Is Weight-Loss Surgery Right for Me?

Is weight-loss surgery the new holy grail of weight management? Can it help you not only lose weight but also keep it off? How does it work? Who should consider this surgery? What if you have arthritis? For answers to these questions, this article takes a closer look at weight-loss, or bariatric, surgery and what it means for the lives of those who have it.

The need grows

Americans of all ages continue to pack on the pounds. Many of them are also developing serious and life-threatening weight-related health conditions, such as high blood pressure, high total cholesterol levels, diabetes, gallstones, certain types of cancer, heart disease, and sleep disorders. Many also have arthritis, especially osteoarthritis (OA) in the joints of the back and the legs, which can be caused or made worse by the physical stress of excess weight. According to one study, the percentage of people in the United States whose arthritis is directly linked to obesity rose from 3% to 18% between 1971 and 2002.

Because obesity has so many bad effects on health, it makes sense that losing weight can offer tremendous health benefits to people who are obese. Studies have shown that many of the obesity-related conditions listed above grow less severe or go away completely after substantial weight loss. This allows people to lower their doses of medicines for such serious conditions as diabetes, high blood pressure, and high cholesterol levels, or even to stop taking them. People with arthritis are also often able to lower doses or stop taking their pain medicines after losing weight.

Of course, losing weight is no simple matter. I know several people who have dedicated themselves in earnest to making the changes needed to lose weight. They have tried every diet and exercise program imaginable, not just for appearance’s sake but because they want to be healthier. They want comfort and relief from joint aches. They want to be able to have a normal life, to be able to work, or to play with their children or grandchildren. And they end up feeling that all their efforts have been for naught. When all else fails, it’s not surprising if they start thinking about weight-loss surgery. The story of one man in particular, a man named Giovanni, stays in my mind.

Giovanni’s story

Giovanni is an engineer and the father of three young boys. At the time a colleague first told me about him, he was 48 years old and more than 120 pounds overweight. He was developing some of the common complications related to obesity. He was easily winded after walking less than a block. He had trouble sleeping and was beginning to suffer from sleep apnea, which causes you to stop breathing temporarily while you’re sleeping. His blood glucose, total cholesterol, and blood pressure levels were all skyrocketing. Worst of all for him was that he had severe arthritis pain from the excessive stress his weight placed on his knees and back. The knee pain in particular had become excruciating and prevented him from taking part in many of his family’s activities.

Giovanni had tried every proven and not-so-proven way to lose weight. Over the years, he had been successful at times, but like so many others he eventually gained back the weight plus even more. He had gotten up to 275 pounds, which for his 5’ 8” height put his body mass index (BMI) at nearly 42. (BMI is a measure of weight relative to height. A person with a BMI of 25 or greater is considered overweight. A person with a BMI of 30 or greater is considered obese.) Giovanni was desperate to find something that worked. Then he heard that weight-loss surgery could help him regain his health, improve his quality of life, and most of all make it possible for him to be the kind of dad he wanted to be. He decided to find out about what it would involve and whether it might be right for him.

A little background

The medical name for weight-loss surgery is bariatric surgery. The term “bariatric” comes from the Greek words “baros,” meaning weight, and “iatrikos,” meaning medicine. It refers to the branch of medicine that deals with the control and treatment of obesity and related disorders. It was only about 50 years ago that surgery began to be used as an approach for weight loss. Since then, the number of procedures performed yearly has risen markedly. In 1998, only about 13,000 weight-loss surgeries were done in the United States every year. In 2008, the estimated yearly number was around 220,000.

Who is eligible?

The generally accepted guidelines are that candidates for weight-loss surgery must be morbidly obese, which means having a BMI of 40 or higher. (Almost 5% of adults in the United States fit into this category. It translates roughly into having 100 pounds or more of excess weight.) Or they must have a BMI of 35 to 39 and a serious obesity-related health problem such as Type 2 diabetes, heart disease, severe sleep apnea, or a physical problem that seriously affects lifestyle. Arthritis that makes it very difficult or impossible to get around is one such physical problem.

There are no hard-and-fast age requirements for weight-loss surgery. However, surgeons are wary of operating on teenagers and recommend that they try other weight-loss strategies first, with surgery as a last resort. Also, some evidence suggests that the surgery is more likely to cause complications in people over 65.

More than anything, eligible candidates need to be prepared for the commitment that weight-loss surgery calls for. Weight-loss surgery is not for just anyone. It requires a lifelong dedication to lifestyle changes that are critical for keeping off weight after it is lost. Without this dedication, excess weight can — and does — come creeping back. Some people are unprepared for the psychological and emotional demands of the surgery and may need to deal with issues such as depression before having it.

How the surgery works

There’s more than one approach to weight-loss surgery. The approaches most often used today make changes in the stomach and the small intestine (bypass surgery) or in the stomach alone (restrictive surgery).

The most common bypass surgery done in the United States is Roux-en-Y gastric bypass surgery. In this procedure, the surgeon uses staples or a plastic band to create a small pouch at the top of the stomach. The pouch is the size of a walnut, able to hold only about an ounce of food (although the pouch can stretch a little with time). The surgeon then cuts the small intestine below its topmost part, the duodenum, and connects the lower part of the intestine to the small stomach pouch. In the new arrangement, food goes from the pouch at the top of the stomach straight into the lower part of the small intestine, bypassing most of the stomach and the duodenum.

This set-up helps people lose weight in two ways. First, by restricting the size of the stomach, it causes a feeling of fullness sooner, so people eat less. Second, because food now bypasses most of the stomach and the duodenum, the body absorbs fewer nutrients and calories. (See “Side effects” below.)

Roux-en-Y gastric bypass surgery can be done either through large “open” incisions or through a laparoscope. Laparoscopic surgery uses multiple small incisions and smaller instruments. It usually results in a shorter recovery time and fewer complications, though in some cases it may be more difficult for the surgeon to do. Also, people who have very high BMIs or who have had previous abdominal surgeries might have to have open surgery.

Another common procedure is the restrictive surgery called laparoscopic adjustable gastric banding (LAGB). The surgeon puts an adjustable plastic band around the middle of the stomach and pulls it tight so there’s only a small opening for food to pass through from the top part of the stomach to the lower part. This reduces the amount of food that it’s comfortable to eat at any one time. The surgeon also makes an access port just under the skin. Later on, the surgeon can use this access port to adjust the size of the opening between the two parts of the stomach. If the person is not losing enough weight, the surgeon can make the opening smaller. If the person can’t eat enough at any one time, the surgeon can enlarge the opening. There is no element of “bypass” in restrictive surgeries. Food travels through all of the stomach and small intestine.

Preparation for surgery

Anyone who wants to have weight-loss surgery has to go through thorough medical and psychological evaluations first. The medical evaluation reveals the kinds of medical problems a particular individual has and if anything needs to be done about them before, during, or after surgery. Or it can reveal if weight-loss surgery is even an option. The psychological assessment is to make sure that the person has realistic expectations about weight-loss surgery’s results, understands what is involved (including the risks), and has the right motivation and ability to cope with a lifelong change in eating habits.

Usually, people are asked to follow certain — and sometimes quite specific — diet and exercise regimens in the months before surgery. This helps improve general health status. For some individuals it is a way to lose enough weight to make surgery easier and safer. In addition, it is a good way to help people prepare for and practice the lifestyle changes that will be critical after surgery.

Before surgery, people who use nonsteroidal anti-inflammatory drugs (NSAIDs) such as Advil or Naprosyn to treat arthritis need to talk to the surgeon about whether they’ll be able to continue taking the drugs after surgery if they still need them. There might be other drug restrictions, too.

Postsurgery management

Individuals who have had weight-loss surgery need to closely follow specific dietary regimens, especially in the first few months after the surgery. This usually means that people do not eat for a day or so immediately after surgery. For the next day or so, they consume only room-temperature liquids or semiliquids. Next, they move on to pureed or soft foods (such as yogurt, eggs, and cottage cheese). At about three months, depending on how quickly each person’s body adjusts, they can be back to eating regular types of food, following a diet plan created by them and the dietitian or doctor. Then, for the rest of their lives, they will need to be very careful about what, how much, and how often they eat. They will have to eat small amounts often, chewing the food thoroughly. Typically, people may begin eating several small meals daily then move to fewer meals over time as they further adjust, until they get to a meal plan that works for them, such as three to four meals a day. Because it is not possible to eat much food, people must eat protein-rich food and severely restrict refined sugars. Eating this way, along with taking vitamin and mineral pills, helps to ensure that they get enough nutrients. People are also advised to sip small amounts of water often between meals but not to drink fluids with meals. Drinking fluids with meals can lead to nausea and vomiting or to feeling overly full, leaving too little room for nutritious food. It can also contribute to “dumping syndrome” (see below).

Exercise is also important. Besides its benefits for overall general health, exercise increases weight loss. Also, it helps to prevent loss of muscle mass, which can occur when individuals lose weight rapidly and are inactive. How much and what kind of exercise people should do will vary, depending on each person’s level of ability and strength.

Risks and complications

How likely it is that someone will develop complications is related to a number of factors. They include the person’s own health. Obesity itself makes surgery more risky, and so do other weight-related conditions such as diabetes. How well a person follows postsurgery instructions plays a role. The surgeon’s technical expertise and experience is important, too: Risks of complications are least when surgeons perform more than 100 procedures a year and greatest when they perform fewer than 25. The type of surgery is another important factor.

Gastric bypass surgery is usually associated with more risks and complications than surgeries that only restrict the size of the stomach, such as adjustable gastric banding. This is in part because after bypass surgery, the body absorbs fewer of some very important nutrients, such as calcium and iron, from food. This, in turn, can cause problems such as anemia or osteoporosis, which is why nutrient supplementation is so important. People who have had gastric bypass surgery have to be tested regularly to make sure they’re getting enough of the nutrients the body needs to function properly.

“Dumping syndrome” is a common complication of gastric bypass surgery. It occurs when food moves too quickly through the digestive tract. Among the causes of dumping syndrome are eating too much, eating too many sugary foods and beverages, and drinking fluids with meals. The syndrome can cause flushing, lightheadedness, nausea, and diarrhea. While dumping syndrome is very unpleasant, weight-loss experts note that it can give people an incentive not to stray from their dietary guidelines.

With adjustable gastric banding, one of the most common complications is vomiting. This may happen because the person eats too much or because the opening from the upper part of the stomach to the rest of the stomach is blocked. Sometimes the band slips or wears away, the access port the surgeon made develops a leak, or the band grows into the stomach tissue.

Among the serious complications common to both types of surgery are blood clots, infection, abdominal hernias, and gallstones. People who lose massive amounts of weight after surgery are sometimes left with flabby skin. Risks and complications are generally more common with “open” surgery than with laparoscopic surgery.

There is also an emotional toll for many people following weight-loss surgery. The first few months may be especially trying, as people adjust to their new eating routine and learn to manage their own diets and new lifestyle. They must also learn to deal with a new body image, a significant factor that can be distressing and challenging.

In one study, 3.7% of people needed to have their weight-loss operations redone. Another study found that the risk of death from gastric bypass was 0.5% — that is, 1 out of every 200 people. For gastric banding, the risk of death was 0.1% — 1 out of every 1,000 people.

Postsurgical expectations

People who have weight-loss surgery and follow the postsurgery recommendations they are given generally do well. People who have bypass surgery can expect to lose about 60% of their excess weight. Weight loss with purely restrictive surgeries such as adjustable banding is usually more modest. The weight is usually lost in the 18&ndash24 months following surgery. Studies show that most people have kept most of the weight off 10 years after gastric bypass. Data about adjustable banding are less certain.

Losing a lot of weight improves serious health conditions such as diabetes and high blood pressure. It also helps relieve arthritis pain. Studies of people who have had weight-loss surgery bear this out. One study found that the percentage of study participants with knee pain dropped from 47% before the surgery to 38% after the surgery. In another study, over half of study participants saw their arthritis symptoms decrease after the surgery. Still another study found that 100% of its participants had lower-extremity musculoskeletal pain before surgery, but only 37% did so 6 to 12 months after surgery. This same study also found symptoms of fibromyalgia pain much reduced after weight loss. In addition, after successful weight-loss surgery some individuals are able to have joint replacement surgery that was earlier ruled out because they were obese. (Weight-loss surgery also reduces blood levels of at least one substance that contributes to the chronic inflammation of rheumatoid arthritis. However, researchers need to do more work before they can say whether this makes any real difference.)

Besides the physical benefits, many people gain confidence and self-esteem after the surgery. They also experience relief from perpetual, sometimes-obsessive thoughts of dieting and a general preoccupation with eating and food.

Giovanni’s story, continued

Giovanni turned out to be a good candidate for weight-loss surgery because of his weight and related health problems and because he had no other serious medical or psychological problems that would get in the way of his losing and keeping off weight. His presurgery preparation was lengthy and thorough. It involved a team of health professionals, including his physician, a dietitian, and a mental health professional. His surgeon explained at length the surgical procedure and its risks and benefits. His mental health professional helped him to reassess the role food played in his life so that he would be better able to cope with stress without overeating. He worked with his dietitian to create a presurgery eating program, to make sure that he understood how he would need to eat after his surgery, because what he ate, how he ate, and how much he ate would be changed forever.

Giovanni underwent the Roux-en-Y gastric bypass procedure. He and his surgeon decided on this procedure because it is associated with greater weight loss than adjustable banding surgery. Also, Giovanni’s surgeon had a great deal of experience with the procedure. After the surgery, Giovanni’s complications were few and mild, and he followed his dietitian’s advice very carefully. Over the year following surgery, his weight quickly came off. His blood pressure, blood glucose, and total cholesterol levels all went down. Furthermore, he found that his joints — especially his knee joints — hurt much less. He could ¬¬bend and move around more easily and slowly began playing a greater role in his sons’ lives.

Giovanni is aware that he will have to continue to be very careful about how much he eats and what he eats for the rest of his life. He also understands that he must take vitamin-mineral supplements religiously because he is less able to absorb important nutrients from food. Deciding to have weight-loss surgery means making a huge commitment to change. But as far as Giovanni is concerned, having the surgery was one of the best decisions he ever made.

Final considerations

Weight-loss surgery continues to grow in popularity, but that does not mean you should not be cautious about it. It was the right choice for Giovanni, but it is certainly not for everyone. More than most surgeries, its long-term success is to a great extent in the hands of the individual. It is also a procedure in which the surgeon’s experience counts for a great deal. Let the buyer beware. People considering weight-loss surgery must do their homework. They must make their decision only after much contemplation and study of the procedure’s risks and benefits for themselves, the surgeon’s experience, and their own willingness to change their eating habits for life. Weight-loss surgery isn’t a miracle, but for people who have tried everything else and are committed to weight loss, it has proved effective.

Bonnie Bruce is a Senior Research Scientist in the Division of Immunology & Rheumatology, Stanford Department of Medicine.

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