For anyone who has considered a weight loss program, there is certainly no shortage of choices. In fact, to qualify for insurance coverage of weight loss surgery, most insurers require patients to document a history of medically supervised weight loss efforts (at least 6 months of consecutive visits to your family doctor).
Gastric Bypass
The 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
- Produces significant long-term weight loss (60 to 80 percent excess weight loss)
- Restricts the amount of food that can be consumed
- May lead to conditions that increase energy expenditure
- Produces favorable changes in gut hormones that reduce appetite and enhance satiety
- Typical maintenance of >50% excess weight loss
Disadvantages
- Is technically a more complex operation than the AGB or LSG and potentially could result in greater complication rates
- Can lead to long-term vitamin/mineral deficiencies particularly deficits in vitamin B12, iron, calcium, and folate
- Generally has a longer hospital stay than the AGB
- Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance
Sleeve Gastrectomy
The 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
- Restricts the amount of food the stomach can hold
- 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%
- Requires no foreign objects (AGB), and no bypass or re-routing of the food stream (RYGB)
- Involves a relatively short hospital stay of approximately 2 days
- Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety
Disadvantages
- Is a non-reversible procedure
- Has the potential for long-term vitamin deficiencies
- Has a higher early complication rate than the AGB
Non-Surgical Treatment
Most non-surgical weight loss programs are based on some combination of diet/behavior modification and regular exercise. Unfortunately, even the most effective interventions have proven to be effective for only a small percentage of patients. It is estimated that less than 5% of individuals who participate in non-surgical weight loss programs will lose a significant amount of weight and maintain that loss for a long period of time. According to the National Institutes of Health, more than 90% of all people in these programs regain their weight within one year. Sustained weight loss for patients who are morbidly obese is even harder to achieve. Serious health risks have been identified for people who move from diet to diet, subjecting their bodies to a severe and continuing cycle of weight loss and gain known as “yo-yo dieting.”
Diet & Behavior Modification
There are literally hundreds of diets available. Moving from diet to diet in a cycle of weight gain and loss – yo-yo dieting – that stresses the heart, kidneys and other organs can also be a health risk. Doctors who prescribe and supervise diets for their patients usually create a customized program with the goal of greatly restricting calorie intake while maintaining nutrition.
These diets fall into two basic categories:
- Low Calorie Diets (LCDs) are individually planned so that the patient takes in 500 to 1,000 fewer calories a day than he or she burns.
- Very Low Calorie Diets (VLCDs) typically limit caloric intake to 400 to 800 a day and feature high-protein, low-fat liquids.
Many patients on Very Low Calorie Diets lose significant amounts of weight. However, after returning to a normal diet, most regain the lost weight in under a year. Ninety percent of people participating in all diet programs will regain the weight they’ve lost within two years.
Exercise
Starting an exercise program can be especially intimidating for someone suffering from morbid obesity. Your health condition may make any level of physical exertion next to impossible. The benefits of exercise are clear, however. And there are ways to get started.
A National Institutes of Health survey of 13 studies concludes that physical activity:
- results in modest weight loss in overweight and obese individuals
- increases cardiovascular fitness, even when there is no weight loss
- can help maintain weight loss
New theories focusing on the body’s set point (the weight range in which your body is programmed to weigh and will fight to maintain that weight) highlight the importance of exercise. When you reduce the number of calories you take in, the body simply reacts by slowing metabolism to burn fewer calories. Daily physical activity can help speed up your metabolism, effectively bringing your set point down to a lower natural weight. So when following a diet to attempt to lose weight, exercise increases your chances of long-term success.
Examples to get you started:
- Park at the far end of parking lots and walk
- Take the stairs instead of the elevator
- Cut down on television
- Swim or participate in low-impact water aerobics
- Ride an exercise bike
Overall, walking is one of the best forms of exercise. Start out slowly and build up. Your doctor, or people in a support group, can offer encouragement and advice. Incorporating exercise into your daily activities will improve your overall health and is important for any long-term weight management program, including weight loss surgery. Diet and exercise play a key role in successful weight loss after surgery.
Over-the-Counter & Prescription Drugs
New over-the-counter and prescription weight loss medications have been introduced. Some people have found them effective in helping to curb their appetite. The results of most studies show that patients on drug therapy lose around 10 percent of their excess weight and that the weight loss plateaus after six to eight months. As patients stop taking the medication, weight gain usually occurs.
Weight loss drugs can have serious side effects. Still, medications are an important step in the morbid obesity treatment process. Before insurance companies will reimburse/pay for weight loss surgery, you must follow a well-documented treatment path.
“Since many people cannot lose much weight no matter how hard they try, and promptly regain whatever they do lose, the vast amount of money spent on diet clubs, special foods and over-the-counter remedies, estimated to be on the order of $30 billion to $50 billion yearly, is wasted.” (New England Journal of Medicine)
The fact remains that morbid obesity is a complex, multifactorial chronic disease.