Supporting Patients in their Weight Loss Journey
Obesity affects nearly 40 percent of American adults. As pounds accumulate, so do co-morbidities such as diabetes, heart disease and cancer, making medically-assisted and surgical weight loss options more critical than ever.
As patients start 2019 full of resolutions to address weight and the chronic conditions exacerbated by obesity, physicians can play an important role in supporting that journey and connecting patients to area specialists to consider all the available options for long-lasting weight reduction.
"Surgery is not one-size-fits-all, and there's often a misconception about what we're trying to accomplish," said Douglas Olsen, MD, medical director for the TriStar Centennial Center for Weight Management.
In the early days of bariatrics, surgery merely created a physical restraint from eating. But as science, and countless Lap-Band revisions have proven, surgery is only effective when used as a tool to help diminish hunger. Hunger, Olsen said, is typically the single factor that keeps patients from being able to reach their goals and make lasting changes.
"We're fighting a disease, and like many others it requires certain dietary restrictions," he said. "Surgery helps make those restrictions more plausible."
By the time patients arrive in a surgeon's office, they are often physically and emotionally exhausted from the weight loss roller coaster. And while others may see bariatric surgery as a cop-out, studies show that patients with severe forms of obesity have a less than 4 percent chance of success going it alone when it comes to losing weight and keeping it off.
Hannah Richards, PA-C, is often the first face patients see at Saint Thomas Medical Partners Center for Surgical and Medical Weight loss. She also regularly discusses the misconception of surgery as a one-step fix for weight loss.
"Obesity is a long-term disease, and patients will still struggle after surgery," she said. "I talk to patients about complying with nutrition, behavioral modifications and the importance of a good support system to help them reach their end goal."
Richards discusses the importance of taking action before a person develops co-morbidities like heart disease and sleep apnea, which often aren't on the radar for younger patients. Bariatric surgery also is a proven treatment for metabolic syndrome.
Medically Assisted Weight Loss
Most insurance policies do require some attempt at weight loss prior to surgery, often followed by medically assisted weight loss. Periodically, a program may require medical weight loss, as well, typically to lower an extremely high body mass index. That usually involves extensive counseling regarding food choices, behavior and exercise, along with prescription appetite suppressants and weight loss medications. While medically assisted weight loss is effective for many, medications are often not covered by insurance, making surgery a more affordable and manageable option long-term.
The Disappearance of Lap-Band
Once considered the gold standard for weight loss surgery, Lap-Band fizzled out after failing to tackle the root cause of obesity: hunger.
"The problem with simple restriction offered by the Lap-Band is that you could still overeat," Olsen explained. "What gives the feeling of fullness are nerves and tissues, because the nerves feel that stretch and send a message to the brain. If the stomach is constantly stretched, those nerves go numb and don't send the message."
While all forms of bariatric surgery utilize the idea of restriction, today's more effective methods are rooted in the idea of borrowing the normal response humans have to control calorie consumption - feeling satisfied after a meal and shutting down the appetite center until the next meal time. Today, Roux-en-Y gastric bypass and gastric sleeve surgery are the most common bariatric procedures yielding lasting results.
Roux-en-Y Gastric Bypass
In Roux-en-Y gastric bypass, a small stomach pouch roughly the size of an egg is created. The pouch bypasses a small portion of the small intestine and is reconnected to a lower limb of bowel.
"The biggest component in this procedure is the hormonal influence, because the patient has to remind himself to eat," Olsen said. "It gives patients a whole lot more power to help them achieve weight loss."
Richards said patients with acid reflux may also experience improvement of GERD symptoms after surgery. Patients with diabetes experience an 80 percent remission of symptoms following gastric bypass.
Gastric Sleeve Surgery
During gastric sleeve surgery, the surgeon removes 70 to 80 percent of the stomach, leaving a stomach roughly the size of a banana. Olsen likens it to a two or three lane highway that narrows to one lane, slowing the ability of food to fill the new pouch.
The laparoscopic procedure involves less rearranging of the anatomy but also can increase heartburn, making it less attractive for reflux patients. However, reduction or resolution in co-morbid conditions like hypertension, diabetes and sleep apnea is upwards of 70 percent.
A less common procedure reserved for the most severe cases is the duodenal switch, in which the surgeon bypasses two-thirds of the small intestine and severely alters the way the body digests food. The surgery puts patients at increased risk for malabsorption and wasted nutrients, which is countered with correct diet and additional vitamin and mineral supplementation.
Life After Surgery
Patients typically experience acute weight loss for 18 months following surgery. The goal for both sleeve and gastric bypass surgery is 75 to 80 percent loss of excess weight, while the duodenal switch typically achieves 80 to 85 percent. It's also not uncommon for patients to regain 10 percent of lost weight five to 10 years out.
Standard guidelines for post-surgical patients include avoiding liquid calories, no snacking between meals, and adopting a protein-based diet. Patients also take multivitamins along with calcium, vitamin D and iron supplements for life and receive regular screenings indefinitely. Some patients also benefit from medically-assisted weight loss after surgery. Providers have said the key to long-term success is staying plugged into the program and annual follow-ups with the surgeon.
"Obesity is a multi-factorial disease characterized by food addiction, which is an eating disorder," Olsen concluded. "Surgery doesn't take that away, so patients have to learn to put all the pieces together to make it work. Through a process of life changes, they learn to stick to it and be healthier."