It’s hard for a person who does not have a weight issue (yes I’ll admit I’m skinny) to proffer advice to those who do. It’s rather like a non-smoker telling a smoker to just throw away the ashtrays and stop! And of course, it’s not fair. Obesity is both horribly complex and chronic; it has genetic, metabolic, endocrinological, psychological and behavioral components, many of which are very difficult to understand much less control. We all want to blame someone or some entity “out there” for the 72 million obese adults in the US. (Well, to be honest, at some point, I do blame larger plates, our over abundance of cheap, highly advertised junk food, our obsession for getting more for our money and the lack or exercise that is pandemic in our society). Having made the last portion of this statement, I should now suggest that you get off your computer, iphone and/or blackberry and go take a brisk walk! But maybe you can wait until you finish reading this.
There are several definitions for the descriptive and medical terms overweight, obese or morbidly obese…however, the models in magazines and popular actresses make most women feel that they fit into the overweight category. But the World Health Organization (WHO) has made it clear that obesity is the abnormal or excessive fat accumulation that presents a risk to health. They use body mass index (BMI) as an estimate of obesity: a BMI of 25 to 29.9 kg/meter squared is defined as overweight, a BMI of 30 to 39.9 obese, and a BMI 40 or over morbidly obese. To figure out your BMI, go to www.nhlbisupport.com/bmi/bminojs.htm.
I receive a publication for continuing medical education in my specialty. (The State requires a certain number of CME credits to renew a medical license, and answering questions attached to the article is one way to get those accredited hours). A recent Postgraduate Obstetrics and Gynecology article dealt with bariatric surgery among reproductive-age women and upon reading it, I thought that its information would be of interest to many women.
We all know the health consequences of obesity: hypertension, coronary vascular disease (heart attack and stroke), diabetes, osteoarthritis and cancer (among them, breast, ovarian, colon, uterine and pancreatic). In the reproductive years, obesity can affect ovulation, periods, fertility, result in complications of pregnancy, higher C Section rates and immediate and long term health for newborns. Between 2002 and 2006 health care costs for treating obese adults increased by more than 81%, rising from $166.7 to $303.1 billion. Obesity weighs heavily on our economy.
The NIH has recommended guidelines for surgery (bariatric) as a treatment for morbid obesity. Potential candidates include anyone with a BMI over 40 or those whose BMI is 35 or over if they have other “co-morbid” conditions such as cardiopulmonary disease, diabetes, difficult ambulation and severe joint disorders as a result of their weight. More and more patients in these categories are undergoing bariatric procedures ….there has been an 800% rise between 1995 and 2005 and that percent keeps leaping (as do some of the now thinner post-op patients as well as the surgeons and surgery centers performing these procedures).
Bariatric surgeries work via restriction (limiting the food that gets to the stomach) and/or malabsorption (limiting food absorbed by the stomach as well as the intestine). There are two common methods performed in the US: the first, the banding procedure, which is restrictive. An adjustable gastric band is positioned around the upper portion of the stomach so that food comes into and is absorbed or propelled downward though a small stomach pouch. The band is usually placed by means of a laparoscope, avoiding the need for a large abdominal incision. The band can be adjusted to widen or narrow the opening of the stomach pouch via a port that is placed under the skin. (Fluid is used to fill and expand the band or conversely fluid can be removed to narrow it.)
The second type of procedure that is available is both malabsorptive and restrictive. It’s called a Roux-en-Y gastric bypass (RYGB). It involves dissecting the stomach to create a small pouch that empties into a portion of the intestine called the jejunum. Most of the stomach and 100 to 150 cm of the bowel are bypassed so that they do not come into contact with food. This procedure can also be done through a laparoscope; but in some cases, if there are complications (it’s more technically difficult than the banding surgery), may have to be completed via an open abdominal incision.
Complications do occur. According to the review article, band slippage occurs in up to 15% of patients; they then can develop nausea, inability to tolerate food and problems swallowing. Others have no overt symptoms but simply start gaining weight. Sometimes it’s hard to get to the port opening or the tube that leads to the band kinks or leaks and this may require re-operation. Most of these problems can be fixed, the real issue is the mortality rates following the procedure; and they are low: between 0.02% and 0.1%. (Remember that many of these patients have medical problems that make anesthesia difficult and aside from their operative risk they could succumb to their weight-caused diseases without the surgery).
There are higher complication rates with the RYGB procedure. These include hernias in the area of incision (15% -24%), fluid or blood collection in the area of incision (8%), infection (7%) and need for re-operation (1.6%). There are also reports in the literature of pulmonary embolism, lung problems, breakdown of the area of the stomach that has been sewn (or stapled) and bleeding. The mortality rates for the RYGB can vary depending on the severity of obesity, the multiple conditions that could already have impacted the health of the patient as well as the experience of the surgeon. It ranges from 0.3% to 7%. (Scores that can predict these rates have been formulated by various agencies.). Then because this procedure promotes weight loss by decreasing nutrient absorption (think malabsorption), it can lead to a deficiency in vitamins and minerals, especially vitamin A,D.E and K as well as the B’s, C, thiamine and calcium. So vitamin supplementation and tests to see “what’s missing” are important subsequent to the surgery….and should be continued, basically, forever.
I should mention a few more potential side effects…the most common is dumping syndrome which can occur at least initially in 25 to 50% of patients who undergo gastric bypass. The dumping can occur 30 minutes after eating and results in nausea, vomiting, fullness, diarrhea and/or palpitations or it can occur hours after eating with symptoms of dizziness and confusion. But before I dump on the procedure, let me quickly state that most patients learn how to control this problem by abstaining from rich carbohydrate laden food, eating small meals and taking additional fiber.
I feel like one of those TV commercials where I list so many possible side effects that, in the end, make the product sound horrendous. Well in the right conditions and appropriate patients, bariatric surgery can be amazing. Maximum weight loss often continues for 2 years and can range from 40 to over a hundred pounds. The procedure can result in complete resolution or improvement of conditions such as chronic hypertension, type 2 diabetes, obstructive sleep apnea and abnormal cholesterol (hyperlipidemia) and of course, the size of waist bands and clothes. In women of reproductive age, there is an improvement in menstrual cycles, fertility, and maternal complications during pregnancy. There have been studies that also have shown lower rates of preterm deliveries and abnormal birth weight of the newborn. (However, the nutrition of the pregnant mother has to be followed carefully so that she has no vitamin deficiencies.) There on ongoing studies to see if there are less C Sections in women who have had the surgery before getting pregnant.
I don’t want anyone to come away embracing the thought that “well I’m fat, but never mind any attempts to lose weight; I can always have the surgery.” This is a procedure that should be considered only when diet with caloric restriction and exercise just don’t work. The decision to undergo lap banding or RYGB can only be made after all the pros and potential side effects are weighed by the patient and her physician.