Obesity poses significant health risks, increasing the likelihood of conditions such as type 2 diabetes, high blood pressure, elevated triglyceride levels, heart disease, stroke, arthritis, and obstructive sleep apnea. Higher body weights are also associated with cancer and early death. This article aims to provide veterans with a detailed understanding of bariatric surgery options, eligibility requirements, available procedures, and the comprehensive support offered through the Department of Veterans Affairs (VA).
Obesity and Veterans: A Pressing Issue
Approximately 78% of the Veteran population, or 6.6 million Veterans enrolled in the Department of Veterans Affairs (VA), are overweight or obese, of which 165,000 (2%) are morbidly obese with a body mass index of >40.1. Recognizing the profound impact of obesity on veterans' health, the VA offers a range of weight management solutions, including bariatric surgery.
Understanding Bariatric Surgery
Bariatric surgery encompasses a variety of surgical procedures designed to aid weight loss by modifying the digestive system. These procedures limit the amount of food the stomach can hold, reduce nutrient absorption, or both. It is important to understand that bariatric surgery is a treatment for obesity, not a cure. Success hinges on the patient's commitment to lifestyle and dietary changes.
VA Bariatric Surgery Programs
The Veterans Health Administration (VHA) provides integrated health care and treatment for 8.5 million enrolled Veterans through a regional system of care defined by 18 Veterans Integrated Service Networks (VISNs). In FY 2015, 135 VHA Surgery Programs performed 408,137 surgical procedures in 844 equipped operating rooms. However, only a fraction of these programs are approved to perform bariatric surgeries. As of 2015, the VHA had 21 VHA Surgery Programs across the country with approved bariatric surgery programs; however, these programs were not evenly distributed geographically or across VISNs.
Accessing Bariatric Surgery Through the VA
Federal regulation establishes that the VA clinician is authorized to deliver the medical care and services needed to promote, preserve, or restore the health of the individual, which is consistent with generally accepted standards of medical practice (38 CFR §17.38). The VA is not limited to providing health care services to only the VHA Surgery Programs providing bariatric surgery. Under Title 38 USC §1703, the VA has the authority to refer enrolled Veterans to a non-VA provider (“Community Care”) when care and treatment are not feasibly available at a VA health care facility. The enactment of the Veterans Access, Choice and Accountability Act of 2014 (Pub. L. 113-146) extended Community Care to Veterans waiting more than 30 days for services, living greater than 40 miles from a VA health care facility, or experiencing an undue burden in receiving VA treatment and services. In FY 2015, the VA provided reimbursement to non-VA providers for 233 enrolled Veterans referred to Community Care for bariatric surgery.
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To apply for bariatric surgery coverage, contact your local VA healthcare facility and discuss your eligibility with your primary care provider.
Eligibility for Bariatric Surgery at the VA
Qualifying for bariatric surgery through the VA involves meeting specific criteria:
- BMI Requirements: Generally, a Body Mass Index (BMI) greater than 30 with HTN, DM, HLD, and severe cardiac disease OR a BMI greater than 35 with or without those comorbidities at the time of surgery.
- Age: Typically, patients must be under 70 years of age.
- Prior Weight Loss Attempts: You must have tried to lose weight by other means, such as diet and exercise.
- Health Status: You must be healthy enough to have surgery.
- Psychological Evaluation: A psychological evaluation may be required.
- Program Participation: Completion of 3 months of the MOVE! program may be required.
Bariatric Surgery Procedures Offered
The VA typically covers various types of bariatric procedures, such as gastric bypass, sleeve gastrectomy, and adjustable gastric banding. The surgeries available can vary depending on your VA medical center. Discuss the types available to you with your surgeon. Each type has its pros and cons. Your surgeon may recommend a type of surgery based on your health conditions and goals.
Roux-en-Y Gastric Bypass (RYGB)
Roux-en-Y Gastric Bypass (RYGB) is known as the gold standard of weight loss surgery. Gastric bypass is the most commonly performed weight loss surgery in the United States. This surgery reduces the size of the stomach and "reroutes” the intestines making it both a restrictive and malabsorptive procedure. In this surgery, the stomach is completely divided with staples creating a small (30 cc) stomach pouch. This becomes the new reservoir that holds food. The remainder of the stomach is no longer used, and is referred to as the excluded stomach. The small bowel is then divided using a stapler. The intestine that is further away (called the Roux limb) is pulled up and connected to the newly formed pouch.
How it Works:
- Restriction: A small stomach pouch is created, limiting food intake.
- Malabsorption: The small intestine is rerouted, reducing calorie and nutrient absorption.
Benefits:
- Significant weight loss.
- Improvement in blood sugar levels and reduced acid reflux.
Vertical Sleeve Gastrectomy
The sleeve gastrectomy is a non-reversible procedure which provides gastric restriction and appetite suppression. In this surgery, the stomach is divided along its vertical length using a stapler. During this surgery, the stomach is divided into 2 unequal parts and up to 80% of the volume of the stomach is removed. The remaining stomach becomes a narrow tube that looks like a banana that holds about 3-6 ounces. All surgery has risks. These risks vary according to your general health, age, and type of surgery you choose.
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How it Works:
- Restriction: A large portion of the stomach is removed, leaving a smaller, sleeve-shaped stomach.
- Appetite Suppression: Gut hormones change how full or hungry you feel.
Benefits:
- Effective weight loss.
- Reduced hunger.
Single Anastomosis Duodenal-Ileostomy Switch (SADI)
SADI reduces the size of the stomach and re-routes the intestines making it both a restrictive and malabsorptive procedure. In this surgery, the stomach is divided along its vertical length using a stapler. The left side of the stomach (~80-85% of the stomach) is surgically removed. This part of the surgery is not reversible. The stomach that remains is shaped like a thin banana and measures 4 -7 ounces (120-250mL). The intestines are divided and rearranged to separate the flow of food from the flow of digestive juices, thereby creating malabsorption. These changes mean that your food does not mix with the enzymes and other digestive juices until very far down in the small intestines. This results in a significant decrease in the absorption of calories, fats, proteins, vitamins and minerals.
How it Works:
- Restriction: Reduces the size of the stomach.
- Malabsorption: The intestines are re-routed to limit the absorption of calories and nutrients.
Benefits:
- Significant weight loss.
- Effective for patients with severe obesity.
Endoscopic Sleeve Gastroplasty (ESG)
ESG is a non-surgical procedure that uses a suturing device during an upper endoscopy to place full thickness sutures within the stomach and then pull them tight to gather portions of the stomach together. This gastric remodeling procedure reduces the volume of the stomach, leading to patients to feelfuller earlier and eat less, and resulting in an average total body weight loss of 10-15 percent, said Dr. Kolb.
Benefits:
- Less invasive.
- Available to patients who either don’t want or don’t qualify for surgery with a body mass index higher than 30.
- Faster recovery time and no scarring, with patients leaving the hospital either the same day, or the next day, and back to work within two to three days.
- Reversible, whereas the surgery results in a permanent reshaping of the stomach.
- Reduces the comorbidities related to obesity, such as Heart Disease and Stroke.
The Surgical Process
Bariatric surgery is typically performed in a hospital setting under general anesthesia. The specifics of the surgery depend on the individual's situation and the type of weight-loss surgery. Most types of bariatric surgery are performed laparoscopically. A laparoscope is a small, tubular instrument with a camera attached. The laparoscope is inserted through small incisions in the abdomen. The tiny camera on the tip of the laparoscope allows the surgeon to see and operate inside the abdomen without making the traditional large incisions. Laparoscopic surgery can make recovery faster and shorter, but it's not suitable for everyone. Surgery usually takes several hours. After surgery, you awaken in a recovery room, where medical staff monitors you for any complications.
Post-Operative Care and Lifestyle Changes
For the surgery to be successful, you must change your diet and lifestyle.
Nutritional Guidelines
Following bariatric surgery, adhering to specific nutritional guidelines is essential for optimal healing and weight management.
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- Bariatric Vitamins/Mineral requirements: Vitamin and mineral deficiencies may occur after surgery because your new pouch is simply too small to get all of the nutrition your body requires from food alone. These supplements do not take the place of a healthy diet, but they can enrich it! Supplements do not provide energy but are needed to stay healthy. Read labels on vitamins too! A serving size can very from 1 to 4 pills in order to get the nutrient content listed. Make sure the dose and form of the vitamin is what your bariatric team advised. And if you’re not sure, ASK! While you are on the pureed diet, you will need to chew or crush your supplements. You may also switch from chewable to regular supplements after the first three months.*It is recommended that you start your vitamins prior to surgery. Avoid gummies as the do not contain iron nor all the vitamins/minerals you will need.*You will need to take the following supplements for the rest of your life unless you are told otherwise by your medical team: A complete multivitamin - A serving size can very from 1 to 4 pills in order to get the nutrient contnet listed. This must contain Iron, Folate, and Vitamins A, D, E and K. B12 can be taken as a liquid, a tablet that you place under your tongue (sub-lingual) or as a monthly injection. Do not take more than 600mg of calcium at a time, because more than that won’t be absorbed. This means taking your calcium citrate pill multiple times per day. You can wait to start Calcium until 1 month post-op. You may also be asked to take additional vitamins/ minerals based on lab values - Iron, extra fat soluble vitamins (Vitamins A, D, E, K), Vitamin C, among others.
The MOVE! Program
The VA's MOVE! (Managing Overweight/Obesity for Veterans Everywhere) program is a comprehensive weight management program designed to support veterans in achieving and maintaining a healthy weight. Potential patients will complete a number of courses in the MOVE program and participate in individual counseling prior to undergoing the procedure.
Follow-Up Care
Post procedure, complications usually only occur when patients don’t follow instructions. Typically we'll do a one week follow up, we'll do a follow up at one month, three months, six months, 12 months at least at a minimum with either the bariatric endoscopist or the medicine obesity doctor, and the dietitians are following closely throughout this first six weeks especially, all through the infrastructure of the MOVE program.
Potential Risks and Complications
All surgery has risks. These risks vary according to your general health, age, and type of surgery you choose. Some of the possible complications with the procedure include bleeding, infection, anesthesia related complications, and very rarely, the suturing needle can injure surrounding organs or require an emergency surgery.
Bariatric Surgery Teams
*Ghazali A Chaudry, MD, FACSProgram director*Afsana Sharmin, PA-C Phone: - Surgeon APP*Debra Waite, RDNDietitian*Dr. Florencia PahlPsychologist*Stephanie Teberion, RNClinical reviewer
At the Ralph H. Johnson VAMC, the bariatric surgery team includes:*Rana Pullatt*Dr. Mary Kate BryantProgram Coordinator/Physician Assistant*Emily Couture, PA-CRegistered Dietitian*Mary Walker, MS, RDN, LDN, CNSC*Pharmacists Dr. Elizabeth Hamilton &Dr. Natalie Kurtkaya*Psychologist Dr.
Resources
- American Society for Metabolic and Bariatric Surgery (ASMBS): A professional, non-profit organization for bariatric surgeons and healthcare professionals.
- Obesity Action Coalition (OAC): A non-profit dedicated to educating and advocating for people affected by obesity.
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