Bariatric Surgery

An Option for Long-Term Weight Loss

According to the Centers for Disease Control and Prevention, 175 million Americans, or nearly two-thirds of the adult population, are either overweight or obese. Of those who are obese, an estimated 5 million to 10 million are considered morbidly obese, meaning they are at least 100 pounds overweight. Because obesity is associated with some very serious health consequences, including early death, losing weight has long been recommended for obese adults. But many people find losing weight and keeping it off very difficult, if not impossible.

For obese people who have not been able to lose weight with diet, exercise, and possibly medication, bariatric surgery represents an option of last resort. Bariatric surgery reduces the size of the stomach, so that very little food can be eaten at one time, and some forms of the surgery also bypass part of the small intestine, so that fewer nutrients are absorbed. Bariatric surgery does not involve removing fat from the body through suction or excision.

Like any major surgery, bariatric surgery has risks and carries the possibility of complications. Even with no complications, it requires making major, lifelong changes in one’s eating habits to adapt to having a very small stomach. Some types of surgery also require taking vitamin and mineral supplements for life. While some people reach a normal weight following surgery, some do not, although they are less overweight than before.

In spite of the risks, drawbacks, and need to make significant lifestyle changes afterward, more and more people are having bariatric surgery. Currently, about 40,000 people annually have it done.

The trouble with obesity

Obesity is a growing problem not just in the United States but in many countries around the world. Multiple factors are playing a role in this increase in obesity. For one thing, there are fewer physically demanding jobs these days, so more people are sedentary in the workplace. Labor-saving devices such as cell phones, TV remote controls, and automobiles also cause people to be less active. Americans, particularly, are eating more meals in restaurants, which often serve larger portions than are needed to maintain a healthy weight.

However, carrying extra weight is not just about food and physical activity. Genetics, or a family history of weight problems, also play a role in body size.

Obesity raises the risk of many serious health conditions, including the following:

• Type 2 diabetes. Obesity is the main environmental risk factor for Type 2 diabetes. In fact, up to 80% of people with Type 2 diabetes are overweight or obese. Obesity is also associated with insulin resistance, which is one of the main causes of high blood sugar in Type 2 diabetes.
• High blood pressure, high cholesterol, and heart disease. Extra body weight puts a strain on the heart and blood circulation. High blood pressure and high blood cholesterol can increase the likelihood of strokes and heart attacks.
• Osteoarthritis. Excess weight on the joints can result in pain from increased wear and tear and inflammation.
• Sleep apnea. Fat can accumulate in the tongue and neck, causing a blockage of air into the lungs. The result is often disturbed sleep and daytime drowsiness. Sleep apnea can also make the heart work harder, resulting in high blood pressure.
• Cancer. Obesity is associated with an increased risk of endometrial, colon, gall bladder, prostate, and kidney cancer and breast cancer in women who have gone through menopause.

In addition to having a higher risk of many medical conditions, obese people often suffer psychologically and financially as well. Feelings of depression are very common among those who are morbidly obese. Such feelings may be caused or reinforced by repeated weight-loss failures; a disapproving attitude among family, friends, or coworkers; or experiences such as not fitting into the seats in public places such as the theater or ballpark. Research has shown that being obese lowers a person’s chances of being hired for a job or promoted. It has also shown that obese women’s wages tend to be lower than the wages of women of normal weight. (Obese men’s wages don’t appear to be lower than those of normal-weight men.)

A reduced quality of life is common among those who are obese. Things that people of normal weight do without much thought—such as bending over to tie their shoes, playing ball with a child, or sitting on the floor to read a book—are frequently done with great difficulty, or not at all, by people who are severely obese.

Weight loss has been shown to lower the risk of developing the medical conditions associated with obesity. Also, people often report an enhanced quality of life, mobility, and endurance after weight loss. But permanent weight loss is typically very hard to achieve. Anyone who has tried to lose weight knows that there is no shortage of programs, books, diets, and gimmicks that are supposed to help people lose weight. However, their success rate for long-term weight loss is very low. According to the National Institutes of Health, 90% of people who enroll in commercial weight-loss programs regain the lost weight within one year. Some people gain even more than they lost. Clearly, the odds are against losing weight and keeping it off long-term.

It is perhaps no surprise, then, that more and more people are turning to surgery to combat obesity.

Who is eligible?

To be considered for bariatric surgery you must meet at least one of the following criteria:

• A body-mass index (BMI) of 40 or higher. For most people, this roughly correlates to being at least 100 pounds overweight.
• A BMI of 35 or higher and at least one comorbidity, such as diabetes, heart disease, or sleep apnea.

(To check your approximate BMI, see this table).

In addition, you must understand the risks of surgery and be highly motivated to lose weight and stick to the restricted diet you will have after surgery.

Surgical procedures available

There are two main categories of weight loss surgery, restrictive and restrictive-malabsorptive.

Restrictive. These operations restrict food intake by reducing the size of the stomach to hold no more than 2 tablespoons, or 1 ounce, of food. Having a smaller stomach allows you to eat less and feel full with smaller portions. The stomach size eventually expands to hold about 8 tablespoons, or 1/2 cup, of food at a time.

In vertical banded gastroplasty (or stomach stapling), the upper stomach near the esophagus is stapled off vertically. A narrow band is placed at the outlet of the upper stomach to the lower stomach allowing food to move through slowly (click here for an illustration).

In adjustable gastric banding, an adjustable band is placed around the stomach, making a small pouch near the upper stomach (click here for an illustration).

Among the advantages of gastric banding is that it is reversible: The band can be removed. Both vertical banded gastroplasty and adjustable gastric banding restrict the amount of food eaten, and the narrow outlet allows food to stay in the small pouch longer, causing a feeling of fullness. Because the small intestine is not altered in either procedure, vitamin and mineral deficiencies are not a big concern, but it wouldn’t hurt to take a daily multivitamin since food intake is restricted.

Disadvantages include less overall weight loss than is seen with malabsorptive procedures. Long-term studies show that people generally maintain 40% to 60% of excess weight loss after vertical banded gastroplasty. In addition, the band or ring may cause an obstruction or perforation, making additional surgery necessary; gallstones may develop; or an infection can develop if stomach contents leak into the abdomen.

Restrictive-malabsorptive. These procedures combine a restrictive procedure with a bypass, or sectioning off, of part of the small intestine, which causes a decrease in nutrient absorption.

The most common restrictive-malabsorptive procedure done in the United States is called gastric bypass Roux-en-Y. This procedure promotes weight loss by doing two things. As in the restrictive procedures, the surgeon staples off most of the stomach, creating a small pouch for food. Additionally, the upper part of the small intestine, called the duodenum, is bypassed (click here for an illustration). Normally, some protein, carbohydrates, fats, vitamins, and minerals are absorbed in the duodenum. With the surgery, not only are you eating less, but also less of the carbohydrates, fats, and proteins are absorbed, contributing to weight loss.

One of the main advantages to this type of procedure is that overall weight loss is higher. Long-term studies show that 50% to 75% of excess body weight loss is maintained with this surgery.

One disadvantage is that a condition called “dumping syndrome” can happen if sweet foods or larger-than-recommended portions are consumed. If this happens, a person may experience nausea, vomiting, light-headedness, or diarrhea after eating. The experience is uncomfortable but not medically serious. Deterioration of the band or the staple line, stretching of the pouch to a larger size, and leakage of stomach acid are some of the other potential complications of this operation. In addition, vitamin or mineral deficiencies are common unless supplements are taken diligently.

There are other variations of the combined procedure involving longer segments of the small intestine being bypassed or surgical removal of part of the stomach, but they tend to have more complications.

Many of these procedures can be performed laparoscopically, that is, making a small incision and performing the operation using a fiberoptic instrument inserted through the incision. This results in less pain and scarring and faster healing time. Ultimately, your surgeon will decide which type of surgery best suits your needs.

After surgery

Success is defined as losing 50% or more of excess weight and maintaining that level for at least five years. Results may vary by the type of procedure being performed and the condition and motivation of the individual. Your ability to exercise and commitment to dietary changes increases effectiveness. Studies show that weight loss is most rapid for the first six months after surgery and generally continues at a lower rate for the next 12 to 18 months.

The majority of people with Type 2 diabetes who have bariatric surgery are able to significantly reduce or discontinue their insulin or oral diabetes medicines after surgery is performed. Normally this happens in the first three months after surgery. Blood sugar levels and HbA1c values normalize. Losing excess weight and keeping blood sugar levels normal can reduce the risk of developing heart disease, stroke, high blood pressure, diabetic nerve damage (neuropathy), diabetic kidney disease (nephropathy), and diabetic eye disease (retinopathy). It may also slow the progression of these complications if a person already has them.

The changes made to the stomach and small intestine require both temporary and permanent dietary changes. As with any major surgery, during the first day or two following surgery, only clear liquids such as broth, gelatin, and clear juices are permitted. When tolerated, and preferably before hospital discharge, other liquid foods, such as thinned hot cereal, strained soups, and milk, are added to the diet. Usually within a week, a person is able to eat more of a variety of foods that have been pureed. Solid foods are reintroduced slowly. Many people find they no longer tolerate foods high in sugar or fat following surgery.

For the rest of a person’s life, it is of utmost importance to sip liquids slowly at and between meals, chew foods well, and consume very small portions. Following a gastric bypass Roux-en-Y procedure, in which the part of the small intestine is bypassed, taking a multivitamin supplement that includes iron, folate, and vitamins A, B12, D, E, and K will help prevent deficiencies. To meet calcium needs, an extra supplement is usually required. Injections of vitamin B12 may also be needed. Regular and life-long follow-up is required for evaluation of possible deficiencies.

Protein malnutrition is another possible side effect. Our bodies use protein to make new cells, enzymes, and hormones. Bypassing part of the small intestine and reduced stomach size results in less protein being consumed and reduced absorption of the protein eaten. Many people find liquid protein supplements are necessary for the first few months after surgery or longer, depending on their tolerance of protein-rich foods. Foods high in protein include beef, pork, fish, chicken, cheese, peanut butter, and eggs. Seeing a registered dietitian for dietary advice before and after the operation will help prevent nutrition problems.

What follows is an example of what may be consumed in the course of a day once your diet has advanced to solid foods (usually 2–3 months after surgery).

8 AM: Breakfast
1/4 cup Cream of Wheat (about 6 bites of food)
1 poached egg
1/2 cup low-lactose milk or soy milk

9–10 AM
1 cup water, sipped slowly

10 AM: Snack
1/2 cup artificially sweetened or plain yogurt
1/2 cup water, sipped slowly

12 Noon: Lunch
1 slice bread
2 ounces turkey breast (about 2 slices)
1 tablespoon mayonnaise or salad dressing
1/3 cup unsweetened applesauce

1–2 PM
1 cup water, sipped slowly

2–3 PM: Snack
1/2 ripe banana
1/3 cup vegetable juice

3–5 PM
1 1/2 cups water, sipped slowly

6 PM: Dinner
2 ounces lean ham (about 2 slices)
1/3 cup mashed sweet potatoes
2 teaspoons margarine
1/3 cup green beans

7–8 PM
1 cup water, sipped slowly

8–9 PM: Snack
1 tablespoon peanut butter
4 crackers
1/2 cup fresh strawberries

Other sugar-free beverages (such as Sugar Free Kool-Aid or Crystal Lite) may be substituted for water. After the first six weeks of surgery, you can try to drink small amounts of a soft drink, but many people find they cannot tolerate the carbonation. Alcohol is also not recommended.

As you can see, portions eaten after surgery are 1/4 to 1/2 the amount a typical person would eat.

Insurance coverage

If you think weight-loss surgery is an option you’d like to explore, discuss it with your primary-care physician. Ask whether you are a good candidate for surgery and, if so, ask for a referral to a surgeon or bariatric center in your area. Bariatric surgery is very expensive (it costs $20,000 to $25,000), so you would want to get insurance approval before surgery.

Going through all of the proper channels and insurance prerequisites can be a challenging task. You may be able to find advice on navigating the insurance process by talking to others who are or have been in your situation by going to a support group.

If you decide to move forward with surgery, your primary-care physician will need to write a “letter of necessity” to submit to your insurance company. This letter explains why this surgery is needed and its benefits. Contact your insurance company to determine what other documentation is needed. It is not uncommon for companies to require preoperative consultations with a dietitian, psychologist, cardiologist, and lung specialist and documentation of failed attempts at weight loss in the past. Having detailed records will help the approval process. People who have untreated depression or alcohol or drug abuse problems will want to get their condition under control before undergoing surgery to satisfy the insurance company’s psychological evaluation.

The company may take 30 days or longer to respond to your inquiry. Although insurance companies are covering the cost of obesity surgery more now than in years past, denial of services is still common. If your request is denied, typically there is an appeals process that lets you address reasons for denial. The process may be lengthy and require the services of an insurance attorney.

State legislators are taking notice of the benefits of obesity surgery, and a few states now require insurance plans to provide the same benefits for the surgical treatment of morbid obesity as they do for any other medically necessary surgical procedure. Currently, legislation exists in Indiana, Georgia, Virginia, and Maryland. Legislation is pending in Ohio, Oregon, and South Carolina. Other states may well follow suit.

Making the choice

Bariatric surgery offers hope to people whose weight has them at risk for many health problems, but it is not without risks. Make an informed decision by talking with your health-care team and with people who have had the surgery before deciding whether it’s right for you.

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