was that this ratio of hip/waist measurements is apparently independent of other risks such as age, body mass, smoking serum cholesterol, and blood pressure.


Should I have gastric bypass surgery?

Gastric bypass surgery has become extremely popular. Dr. Horowitz was a pioneer in this type of surgery more than 25 years ago. They question you may ask is why Atlanta Bariatric Medicine is not performing this type of surgery despite the current fad and the obvious financial windfall earned by performing these procedures?

NAH (National Institutes of Health) lists this surgery as having the highest risk of any elective surgical procedure. This means that comparatively, more people die and suffer surgical complications from these procedures than from heart surgery, brain surgery or any other surgical intervention. Would you have a heart bypass surgery (which is less risky!) unless you are about to die? Bariatric surgery, though indicated for some individuals, is recommended for less than 17% of morbidly obese people. In all other cases the underlying health problems which cause the obesity may be treated by the other available medical modalities with equal success.

Until you have been under the direct care of a board certified bariatric specialist and have exhausted those available medical treatments you have should not consider yourself a reasonable candidate for obesity surgery.

Outcomes of using a second generation AED in Recalcitrant Obesity: A Case Series

Presented by Lonny E. Horowitz, MD
Atlanta Bariatric Medicine Diet & Wellness Centers
53rd Annual Obesity Symposium
American Society of Bariatric Physicians
October 10, 2003 Chicago, Illinois.

Objective: To evaluate the clinical efficacy of topiramate as an adjunctive therapy in medically stable patients with recalcitrant obesity who have reached a plateau.

Background: Diet, pharmacologic intervention, and behavioral modification are successful strategies resulting in weight loss for many patients. Despite early success, some patients who are compliant with medical treatment will reach a plateau. A review of the literature revealed that many of the pharmacologic agents currently used to treatment obesity do not spare lean muscle mass. Weight loss with topiramate, an antiepileptic drug, has been reported as an adverse event in epilepsy with sparing of lean muscle mass. Our study was undertaken as a pilot inquiry to determine: 1) if topiramate would be an efficacious adjunctive agent in the obese patient who had reached a plateau 2) and the effect on body composition in these patients.

Design/Methods: A total of six patients were identified as appropriate candidates for a trial of adjunctive topiramate in addition to their standard bariatric medical treatment (e.g. medication, diet, exercise). Patients had been under the care of a board certified bariatrician for 1-10 years and were medically stable. All patients were assessed at initiation of treatment and monitored weekly and biweekly for a five-month period from April 2003 to September 2003. Weight, BMI and vital signs were recorded for each visit. Body composition was assessed before topiramate was added at incrementally increasing dosages for for eight weeks. Body composition was again performed at study end.

Results: Total weight gain or loss, weight loss or gain with the addition of topiramate, and effects on BMI are listed in Tables 1-3.

Table 1. Total Weight Loss or Gain (in lbs.)

Patient ID Initial Weight Weight Loss or Gain: Pre-TPM Weight at TPM 


Total Weight Loss or Gain with TPM Total Weight Loss
01- SW 185.6 -7.1 179.5 - 3.5 15.0
02- CA 412.0 -74.5 337.5 -28.5 103.0
03- JD 197.5 16.5 179.0 - 4.5 4.0
04- JH 272.0 -52.0 220.0 +1.5 55.5
05- VM 364.0 -6.5 351.5 -35.5 32.0
06- DF 204.5 -20.5 181.0 -17.0 40.5

Table 2a. Weight Gain or Loss by Visit (in lbs.)

Patient ID Visit 1 Visit 2 Visit 3 Visit 4 Visit 5
01- SW -1.0 +0.5 +2.0 -0.5 -2.0
02- CA -4.0 -1.0 -5.5 -2.0 -2.0
03- JD +0.5 0.0 0.0 0.0 -0.5
04- JH 0.0 -1.0 0.0 0.0 -0.5
05- VM -2.0 0.0 -5.5 -7.0 0.0
06- DF 0.5 -5.5 -2.0 -0.5 -2.0

Table 2b. Weight Gain or Loss by Visit (in lbs.) continued

Patient ID Visit 6 Visit 7 Visit 8 Visit 9/ Study Completion Cumulative Weight Loss or Gain with TPM
01- SW -1.0 -0.5 0.0 -2.0 - 3.5
02- CA -2.0 -2.0 0.0 +0.5 -28.5
03- JD -0.5 -2.5 -1.0 -0.5 - 4.5
04- JH -2.0 +3.5 +1.5 -3.0 +1.5
05- VM -5.0 -3.0 -2.0 -3.0 -35.5
06- DF -1.5 +0.5 -1.0 -4.5 -17.0

Graph 1

Weight Gain or Loss by Visit (in lbs.)

Weight Gain or Loss by Visit (in lbs.)

Table 3. Body Mass Index

Patient ID Initial BMI BMI Pre-TPM BMI Last Visit BMI D S/P TPM
01- SW 32.83 32.64 32.18 -0.46
02- CA 70.71 57.92 53.03 -4.89
03- JD 33.89 30.63 30.55 -0.08
04- JH 37.93 30.68 30.89 +0.21
05- VM 58.74 56.72 50.99 -5.73
06- DF 36.22 36.22 29.05 -7.17


Conclusions: Preliminary evidence suggests that topiramate may be a useful adjunct treatment for severely obese patients who have stopped responding to standard medical treatment that included medication, diet, and exercise. All three patients in this sample who lost less than five pounds had beneficial effects on body composition similar to those shown in Table 4 for Patient #04-JH who gained 1.5 lb. over the study period. Furthermore, it is apparent that lean body mass is spared and is apparently augmented in some individuals. These results suggest that further analysis is warranted on patients whom we would normally consider treatment failures with non-surgical intervention for obesity.

Table 4. Patient 04 – JH: Body Composition

Baseline: Pre- TPM Last Visit: Post-TPM
Lean Body Mass 56 % 123 lb. 59 % 160 lb.
Fat Body Mass 44 % 97 lb. 41 % 112 lb.
Body Water 44 % 44 liters 44 % 54 liters
Resistance 595 459


Fat: It’s Location on Your Body and It’s Effect On Your Health

Picture a small pad of fat on the wall of your heart. Now imagine yourself lifting that small fat pad with your hand 70 times a minute for the next  24 hours or 100,00 times without stopping. How tired would your arm, shoulder and neck feel?  Just think of the same strain on your heart.

Fat tissue is found in all human beings. It is present in the layers of skin as well as surrounding many of the major organs and is deposited in and on the cavities found throughout the body.

Fat has several important roles in day to day life…insulation from cold, protection from injury (fat acts as a shock absorber), and of course fat s the body’s “fuel tank”, which stores energy in a form that can be converted to energy when we need it.

Some of the more ominous facts revealed about fat is the relationship between fat and cancer. Interestingly in an issue of JAMA the Journal of the American Medical Association studies have implicated Fat and Diet with a significant relationship and a 3 time greater increase in the incidence of Ovarian Cancer in women.

Proper diet and nutrients appear to be of key importance and are one of the only methods we know of which can help us to prevent these diseases from occurring.

Some reasons why we’re Fat

Centuries ago the tendency for an organism to survive was closely if not completely tied to the availability of food. Over eons mankind has taken at least tenuous control of his environment, certainty making his caloric needs an easy task to complete. Truly, during no time in recorded history was the availability of quality food more plentiful, the selection greater, or the medical risks of Obesity less prevalent!

What is obesity? In 1985 the National Institutes of Health in response to the continual growth in girth of the American Populus announced criteria for the measurement of obesity. Based upon their statistical analysis of the American population along with other epidemiologic factors NIH set forth criteria that outline those individuals with weight problems that transcend casual overweight and become medically significant. According to NIH an individual who is up to 10% above ideal weight is simply overweight. An individual who is 20% or more above ideal weight is by NIH definition suffering from Medical Obesity and noted it at that point to be a disease. More than 100 pounds or 100% above ideal weight is Morbid Obese and represents a level at which significant comorbidities develop. These ratings are rather arbitrary, however, their findings are significant as they reflect the points at which medical risk factors such as hypertension, diabetes, stroke, and cardiac disease begin to increase several fold.

Recently, researchers at the Rockefeller Institute isolated “the fat gene” in laboratory rats. Literally, thousands of dollars have been spent to breed “Fat Rats” or so called “Zucker Rats” to attempt to isolate causes, and develop possible treatments for  eventual use in man. Unfortunately, we are still at the early stages of discovery as far as to the exact cause of obesity in humans. Research is promising and clearly in the not to distant future, more specific causes and treatments will be available. The true answer as to who gets obesity is, just about anyone in whom their intake of calories exceeds the number of calories expended. Certainly, there is a genetic component, and individuals with family history of Obesity are at even greater risk of developing the disease. More importantly anyone is at risk of developing the disease and at this time the official status is that Obesity can be treated and controlled but is considered incurable!

Why is obesity dangerous? Because it kills. Probably the most prevalent disease in the US overweight (> 10% above ideal weight) is encounter in six out of ten adults, obesity (> 20% above ideal weight) is found in four out of ten and recent findings indicate 1 individual in ten is morbidly obese. There is a report that a new heading of Super Morbid obesity >200% or 200 pounds above ideal weight is being considered. Obesity kills by increasing the risks of damage to the cardiovascular system, liver, as well as increasing the development of  Diabetes, Colon Cancer and exacerbating Arthritis. Almost daily, additional risks are associated with increased girth. Pulmonary disease, increased incidence of infection, and is associated with increased Clinical and Sub-Clinical Depression.

Obesity treatment is fraught with failures, and individuals almost never keep weight off long term. Extremely resistant, obesity is a life long disorder that due to it’s recidivism has invited a host of treatment methods, some of which even today are extreme and dangerous as well as being ineffective. Stomach stapling, Intestinal By-passes, Jaw Wiring as well as, Herbal Enemas, Food Allergies, Liquid Fasts, Milk Shakes, Cookies, Vitamins Injections, Amphetamines, Hypnosis and a host of bazaar, sometimes fatal and ineffective treatments have been tried in the treatment hope of procuring a cure. Obesity is a desperate disease. Owing to the social pressures imposed by our society, people so afflicted tend to go to any length to gain control, many times subjecting themselves to life threatening risks. The October 1997 manufactures recall of Phen/Fen & Redux, Much to the financial dismay of the plethora of Phen/Fen clinics that have now come and gone, after being prescribed to 18,000,000+ “guinea pig patients” is a prime example of the overzealousness on the part of both the physician and the patients in attempting to gain control of this disorder.

As is apparent, Obesity is still being treated with less than spectacular results. Current effective treatment methods must include exercise, behavior modification and dietary changes with which the individual can live. Unrealistic goals and diets beyond the realm of reality are ineffective and destined to fail from the beginning. Although there are some hopeful magic bullet medications on the horizon these may be many years away and may be too little too late for those individuals now in need.

The future of Obesity treatment may offer hope from several different approaches. Genetic manipulation and phenotypic controls may become more readily available in the next 10 to 20 years

Fat and Thin Stuff

This is our first 2011 update. We are posting this for our patients and potential new patients and friends in the community. We hope this gives you an opportunity to see some of our inside operations in the office and helps you to learn what make’s our office tic. You can help us in the future by sending us your recipes, or any interesting information, ideas, suggestions or questions you would like to share. We’ll print them in future newsletters and share them with other patients.


Dr. H.

We look forward to assisting you in towards your lifelong goal of good health.

Top Ten New Years Resolutions!!! Weight Loss #1 Again!!!

Start 2011 on the “Right Foot”!!
It’s important to exercise while trying to lose weight. Walking is the key.

Christmas has come and gone. Santa left many shiny new exercise bikes and memberships at the local spa.

Is increased exercise going to help control weight?
The bike manufacturers and spa owners would like you to think so, but, research is recommending less vigorous and stressful physical activities for those of us who wish to lose or control our weight.

Studies from the University of Pennsylvania Department of Exercise Physiology reveal that significant increases in exercise while actively participating in a weight loss program may undermine results several different ways.

Exercising to lose weight tends to be a slow and boring process. Boredom was a key factor in limiting the individuals desire to repetitively participate in an exercise. Evidence is growing which  supports the idea that less strenuous exercise and shorter, more frequent exercise periods for individuals attempting to loss weight is a better and more effective means of assisting in weight loss than a heavy exercise schedule. Obviously choosing an exercise which you find interesting or exciting will help defend against boredom.

We must recognize that the amount of weight we can expect to lose is relatively small in consideration of the amount of effort we must expend. Exercise increases our lean body (muscle) mass which weighs more than fat. You cannot exercise fat. Only muscle can be exercised. This can actually tilt the scales in the wrong direction making us gain by increasing our muscle mass and exceeding the smaller amount of fat weight lost.

Nothing is more detrimental to a dieter than a week of restrictive eating and heavy exercise, punctuated by a gain on the scale!!

How much can exercise help me loose?
All of our patients have had a body composition analysis during their initial exam. This evaluation helps us to determine the net number of calories you can expect to use with your exercise. This calculation is applicable specifically to you and is based on the measurements made by our equipment. Many patients exercise 3-4 hours weekly, usually ever other day. Although this effort is commendable, from a fat burning standpoint, research shows that 30 minutes of exercise daily instead of 1 hour every other day is more effective in specifically raising metabolic rate and burning fat.

Look at the body composition profile from your first visit. Four important calculations are listed on this profile. These are your percentage of body water, lean body mass, percentage of body fat as well as a calculation of your lean to fat ratio. These numbers are important in determining the amount of exercise that will be helpful to your control or loss of weight.

Most of our patients have adequate amounts of lean body mass. In most of our patients this number usually will be close to or exceeding our ideal weight range. This means that you do not need additional muscle and need to lose. Remember you cannot exercise fat and can only exercise muscle. Our body normally responds to exercise by increasing muscle size and thereby increasing lean body mass. Adding additional lean body mass to an individual who is trying to loose fat as mentioned before is detrimental to the whole process. It is quite likely that you will gain weight if you exercise extensively. This will be more pronounced if our protein intake is increased while dieting.

On the last page of your body composition profile is a chart which lists your projected number of calories expended by different types of exercise. As you can see the benefit in calories expended for most people is rather small.

Why exercise at all?
Basically exercise is good because it increases the amount of time that your metabolism is activated and slightly elevated. Theoretically, you should burn calories at a more constant rate when you exercise. It is important to note that exceeding your recommended exercise limit will not raise this metabolic limit any further than that derived by small amounts of exercise. We mustalso consider that developing a daily exercise routine is a mainkey in maintaining our weight and preventing cardiac disease.

Can I never exercise strenuously again?
Once a goal weight has been reached increased exercise is recommended for maintenance and increased cardio-vascular health. Increased aerobic exercise at this point will be beneficial to you and help to continue the healthy lifestyle we are striving. Repeating your body composition profile will be helpful in determining how much increased exercise you should do.

Remember to consult Dr. Horowitz before increasing or changing your exercise program. You may have specific health reasons why you should not exercise strenuously or at all.

New In ’11!!
Good news for our Ptree Followers- We are diligently working on a recipe book for our patients. An interim copy of recipes titled “The Peachtree Recipes” is available to our patients via email on request while or if you are on this program. We will be happy to send you one. (This is only available for active patients)

Where Can I Eat?
Many patients worry about where they can get meals in fast food chains or restaurants. Not to worry it is very easy to get the types of food you need at many fast food chains such as Burger King, Wendy’s, or McDonald’s. All three offer salads that are low in calories and fat while being big enough to satisfy an appetite.

McDonald’s, Wendy’s and Burger King offer Broiled Chicken Salads which are fine if you are following the Ptree Program. Remember that regular Oil and Vinegar based salad dressings are suggested on Ptree. Long John Silver’s offers a three piece Fish-Lemon Crumb or Chicken Lite Herb entre which are both fine (remember no rice, cole slaw or bread sticks) and they will be happy to substitute a salad for the starches you are not permitted to have. Hardee’s offers a grilled chicken sandwich which will be permissible for lunch if you eat only one slice of bread and request it without mayonnaise. Arby’s offers the only turkey sandwich in the fast food circuit which is fine with only 1 slice of the bread. Mrs. Winner’s offers broiled chicken with green beans. You can request a double order of green beans instead of rice with this meal.

Remember the old standby at any of these fast food places. You can always order a garden salad and a few hamburger patties with mustard. This is a quick meal that is available at all the fast food chains.

What do I do in a fancier restaurant?
The rule of thumb is always eat protein. Most will gladly grill or roast a piece of chicken, fish or steak. Even if not mentioned on the menu restaurant’s menu most will gladly make substitutions of permitted vegetables spinach, green beans etc., instead of potatoes or rice.

If the restaurant simply will not prepare a dish which you are permitted to have order something with fish, poultry or steak and a separate plate. Take the protein and scrape the offending sauce, skin, breading, etc. and place it along with any permissible vegetables on your “keeper” plate and give the “Fattening Stuff” back to the waiter (you don’t need the temptation to sneak a taste and no-one in your party needs extra fat or calories). Remember the food you can eat with impunity is protein. At that dinner party load up on salad and protein (push the gravy or sauce to the other side of your dish) and dig in! Although you may not be following the program 100% it won’t be too bad or hurt your progress that much.

Dr. Horowitz’s “Doctors Tip”:
The Key to maintenance is a change in attitude. Remember that you can never be cured of obesity but it can be controlled. Three of the best control methods are:

  • Accept the changes you needed to make to lose weight as a change in your lifestyle not simply a temporary solution to your weight problem.
  • Get as close as possible to your suggested weight as possible (within 10% should be enough).
  • One you are at your goal weight range NEVER allow yourself to regain more than 5 pounds without coming in for a follow-up visit! This helps us work with you to prevent the Yo-Yo of regaining and losing and prevents you from putting it off for an other time.


Obesity Surgery: Practical Reality and Considerations in the New Millennium

By Mary E. Morrison
Mary E. Morrison, P.C.and Elizabeth (“Bj”) Kilbride
Common Ground-The Mediation Firm

Few words strike fear in the hearts of men, women, teenagers and children as “obesity”. Medically speaking, however, “obesity is a chronic disease due to excess fat storage, a genetic predisposition, and strong environmental contributions.” M.A.L. Fobi, Surgical Treatment of Obesity: A Review, 96 J. NAT’L MED. ASS’N 61 (2004). An obese person is one who is determined to have a body mass index over 30. NATIONAL HEART, LUNG, AND BLOOD INSTITUTE, NATIONAL INSTITUTES OF HEALTH, NIH PUB. NO. 98-4083, CLINICAL GUIDELINES ON THE IDENTIFICATION, EVALUATION, AND TREATMENT OF OVERWEIGHT AND OBESITY IN ADULTS: THE EVIDENCE REPORT (1998). Because of the negative social and medical implications of obesity, those who suffer from it rightfully seek a remedy for the condition. Obesity has been determined to be a significant cause of heart disease and diabetes, as well as imposing other physical conditions which the non-obese person would otherwise take for granted (e.g., the airline requirement that obese passengers purchase two airline seats for commercial travel).

In a recently released report, the Center for Disease Control (CDC) estimated that obesity-related medical expenditures were $75 billion in 2003. Press Release, Office of Communication, Centers for Disease Control and Prevention, Obesity Costs States Billions in Medical Expenses (Jan. 21, 2004), available at [link missing]. According to the CDC report, in the year 2003, Wyoming’s state obesity-related expenditures were estimated to be $87 million, while California weighed in at an estimated $7.7 billion. See also, Associated Press, Does Obesity Surgery Save Money?, Oct. 31, 2003. The Secretary of Health and Human Services has observed that obesity is a “crucial health problem for our nation, primarily because of the toll on taxpayer dollars that fund obesity-disease expenses through Medicare and Medicaid.” Id. Conservative estimates are that obesity in America has risen to epidemic proportions. As the concern over obesity as a nationally recognized health risk has risen, so too have the numbers of individuals seeking weight loss surgery. In and of itself, surgery to effect weight loss has been performed by members of the surgical community since the 1950s. These procedures, however, were viewed as highly controversial until 1991, when the National Institute of Health issued its Gastrointestinal Surgery for Severe Obesity Consensus Statement. NATIONAL INSTITUTES OF HEALTH, NIH CONSENSUS DEVELOPMENT CONFERENCE, CONSENSUS STATEMENT: GASTROINTESTINAL SURGERY FOR SEVERE OBESITY, Vol. 9, no. 1 (Mar. 25-27, 1991). The acceptance by the NIH of the procedure thrust it into mainstream acceptance. The NIH sanctioning made it more likely that medical insurance funds would be available for surgical weight loss procedures,an area where insurance coverage had historically been denied. See Livingston v. Central States, Southeast and Southwest Areas Health and Welfare Fund, 900 F. Supp. 108 (E.D. Mich. 1995) (public funds and benefits for obesity procedures denied for the reason that the surgery is “cosmetic”). See also, Exbom v. Central States Central States, Southeast and Southwest Areas Health and Welfare Fund, 900 F.3d 1138 (7th Cir. 1990). After the NIH approved certain surgical procedures for treatment of obesity, Medicare and Medicaid began paying for the procedures when certain medical criteria were met and other insurance availability fell into place.

The availability of third-party payment for these procedures has occurred simultaneously with consumer demand and resultant media attention. Celebrities such as singer Carnie Phillips of the band Wilson Phillips, comedian Rosanne Barr, “Today Show” weatherman Al Roker, and Blues Traveler lead singer John Popper are frequently shown as postoperative success stories. Reports of the complications and medical complications receive less attention.

In most cases, patients are so desperate to undergo surgery and free themselves from traditional weight loss methods that the risks of surgery may seem to outweigh the alluring benefit of a slim and trim life. This desperation is revealed in one published opinion, where an obesity surgery patient was quoted as saying that she would have the proposed obesity surgery, “whether ‘she lived another year or not’”. Tyson v. Webb, 7 B.R. 569, 571 (Bankr. M.D. Ga. 1980). While the patient stated a determination to undergo the surgery, regardless of her life-span, her enthusiasm waned after the procedure when she experienced unexpected and chronic complications. The surgical case resulted in a legal case against the surgeon in state court and then bankruptcy court.

Claims against the surgeon in the bankruptcy court sounded in fraud for the physician’s alleged failure to fully disclose the potential and known risks of the procedure to permit the patient to make a fully informed decision prior to undergoing the procedure. Thus, the convergence of high market demand with lucrative insurance reimbursement and national focus on obesity as a significant health problem may have generated what may be termed “the perfect storm” for patient risk.

Due to the desperation of the obese patient and the desire for a permanent fix, known risks are rarely appreciated by the consumer. Perusal of obesity web sites with testimony from patients who are scheduled to undergo these elective procedures indicate that death rates, which are conservatively reported as 1 in 200-300 surgeries, are not fully appreciated. Mayo Clinic Staff, Surgery for Obesity: What Is it and Is it for You? (November 17, 2003), available at [link missing].

Obese patients suffer from a high incidence of complications such as wound sepsis, respiratory and cardiovascular complications, and thromboembolic disorders. P.S. Pasulka etal., The Risks of Surgery in Obese Patients, 104 ANNALS INTERNAL MED. 540 (1986); P.S. Choban et al., Increased Incidence of Nosocomial Infections in Obese Surgical Patients, 61 AM. SURGEON 1001 (1995). The financial benefit to surgical facilities willing to provide obesity surgery further aggravates the overall risk for patients. Emerging from years of increasingly low margins of Medicare reimbursement and HMO guidelines, obesity surgery’s high dollar margins present a nearly irresistible area of practice for cashstrapped facilities and surgeons. A standard operating room, recovery area and generalized nursing staff, however, may lack appropriate safety and standards for the high-risk obese patient, who requires heightened vigilance in post-operative monitoring, a nursing staff with specialized knowledge in the recognition of obesity surgery complications, and special sized diagnostic and medical equipment. The result is that obesity surgery can and does occur in under-prepared and unsafe facilities. Despite the increasing demand for obesity surgery and its known high risks to the patient, however, the medical community has been slow to respond to this situation by offering certification or promulgating standards for obesity surgery physicians. At the current time, the only apparent means of identifying a physician who is trained to perform bariatric surgery procedures is through the American Society of Bariatric Surgeons (ASBS), an organization whose membership is voluntary and open to all physicians and members of “allied health professions.” The ASBS was originally established to promote the benefits of bariatric surgery, not to certify or standardize the medical practice. Physicians are admitted to the ASBS by payment of an annual membership fee if they meet requirements of satisfying a modicum of bariatric surgery experience and supply letters of recommendation from surgeons in the field. Hospital administrators and committees are given the task of determining a physician’s ability to conduct bariatric surgery.

Surgical treatment of obese patients is an option that will remain available to consumers and will continue to grow. Because of the demand, desperation, and potential for serious injuries to patients, we are at a crucial juncture for the establishment of nationally accepted standards for specialization. If board specialization is not an option, then perhaps a move toward excellence in service, more formal tracking of statistical outcomes, and reporting of surgical results is called for. Most importantly, in this golden age of information,healthcare consumers should be able to satisfy themselves that they have selected a qualified surgeon who will perform the surgical procedure at an accredited facility with specially trained nurses, medical staff, and specialized equipment. Sadly, at this point in time, much of the information available to consumers consists of internet advertising, word-of-mouth, and information received through the media. The authors of this article have seen firsthand how the lack of such certification, accreditation, standards and enforcement has left some members of the patient community with devastating and permanent consequences. The medical profession is in the unique and singular position to establish criteria to reduce such consequences, and the time to act is now.