Is surgery the answer to obesity?

by Diana Pi, M.D.

Tens of millions of Americans qualify for weight-reduction surgery, yet less than 1 percent pursue this option yearly. Shows like “My 600-lb Life” both promote and stigmatize bariatric surgery as a desperate measure for the desperately obese. I think differently. If you’ve dieted, exercised, divorced your carb crutch and still struggle with weight, diabetes, sleep apnea, back and knee pain – then surgery might help.

The criteria for bariatric surgery are simple: BMI of 40 and over, or 35 with at least oneweight-related medical condition. If you’re 5’4” and weigh over 235 pounds, or over 205 lbs with diabetes, you’d qualify.

Currently your two best surgical options are gastric bypass and gastric sleeve. Adjustable gastric band, popular a few years ago, is disappearing because of unsatisfactory weight loss. Five-year data show both procedures have comparable weight loss, maintenance and complication rates. Gastric sleeve is easier surgically, but it’s irreversible and may worsen reflux, a major reason for reoperation.

All gastric surgery severely reduces stomach size (to the size of a thumb for gastric bypass). It works by restriction, malabsorption, and importantly, resetting your hunger threshold and craving. Your brain says “I’m full” after eating next to nothing. Saying no to sweets is that much easier. 

Preferably, surgery is now done laparoscopically – a few small holes. After surgery, you’ll stay in the hospital for two days and can resume regular activities within a few weeks.

Here’s what everybody wants to know: How much weight can I lose, and for how long? The bulk of weight loss occurs the first year after surgery – about 60 percent of “excess weight.”  If you’re 100 pounds over your ideal weight, you can expect to lose around 60 pounds. After the first year, most people will gain some weight back, but still keep most of it off for years. About 1 in 20 regain all the weight back.

First hurdle: cost. Medicare, Ohio Medicaid and some private insurance will pay – with fine print. Insurance may not cover cosmetic surgery for loose skin, which can be equally expensive. Around here, self-paid bariatric surgery packages average $27,000.

Second hurdle: expectation. Surgery changes most people from morbidly obese to obese, not skinny. But the health benefits – this is where I cave – are immediate and impressive. Just months after surgery, half of the diabetics no longer need medication! The majority no longer need cholesterol and blood pressure pills. Benefits differ among individuals but are sustainable.

What about liposuction? Lipo-suction works more like lipo-shuffling. A 2011 study followed people who underwent liposuction to thighs and lower belly. Initially they dropped a few pounds. A year later, the fat returned, albeit in different places like the upper arms and upper abdomen. Liposuction is surgical fat reduction & insufficient for weight reduction.

Yeah, I binge-watch “My 600-lb Life,” in part to see its 73-year-old bariatric surgeon, Dr. “Now” – who has the warmth and charm of a LED lightbulb – straight talk his patients. But, for a carefully selected few, he and his team have changed, if not saved, many unreachable lives.

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