Weight-loss surgery is an option for many

(This article was first printed in the June 2006 issue of the Harvard Women’s Health Watch. For more information or to order, please go to http://www.health.harvard.edu/womens.)

Obesity among American women is leveling off, according to data from the National Health and Nutrition Examination Survey (NHANES), a periodic assessment of American diet and health. Researchers with the Centers for Disease Control and Prevention, which conducts the survey, found that the percentage of obese women did not increase between 1999 and 2004 (Journal of the American Medical Association, April 5, 2006). It’s the first such slowdown in more than 25 years.

Only time will tell if this is a watershed moment in the obesity epidemic. In the meantime, America has a lot of weight to lose. More than 60% of women are overweight and 33% are obese, so putting on the brakes is not enough. Besides, NHANES data also showed that more women than ever have entered a weight category called severe or extreme obesity, once called morbid obesity because of its health effects. Extreme obesity is defined as a body mass index (BMI) of 40 or more, roughly equivalent to being 80 pounds overweight for women (100 for men). Of the more than six million Americans in this group, women outnumber men by more than two to one.

Obesity is associated with a range of conditions that affect women, including infertility and menstrual difficulties, stress incontinence, type 2 diabetes, hypertension, gallbladder disease, osteoarthritis, sleep apnea, heart disease, and stroke, as well as cancers of the endometrium, breast, and colon. Extreme obesity further heightens all of these risks while making physical activity — an important weight-loss and health strategy — nearly impossible.

What to do

Research has shown that diet and weight-loss medications are of little use to people with extreme obesity. Their best chance for long-term weight reduction and improved health is surgery to promote weight loss (called bariatric surgery). Even more than a decade after surgery, 90% of those who have undergone gastric bypass, the most common bariatric procedure, manage to keep off an average of 50% of the excess weight. The result is cure or improvement in diabetes, sleep apnea, degenerative arthritis, and hypertension, and a reduction in major cardiovascular risk factors, including cholesterol.

Surgeons have been doing bariatric surgery for more than 50 years, but the number of people undergoing the procedure (most of whom are women) has soared — from 36,700 in 2000 to 171,000 in 2005, according to figures from the American Society for Bariatric Surgery. The surge has been influenced not only by the growing number of extremely obese people, but also by improved surgical techniques and high-profile success stories, such as NBC television weatherman Al Roker’s loss of 100 pounds after gastric bypass in 2002.

Like all major operations, bariatric surgery has risks — and extreme obesity adds to those risks. Surgical treatment also requires lifelong medical monitoring and major changes in diet and lifestyle. But for most people with extreme obesity, the health benefits far outweigh the risks.

What’s involved?

National Institutes of Health (NIH) guidelines recommend bariatric surgery only for highly motivated people with a BMI of 40 or more and no success or only temporary success with other approaches to weight loss. Less severely obese people may also be candidates if they have an obesity-related health problem, such as type 2 diabetes, heart disease, or sleep apnea. Only experienced bariatric surgeons should perform the surgery (research suggests it’s best to choose one who has performed at least 100 procedures), and patients should receive extensive medical, nutritional, and counseling services before and after surgery.

Bariatric techniques promote weight loss by various mechanisms, not all of them fully understood. Some procedures, such as gastric banding (see illustration above), restrict food intake by making the stomach smaller. Roux-en-Y gastric bypass (see illustration below) restricts food intake and also changes the absorption of some fats and other nutrients. But stomach restriction and preventing nutrient absorption aren’t the whole story.

“We know that most surgery for obesity also acts through hormonal and neurohormonal pathways that change the body’s response to food,” says Dr. Janey Pratt, a bariatric surgeon at Massachusetts General Hospital in Boston. “You get increased feelings of fullness, decreased hunger, and in the case of gastric bypass, resolution of diabetes, sometimes within two weeks of surgery. These changes can’t be accounted for just by the weight loss. There’s some hormonal change that goes on in the body after we do the surgery that causes you to lose weight.”

A lot of research is aimed at finding out why weight-loss surgery is effective. It’s been shown, for example, that levels of ghrelin (GRELL-in), a hormone that stimulates appetite, fall after gastric bypass. Scientists have also cured diabetes in animals by simply bypassing the upper part of the intestine (duodenum) — without decreasing the size of the stomach. “Something changes the body’s response to insulin and its production,” says Pratt. Learning more about these mechanisms may lead to the development of medications and other strategies that will make surgery unnecessary.

If you think surgery might be right for you

Your primary care provider will refer you to a bariatric surgeon or a center that specializes in bariatric procedures, where you’ll be evaluated by clinicians specializing in medicine, nutrition, and psychology. The purpose is to make sure you are physically and mentally prepared for surgery (and the accompanying changes), are willing and able to participate in follow-up care and diet, and understand all the potential risks and benefits.

For the first few months after surgery, you will be restricted to several hundred calories per day. Don’t worry — you won’t feel starved, because you’ll have little appetite or interest in food. If you eat too quickly or too much, the stomach pouch will overfill and you may vomit or feel pain in the chest and upper abdomen. You’ll need to take supplementary vitamins (especially vitamins B1, B12, folate, and D) and minerals (especially calcium and iron). After about a year, most people can increase their intake to 1,200 calories per day.

You may be advised to take a medication to prevent gallstones, which develop in 30% of people who lose weight rapidly. Kidney stones are also common. Ulcers may occur in the small intestine because of contact with stomach acid. Some people develop other complications, such as a hernia at the incision site, or stenosis — narrowing where the stomach is attached to the small intestine.

After a high-carbohydrate meal, a person who has had gastric bypass surgery may suffer from “dumping syndrome,” a reaction that causes flushing, sweating, nausea, vomiting, and sometimes diarrhea. Gas is another common complaint, although the cause is not clear. People who lose 100 pounds or more sometimes need additional surgery to “lift” sagging skin that won’t return to normal.

Insurance coverage for bariatric surgery is variable. In February 2006, Medicare announced that it will cover certain bariatric procedures, including gastric banding and Roux-en-Y gastric bypass, in appropriate patients who are treated at centers endorsed by the American College of Surgeons or the American Society for Bariatric Surgery. This decision may open the door to expanded coverage of other weight-loss treatments as well as bariatric surgery.

(This article was first printed in the June 2006 issue of the Harvard Women’s Health Watch. For more information or to order, please go to http://www.health.harvard.edu/womens.)

	Click to enlarge		Harvard Women's Health Watch Harvard Women’s Health Watch – the monthly newsletter that focuses on the special health concerns of women, with expert information and advice from the specialists at Harvard Medical School. Read more 12 monthly issues (Print+Electronic) $28.00 12 monthly issues (Electronic Only) $24.00