June 14, 2007 -- People who gain 10 pounds or more before weight loss surgery do as well as those who lose 10 pounds or more before having the operation, a new study shows.
"At 12 and 24 months after the operations, there was a 60% to 70% reduction in excess weight for both groups," the losers and the gainers, says Eric DeMaria, MD, professor and vice chairman of surgery and director of the Bariatric Surgery Program at Duke University in Durham N.C. He presented the findings this week at the 24th annual meeting of the American Society for Bariatric Surgery in San Diego.
Both groups, the gainers and the losers, also had similar improvements in type 2 diabetes and high blood pressure problems and in discontinuing treatment for sleep apnea, a condition commonly associated with obesity.
Before bariatric surgery, patients are advised and sometimes required to lose weight.
The Back Story
For years, doctors who perform gastric bypass and other weight loss surgeries have advised patients to hold their weight stable before the surgery or to lose weight.
Some insurance companies and some bariatric surgery programs require patients to lose weight or at least engage in weight loss attempts before they get the surgery, DeMaria says, and his study suggests it may not make a difference in terms of long-term weight loss and health improvements.
An estimated 177,000 people in the U.S. had bariatric surgery in 2006, according to the Society.
DeMaria and his colleagues analyzed the records of 1,629 patients who had undergone the most common type of gastric bypass, called laparoscopic Roux-en-Y gastric bypass, at Duke University between October 2000 and December 2006. From that pool of patients they focused on 115 who had gained 10 pounds or more before having the surgery and 88 who had lost 10 pounds or more before undergoing the operation.
"Ninety percent of patients [in the database] didn’t have significant changes in weight before the operation," counting from four or five months before the surgery, DeMaria says. "We were really just studying 10% of patients.''
The groups were similar in age -- the gainers on average were 41; the losers, 44. The gainers' average preoperative weight was 321 pounds; the losers, 312 pounds. Nearly 30% of each group had diabetes, about half in each group had high blood pressure, and about a third in each group had sleep apnea.
Patients who gained before surgery lost 62.5% of their excess weight a year after the operation; those who lost before surgery had lost 64.5% of their excess weight a year later.
At 24 months, the weight loss was maintained in both groups, DeMaria found. "What we saw was in the first 12 months, the losers are ahead, but that's gone by 24 months after they entered the program."
"The percent of patients off diabetes medications 24 months after the operation was 81% of gainers and 83% of losers," he says. "At 24 months, 48% of gainers and 42% of losers were off medications for blood pressure and had normal blood pressure." An equal number -- 87% -- of both groups could discontinue their nighttime airway treatment for sleep apnea.
The gainers did require 15 more minutes of surgery time, he says. But complications (such as blood clots) occurred equally in both groups.
DeMaria worries that requiring patients to lose weight before the surgery may cause some to get discouraged if they can't and to drop out, not having the potentially lifesaving surgery.
"Gaining before the surgery doesn't have an effect on the surgery," he says. But he emphasizes that he is not discounting the value of patients still trying to lose weight and to learn good nutritional habits before having the surgery.
"We always encourage people prior to surgery to continue to hold their weight and to lose if they can," says Philip Schauer, MD, president of the American Society for Bariatric Surgery and director of the Bariatric and Metabolic Institute at the Cleveland Clinic in Cleveland.
But, he adds, it's extremely difficult for many patients. "My average patient has been on 10 diets or more," he says. "When someone has reached 100 pounds overweight, there is no evidence that diets work long-term. Even if they lose a lot, it is unlikely to replace the need for surgery."
To be considered for bariatric surgery, patients must have a body mass index (BMI) of 40 or more or a BMI of 35 or greater with an obesity-related disease such as heart disease. A person 5-feet-10-inches tall who weighs 280 pounds has a BMI of 40.2.
Insurance Industry Weighs In
The recommendation to attempt weight loss before undergoing bariatric surgery is included in the National Institutes of Health guidelines on obesity surgery, issued in 1991, says Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a Washington, D.C.-based industry group representing insurance companies.
“An individual might avoid surgery,” she says, by first following diet and exercise plans for weight loss. “There is also research telling us there is significant health benefit with relatively modest weight loss.”