With obesity reaching epidemic proportions, many individuals are exploring various weight loss solutions. Bariatric surgery, encompassing procedures like sleeve gastrectomy, Lap-Band, and gastric bypass, presents a viable option for many. However, misconceptions surrounding these surgeries often deter individuals from considering them. Obesity is a disease, according to the American Medical Association (AMA). The AMA defines obesity as a body mass index (BMI) of 30 or above. BMI is calculated using a person’s height and weight, and the normal range is between 18.5 and 25.
Obesity as a Disease and the Role of Bariatric Surgery
Obesity is often linked to serious health issues, including diabetes, cardiovascular problems and premature death. Bariatric surgery is not a cosmetic procedure; it's a medical intervention aimed at improving health, extending life expectancy, and enhancing overall well-being. The goal is to help you feel better, live longer and lead a more active, healthy life.
Eligibility Criteria for Bariatric Surgery
Those with a BMI of 35 - about 60 pounds overweight for your height - or above meet the National Institute of Health's (NIH) criteria for bariatric surgery. Generally, candidacy for bariatric surgery is based on insurance requirements. This may vary depending on your insurance, but the general requirements are based on your body mass index (BMI) and the presence of medical problems related to the disease of obesity, a term known as “co-morbidities.” BMI, which is based on your weight and height, is certainly not the only indicator of health - but it’s one of the best tools we have to monitor weight.
However, the American Society for Metabolic and Bariatric Surgery (ASMBS) has urged consideration of bariatric surgery for individuals with a BMI between 30 and 35.
To determine if bariatric surgery is the right option, assess your Body Mass Index (BMI). If you have a BMI of 27 or greater or need to lose at least 50 pounds, you qualify for bariatric surgery. If your BMI score is between 35 and 40, that typically indicates that you are between 50 and 80 pounds overweight.
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Dispelling Misconceptions About Bariatric Surgery
Several misconceptions surround bariatric surgery. It's crucial to address these to provide a clearer understanding of the procedure and its implications.
Surgery Type Matters
Just as no two people are alike, "every operation we do is very different, and each is tailored specifically to that person," Torquati says. Someone with diabetes would likely need gastric bypass surgery, which reduces the size of the stomach and bypass some of the small intestine. For patients with BMIs up to 50, sleeve gastrectomy - which removes all but a banana-sized portion of the stomach - often is the best option. Once popular, gastric banding - when a band restricts the amount of food your stomach will hold - now is performed on less than 5 percent of patients. The best candidates are those who already maintain a strict diet and exercise regime, avoid high-carbohydrate calories, and are willing and able to have multiple band adjustments.
Bariatric Surgery vs. Diet and Exercise
Most patients who see a bariatric surgeon have already tried diet, exercise and medications to control their weight for years, even decades. "When someone is 20 or 30 pounds overweight, diet and exercise are prescribed and can work," Torquati says. "But once you cross the threshold of being 50 or 60 pounds overweight, the failure rates for controlling weight with exercise and diet are close to 90 percent." Bariatric surgery helps make extreme weight loss more achievable by eliminating the food cravings that can derail your diet. Good diet and exercise regimens are crucial for shedding pounds after surgery - not to mention for weight maintenance. "Surgery is a tool; it's not a magic bullet," Torquati says. "At Rush, it's just part of the patient's weight loss journey."
Long-Term Weight Management After Surgery
Research has shown that not only do patients who have bariatric surgery lose more weight than those who only diet and exercise, they keep it off. A long-term Swedish study compared obese people who had surgery with those who controlled weight by diet and exercise alone. After 20 years, those who had surgery had lost more weight and were better able to maintain their weight loss.
Insurance Coverage for Bariatric Surgery
Although extreme weight loss will transform your appearance, the most important benefits are not cosmetic. That's why most insurance companies follow the NIH guidelines for bariatric surgery to determine coverage. Having other conditions aggravated by obesity - such as blood pressure and diabetes - can increase the likelihood that your procedure will be covered. Most insurance companies will cover this surgery. Some will fight coverage, but we have had great success in getting insurers to realize that this is necessary.
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Addressing Concerns About Excess Skin and Scars
"Today, 99.9 percent of weight loss surgery is done through laparoscopy," Torquati says. "So there is no big scar that will require plastic surgery." In addition, not everyone ends up with large amounts of excess skin after losing weight following bariatric surgery. Torquati finds less than 50 percent of his patients have skin removal surgery.
Weight Limits and Age Considerations
It's true that for patients over 500 pounds, surgery can be challenging. As with weight, age can be a risk factor - especially if you also have other serious health issues that make any surgery riskier.
Post-Surgery Medication and Health Improvements
Along with reducing your weight, bariatric surgery helps change your body chemistry. "After bypass surgery, 80 percent of patients with diabetes and 60 percent of patients with high blood pressure go into remission - and that means no more medication," Torquati says. In addition, 70 percent of those with sleep apnea no longer need their CPAP machines at night after weight loss surgery.
Safety and Recovery
For most people, the risk for bariatric surgery is low, comparable to having your gall bladder removed. As for recovery: It's typically brief. After surgery, most patients stay a night or two in the hospital and can move back to solid foods after two weeks of a liquid diet.
Pregnancy After Bariatric Surgery
"We advise that patients wait at least a year to try to get pregnant since it could interfere with weight loss," Torquati says. "But the surgery won't affect your ability to conceive, carry a baby or give birth." In fact, losing weight is an important step toward having a baby, since obesity can contribute to infertility in both women and men.
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Types of Bariatric Surgery
Several types of bariatric surgery are available, each with its own advantages and considerations.
Roux-en-Y Gastric Bypass
In a Roux-en-y gastric bypass procedure, a small part of the stomach is used to create a new stomach pouch (roughly the size of an egg), which bypasses part of the small intestine. This allows you to feel fuller more quickly, and you won’t be able to eat as much food at one time. The laparoscopic gastric bypass usually takes around two hours, and you will likely stay in the hospital for two to three days. Gastric Bypass provides significant weight loss for one to two years, then plateaus. Gastric bypass requires that you greatly reduce your intake of sweets and fats.
Vertical Sleeve Gastrectomy
With vertical sleeve gastrectomy, a surgeon removes a large portion of your stomach. The laparoscopic vertical sleeve gastrectomy takes about 60 to 90 minutes, and you can expect to stay in the hospital for about two days after the procedure. The Sleeve Gastrectomy results in a banana shaped, or sleeve-like stomach.
Laparoscopic Adjustable Gastric Bands (aka “lap bands”)
We also frequently perform various revisional surgeries - this includes revising a previous surgery, removing laparoscopic adjustable gastric bands (aka “lap bands”), or converting from the band or the sleeve to the bypass.
The Bariatric Surgery Journey: What to Expect
Embarking on a bariatric surgery journey involves several steps, from initial consultation to long-term follow-up.
Initial Consultation and Evaluation
You will meet with the surgeon, or with our nurse practitioner who will initiate the process to become a new healthier you. You will have a thorough history taken at the time of your visit, and as a candidate for weight loss surgery you can expect to go through a series of consultations. Please make sure to bring any pertinent medical information and tests results from other physicians as well as the names and addresses of your primary care physician. Your nurse practitioner may recommend further testing to evaluate any potential obesity-related problems, such as sleep apnea and gastroesophageal reflux disease (GERD). Once you complete your visit with the nurse practitioner, you will then meet with the registered dietician who will evaluate your dietary habits, and discuss healthy lifestyle changes before and after surgery. For this meeting with the dietician, it is a good idea to bring a list of everything you have eaten and their amounts in the two days prior to your appointment. Once the nurse practitioner receives the results of the tests that he/she has recommended that you do, it is then that our office will schedule an appointment to meet with the surgeon again. You are not expected to decide which surgical procedure you would like on the day you first meet with the surgeon or nurse practitioner. It may be beneficial to you to contact some past patients to learn about their experiences with the program. By the time that you meet with the surgeon, you may have already completed any preliminary testing that the nurse practitioner felt you needed in order to evaluate any potential obesity-related problems. Your tests results, as well as your medical and dietary history, will be reviewed by the surgeon and any potential concerns will be discussed. The surgeon will then review with you the various surgical procedures and potential risks of surgery as they pertain to your individual case. Most patients then decide which weight loss surgery is best for them. If you are still undecided, you do not need to make that decision just then. However, when you do decide which procedure you would like to have after meeting with the surgeon, it is then that your date for surgery will be given.
Pre-Surgical Program
At your initial consultation with your bariatric surgery, if you are a good candidate and you desire to proceed, you can join the surgical weight loss program. Our program takes 3-6 months to complete, which is based on meeting the requirements determined by your insurance. These requirements involve dietician visits, support group meetings, evaluation by our mental health counselors, and clearances from other providers. Each patient must be cleared by a heart doctor, and some require clearances from lung doctors, sleep doctors, or other providers based on your health history. 2 weeks before surgery, we go over the surgery consent form and sign it together. We talk over any questions you have, talk about the medications you will need after surgery, and make sure you have everything you need. You will then start your “pre-surgical” diet, which is a diet high in protein and low in fat and sugar. During this time, you will probably lose weight - but that’s not the goal! The goal is to shrink your liver to make your surgery as safe as possible (big livers can make surgery more complicated and increase your risk for complications), so it is very important you follow this diet strictly.
Hospital Stay and Post-Operative Care
After surgery, patients typically stay in the hospital for only one night. In the hospital, we make sure patients are up and moving that same day - this really helps decrease the risk of blood clots. Our team - made up of nurses, nurse practitioners, resident physicians, and your surgeon - will frequently check up on you during your stay in the hospital. You will be working on drinking liquids and protein shakes, making sure that before you leave, you are able to keep up with the requirements needed to stay hydrated. You’ll see us at 1 week, 3 weeks, 6 weeks, 3 months, 6 months, 1 year, and then yearly thereafter. At 1 week, you can start eating some foods (such as eggs) along with your liquids, slowly advancing your diet at each visit until week 6, where you reach the final “advanced” stage. This is the “diet” you will follow forever (diet is in quotations - because ultimately, you will be eating real foods and normal textures, focusing on protein, fiber, and fluids!).
Long-Term Follow-Up and Support
While you are healing you will be seen on a regular basis, usually once after two weeks, and again six weeks after surgery. You return for follow-up visits after three, six, nine, and 12 months to make sure you are adjusting well, and then once a year after that. Our entire team, from the office to the operating room, has seen how bariatric surgery changes lives, time and time again. We want you to know that you are not stuck. When life happens and you slip up - that’s ok! We are here to guide you through to get you back on track.
Lifestyle Changes and Sustained Weight Loss
Bariatric surgery, as stated before, obviously leads to great weight loss - but more importantly, if you stay active and stick to your high protein, high fiber diet, you will be able to MAINTAIN this great weight loss. Good diet and exercise regimens are crucial for shedding pounds after surgery - not to mention for weight maintenance. Exercise is important to overall health. The more you exercise the healthier you will be and the more weight you will lose. Since walking greatly accelerates weight loss, specifically fat loss, we suggest you walk every day. After weight loss surgery, almost any type of food is tolerated if chewed well enough, and eaten slowly.
Success of Weight Loss Surgery
Weight loss surgery is considered successful when 50% of excess weight is lost and the loss is sustained up to five years. For example, a patient who is 100 pounds overweight should lose at least 50 pounds; a patient who is 200 pounds overweight should lose at least 100 pounds. And they should be able to maintain loss successfully for the following five years. However, weight loss isn’t the only goal - our goal is to get you to a happier, healthier lifestyle. That means getting off some of your medications, decreasing your risk for many cancers, having less pain, or being able to do the things you used to do… or have always wanted to do, but couldn’t.
Alternatives to Bariatric Surgery
We have seen advertising for GLP-1 treatments to avoid the surgery route. The GLP-1 medications, which were newly developed to treat the diseases of overweight and obesity, also increase a person’s metabolism - but to a much lesser degree. When we think about weight loss goals after surgery, we frequently use “excess body weight,” or the weight a person is OVER a “normal” weight (normal is in quotations because, well… you don’t have to have a “normal” BMI to be healthy). With bariatric surgery, we can typically achieve an excess weight loss of 50-80%, depending on the surgery. That means if you are 100 pounds over a “normal” BMI of 25, you will lose 50-80 pounds. With the GLP-1 medications, in the best case scenario, total weight loss can reach 15-20%. So, for a 5 foot, 5 inch woman, who weighs 250 pounds and is therefore 100 pounds over a “normal” BMI, she could lose 37-50 pounds with these medications (at most). As you can see here, GLP-1 medications, even if they are well tolerated and affordable (which isn’t a guarantee), don’t lead to nearly the same amount of weight loss compared to bariatric surgery. And unfortunately, if these drugs are stopped for whatever reason, much of the weight could come back on within 2 years - because once the drug is stopped, typically that metabolism "boost" comes back to normal. With bariatric surgery, the hormonal changes and metabolic "boost" is long lasting.
Risks and Considerations
Weight loss surgery is a serious step. Patients with psychiatric conditions such as depression, bipolar disease, and/or schizophrenia should be under the care of a psychiatrist before they consider surgery. These conditions can become exaggerated by the body changes that are associated with weight loss. There are some medical conditions which make the surgery too risky to perform. These occur rarely but must be taken into account. Depending on how well you are recovering from your surgery, lifting, pulling, or pushing may or may not be restricted. Certainly for the first two weeks most patients are not comfortable enough to do any heavy lifting. In the post operative period, especially while using any pain medication, we recommend that you do not drive. Surgery for weight loss can be reversed, but reversal procedures are usually more dangerous than the original ones. We would only consider reversing these operations in patients who have significant long term problems from the surgery.