Adult Obesity Facts

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10 facts on obesity
Finally, I want to talk about our giant backends. Recent advances in laparoscopy have renewed the interest in gastric banding techniques for the control of severe obesity. Regression analyses were performed for all follow-up weight loss data. More activity may be required for weight control. They used rigorous methods to screen studies for eligibility and collected data using standardized forms. Many cultures throughout history have viewed obesity as the result of a character flaw.


Obesity Surgery

The rate of serious AES was 1. The authors concluded that IGBs were more effective than diet in improving obesity-related metabolic risk factors with a low rate of AEs, however the strength of the evidence was limited given the small number of participants and lack of long-term follow-up. On August 10, , the FDA announced that it has received 5 reports of unanticipated deaths that occurred from to the present in patients who received a liquid-filled intra-gastric balloon system to treat obesity; 4 reports involve the Orbera Intragastric Balloon System Apollo Endosurgery and 1 report involves the ReShape Integrated Dual Balloon System ReShape Medical.

All 5 patients died within 1 month or less of balloon placement; 3 patients died 1 to 3 days after the balloon was placed. The FDA stated that "At this time, we do not know the root cause or incidence rate of patient death, nor have we been able to definitively attribute the deaths to the devices or the insertion procedures for these devices e.

The FDA has also received 2 additional reports of deaths from to the present related to potential complications associated with balloon treatment: As part of the ongoing, FDA-mandated post-approval studies for these devices, the FDA will obtain more information to help evaluate the continued safety and effectiveness of these approved medical devices Brooks, Both patients were at a high risk and could not undergo another open or laparoscopic surgery to correct the leaks that were not healing.

In a prospective, single-center, randomized, single-blinded study, Eid et al examined the safety and effectiveness of endoscopic gastric plication with the StomaphyX device versus a sham procedure for revisional surgery in RYGB performed at least 2 years earlier patients to reduce regained weight.

These researchers planned for patients to be randomized 2: Adverse events were recorded. One-year follow-up was completed by 45 patients treated with StomaphyX and 29 patients in the sham treatment group. Primary efficacy outcome was achieved by There was one causally related adverse event with StomaphyX, that required laparoscopic exploration and repair. The authors concluded that StomaphyX treatment failed to achieve the primary efficacy target and resulted in early termination of the study.

The American College of Obstetricians and Gynecologists' practice bulletin on bariatric surgery and pregnancy ACOG, stated that bariatric surgery should not be considered a treatment for infertility.

Fridley et al reviewed the literature on the effectiveness of bariatric surgery for obese patients with idiopathic intracranial hypertension IIH with regard to both symptom resolution and resolution of visual deficits. The published literature was reviewed using manual and electronic search techniques.

Data from each relevant manuscript were gathered, analyzed, and compared. These included demographic data, pre- and post-operative symptoms, pre- and post-operative visual field deficits, bariatric procedure type, absolute weight loss, changes in BMI, and changes in cerebrospinal fluid CSF opening pressure.

A total of 11 relevant publications including 6 individual case reports were found, reporting on a total of 62 patients. The Roux-en-Y gastric bypass was the most common bariatric procedure performed. In 13 patients both pre- and post-operative CSF pressures were recorded, with an average post-operative pressure decrease of mm H 2 O. Changes in weight loss and BMI varied depending on the reported post-operative follow-up interval.

The authors concluded that the published Class IV evidence suggested that bariatric surgery may be an effective treatment for IIH in obese patients, both in terms of symptom resolution and visual outcome.

They stated that prospective, controlled studies are needed for better elucidation of its role. Levin and colleagues stated that IIH occurs most frequently in young, obese women. Gastric bypass surgery has been used to treat morbid obesity and its co-morbidities, and IIH has recently been considered among these indications.

These investigators presented a case report of a year old female with a maximum BMI of She also developed migraine headaches. After a waxing and waning course and various medical treatments, the patient underwent laparoscopic Roux-en-Y gastric bypass surgery with anterior repair of hiatal hernia. Dramatic improvement in IIH headaches occurred by 4 months post-procedure and was maintained at 1 year, when she reached her weight plateau with a BMI of This added to the small number of case reports and retrospective analyses of the successful treatment of IIH with gastric bypass surgery, and brought this data from the surgical literature into the neurological domain.

It offered insight into an early time course for symptom resolution, and explored the impact of weight-loss surgery on migraine headaches. The authors concluded that this treatment modality should be further investigated prospectively to analyze the rate of headache improvement with weight loss, the amount of weight loss needed for clinical improvement, and the possible correlation with improvement in papilledema.

Handley et al systematically reviewed the effect of bariatric weight reduction surgery as a treatment for IIH. These investigators performed a comprehensive literature search using the following databases: No restrictions were placed on these searches, including the date of publication. A total of 85 publications were identified, and after initial appraisal, 17 were included in the final review.

Post-operative lumbar puncture opening pressure was shown to decrease by an average of The authors concluded that bariatric surgery for weight loss is associated with alleviation of IIH symptoms and a reduction in intracranial pressure. Furthermore, an improvement was observed in patients where conventional treatments, including neurosurgery, were ineffective.

They stated that further prospective randomized studies with control groups and a larger number of participants are lacking within the published studies to date. Pujol Gebelli et al stated that laparoscopic gastric plication is a new technique derived from sleeve gastrectomy. Plication of the greater curvature produces a restrictive mechanism that causes weight loss.

The results of the first cases where this technique has been applied in this hospital were presented. Plication of the gastric greater curvature was performed under general anesthetic and by laparoscopy using 3 lines of sutures and with an orogastric probe as a guide. Results of the morbidity, mortality and weight loss were presented. A total of 13 patients were operated on 7 women.

The maximum BMI varied between The most frequently found morbidity was nausea and vomiting. The authors concluded that laparoscopic gastric plication is a new surgical technique which gives equivalent short-term results as vertical gastrectomy. It is a reproducible and reversible technique with results and indications still to be validated.

Brethauer et al presented the results of a feasibility study using laparoscopic gastric plication for weight loss achieved without stapling or banding. After institutional review board approval, 2 methods were used to achieve laparoscopic gastric volume reduction. In the 1st group anterior plication [AP] , the anterior gastric wall was folded inward from the fundus to the antrum using 2 rows of running sutures.

The greater and lesser curvatures were approximated to create an intraluminal fold of the stomach. In the 2nd group greater curvature plication [GCP] , the short gastric vessels were divided, and the greater curvature was folded inward, with 2 suture lines to reduce the gastric capacity by a large intraluminal gastric fold.

The average pre-operative body mass index was Of the 15 patients, 9 underwent AP. For the 9 patients who underwent AP, the 6- and month endoscopic evaluations demonstrated comparable-size plications over time, except for in 1 patient, who had a partially disrupted fold.

Of the 6 patients who underwent GCP, the 6- and month follow-up endoscopic examinations demonstrated a durable intraluminal fold, except for in 1 patient, with a partial disruption at the distal fold owing to a broken suture. For patients completing 1 year of follow-up, the percentage of excess weight loss was No bleeding or infectious complications developed. The 1st patient in the GCP group required re-operation and plication reduction owing to gastric obstruction.

The early weight loss results have been encouraging, with better weight loss in patients who underwent GCP. Both cases were corrected by reoperation. No mortality was observed. The authors concluded that laparoscopic adjustable gastric banded plication provides both restrictive and reductive effects and is reversible. The technique is safe, feasible, and reproducible and can be used as an alternative bariatric procedure. Ji et al conducted a systematic review of the currently available literature regarding the outcomes of laparoscopic gastric plication LGP for the treatment of obesity.

The authors' systematic review yielded 14 studies encompassing 1, LGP patients. Peri-operative data were collected from each study and recorded. Mean pre-operative BMI ranged from Operative time ranged from 50 to Hospital stay varied from 0. The authors concluded that early reports with LGP were promising with a favorable short-term safety profile. However, it remains unclear if weight loss following LGP is durable in the long-term. They stated that additional prospective comparative trials and long-term follow-up are needed to further define the role of LGP in the surgical management of obesity.

In a prospective study, Zeinoddini evaluated safety and effectiveness of LGP on adolescents. Laparoscopic gastric plication was performed in 12 adolescents 9 females and 3 males. Mean SD age of the patients was Mean pre-operative weight and BMI were All medical co-morbidities were improved after LGP.

There were no deaths. One patient required replication 4 days post-operatively due to obstruction at the site of the last knot. No other major complications were observed. No patient required re-hospitalization. The authors concluded that LGP has the potential of being an ideal weight loss surgery for adolescents, resulting in excellent weight loss and minimal psychological disruption.

It is associated with a minimal risk of leakage, bleeding, and nutritional deficiency. However, they stated that large well-designed studies with long-term follow-up are needed.

It is thought that these patients lose restriction because of the dilated gastrojejunostomy and thus overeat.

Surgeons have tried endoscopic injection of sclerosing agents to create scar and a smaller anastomosis, with variable effects. In , Loewen and Barba evaluated the injection of morrhuate sodium as sclerotherapy to decrease the diameter of the gastrojejunostomy anastomosis following gastric bypass. A total of 71 patients underwent sclerotherapy at their gastrojejunostomy from July to August A retrospective review was performed of this group, including chart review, follow-up data with weight checks, and telephone interview findings.

The average age of the patients was 45 years and all but 4 patients were women. Sclerotherapy was done an average of 2. The starting weight at endoscopy was an average of lb lb heavier than the average nadir weight. The average diameter of the gastrojejunostomy was 2. An average of 13 mL morrhuate sodium was injected circumferentially. No hospital admissions or complications occurred in relation to the procedure.

The analysis showed a high body mass index at endoscopy to be the only predictive factor for successful weight maintenance or loss. In a article, Spaulding, Osler and Patlak studied endoscopic sclerotherapy with sodium morrhuate of a dilated gastrojejunostomy in gastric bypass patients.

Their weight trends before and after treatment were assessed by paired t test. A total of 32 patients who were gaining weight after gastric bypass underwent sclerotherapy of their dilated gastrojejunostomy. The timing of treatment ranged from 10 to months average 56 after Roux-en-Y gastric bypass. Before sclerotherapy, patients were gaining weight at a rate of. After treatment, they were losing weight at a rate of. Endoscopic duodenal-jejunal bypass is the endoscopic placement of a duodenal-jejunal bypass sleeve eg, EndoBarrier which lines the first section of the small intestine causing food to be absorbed further along the intestine.

Once implanted, the device is purported to influence gastrointestinal hormones and satiety. It is suggested to promote weight loss in individuals who are potential candidates for bariatric surgery, but are too heavy to safely undergo the procedure. An UpToDate review on " Bariatric surgical operations for the management of severe obesity: The EndoBarrier is cm long and it extends from the proximal duodenum to the mid-jejunum and thus mimics a duodenojejunal bypass.

The ValenTx is a cm barrier device that extends from the gastroesophageal junction to the jejunum. The EndoBarrier, an endoscopically delivered duodeno-jejunal bypass liner DJBL , is a plastic flexible tube that is placed in the duodenal bulb, directly behind the pylorus.

It extends from the duodenum to the proximal jejunum. Recent studies have suggested that the use of EndoBarrier has resulted in significant weight reduction in comparison to control-diet patients. Schouten et al noted that the endoscopically placed duodenal-jejunal bypass sleeve or EndoBarrier Gastrointestinal Liner has been designed to achieve weight loss in morbidly obese patients.

These researchers reported on the first European experience with this device. A multi-center, randomized clinical trial was performed. A total of 41 patients were included and 30 underwent sleeve implantation; 11 patients served as a diet control group. All patients followed the same low-calorie diet during the study period. The purpose of the study was to determine the safety and effectiveness of the device. A total of 26 devices were successfully implanted.

In 4 patients, implantation could not be achieved. The remaining patients all completed the study. Mean procedure time was 35 mins range of 12 to for a successful implantation and 17 mins range of 5 to 99 for explantation. There were no procedure related adverse events. Initial mean BMI was Mean excess weight loss after 3 months was Absolute change in BMI at 3 months was 5.

Type 2 diabetes mellitus was present at baseline in 8 patients of the device group and improved in 7 patients during the study period lower glucose levels, HbA1c, and medication requirements. The authors concluded that the EndoBarrier Gastrointestinal Liner is a feasible and safe non-invasive device with excellent short-term weight loss results. The device also has a significant positive effect on type 2 diabetes mellitus. Moreover, they stated that long-term randomized and sham studies for weight loss and treatment of diabetes are necessary to determine the role of the device in the treatment of morbid obesity.

Escalona et al evaluated safety, weight loss, and cardio-metabolic changes in obese subjects implanted with the DJBL for 1 year.

Morbidly obese subjects were enrolled in a single-arm, open-label, prospective trial and implanted with the DJBL. Primary endpoints included safety and weight change from baseline to week Secondary endpoints included changes in waist circumference, blood pressure, lipids, glycemic control, and metabolic syndrome.

Three subjects could not be implanted due to short duodenal bulb. There were no procedure-related complications and there were 15 early endoscopic removals.

In the week completer population, total body weight change from baseline was There were also significant improvements in waist circumference, blood pressure, total and low-density lipoprotein cholesterol, triglycerides, and fasting glucose. The authors concluded that the DJBL is safe when implanted for 1 year, and results in significant weight loss and improvements in cardio-metabolic risk factors.

They stated that these results suggested that this device may be suitable for the treatment of morbid obesity and its related comorbidities. Verdam et al stated that the prevalence of obesity is increasing worldwide. Its primary treatment consists of lifestyle changes. Operations such as the placement of a gastric band or a gastric bypass can, however, lead to complications and necessitate secondary interventions.

In search of less invasive treatments, placement of the EndoBarrier duodenal jejunal bypass liner appears to be a promising, safe and effective method for facilitating weight loss. Concomitant positive effects on cardiovascular risk factors including diabetes type 2 were observed. The authors noted that a multi-center trial is currently underway to examine the mechanism behind these effects. Mathus-Vliegen stated that the EndoBarrier is a unique concept that starts to ameliorate the symptoms of diabetes mellitus type 2, soon after positioning.

Sufficient implant training is required, but problems can still occur e. The stability of the anchors and the tolerability of the device still leave much to be desired. Only 7 studies on the EndoBarrier are available and these are mostly small in size, short-term and with limited follow-up, and many questions regarding the safety and long-term effects of the device remain. The author concluded that this calls for a large, long-term, randomized, placebo-controlled, double-blind trial.

Lessons should have been learned from the disastrous results with intra-gastric balloon implantation before commercializing another such product. Bolton et al stated that weight regain secondary to VBG pouch dilation is a typical referral for bariatric surgeons.

A retrospective review was completed for patients with a previous VBG presenting with weight regain between to Complications following RYGB include: The median length of stay following RYGB was 6 days compared to 1. The authors concluded that the findings of this study suggested that while RYGB revision may achieve greater weight loss, the complication rates and severity is discouraging.

StomaphyX may be a safe alternative. Moreover, they stated that further technical modifications of the device and longer follow-up may clarify the role of this approach. Goyal et al examined if endoluminal reduction of gastric pouch and stoma using StomaphyX results in sustained weight loss in patients who regain weight after gastric bypass.

Retrospective chart review was performed on 59 post-gastric bypass patients who underwent revision of gastric pouch using StomaphyX from to Post-procedure weight at 1 week, 1 month, and 6 months follow-up as well as weight at the time of the review was recorded for each patient.

Average weight loss and excess body weight loss EBWL were 2. At the time of review, the average follow-up was 41 months, average weight loss was 1. Endoscopy in 12 patients at average 18 months follow-up showed no sustained reduction in pouch and stoma size.

The authors concluded that StomaphyX resulted in weight loss that is not sustained on long-term follow-up. Pouch and stoma tend to regain their pre-procedure size on follow-up. They stated that StomaphyX cannot be recommended as a weight loss strategy in post-gastric bypass patients who regain weight.

There is currently no well-defined management protocol for this complication. Through systematic review, these investigators analyzed the results of endoscopic dilation in patients with stenosis, including complication and success rates.

The PubMed database was searched for relevant studies published each year from to , and 23 studies were identified for analysis. Only papers describing the treatment of anastomotic stricture after RYGB were included, and case-reports featuring less than 3 patients were excluded. The mean age of the trial populations was Through-the-scope balloons were used in 16 studies Other complications were also reported: The authors concluded that endoscopic treatment of stenosis is safe and effective; however, further high-quality randomized controlled trials are needed to confirm these findings.

Thompson et al stated that weight regain or insufficient loss after RYGB is common. This is partially attributable to dilatation of the gastro-jejunostomy, which diminishes the restrictive capacity of RYGB. Endoluminal interventions for GJ reduction are being explored as alternatives to revision surgery. These researchers performed a randomized, blinded, sham-controlled trial to evaluate weight loss after sutured transoral outlet reduction TORe. Intra-operative performance, safety, weight loss, and clinical outcomes were assessed.

Subjects who received TORe had a significantly greater mean percentage weight loss from baseline 3. As-treated analysis also showed greater mean percentage weight loss in the TORe group than controls 3. The groups had similar frequencies of adverse events. These results were achieved using a superficial suction-based device; greater levels of weight loss could be achieved with newer, full-thickness suturing devices.

These researchers stated that TORe is one approach to avoid weight regain; moreover, they noted that a longitudinal multi-disciplinary approach with dietary counseling and behavioral changes are needed for long-term results. Jirapinyo et al evaluated the technical feasibility, safety, and early outcomes of a procedure using a commercially available endoscopic suturing device to reduce the diameter of the GJA.

An endoscopic suturing device was used to place sutures at the margin of the GJA in order to reduce its aperture. On chart review, clinical data were available at 3, 6, and 12 months.

Average anastomosis diameter was The mean weight loss in successful cases was There were no major complications. The authors concluded that this case series demonstrated the technical feasibility, safety, and effectiveness of performing GJ reduction using a commercially available endoscopic suturing device. They stated that this technique may represent an effective and minimally invasive option for the management of weight regain in patients with RYGB.

Dakin and colleagues noted that weight recidivism after RYGB is a challenging problem for patients and bariatric surgeons alike. Traditional operative strategies to combat weight regain are technically challenging and associated with a high morbidity rate.

Endoluminal interventions are thus an attractive alternative that may offer a good combination of results coupled with lower peri-procedure risk that might one day provide a solution to this increasingly prevalent problem.

These investigators systematically reviewed the available literature on endoluminal procedures used to address weight regain after RYGB, with specific attention to the safety profile, effectiveness, cost, and current availability. This retrospective review focused only on endoluminal procedures that were performed for weight regain after RYGB, as opposed to primary endoluminal obesity procedures. Several methods of endoluminal intervention for weight regain were reviewed, ranging from injection of inert substances to suturing and clipping devices.

The literature review showed the procedures on the whole to be well-tolerated with limited effectiveness. The majority of the literature was limited to small case-series. Most of the reviewed devices were no longer commercially available.

The authors concluded that endoluminal therapy represents an intriguing strategy for weight regain after RYGB. However, the current and future technologies must be rigorously studied and improved such that they offer durable, repeatable, cost-effective solutions. Pauli et al stated that despite advances in many areas of therapeutic endoscopy, the development of an effective endoscopic suturing device has been elusive.

These researchers evaluated the safety and effectiveness of a suturing device to place and secure sutures within normal, in-vivo human colonic tissue prior to surgical resection.

Patients undergoing elective colectomy were enrolled in this treat-and-resect model. The OverStitch endoscopic suturing device Apollo Endosurgery, Austin, TX was used to place sutures in healthy colonic tissue during a min, time-limited period. Clinical and operative data were recorded. Seven sutures were successfully placed, incorporating a total of 10 tissue bites in a mean of On inspection of the explanted tissue, all sutures were found to be located sub-serosal no full thickness bites were taken.

The suture and cinch elements were judged to be effective in the majority of cases. One device-related issue did not inhibit the ability to oppose tissue or place the cinch. There were no intra-operative or post-operative complications. The authors concluded that the OverStitch permitted safe and effective suturing in an in-vivo human colon model.

The sutures were placed at a consistent sub-serosal depth and at no point risked iatrogenic injury to adjacent structures. Technical issues with the device were infrequent and did not inhibit the ability to place sutures effectively. This clinical trial is designed to study the Apollo OverStitch endoscopic suturing device that has already been approved by the FDA as an option for bariatric surgery revision without having to re-operate on the patient.

The investigators believe that the endoscopic technique may be able to provide weight loss without having to re-operate on the patient. A total of 22 obese patients mean age of After dissecting the greater omentum and short gastric vessels, the gastric greater curvature plication with 2 rows of non-absorbable suture was performed under the guidance of a F bougie. The data were collected during follow-up examinations performed at 1, 3, 6, and 12 months post-operatively.

All procedures were performed laparoscopically. The mean operative time was There were no deaths or post-operative major complications that needed re-operation. Decreases in the index for homeostasis model assessment of insulin resistance HOMA-IR and in insulin and glucose concentrations were observed. The authors concluded that the early outcomes of LGCP as a novel treatment for obese Chinese with a relatively low BMI were satisfactory with respect to the effectiveness and low incidence of major complications.

They stated that additional long-term follow-up and prospective, comparative trials are still needed. In a pilot study, Legner et al examined the effectiveness of transoral mucosal excision sutured gastroplasty for the treatment of gastro-esophageal reflux disease GERD and obesity. Obese patients BMI greater than 35 underwent a psychological evaluation and tests for co-morbidities. Under general anesthesia, a procedure was performed at the gastro-esophageal junction including mucosal excision, suturing of the excision beds for apposition, and suture knotting.

One patient with micrognathia could not undergo the required pre-procedural passage of a 60 F dilator and was excluded. The first 2 GERD patients had incomplete procedures due to instrument malfunction.

The subsequent 5 subjects had a successfully completed procedure. Four patients were treated for obesity and had an average excess weight loss of Of these patients, 1 had an 8-mm outlet at the end of the procedure recognized on video review -- a correctable error -- and another vomited multiple times post-operatively and loosened the gastroplasty sutures. The treated GERD patient had resolution of reflux-related symptoms and is off all anti-secretory medications at 2-year follow-up.

Her DeMeester score was 8. The authors concluded that the initial human clinical experience showed promising results for effective and safe GERD and obesity therapy. Georgiadou et al summarized the available evidence about the efficacy and safety of laparoscopic mini-gastric bypass LMGB.

These investigators performed a systematic search in the literature, and PubMed and reference lists were scrutinized end-of-search date: For the assessment of the eligible articles, the Newcastle-Ottawa quality assessment scale was used.

A total of 10 eligible studies were included in this study, reporting data on 4, patients. Moreover, resolution or improvement in all major associated medical illnesses and improvement in overall Gastrointestinal Quality of Life Index score were recorded.

Major bleeding and anastomotic ulcer were the most commonly reported complications. The latter were conducted due to a variety of medical reasons such as inadequate or excessive weight loss, malnutrition, and upper gastro-intestinal bleeding. The authors concluded that LMGB represents an effective bariatric procedure; its safety and minimal post-operative morbidity seem remarkable.

They stated that randomized comparative studies seem mandatory for the further evaluation of LMGB. These researchers included 10 studies with a total of patients that primarily investigated a prototype of the DJBL.

In high-grade obese patients, short-term excess weight loss was observed. For the remaining patient-relevant endpoints and patient populations, evidence was either not available or ambiguous. The authors do not yet recommend the device for routine use. Parikh et al compared bariatric surgery versus intensive medical weight management MWM in patients with type 2 diabetes mellitus T2DM who do not meet current National Institutes of Health criteria for bariatric surgery and examined if the soluble form of receptor for advanced glycation end products sRAGE is a biomarker to identify patients most likely to benefit from surgery.

A total of 57 patients with T2DM and BMI 30 to 35, who otherwise met the criteria for bariatric surgery were randomized to MWM versus surgery bypass, sleeve or band, based on patient preference.

The primary outcomes assessed at 6 months were change in homeostatic model of insulin resistance HOMA-IR and diabetes remission. The surgery group lost more weight 7. There were no mortalities. Baseline sRAGE may predict patients most likely to benefit from surgery. However, they stated that these findings need to be confirmed with larger studies. Sjostrom et al noted that short-term studies showed that bariatric surgery causes remission of diabetes. The long-term outcomes for remission and diabetes-related complications are not known.

These researchers determined the long-term diabetes remission rates and the cumulative incidence of microvascular and macrovascular diabetes complications after bariatric surgery. The Swedish Obese Subjects SOS is a prospective matched cohort study conducted at 25 surgical departments and primary health care centers in Sweden. Of patients recruited between September 1, , and January 31, , of 2, control patients and of 2, surgery patients had type-2 diabetes at baseline.

For the current analysis, diabetes status was determined at SOS health examinations until May 22, Information on diabetes complications was obtained from national health registers until December 31, For diabetes assessment, the median follow-up time was 10 years interquartile range [IQR], 2 to 15 and 10 years IQR, 10 to 15 in the control and surgery groups, respectively.

For diabetes complications, the median follow-up time was Main outcome measures were diabetes remission, relapse, and diabetes complications. The diabetes remission rate 2 years after surgery was At 15 years, the diabetes remission rates decreased to 6. With long-term follow-up, the cumulative incidence of microvascular complications was Macrovascular complications were observed in The authors concluded that in this very long-term follow-up observational study of obese patients with type 2 diabetes, bariatric surgery was associated with more frequent diabetes remission and fewer complications than usual care.

Moreover, they stated that these findings require confirmation in randomized trials. Yu et al evaluated the long-term effects of bariatric surgery on type 2 diabetic patients. Randomized controlled trials RCTs and cohort studies of bariatric surgery for diabetes patients that reported data with more than 2 years of follow-up were included.

They used rigorous methods to screen studies for eligibility and collected data using standardized forms. Where applicable, these investigators pooled data by meta-analyses. A total of 26 studies, including 2 RCTs and 24 cohort studies that enrolled 7, patients, proved eligible.

Despite the differences in the design, those studies consistently showed that bariatric surgery offered better treatment outcomes than non-surgical options. Pooling of cohort studies showed that BMI decreased by Diabetes was improved or in remission in The authors noted that bariatric surgery may achieve sustained weight loss, glucose control, and diabetes remission.

Moreover, they stated that large randomized trials with long-term follow-up are warranted to demonstrate the effect on outcomes important to patients e. There are a growing number of unblinded trials comparing bariatric surgery with medical therapy for the treatment of type 2 diabetes ….

Despite these impressive metabolic results, concerns remain about acute post-operative complications including need for re-operations and re-hospitalizations and rare, but potentially severe, adverse events; the long-term success rates in maintaining weight loss; and the reproducibility of the results in patients with an extensive history of diabetes or with a different surgical team. Some weight regain is typical within two to three years of bariatric procedures, and different bariatric procedures result in different levels of weight loss and corresponding reductions in glycemia.

The electrical impulses are purported to block vagus nerve signals in the abdominal region, inhibiting gastric motility and increasing satiety. However, there is currently insufficient evidence to support the VBLOC vagal nerve blocking therapy for the treatment of obesity. In an open-label, 3-center study, Camilleri et al evaluated the effects of vagal blocking VBLOC therapy on excess weight loss EWL , safety, dietary intake, and vagal function.

Electrodes were implanted laparoscopically on both vagi near the esophago-gastric junction to provide electrical block. Patients were followed for 6 months for body weight, safety, electrocardiogram, dietary intake, satiation, satiety, and plasma pancreatic polypeptide PP response to sham feeding. To specifically assess device effects alone, no diet or exercise programs were instituted. A total of 31 patients mean BMI of Mean EWL at 4 and 12 weeks and 6 months after implant was 7. There were no deaths or device-related serious adverse events AEs.

Three patients had serious AEs that required brief hospitalization, 1 each for lower respiratory tract, subcutaneous implant site seroma, and Clostridium difficile diarrhea. The authors concluded that intermittent, intra-abdominal vagal blocking is associated with significant EWL and a desirable safety profile. A total of subjects were enrolled at 15 centers.

Devices in both groups performed regular, low-energy safety checks. The authors concluded that VBLOC therapy to treat morbid obesity was safe, but weight loss was not greater in treated compared to controls; clinically important weight loss, however, was related to hours of device use. Post-study analysis suggested that the system electrical safety checks low charge delivered via the system for electrical impedance, safety, and diagnostic checks may have contributed to weight loss in the control group.

In an open-label study, Shikora et al evaluated the effect of intermittent vagal blocking VBLOC on weight loss, glycemic control, and blood pressure BP in obese subjects with diabetes mellitus type-2 DM2. One serious AE pain at implant site was easily resolved. The authors stated that additional long-term data and continued follow-up of the ReCharge study are needed to further characterize the safety and effectiveness profile of vBloc therapy.

Natural orifice transluminal endoscopic surgery NOTES is being explored for a variety of surgeries, including bariatric procedures. NOTES procedures are incisionless surgeries performed with an endoscope passed through the mouth. Tissue approximation and closure devices are being developed for use in conjunction with various endoscopic procedures, including NOTES. Restorative obesity surgery, endoluminal ROSE procedure is suggested for the treatment of weight regain following gastric bypass surgery due to a gradual expansion of the gastric pouch.

The stomach is accessed orally via an endoscope and reduced in size using an endoscopic closure device. Transoral gastroplasty TG , also referred to as vertical sutured gastroplasty or endoluminal vertical gastroplasty, is an incisionless procedure in which the stomach is purportedly restricted with staples or sutures by using endoscopic surgical tools guided through the mouth and esophagus.

Main outcome measure was technical feasibility. These researchers successfully used an endoscopic free-hand suturing system in 4 subjects, thus demonstrating the technical feasibility of a novel technique to mimic the anatomic manipulations created by surgical sleeve gastrectomy endoscopically. The authors concluded that endoscopic sleeve gastroplasty ESG for treatment of obesity is feasible. The main drawback of this study was that it was a pilot feasibility study with small number of subjects.

Sharaiha et al stated that novel endoscopic techniques have been developed as effective treatments for obesity. Recently, reduction of gastric volume via endoscopic placement of full-thickness sutures, termed ESG, has been described. These investigators evaluated the safety, technical feasibility, and clinical outcomes for ESG. Between August and May , ESG was performed on 10 patients using an endoscopic suturing device. Their weight loss, waist circumference, and clinical outcomes were assessed.

Mean patient age was There were no significant adverse events noted. The differences observed in mean BMI and waist circumference were 4. The authors concluded that ESG is effective in achieving weight loss with minimal adverse events. They stated that this approach may provide a cost-effective out-patient procedure to add to the steadily growing armamentarium available for treatment of this significant epidemic.

Lopez-Nava et al described the ESG used in 50 patients. The goal of this procedure is to reduce the gastric lumen into a tubular configuration, with the greater curvature modified by a line of sutured plications.

General anesthesia with endotracheal intubation is needed. An endoscopic suturing system requiring a specific double-channel endoscope delivers full-thickness sets of running sutures from the antrum to the fundus. Patients were admitted and observed, with discharge planned within 24 hours.

Post-procedure out-patient care included diet instruction with intensive follow-up by a multi-disciplinary team. Voluntary oral contrast and endoscopy studies were scheduled to evaluate the gastroplasty at 3, 6, and 12 months. The technique was applied in 50 patients 13 men with an average BMI of Procedure duration averaged 66 mins during which 6 to 8 sutures on average were placed.

All patients were discharged in less than 24 hours. There were no major intra-procedural, early, or delayed adverse events. Weight loss parameters were satisfactory, mean BMI changes from Oral contrast studies and endoscopy revealed sleeve gastroplasty configuration at least until 1 year of follow-up. The authors concluded that ESG is a safe, effective, and reproducible primary weight loss technique. Furthermore, a Cochrane review on "Surgery for weight loss in adults" Colquitt et al, as well as an UpToDate review on " Bariatric surgical operations for the management of severe obesity: Descriptions " Lim, do not mention endoscopic sleeve gastroplasty as a therapeutic option.

In a pilot study, Sullivan and colleagues evaluated the use of endoscopic aspiration therapy for the treatment of obesity. This method entails endoscopic placement of a gastrostomy tube A-Tube and the AspireAssist siphon assembly Aspire Bariatrics, King of Prussia, PA to aspirate gastric contents 20 minutes after meal consumption. These researchers performed a study of 18 obese subjects who were randomly assigned 2: Lifestyle intervention comprised a session diet and behavioral education program; 10 of the 11 subjects who underwent aspiration therapy and 4 of the 7 subjects who underwent lifestyle therapy completed the 1st year of the study.

After 1 year, subjects in the aspiration therapy group lost There were no AEs of aspiration therapy on eating behavior and no evidence of compensation for aspirated calories with increased food intake. No episodes of binge eating in the aspiration therapy group or serious AEs were reported. The authors concluded that aspiration therapy appeared to be a safe and effective long-term weight loss therapy for obesity.

These preliminary findings from a pilot study need to be validated by well-designed studies. Forssell and Noren evaluated the effectiveness of a novel device, the AspireAssist aspiration therapy system, for the treatment of obesity.

After 4 weeks taking a very-low-calorie diet, 25 obese men and women BMI A low-profile valve was installed 14 days later and aspiration of gastric contents was performed approximately 20 minutes after meals 3 times per day. Cognitive behavioral therapy was also started. At month 6, mean weight lost was The mean percentage EWL was No clinically significant changes in serum potassium or other electrolytes occurred.

The authors concluded that in this study, substantial weight loss was achieved with few complications using the AspireAssist system, suggesting its potential as an attractive therapeutic device for obese patients. A total of 25 obese subjects, mean age of 48 years range of 33 to 65 were included in this study. A custom gastrostomy tube A-tube was percutaneously inserted during a gastroscopy performed under conscious sedation.

Drainage and irrigation of the stomach were performed 3 times daily, 20 mins after each meal, for 1 to 2 years. Efficient aspiration required thorough chewing of ingested food. Treatment included a cognitive behavioral weight loss program. Mean BMI at inclusion was Quality of life, as measured with EQ-5D, improved from 0.

After 2 years BMI was There were no serious AEs or electrolyte disorders. The authors concluded that aspiration therapy is a safe and efficient treatment for obesity, and weight reduction improves quality of life. Excess weight was approximately halved in a year, with weight stability if treatment was continued; and long-term results remain to be investigated. It is unclear whether firm conclusions can be drawn from a person observational study.

This study only encompasses treatment during 1 to 2 years. Long-term patency is still unknown. It is our belief that once the desired weight goal is achieved many, if not most, patients will need to continue aspiration therapy, albeit possibly at a reduced frequency, to maintain weight stability. In this week clinical trial, a total of subjects with a BMI of A total of The most frequently reported AEs were abdominal pain and discomfort in the peri-operative period and peristomal granulation tissue and peristomal irritation in the post-operative period.

Serious AEs were reported in 3. On June 14, , the FDA approved the AspireAssist device to assist in weight loss in patients aged 22 and older who are obese, with a BMI of 35 to 55, and who have failed to achieve and maintain weight loss through non-surgical weight-loss therapy. Side effects related to use of the AspireAssist include occasional indigestion, nausea, vomiting, constipation and diarrhea.

The AspireAssist is contraindicated in those with certain conditions, including uncontrolled hypertension, diagnosed bulimia, diagnosed binge eating disorder, night eating syndrome, certain types of previous abdominal surgery, pregnancy or lactation, inflammatory bowel disease or stomach ulcers.

The AspireAssist is also contraindicated in patients with a history of serious pulmonary or cardiovascular disease, coagulation disorders, chronic abdominal pain or those at a high-risk of medical complications from an endoscopic procedure. Furthermore, the AspireAssist device it is not indicated for use in short durations in those who are moderately overweight.

In a post-market study, Nystrom and colleagues evaluated long-term safety and efficacy of aspiration therapy AT in a clinical setting in 5 European clinics. A total of participants, with BMI of Mean baseline BMI was Mean percent total weight loss at 1, 2, 3, and 4 years, respectively, was Clinically significant reductions in glycated hemoglobin HbA1C , triglycerides, and blood pressure were observed.

The authors concluded that the findings of this study established that AT is a safe, effective, and durable weight loss therapy in people with classes II and III obesity in a clinical setting. Kumar and associates noted that weight management is increasingly incorporating endoscopic bariatric therapy EBT.

As the global burden of obesity and its co-morbidities has increased, it is evident that novel therapeutic approaches will be necessary to address the obesity epidemic. EBTs offer greater efficacy than diet and lifestyle modification and lower invasiveness than bariatric surgery.

The FDA has approved 2 intra-gastric balloons and aspiration therapy AT for the treatment of obesity: These devices have proven safe and effective in clinical trials and are gaining commercial acceptance in the USA; the Orbera has been used extensively outside the USA for over 20 years. These devices will need to be delivered in the context of a multi-disciplinary weight loss program, integrating comprehensive care of obesity.

Patient selection is important, and ensuring appropriate patient expectations and understanding of alternatives such as pharmacologic therapy and surgery is essential.

With several EBTs on the horizon, patients with obesity will have an even broader array of safe and effective options for weight management in the future. The authors stated that AT addresses a broader BMI range and offers the potential for a significant and durable weight loss. Pajot and co-workers stated that EBT is a rapidly developing area that has now seen FDA approval of 6 endoscopic bariatric devices and procedures and there are a number of other novel EBTs progressing through various stages of development with newly published findings.

This paper aimed to assist readers in either selecting an appropriate therapy for their patient or deciding to incorporate these therapies into their practice. This paper provided an updated review of the available data on EBTs, both FDA approved and not, with a particular focus on safety and effectiveness, as well as guidance for discussing with patients the decision to use endoscopic therapies.

The authors of a large meta-analysis of Orbera concluded its ideal balloon volume to be to ml. AspireAssist has had favorable effectiveness and safety data published in a large RCT. A large study of endoscopic sleeve gastroplasty has published findings at up to 24 months showing promising durability.

Elipse, a swallowed intra-gastric balloon not requiring endoscopy for either insertion or removal, has had early favorable results published.

A magnet-based system for creation of a gastrojejunostomy has published favorable findings from its pilot study. The authors concluded that EBTs are safe and effective therapies for weight loss when used in conjunction with lifestyle changes and fill an important gap in the management of obesity.

These researchers stated that more study is needed to understand the role of EBTs used in combination or in sequence with medications and bariatric surgery. Christensen and colleagues noted that AT with AspireAssist is a novel endoscopic obesity treatment. AspireAssist was recently approved by the FDA, and it induced weight loss comparable to the weight loss observed after bariatric surgery, but with a lower risk of complications. The authors stated that few clinical studies about the safety and efficacy of AspireAssist have been carried out and published.

Thus, further intervention studies evaluating acute as well as long-term effects are needed. I could have picked French literature, full of slim little books, but I intentionally went with Russian novels and their reputation for ponderousness.

In Goncharov's Oblomov , for example, the title character spends the first hundred pages just getting out of bed. If you open that tweet in a browser, you'll see the page is KB big. For a single tweet. Or consider this word-long Medium article on bloat , which includes the sentence: Racked by guilt, so rattled by his crime that he even forgets to grab the money, Raskolnikov finds himself pursued in a cat-and-mouse game by a clever prosecutor and finds redemption in the unlikely love of a saintly prostitute.

Dostoevski wrote this all by hand, by candlelight, with a goddamned feather. Here's an article from the Yorkshire Evening Post, typical of thousands of local news sites.

It does not explore the relationship between history and individual will at all: This poignant story of two foods touching on a hospital plate could almost have been written by Marcel Proust, for whom the act of dipping a morsel of cake in a cup of tea was the starting point for an expanding spiral of vivid recollections, culminating in the realization, nine volumes and 3 megabytes of handwritten prose later, that time and memory themselves are only an illusion.

I could go on in this vein. And I will, because it's fun! Here is an instructional article on Best Practices for Increasing Online performance that is 3. Remember when Google Maps, the most sophisticated web app of its day, was thirty-five times smaller than a modern news article? Web obesity can strike in the most surprising places. Tim Kadlec , for example, is an excellent writer on the topic of performance.

His personal site is a model of parsimony. He is full of wisdom on the topic of reducing bloat. But the slides from his recent talk on performance are only available as a 9 megabyte web page, or a 14 megabyte PDF. The article somehow contrives to be 18 megabytes long, including in the page view I measured a 3 megabyte video for K-Y jelly, an "intimate lubricant".

It takes a lot of intimate lubricant to surf the unfiltered Web these days. What the hell is up? These pages are bad enough on a laptop my fan spun for the entire three weeks I was preparing this talk , but they are hell on mobile devices. So publishers are taking action. Facebook made the announcement on a 6. Further down the page, you'll find a 41 megabyte video, the only way to find out more about the project. In the video, this editor rhapsodizes about exciting misfeatures of the new instant format like tilt-to-pan images, which means if you don't hold your phone steady, the photos will drift around like a Ken Burns documentary.

Facebook has also launched internet. The stirring homepage includes stories of people from across the developing world, and what getting Internet access has meant for them. When I left the internet. Surely, you'll say, there's no way the globe in the background of a page about providing universal web access could be a giant video file?

But I am here to tell you, oh yes it is. They load a huge movie just so the globe can spin. This is Facebook's message to the world: I've traveled enough here in Australia to know that in rural places in Tasmania and Queensland, vendors treat WiFi like hundred-year-old brandy. You're welcome to buy as much of it as you want, but it costs a fortune and comes in tiny portions. And after the third or fourth purchase, people start to look at you funny.

Even in well-connected places like Sydney, we've all had the experience of having a poor connection, and almost no battery, while waiting for some huge production of a site to load so we can extract a morsel of information like a restaurant address. The designers of pointless wank like that Facebook page deserve the ultimate penalty. They should be forced to use the Apple hockey puck mouse for the remainder of their professional lives.

Why not just serve regular HTML without stuffing it full of useless crap? The question is left unanswered. The AMP project is ostentatiously open source, and all kinds of publishers have signed on. Out of an abundance of love for the mobile web, Google has volunteered to run the infrastructure, especially the user tracking parts of it.

Jeremy Keith pointed out to me that the page describing AMP is technically infinite in size. If you open it in Chrome, it will keep downloading the same 3.

If you open it in Safari, where the carousel is broken, the page still manages to fill 4 megabytes. These comically huge homepages for projects designed to make the web faster are the equivalent of watching a fitness video where the presenter is just standing there, eating pizza and cookies. The world's greatest tech companies can't even make these tiny text sites, describing their flagship projects to reduce page bloat, lightweight and fast on mobile. I can't think of a more complete admission of defeat.

He acknowledged the bloat, but explained that Google was "resource constrained" and had had to outsource this project. This admission moved me deeply, because I had no idea Google was in a tight spot.

So I spent a couple of hours of my own time making a static version of the AMP website. I began by replacing the image carousels with pictures of William Howard Taft, America's greatest president by volume. I think this made a marked improvement from the gratuitous animations on the original page.

By cutting out cruft, I was able to get the page weight down to half a megabyte in one afternoon of work. This is eight times smaller than the original page. I offered my changes to Google free of charge, but they are evidently too resource constrained to even find the time to copy it over. This project led me to propose the Taft Test: Does your page design improve when you replace every image with William Howard Taft?

At the very least, leave Taft there! You just admitted it looks better. I want to share with you my simple two-step secret to improving the performance of any website. Make sure that the most important elements of the page download and render first. You don't need all that other crap. Have courage in your minimalism. Of course you can! We knew how to make small websites in But we face pressure to make these sites bloated.

Even if it looked great and somehow included all the tracking and ads and social media crap they insisted on putting in. If you've ever struggled to lose weight, you know there are tricks people use to fool themselves into thinking they're thinner. You suck in your gut, wear a tight shirt, stand on a certain part of the scale. The same situation obtains with performance testing. People have invented creative metrics to persuade themselves that their molasses-like websites load fast.

Google has a popular one called SpeedIndex. You know it's from Google because they casually throw an integral sign into the definition. SpeedIndex is based on the idea that what counts is how fast the visible part of the website renders. It doesn't matter what's happening elsewhere on the page. It doesn't matter if the network is saturated and your phone is hot to the touch. It doesn't matter if the battery is visibly draining. Everything is OK as long as the part of the site in the viewport appears to pop into view right away.

Or, if like many mobile users, you start scrolling immediately and catch the 'unoptimized' part of the page with its pants down. There is only one honest measure of web performance: Everything else is bullshit. In conversations with web performance advocates, I sometimes feel like a hippie talking to SUV owners about fuel economy. They have all kinds of weirdly specific tricks to improve mileage. Deflate the front left tire a little bit.

Put a magnet on the gas cap. Fold in the side mirrors. Most of the talk about web performance is similarly technical, involving compression, asynchronous loading, sequencing assets, batching HTTP requests, pipelining, and minification. All of it obscures a simpler solution.

If you're only going to the corner store, ride a bicycle. If you're only displaying five sentences of text, use vanilla HTML. Hell, serve a textfile! Then you won't need compression hacks, integral signs, or elaborate Gantt charts of what assets load in what order. Browsers are really, really good at rendering vanilla HTML.

Nutritionists used to be big on this concept of a food pyramid. I think we need one for the web, to remind ourselves of what a healthy site should look like. Here is what I recommend for a balanced website in A solid base of text worth reading, formatted with a healthy dose of markup.

Some images, in moderation, to illustrate and punch up the visual design. A dollop of CSS. And then, very sparingly and only if you need it, JavaScript. Instead, here is the web pyramid as we observe it in the wild: Fat Ads Web designers! It's not all your fault. You work your heart out to create a nice site, optimized for performance.

The user's experience of your site is dominated by hostile elements out of your control. This is a screenshot from an NPR article discussing the rising use of ad blockers. The page is 12 megabytes in size in a stock web browser. The same article with basic ad blocking turned on is one megabyte. Every beacon, tracker and sharing button has its own collection of scripts that it needs to fetch from a third-party server.

Each request comes packed with cookies. More cookies are the last thing your overweight website needs. These scripts get served from God knows where and are the perfect vector for malware.

Advertisers will tell you it has to be this way, but in dealing with advertisers you must remember they are professional liars. I mean it as a job description.

An advertiser's job is to convince you to do stuff you would not otherwise do. Their task in talking to web designers is to persuade them that the only way to show ads is by including mountains of third-party cruft and tracking. The bloat, performance, and security awfulness, they argue, is the price readers pay for free content. I've come across these diagrams of the "adtech ecosystem", which I love.

They communicate the sordidness of advertising in the way simple numbers never could. By , we were blessed with And in we have of these things. They are all competing for the same little slice of your online spending. This booming industry is very complex—I believe intentionally so. When you're trying to understand a complex system, it can be helpful to zoom out and look at the overall flow of things. For example, here's a German diagram showing the energy budget of the Earth.

All kinds of complicated things happen to sunlight when it shines on plants or water, but you can ignore them completely and just measure the total energy that comes in and out. In the same spirit, let me sketch the way money is flowing in to the advertising bubble. In the beginning, you have the consumer.

In a misguided attempt at cultural sensitivity, I have chosen to represent the consumer with a kangaroo.

Consumers give money to merchants in exchange for goods and services. A portion of this money is diverted to pay for ads. Think of it as a little consumption tax on everything you buy. This money bounces around in the world of advertising middlemen until it ultimately flows out somewhere into someone's pocket. Right now it's ending up in the pockets of successful ad network operators like Facebook, Yahoo!

Think of how many ads you are shown in a given day, compared to the number of purchases you actually make. So thank God for investors! Right now they are filling the gap by pouring funding into this white-hot market. Their hope is that they will pick one of the few companies that ends up a winner. However, at some point the investors who are pouring money in will want to move to the right-hand side of this diagram.

And they'll want to get back even more money than they invested. When this happens, and I believe it is happening right now, something will have to give. Either we start buying more stuff, or a much bigger portion of our purchases goes to pay for ads… Or the bubble is going to burst. As it bursts, the remaining ad startups will grow desperate. They will search for ways to distinguish themselves from the pack with innovative forms of surveillance.

This why I've proposed we regulate the hell out of them now. I think we need to ban third-party tracking, and third party ad targeting. Ads would become dumb again, and be served from the website they appear on. Accepted practice today is for ad space to be auctioned at page load time.

The actual ads along with all their javascript surveillance infrastructure are pulled in by the browser after the content elements are in place. In terms of user experience, this is like a salesman arriving at a party after it has already started, demanding that the music be turned off, and setting up their little Tupperware table stand to harass your guests. It ruins the vibe. Imagine what server-side ad layout would mean for designers.

You would actually know what your pages are going to look like. You could load assets in a sane order. You could avoid serving random malware. Giant animations would no longer helicopter in at page load time, destroying your layout and making your users hate you. In fact, let's be even bolder in our thinking. I'm not convinced that online publishing needs to be ad-supported at all.

People dismiss micropayments, ignoring the fact that we already have a de facto system of micropayments that is working well. This chart from the New York Times shows how much money you spend per page load on an American cell phone network, based on the bandwidth used. For example, it costs thirty cents to load a page from Boston. This is nothing more than a micropayment to the telecommunications company. And I'm sure it's more revenue than Boston.

We're in a stupid situation where ads make huge profits for data carriers and ad networks, at the expense of everyone else. Advertisers will kick and scream at any attempt to make them go back to the dumb advertising model. But there's no evidence that dumb ads are any worse than smart ones. For years and years, poorly targeted advertising brought in enough money to fund entire television studios, radio shows, and all kinds of popular entertainment.

Dumb ads paid for the Batmobile. It costs a lot less to pay for a couple freelance journalists and a web designer than it does to film a sitcom. So why is it unthinkable to force everyone back to a successful funding model that doesn't break privacy? Of course, advertisers will tell us how much better TV in the old days could have been if they had been able to mount a camera on top of every set.

Dumb ads will mean less ad revenue, because a lot of online ad spending is fueled by extravagant promises around the possibilities of surveillance technology.

But the ad market is going to implode anyway when the current bubble bursts. The only question for publishers is whether to get ahead of this and reap the benefits, or circle down the drain with everybody else.

This has been a problem since forever, but as networks get faster, and publishing workflows get more complicated, it gets easier to accidentally post immense files to your website. And yet there's a gratuitous 3 megabyte image at the top of his most recent post.

Presumably this was a simple case of forgetting to resize an image. Without loading it on a slow connection, it's hard to notice the mistake. Making networks faster makes this problem worse. Here's a recent photo of a traffic jam in China. There are 50 lanes of cars here. Adding a 51st lane is not going to make things any better. Similarly, adding network capacity is not going to convince people to start putting less stuff on their website. Consider this recent Vice article about botnets.

At the top of the article is a pointless 3 megabyte photograph of headphones. This page fails the Taft Test. In this case there's no use blaming the author. Something in the publishing toolchain failed to minimize this enormous image. But the larger problem is that fast networks encourage people to include this kind of visual filler. As we rely more and more on compression tricks, minimization, caching, and server configuration, mistakes become harder to catch and potentially more expensive.

Here's another example, interesting for two reasons. First, the original image quality is awful. The picture looks like it was taken with a potato because it's a screen capture from a TV show.

Nevertheless, the image is enormous. If you load this website in Safari, the image is several megabytes in size. As a bonus, if you scroll to the bottom of the page, you see that a tiny animated GIF in the part of the page layout designers call "chum" is over a megabyte in size.

No one has fatter assets than Apple. Their site is laughably bloated. I think it may be a marketing trick. How big do you think this page is? Would you believe that it's bigger than the entire memory capacity of the iconic iMac? In fact, you could also fit the contents of the Space Shuttle Main Computer. Not just for one Shuttle, but the entire fleet 5 MB.

And you would still have room for a tricked out Macintosh SE The page is 51 megabytes big. It's the prevailing design aesthetic of today's web. I wrote an essay about this on Medium. Since this is a fifty minute talk, please indulge me while I read it to you in its entirety:

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