Overcoming Obesity with Surgery

People struggling with excessive weight are increasingly benefiting from bariatric treatment.

By Heather Stringer

Karina Falcon had struggled with being overweight for most of her life, at just an inch over 5 feet tall and weighing 270 pounds. People stared when she stepped on a bus and tried to fit into a seat. Karina was constantly short of breath, her joints ached, and she suffered from sleep apnea—all consequences of her excess weight. She had been unable to get pregnant after years of trying, and she suspected obesity was partly to blame.

“Food was my escape route,” says Karina, 42, of Attleboro, Massachusetts. “If I had a bad day at work or an argument with my spouse, I could eat a full-sized sub sandwich with French fries and a Coke and an hour or two later buy a bag of chips.”

Dieting had never worked, and Karina knew that the health problems associated with her obesity would only worsen over time. She started researching weight-loss surgery options and decided to meet with a bariatric surgeon. In 2008 she underwent gastric bypass surgery at Beth Israel Deaconess Medical Center in Boston. During the procedure her stomach was divided into a small upper pouch (about the size of an egg) and a much larger, lower remnant pouch. Then her small intestines were rearranged to connect to both stomachs.

In the ensuing months, Karina slowly settled into a routine of eating three smaller, healthy meals interspersed with two snacks. She felt full after small portions and started losing 5 pounds per week. Six months after surgery, Karina weighed 140 pounds. As moving became more comfortable, she started dancing, walking more frequently, and traveling out of state for vacations with her husband. Her weight settled at 127 pounds, and for the first time in her life she walked into a Bebe clothing store and tried on clothes. This summer she found out she is pregnant.

Karina is among a growing number of Americans who are opting for weight-loss surgery to treat obesity. According to the American Society for Metabolic and Bariatric Surgery (ASMBS), 196,000 people underwent bariatric surgery in 2015—and the number continues to grow as the procedures become safer, says Dr. Philip Schauer, a bariatric surgeon at Cleveland Clinic in Ohio.

“Now all of these operations are done with minimally invasive surgery, and the risk of complications is similar to common procedures such as an appendectomy, gall bladder surgery, or hysterectomy,” says Dr. Schauer. Patients typically lose about 50 percent or more of their excess weight, and many experience significant improvements in other obesity-related co-morbidities such as type 2 diabetes, sleep apnea, and hypertension.1

The Obesity Epidemic Although about 200,000 people undergo bariatric surgery annually, 18 million Americans qualify for these procedures, according to the ASMBS. To qualify, someone must have a body mass index (BMI) equal to or greater than 40 or be more than 100 pounds overweight. People may also qualify with a BMI of 35 or more if they have at least two obesity-related co-morbidities, such as diabetes, hypertension, sleep apnea, or other respiratory disorder.2 A woman who is 5 feet 6 inches tall and weighs 217 pounds, for example, has a BMI of 35. Patients must also demonstrate an inability to achieve sustained weight loss with prior weight-loss efforts.

Many people are hesitant to seek out bariatric surgery because they “feel like they want to lose the weight themselves,” says John Magaña Morton, MD, chief of bariatric and minimally invasive surgery at the Stanford School of Medicine in California. “When people get over a certain BMI, though, it’s hard to lose weight because the body will defend its set point. Evolutionarily, it’s good to maintain a certain weight, but this can work against you.”

Hormones send signals to the brain to alert us when we’re hungry before eating or full after a meal, but dieting can cause the body to overcompensate by secreting too much of the hunger hormone and not enough of the satiation hormone, Dr. Morton says. “By changing the configuration of the stomach, these surgeries allow those hormones to work for you,” he explains. “The hormone for hunger will decrease, and the one that signals fullness increases.”

The vast majority of patients undergoing bariatric surgery are female—more than 80 percent— and this is likely due in part to the fact that women are more likely to access healthcare in general, Dr.  Morton says.3 “There is also more social pressure for women to not be overweight,” he adds.

The Most Common Procedures

For those considering weight-loss surgery, Dr. Morton urges them to find an accredited bariatric surgery facility.4 In the United States, the most common procedures are gastric bypass, sleeve gastrectomy, and the adjustable gastric band.

Gastric Bypass Surgery

This procedure has the longest history of the three and has been used for the past 40 years. Accounting for about 23 percent of bariatric surgeries, it is known for producing significant long-term weight loss in the range of 60 to 80 percent of excess weight. The procedure is also the most effective for treating diabetes because insulin production becomes more efficient due to hormonal changes caused by bypassing part of the intestine, says Daniel Jones, MD, a bariatric surgeon at Beth Israel Deaconess Medical Center.

The disadvantage of gastric bypass surgery is that it is more invasive than other procedures, and “you can never take Motrin®, Advil®, or ibuprofen due to the risk of developing ulcers,” Dr. Jones explains. There is also a risk of vitamin deficiencies after surgery. Patients also should avoid alcohol because it is absorbed so quickly. “With just one or two glasses, someone can get drunk,” says Dr. Jones.

Sleeve Gastrectomy

This newer procedure has become more common in the past fivevyears. Now more than half of bariatric surgeries are sleeve gastrectomy operations compared with 18 percent five years ago. During surgery about 80 percent of the stomach is removed, and the remaining stomach is a tubular pouch in the shape of a banana. Data show that patients lose 50 percent or more of their excess weight within the first three to five years after having surgery. “A lot of patients like this procedure conceptually because it is just reducing the stomach,” says Dr. Schauer, and it’s somewhat less invasive than the bypass. “It takes about an hour and requires a two day hospital stay.”

The disadvantages of sleeve gastrectomy are that it is a nonreversible procedure, patients typically lose less weight than with bypass surgery, and there is a risk of vitamin deficiencies. Also this surgery is not recommended for people who suffer from severe gastroesophageal reflux disease.

Adjustable Gastric Band

During this procedure an inflatable band is placed around the upper portion of the stomach, which creates a small stomach pouch above the band. This procedure is the least invasive, and it accounted for 35 percent of bariatric surgeries five years ago. Now, however, only 5 percent of patients choose this option, largely because data show that patients experience slower and less weight loss than with the bypass and sleeve procedures. It also requires a foreign object to remain in the body, and patients may experience mechanical problems with the band over time. The advantages are that the procedure is reversible, less invasive, and has the lowest risk of vitamin deficiencies.

Risks after Surgery

Although the majority of patients experience significant improvements in the quality of their lives, a small minority may suffer from negative side effects. For example, losing large amounts of weight can result in loose skin, though this usually occurs among patients who started with a BMI of 55 or higher before surgery, Dr. Morton explains. Staying hydrated, using support garments, or ultimately undergoing reconstructive surgery can mitigate this problem, though the surgery is not usually covered by insurance, he says. Some patients may develop new compulsive behaviors that replace eating, such as excessive alcohol use or spending money. Others may struggle with body image issues related to excess skin.

Embracing Lifestyle Changes

Patients who are interested in having bariatric surgery typically meet with a team that includes a surgeon, physician, psychologist, and dietitian. During a psychological evaluation, practitioners not only assess psychological functioning but also learn about patients’ eating habits and behaviors, how they cope with stress, and any problems they may have with smoking or drinking.

“We very seldom say that someone should not have the procedure, but we may say ‘not yet’ if we identify something that could impact the outcome,” says Leslie Heinberg, MD, a psychologist and director of behavioral services for Cleveland Clinic’s Bariatric and Metabolic Institute. Patients with eating disorders, depression, anxiety, or problems with substances usually work with psychologists to address these issues before moving forward with surgery.

“Sometimes patients have unrealistic expectations that surgery is a magic pill and everything in life will improve,” says Dr. Heinberg. “This is in no way an easy way out, and it requires the hard work of following a new eating routine, exercising, and learning healthy coping skills.”

Patients also meet with dietitians before and after surgery to learn about the lifestyle changes that will increase the odds of keeping the weight off over the long term.

“We encourage a lifestyle of moderation rather than a strict set of rules,” says Kate Otto, a dietitian at Beth Israel Deaconess Medical Center. She suggests a balanced diet limited in processed sugar and high-fat foods, and she encourages patients to listen to their bodies to avoid overeating.

Dietitian Michelle Mamis, who works with Otto, teaches patients about eating three balanced meals per day, including small portions of vegetables, starch, and protein— and there are also times for treats on special occasions. “I suggest that they follow the 90-10 rule,” Mamis says. “Ninety percent of the time they should stick to the healthy eating behaviors, but 10 percent can be reserved for eating something special once in a while.”

For many people the most significant hurdle is making time for a healthy lifestyle, Otto says. Planning and cooking nutritious meals at home takes more time than eating out, but those who are willing to make the needed lifestyle changes reap the benefits.

“The most rewarding part of my job is seeing people overcome battles they’ve dealt with their whole lives,” Otto says. “They can go on walks with their children without getting winded, shop at regular clothing stores, and sit on an airplane without needing a seatbelt extender. These are quality-of-life changes that many thought would never be possible.”


References

  1. Azagury DE, Morton JM. Bariatric surgery: Overview of procedures and outcomes. Endocrinology and Metabolism Clinics of North America. 2016;45(3):647-56. doi: 10.1016/j. ecl.2016.04.013.
  2. Who Is a Candidate for Bariatric Surgery? American Society for Metabolic and Bariatric Surgery website. Available at: https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery. Accessed October 13, 2016.
  3. Young MT, Phelan MJ, Nguyen NT. A decade analysis of trends and outcomes of male vs female patients who underwent bariatric surgery. Journal of the American College of Surgeons. 2016;222(3):226-31. doi: 10.1016/j.jamcollsurg. 2015.11.033.
  4. Bariatric Surgery Centers. American College of Surgeons website. Available at: https://www.facs.org/search/bariatric-surgery-centers?allresults=. Accessed October 13, 2016.