Bariatric Surgery

Good News Regarding the Treatment of Obesity

By Alexandra Garvey and W. Timothy Garvey, MD

The American Medical Association’s (AMA) House of Delegates recently approved a resolution sponsored by the American Association of Clinical Endocrinologists (AACE) officially recognizing obesity as a disease. What does that mean to you and your doctors? What it means to members of AACE – which has been advocating the position for several years – is that obesity is a chronic disease just like diabetes, hypertension or asthma, with its own genetic, behavioral and environmental causes and medical treatment needs that require a range of prevention and treatment interventions.

Scientific research has given us a much better understanding of what regulates how much food we eat, how much energy we burn and the things that go wrong that result in accumulation of too much body fat. Genes make a big difference and explain, in part, why obesity can run in families and why obesity is more prevalent in some ethnic populations. However, just because we inherit these genes does not mean we will be overweight! These genes interact with behavior and environment. We can modify our behavior (e.g., lifestyle factors like daily activity, diet, exercise) to minimize the effects of these genes. However, on average, the people who carry genes for obesity will be the people that gain the most weight. For this reason, designating obesity as a disease does not absolve patients from the responsibility of adopting healthy lifestyles in combating the disease. Nor does it mean that obesity is a lifestyle choice – because it is not. It is a disease that should be treated by endocrinologists and other healthcare professionals using all the tools we have available in ways that are best suited for the treatment of individual patients.

Let’s consider those tools. In many ways, the treatment options are like a three-legged stool. The legs of the stool are the three major ways that obesity can be treated: behavior changes such as diet and exercise, bariatric surgery (surgery for weight loss) and medicines. Effective behavior or lifestyle modification programs have been developed, and the surgery procedures have been improved as well. Still, doctors have lacked effective medications for weight loss. However, recently approved medicines are now giving this stool a better leg to stand on.

In the summer of 2012, the Food and Drug Administration (FDA) approved two new weight loss medicines that have more recently become available for prescription. These medications are called Belviq® [BEL-VEEK] (lorcaserin) and Qsymia® [kyoo-sim- EE-uh] (phentermine/topiramate extended). These medications have changed the weight loss landscape by giving doctors and their patients a wider range of treatment possibilities.

This, of course, sounds great, but you’re probably wondering how these medicines actually work. Qsymia is a combination of two generic drugs that are known to suppress appetite: phentermine and topiramate — which is already available for
migraine headaches and seizures — cause you to feel full or satiated. Qsymia combines these two medicines in lower doses to reduce side effects and takes advantage of the fact that they work together to produce greater weight loss. Belviq, on the other hand, acts on certain receptors (places on or inside cells where hormones and other chemicals attach) in the brain (serotonin receptors) and causes you to feel full. Both Belviq and Qsymia work within the body to improve the results of your weight loss efforts due to diet and exercise. They are meant to be taken in conjunction with making lifestyle changes because patients who combine one of these medicines with a lower calorie diet and regular exercise can expect to see more weight loss than patients who treat their obesity with diet and exercise alone. In this way, these new medicines are game changers, but should not be considered a magic weight loss pill.

And what about the side effects, you may ask? Some of the side effects of Belviq include headache, nausea, constipation, dry mouth and serotonin syndrome (high temperatures, rapid heart rate, muscle twitches, confusion). Qsymia can cause dry mouth, constipation, insomnia, tingling in the fingertips, and a tinny taste to carbonated beverages and should not be taken by people with glaucoma or an overactive thyroid. Pregnant or nursing women should not take either of these medicines. The topiramate in Qsymia can increase risk of cleft lip and palate (abnormalities in the development of the lips and mouth) if taken by women during pregnancy. Therefore, women of child-bearing potential must be on birth control while taking Qsymia and check a home pregnancy test every month so they can stop the drug immediately if the pregnancy test turns positive.

How much weight can you expect to lose on these new medications? When used together with lifestyle modifications in clinical trials, the average weight loss in patients taking Belviq was about 8 percent of their body weight (16 lbs. for someone weighing 200 lbs.), and for Qsymia was around 12 percent of their weight (24 lbs. for someone weighing 200 lbs.). These are the average responses. Some lose more. Some lose less. You may be disappointed that these drugs don’t cause more weight loss on average; for example most patients will not achieve ideal body weight or a size 4 dress size in women, or a 34-inch belt size in men. This gets down to the reason why physicians treat obesity as a medical disease and why it is important for patients and doctors to agree on the goals of therapy at the beginning of treatment.

Although these new medicines may not get you down to a size 4, the weight loss that can be achieved will make a huge difference in the quality of your health. In clinical trials, treatment with either Qsymia or Belviq plus lifestyle change was shown to have impressive benefits by improving many of the complications of obesity. If you are one of the millions of Americans living with the disease, you more than likely know all know too well what some of these complications might be. The first category of obesity complications is metabolic, which includes diabetes, pre-diabetes, metabolic syndrome (a combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes), high blood lipids, hypertension, fatty liver disease and higher risk for heart disease. The second type of obesity complication encompasses mechanical problems due to excess body weight and includes obstructive sleep apnea, osteoarthritis, mobility problems and stress incontinence. Weight loss can be used to improve all of these conditions.

So, are you a patient with diabetes? Hypertension? Dyslipidemia? Sleep apnea? Osteoarthritis? Nonalcoholic fatty liver disease? Stress (urine) incontinence? Well, guess what? These are all things that can be treated effectively by losing 10 percent of your body weight. This will go a long way to prevent the development of future diabetes in high-risk patients with a family history or with prediabetes. And, if diabetes is already present, this amount of weight loss will lower blood sugar and the need for diabetes medicines. It will decrease your risk for heart disease, lower your blood pressure, improve your lipids by increasing good cholesterol while decreasing harmful triglycerides, remove fat from the liver, help with mobility and improve sleep apnea. Patients may not be able to expect to reach their ideal body weight, but they can expect to lose weight to a degree that will improve complications that are the source of suffering and poor health.

This is a medical approach to fighting obesity as a disease. In a society that often treats obesity as a lifestyle failure, these new developments in medicine are altering the way in which patients can approach their health. Attitudes in our society are moving away from the incorrect notion that obesity is merely a lifestyle choice and towards the scientifically correct idea that it is a disease requiring medical therapy, particularly when patients have complications that can be treated with weight loss.

With the help of these recent obesity medicines and a solid lifestyle effort, people with obesity now have new tools and new options to achieve real weight loss results and improve their long-term health. If you are seeking treatment, it is important to determine the goals of therapy up front with your doctor; in other words, how much weight you can realistically be expected to lose, what your role is as a patient in optimizing the success of treatment, and what the goals of treatment are that will improve your health. Armed with these new medicines and new options for challenging obesity and its complications, doctors and patients working together can result in a longer, healthier life for the patient.

Alexandra Garvey is a writer and journalist from Birmingham, AL. She is a recent graduate of Hamilton College in Clinton, NY, where she majored in English. She carries a lifelong passion for advocacy work with a newfound focus on patient education.

Dr. W. Timothy Garvey is Chair of the University of Alabama at Birmingham’s (UAB) Department of Nutrition Sciences and Director and Principal Investigator of the UAB Diabetes Research and Training Center (DRTC). Since 1987, Dr. Garvey has directed an independent laboratory supported by the National Institutes of Health (National Institute of Diabetes and Digestive and Kidney Diseases/National Heart, Lung, and Blood Institute), the Department of Veterans Affairs, the American Heart Association, the Juvenile Diabetes Foundation International, the American Diabetes Association and other agencies.

Is Bariatric or Metabolic Surgery Right for Me?


Is Bariatric or Metabolic Surgery Right for Me?
By Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU

In the ever-frustrating “Battle of the Bulge,” it is best to PREVENT weight gain. Prevention takes the form of healthy eating and physical activity. Unfortunately, many of us fall behind the curve, and over time the pounds pile on. Based on our own personal lifestyle, genetics and medical care, we become “overweight,” or even “obese” (see www.EmPowerYourHealth.org/obesity for more information).

If we do become obese, what are the proven treatments that our doctors can recommend? First and foremost is still a change in lifestyle. All of us can become more physically active. And all of us can control our food portions. If that doesn’t work, then there are certain medicines that help with weight loss. Medications and lifestyle changes are discussed by other authors in this issue. But sometimes lifestyle changes and medications together don’t help you lose weight. If the obesity is severe enough, then there may be a role for surgery of the digestive tract to help with weight loss.

The term “bariatric” [bah-ree-AH-trick] refers to the field of medicine concerned with weight loss. “Bariatric surgery” refers to surgery for weight loss in a person who is obese. Many of us know about complications from bariatric surgery. These complications were mostly from surgeries done in the 1950s through 1970s. During that time, many patients had life-threatening nutritional deficiencies. Fortunately, the currently approved bariatric procedures are considered to be safe and effective. Deciding to have one of these procedures requires help from an expert. This is because each bariatric surgery has its own risks and benefits. Each decision to have bariatric surgery needs to be an individual decision.
Bariatric procedures are right for persons with a body mass index (BMI) of >40 (extreme obesity) or a BMI >35 if there are obesity-related complications such as diabetes, hypertension, high cholesterol, or sleep apnea (halted breathing while you sleep). To calculate your BMI, visit www.powerofprevention.com/bmi/php.

A complete medical evaluation, including a nutritional evaluation, is needed before the surgery. Depending on one’s particular insurance policy, candidates may need to fulfill certain requirements before having surgery. These requirements should be explained by the bariatric surgeon at the time of the initial appointment. The two most common procedures are the laparoscopic [lah-pa-row-SKAH-pic] adjustable gastric band (or “band”) and the Roux [roo]-en-Y gastric bypass (or “bypass”).

BAND PROCEDURE

In the band procedure a plastic ring-like device is placed around the top part of the stomach near the entry of the food-pipe (esophagus). It is done with laparoscopy [lah-pa-RAH-skah-pee], using instruments inserted through several small incisions in the belly. Scarring is minimal. The effect of this procedure is to limit the amount of food entering the stomach. People who have this procedure can’t overeat, so they lose weight. The band can be tightened or loosened at any time after the surgery. This way, weight loss can be controlled: not too slow, not too fast. This procedure is associated with acceptable amounts of weight loss (14 – 60% excess weight loss after 7 – 10 years from surgery). There is very little risk for nutritional deficiencies or surgical complications. Nevertheless, one in every three people who had the band procedure develops iron deficiency and need to take iron supplements. The band procedure is gaining popularity around the world.

ROUX-EN-Y BYPASS PROCEDURE

The bypass procedure is a more involved surgery. It is usually done by laparoscopy. In this procedure, food enters a smaller stomach that is created surgically. This limits food intake, like the banding procedure. The first half of the small intestine is also bypassed. This is how the Roux-en-Y procedure also gets the name “bypass.” Digestion normally occurs in the first part of the small intestine. In the bypass, the exit to the stomach is cut and reattached to a more distant part of the small intestine. Full digestion doesn’t occur. This means there is less absorption of food, or “malabsorption.” Since this is a more involved surgery which causes malabsorption, the risks are higher. However, the malabsorption part causes more excess weight loss by 7 – 10 years (up to 70%). People who have the bypass procedure need to be monitored regularly for vitamin and mineral deficiencies and take dietary supplements as directed by their doctor.

OTHER BARIATRIC SURGERIES

There are other bariatric surgeries that deserve mention:

  • The sleeve gastrectomy (or “sleeve”) is a relatively new procedure, not generally paid for by medical insurance. The sleeve procedure involves the creation of a smaller stomach but without causing malabsorption.
  • The biliopancreatic [bill-ee-oh-pan-kree-AT-ic] diversion with duodenal [dew-oh-DEE-null] switch (or “switch”) is a procedure that is associated with greater amounts of weight loss. This weight loss comes with a price: more nutritional deficiencies. Sometimes “the switch” needs to be reversed because the patient loses too much protein. This procedure is much less common.

PUTTING IT ALL TOGETHER

Overall, bariatric surgery is an appropriate treatment for severe obesity in patients who are at high risk for obesity-related complications, such as heart attacks and strokes. Bariatric surgery should only be considered in patients who did not have success with lifestyle changes, medical nutrition therapy, and treatment with medications.

The band and bypass procedures are safe and effective. These two procedures prolong life when performed in appropriate candidates. The weight loss that comes from bariatric surgery reverses many of the complications of obesity. Type 2 diabetes typically gets much better or even disappears after the surgery.

Bariatric surgery requires a personal commitment to a lifetime of healthy eating and physical activity. Bariatric surgery also requires long-term medical follow-up to monitor for complications. And for people who have malabsorptive procedures, there is a need for lifelong vitamin and mineral supplementation. A team approach to obesity, including dieticians and counselors, is required before and after bariatric surgery.

Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU, received his M.D. degree from Mount Sinai School of Medicine in 1985. He then completed his residency in Internal Medicine at the Baylor College of Medicine in 1988. After returning to Mount Sinai to complete his fellowship training in Endocrinology, Metabolism and Nutrition in 1990, Dr. Mechanick started his private practice in Manhattan in Endocrinology, Diabetes and Metabolic Support. Since then, he has become the Director of Metabolic Support and Clinical Professor of Medicine in the Division of Endocrinology, Diabetes and Bone Disease at the Mount Sinai Hospital. He continues to care for many patients with endocrine, diabetes and nutritional disorders, as well as train physicians in endocrinology and nutrition.

Childhood Obesity’s Rapid Rise

Too Much “Screen Time”

Contributory and causal factors for the epidemic of childhood obesity appear to be changing and continue to be identified and evaluated. Environmental considerations seem particularly significant at this particular point in history. “Screen time,” which takes many forms (computers, televisions, handheld devices), has increased dramatically over the past five years for children and adolescents. Studies have shown that children who watch more than one hour of television per day are more likely to be obese than those who watch less. Unfortunately, the average American child watches more than four hours of television per day, totaling an astonishing two months of non-stop television watching per year. Surveys have revealed that more than 70 percent of American children aged 8-18 years have a television in their bedrooms.

Bad Diets

Dietary habits of young people have also come under increased scrutiny, given the crucial role nutrition plays in weight management and overall health. The benefit of appropriate nutrition tends to start very early on, as infants who are breastfed longer or started on solid food after four months of age are less likely to become obese as adolescents. An alarming trend has been the dramatic three-fold rise in soft drink consumption over the past 20 years. In fact, 56 to 85 percent of children in school consume at least one sugar-sweetened drink per day, including fruit-based juices. Conversely, milk consumption has been halved during this same period of time, with the exception of sugar-sweetened varieties such as chocolate milk. These trends are noteworthy, because for every sugar-sweetened drink a child has the risk of obesity increases by 160 percent. Poor nutritional intakes have also resulted in an increased prevalence and severity of dental problems in children.

In addition to more sugar-sweetened drinks, our children are also having fewer healthy, well-balanced meals. Increasingly hectic lifestyles often crowd out home cooked meals eaten with family members. Low-income and some racial/ethnic minority groups are often exposed to poor food environments, with few grocery stores and an abundance of fast-food and convenience stores. These trends are resulting in Americans consuming almost 34 percent of their meals outside of the home and accounting for 42 percent of their food budget. Past studies have shown that children who report eating fast food consume, on average, 150 more calories per day than children who don’t eat fast food, increasing their risk of gaining weight.

Efforts Underway to Curb the Obesity Epidemic

The cause of rapidly rising childhood obesity is multifactorial. As such, the related treatment modalities must also be multifactorial. Early identification of and intervention in children who are at risk of becoming obese are crucial to stemming the tide of this epidemic. Key organizations, including the American Academy of Pediatrics and the CDC, are increasing their focus on childhood obesity and providing additional treatment guidelines. For example, in overweight or obese children yet to go through their growth phase (younger than 5 years of age), the goal is weight maintenance. For older children, weight loss is recommended, since height gain alone will not correct the obesity. In these children, a weight loss goal of 1 to 2 pounds per month is noted to be appropriate.

Because most children spend a significant amount of time in the school setting, changes also are underway to improve the quality of nutrition offered at various educational sites. The American Beverage Association, with the support of the Clinton Foundation and the American Heart Association, proposed guidelines which would cap the number of calories in beverages in schools to no more than 100 per container. As of the 2009-2010 school year, 98.8 percent of all audited schools were in compliance.

What Can Parents Do?

The strongest predictor of child lifestyle choices is parental lifestyle choices. As such, many groups are now providing dietary and behavioral interventions at the family level. One such group was able to show successful weight control over 10-year periods.

Limited Role of Medication

Medication can play a role in weight management, but only one pharmaceutical is currently approved for use in adolescents. Studies in this age group are marred by significant drop-out rates, a limited number of subjects and very short-term results. Due to the lack of quality, long-term data, medications for adolescent weight management are not often recommended.

When Could Surgery be Considered an Option?

We are finding a similar situation with bariatric (weight loss) surgery. Currently, bariatric surgery is the most definitive and longest-lasting weight loss treatment. There are a small number of studies in adolescents showing significant weight loss and improvement or resolution in related conditions, such as type 2 diabetes, hypertension and obstructive sleep apnea. In adults, patients are considered candidates for bariatric surgery if they have a body mass index (BMI; as kg/m2) of 40 or higher, or a BMI of 35 or higher if one or more weight-related conditions are present. For example, an adult who is 5’ 0” and is 205 pounds has a BMI of 40; someone who is 5’ 4’ and weighs 205 pounds has a BMI of 35.2.

In pediatrics, stricter guidelines should be followed when considering bariatric surgery. The following guidelines are usually followed:

  • BMI ≥ 40 with one or more serious weight-related condition(s)
  • BMI ≥ 50 with less serious condition(s)
  • Failure of non-surgical weight loss
  • Greater sexual maturity (Tanner stage IV or higher) and 95 percent of adult height based on estimated bone age

However, because of relative physical and psychological immaturity and limited research, consideration of adolescent bariatric surgery must occur on a very thorough and case-by-case basis.

Conclusion

In summary, obesity in the pediatric population has risen at an alarming pace in the past several decades. Causal factors of this epidemic are multifactorial, including economic, environmental and genetic considerations. Because obesity is a chronic disease, overweight and obese children typically progress to obese and less healthy adults. Prevention and intervention strategies must be developed and utilized to slow the devastating effects pediatric obesity is having on the physical, emotional and financial health of our country.

Dr. Manpreet Mundi is a senior associate consultant in the Department of Medicine and Division of Endocrinology, Diabetes, Metabolism and Nutrition at the Mayo Clinic. He received his internal medicine and endocrinology training at the University of Southern California and Los Angeles County-USC Medical Center. His clinical interests include inpatient and outpatient nutrition health, bariatric surgery and mentoring endocrine fellows. He would also like to thank Paul A. Lorentz, R.N. for his editorial assistance.

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