Obesity, the Other Gulf War Syndrome
Dr. Osamah Al Sanea, a leading Kuwaiti bariatric surgeon, is describing a stomach he recently stapled. “We don’t take anything out,” he says. “We make the stomach smaller. We restrict the fuel.” Then he opens his laptop and clicks on a link that says “surgery,” and the computer screen fills with video of the darkened interior of a morbidly obese woman. A tiny flashlight illuminates the pinkish stomach and thick folds of gray-yellow fat.
As he watches the video of the procedure, which cordons off nearly 90 percent of the patient’s stomach capacity, Al Sanea says, “One out of three Kuwaiti adults is obese. Ten percent is morbidly obese.” Actually, the numbers are worse: Only 12 percent of Kuwaitis have a body-mass index (BMI) below 25. (The ideal range is 18.5 to 25.) At least 88 percent of Kuwaitis, in other words, are considered overweight. According to a study published in June by the London School of Hygiene and Tropical Medicine, using data from the World Health Organization, Kuwait is the second-most obese nation in the world, behind the U.S.
As waistlines in Kuwait and across the Persian Gulf have expanded over the last three or four years, so too has the business of bariatric surgery. Ten years ago, Al Sanea says, there were only two bariatric surgeons in Kuwait. Today, there are 20. By 2015, he predicts, there will be 40. Other doctors in Kuwait say there are at least five major hospitals that now perform hundreds or even thousands of stomach-stapling procedures each year. At least 5,000 people in Kuwait underwent the procedure last year—compared with 3,000 in Canada, which has more than 30 times the population.
According to surgeons like Al Sanea, the bariatric boom can be traced to the buildup to the 1991 Gulf War. That was when hundreds of thousands of U.S. troops descended on the Gulf nation, bringing with them Taco Bell, Hardee’s, Baskin-Robbins, and Nathan’s Famous hot dogs, among others. “The [war] was the demarcation line,” says Dr. Abdulwahab Naser Al-Isa, at the Department of Community Medicine & Behavioral Sciences at Kuwait University. Andrew Smith, the author of the Encyclopedia of Junk Food and Fast Food, says, “The American military went in, and obviously they wanted fast food. Therefore, the number of fast-food establishments expanded exponentially.” And Kuwaitis fell in love.
If war introduced fast-food joints to Kuwait City, peace made them a permanent fixture. Some 3,400 U.S. troops remained in Kuwait after the war, enforcing the no-fly zone over Iraq. McDonald’s first opened in Kuwait in 1994, three years after the war ended. (In contrast, the U.S. withdrew its troops from Iraq late last year, and ongoing spurts of violence mean it’s unlikely that there will be a surge in U.S. restaurants there. In 2011, Pizza Hut, Cinnabon, and Burger King started closing locations in Iraq.)
In Kuwait, malls and food courts stocked with American franchises such as Burger King, Domino’s, and Krispy Kreme Doughnuts have since proliferated. Last year, the high-end Manhattan burger chain Shake Shack opened one of its two international outposts in Kuwait City. (The other is in Dubai.)
Dr. Al-Isa says the weather is a factor in the Gulf’s weight problem. In the summer temperatures soar to 110F or 120F. Locals say there are mosques everywhere in Kuwait not just because people are religious but because no one wants to walk too far. “From April 1 to Dec. 1, from 10 a.m. to 4 p.m.,” Dr. Al-Isa says, “it’s not possible to do any walking.”
It took several years after the influx of fast food for stomach stapling, another North American import, to come to Kuwait. For anyone in private practice, there is a lot of money to be made. Each operation at Royale Hayat Hospital, the gleaming five-star resort-slash-wellness center where Dr. Al Sanea is the chief executive officer, runs from $8,000 to $12,000. (For those willing to be operated on at a state-run hospital, the procedure is free, but patients have to buy the staples—they usually cost between $2,500 and $3,600—and there’s a two- to three-year wait.)
Dr. Mitchell Roslin, a bariatric surgeon at Lenox Hill Hospital in Manhattan, says there are fewer legal obstacles to stomach stapling in Kuwait than in the U.S. If he operated on someone with a marginal BMI in New York State, “I’d be subjecting myself to litigation,” he says. “If somebody came to me with a BMI of 32 in Kuwait, that’s completely fine.” Dr. Roslin says that if something went wrong on the operating table for a patient with a BMI that was not considered life-threatening, he could be accused of performing an unnecessary procedure and risking the patient’s life. Roslin’s patients’ average BMI is 49, but bariatric surgeons in Kuwait routinely operate on people with BMIs in the 30s. Kuwaiti doctors are generally willing to staple the stomachs of most anyone with a little extra flab.
Other obesity-related businesses are also sprouting up across Kuwait, ranging from gyms and weight-loss camps to diet centers and personal caterers that specialize in low-calorie meals. An array of sporting-equipment manufacturers, drug companies, medical clinics, and health spas, among others, will exhibit at the Health, Fitness & Weight Loss Expo in Kuwait in September. Kuwaitis may have been disinclined to walk, let alone work out, before the advent of the Big Mac. But the arrival of McDonald’s et al. greatly exacerbated existing tendencies. Dr. Salman Al-Sabah, another bariatric surgeon, says, “We have all had the bad influence from the West—the fast-food restaurants—but, until recently, we did not have the good influence. Now we have that.”
The mostly Indian and Pakistani tailors who sew the white robes, or dishdashas, for men and black robes, or abayas, for women are constantly busy taking in (or letting out) their customers’ clothes. One local fashion blogger who goes by the name Confashions from Kuwait writes in an e-mail that “in almost every suburban area, you’ll find a skillful tailor who makes it easy for obese women to buy a size 12 U.S. and alter it to fit a size 20+.”
There are signs that Corporate America is aware of growing concerns about obesity in Kuwait and may be taking action to save its market share. At the very bottom of its website, McDonald’s Kuwait reports that besides supporting Earth Day and Mother’s Day, “it is also involved in various sports events that promote an active lifestyle including marathons.” (The Kuwait Marathon is held, mercifully, in the relative cool of November.)
Despite efforts to promote exercise and healthier living, however, Kuwaitis’ demand for stomach-stapling isn’t likely to subside. “In the Middle East, people are lazy,” says Sarah Dimashkieh, the Lebanese dietetics operation manager at Diet Care, the largest provider of healthy, gourmet meals in Kuwait. Dr. Al Sanea puts things more diplomatically. He points out that the Kuwaiti government, overflowing with oil revenue, generously subsidizes weddings, marriages, pregnancies, and first-time homes. Last year, to prevent unrest stoked by political turmoil across the Arab world, the government gave each of Kuwait’s 1.1 million citizens about $3,600 and subsidized food. This year, it gave all state employees a 25 percent raise, which only prompted protests demanding more money. All this coddling has encouraged lethargy, says Dimashkieh.
Dr. Al Sanea sees the operating room as a one-stop shop that can reverse the effects of state-subsidized weight gain. “Improved lung function, reducing diabetes, healthy liver, kidneys, hypertension—you get all that if you give me one hour in your body,” he says. “And it will make you feel better. Your self-esteem will be resumed.” Also, it lets you go back to eating Whoppers and bottomless buckets of extra-crispy chicken.
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