GETTYSBURG MEDICAL NEWS
The Clinical View
By P. E. Hoffsten, M.D.
30 April 2008

SURGERY FOR WEIGHT LOSS

            Many things in our lives just don’t seem to be preventible.  Others really are even though we tell ourselves that “we just can’t help it.”  That little lie that we tell ourselves lets us continue our self-destructive habits.

            The most preventible self-destructive habit in the United States is smoking cigarettes.  It accounts for 435,000 deaths or about 20 percent of all the people who die in the United States annually.  But it will soon be supplanted by the overweight problem, which accounted for 400,000 deaths in the same year that the statistic above was mentioned.  Fortunately, the incidence of cigarette abuse has decreased from about 65 percent of the adult population after World War II, now down to 20 percent of the adult population.  So as a preventible cause of death, cigarette problems are decreasing.  But the overweight problem is increasing at a very rapid rate and when new statistics are published in the near future, overweight will be a greater cause of preventible death than cigarette abuse.  That is not to mention all the grief and complications that come from these two habits prior to the person dying.

            Statistics have also shown that when asked, the majority of the overweight population is “trying to lose weight.”  Note that word “trying.”  The word try is a command to fail.  People who try make an effort.  They mess around for a while and then they say they tried.  Note that they didn’t do.  They tried, but just didn’t achieve.  Thus, “trying” just isn’t going to work.

            There are three categories of ways to lose weight.  One of these is dieting / lifestyle change.  It has been more than adequately demonstrated that as a long-term treatment for the group of people who are overweight, diets do not work.  By definition, a diet is an abnormal way to eat.  Nobody is going to eat “abnormally” for very long.

The second method of losing weight is the use of various drugs.  To this time, there have been no medications with demonstrated effectiveness to maintain a person’s body weight over a prolonged period of time.  Many drugs are effective for short-term weight loss.  But overweight is a disease every bit as persistent as high blood pressure or diabetes or high cholesterols.  These problems require long-term medications to avoid complications and premature death that come from these problems.  We are still waiting for the magic pill which will help people maintain their ideal body weight through no effort of their own.  Rimanobant is the only drug on the horizon that would be possibly useful in this regard and it is still not FDA approved. 

            The third method of weight loss is a surgical intervention which a recognized treatment for those whose body mass index is greater than 40 or those whose body mass index is greater than 35 but with complications such as diabetes or hypertension.  The surgery modifies a person’s stomach so that they simply cannot eat excessively.  This method is predicated on the fact that overweight is a problem of excessive food intake.  Excessive means more than the person needs, whatever that amount is.  There are basically two surgical interventions available at this time.  One of these is called gastric banding whereby a plastic strip is placed around the top of the stomach thereby preventing excessive intake.  On average, this method results in a 20 percent decrease in total body weight after the first year and a long-term 14% loss of body weight after 10 years.  The second type of gastric surgery is called a roux-en-Y gastric bypass.  This method actually disconnects the top of the stomach leaving most of the stomach as a blind pouch.  The small pocket at the top of the stomach is then connected downstream to a portion of the intestine.  This method on average results in a 32 percent decrease in body weight by the second year with a 25 percent 10 year loss in weight.

            Recently, there were articles in the news media addressing the results of surgical interventions as mentioned above.  The results were:

 1. All those expensive diabetes, high blood pressure, and cholesterol medications the person was taking are no longer necessary.  It is now even shown that the surgery is a money saving long-term step. 

2. There is a 29 percent decreased mortality associated with having gastric surgery.

3. Complications of overweight such as sleep apnea and diabetes are cured even before the person has lost all the weight that they are going to lose. 

4.  The quality of life is much improved.  As a group, those treated surgically say they would do it again and wish they had done it sooner.

            What about the downside?  There is a one chance in 200 of mortality associated with the surgery.  There are the adjustments in diet imposed upon the person by their surgery.  Drinking carbonated beverages such as Coca-Cola or beer are a special no-no for those with the roux-en-Y procedure.  Those beverages run right on through the surgical site into the small bowel and release their gas very much as occurs when shaking a bottle of Coca-Cola with your thumb over the top.  Thus, carbonated beverages can result in severe abdominal pain and bloating. 

            People often ask why their weight doesn’t keep going down so that they just finally starve to death and disappear.  The answer is “a new normal eating habit does develop and the person’s weight does stabilize.”  Those that have a psychological need to maintain their weight often learn that ice cream and sweet “energy” beverages will allow them to regain lost weight.  Thus, the surgery does not prevent the psychological drive some people feel to be overweight.  Hormonal changes related to the roux-en-Y procedure do allow some decrease in the psychological drive to eat and is the preferred procedure for those with this problem.

            In summary, surgical intervention for weight loss is a huge change in the person’s life.  But it is the only effective long-term method for achieving weight loss.  Surgery is effective as opposed to those who are “trying.”