Photograph by Lauren NassefRoughly 900 miles away, a few years later, a similar story was starting to unfold for Jane Smith (who asked Prevention to change her last name). A big woman at 197 pounds, she nonetheless had a BMI of only 34, barely in the top quartile for Americans and not alarming to any doctor. But the 52-year-old pediatric nurse had just joined the estimated 28 million Americans diagnosed with type 2 diabetes. She too had been on every diet: "I never lost the baby weight after my pregnancies 20 years ago and was always yo-yoing," she says. Though she had no complications from her condition, Smith suspected that someday her health would deteriorate fast. "My numbers were getting worse," she says. So she chose weight loss surgery, too, in the form of a sleeve gastrectomy procedure.
Both decisions took guts. To put it bluntly, Americans aren't very nice about weight loss surgery, also known as gastric or bariatric surgery. We still largely view getting fat as a personal failing and surgery as a lazy way out for those too undisciplined to eat right and exercise. A 2013 statement by the American Medical Association noted a widespread perception among Americans that obesity is simply the result of bad habits, and not actually a medical issue.
But it certainly is a medical issue, and these two stories frame a breakthrough approach to treating it more liberally with bariatric surgery—a variety of procedures that alter the stomach (and, in some cases, intestines) to facilitate weight loss. Nine years ago, Adams's request for surgery was denied, sending her health into a dark place from which she barely escaped. Hers is the cautionary tale of what can happen when patients aren't thrown (or don't grab) the life raft of surgery in time.
Smith's story, meanwhile, shows us the other side of the coin. Her unusual request for surgery, before her health was at the point where many doctors would say she needed it, was granted. And her success with it—success that has been reproduced in startling new research—throws open the window on a controversial future in which tens of millions of us would be candidates for gastric surgery, a future in which the nation's scandalously huge diabetes epidemic is mitigated by such an intervention. "The data is mind-boggling," says bariatric surgeon Mitchell S. Roslin, chief of obesity surgery at Lenox Hill Hospital in New York City. "Putting off surgery raises health risks. Surgery can put diabetes into remission, reverse high blood pressure and high cholesterol, and improve serious health problems like sleep apnea and joint pain. If there were a pill with all these benefits, everyone would want it."
Photograph by Lauren Nassef
Let's start with the millions of Americans who, medical experts now agree, qualify for the surgery: those who've tried seriously to lose weight for years but still have BMIs of 40 or higher. A 5'3" woman who weighs 235 pounds would almost certainly fit that profile. Pam Adams fit that profile. Yet, shockingly, few like her are having the surgery. Of the 18 million Americans who qualify, only 180,000 a year go ahead with it. That's a paltry 1%, and research suggests a lot of people would benefit if that changed. (If the solution for obesity and diabetes already exists, why do so few people know about it?)
Adams was the classic patient in need, and at first, despite her steadily declining health and increasing weight, she didn't seek surgery. Many people are reluctant to; it's a major procedure with general anesthesia and can't be reversed, says Sangeeta Kashyap, an endocrinologist at Cleveland Clinic and an associate professor of medicine at the Cleveland Clinic Lerner College of Medicine. "Surgery is scary," she says. "It's natural to say, 'I'll try harder to lose weight on my own.'" Eventually, however, Adams recognized that her downward spiral was treacherous, and she tried for surgery. But back in 2006 the research wasn't as clear, and not all insurance companies recognized the benefits. Her request was denied. As a teacher, she couldn't afford the $24,000 bill on her own.
To be clear, even for those like Adams who are in dire health straits, surgery is neither risk-free nor a panacea. Approximately 17% of people experience complications, including infections, gastric leaking, and blood clots. For some doctors, that's enough to give them pause. And hard-core dieting and exercise are still lifelong nonnegotiables for surgery patients, as is taking supplements to ward off the inevitable malnutrition that comes with limited food intake. Several recent studies show that those who don't follow through see their health decline again over time.
Smith's quest for surgery—before her health was at the point that many doctors would say she needed it—was a harbinger for all of us.
And yet it's evident that even patients who don't sustain all the positive effects do get some benefit overall. Gastric surgery helps up to 80% of people with diabetes gain better control of their blood sugar, per recent findings; a majority of them see positive health effects 5 to 6 years down the road. Surgery gives patients' bodies a jump-start, says Roslin. Among many reasons for this: Hunger hormones that might once have driven a ravenous diabetic to overeat are at a far lower level, since part of the stomach tissue responsible for producing those hormones has been removed (with some surgeries), so as patients begin shedding pounds and eating less, they don't feel hungry—even though they're eating a fraction of their usual calories. Meanwhile, levels of a peptide called GLP-1, which triggers the release of blood sugar–controlling insulin, are about 20 times higher after meals postsurgery than they were before surgery, according to one 2013 review. Turning over the majority of the digestive duties to the small intestine—an inevitable result of shrinking the stomach's role—is thought to stimulate the release of GLP-1. Ongoing studies are attempting to tease out more of what's behind the dramatic changes patients undergo.
Photograph by Lauren Nassef
Without access to such alterations to her failing anatomy, Adams had no defense. Her weight climbed, and she became unable to work. Eventually she spent most of her days in bed. "I had nowhere to turn," she says. "I felt like a such a burden."
On a late spring evening in 2010, she and her husband, Gregg, had just come home from a dinner that Adams had organized for her parents' 50th anniversary and were sitting in the living room of their Florida home. Gregg began to tell his wife how proud he was of her and how much he loved her. He had no idea she intended to take a fistful of pills she'd set aside and go to bed for the last time. He happened at that moment to take her hands. "I don't know what I'd do without you," she remembers him saying. She excused herself and flushed the pills down the toilet. "Then I went into our bedroom and deleted my suicide note," she says. "I prayed to find a way to live."
On a friend's suggestion, she reapplied for coverage for gastric bypass. At the same time as acceptance of the surgery's efficacy had grown, Gregg's insurance coverage had changed, and this time she qualified. Adams had the procedure on Nov. 8, 2010, at the Sacred Heart Surgical Weight Loss Center in Pensacola, FL. Seven months after her surgery, she no longer needed diabetes treatment. She stopped her blood pressure and cholesterol meds. She's now down to 144 pounds and wears a size 12, goes for rides with her husband on their tandem bike for 20 miles at a time, and has kayaked Key West. Still, she has vision issues and residual balance problems from her ministrokes—all of which occurred after her insurance first denied coverage for surgery. "Gastric surgery saved my life," she says. "I only wish I could have helped myself before the irreversible damage was done."
The Gastric Menu
The top three weight loss procedures in the US, in order of popularity:
1. Sleeve gastrectomy surgically removes about 85% of the stomach, leaving a "sleeve" the size and shape of a banana. The small intestine stays intact. Average cost: $19,000
2. Gastric bypass involves two surgical steps: stapling the stomach to create a walnut-size pouch, then "bypassing" the upper section of the small intestine, where a large percentage of carbohydrates are absorbed. Average cost: $24,000
3. Gastric banding uses an adjustable saline-filled band to cinch the stomach to restrict the amount of food that can be comfortably eaten. Average cost: $15,000
Avoiding damage before it happens, before it's even a threat: That's the goal for doctors and scientists who would take bariatic surgery to a large number of the 30 million Americans with diabetes, patients far healthier than Pam Adams. This, of course, is viewed with alarm by many experts. Most still agree that if people can lose weight promptly and keep it off with a healthy lifestyle, that's the ideal worth holding out for. But many other experts—including but not limited to bariatric surgeons—have turned a corner. By kick-starting dramatic weight loss as soon as possible, they say, surgery addresses chronic conditions before the damage becomes permanent.
"Even if diabetes returns," says Roslin, and even if a patient isn't able to maintain the surgery's effects with diet and exercise, "you've still lowered the risk of serious complications like lost eyesight, leg amputation, and heart disease."
By the time Jane Smith reached the conclusion that her health was going in the wrong direction, her doctor was one of those on board with the latest findings, and her insurance company green-lit a $19,000 sleeve gastrectomy procedure even though her BMI previously would have meant she didn't qualify and she'd been diagnosed with diabetes only 1 year before. On May 28, 2015, Smith had the surgery, which converts the stomach from a sizable pouch to a narrow sleeve. "I was in and out in 24 hours," she says. Just 13 days after surgery, she had lost 10 pounds, and her blood sugar numbers were in the healthy range.
Photograph by Lauren Nassef
Her results reflect the recent research that has truly rocked weight loss science. In the past few years, several studies have shown that people with type 2 diabetes who have surgery fare better than their counterparts who simply eat better and exercise to lose weight. In a recent study, University of Pittsburgh researchers randomly assigned 61 obese women and men with type 2 diabetes to either join a lifestyle program of eating right and exercising or have the surgery before embarking on that plan. Of the study group, 43% had BMIs below 35. After 3 years, the surgery patients who had gastric bypass lost 25% of their body weight—an average of about 63 pounds for someone who weighs 250 (those who had opted for gastric banding lost 15%). Forty percent of the bypass patients had a partial or complete diabetes remission (two-thirds of them no longer needed their drugs), their blood pressure fell by as much as 13 points, and good-cholesterol levels rose 16 points. Meanwhile, people in the eat-right-and-exercise group lost 5.7% of their body weight—about 14 pounds for someone who weighs 250—and none could go off their diabetes drugs.
Lead researcher Anita P. Courcoulas, chief of minimally invasive bariatric and general surgery at the University of Pittsburgh Medical Center, concluded that for those with type 2 diabetes and BMIs between 30 and 35, "gastric surgery is superior to lifestyle intervention treatment alone." And results last: A Cleveland Clinic study of 217 weight loss surgery patients with type 2 diabetes found that after 6 years, one in four was in complete remission and another 26% had a partial remission. Blood pressure returned to normal levels for 62% of the group, and 72% of the patients saw their cholesterol levels reach healthy numbers.
Operating on someone very early in their diabetes history, a decision—like the one Smith and her doctor made—that provokes the most controversy, may yield especially good results. A study Kashyap coauthored, published in the New England Journal of Medicine last year, found that people who'd had diabetes for less than 8 years, and whose cases were mild enough not to require insulin, had the best remission rates.
"Not waiting for the outcome of lifestyle changes is a smart choice," Kashyap says. She's overseen surgery for patients whose BMIs were as moderate as 27—just 150 pounds for a 5'3" woman—since to her, the benefits of not waiting outweigh the risks of surgery.
Life Postsurgery: Not a Piece of Cake
Here are some of the many requirements.
- In the first year, you're allowed 400 to 900 calories a day; your diet should be low in fat and sugar and very high in protein.
- Eat slowly and chew thoroughly; avoid rice, bread, raw vegetables and fruit, and tough meat (which can cause blockages).
- Sweets and high-fat foods can cause the cold sweats and nausea known as "dumping syndrome." Avoid them.
- No straws or carbonated drinks, no chewing gum or ice—they risk introducing too much air into your new, tiny stomach.
- Crush all pills completely; whole pills can't be absorbed.
- Staying hydrated is hard—and imperative; you have to drink about 2 liters of fluid a day.
- Avoid alcohol; you'll get drunk extremely quickly and are at especially high risk of alcoholism.
The happiest ending of a gastric surgery story is always the same: Somehow the procedure triggers a change of lifestyle that sticks, and the patient becomes a new person who eats differently and exercises more, forever. Interestingly, that's the very same happy ending as in all great tales of diet-and-exercise transformation. So which is more realistic and safe?
Endocrinologist Osama Hamdy, medical director of the Obesity Clinical Program at the Joslin Diabetes Center in Boston, remains opposed to the "surgery first" narrative. Hamdy's own research shows that a serious weight loss program, including a weight loss prescription drug if needed, also delivers diabetes control or even remission but is safe, he says, unlike surgery. His recent study compared 22 people on an intensive supervised weight loss program, which included weekly adjustments to weight loss drug doses, with 23 who had gastric band surgery. The study found that the surgery group lost a little more (29 pounds versus 18 pounds) and were a bit more likely to have healthy blood sugar levels, but those small edges, he says, ignore the elephant in the room—that is, that they'd had major surgery.
Smith's diabetes is now in remission. If she can maintain it, she faces a future without the nightmares of chronic disease.
"Weight loss surgery changes the anatomy of the digestive system," he says, citing deficiencies of B12, folic acid, and vitamin D; osteoporosis; and severe hypoglycemia as some of its nasty side effects. "This causes all sorts of problems." He also notes that 8% of the time, surgeons resort to opening up the patient instead of doing less-invasive laparoscopic surgery, pointing out that the blood clots that mar about 1.3% of surgeries can be deadly.
In Hamdy's view, many doctors believe that long-term weight loss is impossible without surgery—so they may talk with a patient with diabetes about weight, nutrition, and physical activity for a minute or less before discussing surgery or medications. "People think bariatric surgery is magic, and by this magic, diabetes will go out the window," he says. "But in general, in my opinion, it's overpromised, oversold, and overestimated—and the risk is underestimated."
But neither obesity nor diabetes is an easy enemy to toss aside. In even the most optimistic research comparing protocols, it's sobering to see that some subjects don't achieve healthy blood sugar levels despite losing weight—not even if they've had surgery, adopted a diet-and-exercise regimen, or taken medications. The complications that come with diabetes will be with them for the long haul.
Adams and Smith have more hopeful stories to tell. Five days after the procedure, when Adams got home from the hospital, she dove into a new way of living, starting with a liquid diet and a minimal exercise regimen. "At first I could barely walk, but I was determined to exercise," she says. "So I'd drag a chair to my mailbox every day, then walk up to it, sit and rest, then go back to the house over and over again. At the end of the day, I'd drag the chair back." Eventually, she could walk 7 miles on a familiar route through her neighborhood. "My neighbors saw my progress and started coming out, asking if they could walk with me," she recalls.
Meanwhile, Smith's diabetes is in remission. She is drug-free and eats carefully to maintain her advantage. She's been given a chance at a reset; if she can maintain the lifestyle now, she faces a future without chronic disease and all the nightmares that come with it.
She says she's heard over and over again how she should have turned to diet and exercise to manage her health. "I can tell you, I never had any trouble losing weight, but I couldn't keep it off," she says. And, she adds, it's not that the path she chose is much easier—it just comes with a greater likelihood of success. "I had to consciously make a lifelong decision to change the way I eat. And I know I did the right thing."
