Bariatric Surgery
Clinical Diagnosis of Obesity
Obesity is a rapidly expanding problem in the United States. Current research suggests that over 127 million Americans are overweight, and over 34% of Americans are obese. This means three out of every five Americans are either overweight or obese and the percentages have doubled over the past 20 years. In the United States, up to 300,000 deaths per year can be linked to obesity.
Morbid obesity was originally defined as any individual weighing twice their ideal body weight or greater than 100 pounds over their ideal body weight. The current definition of obesity is based on body mass index (BMI) which is a mathematical formula that compares a person’s height and weight. A value less than 25 kg/m2 is considered “normal”. Overweight individuals are classified as having a BMI between 25 and 30 kg/m2. Obese patients have a BMI over 30 kg/m2 and individuals who are morbidly obese have a BMI over 40 kg/m2. It is now estimated that over 12 million Americans are morbidly obese.
Causes of Obesity
The causes of obesity are multiple and complex and are related to different genetic, environmental, cultural, socioeconomic and psychological influences. It is not simply a result of overeating. Studies have demonstrated that once the problem is established, efforts such as dieting and exercise programs have a limited ability to provide effective long-term relief.
Genetic factors
Obesity tends to run in families, suggesting a genetic cause. There are numerous studies that show genes play a role in the tendency to gain excess weight. Just as some genes determine eye color or height, others affect metabolism, appetite, satiety (ability to feel full), fat-storing ability, and our natural activity levels. However, family members share not only genes, but also diet and lifestyle habits.
Environmental factors
Environmental factors deal with a person’s lifestyle behavior. Some examples are what a person eats and how active he or she is. Americans tend to have high-fat diets, often putting taste and convenience ahead of nutritional content when choosing meals. Sedentary lifestyles also contribute greatly to obesity. These factors combined with a genetic predisposition to morbid obesity can make controlling weight much more difficult.
Psychological factors
There can often be psychological factors which contribute to weight gain. Some people use eating as a negative response to sadness, anger or even boredom. Other individuals have difficulties with binge eating where they eat large amounts of food and are unable to control how much they are eating. These problems can often lead to great difficulty in achieving and sustaining weight loss. Some individuals will need counseling or medication to help successfully control binge eating or depressive symptoms.
Other causes
In addition to the above, obesity can sometimes be caused by certain medical conditions such as hypothyroidism or certain neurologic diseases. Some types of antidepressants, steroids or other medications can also cause excessive weight gain. These causes can be detected by your doctor and it is estimated that they only account for about one percent of all cases of obesity.
Why lose weight?
Obesity is directly harmful to a person’s health. Studies show that someone who is obese is twice as likely to die prematurely a non-obese individual. The risk of death from diabetes or heart disease is five to seven times greater. There is a direct association between the degree of obesity and the development of medical problems, with an exponentially increased risk of death from comorbid conditions as the body mass index increases. Agencies such as the US Public Health Service now consider obesity as serious as tobacco in contributing to increased health problems.
Obesity is a risk factor for many serious, life-threatening diseases, including:
- Diabetes
- Stroke
- Heart disease
- High blood pressure (hypertension)
- Obstructive sleep apnea/Hypoventilation (breathing disorders)
- Heartburn or reflux disease High Cholesterol
- Cancer – esophagus, colon, liver, gallbladder, pancreas, kidney, stomach, prostate, breast, uterus, cervix, ovaries
- Obesity also contributes to many other medical conditions including:
- Infertility/ menstrual irregularities
- Degenerative Joint Disease / Debilitating arthritis
- Gallbladder disease and gallstones
- Depression
- Urinary Stress Incontinence
There are also physical limitations to obesity. Patients have complained about the inability to:
- Go to the movies
- Sit on a plane or bus seat
- Use a seat belt
- Fit through a turnstile
- Play/pick up children
- Maintain adequate hygiene
- Buy stylish clothes
In addition, obesity has other potential consequences. The psychological toll can be tremendous as obese individuals deal with repeated failures with dieting, limited access to public conveniences, prejudice and even ridicule. The rate of depression in the morbidly obese is increased tenfold what it is in the non-obese population. Obese individuals often face discrimination at work. This unfair reality can affect hirings, promotions and perceptions about overall job performance.
Options for weight loss
Non-surgical approaches to weight loss include various diet programs, exercise programs and medications. The goal is to decrease the calories consumed and increase the energy expended. There are multiple commercial diet programs available including low calorie, protein sparing, and high-protein/low carbohydrate varieties. Calorie restriction has always been one of the cornerstones in the treatment of obesity.
Weight loss can be achieved with these programs, however it is usually short-lived. Most of the initial weight loss is in fluids, and fat and even muscle is lost later. Extreme dieting (less than 1100 calories/day) can have significant health risks and is often followed by binging or overeating. Regain of all or even additional weight is common and is often referred to as “yo-yo dieting”. The health benefits of weight loss are not realized and long-term maintenance of weight loss has not been documented in any study.
An exercise program to increase energy expenditure is a vital component of any successful weight loss program. At least thirty minutes of daily moderate-intensity physical activity is generally recommended. Exercise helps replace fat with muscle and keeps the metabolism elevated even after the exercise is completed. It also improves psychological well-being. As weight loss occurs, the exercise should be become easier and the intensity or duration increased.
There have been multiple attempts to manage morbid obesity with various medications. Some of the early trials used amphetamine-like drugs or administration of thyroid hormone. These were subsequently abandoned for a variety of causes including abuse, side effects, and weight regain upon withdrawal of the medication. In the 1990’s the combination of phentermine and fenfluramine (“phen/fen”) was heralded as a pharmacological breakthrough. This was later found to contribute to cardiac valvular disease and primary pulmonary hypertension and was subsequently withdrawn from the market. There are some current medications that are used in various weight loss programs. Medications like phentermine alone, sibutramine or orlistat are examples and are generally reserved for individuals with a BMI over 30. Unfortunately, the weight loss with these medications is limited and all drug trials have been disappointing.
In 1996 the National Institute of Health (NIH) held a Consensus Conference on Obesity attended by experts in all medical fields including internists, nutritionists, surgeons, psychologists and basic scientists. They reached two main conclusions about morbid obesity:
1. Surgical intervention is the only method proven to have a significant long-term impact on the disease
2. Less invasive methods have failed to have any significant impact.
The problem with medical management is not in achieving weight loss, but in keeping the weight off!
How Does Weight Loss Surgery Work?
There are two main types of weight-loss surgery:
1. Restrictive
2. Malabsorptive
Restrictive procedures aim to limit the amount of food one can eat in a given time. They will limit the amount of calories that can be consumed but restricting the volume of food. Patients feel full with a small portion of food, thereby limiting hunger and allowing weight loss. This is why the surgery works better than any diet program – you will actually feel full eating a small amount of food. Examples include laparoscopic adjustable gastric banding (LAP-BAND) and laparoscopic sleeve gastrectomy. Another older example is the vertical banded gastroplasty (VBG or stomach-stapling). Because of the limitations of vertical banded gastroplasty (ie., less weight loss, failures with later weight gain, and the need for repeat surgery) most experienced bariatric surgeons no longer perform this procedure.
Malabsorptive procedures limit the amount of calories that are absorbed in the intestines. Malabsorptive procedures include the jejuno-ileal bypass. Because this purely malabsorptive procedures can lead to severe nutritional deficiencies and metabolic abnormalities, it has generally been abandoned. Biliopancreatic Diversion and Duodenal Switch variants also rely mainly on malabsorption and again carry higher risks of nutritional deficiencies and metabolic abnormalitites.
The Roux-en-Y gastric bypass has been the most common type of weight-loss surgery over the past two or three decades. The main advantage of RYGB is that it encompasses advantages of both restrictive and malabsorptive procedures while minimizing or eliminating some of the disadvantages of both approaches.
The NIH Consensus statement on obesity endorses both Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding for the surgical treatment of morbid obesity.
At Atlanta Bariatrics, we offer multiple procedures for those requiring surgical weight loss. These procedures can help provide and maintain weight loss, thereby allowing resolution of co-morbidites and improving the overall quality of life. Because of our extensive laparoscopic bariatric surgical experience, we are able to provide a comprehensive approach suited to the needs of the individual patient.
Click below to learn more about the procedures.
