Information from ASMBS


Disease of Obesity

Defining Obesity

Obesity is now recognized by The World Health Organization (W.H.O.), and the National and International medical and scientific societies, as a chronic progressive disease as a result of both environmental and genetic elements.

Obesity presents both economic challenges to individual and seriously effects an individuals life span and mental well being. Obesity requires sustained lifelong care pathway in order to successfully control this problem.

Body Mass Index (BMI)

Body Mass index or BMI is the most common and most widely used measurement in determining an individuals obesity ranking.  BMI generally indicates the amount of excessive body fat an individual has, with certain exceptions such as pregnancy, an athletic build, and age. BMI does not define the distribution of fat (where it is on the body). BMI aslo does not take in to account other factors related to the metabolism of fat tissue.

BMI considers an individual‘s height and weight and is determined through a BMI chart or calculator as follows:

(1) Weight in kilograms divided by Height in meters squared (BMI = kg/m2)

Or

(2) Weight in pounds divided by Height in inches squared and this value multiplied by 705 (BMI= [(lbs/in2) x 705])

BMI ranges area as follows:

Category BMI Range
Normal Size 18.9 to 24.9
Overweight 25 to 29.9
Class I, Obesity 30 to 34.9
Class II, Serious Obesity 35 to 39.9
Class III, Severe Obesity 40 and greater

Calculate your BMI Here

Obesity Prevalence and Rate of Occurrence

According to the W.H.O., 65 percent of the world‘s population lives in countries where overweight and obesity kills more people than underweight. Approximately 500 million adults in the world are affected by obesity and one billion are affected by overweight, along with 48 million children.

In the United States, epidemiological data from an ongoing study that measures the actual body size of thousands of Americans, show that 34 percent of adults more than 20 years old are affected by obesity and 68 percent are overweight (2007-2008 data). Obesity affects 10 percent of children between two and five years of age, 2 percent of those between 6 to 11 years old, and 18 percent of adolescents.

Throughout the last 20 to 25 years, the prevalence of obesity has been increasing at an alarming rate. Since 1985, the Center for Disease Control (CDC) has supported an ongoing study, conducted on a yearly basis by state health departments, to examine changes in obesity prevalence state-to-state, and has found the following:

  • In 1990, the obesity prevalence for most of the states was 10 percent or less.
  • By 1995, more than half the states had a prevalence of 15 percent.
  • By 2000, nearly half the states had a prevalence of 20 percent or higher.
  • Five years later (2005), all but three states had a prevalence greater than 20 percent and nearly a third had a prevalence of 25 percent or more.
  • By 2010, the data show that most of U.S. states had a prevalence of 25 percent and many had a prevalence of 30 percent or higher.

Not only has the obesity epidemic increased in number throughout the past two decades, but also in severity. Data obtained from the yearly ongoing CDC-supported U.S. study found that between the years 1987 to 2005 the prevalence of severe obesity increased by 500 percent and super severe obesity (BMI greater than 50) increased by nearly 1,000 percent. According to the 2007-2008 NHANES findings, 5.7 percent of American adults, or nearly 14 million people, are affected by severe obesity.

Progressive Nature of the Disease of Obesity

Obesity is considered a multifactorial disease with a strong genetic component. Acting upon a genetic background are a number of hormonal, metabolic, psychological, cultural and behavioral factors that promote fat accumulation and weight gain.

Positive Energy Balance

A positive energy balance causes weight gain and occurs when the amount of calories consumed (energy intake) exceeds the amount of calories the body uses (energy expenditure) in the performance of basic biological functions, daily activities, and exercise. A positive energy balance may be caused by overeating or by not getting enough physical activity. However, there are other conditions that affect energy balance and fat accumulation that do not involve excessive eating or sedentary behavior. These include:

  1. Chronic sleep loss
  2. Consumption of foods that, independent of caloric content, cause metabolic/hormonal changes that may increase body fat. These include foods high in sugar or high fructose corn syrup, processed grains, fat, and processed meats
  3. Low intake of fat-fighting foods such as fruits, vegetables, legumes, nuts, seeds, quality protein
  4. Stress and psychological distress)
  5. Many types of medications
  6. Various pollutants

Weight Gain

Weight gain is yet another contributor to weight gain or, in other words, obesity ‘begets‘ obesity, which is one of the reasons the disease is considered ‘progressive‘. Weight gain causes a number of hormonal, metabolic and molecular changes in the body that increase the risk for even greater fat accumulation. Such obesity-associated biological changes reduce the body‘s ability to oxidize (burn) fat for energy, increase the conversion of glucose (carbohydrate) to fat, and increase the body‘s capacity to store fat in fat storage depots (adipose tissue). This means that more of the calories consumed will be stored as fat. To make matters worse, obesity affects certain regulators of appetite and hunger in a manner that can lead to an increase in meal size and the frequency of eating. Weight gain, therefore, changes the biology of the body in a manner that favors further weight gain and obesity.

Obesity-related Conditions

A number of other conditions associated with obesity contribute to the progression of the disease. Obesity reduces mobility and the number of calories that would be burned in the performance of activity. Weight gain may also cause psychological or emotional distress which, in turn, produces hormonal changes that may cause further weight gain by stimulating appetite and by increasing fat uptake into fat storage depots.

Sleep duration is reduced by weight gain due to a number of conditions that impair sleep quality such as pain, sleep apnea and other breathing problems, a need to urinate more frequently, use of certain medications, and altered regulation of body temperature. Shortened sleep duration, in turn, produces certain hormones that both stimulate appetite and increase the uptake of fat into fat storage depots.

Weight gain also contributes to the development of other diseases such as hypertension, diabetes, heart disease, osteoarthritis and depression, and these conditions are often treated with medications that contribute to even further weight gain. In all of these ways and more, obesity ‘begets‘ obesity, trapping the individual in a vicious weight gain cycle.

Diets

A low calorie diet is the primary treatment for overweight and obesity, but, dieting is also a contributor to obesity progression. Dietary weight-loss causes biological responses that persist long-term and contribute to weight regain. One of these responses affects energy balance. When a person loses weight, the body ‘thinks‘ it is starving and energy expenditure is reduced in order to conserve calories. The reduction in energy expenditure with dietary weight-loss requires that, in order to maintain weight-loss, the dieter eat even fewer calories than someone of equal body size who has never been on a diet. However, eating less is difficult following a diet because there are long-term changes in regulators of appetite that increase the desire to eat and the amount of food that can be consumed. Such diet-induced changes favor a positive energy balance and weight regain and, because the conditions responsible for the reduction in energy expenditure and increased drive to eat persist long-term, an individual will often not only regain all of their lost weight, but even more.

Another biological response that occurs with dieting involves changes in fat metabolism that reduce the body‘s ability to burn fat and increase the capacity for fat to be stored in adipose depots (fat storage depots). With dietary weight-loss, the amount of dietary fat the body burns is reduced by approximately 50 percent. In addition, dieting reduces the amount of fat the body burns for fuel during low-grade activity such as walking, cleaning the house, fixing dinner, or working on a computer. The reduction in the amount of fat that is burned for fuel following a dietary weight-loss makes more fat available to be taken up by fat storage depots, and dieting increases the capacity for fat depots to store even more fat than before a diet. Altogether dietary weight-loss reduces the use of fat for fuel and increases the capacity for the fat that is not utilized to be stored. These changes lead to a progressive increase in fat accumulation even if the individual is not overeating.

Summary

Multiple factors acting upon a genetic background cause weight gain and obesity. Conditions associated with weight gain and biological changes in the body that occur as a result of weight gain contribute to progression of the disease, often trapping the individual in a vicious weight gain cycle. If you are concerned with your weight, please speak to your primary care physician to learn more about how to improve your weight and health.

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The Impact of Obesity on Your Body and Health

Obesity is when your body has too much fat. Obesity can cause a lot of damage to your body. People with severe obesity are more likely to have other diseases. These include type 2 diabetes, high blood pressure, sleep apnea, and many more. Combined with obesity, these diseases may lead people to have a lower quality of health. In some cases, these can lead to disability or early death.

Diabetes

Obesity is a major cause of type 2 diabetes. People affected by obesity or severe obesity are about 10 times more likely to have type 2 diabetes (1). Type 2 diabetes can nearly double the risk of death (2). Type 2 diabetes can lead to:

  • Amputations
  • Heart disease
  • Stroke
  • Blindness
  • Kidney disease
  • High blood pressure
  • Circulatory and nerve defects
  • Hard-to-heal infections
  • Impotence
  • And more

Hypertension

Obesity is a major risk factor for high blood pressure(also known as  “hypertension”)(3).About 3 out of 4 hypertension cases are related to obesity(4).  Hypertension increases the risk of other diseases. These include coronary heart disease (CHD), congestive heart failure (CHF), stroke, and kidney disease.

Heart Disease

Heart disease kills about 600,000 people every year in the United States. The American Heart Association considers obesity a major risk factor for heart disease. Large studies show that the risk for heart disease increases with obesity(5). People with severe obesity are at a higher risk for coronary artery disease. This means they have a higher risk of a heart attack.

Obesity increases your risk of heart failure. Severe obesity is associated with irregular heartbeats (arrhythmias). These arrhythmias can triple the risk of cardiac arrest. However, some excess weight can protect against dying from heart failure after the diagnosis is made(6).

Respiratory Disorders

People with obesity have reduced lung capacity. These people are at higher risk for respiratory infections. They are more likely to have asthma and other respiratory disorders.  Asthma has been shown to be three to four times more common among people with obesity(8).

More than half of those affected by obesity (around 50-60 percent) have  obstructive sleep apnea (OSA) In cases of severe obesity, this figure is around 90 percent7). OSA is a very serious breathing disorder. OSA occurs when excess fat in the neck, throat, and tongue block air passageways during sleep. This blockage causes apnea, which means a person stops breathing for a time. A person with OSA may have hundreds of apnea episodes each night. Apnea episodes reduce the amount of oxygen in a person‘s blood.

OSA may lead to high blood pressure, pulmonary hypertension, and heart failure. OSA can cause sudden cardiac death and stroke. Because apnea episodes interrupt the normal sleep cycle, you may not reach restful sleep. This can lead to fatigue and drowsiness. If untreated, this drowsiness may raise your risk of motor vehicle accidents.

Cancer

Cancer affects more than half a million lives per year in the United States alone. Obesity is believed to cause up to 90,000 cancer deaths per year. As body mass index (BMI) increases, so does your risk of cancer and death from cancer. These cancers include:

  • Endometrial  cancer
  • Cervical  cancer
  • Ovarian  cancer
  • Postmenopausal breast  cancer
  • Colorectal  cancer
  • Esophageal  cancer
  • Pancreatic  cancer
  • Gallbladder  cancer
  • Liver  cancer
  • Kidney  cancer
  • Thyroid  cancer
  • Prostate cancer
  • Non-Hodgkin‘s lymphoma
  • Multiple myeloma
  • Leukemia

For people with severe obesity, the death rate increases for all types of cancer. The death rate is 52 percent higher for men and 62 percent higher for women(9).

Cerebrovascular Disease and Stroke

Obesity puts a strain on your whole circulatory system. This strain increases your risk for stroke. Obesity can lead to other stroke risk factors. Stroke risk factors include heart disease, metabolic syndrome, hypertension, lipid abnormalities, type 2 diabetes and obstructive sleep apnea(10).

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD) causes stomach acid or intestinal secretions to leak into your esophagus. Common GERD symptoms include heartburn, “indigestion”, throwing up food, coughing (especially at night), hoarseness, and belching. Between 10 percent and 20 percent of the general population experience GERD symptoms regularly.

Obesity has been associated with higher risk of GERD, erosive esophagitis and rarely, esophageal cancer (adenocarcinoma)(11).

Bone/Joint Damage and Accidents

Obesity, in particular severe obesity, contributes to a number of bone and joint issues. These issues can increase the risk for accidents and personal injury. Bone and joint issues can include:

  • Joint diseases (osteoarthritis, gout)
  • Disc herniation
  • Spinal disorders
  • Back pain
  • Pseudotumor cerebri, a condition associated with disorientation, headache, and visual impairment.

Other Conditions

  • Alzheimer‘s Disease: Studies find that obesity during middle-age may contribute to conditions that increase the risk for dementia and Alzheimer‘s disease later in life(12).
  • Kidney Disease: Hypertension, Type 2 diabetes and congestive heart failure are major contributors to kidney disease and kidney failure. All of these conditions are caused or made worse by obesity.
  • Suicide: Studies have shown a correlation between severe obesity and major depressive disorder (12). Physical and social discrimination issues surrounding obesity  may contribute to this depression. Studies are mixed on whether obesity is associated with higher suicide rates. However, most studies seem to suggest lower rates of suicide in people with obesity.
  • Septicemia: Septicemia is a serious infection that can quickly lead to septic shock and death. Studies have shown that people affected by obesity, particularly severe obesity, are at higher risk of septicemia.
  • Liver Disease: Obesity is the major cause for fatty liver and non-alcoholic fatty liver disease. Most people with severe obesity have non-alcoholic fatty liver disease. Fatty liver disease can cause scarring of the liver, resulting in worsened liver function, and this can lead to cirrhosis and liver failure.
  • Other conditions that could become life-threatening:  maternal gestational diabetes and preeclampsia during pregnancy, increased incidence of miscarriages and stillborns, gallbladder disease, pancreatitis, and more.
  • Other conditions resulting in diminished quality of life: stress urinary incontinence (leakage), polycystic ovarian syndrome, infertility, and skin fold rashes.

Obesity can have a dramatic impact on your body. The conditions related to obesity can be detrimental to your health. However, many of these complications can be avoided or cured through weight loss.

References

  1. Guh DP, Zhang W, Bansback N, et al. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health. 2009; 9:88
  2. Mulnier HE, Seaman HE, Raleigh VS, et al. Mortality in people with Type 2 diabetes in the UK.   Diabet Med. 2006 May;23(5):516-21
  3. Wilson, Peter WF, et al.   Overweight and obesity as determinants of cardiovascular risk: the Framingham experience.   Arch Int Med   2002;162(16): 1867-1872.
  4. Landsberg, Lewis, et al. “Obesity” related hypertension: Pathogenesis, cardiovascular risk, and treatment—A position paper of the The Obesity Society and the American Society of Hypertension.” Obesity 21.1 (2013): 8-24.
  5. Jensen, Michael D., et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. J Am Coll Cardiol (2013).
  6. Curtis, Jeptha P., et al. “The obesity paradox: body mass index and outcomes in patients with heart failure.” Archives of internal medicine 165.1 (2005): 55-61.
  7. Drager, Luciano F., et al. “Obstructive sleep apnea: a cardiometabolic risk in obesity and the metabolic syndrome.” Journal of the American College of Cardiology 62.7 (2013): 569-576.
  8. Camargo, Carlos A., et al. “Prospective study of body mass index, weight change, and risk of adult-onset asthma in women.” Archives of Internal Medicine 159.21 (1999): 2582-2588.
  9. Calle, Eugenia E., et al. “Overweight, obesity, and mortality from cancer in a prospectively studied cohort of US adults.” New England Journal of Medicine 348.17 (2003): 1625-1638.
  10. Chen, Hsin-Jen, et al. “Influence of metabolic syndrome and general obesity on the risk of ischemic stroke.” Stroke 37.4 (2006): 1060-1064.
  11. Hampel, Howard, Neena S. Abraham, and Hashem B. El-Serag. “Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications.” Annals of Internal Medicine 143.3 (2005): 199-211.
  12. Kivipelto, Miia, et al. “Obesity and vascular risk factors at midlife and the risk of dementia and Alzheimer disease.” Archives of neurology 62.10 (2005): 1556-1560.
  13. Onyike, Chiadi U., et al. “Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey.” American journal of epidemiology 158.12 (2003): 1139-1147.

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Bariatric Surgery Misconceptions

Misconception:  Most people who have metabolic and bariatric surgery regain their weight.

Truth:

As many as 50 percent of patients may regain a small amount of weight (approximately 5 percent) two years or more following their surgery. However, longitudinal studies find that most bariatric surgery patients maintain successful weight-loss long-term. ‘Successful‘ weight-loss is arbitrarily defined as weight-loss equal to or greater than 50 percent of excess body weight. Often, successful results are determined by the patient, by their perceived improvement in quality of life. In such cases, the total retained weight-loss may be more, or less, than this arbitrary definition. Such massive and sustained weight reduction with surgery is in sharp contrast to the experience most patients have previously had with non-surgical therapies.

Misconception:  The chance of dying from metabolic and bariatric surgery is more than the chance of dying from obesity.

Truth:

As your body size increases, longevity decreases. Individuals with severe obesity have a number of life-threatening conditions that greatly increase their risk of dying, such as type 2 diabetes, hypertension and more. Data involving nearly 60,000 bariatric patients from ASMBS Bariatric Centers of Excellence database show that the risk of death within the 30 days following bariatric surgery averages 0.13 percent, or approximately one out of 1,000 patients. This rate is considerably less than most other operations, including gallbladder and hip replacement surgery. Therefore, in spite of the poor health status of bariatric patients prior to surgery, the chance of dying from the operation is exceptionally low. Large studies find that the risk of death from any cause is considerably less for bariatric patients throughout time than for individuals affected by severe obesity who have never had the surgery. In fact, the data show up to an 89 percent reduction in mortality, as well as highly significant decreases in mortality rates due to specific diseases. Cancer mortality, for instance, is reduced by 60 percent for bariatric patients. Death in association with diabetes is reduced by more than 90 percent and that from heart disease by more than 50 percent. Also, there are numerous studies that have found improvement or resolution of life-threatening obesity-related diseases following bariatric surgery. The benefits of bariatric surgery, with regard to mortality, far outweigh the risks. It is important to note that as with any serious surgical operation, the decision to have bariatric surgery should be discussed with your surgeon, family members and loved ones.

Misconception:  Surgery is a ‘cop-out‘. To lose and maintain weight, individuals affected by severe obesity just need to go on a diet and exercise program.

Truth:

Individuals affected by severe obesity are resistant to long-term weight-loss by diet and exercise. The National Institutes of Health Experts Panel recognize that ‘long-term‘ weight-loss, or in other words, the ability to ‘maintain‘ weight-loss, is nearly impossible for those affected by severe obesity by any means other than metabolic and bariatric surgery. Bariatric surgeries are effective in maintaining long-term weight-loss, in part, because these procedures offset certain conditions caused by dieting that are responsible for rapid and efficient weight regain following dieting. When a person loses weight, energy expenditure (the amount of calories the body burns) is reduced. With diet, energy expenditure at rest and with activity is reduced to a greater extent than can be explained by changes in body size or composition (amount of lean and fat tissue). At the same time, appetite regulation is altered following a diet increasing hunger and the desire to eat. Therefore, there are significant biological differences between someone who has lost weight by diet and someone of the same size and body composition to that of an individual who has never lost weight. For example, the body of the individual who reduces their weight from 200 to 170 pounds burns fewer calories than the body of someone weighing 170 pounds and has never been on a diet. This means that, in order to maintain weight-loss, the person who has been on a diet will have to eat fewer calories than someone who naturally weighs the same. In contrast to diet, weight-loss following bariatric surgery does not reduce energy expenditure or the amount of calories the body burns to levels greater than predicted by changes in body weight and composition. In fact, some studies even find that certain operations even may increase energy expenditure. In addition, some bariatric procedures, unlike diet, also causes biological changes that help reduce energy intake (food, beverage). A decrease in energy intake with surgery results, in part, from anatomical changes to the stomach or gut that restrict food intake or cause malabsorption of nutrients. In addition, bariatric surgery increases the production of certain gut hormones that interact with the brain to reduce hunger, decrease appetite, and enhance satiety (feelings of fullness). In these ways, bariatric and metabolic surgery, unlike dieting, produces long-term weight-loss.

Misconception:  Many bariatric patients become alcoholics after their surgery.

Truth:

Actually, only a small percentage of bariatric patients claim to have problems with alcohol after surgery. Most (but not all) who abuse alcohol after surgery had problems with alcohol abuse at some period of time prior to surgery. Alcohol sensitivity, (particularly if alcohol is consumed during the rapid weight-loss period), is increased after bariatric surgery so that the effects of alcohol are felt with fewer drinks than before surgery. Studies also find with certain bariatric procedures (such as the gastric bypass or sleeve gastrectomy) that drinking an alcoholic beverage increases blood alcohol to levels that are considerably higher than before surgery or in comparison to the alcohol levels of individuals who have not had a bariatric procedure. For all of these reasons, bariatric patients are advised to take certain precautions regarding alcohol:

  • Avoid alcoholic beverages during the rapid weight-loss period
  • Be aware that even small amounts of alcohol can cause intoxication
  • Avoid driving or operating heavy equipment after drinking any alcohol
  • Seek help if drinking becomes a problem

If you feel the consumption of alcohol may be an issue for you after surgery, please contact your primary care physician or bariatric surgeon and discuss this further. They will be able to help you identify resources available to address any alcohol-related issues.

Misconception:  Surgery increases the risk for suicide.

Truth:

Individuals affected by severe obesity who are seeking bariatric and metabolic surgery are more likely to suffer from depression or anxiety and to have lower self-esteem and overall quality of life than someone who is normal weight. Bariatric surgery results in highly significant improvement in psychosocial well-being for the majority of patients. However, there remain a few patients with undiagnosed preexisting psychological disorders and still others with overwhelming life stressors who commit suicide after bariatric surgery. Two large studies have found a small but significant increase in suicide occurrence following bariatric surgery. For this reason, comprehensive bariatric programs require psychological evaluations prior to surgery and many have behavioral therapists available for patient consultations after surgery.

Misconception:  Bariatric patients have serious health problems caused by vitamin and mineral deficiencies.

Truth:

Bariatric operations can lead to deficiencies in vitamins and minerals by reducing nutrient intake or by causing reduced absorption from the intestine. Bariatric operations vary in the extent of malabsorption they may cause, and vary in which nutrients may be affected. The more malabsorptive bariatric procedures also increase the risk for protein deficiency. Deficiencies in micronutrients (vitamin and minerals) and protein can adversely affect health, causing fatigue, anemia, bone and muscle loss, impaired night vision, low immunity, loss of appropriate nerve function and even cognitive defects. Fortunately, nutrient deficiencies following surgery can be avoided with appropriate diet and the use of dietary supplements, i.e. vitamins, minerals, and, in some cases, protein supplements. Nutrient guidelines for different types of bariatric surgery procedures have been established by the ASMBS Nutritional Experts Committee and published in the journal, Surgery for Obesity and Other Related Disorders. Before and after surgery, patients are advised of their dietary and supplement needs and followed by a nutritionist with bariatric expertise. Most bariatric programs also require patients to have their vitamins and minerals checked on a regular basis following surgery. Nutrient deficiencies and any associated health issues are preventable with patient monitoring and patient compliance in following dietary and supplement (vitamin and mineral) recommendations. Health problems due to deficiencies usually occur in patients who do not regularly follow-up with their surgeon to establish healthy nutrient levels.

Misconception:  Obesity is only an addiction, similar to alcoholism or drug dependency.

Truth:

Although there is a very small percentage of individuals affected by obesity who have eating disorders, such as binge eating disorder syndrome, that may result in the intake of excess food (calories), for the vast majority of individuals affected by obesity, obesity is a complex disease caused by many factors. When treating addiction, such as alcohol and drugs, one of the first steps is abstaining from the drugs or alcohol. This approach does not work with obesity as we need to eat to live. Additionally, there may be other issues affecting an individual‘s weight, such as psychological issues. Weight gain generally occurs when there is an energy imbalance or, in other words, the amount of food (energy) consumed is greater than the number of calories burned (energy expended) by the body in the performance of biological functions, daily activities and exercise. Energy imbalance may be caused by overeating or by not getting enough physical activity and exercise. There are other conditions, however, that affect energy balance and/or fat metabolism that do not involve excessive eating or sedentary behavior including:

  • Chronic sleep loss
  • Consumption of foods that, independent of caloric content, cause metabolic/hormonal changes that may increase body fat (sugar, high fructose corn syrup, trans fat, processed meats and processed grains)
  • Low intake of fat-fighting foods (fruits, vegetables, legumes, nuts, seeds, quality protein)
  • Stress and psychological distress
  • Many types of medications
  • Pollutants

Obesity also ‘begets‘ obesity, which is one of the reasons why the disease is considered “progressive.” Weight gain causes a number of hormonal, metabolic and molecular changes in the body that increase the risk for even greater fat accumulation and obesity. Such obesity-associated changes reduce fat utilization, increase the conversion of sugar to fat, and enhance the body‘s capacity to store fat by increasing fat cells size and numbers and by reducing fat breakdown. Such defects in fat metabolism mean that more of the calories consumed are stored as fat. To make matters worse, obesity affects certain regulators of appetite and hunger in a manner that can cause an increase in the amount of food eaten at any given meal and the desire to eat more often.  There are many causes for obesity and that the disease of obesity is far more than just an ‘addiction‘ toward food. The treatment of obesity solely as an addiction may be beneficial for a very small percentage of individuals whose only underlying cause for obesity is excessive and addictive eating, but would be unlikely to benefit the multitudes, particularly those individuals affected by severe obesity.

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Surgery for Diabetes

Did You Know?

  • Someone in the world dies from complications associated with diabetes every 10 seconds.
  • Diabetes is one of the top ten leading causes of U.S. deaths.
  • One out of ten health care dollars is attributed to diabetes.
  • Diabetics have health expenditures that are 2.3 times higher than non-diabetics.
  • Approximately 90 percent of type 2 diabetes mellitus (T2DM), the most common form of diabetes, is attributable to excessive body fat.
  • If current trends continue, T2DM or pre diabetic conditions will strike as many as half of adult Americans by the end of the decade. (according to the United HealthGroup Inc., the largest U.S. health insurer by sales).
  • The prevalence of diabetes is 8.9 percent for the U.S. population but more than 25 percent among individuals with morbid obesity.
  • Metabolic and bariatric surgery is the most effective treatment for T2DM among individuals who are affected by obesity and may result in remission or improvement in nearly all cases.

Type 2 Diabetes Mellitus (T2DM)

Type 2 diabetes(T2DM) is the most common form of diabetes, accounting for approximately 95 percent of all cases. Obesity is the primary cause for T2DM and the alarming rise in diabetes prevalence throughout the world has been in direct association increase rates of obesity worldwide. T2DM leads to many health problems including cardiovascular disease, stroke, blindness, kidney failure, neuropathy, amputations, impotency, depression, cognitive decline and mortality risk from certain forms of cancer. Premature death from T2DM is increased by as much as 80 percent and life expectancy is reduced by 12 to 14 years.

Current therapy for type 2 diabetes includes lifestyle intervention (weight-loss, appropriate diet, exercise) and anti-diabetes medication(s). Medical supervision and strict adherence to the prescribed diabetes treatment regimen may help to keep blood sugar levels from being excessively high although medications and lifestyle changes cause remission of the disease. In fact, T2DM often worsens with time, requiring even greater numbers of medication or a higher dosage to keep blood sugar under control. For this reason, T2DM has been considered a chronic and progressive disease.

Metabolic and Bariatric Surgery and Type 2 Diabetes

Nearly all individuals who have bariatric surgery show improvement in their diabetic state. Bariatric surgeries performed in more than 135,000 patients were found to affect type 2 diabetes in the following ways:

Surgery improves type 2 diabetes in nearly 90 percent of patients by:

  • lowering blood sugar
  • reducing the dosage and type of medication required
  • improving diabetes-related health problems

Surgery causes type 2 diabetes to go into remission in 78 percent of individuals by:

  • reducing blood sugar levels to normal levels
  • eliminating the need for diabetes medications

Health Improvements

  • Cause the improvement or remission of T2DM to last for years

Types of Metabolic and Bariatric Surgeries

The following are the most common bariatric surgeries performed in the United States and their known effects on T2DM.

ROUX-EN-Y GASTRIC BYPASS

Roux-en-y Gastric Bypass is a surgery that alters the GI tract to cause food to bypass most of the stomach and the upper portion of the small intestine. The operation results in significant weight-loss and causes remission of T2DM in 80 percent of patients and improvement of the disease in an additional 15 percent of patients.

Improvement or remission of diabetes with gastric bypass occurs early after surgery and before there is significant weight-loss. The weight-loss independent mechanisms of diabetes improvement after gastric bypass are partially explained by changes in hormones produced by the gut after the surgery, and this is an active area of research in the field of metabolic and bariatric surgery.

SLEEVE GASTRECTOMY

Sleeve Gastrectomy (Vertical gastrectomy) is an operation that removes a large portion of the stomach and, in doing so, causes weight-loss. The remaining stomach is narrow and provides a much smaller reservoir for food.

Sleeve gastrectomy also appears to have some weight-loss independent effects on glucose metabolism and also causes some changes in gut hormones that favor improvement in diabetes. Diabetes remission rates after sleeve gastrectomy are also very high (more than 60%) and, in some studies, similar to results seen after gastric bypass.

ADJUSTABLE GASTRIC BAND

The Adjustable Gastric Band is a weight-loss procedure that involves the placement of a band around the upper portion of the stomach.

Remission of diabetes occurs in approximately 45-60 percent of patients. The remission or improvement of diabetes, however, is secondary to the weight-loss produced by the procedure, and there does not appear to be any other mechanism for diabetes improvement in band patients. In other words, patients who have diabetes and who are unsuccessful in losing weight with the AGB will unlikely see any improvement in the diabetes.

DUODENAL SWITCH

The Duodenal Switch is a malabsorptive procedure performed far less frequently than the gastric bypass, sleeve gastrectomy or the adjustable gastric band due to the complexity of the procedure and the greater risk of complications. Studies find, however, that the operation is most effective in inducing early and sustained remission or improvement of T2DM (more than 85 percent remission rates with weight-loss independent effects)

BENEFITS VS. RISKS

Type 2 Diabetes is a leading cause of death in the U.S. and is a major contributor to morbidity and mortality from heart disease, stroke and kidney failure. Each year millions of individuals die from the effects of T2DM. With the advancements in bariatric surgery, many of these individuals could be saved and experience an improved quality of health and life.

While bariatric surgery certainly has some risk, the long-term risk of continued diabetes (which is often inadequately treated with medication) typically outweighs the risk of a surgical procedure for most patients. Each patient‘s individual risks for surgery, though, should be evaluated in the context of the duration and severity of their diabetes as well as their other obesity-related health problems.

INTERNATIONAL DIABETES FOUNDATION POSITION STATEMENT ON BARIATRIC SURGERY IN THE TREATMENT OF T2DM

In 2011, diabetologists, endocrinologists, surgeons and public health experts convened at the 2nd. World Congress on Interventional Therapies for Type 2 Diabetes in New York City. Based upon the evidence presented by these world-renowned experts, The International Diabetes Foundation (IDF) released a Position Statement calling for bariatric surgery to be considered early in the treatment of T2DM.

The document recognized that:

  • In addition to behavioral and medical treatments, bariatric surgeries constitute a powerful option to ameliorate diabetes in patients affected by severe obesity.
  • Bariatric surgery is an appropriate treatment for people with T2DM and obesity not achieving recommended treatment targets with medical therapies
  • Surgery should be an accepted option in people who have T2DM and a BMI of 35 or more.
  • Surgery should be considered as an alternative treatment option in patients with a BMI between 30 and 35 when T2DM cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors.
  • Bariatric surgery for treatment of T2DM is cost-effective
  • The risk for complications and death with bariatric surgery is low and similar to that of well-accepted procedures such as gallbladder surgery

Metabolic and bariatric surgery for T2DM must be performed within accepted guidelines which include an ongoing multidisciplinary care, patient education, follow-up and clinical audit, as well as safe and effective surgical procedures.

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Bariatric Surgery Procedures

Bariatric surgical procedures cause weight loss by restricting the amount of food the stomach can hold, causing malabsorption of nutrients, or by a combination of both gastric restriction and malabsorption. Bariatric procedures also often cause hormonal changes. Most weight loss surgeries today are performed using minimally invasive techniques (laparoscopic surgery).

The most common bariatric surgery procedures are gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch. Each surgery has its own advantages and disadvantages.

Jump to a Procedure


 

Gastric Bypass

gastric bypassThe Roux-en-Y Gastric Bypass – often called gastric bypass – is considered the ‘gold standard‘ of weight loss surgery.

The Procedure

There are two components to the procedure. First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food.

The gastric bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less calories consumed. Additionally, because there is less digestion of food by the smaller stomach pouch, and there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer has food going through it, there is probably to some degree less absorption of calories and nutrients.

Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes.

Advantages

  1. Produces significant long-term weight loss (60 to 80 percent excess weight loss)
  2. Restricts the amount of food that can be consumed
  3. May lead to conditions that increase energy expenditure
  4. Produces favorable changes in gut hormones that reduce appetite and enhance satiety
  5. Typical maintenance of >50% excess weight loss

Disadvantages

  1. Is technically a more complex operation than the AGB or LSG and potentially could result in greater complication rates
  2. Can lead to long-term vitamin/mineral deficiencies particularly deficits in vitamin B12, iron, calcium, and folate
  3. Generally has a longer hospital stay than the AGB
  4. Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance

 

Sleeve Gastrectomy

gastric sleeveThe Laparoscopic Sleeve Gastrectomy – often called the sleeve – is performed by removing approximately 80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana.

The Procedure

This procedure works by several mechanisms. First, the new stomach pouch holds a considerably smaller volume than the normal stomach and helps to significantly reduce the amount of food (and thus calories) that can be consumed. The greater impact, however, seems to be the effect the surgery has on gut hormones that impact a number of factors including hunger, satiety, and blood sugar control.

Short term studies show that the sleeve is as effective as the roux-en-Y gastric bypass in terms of weight loss and improvement or remission of diabetes. There is also evidence that suggest the sleeve, similar to the gastric bypass, is effective in improving type 2 diabetes independent of the weight loss. The complication rates of the sleeve fall between those of the adjustable gastric band and the roux-en-y gastric bypass.

Advantages

  1. Restricts the amount of food the stomach can hold
  2. Induces rapid and significant weight loss that comparative studies find similar to that of the Roux-en-Y gastric bypass. Weight loss of >50% for 3-5+ year data, and weight loss comparable to that of the bypass with maintenance of >50%
  3. Requires no foreign objects (AGB), and no bypass or re-routing of the food stream (RYGB)
  4. Involves a relatively short hospital stay of approximately 2 days
  5. Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety

Disadvantages

  1. Is a non-reversible procedure
  2. Has the potential for long-term vitamin deficiencies
  3. Has a higher early complication rate than the AGB

 

Adjustable Gastric Band

The Adjustable Gastric Band – often called  the band  – involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch above the band, and the rest of the stomach below the band.

The Procedure

gastric bandThe common explanation of how this device works is that with the smaller stomach pouch, eating just a small amount of food will satisfy hunger and promote the feeling of fullness. The feeling of fullness depends upon the size of the opening between the pouch and the remainder of the stomach created by the gastric band. The size of the stomach opening can be adjusted by filling the band with sterile saline, which is injected through a port placed under the skin.

Reducing the size of the opening is done gradually over time with repeated adjustments or “fills.” The notion that the band is a restrictive procedure (works by restricting how much food can be consumed per meal and by restricting the emptying of the food through the band) has been challenged by studies that show the food passes rather quickly through the band, and that absence of hunger or feeling of being satisfied was not related to food remaining in the pouch above the band.  What is known is that there is no malabsorption; the food is digested and absorbed as it would be normally.

The clinical impact of the band seems to be that it reduces hunger, which helps the patients to decrease the amount of calories that are consumed.

Advantages

  1. Reduces the amount of food the stomach can hold
  2. Induces excess weight loss of approximately 40 – 50 percent
  3. Involves no cutting of the stomach or rerouting of the intestines
  4. Requires a shorter hospital stay, usually less than 24 hours, with some centers discharging the patient the same day as surgery
  5. Is reversible and adjustable
  6. Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedures
  7. Has the lowest risk for vitamin/mineral deficiencies

Disadvantages

  1. Slower and less early weight loss than other surgical procedures
  2. Greater percentage of patients failing to lose at least 50 percent of excess body weight compared to the other surgeries commonly performed
  3. Requires a foreign device to remain in the body
  4. Can result in possible band slippage or band erosion into the stomach in a small percentage of patients
  5. Can have mechanical problems with the band, tube or port in a small percentage of patients
  6. Can result in dilation of the esophagus if the patient overeats
  7. Requires strict adherence to the postoperative diet and to postoperative follow-up visits
  8. Highest rate of re-operation

 

Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Gastric Bypass

switch asmbsThe Biliopancreatic Diversion with Duodenal Switch – abbreviated as BPD/DS – is a procedure with two components. First, a smaller, tubular stomach pouch is created by removing a portion of the stomach, very similar to the sleeve gastrectomy. Next, a large portion of the small intestine is bypassed.

The Procedure

The duodenum, or the first portion of the small intestine, is divided just past the outlet of the stomach. A segment of the distal (last portion) small intestine is then brought up and connected to the outlet of the newly created stomach, so that when the patient eats, the food goes through a newly created tubular stomach pouch and empties directly into the last segment of the small intestine. Roughly three-fourths of the small intestine is bypassed by the food stream.

The bypassed small intestine, which carries the bile and pancreatic enzymes that are necessary for the breakdown and absorption of protein and fat, is reconnected to the last portion of the small intestine so that they can eventually mix with the food stream. Similar to the other surgeries described above, the BPD/DS initially helps to reduce the amount of food that is consumed; however, over time this effect lessens and patients are able to eventually consume near “normal” amounts of food. Unlike the other procedures, there is a significant amount of small bowel that is bypassed by the food stream.

Additionally, the food does not mix with the bile and pancreatic enzymes until very far down the small intestine. This results in a significant decrease in the absorption of calories and nutrients (particularly protein and fat) as well as nutrients and vitamins dependent on fat for absorption (fat soluble vitamins and nutrients). Lastly, the BPD/DS, similar to the gastric bypass and sleeve gastrectomy, affects guts hormones in a manner that impacts hunger and satiety as well as blood sugar control. The BPD/DS is considered to be the most effective surgery for the treatment of diabetes among those that are described here.

Advantages

  1. Results in greater weight loss than RYGB, LSG, or AGB, i.e. 60 – 70% percent excess weight loss or greater, at 5 year follow up
  2. Allows patients to eventually eat near “normal” meals
  3. Reduces the absorption of fat by 70 percent or more
  4. Causes favorable changes in gut hormones to reduce appetite and improve satiety
  5. Is the most effective against diabetes compared to RYGB, LSG, and AGB

Disadvantages

  1. Has higher complication rates and risk for mortality than the AGB, LSG, and RYGB
  2. Requires a longer hospital stay than the AGB or LSG
  3. Has a greater potential to cause protein deficiencies and long-term deficiencies in a number of vitamin and minerals, i.e. iron, calcium, zinc, fat-soluble vitamins such as vitamin D
  4. Compliance with follow-up visits and care and strict adherence to dietary and vitamin supplementation guidelines are critical to avoiding serious complications from protein and certain vitamin deficiencies

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Who is a Candidate for Bariatric Surgery?

Qualifications for bariatric surgery in most areas include:

  1. BMI ≥ 40, or more than 100 pounds overweight.
  2. BMI ≥35 and at least one or more obesity-related co-morbidities such as type II diabetes (T2DM), hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.
  3. Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts.

For example, an adult who is 5‘11″ tall and weighs 290 lbs would have a BMI over 40.  BMI.

The NIH, as well as the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) also recommend that surgery be performed by a board certified surgeon with specialized experience/training in bariatric and metabolic surgery, and at a center that has a multidisciplinary team of experts for follow-up care. This may include a nutritionist, an exercise physiologist or specialist, and a mental health professional. In addition, some insurance companies require that the surgery be performed at a facility that meets the ASMBS-approved quality standards (MBSAQIP). Facilities which meet high standards or quality, like those outlined in MBSAQIP, are preferable choices for patients.


Childhood and Adolescent Obesity

Introduction

Obesity is not exclusive to adults. Each day, more and more children are finding themselves at risk for overweight and obesity. Childhood obesity often accompanies many of the obesity-related conditions adults affected by obesity often experience, such as type 2 diabetes, hypertension, sleep apnea and more. Recent data shows that up to 80 percent of children affected by obesity will continue to be affected by obesity into adulthood.

Childhood Obesity at a Glance

Obesity impacts children in a variety of ways. First and foremost, a child‘s health is impacted as they have now opened themselves up to a wide variety of health issues – issues that most of us didn‘t experience until middle-age. In addition to health implications, there‘s also one other area that children face which can be very serious – weight bias and bullying.

Kids impacted by obesity often find themselves the target of bullying. This bullying can take place in the classroom, in your neighborhood and even in your own home. It is very important to recognize this type of behavior and address it quickly. The Obesity Action Coalition (OAC), a nonprofit dedicated to educating and advocating for those affected by obesity, provides valuable resources on weight bullying.

How Do We Treat Childhood Obesity?

You may be thinking to yourself, “I know my child is affected by obesity, but I don‘t know what to do.” This is not uncommon. Treating childhood obesity is similar to treating obesity in adults; however, it is important to keep very open lines of communication with your children during treatment choice and when it starts as children will often not share their feelings as they fear disappointing you as their parent.

There are various treatments available for childhood obesity, such as behavioral and lifestyle modification, pharmacotherapy and bariatric (weight-loss) surgery. We are going to focus on bariatric surgery in this section.

Why Bariatric Surgery?

When a child is first examined by his or her pediatrician or primary care doctor, you can expect a thorough evaluation detailing the child‘s food intake, physical activity level, blood work and more. Once you, your child and their healthcare professional have gathered this information, you can then begin to discuss treatment options.

While treatments such as behavioral and lifestyle modifications may work for the majority of children affected by obesity and help them increase their health, there are children affected by severe obesity that require more aggressive treatment such as bariatric surgery.

Bariatric surgery, which is commonly performed on adults affected by severe obesity, has been shown to produce long-lasting weight-loss and improvement in many obesity-related conditions such as type 2 diabetes, high blood pressure, sleep apnea and more.

Currently, the most common operations being performed in children affected by severe obesity are the Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB) and vertical sleeve gastrectomy.

The goal of bariatric surgery is to provide the most benefit possible with the lowest risk. With this in mind, many research studies have been done to evaluate outcomes following bariatric surgery in adolescents, and many more are ongoing. The information and recommendations contained here are based on a recent review of the available medical literature and extensive discussion by a panel of experts on childhood obesity and bariatric surgery.

Co-Morbidities (obesity-related health problems)

TYPE 2 DIABETES MELLITUS (T2DM)

Compared with Type 1 (or juvenile) diabetes, T2DM usually develops later in life, and is associated with overweight and obesity. Some children and adolescents affected by obesity develop T2DM early. This is a long-standing disease that tends to worsen throughout time, and diabetic children are at increased risk of developing high blood pressure, high cholesterol and liver disease. Recent data suggests that adolescents who undergo bariatric surgery can have significant improvement or complete remission of their T2DM.

OBSTRUCTIVE SLEEP APNEA

Up to 22 percent of children and adolescents affected by obesity have obstructive sleep apnea, which is characterized by shallow breathing or abnormal pauses in breathing during sleep. Sleep apnea can cause fatigue, moodiness and difficulties with paying attention and completing tasks. In many patients, obstructive sleep apnea has been shown to improve or go away after bariatric surgery.

NON-ALCOHOLIC FATTY LIVER DISEASE AND NON-ALCOHOLIC STEATOHEPATITIS

Approximately 38 percent of children and adolescents affected by obesity have fatty deposition in their livers, compared with 5 percent of normal-weight individuals, and about 9 percent have associated inflammation (called  steatohepatitis), compared with 1 percent of lean children. Studies have shown that such fatty deposition and inflammation may lead to fibrosis, or scarring in the liver. This has been shown to improve in adolescents who have undergone bariatric surgery.

PSEUDOTUMOR CEREBRI

Pseudotumor cerebri is a condition caused by increased pressure inside the skull, and symptoms can include headache, visual changes, ringing in the ears, nausea and vomiting.   There is often no obvious cause for this condition, but it has been associated with obesity and symptoms frequently improve several months after bariatric surgery.

CARDIOVASCULAR DISEASE

Although we are still learning about risk factors for heart disease in children affected by obesity, research suggests that childhood obesity may lead to increased risk of heart and vascular diseases in adulthood. Weight-loss from bariatric surgery has been shown to improve several such risk factors in adults; however, for children and adolescents these effects would take many years to measure, and studies are still ongoing.

QUALITY OF LIFE

Many children and adolescents affected by obesity feel that their obesity and health issues have a negative impact on their quality of life and emotional health, and several studies have shown significant improvement after weight-loss.

DEPRESSION

Adolescents affected by obesity often find themselves affected by depression as well. Adolescents who undergo weight-loss surgery often see improvement in their emotional wellbeing. Conversely, weight-loss studies suggest that adult patients seem to be at slightly increased risk for suicide after bariatric surgery. We recommend that adolescents with depression before surgery be watched closely for signs of depression after surgery.

EATING DISORDERS

Binge eating and purging (sometimes called  bulimia) has been seen in some adolescents with obesity who desire bariatric surgery. Eating disturbances are quite serious, and outcomes following bariatric surgery in teens with eating disorders have not been studied. Because of this, bariatric surgery in these adolescents is generally discouraged unless the eating disturbance has been appropriately treated and is well-controlled.

Who Should Be Considered for Bariatric Surgery?

In general, the more severe obesity is, the higher the risk for co-morbidities. The BMI (body mass index) is an index of weight for height that is commonly used in the medical profession to classify underweight, overweight, obesity and severe obesity in adults. BMI is typically used a little differently for children, but most surgeons use BMI thresholds while trying to determine if an adolescent is a candidate for weight-loss surgery.

In addition to BMI, physicians consider co-morbidities and the potential long-term health risks associated with untreated obesity when determining a patient‘s appropriateness for bariatric surgery.

Recommended selection criteria for adolescents being considered for a bariatric procedure include:

  1. BMI 35 kg/m2 or higher with major co-morbidities (such as type 2 diabetes, moderate or severe sleep apnea, pseudotumor cerebri, or severe fatty liver disease)
  2. BMI 40 kg/m2 or higher with other less severe co-morbidities (such as high blood pressure, high cholesterol, mild or moderate sleep apnea)

Despite the above minimum BMI criteria, many insurance companies will not cover bariatric surgical procedures for adolescents under the age of 18 years, or they may have different criteria or only cover a certain specific procedure or procedures. If you are considering bariatric surgery for your child, it would be helpful to contact your insurance company to see if these procedures are covered under your plan.

Team Member Qualifications

Adolescents qualified for bariatric surgery should be evaluated and cared for by a team of expert individuals. The makeup of this team may vary among institutions, but may typically include the following members:

  1. Bariatric Surgeon  – experienced in performing bariatric procedures.
  2. Pediatric specialist  – a pediatrician with special training in endocrinology, gastroenterology, nutrition and/or adolescence, or an internist or family practitioner with special experience caring for adolescents.
  3. Registered dietitian  – should be experienced in treating obesity and working with children and families, and is helpful if also experienced in caring for patients undergoing bariatric surgery
  4. Mental health specialist  – psychiatrist, psychologist, or other qualified and independently licensed mental health specialist with specialty training in pediatric, adolescent and family treatment. The specialist should also be trained in the treatment of eating disorders and obesity, with special experience evaluating patients and families for bariatric surgery.
  5. Coordinator  – typically a registered nurse, social worker, or another team member who coordinates the evaluation and follow-up care for each child.
  6. Exercise specialist  – exercise physiologist, physical therapist or other individual trained to provide safe physical activity prescriptions to adolescents affected by severe obesity.

Risks and Outcomes

When considering bariatric surgery as a treatment for your child‘s weight, it is important to recognize that bariatric surgery is a serious procedure. All surgical procedures have an associated risk of complications. Patients with a higher BMI and more serious medical illness are at increased risk of complications after bariatric surgery, some of which can be life-threatening.   Having surgery earlier rather than later in life (before obesity-associated health problems can worsen) may decrease the risks of complications after surgery and of long-term complications from obesity.

The risks specifically associated with the surgical procedure should be discussed at length with your surgical team. A few particular risks of concern in the adolescent population include:

PSYCHOSOCIAL RISKS

Short term data suggest that weight-loss following bariatric surgery improves depression, eating disturbances and quality of life. However, potential negative psychosocial risks have not been well studied.

NUTRITIONAL RISKS

Depending on the type of bariatric surgery chosen, certain vitamin and other nutritional deficiencies have been reported in adolescents after bariatric surgery. In particular, low levels of iron, vitamin B12, vitamin D and calcium are common problems after RYGB.   Calcium and vitamin D are crucial for bone development during adolescence. In order to prevent these nutritional deficiencies, all patients need to follow special dietary recommendations and take vitamin supplements after bariatric surgery.   Because this is so important, adolescents preparing to undergo bariatric surgery are carefully assessed for their ability to follow the recommended regimens and come to scheduled appointments.

INFORMED CONSENT

Individuals under the age of 18 years cannot legally provide consent for bariatric surgery; formal consent must be provided by an adolescent‘s parent or guardian. However, informed consent for bariatric surgery is a complex process that involves much more than the simple signing of a consent form for the surgical procedure. It is important for the health care team to discuss in detail with the adolescent and his or her parent(s) or guardian(s) the anticipated benefits and specific risks of bariatric surgery, especially those that are most relevant for adolescents.     An understanding of the many complex issues involved should be formally assessed as part of the consent process.

Frequently, the adolescent and parent have differing ideas about the effect that obesity has on their lives, and may disagree about bariatric surgery. While a child cannot consent to surgery, it is important that they are in agreement (called  assent) without inappropriate influences, even if those influences are subtle. Assessing an adolescent‘s capacity to make an informed decision about bariatric surgery can be challenging; the clinical team must consider the adolescent‘s cognitive, social and emotional development and support his or her independent role in the decision-making process.

Types of Bariatric Surgery

Current data shows that bariatric surgery in adolescents is as safe and effective as bariatric surgery in adults. A number of different weight-loss procedures are performed in adults, and many of these have also been performed in adolescents. The decision regarding which procedure is appropriate for an individual patient is a complex one that is made by the surgical team, in conjunction with the adolescent and his or her family.

GASTRIC BYPASS

In the United States, gastric bypass surgery (RYGB) for weight-loss was first performed in adults in the 1960s and in adolescents in the 1970s.  Recent data shows that this procedure provides lasting weight-loss in adolescents, with complication rates similar to those seen in adults. Severe complications, although rare, have been reported. It is very important that adolescents undergoing this or any bariatric procedure attend all follow-up visits with their bariatric health care team, and that this follow-up should be long-term (at least several years).

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING

Placement of an adjustable gastric band is not yet approved by the Food and Drug Administration in children under the age of 18 years, but some institutions perform this procedure through what is known as “off-label” use of the banding device. Adjustable gastric banding (LAGB) involves the placement of an adjustable band around the upper portion of the stomach so that an individual will feel full sooner and eat less. A balloon on the inner surface of the band is connected to a port that sits under the skin on the abdomen. Injecting saline into the port will fill the balloon and tighten the band around the stomach. These band adjustments are done periodically during special visits to the surgeon, and close follow-up with the surgical team after LAGB is necessary for the best outcomes.

Studies of adolescents who have undergone LAGB demonstrate it to be an effective and safe procedure, and associated with fewer nutritional complications than RYGB. Weight-loss and improvement in obesity-related co-morbidities appear similar to those seen in adults, though long-term data has not yet been published. Most complications are device-related and not life threatening. In two studies, 8-25 percent of adolescents needed another operation to fix a mechanical problem related to the band. LAGB has been shown to be more effective than behavioral interventions alone in producing significant weight-loss and reduction in obesity-related co-morbidities, but long-term data is still lacking.

VERTICAL SLEEVE GASTRECTOMY

The vertical sleeve gastrectomy (VSG) involves cutting the stomach to make it into a smaller tube shape. No intestinal bypass is performed, and no devices are left in place.  This procedure has been performed less often in adolescents than the RYGB or the LAGB, but has been performed in increasing numbers throughout the past few years.   Long term data is not yet available, but preliminary results from on-going studies of adolescents undergoing VSG demonstrate excellent weight reduction, reversal of co-morbidities, and complication rates similar to those of the adult population.

OTHER PROCEDURES

Other bariatric procedures, such as the biliopancreatic diversion and duodenal switch (both of which involve intestinal bypass) have been performed in adolescents, but outcome data is scarce. These procedures are less commonly performed in the pediatric population than the others, largely due to concerns for vitamin deficiencies and protein malnutrition.

SELECTED REFERENCES:

  1. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a  systematic review and meta-analysis. JAMA 2004;292:1724 –37.
  2. Silberhumer GR, Miller K, Kriwanek S, Widhalm K, Pump A, Prager  G. Laparoscopic adjustable gastric banding in adolescents: the Austrian  experience. Obes Surg 2006;16:1062–7.
  3. Lawson ML, Kirk S, Mitchell T, et al. One-year outcomes of Rouxen-Y gastric bypass for morbidly obese adolescents: a multicenter  study from the Pediatric Bariatric Study Group. J Pediatr Surg 2006;  41:137– 43.
  4. Sugerman HJ, Sugerman EL, DeMaria EJ, et al. Bariatric surgery for  severely obese adolescents. J Gastrointest Surg 2003;7:102– 8.
  5. Barnett SJ, Stanley C, Hanlon M, et al. Long-term follow-up and the  role of surgery in adolescents with morbid obesity. Surg Obes Relat  Dis 2005;1:394–8.

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Benefits of Bariatric Surgery

Severe Obesity: Why the Need for Surgical Intervention

Severe obesity is one of the most serious stages of obesity. You may often find yourself struggling with your weight and essentially feeling as if you‘re trapped in a weight gain cycle. In addition, you most likely have attempted numerous diets – only in the end, to see your weight continue to increase.

More than a decade ago, The National Institutes of Health, better known as NIH, reported that individuals affected by severe obesity are resistant to maintaining weight loss achieved by conventional therapies, such as consuming fewer calories, increasing exercise, commercial weight-loss programs, etc.). The NIH recognized bariatric (weight-loss) surgery as the only effective treatment to combat severe obesity and maintain weight loss in the long term.

How Can Bariatric Surgery Help Me?

When combined with a comprehensive treatment plan, bariatric surgery may often act as an effective tool to provide you with long term weight-loss and help you increase your quality of health. Bariatric surgery has been shown to help improve or resolve many obesity-related conditions, such as type 2 diabetes, high blood pressure, heart disease, and more. Frequently, individuals who improve their weight find themselves taking less and less medications to treat their obesity-related conditions.

Significant weight loss through bariatric surgery may also pave the way for many other exciting opportunities for you, your family, and most importantly – your health.

How Does Bariatric Surgery Work?

Bariatric surgery, such as gastric bypass, gastric sleeve, and laparoscopic adjustable gastric banding, work by changing the anatomy of your gastrointestinal tract (stomach and digestive system) or by causing different physiologic changes in your body that change your energy balance and fat metabolism. Regardless of which bariatric surgery procedure you and your surgeon decide is best for you, it is important to remember that bariatric surgery is a “tool.” Weight loss success also depends on many other important factors, such as nutrition, exercise, behavior modification, and more.

By changing your gastrointestinal anatomy, certain bariatric procedures affect the production of intestinal hormones in a way that reduces hunger and appetite and increases feelings of fullness (satiety). The end result is reduction in the desire to eat and in the frequency of eating. Interestingly, these surgically-induced changes in hormones are opposite to those produced by dietary weight loss. Let‘s take a closer look at the differences in hormonal changes between surgery and dietary weight loss:

  • Bariatric Surgery and Hormonal Changes
    Hormonal changes following bariatric surgery improve weight loss by maintaining or enhancing energy expenditure (calories burned). In fact, some surgeries even increase energy expenditure relative to changes in body size. Thus, unlike dietary weight loss, surgical weight loss has a higher chance of lasting because an appropriate energy balance is created.
  • Dieting and Hormonal Changes
    In dietary weight loss, energy expenditure is reduced to levels lower than would be predicted by weight loss and changes in body composition. This unbalanced change in energy can often lead to weight regain.

Significant weight loss is also associated with a number of other changes in your body that help to reduce defects in fat metabolism. With increased weight loss, you will find yourself engaging in more physical activity. Individuals who find themselves on a weight-loss trend often engage in physical activity, such as walking, biking, swimming, and more. Additionally, increased physical activity combined with weight loss may often improve your body‘s ability to burn fat, lead to a positive personal attitude, and decrease stress levels. Massive weight loss, as a result of bariatric surgery, also reduces hormones such as insulin (used to regulate sugar levels) and cortisol (stress hormone) and improves the production of a number of other factors that reduce the uptake and storage of fat into fat storage depots. Physical activity is also a very important component of combating obesity.

Bariatric surgery may improve a number of conditions and biological actions (hormonal changes) to reverse the progression of obesity. Studies find that more than 90 percent of bariatric patients are able to maintain a long-term weight loss of 50 percent excess body weight or more.

Bariatric surgery can be a useful tool to help you break the vicious weight gain cycle and help you achieve long term weight loss and improve your overall quality of health and life.

Long Term Weight Loss Success

Bariatric surgeries result in long-term weight-loss success. Most studies demonstrate that more than 90 percent of individuals previously affected by severe obesity are successful in maintaining 50 percent or more of their excess weight loss following bariatric surgery. Among those affected by super severe obesity, more than 80 percent are able to maintain more than 50 percent excess body weight loss.

Improved Longevity

Several large population studies find that individuals affected by severe obesity who have had bariatric surgery have a lower risk of death than individuals affected by obesity who do not have surgery. One of these studies found up to an 89 percent greater reduction in mortality throughout a 5-year observation period for individuals who had bariatric surgery when compared to those who did not. Another large population study comparing mortality rates of bariatric and non-bariatric patients found a greater than 90 percent reduction in death associated with diabetes and a greater than 50 percent reduction in death from heart disease.

The mortality rate for bariatric surgery (3 out of 1000) is similar to that of a gallbladder removal and considerably less than that of a hip replacement. The exceptionally low mortality rate with bariatric surgery is quite remarkable considering that most patients affected by severe obesity are in poor health and have one or more life-threatening diseases at the time of their surgery. Therefore, as regards mortality, the benefits of surgery far exceed the risks.

Improvement/Resolution of Coexisting Diseases

The exceptionally high reduction in mortality rates with bariatric surgery are due to the highly significant improvement in those diseases that are caused or worsened by obesity.

Bariatric surgery is associated with massive weight-loss and improves, or even resolves (cures), obesity-related co-morbidities for the majority of patients. These co-morbidities include high blood pressure, sleep apnea, asthma and other obesity-related breathing disorders, arthritis, lipid (cholesterol) abnormalities, gastroesophageal reflux disease, fatty liver disease, venous stasis, urinary stress incontinence, pseudotumor cerebri, and more.

Bariatric surgeries also lead to improvement and remission of Type II diabetes mellitus (T2DM). In the past, diabetes was considered to be a progressive and incurable disease. Treatments include weight loss and lifestyle changes for those who are overweight or obese and antidiabetic medication, including insulin. These treatments help to control T2DM but rarely cause remission of the disease. However, there is now a large body of scientific evidence showing remission of T2DM following bariatric surgery. A large review of 621 studies involving 135,247 patients found that bariatric surgery causes improvement of diabetes in more than 85 percent of the diabetic population and remission of the disease in 78 percent. Remission of T2DM was highest for the bilio-pancreatic diversion with duodenal switch (BPD/DS) with a remission rate of 95 percent, followed by the Roux-en-Y gastric bypass (RYGB) with remission in 80 percent of patients, and the adjustable gastric band (AGB) with a remission rate of 60 percent. Other studies comparing remission of diabetes between surgeries found comparable rates between the laparoscopic sleeve gastrectomy (LSG) and RYGB, i.e. 80 percent.

Causes of improvement or remission of diabetes have not been completely identified. Improvement of T2DM with AGB is related to weight loss. However, with other surgeries, such as the LSG or RYGB, diabetes remission or improvement occurs early after surgery – well before there is significant weight reduction. In fact, some bariatric patients with T2DM leave the hospital with normal blood sugar and without the need for antidiabetic medication.

Changes in Quality of Life and Psychological Status with Surgery

In addition to improvements in health and longevity, surgical weight-loss improves overall quality of life. Measures of quality of life that are positively affected by bariatric surgery include physical functions such as mobility, self-esteem, work, social interactions, and sexual function. Singlehood is significantly reduced, as is unemployment and disability. Furthermore, depression and anxiety are significantly reduced following bariatric surgery.

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Life After Bariatric Surgery

Bariatric surgery is a major event in a patient‘s weight-loss journey, but the event is best seen as a new beginning. Obesity is a lifelong disease and there is no operation, diet or medication that can by itself offer a permanent cure. Surgery with good aftercare and moderate lifestyle changes can give wonderful long-term results for health and weight.

Nutrition (food and supplements) and Fluids

In the weeks after surgery, your surgeon will have a plan for you to follow, including instructions for nutrition and activity. This may include a liquid diet for a period of time followed by a progression to soft or pureed foods, and eventually more regular food. While you are healing in the first few months, it is extra hard to get enough fluid. Most surgeons advise a goal of 64oz or more of fluids daily to avoid dehydration, constipation, and kidney stones. You will also need a lifelong habit with daily supplements, usually including:

  • Multi-vitamins
  • Vitamin D
  • Calcium
  • Iron
  • Vitamin B12

The American Society for Metabolic and Bariatric Surgery (ASMBS) has specific recommendations on the recommended doses, but be sure that you follow your surgeon‘s advice.

Healthy lifestyle choices give the best results for health and Quality of Life after surgery. Protein-rich foods are important, with patients advised to take in 60-100g of protein daily, depending on their medical conditions, type of operation and activity level. The ASMBS warns patients to avoid excessive carbohydrate intake, such as starchy foods (breads, pastas, crackers, refined cereals) and sweetened foods (cookies, cakes, candy, or other sweets). Limiting carbohydrates to 50 grams per day or less helps avoid rebound hunger problems which can lead to weight regain.

Common Questions

Q: Which vitamin and mineral supplements should I expect to take after weight-loss surgery?
A: Multivitamin, calcium with vitamin D, and in some cases, an iron and/or vitamin B12 supplement. Sometimes Vitamin A is added to the regimen depending on the operation‘s degree of malabsorption. A chewable form is recommended, at least initially after surgery. Be sure you are using a vitamin appropriate for adults, not a children‘s multivitamin.

Q: How long will I need to take vitamin supplements?
A: Vitamin supplements will be a lifelong requirement.

Q: How much protein do I need daily?
A: Most patients get 60-80 grams daily, but some may require more depending on their response to surgery or their type of operation. Your dietitian can provide more detailed information.

Q: Can I take all of the protein in one dose?
A: Protein should be taken in multiple doses, across multiple meals or healthy snacks. The body cannot absorb more than approximately 30 grams at once. Also, protein is a nutrient that helps us feel fuller, longer. If we try to include proteins in each of our meals or healthy snacks, we‘re less likely to feel hungry when it‘s not time to eat.

Q: How should I get my protein? With shakes? Bars? What if I‘m a vegetarian?
A: There are many options even for those with special dietary needs or preferences. Your dietitian can provide additional information on protein sources. Meats, eggs, dairy products, and beans are common protein sources in everyday foods. Protein extracts made from soy, brown rice and whey are commonly sold in stores. Protein shakes or bars may offer additional ways to meet your protein needs. You may find it helpful to calculate your daily protein intake to be sure you‘re not falling short. As you are able to tolerate more regular foods, you get a higher portion of the requirement during regular meals and supplements become less necessary.

Q: What happens if I don‘t take in enough protein?
A: The body needs additional protein during the period of rapid weight loss to maintain your muscle mass. Protein is also required for your metabolism to occur. If you don‘t provide enough protein in your diet, the body will take its protein from your muscles and you can become frail.

Q: Do I need to avoid caffeine after bariatric surgery?  A: Caffeine fluids have been shown to be as good as any others for keeping you hydrated. Still, it is a good idea to avoid caffeine for at least the first thirty days after surgery while your stomach is extra sensitive. After that point, you can ask your surgeon or dietitian about resuming caffeine. Remember that caffeine often comes paired with sugary, high-calorie drinks, so be sure you‘re making wise beverage choices.

Q: Why is fluid intake important?
A: Dehydration is the most common reason for readmission to the hospital. Dehydration occurs when your body does not get enough fluid to keep it functioning at its best. Your body also requires fluid to burn its stored fat calories for energy. Carry a bottle of water with you all day, even when you are away from home; remind yourself to drink even if you don‘t feel thirsty. Drinking 64 ounces of fluid is a good daily goal. You can tell if you‘re getting enough fluid is if you‘re making clear, light-colored urine 5-10 times per day. Signs of dehydration can be thirst, headache, hard stools or dizziness upon sitting or standing up. You should contact your surgeon‘s office if you are unable to drink enough fluid to stay hydrated.

Medications

Many Americans with obesity have severe health problems such as diabetes, high blood pressure, elevated cholesterol and coronary heart disease. Patients who undergo bariatric surgery and successfully lose weight see these health conditions improve, and they may be able to stop some medications with their doctor‘s advice.

Taking fewer prescription medications doesn‘t always mean “no more pills,” though. Good health is the goal, not fewest pills. Many people actually take more pills, as they follow vitamin and mineral plans, and have better awareness of benefits.

Common Questions

Q: What effect does weight loss surgery have on my medications?
A: Prescription or over-the-counter drugs may be absorbed differently after surgery, depending on the type of procedure. Your medication therapy may be affected by this change. In the early period right after surgery, larger tablets or capsules may not be recommended by your surgeon so that pills do not become stuck. Because of this, your surgeon may recommend that you take medications different forms, such as crushed, liquid, suspension, chewable, sublingual or injectable. Some long-acting medications and “enteric coated” medication may not be crushable. Some medication may be crushed and administered with food.

Sleeve gastrectomy and adjustable gastric banding tend to have little to no change in the absorption of medications. Roux-en-Y gastric bypass and duodenal switch can have more significant changes in how medications are absorbed. Check with your surgeon and pharmacist about how you should take each of your medications. Some patients need a higher dose of anti-depressants to have the same effect. This is not a complication, but you need to be aware of how you feel, and speak up with all your caregivers

Q: Will my medications change after bariatric surgery?
A: Maybe. Some doses may change (see the previous question). Some medication doses may decrease as the obesity-related health conditions improve. For example, diabetic patients often require less insulin or other diabetes medications after surgery because glucose control can improve quickly. Patients who take high blood pressure and cholesterol medication can see their doses lowered if these disease states improve. Any changes in prescription medication should be overseen by your doctor; this is not something that you should do yourself.

Q: Which medications should I avoid after weight loss surgery?
A: Your surgeon or bariatric physician can offer guidance on this topic. One clear class of medications to avoid after Roux-en-Y gastric bypass is the “Non-steroidal anti-inflammatory drugs” (NSAIDs), which can cause ulcers or stomach irritation in anyone but are especially linked to a kind of ulcer called “marginal ulcer” after gastric bypass. Marginal ulcers can bleed or perforate. Usually they are not fatal, but they can cause a lot of months or years of misery, and are a common cause of re-operation, and even (rarely) reversal of gastric bypass.

Some surgeons advise limiting the use of NSAIDs after sleeve gastrectomy and adjustable gastric banding as well. Corticosteroids (such as prednisone) can also cause ulcers and poor healing but may be necessary in some situations. Some long-acting, extended-release, or enteric coated medications may not be absorbed as well after bariatric surgery, so it is important that you work with your surgeon and primary care physician to monitor how well your medications are working. Your doctor may choose an immediate-release medication in some cases if the concern is high enough. Finally, some prescription medications can be associated with weight gain, so you and your doctor can weigh the risk of weight gain versus the benefit of that medication. There may be alternative medications in some cases with less weight gain as a side effect.

Q: Are there any additional prescription medications I will have to take after bariatric surgery?
A: Some patients may require anti-acid medications, either temporarily or indefinitely. Some surgeons prescribe a temporary medication for gallstone prevention if you still have a gallbladder. Ask your surgeon if these will be needed.

Q: Are all medications crushable?
A: Not all medications are crushable. Whether or not a medication can be crushed would depend on the drug formulation. In general, non-coated, immediate release tablets may be crushed. It is important that you are VERY careful with medications, so please always check with your surgeon, primary physician, or pharmacist prior to making medication decisions.

Fitness

Physical activity is very important for long-term weight management. Different patients may have different needs and abilities. As you progress in your fitness program, your body becomes more efficient at the same activity, which means that you tend to burn fewer calories. As you lose weight, the number of calories burned per hour tends to decrease as well. And so, throughout time, it is necessary to gradually increase the intensity or length of your fitness activities. Your surgeon or fitness instructor may have specific recommendations for you in this regard.

Q: How much exercise should I get?
A: Current recommendations for activity are 150 minutes of moderate activity each week such as brisk walking, jogging, Zumba, swimming, or using exercise machines. Please note that the ability to safely tolerate exercise differs from person to person. Please make sure that your chosen exercise and amount will be safely tolerated by you.

Q: How soon after surgery can I exercise?
A: That depends on the type of exercise. You should begin walking while still in the hospital, unless instructed otherwise. As you heal, begin to increase your exercise time and intensity. Your doctor will release you to increase your activity based on your progress. After surgery, exercises such as weights, sit-ups, pull-ups, or any abdominal straining should wait until you get the go-ahead from your doctor.

Q: What type of exercise should I do?
A: Include aerobic (“cardio”), resistance (strength) and flexibility exercise into your routine for best results. Try different exercise programs to find what is right for you. Learn what is available in your community through your bariatric program, local fitness centers, and fellow patients. Warm water exercise (such as lap swimming or water aerobics) is excellent for those with joint pain. Home exercise videos are another option if you do not have access to a nearby gym.

Mental Health

Not surprisingly, When a person goes through major lifestyle and body changes after surgery, major adjustments occur in how we think about ourselves and how others think of us. Some patients gain much more confidence as they successfully change their lifestyle and manage their weight. Others struggle with continuing to see themselves as affected by obesity. Marriages and relationships can be strained with the adjustments that occur. Strong relationships can become stronger as those involved communicate and work through these changes. Weak relationships can fracture and suffer as a result of these changes. Your workplace dynamics can change; some of your teammates at work may support and cheer you on, while others may be less supportive. For all of these reasons, access to an experienced mental health professional can be an important part of postoperative recovery. Above all, each patient should be prepared for “bumps in the road” along the journey, whether it‘s interpersonal conflict, marriage stress, a surgical complication, or a plateau in weight-loss.

Eating habits are frequently affected by emotions, stress, boredom, mindless eating, or even eating disorders. These are very common but not always obvious. If you find yourself eating to relieve stress or eating when you are full or not hungry, you should seek additional help from your surgeon, qualified psychologists, or behavioral therapists. These issues can be successfully treated to get patients back on track if identified.

Weight Plateaus

Once you have had surgery, your life will be forever different. Your body has now been modified to give you a better chance to overcome the underlying genetic, metabolic, environmental and lifestyle-induced state of obesity. These are powerful forces that created an unhealthy “weight set point” where your body has likely been stuck or hovering around, almost like a thermostat that is set too high. Your body is very effective at trying to maintain that weight and preventing change. As you lose weight, it is important to know that your body will try to establish a new set point. This leads to periodic plateaus in weight. This is normal and expected. Do not allow yourself to be discouraged when you reach a plateau, as these are normal and necessary parts of the weight-loss journey.

Sleep and Stress

A healthy sleep pattern (called “sleep hygiene”) is another key to successful weight management. Setting a regular bedtime is not just for kids! Even adults benefit from regular sleep times, and from setting aside enough time to sleep. Inadequate sleep has been identified as one contributing factor in weight gain. As you seek to improve your sleep habits, there are techniques that can help: avoiding evening caffeine, exercising earlier in the day (not in the few hours before bed), and creating a peaceful bedroom environment that is quiet, not too bright, and comfortable. Also, many patients have sleep apnea before bariatric surgery. While sleep apnea can improve with weight loss, it is important to continue your treatment for sleep apnea. You should discuss the appropriateness of changing sleep apnea treatment with your doctor before you make any modifications.

Successful stress management is another pillar of post-operative success. We know that unmanaged stress can lead to poor choices which can derail your weight-loss attempts. Stress can stifle your success if it is not acknowledged and managed. Even before surgery, it is important to cultivate habits and relationships that relieve stress. Strong relationships with open communication, regular exercise, , and calming habits such as meditation or yoga are all ways to deal with stress. Support groups are readily available in many weight-loss programs. These provide a venue to interact with your healthcare providers and with other patients to share stories, lend support, and to continually be educated with the latest developments in the rapidly evolving field of obesity medicine.

Smoking

To have a lower risk of complications with weight-loss surgery, almost every bariatric surgery program will recommend that you quit smoking or using chewing tobacco prior to your surgery. Hopefully, this can be an opportunity for you to kick the habit for good.

Q: Why do I have to quit smoking or using tobacco before surgery?
A: Smoking or chewing tobacco leads to decreased blood supply to your body‘s tissues and delays healing. Smoking harms every organ in the body and is been linked to:

  • Blood clots (the largest cause of death after bariatric surgery)
  • Marginal ulcers after gastric bypass
  • Heart disease
  • Stroke
  • Chronic obstructive pulmonary (lung) disease
  • Increased risk for hip fracture
  • Cataracts
  • Cancer of the mouth, throat, esophagus, larynx (voice box), stomach, pancreas, bladder, cervix, and kidney

Q: How soon do I have to quit smoking before surgery?
A: Six weeks is needed to reduce the risk of fatal blood clots and pneumonia. Stopping just a week or two before can even make some risks worse; this is not unique to bariatric surgery. Your surgeon will have specific guidelines on how long you must be tobacco-free before surgery, and many will reschedule surgery until you are “clean.” There are blood tests that can show if you have been smoking, even if you are on a nicotine patch or gum, so don‘t cheat!

Q: Where can I get help to help me quit?
A: Talk to your primary care practitioner; they would be glad to help! You can also call 1-877-44U-QUIT (1-877-448-7848) or 1-800-QUIT-NOW (1-800-784-8669).

Drinking Alcohol

Q: Can I drink alcohol after surgery?
A: Alcohol is not recommended after bariatric surgery. Alcohol contains calories but minimal nutrition and will work against your weight loss goal. For example, wine contains twice the calories per ounce that regular soda does. The absorption of alcohol changes with gastric bypass and gastric sleeve because an enzyme in the stomach which usually begins to digest alcohol is absent or greatly reduced.

Alcohol may also be absorbed more quickly into the body after gastric bypass or gastric sleeve. The absorbed alcohol will be more potent, and studies have demonstrated that obesity surgery patients reach a higher alcohol level and maintain the higher levels for a longer period than others. In some patients, alcohol use can increase and lead to alcohol dependence. For all of these reasons, it is recommended to avoid alcohol after bariatric surgery.

Pregnancy after Bariatric Surgery

Q: Is it safe to get pregnant after I have bariatric surgery?
A: It is recommended you avoid getting pregnant for 12-18 months after surgery. This allows you to have maximum weight loss and reach a stable weight. You will also be very limited in your nutrient intake for quite some time after surgery.

Q: I‘ve never been able to get pregnant anyway, so I won‘t need to worry about avoiding pregnancy after surgery, will I?
A: You can experience a boost in fertility quite soon after surgery, so it is important to use a barrier method of birth control such as IUD, or condoms and spermicide to ensure you do not become pregnant. Birth control pills are much less effective patients with obesity and in the phase of rapid weight loss. If you do become pregnant, please contact your bariatric surgeon and your obstetrician to monitor your progress. You will need to closely monitor your nutrient intake and be evaluated for vitamin deficiencies.

Overall, pregnancy after weight loss surgery can be done safely, by taking steps to minimize risks to your body and to the developing fetus. Studies demonstrate a decreased risk of pregnancy-induced hypertension (high blood pressure) and a decreased risk for gestational diabetes. For best outcomes, discuss your options with your surgeon and obstetrician.

Follow-up Care

Many studies show that we‘re all more likely to engage in better habits when we know that someone will be regularly checking in with us. For this reason, most bariatric surgery programs plan for long-term follow-up visits with a healthcare provider experienced with obesity management. These follow-up visits may be the surgeon, a physician assistant or nurse practitioner, dietitian, mental health professional, exercise specialist, or a medical weight-loss specialist (bariatrician). The most important thing is that you find a bariatric surgery program that provides for this long-term care, so that any problems or concerns that develop over time can be addressed by an experienced team.

Medical professionals are not replaceable, but joining with others on the journey can be just as important. Support groups can be a great way to learn, and to share in a safe setting.

Most programs are very sensitive to the fact that patients feel vulnerable to criticism and bias. You need to be able to feel safe to share your challenges and struggles, so that you can get help when you need it most! Your caregivers understand and expect that ups and downs happen, and that life changes and the body adapts over time. “Tune-ups” are possible, and useful.

Congratulations on taking such an important step toward a healthier life! Life after bariatric surgery is not all easy, but strong planning, appropriate education, and determination can help as you make this journey.

Contributed by members of the American Society for Metabolic and Bariatric Surgery (ASMBS) Patient Safety Committee and Public Education Committee

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Dr. Felts

Our Weight
Loss Team

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Memorial Weight Loss Surgery of New Mexico

Experience Counts! Recipient of the "Best Hospital" Reader's Choice Award 2003 - 2013 and 2015

Located in the Mesilla Valley of southern New Mexico – between the stunning Organ Mountains and the rambling Rio Grande – Memorial Weight Loss Center serves the 300,000 residents of Las Cruces New Mexico, Doña Ana County and El Paso Texas by performing bariatric procedures including Gastric Bypass surgery, Gastric Sleeve surgery and LAP-Band surgery. We offer the latest minimally invasive laparoscopic weight loss procedures available in the nation today. Our comprehensive weight loss surgery procedures include comprehensive pre-operative and post-operative care for our patients. Our weight loss surgery clinic in Las Cruces New Mexico provides the latest in diagnostic, therapeutic and rehabilitative services , all for the inpatient and outpatient.

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