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In gastric bypass, a surgeon uses staples to section off a small part of the stomach, then connects that section directly to the small intestine—effectively shrinking the stomach. The result is typically a loss of 50 to 60 percent of excess body weight within a year. Traditionally, the procedure has been reserved for patients with a body mass index (BMI) of at least 35. Yet studies show that gastric bypass surgery may also have the potential to prevent or reverse type 2 diabetes—even in patients on the lower end of the obesity scale, and even before any weight is lost.

"The gut is the center of a very sophisticated endocrine system," says Francesco Rubino, MD, director of the gastrointestinal metabolic surgery program at New York–Presbyterian Hospital/Weill Cornell Medical Center. "Changing the anatomy of the gastrointestinal tract can have a profound effect on insulin production and sensitivity." Though doctors don't yet understand exactly how gastric bypass regulates insulin, clinical trials show dramatic results. Rubino cites one study participant, on insulin therapy for type 2 diabetes, whose BMI of 31 would normally have ruled out gastric bypass: "Three weeks after surgery, she no longer required any medication."

Last year 22 international medical and scientific groups backed a consensus statement recommending less stringent weight guidelines for gastric bypass surgery for patients with diabetes. While more study is needed, doctors say that within a few years even some moderately obese patients with diabetes likely will be considered strong candidates for the procedure. Says Rubino: "We are starting to look at diabetes as a surgically fixable disease."

Yet, as exciting as such a fix would be, the truly groundbreaking news in the battle against obesity isn't a matter of surgery or pharmacology. It's that as a society we're coming to realize that an ounce of prevention really is worth a pound of cure. Although America's transformation into a fast-food nation may seem irreversible, some public health experts say that by radically changing the cultural environment, we can stop the disease before it starts. "During the 1990s, we started seeing obesity as a public health problem, not a personal failing, and that substantially changed how we approached prevention," says Kelly Brownell, PhD, director of the Rudd Center for Food Policy and Obesity at Yale University. Today government agencies, schools, and other institutions have turned their attention to reversing some of the conditions that have made obesity so widespread.

In one prevention program in Somerville, Massachusetts, local leaders, schools, and businesses collaborated to widen sidewalks and build bike lanes, add healthier fare to restaurant menus, improve school food, and create more exercise opportunities. Afterward, researchers from nearby Tufts University determined that the project had slowed weight gain among local schoolkids compared with children in similar areas. Around the country, comparable ventures are under way. Last year the Robert Wood Johnson Foundation launched the Center to Prevent Childhood Obesity and pledged $500 million to reverse the epidemic by 2015. The cornerstone of the effort, Healthy Kids, Healthy Communities, operates 50 local programs nationwide aimed at increasing bike safety, creating routes for children to walk to school, and offering affordable fresh foods to families.

"There have been massive changes in our lifestyle that underlie the obesity epidemic," says Ludwig. "It's going to take comprehensive changes throughout society to reverse it."

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