Why bariatric surgery works when diets don’t.
“Bariatric surgery is probably the most effective intervention we have in health care,” said Laurie K. Twells, a clinical epidemiologist at Memorial University of Newfoundland. She bases this bold claim on her experience with seriously obese patients and a detailed analysis of the best studies yet done showing weight-loss surgery’s ability to reverse the often devastating effects of being extremely overweight on health and quality of life.
“I haven’t come across a patient yet who wouldn’t recommend it,” Twells said in an interview. “Most say they wish they’d done it 10 years sooner.” She explained that the overwhelming majority of patients who undergo bariatric surgery have spent many years trying — and failing — to lose weight and keep it off. And the reason is not a lack of willpower.
“These patients have lost hundreds of pounds over and over again,” Twells said. “The weight that it takes them one year to lose is typically back in two months,” often because a body with longstanding obesity defends itself against weight loss by drastically reducing its metabolic rate, an effect not seen after bariatric surgery, which permanently changes the contours of the digestive tract.
In reviewing studies that followed patients for five to 25 years after weight-loss surgery, Twells and colleagues found major longlasting benefits to the patients’ health and quality of life.
Matched with comparable patients who did not have surgery, those who did fared much better physically, emotionally and socially. They rated themselves as healthier and were less likely to report problems with mobility, pain, daily activities, and feelings of depression and anxiety, among other factors that can compromise well-being.
Equally important are the undeniable medical benefits of surgically induced weight loss. They include normalizing blood sugar, blood pressure and blood lipid levels and curing sleep apnea. Although bariatric surgery cannot cure Type 2 diabetes, it nearly always puts the disease into remission and slows or prevents the life-threatening damage it can cause to the heart and blood vessels.
Even in the small percentage of patients who ultimately lose little weight after surgery, significant metabolic benefits persist, according to findings at the Cleveland Clinic. In a study of 31 obese diabetic patients who had not lost a lot of excess weight five to nine years after surgery, a “modest” weight loss of just 5 to 10 percent resulted in a reduction of cardiovascular risk factors and blood sugar abnormalities, Dr. Stacy Brethauer and colleagues reported.
For the two most popular surgical techniques — the gastric bypass and the gastric sleeve — “the metabolic benefits are independent of weight loss,” Brethauer said in an interview. Both methods permanently reduce the size of the stomach.
But the gastric band procedure, which is reversible, lacks these benefits unless patients maintain significant weight loss, he said.
Furthermore, as a study last year of 2,500 surgical patients at the Veterans Affairs Medical Center in Durham, North Carolina, found, those who underwent
bariatric surgery had lower overall death rates up to 14 years later than comparable patients who did not have weight-loss surgery.
Experts regard the reluctance of some insurers, including Medicaid programs in many states, to cover the cost of bariatric surgery as penny-wise, pound-foolish. Failing to reverse extreme obesity can end up costing far more per patient than the typical $30,000 price of bariatric surgery — sometimes even millions more.
Counter to popular impressions that most people treated surgically regain most or all the weight they lose initially, the latest long-term research has shown otherwise. In a decadelong follow-up of 1,787 veterans who underwent gastric bypass, a mere 3.4 percent returned to within 5 percent of their initial weight 10 years later. This finding is especially meaningful because the researchers at the VA center in Durham were able to keep track of 82 percent of gastric bypass patients, a task too challenging for most clinics.
The study, by Matthew L. Maciejewski and colleagues published in August in JAMA Surgery, found that 10 years later, more than 70 percent of surgical patients lost more than 20 percent of their starting weight, and about 40 percent had lost more than 30 percent. Gastric bypass, an operation called Roux-en-Y, resulted in a somewhat greater weight loss at 10 years than the newer gastric sleeve surgery and significantly more than the adjustable gastric band (Lap-Band) surgery, which “has fallen out of favor in the last two or three years,” Maciejewski said.
Bariatric surgery, regardless of the method used, is also much safer nowadays than it was even a decade ago, said Dr. Jon C. Gould, a surgeon at the Medical College of Wisconsin in Milwaukee who wrote a commentary on the VA study.
However, he noted, the surgery is “vastly underutilized,” to the detriment of patients’ health and the nation’s health care costs.
“Less than 1 percent who would qualify for bariatric surgery are actually getting it,” Gould said. “Although the vast majority have health coverage, insurance companies and many Medicaid programs put it out of reach for most people by demanding that they already have several obesityrelated health conditions and are taking a slew of medications to control them.”
Gould suggested that people interested in bariatric surgery seek out programs that have been jointly accredited by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery, which have combined forces to promote quality control.