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Is Bariatric Surgery The Answer To Obesity?
Introduction
Against a background of widespread obesity among all US
age-groups, and the relative failure of conventional weight loss
methods, doctors are increasingly resorting to gastrointestinal
surgery in order to curb the rise of weight-related disease, and
associated costs. An estimated 170,000 weight loss surgeries
will be performed in 2005, and although the average bariatric
surgery patient is a woman in her late 30s who weighs
approximately 300 pounds, operations such as vertical banded
gastroplasty and roux-en-Y bypass are now being successfully
conducted on patients as young as 13 years.
But Does Bariatric Surgery Work?
While the increasing popularity of obesity surgery is a clear
reflection of the inability of most obese patients to comply
with conventional dietary treatments, the question remains: does
this type of surgical treatment offer an effective solution for
severe clinical obesity? To understand the issues raised by this
question, let us examine the problem of obesity and how surgery
attempts to reduce it.
How Widespread is Obesity?
According to current statistics, 61.3 million American adults
(30.5 percent) are obese. In addition, an estimated 10-15
percent of children (ages 6?11) and 15 percent of teenagers are
overweight and at risk of developing weight-related disorders.
Severe obesity is also on the rise. Six million American adults
are morbidly obese (BMI 40+), while another 9.6 million have a
BMI of 35-40. (Source: US Census 2000; NHANES III data
estimates)
How Does Obesity Affect Health?
Excess body fat associated with high body mass index (BMI)
carries an increased risk of premature death. Obese patients
(BMI 30+) have a 50-100 percent increased risk of death from all
causes, compared with individuals of normal weight (BMI 20?25).
Morbid obesity (BMI 40+) and super-obesity (BMI 50+) carries a
still higher risk of dying younger. Most of the increased risk
is due to co-morbid conditions like cardiovascular disease
(atherosclerosis, heart attack or stroke). The effects of severe
obesity on longevity are dramatic. Obese white males between 20
and 30 years old (BMI > 45) can shorten their life expectancy by
13 years. African-American men of similar age and BMI can lose
up to 20 years of life. Obese white females between 20 and 30
years old (BMI > 45) can shorten their life expectancy by 8
years. African-American women of similar age and BMI can lose up
to 5 years of life.
Research Into Obesity and Premature Death
A 12-year study of 330,000 obese men and 420,000 obese women,
revealed that premature mortality rates for morbidly obese men
were twice the normal: 500 percent higher for diabetics and 400
percent higher for those with digestive tract disease. In
severely obese women, the mortality was also increased two fold,
while in female diabetics the mortality risk increased eight
fold and three fold in those with digestive tract disease.
Another study of 200 men aged 23-70 years with severe clinical
obesity, showed a 1200 percent increase in mortality in the
25-34 year age group and a 600 percent increase in the 35-44
year age group. Average cancer mortality rates are 150-500
percent higher in obese patients.
Other Obesity-Related Diseases
Aside from premature death, obesity is strongly associated with
a wide range of health disorders. 80 percent of patients with
type 2 diabetes are obese, while almost 70 percent of diagnosed
heart disease is obesity-related. Other obesity-related
disorders include: high blood pressure, cancer, carpal tunnel
syndrome, depression, gallstones, gastroesophageal reflux
(GERD), insulin resistance, low back pain, obstructive sleep
apnea, musculoskeletal complaints and osteoarthritis,
respiratory problems, stroke, and vein disorders.
Why is Surgical Treatment is Needed?
As the facts demonstrate, obesity is an independent risk factor
for a number of serious diseases. Severe obesity, if left
untreated, leads to life-threatening disorders and possible
premature death. It is against this background that the
viability of bariatric surgery should be assessed. Three key
questions are: (1) Does bariatric surgery lead to a significant
loss of weight? (2) What are the health benefits of surgery? (3)
What are health risks?
Does Bariatric Surgery Lead To A Significant Loss of
Weight?
Yes. According to most patient-surveys the health and weight
reduction benefits of bariatric surgery exceed all other
treatment methods by a wide margin. Weight loss surgery is
considered successful when excess weight is reduced by 50
percent and the weight loss is sustained for five years. At
present, average excess weight reduction at five years is 45-75
percent after gastric bypass and 40-60 percent after vertical
banded gastroplasty. In a statistical review of over 600
bariatric patients following gastric bypass, with 96 percent
follow-up, mean excess weight loss still exceeded 50 percent of
initial excess weight at fourteen years. Another 10 year
follow-up study from the University of Virginia reports weight
reduction of 60 percent of excess weight at 5 years and in the
mid 50's between years 6 and 10. A significant percentage of
less-committed patients do regain weight 2-5 years after having
surgery, especially those who undergo the less drastic stomach
banding procedure, but if the patient is well motivated and
given proper post-operative support, the weight loss is usually
permanent. By comparison, according to one 4-year study of
non-surgical weight loss programs involving obesity
medication,
behavior modification, diet and exercise, average weight
reduction was 3 pounds in those subjects who were followed for
the four years of the study.
What Are The Health Benefits of Surgery?
According to the International Federation for the Surgery of
Obesity (IFSO), weight reduction caused by gastric reduction
surgery improves longevity and reduces rates of premature death.
In addition, hypertension is cured in about 50 percent of
patients, while measurements of cholesterol and other blood fats
show visible improvements, all leading to a reduction in the
risk of heart disease. Type 2 diabetes is cured in 80 percent of
diabetic patients while hyperglycemia and associated conditions
such as hyperinsulimia and insulin resistance are even more
likely to benefit from gastric bypass. Obstructive sleep apnea
is cured in about 75 percent of patients, shortness of breath is
relieved in 75-80 percent of cases, while asthma attacks are
significantly reduced, particularly when associated with
gastroesophageal reflux disease. Obesity surgery also relieves
low back pain and arthritis, heartburn, urinary incontinence,
and lower limb venous disorders.
What Are The Health Risks?
Generally speaking, the health complications of bariatric
surgery divide into three classes. First, during the operation
itself, patients are subject to the normal health dangers of any
serious surgical procedure. Risk factors include: patient
condition, the expertise of the bariatric surgeon and
anesthesiologist and the quality of operating room services.
Premature death occurs in about 1-2.5 percent of bariatric
cases. Second, there are well-documented post-operative health
risks, which largely depend on the type of procedure
performed.
Post-Operative Health Problems of Gastric Banding
Restrictive procedures like gastric-banding and stomach
stapling carry a number of short-term post-operative health
risks, including: (1) Risk of hernia. About 10-20 percent of
patients require additional surgery to fix problems like
abdominal hernias caused by excessive straining after surgery
before the incision heals. Laparoscopic surgery reduces this
risk. (2) Risk of blood clots. About 1 percent of patients
contract blood clots in the legs. (3) Risk of infection. On
average, there is a 5 percent risk of infection in the incision
area. (4) Risk of gastric staple breakage. This occurs in
bariatric operations like vertical banded gastroplasty, that use
staples to reduce stomach size. (5) Risk of band slippage and
saline leakage. A routine complication, this occurs after lap
band or other forms of adjustable gastric banding. (6) Risk of
bowel obstruction. This rare complication may occur due to
adhesions caused by scar tissue. (7) Risk of stomal stenosis and
marginal ulcers.
Post-Operative Health Problems of Gastric Bypass
Post-operative health dangers of bypass procedures like
roux-en-y or biliopancreatic diversion include: (1) Corrective
operations. About 15-20 percent of bypass patients require
follow-up gastrointestinal operations to correct complications
(eg. hernias). These follow-up operations tend to carry higher
risk of complication and death. (2) Dumping Syndrome. Caused by
overeating or over-rapid eating, dumping, is not a real health
danger, but symptoms (nausea, faintness, sweating and diarrhea)
can be distressing. (3) Risk of nutritional deficiency. Since
stomach bypass surgery involves bypassing the duodenum and
part/all of the jejunum, causing insufficient absorption of
vitamins and minerals, patients can develop deficiencies in
nutrients like: iron, calcium, vitamin D and B12 deficiency.
This can be easily corrected by a program of nutritional
supplementation. (4) Risk of gallstones. About one-third of
bypass patients develop gallstones. (5) Bowel Disorders. After
all bypass operations, there is a period of intestinal
adaptation during which bowel movements can be liquid and
frequent. Typically accompanied by bloating, gas and foul
smelling stools, this complaint may reduce with time, but
occasionally becomes a permanent condition.
Bariatric Surgery is No Easy Answer To Obesity
Even though surgical methods are becoming more and more
successful for the reduction of severe obesity, it would be
misleading to present surgery as an easy option. To begin with,
its success depends entirely on patient compliance with
post-operative guidelines. And pressures to overeat do not
disappear after surgery. If patients adhere to instructions,
they tend to lose weight without regain. If they "cheat", they
tend to regain most of their weight loss and may end up in a
worse condition than before. Second, due to cost and
availability issues, bariatric surgery can only ever treat a
tiny percentage of the population who are severely obese. Third,
we lack long term feedback on the success of these operations.
For these reasons, it seems that bariatric surgery is no easy
solution to our obesity epidemic.
More Information
Bariatric
Surgery
Gastr
ic Bypass
About the author:
David Johnson, LLb., is the senior researcher at
www.bariatric-surgery.info which offers a range of information
about gastric banding, stomach bypass and other weight-related
surgeries to more than 2 million unique visitors per year.
Bariatric
Surgery
Gastr
ic Bypass
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