In an operating room at Baptist Memphis Hospital, surgeon George Woodman stood over a sedated patient, preparing to insert a 5-inch needle into her huge abdomen, draped with yards of blue surgical cloth. The 30-year-old patient weighed 330 pounds with a body mass index of 46—so heavy she’s considered “morbidly” obese. Woodman made five small incisions and slowly inserted the instruments he would use to remove most of her stomach. As he and his team worked, the patient’s organs—stomach, spleen, pancreas, liver, pulsing heart—could be seen on a video monitor. Two gaping hernias became visible, holes torn in the abdominal sac that holds the body’s major organs. “The belly wall is not designed to hold this much weight,” Woodman observed. He pointed out the many tiny blood vessels in the stomach lining. “The stomach has a lot of blood supply. That’s why it’s so good at absorbing terrible foods,” he said.

By the operation’s end, most of the patient’s stomach was trimmed away, leaving a much smaller “gastric sleeve” that will allow her to feel full after eating only small amounts of food. Removing a portion of the stomach also suppresses the hormones that stimulate hunger. The operation (known as a laparoscopic sleeve gastrectomy) is now the most common type of weight-loss surgery performed in the U.S.

Woodman has conducted 6,000 bariatric surgeries, and did three more that morning. Memphis is the heaviest metropolitan city in the country, with an adult obesity rate of about 36 percent—approaching the rate of more than 40 percent that researchers say we’ll reach by 2030, if current trends continue.

“There is an unlimited number of patients,” he said.

Memphis may be the heaviest city in the country, but it isn’t much of an outlier. From the trimmest state, Colorado, to the most obese, Mississippi, the entire nation has been on a perilous—and costly—upward track when it comes to extreme weight gain. Severe obesity (a BMI of 40 or more)—the kind most harmful to individual well-being and expensive to society—is rising at an alarming rate and may affect 11 percent of U.S. adults by 2030.

Dieting and exercise are the prescription for most Americans who want to lose weight, but only a minority succeed. Woodman estimates that just 3 percent of his morbidly obese patients could lose their excess weight on their own, so for most, bariatric surgery is a last-resort option. With luck, this patient will lose about 75 percent of her excess weight, putting her on track to a healthier future.

“People say that obesity is self-induced,” Woodman said. “But it doesn’t matter. We have to do something about it.”

Every five days, Woodman holds a seminar for prospective patients. On a recent Saturday, 60 people showed up. Perhaps one-third would follow through with surgery. For some, Medicare, Medicaid, or private insurers will pay, calculating that the price of the surgery is less than the cost of a lifetime of chronic disease. At Baptist Memphis, the operation costs $14,000—the cost is often higher elsewhere, $25,000 or more.

That may seem expensive, but it could be a bargain compared with the estimated $200,000 in excess medical costs obese Americans can rack up over their lifetimes.

Memphis has the highest obesity rate among U.S. cities, and its appetite for unhealthy food is part of the reason. Pedestrians on Beale Street take in the sights, top, including the day's menu at B.B. King's famous blues club, left. At right, spectators wait for the city's famous Mardi Gras parade to pass by. | M. Scott Mahaskey/POLITICO

As American waistbands continue to expand, researchers and policymakers are trying to figure out just what the obesity epidemic is going to cost the nation. There are the direct medical costs of treating obesity-related diseases including Type 2 diabetes, heart disease and stroke, high blood pressure, arthritis, and related cancers, among others. And then there are the indirect costs: lost productivity, more illness, extra infrastructure to handle heavier patients and residents.

These bills are already coming due in Memphis. Last year, extra health care costs from obesity were $538 million—more than half the budget of the city’s public school system, according to Gallup-Healthways Well-Being Index. For the state of Tennessee, the annual excess health costs of obesity were $2.29 billion—equivalent to more than 6 percent of the entire state budget. No matter how many surgeries Woodman conducts, he won’t make a dent; many more Americans are tipping the scales into the obese range each year.

Endocrinologist Jay Cohen, who treats many patients with obesity-caused diabetes, estimates that the average diabetic patient costs the health care system triple what a healthy person costs. Add in their lost productivity and the price tag skyrockets.

“It’s politically imperative to reduce the obesity rate,” said Cohen. Nationally, ``it costs literally trillions of dollars to treat these conditions.”

AS COSTLY AS the obesity problem is now, it’s set to get worse. The baby boom generation is the fattest on record, and they are just reaching the age where health problems begin to mount. Federal and state officials are growing increasingly worried about the steep price the country will pay for its weight problem.

In West Virginia, one of the most obese states, public health commissioner Rahul Gupta says the preventable direct medical costs of obesity are $1.4 billion to $1.8 billion a year, with an additional $5 billion in indirect costs, such as lost productivity. Obese patients submit up to seven times the number of medical claims compared with normal-weight patients, he said.

“At the state and federal levels, chronic disease burden is among the largest drivers of health care costs,’’ Gupta said, "and among chronic diseases it comes down to the consequences of obesity and tobacco.”

And then there are the national costs. Zhou Yang, a professor at Emory University who studies the impact of obesity on the medical system, found that obese older males spent $190,657 more on lifetime health care expenses than their normal weight peers while older obese women spent $223,629 more. A 2016 meta-analysis by University of Washington researchers found that annual medical spending attributed to obesity nationally was nearly $150 billion—more than four times the federal budget for foreign aid and nearly enough to fund the entire U.S. Department of Veterans Affairs.

Other potential costs are harder to quantify but no less worrisome, for patients, taxpayers and society at large. For example, researchers are discovering that vaccines may not be as effective in those who are obese. Studies have found that obese patients do not respond as well to the HIV vaccine and the flu vaccine, leaving them more vulnerable to infection—and to passing those diseases on to others. Over time, it’s possible that a community’s “herd immunity” could suffer, creating the conditions for the return of diseases that were once controlled through immunization—and that could affect us all, according to an analyst at the Union of Concerned Scientists.

Even the military is affected, as recruiters struggle to find enough soldiers who meet fitness requirements. The percentage of overweight and obese young men doubled over a 50-year period and tripled for young women. According to a study by the National Bureau of Economic Research, Navy recruits who were overweight were more likely than their normal-weight peers to fail semiannual physical readiness tests. In all, overweight and obese active duty military personnel cost the taxpayer $105 million a year in lost productivity, and $1 billion annually on treating obesity-related illness—more than treating military tobacco- and alcohol-related illness combined, NBER estimated.

Transportation costs, too, are rising, and not only for obese passengers who must purchase two seats to fly. Researchers at the University of Illinois estimated that 1 billion additional gallons of gasoline are consumed in the U.S. each year to ferry overweight and obese car passengers from place to place. One study estimated that U.S. airlines purchased 350 million more gallons of jet fuel because of the number of heavier passengers.

Obesity also affects the bottom line of employers. Obesity contributes to absenteeism and “presenteeism,” when people show up but are less productive. Based on current trends, the cost of obesity in lost economic productivity by 2030 will be between $390 billion and $520 billion annually.

In the pediatric obesity program at Le Bonheur Children's Hospital, 6-year-old Angel, left, and 12-year-old Ke'Mareon, right, learn to exercise on a treadmill. | M. Scott Mahaskey/POLITICO

Obese employees may suffer financially as well. A 2010 study found that white women had 9 percent lower wages because of obesity, “equivalent in absolute value to the wage effect of roughly 1.5 years of education or three years of work experience.” A study in the Journal of Health Economics found that some employers pay lower wages to obese workers to cover higher insurance costs.

Even the cost of dying is higher for obese people. Companies like Goliath Caskets specialize in funeral products for the obese—for a price. Everything from wider grave plots to specialized hearses with reinforced chassis and heavy-duty lifting equipment must be used. Crematories are widening furnace doors and chambers to accommodate very large bodies. A “supersize” funeral costs between $800 and $3,000 more, notes U.S. Funerals Online.

“The costs are not just related to health care,” said Gupta. “There’s a cost for people who can’t reach their full potential in terms of education, employment, mobility, physical activity and productivity.”

AT BAPTIST MEMPHIS, case managers Bonnie Jeter and Phyllis Lutz see the costly impact of obesity in the long-term acute care hospital, a special wing for critically ill patients. When Jeter began as a case manager 27 years ago, obesity was rare. Today, some 40 to 50 percent of the patients she sees are obese or “super obese.” Before opening this special wing, the rooms had to be retrofitted with hydraulic ceiling lifts and wider doorways because of the large number of obese patients. On a tour of the unit, Jeter and Lutz led visitors to the bathing room. They cannot lift their most obese patients into the extra-large tub, so these patients must be given sponge baths. The large toilet is mounted on the floor, rather than the wall, to hold heavy patients.

“It can take three people to turn a superobese patient,” said Lutz. Patients must be turned every two hours to prevent pressure ulcers, in addition to being moved for wound care, bed baths, and other needs. To make matters worse, “We don’t have any more staff [to handle obese patients],“ she said.

These patients face numerous complex medical problems. “They take longer to get better,” said Jeter. “There are a lot of complications—diabetes, renal failure, terrible skin wounds, circulatory issues, cellulitis, breathing difficulties.” Providing care is not incrementally more difficult, she said, “It’s a quantum leap.”

Not surprisingly, patients often grow depressed and unmotivated. “They’re dying younger and younger,” said Jeter. “It’s horrific.”

At Baptist Memphis Hospital, left, an extra-wide hospital door has been constructed to handle obese patients. Bariatric surgeon George Woodman, right, talks with patient Dana Brown one day after she received gastric sleeve surgery to shrink the size of her stomach. | M. Scott Mahaskey/POLITICO

Then there’s the discharge planning for patients ready for release. Nursing homes and dialysis clinics can be hard to find. “Some [clinics] have a 350-pound size limit,” said Jeter. She and Lutz must plan far ahead to locate places to send the patients.

Usually, hospitals must eat the cost for expensive bariatric equipment. A mechanical lift that can hold up to 600 pounds costs $6,000—a bariatric lift, for up to 1,000 pounds, $13,000. A standard hospital bed runs $8,000 compared with a large bed for $45,000. Everything from larger blood pressure cuffs to wheelchairs, stretchers, waiting room chairs and patient gowns must be on hand. Yet health care providers cannot charge insurers for these costs.

“Obesity is one of the most urgent public health problems in our nation today,” said Jay Bhatt, chief medical officer of the American Hospital Association. In addition to equipment costs, he said, hospitals pay for special safety training for workers. Nurse’s aides rank 4th nationally in job injuries, behind police officers, jailers and firefighters, in part due to lifting heavy patients.

Nursing homes face many of the same challenges, said Cheryl Phillips, senior vice president for Public Policy and Health Services for Leading Age, the trade association of nonprofit nursing homes. “We are arguing for better reimbursement that is risk-adjusted,” said Phillips. “Medicaid doesn’t even meet the costs for much of the care—obesity is but one example.” According to research by Yang, overweight and obese baby boomers will spend 1.3 billion more days in long-term care than previous generations, costing Medicaid at least $68 billion.

DRIVING AROUND MEMPHIS, as in many American cities, it’s easy to find cheap fatty food—Church’s Fried Chicken, McDonald’s, Crumpy’s Hotwings. Barbecue joints abound.

Signs along Beale Street in Memphis, dotted with barbeque restaurants. | M. Scott Mahaskey/POLITICO

“Memphis is the hub of diabetes,’’ said endocrinologist Cohen. "We fry Twinkies.”

If Memphis is to avoid an unaffordable fat future, it has to prevent the younger generation from adopting the lifestyle habits of their elders. To that end, Le Bonheur Children’s Hospital created a pediatric obesity program aimed at low-income children. For some kids, it may already be too late. “We’re seeing adolescents who are more than 500 pounds,” said program director Joan Han.

At the end of a workday, she and pediatrician-in-chief Jon McCullers sit in his office to reflect on the obesity epidemic. McCullers was an infectious disease researcher until five years ago, when he was recruited to Le Bonheur. “It was obvious that my research wasn’t what they needed,” he said. High poverty levels in Memphis led to a host of urgent problems. Topping the list was obesity. With an infusion of state and hospital funding, he launched the obesity program, which combines research, community outreach and a Healthy Lifestyle clinic. Most of the program’s $3.5 million annual budget is not covered by patient insurance.

What is the goal? “Not to be the worst in the country,” McCullers said wryly.

The clinic has served 650 high-risk kids since opening in October 2014, the majority African-American girls. For these children, a healthy lifestyle can be a new concept. Through surveys, Han’s team found that two-thirds of the families they serve are considered “food insecure,” despite their obesity. “So it’s the types of foods they’re eating—high in fat, high in sugar,” she said. As for exercise, Han, whose own children go to Memphis public schools said gym class is held in the hallways, if at all.

Despite the immensity of the problem, Han and McCullers try to be hopeful. Nationally, the prevalence of obesity has remained stable for children and teens, and the rate decreased significantly among preschoolers in 2013-2014, according to the Centers for Disease Control and Prevention. “We know we can make the obesity rate plateau,” said Han. “Now we need to make it reverse.”

The challenge is finding creative ways to connect with people where they live. “Most hospitals look at who is inside their walls,” said McCullers. “You have to look outside your walls, and be engaged with local and state governments and community groups.”

Ultimately, they said, it’s clear obesity has stopped being a problem for only those affected and is now a national crisis. The country literally cannot afford the impending costs. Shifting investments toward encouraging healthy environments and behaviors rather than paying for expensive, life-threatening chronic disease is the only affordable —and humane—response.

“[Obesity] costs everybody,” said Yang. “Nobody can escape. Someone has to pay the bill.”

Beth Baker is a freelance health care journalist. Her most recent book is With a Little Help from our Friends: Creating Community as We Grow Older (Vanderbilt University Press, 2014).

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