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For other articles and previous issues click here. May 31, 2004 Tom-Fullery Like obesity itself, the rate of surgical procedures performed for it is on the rise. Americans for whom simpler measures fail to produce weight loss are turning to bariatric surgery to escape the potentially deadly consequences of morbid obesity. Yet, many who might benefit from this surgery may never receive it because both obesity and its surgical treatment are mired in controversy and misunderstanding. According to the Centers for Disease Control and Prevention (CDC), 30% of the nation’s adults are obese and 64% are overweight. On top of that, the number suffering from morbid obesity—those who are 100 pounds overweight or have a body mass index (BMI) of greater than 40—is mushrooming. Some estimates suggest that between 6 million and 12 million American adults are morbidly obese, while the World Health Organization says 300 million adults worldwide are clinically obese. According to the CDC, approximately 400,000 Americans die each year of obesity and its complications, which include diabetes, hypertension, cardiovascular disease, stroke, sleep apnea, and pulmonary conditions. The obese also suffer from related conditions such as hyperlipidemia, digestive diseases, and degenerative arthritis, as well as depression and other psychological disorders. The toll of obesity is not only medical and psychological but also social. “Discrimination and prejudice against obese people has been documented in numerous studies in every walk of American life,” says Louis Flancbaum, MD, chief of the division of bariatric surgery at St. Luke’s-Roosevelt Hospital Center in New York and coauthor of The Doctor’s Guide to Weight Loss Surgery: How to Make the Decision That Could Save Your Life (Bantam Books, 2003). “Very powerful statistical data show that these individuals, in addition to having a poorer quality of life, are discriminated against in schools, in social settings, in the job market, and even in healthcare by healthcare professionals.” A measure of this discrimination stems from the misconceptions that weight control is a matter of willpower and that obesity is the consequence of sloth or gluttony, rather than it being a disease that’s influenced by genetics and other physiological factors. The common view—and the biggest misunderstanding—says Flancbaum, is that “this is a procedure that’s not done for a disease—that people who need gastric bypasses for morbid obesity don’t really have a medical problem. Everything that follows in terms of what people ask about the surgery and how people analyze it comes back to this basic underlying prejudice that morbid obesity is not a medical problem but some sort of personality trait, a self-control issue, or a psychological issue.” This discrimination factors into bariatric procedures being perceived as cosmetic rather than lifesaving operations. The surgery is sometimes viewed as a drastic means to accomplish what patients could achieve through diet and exercise. Studies, however, suggest that diet and exercise are often ineffective treatments in the long run. According to Flancbaum, more than 95% of people who receive dietary therapy for morbid obesity regain all the weight they lose within three years. Bariatric surgery, he insists, helps patients achieve long-term weight control and a reduction of risk factors associated with obesity. “The evidence is essentially irrefutable that almost every comorbidity improves or disappears with the weight loss from the surgery,” says Flancbaum, who adds that the subsequent weight loss is durable. “Most patients 10 or 15 years after a gastric bypass will keep off 50% of their excess weight,” he says. The American Society for Bariatric Surgery estimates that more than 100,000 surgical procedures for obesity were performed last year at a cost of more than $3 billion. Although these operations—most commonly gastric bypass surgery—offer patients a more normal life and reduced risk of comorbid conditions, a number of insurers are balking over reimbursement, sometimes characterizing the surgeries as unnecessary, excessively risky, or ineffective. Bariatric surgeons, however, are quick to put the risks in perspective. They suggest that the procedure should be viewed relative to the risks of morbid obesity itself. An enormous misconception, claims Flancbaum, is that bariatric surgery is accompanied by greater risks than procedures for other equally life-threatening diseases, such as cancer. GASTRIC BYPASS CANDIDATES FOR SURGERY According to Joseph Afram, MD, FACS, director of the Center for Obesity Surgery in Washington, D.C., patients who have many risk factors or cannot tolerate anesthesia and major surgery will not be considered candidates for gastric bypass. In addition, he says, patients who are psychologically unstable may not meet the selection criteria. “We recommend that patients go through a lot of testing, including psychological testing, to make sure they understand the behavioral aspects of the operation, so there will be a few patients who are not going to be qualified after such evaluation,” Afram says. Anita P. Courcoulas, MD, MPH, assistant professor of surgery, division of thoracic and foregut surgery, University of Pittsburgh, is codirector of bariatric surgery at the University of Pittsburgh Medical Center (UPMC) and the director of bariatric surgery at UPMC Shadyside Hospital. In her practice, she observes that at least 70% of patients have depression that must be addressed. These patients, as well as those with eating disorders, are treated before surgery and given additional and ongoing psychological support. The surgery itself brings positive psychological rewards to many of these patients. “It doesn’t make other characterologic psychological problems change or go away, but the depression that’s related to the medical, social, and psychological situation obviously improves after surgery, so the majority of patients reap positive psychological benefits in terms of self-esteem and relief of depression,” she explains. Most patients who undergo gastric bypass do so only after trying to navigate numerous weight-loss paths. In some cases, says Afram—who performs surgery at the George Washington University Hospital—insurance coverage demands that patients document having participated in a six-month physician-supervised diet. “There’s a common denominator of an emotional issue,” he says. “Most of the time, patients in this category have chosen food as a venue for so many other things, and it’s a vicious cycle. At some point, they just use food as a treatment for other issues.” SURGERY RISKS Other long-term complications result from reduced absorption of vitamins, including anemia due to iron or vitamin B12 deficiency and osteoporosis from calcium deficiency. In addition, says Courcoulas, anyone who has an abdominal operation runs a small but lifetime risk of scar tissue or adhesions, which could cause a bowel obstruction. Furthermore, she says, since the part of the stomach that’s been detached through gastric bypass can never again be accessed through the mouth, “there’s the theoretical risk that if the patient ever developed an ulcer or bleeding or other problem in that part of the bypassed stomach, it could not be accessed by the route through the mouth and esophagus.” POSTSURGERY Because surgery leads to such lifestyle changes and requires dedication, patients must be extremely committed. “We go through extensive counseling before surgery, making sure that patients understand the procedure and that they are committed to wanting to change,” Afram says. In his program, the support group meets once per week for six months after surgery. “That kind of intensive support and behavior modification and follow-up enhance the course and the results of surgery and decrease complications,” he says. Because patients lose extraordinary amounts of weight in the first year or two following surgery, cosmetic surgery is typically required afterward to attend to excess skin. “Once they lose the weight, it’s almost like somebody stuck a pin in them and they’ve been deflated,” observes Leo R. McCaffery, MD, chair of the public education committee for the American Society for Aesthetic Plastic Surgery. He says there are a number of procedures that can be done to normalize the patient’s appearance, such as a tummy tuck, the removal of skin from the arms, and, for women, lifting the breasts, which may also seem to have deflated after weight loss. NUTRITION Courcoulas says patients stay on a liquid diet until their first checkup approximately 10 days to two weeks following surgery. If they’re doing well, she advances them to what she calls phase two, or the puree diet. For four weeks, patients can start eating yogurt, baby food, or anything they can puree. “If they’re not getting overly full, vomiting, or having pain or other problems, they’re usually moved up at that point to phase three—the solid diet,” she says. She instructs patients to refrain from eating red meat or white bread—foods that tend to be hard to digest by a small gastric pouch. The poor absorption of vitamins plays a significant role. “These elements are normally absorbed in the first part of the small intestine, which, with gastric bypass, is sort of out of the system, so supplementation is necessary,” Courcoulas says. It’s important, however, to monitor the absorption to prevent deficiencies. If absorption is inadequate with oral supplementation, Courcoulas says it may be delivered intravenously or intramuscularly, where it can be absorbed outside the gut. FOLLOW-UP PARTNERING FOR THE FUTURE “All of the research and attention that’s coming because of the success of this procedure is going to help ultimately really define the underlying molecular and genetic reasons for obesity,” Courcoulas says. In the meantime, bariatric surgeons agree that gastric bypass offers hope to those who’ve exhausted other options and have tried unsuccessfully to conquer obesity. But patients must form a partnership with their physicians and dedicate themselves to long-term success. “The public is under the impression that surgery will correct everything, but surgery is only part of the treatment,” says Afram. “The other part—which is equal to the surgery—is the behavioral modification. The patient must understand that this is basically an instrument for them to change their lifestyles.” According to Courcoulas, surgery is not a cure. “I’m not curing anyone of obesity,” she says. “When I operate, I provide a very useful tool that’s the only successful way to lose weight long term for one who has more than 100 pounds to lose.” — Kate Jackson is a staff writer at For the Record. |
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