For anyone who has considered a weight loss program, there is certainly no shortage of choices. In fact, to qualify for insurance coverage of weight loss surgery, many insurers require patients to have a history of medically supervised weight loss efforts.
Most non-surgical weight loss programs are based on some combination of diet/behavior modification and regular exercise. Unfortunately, even the most effective interventions have proven to be effective for only a small percentage of patients. It is estimated that less than 5% of individuals who participate in non-surgical weight loss programs will lose a significant amount of weight and maintain that loss for a long period of time.
According to the National Institutes of Health, more than 90% of all people in these programs regain their weight within one year, and almost all by five years. Sustained weight loss for patients who are morbidly obese is even harder to achieve. Serious health risks have been identified for people who move from diet to diet, subjecting their bodies to a severe and continuing cycle of weight loss and gain known as "yo-yo dieting."
The fact remains that morbid obesity is a complex, multifactorial chronic disease. For many patients, the risk of death from not having the surgery is greater than the risks from the possible complications of having the procedure.
Patients who have had the procedure and are benefiting from its results report improvements in their quality of life, social interactions, psychological well-being, employment opportunities and economic condition.
In clinical studies, candidates for the procedure who had multiple obesity-related health conditions questioned whether they could safely have the surgery. These studies show that selection of surgical candidates is based on very strict criteria and surgery is an option for the majority of patients.
Weight Loss Surgery
The increase in the number of weight loss surgeries in the treatment of morbid obesity is the result of three factors:
- Our current knowledge of the significant
health risks of morbid obesity. - The relatively low risk and complications
of the procedures especially when compared
to the natural outcome of untreated or undertreated obesity. - The ineffectiveness of current non-surgical
approaches to produce sustained weight loss.
Surgery should be viewed first and foremost as a method for alleviating debilitating, chronic disease. In most cases, the minimum qualification for consideration as a candidate for the procedure is 100 lbs. above ideal body weight or those with a Body Mass Index of 40 or greater. procedure Surgery is also available for patients with a BMI of 35 or higher if they are affected by many of the diseases that are brought on by or made worse by obesity. In many cases, patients are required to show proof that their attempts at dietary weight loss have been ineffective before surgery will be approved. More important, however, is the commitment on the part of the patient to required, long-term follow-up care. Patients should demonstrate serious motivation and a clear understanding of the extensive dietary, exercise and medical guidelines that must be followed for the remainder of their lives after having weight loss surgery (see Life After Surgery).
Roux-en-Y Gastric Bypass
(Combined Restrictive & Malabsorptive Procedure)
In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.
According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss therapy of any kind. It is one of the most frequently performed weight loss procedures in the United States. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into a lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.
Advantages
The average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
One year after surgery, weight loss can average 77% of excess body weight.
A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.
Risks
Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss.
Bypassing the duodenum has caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hipbones. All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements.
A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections.
A condition known as "dumping syndrome " can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar, fat, or large amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include any or all of the following: nausea, weakness, sweating, faintness, feeling flushed, cramps, vomiting, and diarrhea.
The bypassed portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using X-ray or endoscopy if problems such as ulcers, bleeding or malignancy should occur.
Laparoscopic Adjustable Gastric Banding
The Lap Band was recently approved by the FDA and is an option for patients who need to lose a significant amount of weight but want a less invasive -- although still permanent -- procedure, other than gastric bypass surgery.
The Lap Band is an adjustable silicon band with a balloon at the end. Surgeons wrap the Lab Band around the top part of the stomach and fill the balloon with saline solution that will help make the patient feel full more quickly. The operation can be tailored to the individual patient's symptoms and weight loss. By adding saline to the band, the person will feel full and lose weight faster. If they aren't eating enough or have problems with nausea and vomiting, the band can be deflated.
Because the entire procedure is performed laparoscopically, using only a few, very small incisions, the patient's recovery from surgery is quicker than traditional surgery. The procedure is usually less than an hour and requires an overnight stay. One group of patients that might benefit from the Lap Band are those female patients who wish to become pregnant. Pregnancy, although possible after gastric bypass surgery, requires strict nutritional counseling. The process is a lot easier and perhaps safer with the Lap Band procedure. Because it's adjustable, the lap band can be deflated for a patient's pregnancy, and the patient is able to ingest the appropriate amount of food daily to sustain a normal pregnancy.
Diet & Behavior Modification
There are literally hundreds of diets available. Moving from diet to diet in a cycle of weight gain and loss - yo-yo dieting - that stresses the heart, kidneys and other organs can also be a health risk.
Doctors who prescribe and supervise diets for their patients usually create a customized program with the goal of greatly restricting calorie intake while maintaining nutrition.
These diets fall into two basic categories:
- Low Calorie Diets (LCDs) are individually planned so that the patient takes in 500 to 1,000 fewer calories a day than he or she burns.
- Very Low Calorie Diets (VLCDs) typically limit caloric intake to 400 to 800 a day and feature high-protein, low-fat liquids.
Many patients on Very Low Calorie Diets lose significant amounts of weight. However, after returning to a normal diet, most regain the lost weight in under a year. Ninety percent of people participating in all diet programs will regain the weight they've lost within two years.
If diets have failed you and surgery is your next option, it is important to understand that diet and behavior will be instrumental to sustained weight loss after your surgery. The surgery itself is only a tool to get your body started losing weight - complying with diet guidelines and a change in your behavior is required by most surgeons and will determine your ultimate success.
Exercise
Starting an exercise program can be especially intimidating for someone suffering from morbid obesity. Your health condition may make any level of physical exertion next to impossible. The benefits of exercise are clear, however. And there are ways to get started.
A National Institutes of Health survey of 13 studies concludes that physical activity:
- results in modest weight loss in overweight and obese individuals
- increases cardiovascular fitness, even when there is no weight loss
- can help maintain weight loss
New theories focusing on the body's set point (the weight range in which your body is programmed to weigh and will fight to maintain that weight) highlight the importance of exercise. When you reduce the number of calories you take in, the body simply reacts by slowing metabolism to burn fewer calories. Daily physical activity can help speed up your metabolism, effectively bringing your set point down to a lower natural weight. So when following a diet to attempt to lose weight, exercise increases your chances of long-term success.
Examples to get you started:
- Park at the far end of parking lots and walk
- Take the stairs instead of the elevator
- Cut down on television
- Swim or participate in low-impact water aerobics
- Ride an exercise bike
Overall, walking is one of the best forms of exercise. Start out slowly and build up. Your doctor, or people in a support group, can offer advice and encouragement. Incorporating exercise into your daily activities will improve your overall health and is important for any long-term weight management program, including weight loss surgery. Diet and exercise play a key role in successful weight loss after surgery.
Over-the-Counter & Prescription Drugs
New over-the-counter and prescription weight loss medications have been introduced. Some people have found them effective in helping to curb their appetite. The results of most studies show that patients on drug therapy lose – at best - around 10 percent of their excess weight and that the weight loss plateaus after six to eight months. As patients stop taking the medication, weight gain usually occurs.
Weight loss drugs can have serious side effects. Still, medications are an important step in the morbid obesity treatment process. Before insurance companies will reimburse/pay for weight loss surgery, you must follow a well-documented treatment path.
"Since many people cannot lose much weight no matter how hard they try, and promptly regain whatever they do lose, the vast amount of money spent on diet clubs, special foods and over-the-counter remedies, estimated to be on the order of $30 billion to $50 billion yearly, is wasted." (New England Journal of Medicine)