Monday, May 23, 2011

Why I Support Bariatric Surgery

Let me start this post with a few disclaimers:

1) I am not a surgeon and do not get paid based on whether any of my patients decides for or against surgery.

2) The average BMI of patients seen in our program is 49.7 kg/m2 – the average patient is just below 40 years of age. Most have substantial health problems – many cannot work or perform even simple tasks of daily living because of their weight – most have tried every commercial diet or pill they could lay their hands on – they are all ‘experts’ on weight loss.

3) Many have significant psychosocial problems and mobility issues that may have contributed to their weight gain – these are dealt with by an interdisciplinary team of psychiatrists, psychologists, occupational and physiotherapists, nurses and dietitians – treatments that start months before any patient is considered a candidate for surgery.

4) I do not for once believe that bariatric surgery addresses any of the ‘root causes’ of severe obesity and I am sure that none of my surgical colleagues believe it does. As I often tell my patients, “the surgery is on your gut and not your head”.

5) Our program regularly talks patients, who come to us wanting surgery, out of surgery, if we feel that it is not in their best interest or unlikely to have a successful outcome – to these patients we offer the best non-surgical care we can – but of course, many are disappointed.

And yet, our program regularly performs bariatric surgery and prepares patients for it in a process that can often take 6 months or longer. We proactively discuss surgery with all patients, who meet the criteria for surgery – both the pros and the cons. We offer comprehensive dietary, psychological and medical support to all patients who decide to undergo surgery but make it very clear that surgery is not a ‘cure’ and that patients have to make substantial lifestyle changes in order to be ‘successful’ (we measure ‘success’ in improvement in comorbidities and quality of life – not in pounds lost!).

With these caveats out of the way, I would today like to dispel some common myths about bariatric surgery and discuss why for many patients with severe obesity, it is in fact a very realistic and successful option.

The first common and pervasive misconception relates to risk – both short-term and long-term risk.

Let me begin by paraphrasing the concept of risk according to Seth Godin’s Poke the Box:

“Risk, to some, is a bad thing, because risk brings with it the possibility of failure. It might be only temporary failure, but that doesn’t matter so much if the very thought of it shuts you down. So for some, risk comes to equal failure (take enough risks, and sooner or later, you will fail). Risk is avoided because we’ve been trained to avoid failure. I define anxiety as experiencing failure in advance…and if you have anxiety about initiating a project, then of course you will associate risk with failure.”

So, why do people with cancer opt to expose themselves to sublethal doses of radiation, radical surgery, or deadly chemotoxins? Because they reckon that the risk of these aggressive treatments is probably less than the risk of simply living with their cancer (even if the cancer grows slowly and may never kill them).

In many cases these patients are just ‘buying’ a few months of additional life – much of it spent in hospital or dealing with the often considerable adverse effects of treatment – yet they perceive the ‘risk’ of undergoing treatment to be lower than the ‘risk’ of not being treated – because they are ‘hoping’ for success.

Readers, who find this comparison to cancer seemingly far fetched, may be interested in noting that the reported quality of life of many patients (both kids and adults) with severe obesity is comparable or worse than that of people living with cancer. Add the social stigma of obesity and every day becomes a struggle with zero sympathy from family and friends. And I am not even mentioning the potential health and economic risks of severe obesity.

So what is the risk of being severely obese? Interestingly, for some people not much.

In our program we see a significant, albeit small proportion (~15%) of severely obese individuals, who have no detectable health problems – they feel good about themselves – eat healthy diets – are physically very active – have been weight stable for years – have great jobs and families – all power to them, I say!

But for the other 85% the picture is not all that rosy. Here we see everything from fatty livers, severe sleep apnea, intractable back and joint pain, urinary incontinence, diabetes, lymphedema, and countless other health problems, which get worse with progressive weight gain (stable weights in this population are the rare exception) and so much better with weight loss (although not in every case).

All of these conditions have some very real risk – our own research shows that when obesity (even moderate obesity) is associated (note the use of the word ‘associated’!) with a single comorbidity with clinical signs of end-organ damage (e.g diabetic kidney disease), 20-year life expectancy drops to 50% in absolute terms. And this is in patients receiving all the usual conservative treatments for whatever comorbidity they may have.

A 50% chance of dying in the next 20 years is an annual risk of about 2.5% per year. This means that out of 100 obese patients WITH end-organ damage, statistically speaking, 2.5 will die every year. This is a 1 in 40 risk of death per year or a 1 in 2 risk of death in just 20 years.

Obviously, for someone with obesity, who has a comorbidity (e.g. diabetes) but does not (yet) have end-organ damage (e.g. no kidney damage), the risk of dying is substantially lower – only about 20% over 20 years or about 1 in 100 per year or 1 in 5 over 20 years.

Without any sign of obesity-related comorbidity (irrespective of BMI), the risk of dying is less than 5% over 20 years – only about 1 in 400 per year or 1 in 20 over 20 years.

So, if risk of dying was your only criteria for deciding for or against surgery, you would need to first understand the risk of not having surgery. As explained above, this risk is very much dependent on whether or not there are any comorbid health problems – the more existing health problems and the more severe these are, the greater the risk of simply sticking with what you are doing and hoping for the best.

This makes all the difference when considering the risks of surgery – both in the short and long term – because any discussion about the risk of surgery is meaningless without first fully understanding the risk of not having surgery.

As previously blogged, a recent analysis of over 15,000 cases of laparoscopic bariatric surgery found a mortality risk of less than 0.04% of laparoscopic adjustable gastric band, 0.0% sleeve gastrectomy, and 0.14% of the gastric bypass patients.

Even if we assume the worst and say that surgical mortality risk is as high as 0.2% – this translates to a risk of 1 death in 500 patients undergoing surgery – a risk of 0.1% would be 1 in 1,000 – a risk of 0.05% would be 1 in 2,000.

Compare this to the annual risk of not having surgery in an obese patient with end-organ damage of 1 in 40 and that of an uncomplicated obese patient of 1 in 400.

So if risk of death is all that you care to consider, let us be clear that an obese patient with end-organ damage is over 10 times more likely to die within one year without surgery than from having surgery.

In contrast, an uncomplicated obese patient is just about as likely to die within one year without surgery as from surgery!

Thus, amazing as it may seem to some readers (given all the talk about the apparent ‘riskiness’ of bariatric surgery), the risk of not having surgery actually substantially exceeds the short-term risk of having surgery in patients with comorbidities and end-organ damage and may even have a slightly favourable risk in uncomplicated patients – this, perhaps goes to show just how safe modern bariatric surgery has actually become.

But of course, the risks of bariatric surgery are not limited to simply the actual risk of surgery – there is no doubt that even after recovering from the surgery itself, there may well be an increased risk of nutritional, psychological, and other complications that may result from having had surgery.

But one can make very similar calculations as I have made for mortailty, and in every case, the risk (even the long-term risks) of surgery come nowhere close to the risks of not having surgery (just take a minute to compare the very real risks of hypoglycemic shock from insulin treatment or falling asleep at the wheel due to sleep apnea to the risk of having to have annual blood tests and taking daily protein or vitamin supplements).

Of course, any discussion of risk is meaningless without also discussing the possible benefits – after all, no one wants to have surgery simply because it is relatively safe unless it also provides some very real benefits (or at least has a statistically substantial chance of delivering such benefits).

So tomorrow, we will look at the data on the benefits of surgery compared to ‘conventional’ treatments – without which, even the safest bariatric surgery would be useless.

For today, let me leave you with this advice from Harvard Business Review:

“Every important decision inevitably involves a trade-off. Knowing what you can’t pursue is as valuable as articulating what you will. But how do you know which trade-offs are acceptable and which are losing propositions? Here are three ways to help make the distinction:

- Get input on pros and cons. List advantages and disadvantages and ask others for their perspective on which carries the heaviest weight [sic].

- Balance short term with long term. Determine what you’d be willing to give up in the long run for some important short-term gain — and vice versa.

- Gauge support. While weighing alternatives, think about who will support a particular idea and who will oppose it. Ask whose support you can live without, and whose backing and buy-in you absolutely need.

AMS
Edmonton, Alberta

Disclosures: I have received consulting and speaking honoraria from makers of surgical devices used for bariatric surgery

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14 Responses to “Why I Support Bariatric Surgery”

  1. Wendy H. says:

    Great article! I’m passing it on to friends who are considering the surgery. As my surgeon said to me when I asked him “How risky is this surgery?”: “A lot less than being morbidly obese.” Also, it’s hard to explain to people how profound is the change in one’s quality of life. No more insulin shots, no more “accidents,” no more hideous skin disorders, no more cane for walking. I just walked a mile to work today, from the garage where I dropped my car off for repairs. Being able to do small things like that is a very big deal.

  2. fredt says:

    I know two of your surgery non-success stories. Both suffer terribly. One has all the signs of scurvy, the other is badly addicted to sugar-wheat-carbohydrate. Both are not able to follow their medical advised high carbohydrate food programs, likely due to hunger.
    And here I site, doing well on low carb and high vitamin C, with little hunger.

  3. Cindy Marsch says:

    Without comorbidities and with great effort I’ve been able to go from a BMI of 43 to a BMI of 36 without surgery, and I hope to keep going down from here. It’s a long-haul effort, with different approaches at each stage. I really appreciate your work (and that of Yoni Freedhoff and others), especially your compassion!

  4. Barb says:

    I agree with FredT… as a nutritionist in Edmonton who promotes a “Paleo” or “Evolved” style mealplan, I am always amazed at the condition of bariatric patients within a short time after having the surgery.
    I am currently watching my own brother-in-law who has had the surgery ~2 years ago. He has lost most of his muscle mass, which is not a good thing for a middle aged man. He appears sallow with untoned muscle and skin. He is ANYTHING BUT the picture of health!! He now has skinny arms and legs and still sports quite a lot of visible abdominal fat. He will never be the same in either body or mind.
    The sad thing is that there was absolutely NO reason for his to have the surgery. He was an able bodied man in good health, considering his massive obesity. When placed on any sort of weight loss program, he lost weight extremely well without starving or exercise. His main reasons for failure were lack of motivation, lack of support and mostly, a lack of knowledge about food and how our body processes it. He too, as well as his very obese wife (my sister) are also “weight loss experts”.

    As FredT states, “And here I sit, doing well on low carb and high vitamin C, with little hunger.”

  5. vesta44 says:

    I had a VBG 13 years ago, wasn’t counseled nearly as well as you seem to counsel your patients (if I had been, I think my surgeon would have refused to do the surgery). I had a lot of questions, but none of them were really answered to my satisfaction. I went ahead with the surgery because I was told it was my only option left to lose enough weight so I could have my knees replaced when the time came (a lie, I later found out). The only problems I had at the time were arthritic knees and lower back pain. After the VBG, I have migraines, fibromyalgia, veinous insufficiency in my lower legs (my legs swell and my lower legs are discolored and that will never go away), my back pain is severe now, my arthritis is worse, what weight I lost came back and brought friends with it, and I have foods I can’t eat if I don’t want to have explosive diarrhea right after eating – and those foods are the ones I need to maintain health, fresh fruits, vegetables, and dairy products. I have to stay away from most fats, as those are also a problem, and some carbs also cause problems. So I’m stuck taking a multi-vitamin, and supplemental vitamins daily just to maintain a semblance of health (protein shakes are out, they go right through me). WLS was the worst mistake I ever made. I would have been better off staying at 350 lbs and looking for a doctor who had better ideas for treating the problems I had other than saying “ELMM and your problems will be solved, your weight is what’s causing them.” She never even looked to see if there was an underlying cause for my back problem, she just assumed that because I was fat, it was caused by my fat and refused to look farther than that. I’m without a doctor now because she’s the same way as the one who recommended WLS, all my problems are caused by being fat and losing weight will solve them all, even though I can’t maintain that weight loss forever. Evidently, she thinks repeated weight loss and regain is just fine and won’t harm my health at all (which is why she’s no longer my doctor).

  6. Nicole says:

    This is an excellent article and as someone who made the decision to have gastric surgery, it was NOT an easy choice. I would never try to talk someone into or out of surgery but would encourage them to really research both sides of the argument. The complications I have incurred do outweigh the problems I was facing in my life. It takes work, determination and lots of support to go through the process. I am 3.5yr post op and I still struggle. I would also like to mention that I have maintained my weight loss of 190lbs for almost 2yrs and have taken up triathlon as a way to help maintain my weight and keep active. Surgery helped me to completely transform my life in a way that no other diet or exercise program ever did. It was a decision that took 5 years for me to make. I went from a BMI of 52.9 to 26.6……my muscle mass has been maintained because I weight train and run. I take my vitamins religiously everyday and get an annual physical and blood work to ensure I am healthy on the inside too. Surgery was the TOOL that helped me get where I am today, not the miracle cure. I took the information I learned to heart, to change my lifestyle and not rely on just the surgery to lose the weight. I saw a therapist to address the mental aspects of my weight gain and have to be conscious of the internal messaging I send myself about my body everyday. I fought to get where I am today and I am determined to stay here.

  7. Heather says:

    I love this post! I have been thinking on and off again about WLS for about 7 years. Seriously for the 3 years. Sometimes I have trouble explaining the risk benefit thing. This will be a useful tool.

  8. DebraSY says:

    There would be less heartache in the world if other doctors who practice bariatrics were so thoughtful. It may also be the difference between the Canadian system and the US system.

    I’m a lay person, but as I understand it, in the states most people are referred directly from their GP to a surgeon without this important step in the middle where they get the important analysis: what are ALL the options, the risks, the benefits. Instead, they go sit in front of a surgeon, and, as the saying goes, to a hammer everything looks like a nail, and to a bariatric surgeon every fat person looks like a candidate.

  9. Bill Graber says:

    thanks, this is a very balanced post, I want to say that I am a bariatric surgeon.
    There are several important things to mention about weight loss surgery,
    1) the gut is connected to the brain, so changing the anatomy does influence the mind.
    2) there are some posts by post op people who are not doing well, may have had an operation that has been shown not to work well, so please consider finding a modern bariatric program to get some help

  10. DeeLeigh says:

    This post neglects the lowered quality of life and health issues that can result from bariatric surgery and exaggerates the health risks of obesity.

    Dr. Sharma must be using risk data for people who are extremely heavy (BMI of 50+? 60+?). Remember that “obesity” starts with a 30 BMI, and people with BMIs of 30-40 have roughly the same life expectancy as people with BMIs of 18-25 (Flegal, 2005). Dr. Sharma is talking about risks of death without defining his data ranges or giving us anything to compare them to.

    Moreover, weight loss surgery doesn’t turn fat people into naturally thin people. It turns them into starving fat people with damaged digestive systems that don’t allow them to eat a healthy and balanced diet. People who are post-weight loss surgery do NOT have the same health status or health risks as people who started out thin and their “weight related” health problems are not necessarily cured. This whole article appears to be steeped in those incorrect assumptions.

    There are a lot of other things I could take issue with in this post, but I think that at this point, I’ll just stop and go away.

  11. NewMe says:

    I am surprised that you did not examine the many side-effects that a significant number of WLS patients suffer after the surgery. The risk of death is only one (albeit the most serious by far!) among the many risks associated with this type of surgery. Your post is therefore interesting and informative, but it is far from telling us the whole story.

    With all due respect, perhaps you could have written a three-part series: risk of surgical mortality vs. risk of mortality from extreme obesity (this article); the next on post-surgical side-effects (the missing article, in my opinion); and finally, the last one on the benefits of this surgery.

  12. Can The Edmonton Obesity Staging System Provide A Path For New Anti-Obesity Drugs? « Longwoods Blog says:

    [...] As discussed previously in the context of bariatric surgery, the risk side of this equation is not limited to the ‘risk’ associated with treatment but must also include the ‘risk’ associated with not treating the condition. [...]

  13. Jessica says:

    In the past three years I have been suffering with menopausal pain. Since I started this process, my weight has blossomed to over 300 lbs because I fried my thyroid by being super women. I used to attend the gym 5 days a week and was feeling great until all the pain started at the same time the menopause did. It feels similar to having a sever case of the flu 24/7. I have been fighting to get his weight off but to no avail. I have totally given up on trying and cant get back on the band wagon. I have no fight left. Its like I have lost all incentive which I now believe is more than just motivation. The pain has take over my life. My current doctor has given my an anti inflamatory for pain and it started to work for a while. I started to get back to my old self but that only lasted for a while, not this pills dont work. Over the past two years I have gone through the program at the Weight Loss clinic and now I am waiting to get into surgery. After really all of these posts, I am now afraid. I dont want anymore pain, cause I cant handle anymore. If the surgery is going to make me worse them I am out. I am thinking that once the weight is off my back pain will go away and so will my constant stillness in my legs. What do you think?

  14. fivehundredpoundpeep says:

    Let me be frank, I know several people PERSONALLY who died from WLS, from complications and whose health immediately took a nose dive from this surgery. WLS is basically torture for the fat, let us chop your stomach up, so you will lose weight. They know they can’t lock the fat person in a room so they instead “lock” up and mutilate the stomach for good. Instead what is done to the fat person is they are made “ill” digestively and otherwise so of course some weight will come off. Of course this surgery can’t even guarantee the weight will stay off and their disclaimers that you must continue to “diet and exercise” are nonsense, when one considers that did not work before. The people that regain and who move into ill health, often ARE shamed and blamed by the medical professionals or drop out of sight due to their unwellness. Even the fact this surgery focuses on the stomach as be end and end all ignores issues of metabolism and brain satiety and more. They push this stuff even on the endocrine cases. I as a woman with a history of severe digestive problems-nutritional deficients NOW without surgery, and endocrine problem has had this surgery shoved down her throat. Odd when they told me other surgeries would be impossible.

    http://fivehundredpoundpeeps.blogspot.com/2013/01/weight-loss-surgery-medical-treatment.html

    “4) I do not for once believe that bariatric surgery addresses any of the ‘root causes’ of severe obesity and I am sure that none of my surgical colleagues believe it does. As I often tell my patients, “the surgery is on your gut and not your head”.”

    I am glad you believe this but do you realize all the research is being poured into this torturous surgery!? They can’t do better then THIS?

    I actually went to go look for any studies of the severely obese that were comprehensive and could not find any. I am serious. Isn’t this a bit of an oversight that people in the severe weight categories aren’t being studied?

    See this post….

    http://fivehundredpoundpeeps.blogspot.com/2011/02/letter-to-obesity-researchers.html

    ” that patients have to make substantial lifestyle changes in order to be ‘successful’ (we measure ‘success’ in improvement in comorbidities and quality of life – not in pounds lost!).”

    If that didn’t work before, why after the surgery?

    You mention cancer and people signing up for radiation, chemotherapy etc. If one was to use cancer as an example, cancer death rates have been going up. The war on cancer has failed same as the war on obesity. Could it be possible that there too the scientists have locked themselves in a certain box that no one is thinking outside of? There are many people who question the cancer health care system and I am one of them.

    Severe obesity is hard, you are right about that… My entire blog is a story about the pain and suffering of extreme obesity.

    but what is the response of the medical community but MORE SUFFERING?

    Haven’t fat people been abused, hurt, shamed enough and gone through enough physical and emotional suffering.

    It’s like Satan himself sat around a table with those who wanted to make money and thought what procedure would be the most dangerous, the most painful and bring the most suffering to the severely obese.

    If you think I am being overdramatic here, 10s of thousands of clinics and help for drug addicts says one thing while the fat either have to hand out the cash, or sign up for this surgery with few other options unless they are nursing home material and total bed bound and at that point most are probably going to die.

    I actually told someone, “I have suffered enough in this life, I will not have weight loss surgery, because I cannot take anymore pain”. Some people can judge me for that, but I not care. All I got to say is the surgery even scientifically is nonsense. The people still regain. The stomach is not the center of hunger and metabolism. With many individuals the metabolism drops in response to the period of starvation so when food is reintroduced the weight loss stops and many regain with time.

    Death on the table, is not the only way people die or suffer from weight loss surgery. Some make it through the dangerous times and the time on the respirator and then out only to get sicker and sicker.

    http://fivehundredpoundpeeps.blogspot.com/2013/01/weight-loss-surgery-medical-treatment.html

    http://fivehundredpoundpeeps.blogspot.com/2011/06/bariatric-surgery-doesnt-help-obese.html

    http://fivehundredpoundpeeps.blogspot.com/2010/07/why-dont-you-get-weight-loss-surgery.html

    This is the best they can do for fat people?

    I think locking someone in a room for 6 months and just handing water through the door would be less risk.

    I have to admit I am disappointed by this, I think the focus on weight loss surgery has narrowed down the obesity field, it is narrow science make even more narrower. No real obesity help, answers or cures will come from this surgery.

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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