Since undergoing gastric bypass surgery this past March, Janice, an admitted shopaholic, has not done much shopping. "I have nothing to wear, but you go through so many sizes so quickly, it doesn't make any sense to shop."
Not that this retired art teacher from West Bloomfield, Mich. is complaining. Janice has dropped 70 pounds since her gastric bypass surgery and she is off just about every medication she was taking before her weight loss including asthma medications.
Like growing numbers of Americans (including such famous folk as weatherman Al Roker and singer Carnie Wilson), Janice turned to gastric bypass surgery to lose weight and live a longer, healthier life.
And despite the fact that this is a major surgery involving a whole host of often-difficult lifestyle changes and the potential for even more follow-up surgeries, most people would do it again -- in a minute. All in all, former gastric bypass surgery patients are an average of 100 pounds lighter, more active, feel better and take significantly less - if any - medication to treat the complications of obesity including diabetes, asthma, high blood pressure, and sleep apnea.
"I am only sorry I didn't do it sooner," Janice says.
According to the New York Times,weight loss surgery procedures increased 40% last year, with 80,000 occurring nationwide. And statistics from the American Society for Bariatric Surgery predict there will be more than 103,000 such surgeries performed in 2003. By comparison, in 1998 there were less than 26,000, and in 1993 the number was just shy of 17,000.
Gastric bypass surgery involves shrinking the stomach size by sealing off most of the stomach and creating a small, thumb-sized pouch at the top of it, as well as bypassing a length of the small intestine to reduce the amount of calories and nutrients absorbed from food.
One thing for certain, gastric bypass surgery isn't always easy, or necessarily safe. The death rate nears 1%, meaning up to 400 people may die from the procedure annually. As many as 20% of patients need additional surgery to mend complications such as abdominal hernias. Due to malabsorption in the shortened digestive tract in procedures such as the jejunoileal bypass, roughly 30% of patients develop conditions due to malnutrition, such as anemia and osteoporosis, according to the National Institute of Diabetes and Digestive and Kidney Diseases.
"There are immediate and long term issues following surgery," says C. Daniel Smith, MD, chief of general surgery and director of Emory Bariatrics at Emory University School of Medicine in Atlanta. "The immediate issue is the pain and suffering of surgery and the risk as it is a major surgery and there is a risk of significant complications -- even death," he tells WebMD. It's also expensive and is often not covered by insurance.
"In the long term, the upside is that medical conditions related to weight will subside, but the downside is that the alteration in how you eat is permanent. This is not something to try out for three to six months," Smith stresses.
All candidates have to undergo a fairly extensive pre-operation evaluation including medical clearance for surgery, assessment of psychological appropriateness for weight loss surgery, nutrition counseling and in some institutions, candidates take a test to demonstrate a comprehensive understanding of the lifestyle changes and what they will mean after weight loss surgery.
Not a magic bullet.
Jacqueline Odom, PhD, the psychological director of the Beaumont Weight Control Center in Royal Oak, Mich., evaluates patients that are on the path to weight loss surgery to help make sure they are ready for this step and to handle the life afterward.
"A lot of people want a magic bullet and really don't understand what is involved," she tells WebMD.
The new stomach requires several tiny, nutrient-rich meals a day supplemented with additional vitamins and minerals. Eating too much or indulging in rich, sugary or fried foods can overload the pouch and cause dumping -- a term used to describe the sweats, chills and nausea that result from food filling the pouch and overflowing straight into the small intestine.
The re-feeding process starts with getting in protein because that will repair the cells and help them heal after surgery. "We use liquid protein supplements to start, then pureed foods, then soft foods like scrambled eggs and then eventually graduate to other foods," Odom says.
"It's not glamorous,' she says. "You have to chew your food more thoroughly then you ever did and really emulsify it. You must eat very slowly and in small portions."
Emory's Smith adds: "The volume of food they can eat and the types of food they can eat changes dramatically. And there are indirect changes surrounding eating. Many people who eat for social reasons have significant changes in interpersonal relationships."
For starters, Odom tells WebMD, there are the chemical changes that are causing a loss in appetite. The hormone ghrelin decreases in patients after gastric bypass surgery. This contributes to the decrease in appetite, which helps people not crave foods they used to.
However, she adds, most of the patients report that this stabilizes and that their urges for food start coming back within six to nine months.
Three months after her surgery, Kathy, 43, a home health care specialist in Watervliet, Mich., eats by the clock.
"You are on a really strict regimen of eating six times day," she says. But "I have no desire to eat."
Janice agrees: "When we talk about going out for a meal, I always opt out of the selection of where we are going because it really makes no difference for me."
But Anita, a 44-year-old mother of two from Dearborn, Mich., who underwent her gastric bypass surgery in February 2002 and has since lost 132 pounds, knows first hand that appetite does, in fact, return.
"In my case, it did come back because I tend to be an emotional eater and even though I can't eat as much, the reasons I eat are still there," she says. "I still give in to emotional cravings, but not to the degree that I did before."
Smith says the new stomach will eventually stretch to be the size of a tennis ball. "I tell my patients that they can never eat more than equivalent of a tennis ball in a seating and if they do eat more, they will be miserable," he says.
Sweets, in any volume, can also make many patients sick, Smith says.
Elena (not her real name), age 57, a former teacher from Racine, Wis., who has gone down five sizes since undergoing gastric bypass surgery in early April 2003, says this makes her nervous. "I don't want to be sick and there are still some stomach episodes from eating the wrong things or the right things in the wrong amount."
The weight loss surgery isn't the last surgery people undergo - not by a long shot, says Lawrence Reed, MD, a New York City-based plastic surgeon. "Post-bariatric surgery is a very important part of rehabilitation," he tells WebMD.
Reed says he typically does a series of procedures in three stages after weight loss surgery starting with a lower body lift "that will improve the tummy, the thighs, buttocks and back."
Then, several months later, "the patient will undergo a breast lift and complete inner thigh reconstruction because I only get some of it with lower body lift and then months down the road we do the face, neck and arms," he says. "You break it down because it's unsafe to do it all at once."
Follow-up surgeries are typically performed about 12 to 18 months after surgery when a patient has lost all their weight and has adapted to lifestyle changes, Smith says. Some may opt for nips and tucks when excess skin that hangs limits their ability to be as active as they like by flopping all over the place, he says.
Kathy says that "I wasn't that idealistic, but my surgeon said you will have to have plastic surgery afterward and I said 'I am flabby, baggy and saggy now - I am not doing this to be a swimsuit model, I am doing this to get my life back.'"
Elena says she plans to have follow-up surgeries after she reaches her goal weight and maintains it for a certain amount of months. "I am thinking, tummy, breast and upper arms," she says.
Reshaped body may not mean reshaped life.
"If you have a crummy marriage before surgery, you will have a crummy marriage after surgery," Odom says, addressing the issue that many people assume that re-shaping their body will re-shape their life.
Anita agrees. "I do feel much better, physically and emotionally, but some of the problems I thought would disappear with the excess weight have not," she admits. Namely anxiety. "I thought my anxiety was because of weight and now still have it," she says.
Would Anita do it again?
"If you asked me right after the surgery, I am not sure what I would have said because my recovery was rough physically and emotionally. I did a lot of vomiting and was nauseous and knew I did this all to myself," she says. But now, close to two years later, she feels much better about her decision and is enjoying her new life and body to the fullest.