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Weight Loss Surgery More Effective Than Diet

But Risks of Obesity Surgery Are Serious and Real

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April 4, 2005 - Weight loss surgeryWeight loss surgery is the most effective way for extremely obese people to lose weight. But this drastic surgery isn't for everybody, a review of obesity treatments shows.

Patients can expect to lose 44 to 67 pounds after weight loss surgery -- and keep it off for up to 10 years, the studies show. Moreover, this weight loss leads to improvements in diabetes and reduced risk of stroke and heart disease, says researcher Melinda A. Maggard MD, of UCLA medical center.

"For patients who are severely obese -- a body mass index [BMI]body mass index [BMI] of 40 or greater -- the surgery is going to produce a very dramatic weight loss for those individuals," Maggard tells WebMD. "But having surgery is not without its risks. That is the other thing this study really highlights. There is a significant morbidity, and a mortality that goes along with the surgery. Even though it is low, if there is a 1% death rate attached to it; it is real."

There is, of course, a catch. Weight loss surgery doesn't work by itself. After any of the various bariatric surgeries,various bariatric surgeries, patients have to go on -- and, for the rest of their lives, stay on --- a strict diet and exercise program.

The first thing that all overweight and obese patients should try is diet and and exercise.

That's because weight loss surgery is not a cosmetic procedure. It's intended to restore health, says surgeon Leena Khaitan, MD, MPH, co-director of the Emory Bariatric Center in Atlanta.

"Weight loss surgery is not done to make patients into supermodels, but to make them healthier," Khaitan tells WebMD. "With exercise and diet alone, often there is a regain of lost weight. Most people are not able to maintain that. But weight loss surgery is not for everybody. It is for the patient who is willing to make the necessary lifestyle change to make the surgery successful. We should not walk up to every obese patient in the world and say, 'You need an operation.'"

The studies -- and obesity treatment guidelines from the American College of Physicians -- appear in the April 5 issue of Annals of Internal Medicine.


A Role for Weight Loss Drugs

Weight loss drugs Weight loss drugs work, too, the studies show. But they have a much more modest effect than surgery -- a weight loss of about 10 pounds after one year of treatment. And the long-term health effects of these drugs is unknown, the studies show.

"The medicines are useful, but they do have a lot of side effects that patients have trouble dealing with," Khaitan says. "And none are approved for long-term use. So when patients stop taking the drugs, they regain weight. So should patients use them? That depends. If a patient has a BMI over 40, if they lose 20 to 30 pounds on a diet and weight loss medications, they will notice some improvement in their health. But they will not be able to achieve the same weight loss as they would with weight loss surgery."

Most people think weight loss drugs are little magic bullets that make fat melt away. Sadly, that's not the case. Like surgery, the drugs work only for patients who follow strict diet and exercise programs, says guidelines author Vincenza Snow, MD, director of clinical programs for the American College of Physicians.

"People need to know they'll have to continue diet and exercise even if they undergo weight loss treatment," Snow tells WebMD. "People need to be aware of the very modest effects of all weight loss drugs. Even so, these small amounts of weight loss can produce good physiological effects. You may not get the figure you want, but those are good things to happen. We want to make sure doctors and patients are very clear about the modest efficacy -- and that there is no long-term data on efficacy or safety."

In other words, Snow says, there's no way -- yet -- to know for sure whether the gains a person gets from weight loss drugs will last over time. And there's no way -- yet -- to know the long-term effects of these drugs.

"We have no evidence one way or the other to say what will happen if you do continue to take obesity drugs for more than one or two years -- we don't know, it is a total black box," Snow says. "These are not cheap drugs. It would be pretty sad if patients were taking these drugs over the long term, spending money, not getting any weight loss, and getting side effects we don't know about yet."


Based on this data, the American College of Physicians has issued new obesity treatment guidelines. The guidelines call for doctors to discuss weight loss surgery with all patients who have a BMI of 40 or more and who suffer from weight-related health problems,weight-related health problems, such as high blood pressure, diabetes, or sleep apnea.

The guidelines strongly suggest that patients first try a doctor-supervised effort to lose weight with diet and exercise, Snow says. Unfortunately, they don't specify how long a person should try this before moving on to surgery.

"We grappled with this question of when to tell a patient that diet and exercise has failed," Snow tells WebMD. "That is where doctor judgment and patient discussion comes in. When do you decide? At three months, six months, nine months? We thought at least three to six months would be a reasonable time, but we could not find an evidence-based figure to put in the guidelines."

Here are the new weight loss treatment guidelines in a nutshell:

  • If you're overweight -- a BMI of 25 to 25.9 -- you need to lose weight. Diet and exercise arerecommended.
  • If you're obese -- a BMI of 30 to 39.9 -- your health depends on losing weight. The new guidelines apply to people with a BMI of 30 or more.
  • A doctor-supervised weight loss program may be all you need.
  • If your weight loss program isn't getting results, you and your doctor may wish to discuss weight loss drugs. The important facts about these drugs are that after six to 12 months, you stand to lose up to 11 extra pounds. This may be enough for important health effects.
  • If your BMI is 40 or more -- and if you have complications such as high blood pressure, diabetes, or sleep apnea -- you should discuss weight loss surgery with your doctor. This does not mean that surgery is an automatic choice for all patients in this category. Weight loss surgery carries considerable risk, including risk of death.
  • Regardless of the weight loss treatment chosen, diet and exercise remain essential

"What is nice is this is the first time we have put together a summary of the surgical versus the nonsurgical treatments for weight loss," Maggard says. "It shows you what you can expect if you try to do drugs plus diet treatments versus surgery. It is a very nice comparison to see what the amount of weight loss to be achieved is likely to be from these treatments. And it helps doctors and patients understand what some of the risks are with surgery."


What if You're Obese, but Not Morbidly Obese?

If surgery gets such good results, why not recommend it for appropriate patients who aren't yet morbidly obese? Snow says the evidence just isn't there.

"We did not feel the evidence was strong enough to recommend surgery in the group of patients with a BMI of 35-40 and [obesity-related health problems]," she says. "We just felt this is not an emergency for these patients. Given that this is an elective surgery, with very real risks, we felt that the benefits for this patient group were not clear enough. We felt patients with BMIs over 40 were likely to receive more benefit."

Snow, of course, is talking about official guidelines based on evidence from clinical trials. Khaitan says doctors may very well consider weight loss surgery for some patients whose BMI has not yet reached 40.

"The operation is a big deal. It is not something to take lightly," she says. "For someone with a BMI below 35, it is hard to justify a big operation for that degree of weight loss. But if someone has a BMI of 35 to 40 and obesity-related medical problems, it is still reasonable to seek surgical treatment."

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SOURCES: Snow, V. Annals of Internal Medicine, April 5, 2005; vol 142: pp 525-531. Maggard, M.A. Annals of Internal Medicine, April 5, 2005; vol 142. Leena Khaitan, MD, MPH, assistant professor of surgery, director of surgical grand rounds, director of the GI Physiology Lab, and co-director, Emory Bariatric Center, Emory University School of Medicine, Atlanta. Melinda A. Maggard MD, MSHS, general surgeon, University of California, Los Angeles. Vincenza Snow, MD, director of clinical programs, American College of Physicians.
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