For some of us, however, the goal isn’t merely elusive: It’s out of reach. No amount of dieting or exercise is going to lead to significant and lasting weight loss. We are — in medical terms — obese. And the more obese we are, the less likely we are to lose weight and keep that weight off through diet and exercise.
Some people who have made repeated serious-but-failed attempts at traditional weight loss programs are turning to weight loss surgery, which is called “bariatric” surgery. This type of surgery alters the digestive system to help people lose weight by limiting how much they can eat. Bariatric surgeries have become so popular that about 200,000 of them are performed each year in the U.S., a tenfold increase since the early 1990s. Although they were considered to be rather exotic, high-risk procedures not long ago, they have now become a safe, relatively standard, and effective surgical approach to a lifestyle problem.
In fact, these surgeries have become so effective that many healthcare insurers in Virginia and at least 47 other states as well as Medicare and Medicaid cover them, as long as the somewhat stringent eligibility requirements and patient education requirements are met.
The Roanoke/Southwest Virginia area, unfortunately, is among the top five overweight communities in Virginia. In Roanoke, Arnold D. Salzberg, MD, heads the metabolic and bariatric surgery activities of the Carilion Clinic. Carilion’s program has earned it accreditation as a Center of Excellence by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). This accreditation means that the bariatric program at Carilion Roanoke Memorial Hospital is one of the most experienced in existence, with low surgical complication rates and a track record of favorable outcomes. The bariatric surgery program at Carilion is also a tertiary center, which means that it is a center for corrective surgery for people who have had technical problems with earlier surgeries elsewhere.
Dr. Salzberg says that Carilion Clinic’s criteria for people seeking bariatric surgery is fairly straightforward and has been largely determined by healthcare insurers. “It’s important that people understand that surgery is a tool to help meet weight loss goals,” Dr. Salzberg notes. “It’s not a magic bullet.” Even after weight-loss surgery, people have to be mindful of what they eat. The operation doesn’t force anyone to eat the right foods and the right portion sizes.
For that reason, candidates for surgery at Carilion must first participate in an unusually broad evaluation and informational activities by multiple professionals, including bariatric surgeons, physicians in allied medical specialties, clinical psychologists, specially trained nurses, exercise physiologists, dietitians, diabetes educators and more. Their job is to be sure that each person is fully aware of the post-surgical diet and exercise requirements so that he or she will have a successful life going forward.
To be sure that each patient will sustain the lifestyle changes that go along with the surgery, most insurance companies require that surgery candidates go through a medically supervised weight loss program of between 6 and 12 months. After that, the metabolic and bariatric surgery team members put each patient through an extensive program of evaluation, and patients are encouraged to participate in support groups where they can speak with people who have already had bariatric surgery.
“We mention this over and over again,” Dr. Salzberg stresses. “The surgery does not work on its own. The surgery works only as well as the patient allows it to by faithfully following a strict diet and daily exercise.”
One key criterion for receiving weight-loss surgery is having a body mass index (BMI) of 40 and above, if there are no accompanying medical problems. If a person has diabetes, blood pressure issues, sleep apnea, reflux, or any other weight-related ailments, the BMI requirement drops to 35, Dr. Salzberg notes.
Body Mass Index
BMI is a measurement of body fat based on each person’s weight and height. It’s a numerical score that applies to both women and men, and it is used to indicate whether a person is underweight, of normal weight, overweight, obese or severely obese. If you score a BMI of between 18.5 and 25, you are considered to be a normal weight for your height. If your BMI is between 25 and 30, you are considered overweight. Medical professionals consider you to be obese if your BMI is 30 or higher and severely obese if you have a BMI of 40 or higher.
About two out of every three American adults are overweight, and one out of three can be said to be obese. In 1990, hardly any states had obesity rates of more than 15 percent; today, all 50 states have obesity rates of at least 20 percent. A 2012 study in the Journal of Health Economics estimated the medical-care costs of obesity in the U.S. in 2005 to have been as high as a 190 billion dollars, a figure that is steadily increasing each year.
This is a major problem because weight gain gives rise to looming health risks. The physical ailments that are associated with obesity include higher rates of heart disease, stroke, diabetes, sleep difficulties and joint problems as well as an increased risk of certain types of cancers. Obesity, in fact, has become second only to tobacco as a major killer in the United States. This is part of the reason that healthcare insurers cover bariatric surgery. The surgery helps prevent the costs associated with serious weight-related diseases.
Bariatric surgeries do not remove fat tissue. Instead, surgeons rework the stomach and intestine to help a person feel full more quickly, ingest fewer calories, or both.
Types of Surgery
Carilion’s gastric surgeons perform three types of bariatric operations, all of them laparoscopic surgeries. This is a type of surgery in which small “keyhole” incisions rather than one larger open incision allow surgeons to introduce a video camera and surgical instruments. The laparoscopic techniques free patients from prolonged hospitalization and the risks of complications that were the norm when this branch of surgery was new 25 years ago.
Gastric bypass surgery is the “old faithful” of the bariatric operations. It has been in use for the longest time and often offers the best and longest-lasting results. In this surgery, the stomach is made smaller by creating a small pouch at its top using surgical staples. The smaller stomach is connected directly to the middle portion of the small intestine, bypassing the rest of the stomach and the upper portion of the small intestine.
In a sleeve gastroectomy, the stomach is surgically narrowed to resemble a sleeve. The smaller stomach pouch is about 15 percent the size of the “original,” and the capacity of the stomach is reduced from about 1½ quarts to between 4 and 6 ounces.
The third approach, gastric banding, is falling out of favor with surgeons and patients alike, Dr. Salzberg says, because of the intensive level of follow-up it requires. In this surgery, a device is wrapped around the upper part of the stomach to form a ring. A thin tube is attached to the ring, and an access port in the body allows surgeons to tighten or loosen the band by injecting saline solution.
The recovery time with all approaches is relatively rapid, with most patients going home a day or two after surgery and getting back to work a week or two later, depending on the kind of work they do.
The results, on the other hand, can be dramatic. “Nationally, about half of the patients who are insulin-dependent diabetic and who have gastric bypass surgery never have to take their insulin after the moment of surgery,” Dr. Salzberg notes. “Some of the results are truly astounding. That’s where we get our passion for this from.”
However, health professionals do note that bariatric surgery does not signal the end to a person’s fight against obesity. “For the patient, the surgery is the easy part,” Dr. Salzberg cautions. “Surgery has to be accompanied by a lifestyle change.” For those who have turned to the surgery, it creates new and different nutritional, medical and physical challenges along with changes in their emotional behavior.
That’s why the Carilion program has assembled a large team of healthcare professionals who treat and counsel bariatric surgery patients for as long as they live. ”We’re here to cure weight-related disease. We treat patients for life,” Dr. Salzberg explains.
For more information on bariatric surgery at Carilion Clinic, go to https://www.carilionclinic.org/bariatric-surgery or call 540.224.5170. Carilion offers free informational seminars on bariatric surgery twice each month.
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