Serious treatment for the seriously obese

A 1998 survey of the Food and Nutrition Research Institute of the Philippines found that 23.3 percent of Filipinos are overweight, and more than 20 percent of these overweight people are obese. These folks run a high risk of developing disorders that range from knee damage to heart attack. But when they try to lose weight through diet and exercise, the majority find to their frustration that they can’t keep it off long-term.

Unfortunately, most people and their physicians still believe that the failure to lose weight through diet and exercise represents weakness of character. Obese people should just eat less, they say, and it’s their fault if they don’t.

But obesity specialists now know that this belief is misguided. For reasons we don’t understand, once a person gains enough weight to enter the realm of obesity – say, an extra 25 pounds as an adult – the body’s normal fat-regulating processes stop working properly. The body’s metabolism erroneously stores more calories as fat, and fat begets more fat. An obese person in this situation finds no success with dieting and faces both society’s condemnation and the health consequences of obesity.

Surgery – The Final Frontier

If you are severely obese – that is, a BMI (Body Mass Index) of above 40 or at least 35 but with associated health problems such as hypertension or diabetes – your doctor may suggest you consider bariatric surgery. (BMI is the ratio between an individual’s weight and the square of his or her height, and is reported as kg/m2.)

Bariatric surgery involves procedures that alter the normal path of digestion through the stomach and small intestine. In the most common form of this procedure, Roux-en-Y gastric bypass, the surgeon creates a small pouch for the food entering the stomach. The pouch bypasses most of the stomach (which has been closed) and connects directly to a portion of the small intestine below the first and second sections (the duodenum and jejunum). The surgeon seals off most of the stomach and some of the small intestine. Food is routed through the tiny stomach pouch and the remaining truncated intestine.

People who’ve had this surgery can eat only a few tablespoons of food at a time before feeling full, and their shortened small intestine can’t absorb as many calories. If they eat more than they should or eat high-sugar foods, they feel lightheaded and ill. With such deterrents to overeating, bariatric patients lose lots of weight.

Results

In one study published in the October 2000 issue of the Annals of Surgery, 275 people weighing at least 300 pounds lost 83 percent of their excess body weight two years after Roux-en-Y gastric bypass. Furthermore, within the first year, these people no longer suffered from obesity-related conditions such as sleep apnea. As a bonus, some surgeons can perform this procedure laparoscopically, meaning that they operate through several tiny holes instead of one large incision.

It’s easy to see why bariatric surgeries have doubled in the US – from 20,000 in 1995 to 40,000 last year. The American Society for Bariatric Surgery (ASBS) expects about 62,400 patients to have their stomachs surgically shrunken in 2002. (Bariatrics is the field of medicine that deals with the overweight.)

The number of bariatric surgeries is expected to increase further in the US as obesity becomes more common. Likewise, the health insurance industry, rather than waiting until their obese policyholders develop serious weight-related problems like heart failure, have been easing their rules to cover the surgery. In addition, the Internal Revenue Service (IRS), in a recent ruling, has made it easier to deduct the cost of surgery, which will probably spur further its increase in popularity.

Limitations

But bariatric surgery is not just for any overweight person. Most surgeons accept only morbidly obese patients, defined as those who exceed their ideal weight by at least 100 pounds. The typical age limit is 55; older patients, adolescents and those who have had previous abdominal surgery will need special informed consent. A good candidate for surgery should also have no serious medical or psychological illness, and should have a history of failed weight-loss attempts. Another limitation is the cost of the procedure which is estimated to be about US$6,000 in the Philippines (US$20,000 in the United States).

The procedure, like any major surgery, carries risk. About three of every 200 patients die during surgery or shortly thereafter; the leading cause of death is infection due to leaking sutures. About eight percent of patients develop serious but nonfatal complications, such as vomiting and ulcers. "After surgery, the patient goes from having a stomach with a two-liter capacity to one with a two-ounce capacity. The patient should be trained to adapt to this change. Without the diet regimen, his stomach can dilate again and the surgery would have been for nothing," says Dr. Edward Oliveros, another bariatric surgeon at St. Luke’s.

Interested?

If you are interested in bariatric surgery, and fit the above profile, talk to your doctor about a referral to a good treatment center. Like all major operations, bariatric surgery requires an experienced and expert team of specialists, from surgeons to nutritionists. You should seek a surgeon who performs this type of operation not just occasionally but many times each year, with complications in fewer than 10 percent of cases and fatalities in fewer than one percent.

Also, make sure you understand the degree to which the surgery will alter your lifestyle. Meet the people who have had the procedure and ask about their experience. Discuss with your doctors all possible issues before you decide so that your expectations will realistically match what the surgery will deliver. If you are unhappy because of your weight, the surgery will help you feel better, but it certainly can’t treat clinical depression or any other mental illness.

Above all, bariatric surgery should not be done primarily for the sake of improving your personal appearance. Yes, it is an important goal but it should not be the most important reason. "This surgical treatment is not a cosmetic procedure," says Dr. Hildegardes Dineros, a surgical consultant at St. Luke’s Medical Center and the foremost exponent of bariatric surgery in the country. "We usually perceive severe obesity as just a problem of looks when more importantly, it is a problem of health," he adds. He points out that being overweight is a ticket to potentially fatal conditions such as heart disease, high blood pressure, blood clots, diabetes, stroke, sleep apnea and some types of cancer.

Indeed, people are more familiar with liposuction or abdominoplasty. But these are mainly cosmetic procedures. The gastric reconstruction techniques being done by bariatric surgeons offer a more permanent and effective solution to the serious medical complications that seriously obese patients must contend with.

It Can Work Well

Bariatric surgery can offer dramatic results in some people and although most patients regain some of their lost weight, very few regain it all. If you are severely obese, gastric bypass surgery may be the last-ditch solution to your intractable weight woes. It may not only add years to your life but it may also add life to those additional years!