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Obesity Surgery is the official journal of the International Federation for the Surgery of Obesity and metabolic disorders (IFSO). A journal for bariatric/metabolic surgeons, Obesity Surgery provides an international, interdisciplinary forum for communicating the latest research, surgical and laparoscopic techniques, for treatment of massive obesity and metabolic disorders. Topics covered include original research, clinical reports, current status, guidelines, historical notes, invited commentaries, letters to the editor, medicolegal issues, meeting abstracts, modern surgery/technical innovations, new concepts, reviews, scholarly presentations and opinions.

Obesity Surgery benefits surgeons performing obesity/metabolic surgery, general surgeons and surgical residents, endoscopists, anesthetists, support staff, nurses, dietitians, psychiatrists, psychologists, plastic surgeons, internists including endocrinologists and diabetologists, nutritional scientists, and those dealing with eating disorders.

  • An international, interdisciplinary forum for the latest in research, clinical care, and surgical innovations for the treatment of severe obesity
  • The journal’s articles and videos cover original research, clinical reviews, technical innovations, medicolegal issues, and more
  • The journal benefits all clinicians, researchers, and students involved or interested in the care of the severely obese
  • 98% of authors who answered a survey reported that they would definitely publish or probably publish in the journal again

Weight-Loss Surgery Dramatically Lowers the Risk of Early Death, a New Study Finds

For decades, doctors have known that losing weight can significantly lower risk of heart disease and by extension, reduce the risk of dying from heart-related events such as stroke and heart attack. Studies have shown that both lifestyle changes including diet and exercise as well as medications and weight-loss surgery can improve heart disease risk factors such as obesity and diabetes, for example, but data supporting the benefits of any of these approaches in actually lowering rates of heart events such as heart attack and atrial fibrillation, or in reducing early deaths from heart disease, have been less robust. The data that do exist come from observational studies or smaller trials.

Now a new study, published Sept. 2 in JAMA and simultaneously presented at the European Society of Cardiology annual meeting, takes that previous work a step further, suggesting that weight-loss surgery can lower rates of heart attack, heart failure, atrial fibrillation and stroke, and lower death rates from any cause in a large group of at-risk patients.

A team of researchers led by Dr. Ali Aminian, associate professor of surgery at the Cleveland Clinic, looked at obese patients with type 2 diabetes, who are at higher risk of heart events. Among more than 2,200 such patients who underwent any form of weight-loss surgery, heart-related events dropped by 39% over eight years of follow up and deaths from any cause declined by 41% compared to a group of more than 11,000 matched controls who did not receive any weight loss surgery.

“As a cardiologist, I cannot remember any study, not studies involving statins, or studies involving blood pressure medication, having this large of a treatment effect,” says Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic and senior author of the paper. “What this tells me is that the heart-related morbidity and mortality associated with diabetes and obesity is reversible with the right procedure.”

The magnitude of the reduction in heart events and deaths suggests that the benefits of the surgery may extend beyond those attributable to weight loss alone. “There are neurohormonal changes we see after these procedures that could have significant metabolic effects and benefits for patients,” says Aminian.

The majority of the study participants who had weight-loss surgery underwent gastric bypass, an operation in which surgeons shrink the size of the stomach by creating a small pouch from its tissues and shunting food more directly from that pouch to the upper intestine. The researchers found that, after patients had their digestive tracts re-routed, there were changes in the pattern of hormones their bodies produced. Insulin, produced by beta cells in the pancreas, is responsible for breaking down glucose, and those with diabetes have lower insulin responses to food. But gastric bypass surgery seemed to restore some of the normal insulin response in the study—Aminian found that many patients no longer needed insulin by the end of the study period. In addition, the share of patients relying on non-insulin diabetic medications also dropped, by half, from 80% to nearly 40%.

Weight-loss surgery, and in particular gastric bypass, may also change the composition of healthy bacteria living in the gut. Previous studies have shown that people with diabetes have different species of bacteria in their digestive tract compared to people without diabetes, which may influence how their bodies respond to sugars. In other research in his lab, Aminian has taken fecal samples from patients pre- and post-surgery and transferred them to mice, which acted as simulated human guts. Animals receiving samples from patients before surgery tended to become obese and develop diabetes and fatty liver syndrome, while those receiving samples from patients three months after weight-loss surgery did not.

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These findings, taken together, strongly suggest that addressing obesity among diabetics may reverse some of their risk of disease and early death, but that weight loss alone, especially through lifestyle changes such as diet and exercise, may not be enough.

“It’s not just one factor. Weight loss is important, the gut hormones are important, and the microbiome is important,” says Aminian. “They all work together like an orchestra to improve the metabolic condition of the patient.”

He and Nissen agree that weight loss surgery may not be an option for every overweight or obese diabetic patient, but the data suggest that it might be considered for more people in coming years. Because the study did not randomly assign diabetic patients to surgery or the control group, but relied on a matched set of controls for comparison, the next step in confirming the results would be to conduct a randomized control trial. If those findings support these, then a stronger case might be made for considering weight loss surgery for more people.

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  1. Obesity is not just a weight problem.
    Obesity is a metabolic disease. Your metabolism slows so that you can remain severely overweight even when eating a modest number of calories.
  2. Surgery counteracts the metabolic changes.
    After bariatric surgery, you can feel full and satisfied after eating just a small meal.
  3. The risk is about the same as the risk for gallbladder surgery.
    The health risks of bariatric surgery are much lower than the health risks of obesity itself.
  4. Bariatric surgery is an emotional experience.
    That’s why you get psychological as well as nutritional support beforehand.
  5. Its health benefits go beyond weight loss.
    Bariatric surgery often improves high blood pressure, sleep apnea, joint pain and type 2 diabetes.
  6. Surgery can cure newly diagnosed type 2 diabetes.
    If you’ve just been diagnosed with type 2 diabetes and have bariatric surgery, you may not need to start insulin shots.
  7. In most states, government insurance covers the surgery.
    Many people don’t realize Medicare and Medicaid often cover weight loss surgery.
  8. You’re unlikely to get a big scar.
    The two most common bariatric procedures involve three to five incisions that are 1/2 to 1 inch long.
  9. Recovery from surgery is surprisingly fast.
    You’ll be back at a desk job in two weeks and at any job four weeks after bariatric surgery.
  10. For 1-2 months after surgery, eating is work.
    Eating slowly becomes pleasurable again as swelling recedes and you get used to smaller portions.
  11. You’ll want to minimize liquids during meals.
    This allows room for solid foods and minimizes discomfort.
  12. Bariatric surgery is a journey, not a destination.
    Most people lose half their extra weight during the six months they prepare for surgery and the rest over six to 12 months after surgery.
  13. Success rates are ~ 85% five years after surgery.
    Bariatric surgery has helped millions maintain their weight loss. But because it’s been around since the 1970s, it’s not unusual to run into people who did not succeed in keeping weight off.

Definition & Facts for Bariatric Surgery

What is obesity?

Obesity is defined as having a body mass index (BMI) of 30 or more. BMI is a measure of your weight in relation to your height. Class 1 obesity means a BMI of 30 to 35, Class 2 obesity is a BMI of 35 to 40, and Class 3 obesity is a BMI of 40 or more. Classes 2 and 3, also known as severe obesity, are often hard to treat with diet and exercise alone.

Calculate your BMI to learn your BMI category.

What is bariatric surgery?

Bariatric surgery is an operation that helps you lose weight by making changes to your digestive system. Some types of bariatric surgeries make your stomach smaller, allowing you to eat and drink less at one time and making you feel full sooner. Other bariatric surgeries also change your small intestine—the part of your body that absorbs calories and nutrients from foods and beverages.

Bariatric surgery may be an option if you have severe obesity and have not been able to lose weight or keep from gaining back any weight you lost using other methods such as lifestyle treatment or medications. Bariatric surgery also may be an option if you have serious health problems, such as type 2 diabetes or sleep apnea, related to obesity. Bariatric surgery can improve many of the medical conditions linked to obesity, especially type 2 diabetes.

Does bariatric surgery always work?

Studies show that many people who have bariatric surgery lose about 15 to 30 percent of their starting weight on average, depending on the type of surgery they have. However, no method, including surgery, is sure to produce and maintain weight loss. Some people who have bariatric surgery may not lose as much as they hoped. Over time, some people regain a portion of the weight they lost. The amount of weight people regain may vary. Factors that affect weight regain may include a person’s level of obesity and the type of surgery he or she had.

Bariatric surgery does not replace healthy habits, but may make it easier for you to consume fewer calories and be more physically active. Choosing healthy foods and beverages before and after the surgery may help you lose more weight and keep it off long term. Regular physical activity after surgery also helps keep the weight off. To improve your health, you must commit to a lifetime of healthy lifestyle habits and following the advice of your health care providers.

Maintaining healthy lifestyle habits may help
you succeed after bariatric surgery.

How much does bariatric surgery cost?

On average, bariatric surgery costs between $15,000 and $25,000, depending on what type of surgery you have and whether you have surgery-related problems. Costs may be higher or lower based on where you live. The amount your medical insurance will pay varies by state and insurance provider.

Medicare and some Medicaid programs cover three common types of bariatric surgery—gastric bypass, gastric band, and gastric sleeve surgery—if you meet certain criteria and have a doctor’s recommendation. Some insurance plans may require you to use approved surgeons and facilities. Some insurers also require you to show that you were unable to lose weight by completing a nonsurgical weight-loss program or that you meet other requirements.

Your health insurance company or your regional Medicare or Medicaid office will have more information about bariatric surgery coverage, options, and requirements.

Misconception: Most people who have metabolic and bariatric surgery regain their weight.

As many as 50 percent of patients may regain a small amount of weight (approximately 5 percent) two years or more following their surgery. However, longitudinal studies find that most bariatric surgery patients maintain successful weight-loss long-term. ‘Successful’ weight-loss is arbitrarily defined as weight-loss equal to or greater than 50 percent of excess body weight. Often, successful results are determined by the patient, by their perceived improvement in quality of life. In such cases, the total retained weight-loss may be more, or less, than this arbitrary definition. Such massive and sustained weight reduction with surgery is in sharp contrast to the experience most patients have previously had with non-surgical therapies.

Misconception: The chance of dying from metabolic and bariatric surgery is more than the chance of dying from obesity.

As your body size increases, longevity decreases. Individuals with severe obesity have a number of life-threatening conditions that greatly increase their risk of dying, such as type 2 diabetes, hypertension and more. Data involving nearly 60,000 bariatric patients from ASMBS Bariatric Centers of Excellence database show that the risk of death within the 30 days following bariatric surgery averages 0.13 percent, or approximately one out of 1,000 patients. This rate is considerably less than most other operations, including gallbladder and hip replacement surgery. Therefore, in spite of the poor health status of bariatric patients prior to surgery, the chance of dying from the operation is exceptionally low. Large studies find that the risk of death from any cause is considerably less for bariatric patients throughout time than for individuals affected by severe obesity who have never had the surgery. In fact, the data show up to an 89 percent reduction in mortality, as well as highly significant decreases in mortality rates due to specific diseases. Cancer mortality, for instance, is reduced by 60 percent for bariatric patients. Death in association with diabetes is reduced by more than 90 percent and that from heart disease by more than 50 percent. Also, there are numerous studies that have found improvement or resolution of life-threatening obesity-related diseases following bariatric surgery. The benefits of bariatric surgery, with regard to mortality, far outweigh the risks. It is important to note that as with any serious surgical operation, the decision to have bariatric surgery should be discussed with your surgeon, family members and loved ones.

Misconception: Surgery is a ‘cop-out’. To lose and maintain weight, individuals affected by severe obesity just need to go on a diet and exercise program.

Individuals affected by severe obesity are resistant to long-term weight-loss by diet and exercise. The National Institutes of Health Experts Panel recognize that ‘long-term’ weight-loss, or in other words, the ability to ‘maintain’ weight-loss, is nearly impossible for those affected by severe obesity by any means other than metabolic and bariatric surgery. Bariatric surgeries are effective in maintaining long-term weight-loss, in part, because these procedures offset certain conditions caused by dieting that are responsible for rapid and efficient weight regain following dieting. When a person loses weight, energy expenditure (the amount of calories the body burns) is reduced. With diet, energy expenditure at rest and with activity is reduced to a greater extent than can be explained by changes in body size or composition (amount of lean and fat tissue). At the same time, appetite regulation is altered following a diet increasing hunger and the desire to eat. Therefore, there are significant biological differences between someone who has lost weight by diet and someone of the same size and body composition to that of an individual who has never lost weight. For example, the body of the individual who reduces their weight from 200 to 170 pounds burns fewer calories than the body of someone weighing 170 pounds and has never been on a diet. This means that, in order to maintain weight-loss, the person who has been on a diet will have to eat fewer calories than someone who naturally weighs the same. In contrast to diet, weight-loss following bariatric surgery does not reduce energy expenditure or the amount of calories the body burns to levels greater than predicted by changes in body weight and composition. In fact, some studies even find that certain operations even may increase energy expenditure. In addition, some bariatric procedures, unlike diet, also causes biological changes that help reduce energy intake (food, beverage). A decrease in energy intake with surgery results, in part, from anatomical changes to the stomach or gut that restrict food intake or cause malabsorption of nutrients. In addition, bariatric surgery increases the production of certain gut hormones that interact with the brain to reduce hunger, decrease appetite, and enhance satiety (feelings of fullness). In these ways, bariatric and metabolic surgery, unlike dieting, produces long-term weight-loss.

Misconception: Many bariatric patients become alcoholics after their surgery.

Actually, only a small percentage of bariatric patients claim to have problems with alcohol after surgery. Most (but not all) who abuse alcohol after surgery had problems with alcohol abuse at some period of time prior to surgery. Alcohol sensitivity, (particularly if alcohol is consumed during the rapid weight-loss period), is increased after bariatric surgery so that the effects of alcohol are felt with fewer drinks than before surgery. Studies also find with certain bariatric procedures (such as the gastric bypass or sleeve gastrectomy) that drinking an alcoholic beverage increases blood alcohol to levels that are considerably higher than before surgery or in comparison to the alcohol levels of individuals who have not had a bariatric procedure. For all of these reasons, bariatric patients are advised to take certain precautions regarding alcohol:

  • Avoid alcoholic beverages during the rapid weight-loss period
  • Be aware that even small amounts of alcohol can cause intoxication
  • Avoid driving or operating heavy equipment after drinking any alcohol
  • Seek help if drinking becomes a problem

If you feel the consumption of alcohol may be an issue for you after surgery, please contact your primary care physician or bariatric surgeon and discuss this further. They will be able to help you identify resources available to address any alcohol-related issues.

Misconception: Surgery increases the risk for suicide.

Individuals affected by severe obesity who are seeking bariatric and metabolic surgery are more likely to suffer from depression or anxiety and to have lower self-esteem and overall quality of life than someone who is normal weight. Bariatric surgery results in highly significant improvement in psychosocial well-being for the majority of patients. However, there remain a few patients with undiagnosed preexisting psychological disorders and still others with overwhelming life stressors who commit suicide after bariatric surgery. Two large studies have found a small but significant increase in suicide occurrence following bariatric surgery. For this reason, comprehensive bariatric programs require psychological evaluations prior to surgery and many have behavioral therapists available for patient consultations after surgery.

Misconception: Bariatric patients have serious health problems caused by vitamin and mineral deficiencies.

Bariatric operations can lead to deficiencies in vitamins and minerals by reducing nutrient intake or by causing reduced absorption from the intestine. Bariatric operations vary in the extent of malabsorption they may cause, and vary in which nutrients may be affected. The more malabsorptive bariatric procedures also increase the risk for protein deficiency. Deficiencies in micronutrients (vitamin and minerals) and protein can adversely affect health, causing fatigue, anemia, bone and muscle loss, impaired night vision, low immunity, loss of appropriate nerve function and even cognitive defects. Fortunately, nutrient deficiencies following surgery can be avoided with appropriate diet and the use of dietary supplements, i.e. vitamins, minerals, and, in some cases, protein supplements. Nutrient guidelines for different types of bariatric surgery procedures have been established by the ASMBS Nutritional Experts Committee and published in the journal, Surgery for Obesity and Other Related Disorders. Before and after surgery, patients are advised of their dietary and supplement needs and followed by a nutritionist with bariatric expertise. Most bariatric programs also require patients to have their vitamins and minerals checked on a regular basis following surgery. Nutrient deficiencies and any associated health issues are preventable with patient monitoring and patient compliance in following dietary and supplement (vitamin and mineral) recommendations. Health problems due to deficiencies usually occur in patients who do not regularly follow-up with their surgeon to establish healthy nutrient levels.

Misconception: Obesity is only an addiction, similar to alcoholism or drug dependency.

Although there is a very small percentage of individuals affected by obesity who have eating disorders, such as binge eating disorder syndrome, that may result in the intake of excess food (calories), for the vast majority of individuals affected by obesity, obesity is a complex disease caused by many factors. When treating addiction, such as alcohol and drugs, one of the first steps is abstaining from the drugs or alcohol. This approach does not work with obesity as we need to eat to live. Additionally, there may be other issues affecting an individual’s weight, such as psychological issues. Weight gain generally occurs when there is an energy imbalance or, in other words, the amount of food (energy) consumed is greater than the number of calories burned (energy expended) by the body in the performance of biological functions, daily activities and exercise. Energy imbalance may be caused by overeating or by not getting enough physical activity and exercise. There are other conditions, however, that affect energy balance and/or fat metabolism that do not involve excessive eating or sedentary behavior including:

  • Chronic sleep loss
  • Consumption of foods that, independent of caloric content, cause metabolic/hormonal changes that may increase body fat (sugar, high fructose corn syrup, trans fat, processed meats and processed grains)
  • Low intake of fat-fighting foods (fruits, vegetables, legumes, nuts, seeds, quality protein)
  • Stress and psychological distress
  • Many types of medications
  • Pollutants

Obesity also ‘begets’ obesity, which is one of the reasons why the disease is considered ”progressive.” Weight gain causes a number of hormonal, metabolic and molecular changes in the body that increase the risk for even greater fat accumulation and obesity. Such obesity-associated changes reduce fat utilization, increase the conversion of sugar to fat, and enhance the body’s capacity to store fat by increasing fat cells size and numbers and by reducing fat breakdown. Such defects in fat metabolism mean that more of the calories consumed are stored as fat. To make matters worse, obesity affects certain regulators of appetite and hunger in a manner that can cause an increase in the amount of food eaten at any given meal and the desire to eat more often. There are many causes for obesity and that the disease of obesity is far more than just an ‘addiction’ toward food. The treatment of obesity solely as an addiction may be beneficial for a very small percentage of individuals whose only underlying cause for obesity is excessive and addictive eating, but would be unlikely to benefit the multitudes, particularly those individuals affected by severe obesity.

Weight loss surgery facts

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