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Help for Obesity

If at first you don’t succeed, try, try again. Every January arrives with new determination to try again: Try to stop smoking, try to exercise more, try to lose weight. The annual round of making and breaking resolutions eventually evolves into a self-defeating cycle of high aspirations ending in unrealized success. Even those with stamina and a no-quit attitude decide it isn’t worth the fight.

Nonetheless, doctors continue to dose out a good measure of rational thinking designed to improve health and lower healthcare costs. Obesity and morbid obesity alone account for more than a hundred-billion dollars in medical bills in the U.S. every year. Aside from limited mobility, poor self-image and impact on relationships, carrying excess weight also increases the chances of developing illnesses such as heart disease, diabetes, arthritis, sleep apnea and depression. It’s the most common cause of preventable death in the country. From an objective point of view, it’s worth trying and trying again to lose weight.

Results of a recent study released by Mayo Clinic researchers suggest that health costs due to obesity exceed even those accrued by smokers. While smokers, as compared to nonsmokers, can expect to pay about $1,275 more per year for healthcare, obese patients see an increased cost of approximately $1,850 per year compared to people of normal weight. Morbidly obese patients experience up to $6,500 in additional medical costs each year. When adding in the expenses of co-morbid conditions, these numbers may be even higher. “Long term, it is cheaper for us to offer an operation to morbidly obese people than to manage their medical conditions over the course of their life,” says Michael Edwards, M.D., the director of Georgia Health Sciences’ bariatric program in the Comprehensive Weight Loss Center.

Gastric surgery intended for weight loss has been around for about 60 years, with the first reported surgery occurring in 1954. In 2008, more than 340,000 bariatric surgeries were performed.  More than 200,000 of those were done in the U.S. The development of minimally invasive laparoscopic techniques has reduced risk of complications and improved patient recovery time, making bariatric surgeries less intimidating to and more accepted by patients.

The one thing that all bariatric surgeries have in common is that each, in its own specific way, alters the physical structure of the stomach to limit the amount of food it can hold. Initially, in the early stages of developing surgeries to treat obesity, decrease of absorption of calories was the primary focus. Unfortunately, this also resulted in malabsorption of vitamins and nutrients, which created other critical health issues. Today, bariatric surgeries get their punch either from restriction or from a combination of restriction and malabsorption.
The three common bariatric surgeries are gastric bypass, sleeve gastrectomy and gastric banding.  “All of the operations are very good at affecting long-term weight loss,” says Dr. Edwards. He notes, however, that the research in regard to gastric bypass surgery is much denser and thorough than that related to the other two, newer techniques.

In gastric bypass surgery, a small pouch is sectioned off at the upper part of the stomach and the small intestine is rerouted from the lower portion of the stomach to this small pouch. Gastric bypass is the most common bariatric surgery. It also appears to result in the most success for patients. The empirical data definitely suggests that it is very effective for the morbidly obese. Not only does gastric bypass surgery limit the number of calories that can be consumed and the number of calories that the body absorbs, it also increases the hormones that suppress hunger. As an added advantage, in the case of complications, such as severe nutritional deficits, it can be surgically reversed.

A sleeve gastrectomy is a more drastic surgery compared to gastric bypass. Seventy-five to eighty-five percent of the stomach is removed, giving it a banana shape. This procedure is not reversible. Nonetheless, it’s a simple operation in comparison to gastric bypass, and the data collected to date demonstrate good weight loss accompanied by improvements in conditions like hypertension and diabetes. With such a significant quantity of the stomach removed, the amount of hunger inducing hormones produced by the stomach is reduced, working to suppress appetite in conjunction with restricting food consumption and calorie absorption. Some patients may undergo a follow-up surgery known as duodenal switch, which decreases absorption even further, if unable to reach weight loss goals with sleeve gastrectomy alone.

For patients who prefer or are better suited to measures that do not surgically change the physical structure of the digestive system, gastric banding offers an easily reversible option that relies solely on restricting food intake. A band is placed around the top of the stomach creating a small pouch, forcing the patient to consume only small portions of food. Once food passes through the small pouch into the larger lower stomach area, digestion continues as normal.

Like any surgery, bariatric surgery has risks along with benefits. There are the immediate risks of an allergic reaction to anesthesia or a wound infection, and there are risks that can develop down the road, like stomach erosion by the gastric band or a leak in the staple line used in gastric bypass. At the same time, however, patients typically lose, on average, 70-percent of their excess weight. Most gastric surgery patients can look forward to improved mobility, quality of life and overall health. In addition, surgical weight-loss procedures, especially gastric bypass and sleeve gastrectomy, have a significant positive impact on type II diabetes. In fact, the majority of those who had type II diabetes prior to surgery are able to lower or stop taking their medications shortly after surgery. Other co-morbidities, including heart disease, hypertension, joint pain and sleep apnea, improve as well.

Nonetheless, it is vitally important that patients understand weight-loss surgery and its ramifications. It is not a cosmetic surgery. It is a medical intervention. “Most of these people have been overweight the majority of their lives,” explains Bunny Simon Williams, RN, Ph.D., the director of bariatric services of Trinity Hospital of Augusta. “The fear of dying or being put in a wheelchair for the rest of their lives brings them in.” In the seven years following surgery, the mortality rate of patients is around 40-percent less than that of obese patients who do not choose surgical weight loss. Essentially it is a life-saving measure.    

But surgery is not a magic bullet. It’s only a tool for weight loss that requires exceptional continued effort on the part of the patient. “It doesn’t necessarily mean you’re never going to want to eat again,” says Dr. Williams. “It’s very important to have counseling and education ahead of time and counseling, education and support afterwards.” If considering surgical weight loss as a possible remedy for obesity, a person should seek a bariatric surgeon who is experienced and embedded in a weight-loss program staffed with medical doctors, nurses, psychologists, nutritionists and fitness experts. Changing one’s lifestyle and health behaviors is essential to the lasting success of the surgery. The pre-operative discernment period should last several months and include education, support and counseling as well as medical, psychological and nutritional evaluations. The program should also provide ongoing post-operative support and counseling in regard to nutrition, behavior and emotional adjustment.

Under these conditions, results aren’t immediate, but they are excellent. “We talk to patients about what defines success with weight loss surgery,” says Dr. Edwards. The exact number of pounds shed and the resulting reduction of other health issues will vary by individual, but weight loss and improved health are the primary goals of all. One month post-operation there should be some weight loss, the patient should feel more energized and positive changes in health conditions should be evident. By one year out, a patient will be at or near his maximum weight loss and experience significant improvements in energy and activity, medical conditions and overall quality of life. (With gastric banding, the weight loss is somewhat slower.) Medical miracles are costly, though, and not all insurance companies provide coverage. Depending on the procedure, the price tag can approach the $20,000 mark.

Bariatric surgery is not intended for people who want to lose 10 or 15 pounds or baby-weight left over from pregnancy. The patient must either present with a body mass index (BMI) of 40 or higher or present with a BMI of 35-39.9 and a medical condition related to his excess weight. Plus the patient must have tried medical weight loss strategies. Dr. Edwards adds, “We get concerned about some psychiatric disorders. Those have to be treated and controlled before surgery is performed. We don’t typically offer surgery to smokers. You can’t offer a safe operation to patients with severe lung disease or heart disease.”

Even if a patient qualifies for bariatric surgery based on objective criteria, it may not be the right solution for his or her weight problem. Regardless of the surgical procedure, the ultimate responsibility for ensuring success rests on the shoulders of the patient. Unfortunately, Dr. Edwards estimates about 20 to 35 percent of bariatric surgery patients fail to continue the follow-up program and lifestyle changes necessary for the desired outcome. Not only should patients research the various surgical options, they should also evaluate the services offered before and after the surgery itself and commit to using those services both to discern if surgical weight loss is right for them and to get maximum benefit from follow-up support.

“The most rewarding thing is to see people live normal lives and to keep them on track. It’s almost miraculous,” says Dr. Williams. For the patient serious about making a change for the better, bariatric surgery can be the end of try-try-again dieting and the beginning of a healthier, happier future.

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