Overcoming Obesity
When diet, exercise, and willpower aren't enough to shed excess pounds, bariatric surgery can help.

A number on a scale can tell you how much someone weighs, but for people who are obese—defined as having a body mass index (BMI) of 30 or more, based on individual height and weight—the number is only part of the story. It says nothing about the ways excess weight affects lifestyle or self-esteem. It says nothing about health implications—everything from sleep apnea and achy, worn-out joints to an increased risk for stroke and heart attack.

The burden of obesity is in itself a heavy weight to carry, and for people who are severely or morbidly obese (a BMI of more than 35 or more than 40, respectively), there is sometimes no amount of effort that can help them achieve a healthy weight. For many people, bariatric surgery is the only route to wellness. "Obesity is the end result of a combination of genetics and eating habits, and lack of exercise," explains Muhammad Feteiha, MD, chief of Minimally Invasive Surgery at Overlook Medical Center, and the founder of the hospital's Bariatric Program. "Once you have the disease of obesity, it's not easily treated with exercise and dietary modifications. There are biochemical and hormonal effects that you can't necessarily change with exercise and diet. That's why diets fail to treat obesity.

"Try as you may, as much as you struggle, as guilty as you feel, you cannot necessarily fix this problem on your own, and we don't have all the answers," Feteiha continues. "Statistically, surgery is the only thing known to treat obesity today."

In fact, adds Ajay Goyal, MD, FACS, director of Bariatric Surgery at Overlook Medical Center and founder of the New Jersey Bariatric Center, studies have found that among morbidly obese patients who have taken off excess weight through diet and exercise alone, only one percent were able to keep the weight off after five years. "Compare that with those who lost the excess pounds through weight-loss surgery," he says, "and you find that on average more than 75 percent kept the weight off after five years. That's an amazing statistic. It really drives home the point that bariatric surgery is the best chance for these patients to have long-term weight-loss success."

Choosing surgery

There are three common forms of bariatric surgery. The procedures assist patients in losing weight in a couple of different ways—either by limiting the amount of food that one can consume, through a reduction in the size of the stomach (known as restrictive procedures); or by reducing the size of the stomach and reducing the absorption of calories into the body (known as malabsorption).

Gastric bypass: The stomach is divided into two sections, creating a small pouch (approximately the size of an egg) at the top of the stomach. The small intestine is also divided and is connected to the new smaller pouch. Food enters the small pouch and bypasses the stapled-off section of the stomach and the upper portion of the small intestine, where the majority of nutrients and calories are absorbed, explains Goyal. Bypass is the only one of the three procedures that affects both the amount of food a patient can eat and the way the body absorbs it. The surgery limits the amount of food that can be eaten at one time and also has been shown to decrease hunger hormones, so patients feel full sooner and stay that way longer. Bypass patients absorb fewer calories as well. This is the most invasive of the bariatric procedures, but also results in the most significant weight loss and is considered the gold standard among bariatric surgeries.

Sleeve gastrectomy: With this procedure, three-quarters of the stomach is removed, leaving a sleeve-shaped portion. The intestines are left in place. It is less invasive than gastric bypass, but weight loss is still significant. Feteiha reports that sleeve gastrectomy is gaining in popularity, owing to overall patient satisfaction, less-severe food restrictions than those necessitated by gastric bypass, and less follow-up than is required with gastric banding.

Gastric banding: This is the least invasive procedure, but requires the most follow-up. Here, an inflatable band (LAP-BAND or REALIZE Band) is placed around the upper portion of the stomach, creating a small pouch on top. Since the band creates such a small channel between the sections, this slows down the emptying of the upper section into the lower section, thereby restricting the amount of food that can be consumed at one sitting. Patients feel fuller faster and stay that way longer. The band is made tighter by inflating it with more saline as the stomach shrinks. Weight loss is slower than with bypass surgery or sleeve gastrectomy. In some cases, notes Goyal, gastric banding can be done with a single incision called SILS. He and Glenn Forrester, MD, FACS, were the first surgeons in the state to perform a single-incision gastric-band procedure.

The bariatric surgeons at Overlook Medical Center perform all of the procedures laparoscopically (and also perform bariatric revision surgery in the case of failed weight loss). Deciding which procedure is the best fit depends on each person's weight-loss goals and level of commitment to lifestyle changes, as well as such other factors as co-morbidities (diabetes, hypertension, etc.) and how much weight one needs to lose.

Patients with a BMI of 40 or more (about 100 pounds or more overweight) usually qualify for surgery. Patients with a BMI between 35 and 40 and who have at least one other severe obesity-related condition, such as high blood pressure or diabetes, also qualify. Last year, the FDA approved LAP-BAND for people with a BMI between 30 and 35 who have an obesity-related co-morbidity (though insurance companies presently do not cover the procedure for people in this category).

Not at all a quick fix

Bariatric surgery is a weight-loss solution, but one that is a serious step that should not be considered until other weight-loss methods have proven unsuccessful. Still, says Goyal, "if you have tried dieting and exercising repeatedly and have failed to keep the weight off, and you realize that your weight is holding you back from living your life to the fullest—it could be you're too tired or uncomfortable to play with your kids, or you're inhibited from doing what you love—or you're taking a lot of medications … when you are motivated to make a serious long-term change to your lifestyle, that's when you should think about surgery as a serious option."
Unfortunately, too many people fail to seek the kind of help that can make a difference in their lives—even save their lives. "What keeps people who suffer from obesity from getting the care they need is the stigma of obesity," says Feteiha. "We know that obese people are more likely to develop colon cancer, and four times more likely to develop breast cancer. To get treated, we don't tell them to diet and exercise. When a person is diabetic, we are going to give them medication. But we don't focus on treating obesity. Society is not geared to view obesity that way. We've been trained by society at a young age to think of people who are obese as lazy or uninterested—not go-getters. And the person who suffers from obesity feels shameful and guilty. Family and friends put pressure on them—they're under social and physiological pressure."

For those who opt for surgery, it's not a quick fix. They must change what they eat and how they eat (bypass patients, must be on protein shakes for life, and vitamin supplements are required for most patients). There also must be a commitment to wellness. "Patients need to understand that this is a lifelong change," says Feteiha. "They're making a decision for life to modify their behavior."

Adds Goyal, "We have the ability to surgically help people who have in the past been unable to control their weight gain, but it's not magic. Weight-loss surgery is just a tool; it still takes work. The procedures are designed to help patients control their hunger, but the reasons they overate in the first place will still be there—those temptations are not going to go away. Patients still have to watch what they eat, exercise, and live a healthy lifestyle to have the best results."

Given the lifestyle modifications associated with bariatric surgery, insurance companies require patients to receive counseling prior to surgery. Psychologist Erika January, PhD, of the Atlantic Health Weight and Wellness Center at Overlook Medical Center, meets pre-operatively with most of the patients who have bariatric surgery at the hospital. "Bariatric surgery is an elective procedure," says January, "and we have to make sure patients are prepared and understand all the follow-up beforehand in order to avoid medical problems and help to ensure a successful weight loss. Surgery doesn't address the behavioral component of weight loss."

January evaluates each patient's food choices, patterns of eating, and what food means to their family. "Patients benefit from talking about their relationship with food," she says. She counsels patients pre- and post-operatively, and hosts support groups. "Our patients are dealing with patterns that have been in place for years, and it takes a long time to change a pattern," she says. "These supports help to facilitate change."
Adds Feteiha, "The weight-loss part is straightforward; it's what patients do in the five and ten years after that. That's why support is so crucial to success."

Success, of course, comes in many forms: a healthier body, a slimmer figure, more energy, improved self-esteem. Says Goyal, "The majority of my patients have obesity-related health conditions, such as diabetes, high blood pressure, or sleep apnea. After surgery, these conditions are resolved or vastly improved; patients often are able to come off medications. And even for those without co-morbid conditions, their lives are greatly improved. Patients tell me about their 'non-scale victories' all the time: little things like being able to wrap a towel around themselves after getting out of the shower, getting a haircut and having the cape fit around their necks, and being able to ride a roller coaster with their kids—these are the things that make a difference in people's lives."

For more information about bariatric surgery at Overlook Medical Center, call (908) 522-5794.