Obesity has become a major health problem worldwide and especially in the western world. Could lap bands make a difference?

Faced with years of failure at losing weight through diet and exercise, many obese people are turning to bariatric surgery to solve their weight problem. Over 60,000 procedures are performed yearly in the United States but, does it really work? Is it the right approach? These are the questions that millions of seriously overweight people are asking.

The World Health Organization (WHO) estimates that this "globesity" epidemic includes over one billion overweight adults of which at the least 300 million are considered obese. Over two thirds of Americans are overweight and about one third are considered obese. Likewise in 2004, over 6 million Canadians were overweight and over 4.5 million were obese.

In 2009 ~64% of all Americans were either overweight or obese defined as having a Body Mass Index of 25.0 to 29.9 and 30.5% of all Americans are obese, defined as having a Body Mass Index of 30.0 or higher. The tendency to become obese increases with age and, while there are slightly more overweight men than women, there are significantly more obese and very obese women than men.^1,2

Contributing factors such as reliance on fast foods, super-sized eating and substituting television and computers for more active pursuits, is fueling a continued growth in the number of people battling a weight problem. The enormous surge in obesity has meant a similar surge in obesity-related diseases such as diabetes, heart disease and orthopedic problems – disorders that are costly to treat, often impossible to cure and detrimental to quality of life.

People who become or remain seriously overweight face a disturbing array of possible obesity-linked problems including; high blood pressure and high blood cholesterol, coronary heart disease, stroke, congestive heart failure, Type 2 diabetes, osteoarthritis, gallstones, low back pain, heartburn, gout, obstructive sleep apnea and other respiratory problems, some types of cancer, including endometrial, breast, prostate and colon, complications of pregnancy, poor female reproductive health such as menstrual irregularities, infertility, bladder control problems (e.g., stress incontinence) and osteoporosis, to name a few.

Beyond medical problems, obesity also creates psychological disorders including depression, eating disorders, distorted body image and low self esteem. These issues are aggravated by social norms that place a high value on physical attractiveness and stereotype obese people as lazy or undisciplined. As a result, overweight and obese people often have difficulty leading the active and satisfying life that most people would like to lead.

The percentage of obesity that can be attributed to genetics varies from 6% to 85% depending on the population examined. However, while genes may increase one's risk for obesity, they do not by themselves cause obesity. Genes do not explain the rapidly increasing prevalence of obesity around the world.³

For most people, obesity results from eating too much and not being active enough. Less than one-third of American adults report that they do at least thirty minutes of brisk walking or other moderate activity on most days of the week, and almost half engage in no leisure-time activity at all.

The overwhelming factors responsible for obesity are environmental. Portion sizes continue to increase. Americans were eating about 200 more calories per day in 2003 than they were in 1993. Fast-food restaurants encourage customers to "super size" and purchase "value" meals. Further, people eat out more often than in the past and many restaurants offer huge portion sizes. Television and other electronic media contribute to obesity through commercials urging people to buy food of low nutritional value, and by encouraging sedentary behavior.

David B. Allison, PhD, director of the University of Alabama at Birmingham clinical nutrition research center, and his colleagues have proposed a number of additional causes or contributing factors for obesity.⁴

• Getting too little sleep.
• Hormones control body weight. Many of today’s pollutants affect hormones.
• More people live and work in temperature-controlled homes and offices, reducing the body’s requirement to burn calories staying cool or warm.
• As people smoke less, they eat more.
• Many drugs — including contraceptives, steroid hormones, diabetes drugs, some antidepressants, and blood pressure drugs — can cause weight gain.
• People gain weight as they age. The world is getting older as a group.
• There's some evidence that the older a woman is when she gives birth, the higher her child's risk of obesity. Women are giving birth at older and older ages.
• The environment may create genetic changes that increase obesity.
• There's some evidence obese people are more fertile than lean ones. If obesity has a genetic component, the percentage of obese people in the population should increase.
• Obese women tend to marry obese men. To the extent that obesity is genetic, it may become more prevalent.

What's frustrating is that weight loss diets don't appear to the answer

In a recent study more than 30 percent of respondents cited having dieted between three to five times in their lifetime, and a quarter has attempted dieting at least 20 times. 60 percent of respondents regained weight after their diets ended, almost half seeing at least 75 percent of total weight lost return and 20 percent adding more weight than they lost. The average dieter shed between five and nine pounds on their most recent diet, 25% dropping between 50 to 99 pounds on all diets combined with an equal number of respondents losing between 10 to 29 pounds. Other studies have cited overall diet failure rates as high as 95%.^5-7

Diets fail for several reasons. It's now generally accepted that most people will plateau at a certain weight due to a decreased metabolic rate which causes most people to give up and go back to their old ways. Furthermore diets fail because most are not sustainable. The more restrictive the diet, the less likely an individual will be to remain faithful to it because in general, people cannot endure extended periods of hunger and deprivation.

Another reason diets may fail is that they neglect to teach dieters new eating habits to assist them to maintain their weight loss. Since the weight-loss diet is viewed as a temporary measure with a beginning and an end, at its conclusion, most dieters return to their previous eating habits and often regain the lost weight or even more weight. Those who work with people who are overweight or obese assert that diets do not fail; instead, dieters fail to learn how to eat properly to prevent weight regain. In addition, despite the many benefits of exercise, U.S. statistics show that two-thirds of adults are not physically active on a regular basis and a quarter get virtually no exercise at all.

So, what about weight-loss or bariatric surgery?

Bariatric surgery has become an increasingly popular alternative to diets. The number of weight-loss surgeries has skyrocketed with 205,000 surgeries performed in 2007, up from 47,200 in 2001 and 16,200 in 1992, according to the American Society for Metabolic and Bariatric Surgery. The average cost of bariatric surgery is $30,000, the average bariatric surgery patient is a woman in her late 30s who weighs approximately 300 pounds and the average patient was obese for 20 years before surgery.⁸

Bariatric surgery can be dramatically successful. Patients can lose up to 80% of their pre-operative weight. In general, bariatric surgery patients had tried 24 diet and exercise programs before deciding on the surgery. Two-thirds had an average of five obesity-related conditions, including high blood pressure, diabetes and sleep apnea. The average patient spent three years deciding whether to have surgery before making the final decision.⁹

The 1991 Consensus Panel of the National Institutes of Health (NIH) recommended the following criteria for consideration of bariatric surgery, including gastric bypass procedures: People who have a body mass index (BMI) of 40 or higher or people with a BMI of 35 or higher with one or more related co morbid conditions such as diabetes. The Consensus Panel also emphasized the need for multidisciplinary care of the bariatric surgical patient to manage problems and address nutrition, physical activity, behavior and psychological needs.¹⁰

In 2004 a new Consensus Conference, sponsored by the American Society for Bariatric Surgery (ASBS), updated these recommendations to include persons with a BMI of 30 to 34.9 with additional medical problems and underscored the need for multidisciplinary pre=operative and post-operative care. In 2011, the FDA finally adopted this recommendation, thereby opening up the procedure to thousands of more patients.^11,12

There are two main types of bariatric surgery which results in a modification of the digestive tract so that less food can be eaten and/or fewer nutrients can be absorbed into the body.

• Restrictive Operations, otherwise known as lap bands or lap belts
  These operations alter the size of the stomach by placing a constricting band around it, reducing its capacity from melon-sized to egg-sized. A person who has undergone “lap band” surgery usually cannot eat more than one cup of food at a time
• Gastric by-pass surgery
  In gastric bypass surgery, the surgeon removes a portion of the stomach to reduce the size. Then, the first part of the small intestine is bypassed. As a result, the patient can tolerate only small amounts of food and the food that is consumed passes much more rapidly through the digestive tract, reducing the amount of nutrients that can be absorbed.

Typical success rates range from 45-75 percent for stomach bypass and 40-60 percent for gastroplasty. Success rates for bariatric surgery far exceed those for conventional dieting, especially when patients take advantage of bariatric support groups or other types of weight loss help.¹³

The latest review of clinical studies of bariatric surgery suggest that bariatric surgery provided greater weight loss for any degree of obesity compared with non-surgical treatments. Surgery was also associated with reductions in diabetes, hypertension, and other co-existing conditions. The study found improvements in health-related quality of life at the two year mark.¹⁴

However, even bariatric surgery is not the ultimate answer for obesity.

There are significant surgical risks and the results do not always last. According to the Mayo Clinic, there is approximately one death per 200-300 surgeries. Naturally, the risk of fatality depends upon an individual’s age, prior medical history and general health. Blood clots, which are more likely to occur in the seriously overweight, have also been associated with this surgery. Surgical intervention issues such as leaking at the staple lines in the stomach or incision hernia are also possible complications.

Some patients, especially those who continue to eat sweet or high fat foods, experience “dumping syndrome”. Food moves too quickly through the digestive system, resulting in nausea, vomiting, diarrhea, dizziness and sweating. The lowered absorption of food and nutrients can lead to vitamin deficiencies, dehydration, gall stones, low blood sugar, kidney stones and intolerance for certain foods.¹⁵

Although not properly labeled a risk, many people who undergo bariatric surgery lose weight very quickly and consequently are left with large amounts of excess skin that cannot be re-absorbed by the body. Also, weight loss is sometimes uneven, leading to excess fat deposits in some areas of the body. These people often undergo plastic surgery to remove excess skin and fat and create better body contours.

While bariatric surgery can seem like a miracle for the seriously obese, making that “slicing off fat” dream come true, the tragic reality is that for some people, the weight loss is not sustained. A landmark 2006 study of the long term outcomes of bariatric surgery showed that the failure rate when all patients are followed for at least 10 years was 20.4% for morbidly obese patients (BMI< 50) and 34.9% for super obese patients (BMI>50). ¹⁶

How can this happen? It’s actually not that difficult. Even when a person’s stomach has been banded or surgically altered to reduce the size, it is possible to slowly re-expand the size of the stomach so that it can accommodate more food. When a person who undergoes bariatric surgery does not make the necessary lifestyle changes that include good nutrition and exercise, they can undo all of the good that was done by the surgery.

The Bottom Line

The decision to undergo bariatric surgery should not be made without fully exploring the benefits and the risks. The rock bottom reality is that bariatric surgery can give an obese person a fresh start, rapidly improving their health and dramatically accelerating the so often discouraging weight loss process.

But, even if it looks like a magic bullet, it’s not. The same need to change lifestyle habits apply. The good news is that it may be much easier to make those changes when a person is not facing the uphill battle of needing to lose 100+ pounds allowing one to quickly enjoy much greater physical health and the emotional boost that comes from achieving a better physical appearance.

While there are inherent risks, the consensus is that bariatric surgery is the most effective treatment for severe clinical obesity. However, anyone considering this surgery should recognize that success is fleeting unless there is a serious and long term commitment to changes in lifestyle.

Published August 5, 2009, updated May 18, 2012

References

1. Hendrick B, Americans Are Eating Poorly, Exercising Less, and Getting Bigger, Survey Finds, WebMD, Feb 10, 2010
2. Current prevalence (%) of overweight, obesity, and extreme obesity among U.S. adults, by gender, age, and ethnicity, OxfordJournals.org
3. Yang W et al, Genetic epidemiology of obesity, Epidemiol Rev (2007) 29 (1): 49-61
4. DeNoon D, Study Suggests 10 New Obesity Causes, HealthWatch CBS News, June 27, 2006
5. National Association to Advance Fat Acceptance, NAAFA
6. Diets and Myths Weight-Loss Lore and Controversies-Why Diets Fail, LibraryIndex.com
7. Stenson J, Excuses, Excuses, Smart Fitness, MSNBC, Dec 16, 2004
8. Solomont EB, State to Slim Weight Loss Surgery Options, New York Sun, March 3, 2008
9. Bariatric Surgery; Following Doctor’s Orders Results in 35% More Weight Loss, Medical News Today, June, 2008
10. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement, Am J Clin Nutr February 1992 vol. 55 no. 2 615S-619S
11. Buchwald H, Consensus Conference Statement: Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third-party payers, Surgery for Obesity and Related Diseases 1 (2005) 371–381
12. FDA expands use of banding system for weight loss, FDA, February 16, 2011
13. How Effective is Weight Loss Surgery, Bariatric-Surgery.info
14. Surgery Effective for Moderate Obesity, Reuters Health, April 29, 2009
15. Gastric Bypass surgery, MayoClinic.com
16. Christou N, Weight Gain After Short- and Long-Limb Gastric Bypass in Patients Followed for Longer Than 10 Years, Ann Surg. 2006 November; 244(5): 734–740