Bariatric surgery, better option than diets

Compared to those who did not have surgery, those who did fared much better physically, emotionally

“Bariatric surgery is probably the most effective intervention we have in healthcare,” said Laurie K Twells, a clinical epidemiologist at Memorial University of Newfoundland.

She bases this bold claim on her experience with seriously obese patients and a detailed analysis of the best studies yet done showing weight-loss surgery’s ability to reverse the often devastating effects of being extremely overweight on health and quality of life.

“I haven’t come across a patient yet who wouldn’t recommend it,” Twells said in an interview. “Most say they wish they’d done it 10 years sooner.” She explained that the overwhelming majority of patients who undergo bariatric surgery have spent many years trying — and failing — to lose weight and keep it off. And the reason is not a lack of willpower.

“These patients have lost hundreds of pounds over and over again,” Twells said. “The weight that it takes them one year to lose is typically back in two months,” often because a body with long-standing obesity defends itself against weight loss by drastically reducing its metabolic rate, an effect not seen after bariatric surgery, which permanently changes the contours of the digestive tract.

In reviewing studies that followed patients for five to 25 years after weight-loss surgery, Twells and colleagues found major long-lasting benefits to the patients’ health and quality of life. Matched with comparable patients who did not have surgery, those who did fared much better physically, emotionally and socially. They rated themselves as healthier and were less likely to report problems with mobility, pain, daily activities, and feelings of depression and anxiety, among other factors that can compromise well-being.

Equally important are the undeniable medical benefits of surgically induced weight loss. They include normalising blood sugar, blood pressure and blood lipid levels and curing sleep apnea. Although bariatric surgery cannot cure Type 2 diabetes, it nearly always puts the disease into remission and slows or prevents the life-threatening damage it can cause to the heart and blood vessels.

Even in the small percentage of patients who ultimately lose little weight after surgery, significant metabolic benefits persist, according to findings at the Cleveland Clinic.

In a study of 31 obese diabetic patients who had not lost a lot of excess weight five to nine years after surgery, a “modest” weight loss of just 5 to 10% resulted in a reduction of cardiovascular risk factors and blood sugar abnormalities, Dr Stacy Brethauer and colleagues reported.

For the two most popular surgical techniques — the gastric bypass and the gastric sleeve — “the metabolic benefits are independent of weight loss,” Brethauer said in an interview. Both methods permanently reduce the size of the stomach. But the gastric band procedure, which is reversible, lacks these benefits unless patients maintain significant weight loss, he said.

Furthermore, as a study last year of 2,500 surgical patients at the Veterans Affairs Medical Centre in Durham, North Carolina, found, those who underwent bariatric surgery had lower overall death rates up to 14 years later than comparable patients who did not have weight-loss surgery.

Experts regard the reluctance of some insurers, including Medicaid programmes in many states, to cover the cost of bariatric surgery as penny-wise, pound-foolish. Failing to reverse extreme obesity can end up costing far more per patient than the typical $30,000 price of bariatric surgery — sometimes even millions more.

Counter to popular impressions that most people treated surgically regain most or all the weight they lose initially, the latest long-term research has shown otherwise.

In a decade-long follow-up of 1,787 veterans who underwent gastric bypass, a mere 3.4% returned to within 5% of their initial weight 10 years later. This finding is especially meaningful because the researchers at the VA centre in Durham were able to keep track of 82% of gastric bypass patients, a task too challenging for most clinics.

The study, by Matthew L Maciejewski and colleagues published in August in JAMA Surgery, found that 10 years later, more than 70% of surgical patients lost more than 20% of their starting weight, and about 40% had lost more than 30%.

Gastric bypass, an operation called Roux-en-Y, resulted in a somewhat greater weight loss at 10 years than the newer gastric sleeve surgery and significantly more than the adjustable gastric band (Lap-Band) surgery, which “has fallen out of favour in the last two or three years,” Maciejewski said.

Safer procedure

Bariatric surgery, regardless of the method used, is also much safer nowadays than it was even a decade ago, said Dr Jon C Gould, a surgeon at the Medical College of Wisconsin in Milwaukee who wrote a commentary on the VA study. However, he noted, the surgery is “vastly underutilised,” to the detriment of patients’ health and the nation’s health care costs.

“Less than 1% who would qualify for bariatric surgery are actually getting it,” Gould said. “Although the vast majority have health coverage, insurance companies and many Medicaid programmes put it out of reach for most people by demanding that they already have several obesity-related health conditions and are taking a slew of medications to control them.”

For example, he said, to be covered for bariatric surgery, Wisconsin Medicaid requires that a person with dangerously high blood pressure has to be taking three or more medications for it and still not have a normal pressure.

He cited a further deterrent to bariatric surgery: “a perception that it’s dangerous and doesn’t work,” beliefs countered by the research findings cited above. Most of the surgeries are now done laparoscopically through tiny incisions.

Given the well-documented safety and effectiveness of bariatric surgery, it is increasingly being performed in people whose obesity is less severe — those with a body mass index (BMI) of 35 or lower — but who have a metabolic disorder like Type 2 diabetes related to their weight.

Gould suggested that people interested in bariatric surgery seek out programmes that have been jointly accredited by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery, which have combined forces to promote quality control.

While experts agree that money would be better spent on prevention than treatment, Twells pointed out that “we have yet to find a way to prevent obesity, and people whose health is compromised by their weight deserve to be treated by the most effective method we have.”