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.