BY GLORIA BUTLER BALDWIN

Tennessee now ranks ninth in obesity. The Centers for Disease Control and Prevention study showed that in 1993, 15 percent of Tennesseans aged 18 and above were overweight. In 2003, that number had climbed to over 25 percent. Tennessee high school students are the second most overweight in the nation.

With ever-expanding waistlines, more people need aggressive interventions to help them lose weight. Yet, discussing weight with patients is like being called before the licensure board. You just don't want to go there. Time after time people try weight loss therapies only to get frustrated that their weight comes back so quickly when they return to their normal routine. Frustration is leading more of them down the path to bariatric surgery and leading doctors to reevaluate how they should address the toxic weight issue.

Dr. Gregory J. Mancini, assistant professor and surgeon at the Department of Surgery at the University of Tennessee in Knoxville, said surgery is one of the largest growth areas in the treatment of obesity.

Between 200,000 and 400,000 bariatric procedures are performed each year making it almost as common as gall bladder surgery.

"Obesity is having a Body Mass Index (BMI) of over 30," said Mancini who spends his time performing bariatric surgeries. "A female that's 5 ft., 4 in., and weighs 175 pounds has a BMI of 30 which means they are overweight. You don't get described as being obese until you have a BMI of 35, which would be that same 5 ft. 4 in. woman, but weighing 205 pounds. Bariatric surgery may be the best alternative for some of these patients."

Five year results from people who have had gastric bypass still weigh 70 percent less than prior to surgery. After five years of having the Lap band procedure, patients still are at about 50 percent less than their initial excess weight.

In 1991, the National Institutes of health, issued guidelines for when people should have bariatric surgery. They were reevaluated and republished in 2003.

If a patient has a BMI over 35 and at least one major co-morbidity such as high blood pressure, diabetes or high cholesterol that must be medically managed, surgery should be considered. Patients may still be a good candidate when their BMI is over 40, and don't have other health issues.

Baptist Hospital reports that many patients experience almost immediate health benefits after bariatric surgery with reductions in high blood pressure, Type 2 diabetes and sleep apnea. One such example was a diabetic using 100 units of insulin per day. Nearly immediately after gastric bypass, he went off the insulin completely.

Dr. Albert Spaw, medical director for Baptist Hospital Metabolic Surgery Center, also performs the duodenal switch surgery

There are two strategies we use in weight loss," Spaw said. "Restriction, for example, the Lap Band and gastric bypass, and malabsorption which allows 60 percent of the nutrients to bypass the intestine so they actually ingest less food. Both duodenal surgery and gastric bypass combine restriction and malabsorption. Gastric bypass crates restriction primarily and to a smaller amount malabsorption. Duodenal primarily controls malabsorption with some restriction."

Of the three main bariatric procedures, Lap Band is the least aggressive, followed by gastric bypass and then duodenal switch surgery, which is reserved for the heaviest patients with more weight associated illnesses.

However, only about 30 percent of those patients who fit the physical criteria are emotionally and mentally stable enough to have such a life altering procedure done. Patients with depression, poor coping skills or other emotional or mental issues should not be considered. In addition, patients must be extremely strict and able to follow exact protocol afterward, which includes taking nutritional supplements daily for the rest off their life, or serious problems will also develop.

Mancini said primary care physicians should do more to address weight issues with clients, but usually skirt the issue.

Spaw said he feels doctors are unwilling to discuss such dramatic procedures because they don't understand all about them.

"Physicians understand the link between illness and weight, but what they don't understand is that all these diet therapies are just temporary fixes," said Spaw. "We live in a society where food is the reward for anything, sadness, holidays….We are genetically designed to store food. I think most physicians are afraid to send patients to weight loss surgery because there's a lot of negative press around it. But, if you look at the mortality rates with gastric bypass, the chances of dying are one in 200 patients. If you're that patient that's pretty high. But, the death rate is 2 1/2 times that in hip replacement."


January 2007