Carmen Pirollo expected his latest effort to lose weight would take a while. At 5 feet 11 inches, he wanted to weigh 180 pounds, down from 260. A veteran dieter _ "I've lost and gained a whole person in my lifetime" _ he knew it would not be easy.
But while Pirollo, a 55-year-old sixth-grade teacher in Haddon Heights, N.J., says he is healthy, he worries that his excess weight might take a toll on his health. And, of course, he wants to look good. "I'm an American," he says. "We live in a society where people have to be beautiful."
Who should pay for people like Pirollo to try to lose weight? For decades the answer has been the people themselves.
That may soon change.
At a meeting in November, Medicare's advisers will assess the safety, efficacy and cost of one increasingly popular method of weight loss _ surgery _ as a first step in a new policy that could lead to the use of federal money to cover a range of other obesity treatments.
Yet, at a time when coverage may increase, the evidence suggests that few obese people can lose significant amounts of weight in the long term. And some obesity researchers are also questioning the fundamental idea that losing weight improves health. Are weight loss programs, they ask, unnecessary medicine?
"No one wants to hear this," says Dr. Jules Hirsch, an obesity researcher at Rockefeller University. "But I would ask where the data are."
At the moment, Medicare will pay for surgery for obesity when patients suffer other problems associated with obesity, like diabetes. Now, Medicare says it may decide to cover treatment for those who are simply obese, meaning their body mass index, a measure of body fat, is at least 30.
The agency says it will need to determine if obesity treatments help people lose weight and improve their health, adding that as yet it has no estimate on costs.
The insurance debate, for now, is aimed at the obese, not those who want to lose a few pounds here and there. But that still includes 61-million adult Americans, nearly one-third of the adult population, and 9-million of Medicare age, 65 and older.
Doctors, of course, have been telling patients for years that weight loss will greatly improve their health. But, in fact, there is only one long-term study following obese people who deliberately lost weight _ in this case, with weight-loss surgery _ and comparing their health to those of similar people who did not lose weight. The results were a surprise.
The study of 692 patients, by Dr. C. David Sjostrom of the University of Goteborg in Sweden, found, as expected, that the surgical patients lost weight _ 68 pounds in the first year and 44 pounds after eight years.
Otherwise, the results were mixed. Diabetes in the surgical patients remained steady at 10 percent but tripled to 24 percent in patients who did not have surgery and did not lose weight.
Blood pressure, however, was a different story. It fell in the first year after surgery but then crept up again. Eight years later, the blood pressure readings of the surgical patients were the same as those who did not have surgery.
For a minority of obese people who are surgical candidates, the operation can turn their lives around. What is not known is whether surgery's benefits outweigh its risks over the long term.
Other large studies have focused on populations, asking whether overweight or obese people who voluntarily lose weight are healthier. Some reported that they were, some found no difference, and some found that they actually died at a greater rate.
The reason for the dearth of information on the long-term effects of weight loss, researchers say, is that very few keep weight off. The National Institute of Diabetes and Digestive and Kidney Disease is now, for the first time, trying to get some concrete answers with an 11-year study of 5,000 diabetes patients.
The new federal study's protocol states the quandary: "Given the paucity of data on the impact of weight loss on morbidity and mortality, an increasing number of critics in both the lay press and professional literature have questioned whether obesity should be treated at all."
While scientists ask questions, a robust weight-loss industry takes in tens of billions of dollars each year. It includes diet foods and beverages, weight-loss centers, diet books and medicines, diet supplements, office visits to doctors, lab tests and surgery. The Federal Trade Commission estimates that the annual revenue from sales of diet foods and beverages alone reaches $40-billion.
And, weight-loss surgery has begun to hurt insurers. In Pennsylvania, the number of operations went from 674 in 1999 to 6,791 in 2003, and total charges went from $24-million to $242-million. Private insurance paid for 85 percent of the operations. Blue Cross Blue Shield of Florida announced that it would not pay for the operation after this year, saying its costs nearly doubled in two years, to $17-million a year.
It is almost impossible to tell the blunt truth about the success rates of treatments, some say.
Dr. Bruce Schneider, associate vice president for clinical research at the Association of American Medical Colleges, said, "It is like resisting mom, apple pie and the flag."