When all else fails, experts agree that weight loss surgery is the best bet for dropping those unwanted, unhealthy pounds. But weight loss surgery isn't for everyone. There are physical and emotional hurdles to get over before putting yourself in a surgeon's hands.
The number of adults and children with obesity is on the rise -- affecting about 60 million Americans, six million of whom are considered severely or morbidly obese. At the same time, interest in weight loss surgery is growing, in part because of the widely publicized success stories of celebrities like singer Carnie Wilson and the Today show's Al Roker.
There are many accepted benefits to weight loss surgery -- including lowering blood pressure, improving diabetes, and improving breathing problems. But still, not everyone is suited for the physical and emotional road ahead.
Is Surgery the Solution?
According to Georgeann Mallory, RD, LD, executive director of the American Society for Bariatric Surgery, about 103,000 Americans will undergo weight loss surgery in 2003 -- a four-fold increase over just five years earlier -- and the results of the procedure can be impressive.
"The average weight loss with the surgery is about two-thirds to three-fourths of an individual's excess weight," says Elliot Goodman, MD, founding surgeon of the Montefiore Center for Weight Reduction Surgery and assistant professor of surgery at the Albert Einstein School of Medicine in the Bronx, N.Y.
But weight loss surgery has always been considered a last-resort measure, reserved for the severely obese whose options are growing thin, having tried in vain to repeatedly lose weight with diet, exercise, and weight-loss drugs. To determine if you're a candidate for this surgery, doctors will use a calculation called the body mass index, or BMI, as a guide.
Individuals with a BMI of 40 or greater -- which translates to about 100 pounds or more of excess body weight -- are prime candidates for the surgery. For obese individuals with serious medical conditions (e.g., diabetes, severe sleep apnea), the BMI guidelines for surgery drop to 35 to 39.9.
If you have serious heart or lung problems, however, many bariatric surgical centers would turn you away. The same is true if you're over a certain age (some programs rarely perform surgery on patients in their 60s or older). Some may also refuse to perform the surgery if you weigh more than 450 or 500 pounds, although others are more flexible in the patients they'll accept and have good success records with higher-risk cases.
Patients who weigh 500 pounds, for example, are definitely at greater risk when undergoing the weight-loss operation, says Philip Schauer, MD, the director of bariatric surgery at the University of Pittsburgh. "But surgery is literally life-sparing for them. For someone that size, it's the only option."
And what if you don't meet the BMI criteria? Some bariatric surgeons are debating whether the generally accepted BMI thresholds should be relaxed because of the documented health benefits of weight loss surgery, thus offering the procedure to individuals with more moderate obesity. With so many serious medical problems associated with being overweight -- including heart disease, high blood pressure, stroke, joint problems, gallbladder disease and some types of cancer -- the risks of obesity may need to be weighed in the decision-making process, say some surgeons.
Certainly not everyone agrees that the surgery should be available to those who don't meet the current BMI guidelines. "Although you could make an argument to liberalize the criteria for some patients, I feel strongly that anything outside of the National Institutes of Health guidelines should only be done in a research study," says Mitchell Roslin, MD, chief of obesity surgery at Lenox Hill Hospital in New York City.
What to Expect
"For the most part, patients have very realistic expectations about this surgery," says Cathy Reto, PhD, a San Diego, Calif. clinical psychologist who consults with patients contemplating weight loss surgery. "When people have reached the decision to have this operation, they have already done their own extensive research, and are quite prepared for the possibility that some changes in their life are going to happen," she tells WebMD.
At the University of Pittsburgh Medical Center, candidates for weight loss surgery attend a half-day workshop, where they're educated about the operation by watching a video, listening to lectures and participating in discussions with surgeons, nurses and dietitians, and learning from handouts that they can take home with them. Before the operation, they might also be asked to stop smoking, exercise a bit to boost their stamina, and lose a little weight before surgery if possible.
If you're considering weight loss surgery, you also can expect to be put through a rigorous screening process, with both physical and psychological components. In preoperative discussions and screenings, you'll be told the details and ramifications of the surgery -- for example, that the size of your stomach may be reduced so significantly that you'll no longer be able to eat too much or too fast.
"A lot of these patients have used food to cope with the stress in their life," Goodman tells WebMD, but they won't be able to use that coping mechanism after surgery. In pre-surgical counseling, they may be helped to devise alternative strategies to use in response to sadness and anxiety.
In discussions with your surgeon, you're also likely to be reminded that this is a major operation -- it's much more complex than a tummy tuck or a liposuction procedure -- and while it certainly has potential life-saving benefits, there are also risks. A minority of patients may develop infections, abdominal hernias, gallstones, anemia, or osteoporosis after surgery. About 1% of those who undergo gastric bypass surgery die, often due to surgical, heart, or lung complications. Other, newer procedures, such as the minimally invasive operations done by laparoscope, appear to be just as effective with a lower complication rate.
Increasing numbers of weight loss surgeries are performed using these minimally invasive, laparoscopic procedures, requiring only one or more small incisions, and using a laparoscope (a tubular instrument with a tiny camera attached). Although these laparoscopic operations may reduce the likelihood of wound infections, lower post-operative pain, and shorten hospital stays, they certainly aren't risk-free.
"Once you've accessed the abdominal cavity, it's the same operation, whether you're doing it through an open incision or through a scope," says Goodman. "I think there's a danger in appearing to minimize the risk of big complications by calling it 'Band-Aid surgery.'"
While acknowledging the risks inherent in weight loss surgery, Roslin tells WebMD, "There is no other way to treat serious obesity. ... By far, this is the best treatment for people who are really suffering from their obesity. We can give them back their life," although it can come at a cost.
Roslin, who performed the weight loss surgery on Al Roker along with his surgical colleague, Marina Kurian, MD, adds, "I do a lot of research trying to find less invasive approaches, because anyone who tells you there are no complications associated with doing this serious operation isn't telling you the truth."
Psychological Assessments
In the psychological evaluation required by many bariatric surgeons (as well as by insurance companies), patients will be assessed to ensure that they're emotionally prepared and properly motivated for the operation. Most often, this evaluation lasts just a single session, but at times, it could involve a series of meetings with a counselor, particularly in patients who have a mental-health problem.
A study by Goodman, published in Obesity Surgery in 2002, concluded that 56% of the candidates for weight loss surgery have had depression at some point in their lives.
"Very few patients are turned away because they're psychologically unfit for the surgery," he says, although some might need psychological "tuning up." On occasion, he says, "we'll postpone surgery until patients have been in therapy for a few months, and then reassess them to determine if they're ready for surgery."
Reto agrees that in and of itself, an episode of major depression does not turn an otherwise good candidate for surgery into a poor one. "As part of my assessment, I try to differentiate between a person who is ready for surgery now, and one who may be a good future candidate," she tells WebMD. Once a patient's depression is successfully treated with antidepressant medication, for example, any doubts about her suitability for weight loss surgery may wane.
"If an individual is really struggling with depression," says Reto, "and that depression isn't being treated, that's an indication that we may need to pay more attention to the depression before proceeding with surgery."
Reto adds, "If someone came into my office and was going to have surgery, but was in the midst of a tumultuous emotional event in her life -- maybe her spouse had just left her days earlier -- I might recommend, 'Let's get you feeling better about what's going on in your life, and only then proceed with surgery.'"
