Nov 3, 2015 — When should you consider weight-loss surgery? And is it a good solution for long-term weight loss? If you have a certain BMI and suffer from a weight-related medical problem such as diabetes or sleep apnea, your insurance might cover the procedure. Dr. Tom Miller and bariatric surgeon Dr. Eric Volckmann discuss the surgery and what to consider before you have it.

Interview

Dr. Miller: Weight loss surgery, is that right for you? We're going to talk about that next on Scope Radio.

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Dr. Miller: Hi, I'm here today with Dr. Eric Volckmann. He's a bariatric surgeon and a professor of surgery here at the University of Utah. Eric, we talked a little bit on our last talk about body mass index and the scales of weight gain associated with overweight or obese. Can you talk a little bit about when one might want to consider bariatric surgery and under what circumstances?

Dr. Volckmann: Well, most insurers, including Medicare or Medicaid, start approving bariatric surgery at the body mass index of 35 kilograms per meter squared with a weight-related medical problem, such as diabetes, high blood pressure, high cholesterol, osteoarthritis, obstructive sleep apnea, things like that.

Dr. Miller: Could you give an example of what that would look like for a person that was maybe 5'10"?

Dr. Volckmann: Someone 5'10", I wouldn't be able to tell you the exact weight, but what I can tell you is most of us have become so immune to the fact that obesity and overweight are all around us that you wouldn't think that with the body mass index of 35 would qualify for surgery. They don't look like someone we typically consider morbidly obese.

And then, if you have a body mass index of 40 or higher, you do not need a weight-related medical problem to qualify for surgery. Those criteria came for my 1991 NIH consensus conference statement on gastrointestinal surgery for obesity. And at that time, what they thought was that once you reach those body mass indexes at 35 with a medical problem or 40 and higher, that the risk of being at that weight outweighed the risks of surgery, which is nowadays, almost 25 years later, much safer and easier to perform. And they also thought that your chance of achieving long-lasting weight loss without surgery was relatively low.

Dr. Miller: Is that still true, that your chance of weight loss without surgery is relatively low? For instance, what percentage of patients who would undergo a weight loss plan would be effective five years out, would actually lose the right amount of weight just by paying attention to exercise and diet?

Dr. Volckmann: Very low. What we see with our patients who come in the clinic, most of them have tried to lose weight on at least five to 10 separate occasions. And it's not the fact that patients can't lose weight. They do, sometimes 20, 30, 40, 50 pounds, but then they end up regaining the weight and then some. So you'll see this oscillating, fluctuating weight where it goes up and down with an overall upward trajectory. And what we're trying to do is stop that and allow patients to lose weight and keep it off. Bariatric surgery is really the most durable, best, long-lasting form of weight loss that we have in the current day and age.

Dr. Miller: One of the things that I might ask is in the long run after bariatric surgery, what sorts of outcomes do people expect? I mean, do they keep the weight off at five years? What are we looking at there?

Dr. Volckmann: Yeah, I compare it to having a bad meal in a restaurant. Everyone notices the person who has had weight loss surgery and regained the weight, much like the person who had a bad meal at a restaurant is very vocal about it. But people who do well with weight loss surgery often keep it to themselves. The majority of patients lose the majority of the weight and keep it off.

So what is the majority of the weight? We talk about excess body weight loss and that's the percentage of weight that you lose above your ideal body weight. So everything above your ideal body weight is your excess body weight. So gastric bypass patients, on average, lose about 60 to 80% of their excess body weight. So for someone who 100 pounds overweight that means they'll lose 60 to 80 pounds. Two hundred pounds overweight, 120 to 160 pounds. With sleeve gastrectomy, the average excess body weight loss is about 50 to 70% excess body weight loss. So a little bit less than what we see with gastric bypass.

Gastric bypass has been around since 1967. So we know a lot about weight loss surgery. The sleeve gastrectomy has not been around for as long, although it seems to be close to gastric bypass, but we don't have as know it is very good with gastric bypass and it seems to be somewhat similar with vertical sleeve gastrectomy.

Dr. Miller: Well, if you look at gastric bypass five years out, would you say that the majority of people who have had that surgery are able to keep that 40 to 60% weight off?

Dr. Volckmann: In my practice here, and we're about four to five years in, it seems like about 90% of our patients have kept the weight off.

Dr. Miller: That's great. That's really great.

Dr. Volckmann: It is a forced lifestyle change and that's what I tell patients, that the operation will help them eat less and stay full between meals. The people who are more successful, though, are the ones who eat properly and exercise. It requires really a lifestyle modification. Any of the operations can be overcome by emotional eating, eating for reasons other than hunger, stress, anxiety, depression, boredom, inactivity. So when I see patients who have regained the weight, they often have started consuming sugary beverages or . . .

Dr. Miller: Small meals frequently

Dr. Volckmann: Yeah. They'll start just eating throughout the day, often making poor food choices.

Dr. Miller: Well, this leads me to the discussion that when people come to see you, you have a whole program designed for them, prior to them ever having surgery that's focused around their eating habits, improving their healthy eating. Can you talk a little bit about that?

Dr. Volckmann: Here at the University of Utah, we're really committed to not only having great short-term outcomes, but we want patients to do well in the long-term. And that means staying healthy and keeping the weight off. Part of staying healthy means taking vitamins and minerals regularly after surgery. All of these surgeries require that you take them a multivitamin once or twice a day and calcium with vitamin D three times a day. So although patients generally improve their health and get off medications, they still need to take vitamin and mineral supplement and they need to be followed for life. So this is a commitment. It's certainly not an easy way out. Talk to any patient. They'll tell you it's not easy, but they're glad they did it and they'll do it again.

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