More than one-third of American adults are considered obese.
It's not just about being overweight. Obesity is linked to the development of many chronic diseases. In some cases, bariatric surgery can be an effective tool for losing a large amount of weight. This major surgery has come a long way over the decades, but is not the answer for everyone.
Host, Jonathan Fialkow, M.D. welcomed a bariatric surgeon and a mental health professional to talk about the physical and emotional factors to be considered when thinking about bariatric surgery.
Guests:
More than one-third of American adults are considered obese.
It's not just about being overweight. Obesity is linked to the development of many chronic diseases. In some cases, bariatric surgery can be an effective tool for losing a large amount of weight. This major surgery has come a long way over the decades, but is not the answer for everyone.
Host, Jonathan Fialkow, M.D. welcomed a bariatric surgeon and a mental health professional to talk about the physical and emotional factors to be considered when thinking about bariatric surgery.
Guests:
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Dr. Fialkow:
Welcome Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Miami Cardiac & Vascular Institute where I'm also chief of cardiology at Baptist Hospital and the chief population health officer at Baptist Health. Obesity rates have been rising in the United States with now more than one third of American adults considered obese. It's not just about being overweight. Obesity can be linked to the development of several chronic diseases. In some cases, bariatric surgery can be an effective tool for weight loss. It's a major surgery not to be approached lightly. In a recent episode of Baptist Health's resource live program I spoke with two experts on the realities of bariatric surgery. My guests were Dr. Anthony Gonzalez, Medical Director of Bariatric Surgery at Baptist Health, and Carmen Barresi, a psychotherapist with Community Health and Wellness at Baptist. Let's listen in.
Dr. Fialkow:
Tony, let's hit the ground running. So first, before we start getting into bariatric surgery as a treatment option for obesity, let's talk about obesity itself. How do we define obesity? Is it one of those things that it's said, "You know it when you see it"? Are there real definitions for obesity? And the follow up to that is why do we care about being obese? What are the consequences of being obese?
Dr. Gonzalez:
Yeah, so we know what obesity is. Obesity is obviously a lifelong disease. It's progressive, it's costly, it's multifactorial, but the bottom line is obesity is an excessive amount of fat storage. Obesity can be easily measured and the simplest way that a viewer can measure obesity is by their body mass index, their BMI. The BMI is a calculation of your weight versus your height and, of course, your weight will vary depending on how tall you are. There are multitude of online calculators you could plug in your weight in pounds or in kilograms and your height in meters or in inches and you could figure out your BMI. So obesity can be well defined. It could be well classified.
Dr. Gonzalez:
Your second question was, what are the consequences of obesity and why is it important? Well, obesity will reduce your life expectancy because of the multitude of medical problems that obesity causes, simple ones like high blood pressure, high cholesterol, hyperlipidemia, elevated lipids, heart disease, stroke, heart attacks, increased cancer risk and obviously that is the importance of obesity in its medical context.
Dr. Fialkow:
Very well said. So the viewers can understand, Dr. Gonzalez and I have these conversations all the time. It's increased energy storage as fat. So ultimately we get fat and it is fat in our cells, but I just want to make sure that we know that any kind of excess energy could be stored as fat, so that's my cardiovascular two cents. But yes, increased fat storage. Carmen, we know that there's been higher rates of obesity. We've seen the trends over the last several decades, many reasons for that. What are some of the psychosocial triggers that might lead for someone to gain weight, become obese and how can by recognizing those triggers both contribute to obesity when they're ignored or how can people help themselves decrease the risk of obesity?
Carmen Barresi:
There's multiple factors that contribute to obesity. When we're looking at the external factors and environmental factors, some of the things to keep in mind, eating disorders, medications that are being prescribed to individuals can impact weight. In addition to that, poverty, even though one would think if populations are malnourished maybe they won't have the obesity concern, but actually access to diet that's high in sugar, high in fat and high in calories contributes to obesity and the increase that we're seeing, as well as lack of sleep and even decisions like deciding quitting smoking can actually contribute to higher rates of obesity as well. Having a lifestyle that's less mobile can also contribute to gaining weight and obesity.
Dr. Fialkow:
So as you articulate, it's not a lack of willpower. There's many factors that affect someone that might lead them to start depositing weight, depositing energy and gaining weight. So now let's talk about some of the treatment options, back to Dr. Gonzales. Tony, so clearly not every overweight person is a candidate for bariatric surgery. Let's talk about this valuable tool with a lot of data behind it supporting the benefit in certain populations. So who would be considered a candidate for bariatric surgery?
Dr. Gonzalez:
Yeah, you're exactly right, Jon. We only deal with those that have extreme weight and as we'll talk about bariatric surgery in and of itself have risks. And so the risk of being at a level of obesity that is life threatening is when we begin to consider a bariatric surgery. So the guidelines since 1991 by the National Institutes of Health are that if your BMI is 35, which is about 75 pounds overweight, and you have diabetes, or high blood pressure or sleep apnea you should be a candidate for bariatric surgery. And if your BMI is 40, which is about a hundred pounds of excess weight, no matter whether or not you have medical problems or comorbidities you're a candidate for bariatric surgery. So as you can see, it's not somebody who's 10 or 20 pounds overweight. It's beginning at around 75 pounds of excess weight and really a hundred pounds of excess weight is really when we start considering bariatric surgery.
Dr. Fialkow:
When someone comes to you for an assessment of bariatric surgery, which clearly you have the expertise in, do they go through a process or do you go with the process with them to look for alternatives or at that point are they generally meeting those criteria for bariatric surgery? What do you find in your experience?
Dr. Gonzalez:
Yeah, what we find in our experience is that most patients have actually looked into bariatric surgery for at least two years prior to even coming to see us and they have been on multiple diets. Usually the average is about a handful of different type of diet programs and lifestyle modifications, but we don't take that for granted. We obviously put the patient through the preoperative medical evaluation. We put them through nutritional counseling preoperatively, a psychological evaluation, and then obviously we have a very robust educational program as part of the preoperative rehabilitation of our surgical program.
Dr. Fialkow:
And that's a great take-home point and I appreciate that. It's not just, I need surgery, sure, I'll do the surgery. It's a holistic approach to the patient optimizing their state before it gets to the point where, okay, now we feel surgery is a good option for you. So again, appreciate that [crosstalk 00:06:55].
Dr. Gonzalez:
No doubt about that. Surgery in and of itself is not going to solve the problem. It's a lifestyle change and obviously we have to put the patient's mind in the correct location.
Dr. Fialkow:
We know, Carmen, that with bariatric surgery there's a lot of emotional changes that come into the patient condition. Can you speak a little bit about that? What's the expected emotional results that you see in patients who undergo successful bariatric surgery?
Carmen Barresi:
Definitely. This decision can be very life changing and just like any changes in our life our body responds to that with different emotions. And really when we look at the process, it's a way of us reacting and responding to the physical changes that are taking place in our body post surgery. So there's hormonal differences and changes that are occurring that can contribute to maybe individuals feeling a little bit more anxious or a little bit more sad. In addition to that, there's a new sense of attention that can warrant someone feel maybe uncomfortable or not accustomed to that reaction from others. That can prompt someone to maybe want to isolate or not feel as comfortable in social situations. So it's important to keep that in mind as you go into this journey and also take it with this approach of a time for self discovery. So it's a change and how can you welcome that and embrace it?
Carmen Barresi:
In addition to that, someone may be feed excited for this opportunity and like Dr. Gonzalez mentioned, sometimes it's not a decision that happens rapidly but rather takes time to really commit and make the decision. So in that planning phase and that time where you kind of go from the contemplation to the action phase, we see that in therapy as well. So it's kind of going that process and really identifying what are the emotions that you're feeling, and what's the purpose and being aware of the changes, not only of your body but also how you're reacting and acting to those changes.
Dr. Fialkow:
So a patient's obese, they've obviously been dealing with the consequences of that physically and emotionally for many years. They have other medical issues. They wind up having bariatric surgery, expected significant improvement in their weight and their quality of life, et cetera and we'll get into that a little bit. Do you personally or do we recommend or see a lot of these post-bariatric patients continue to be cared for for those postoperative emotional type of support that we're talking about might be necessary?
Carmen Barresi:
There are support groups available and we definitely encourage individuals to seek support and even professional help. There are processes that are in place to be able to link patients to continue services like Dr. Gonzales mentioned, a nutrition consultant. In addition to that, seeking professional help is one avenue to take, but also journaling, keeping track and monitoring. And again, going back to that self discovery, so paying attention to where you're at in that moment and going through that journey with your own thoughts and emotions can be helpful. But definitely, recommendation is to seek out support and the impact and importance of support groups that are available.
Dr. Fialkow:
So now Tony, let's talk about bariatric surgery itself. If you could take us a little bit through what is bariatric surgery, maybe a little bit of the history, what are the advancements in bariatric surgery? Take us through a little bit of the history of bariatric surgery and to its present state.
Dr. Gonzalez:
Yeah, so bariatric surgery has been around in our country for over 50 years. It was really stumbled upon on on patients who had to have surgery for either gastric cancer or gastric ulcers and they saw that those patients had a difficulty in maintaining their weight. So in 1967 the first gastric bypass was performed in our country and that operation obviously was not done with the technological advantages that we have today. What bariatric surgery does is try to modify your eating behavior so that you will lose weight in the first year's time. Eating behavior can be defined or categorized as quantity of food or quality of food. So there are bariatric procedures like the laparoscopic adjustable band or the sleeve gastrectomy that control quantity of food but not quality of food and then there are operations like the gastric bypass that control quantity and quality of food.
Dr. Gonzalez:
And of course, in the last 27 years that I've been doing bariatric surgery we've gone from open bariatric surgery with a big open incision and six, seven days in the hospital. We progressed through laparoscopic bariatric surgery, which is minimally invasive surgery, working on two dimensional imaging and with instruments that are like chopsticks. And now today in the last 11, 12 years we've been working with robotic surgery and our program here at Baptist Health is a pioneer in the country and the world in regard to robotic bariatric surgery. Robotic surgery is just an advancement of laparoscopic surgery. Now the vision is three dimensional and the instruments are like fingers and wrists. That is shown to improve outcomes, decrease length of stay, decrease complications and that is the way we do it today in our bariatric program.
Dr. Fialkow:
You mentioned three processes, the gastric band, the sleeve gastrectomy, the full gastric bypass. Does a person come in and based on certain qualifications they're predetermined to have one or the other or is it really more what the patient expectation is from the surgery? How do you choose?
Dr. Gonzalez:
Yeah, the patient always comes in with an expectation. They already have in their mind that they're going to have a particular operation based on what they've heard, what they've read, experiences of friends and family members. But as the educated professionals in our program we take a couple factors into account. Number one, we take into the patient's BMI. We consider the patient's eating habits. We consider their comorbidities. And for just some simple examples, the gastric bypass has the best outcomes in regard to weight loss and in regard to the decreased chance of weight regain. And so when your BMI is very high, you're really going to have to sway into the bypass category. If you're diabetic, diabetes is best cured with a gastric bypass or controlled with a bypass. And so there again, it depends on your level of diabetes. Are you just on oral medication? Do you need insulin? We have also seen the longevity of your diagnosis of diabetes can be impacted as well with regard to procedural choice.
Dr. Gonzalez:
So yeah, the patient comes in, we give them a very good educated suggestion of what could be best for them because we want to get it right the first time. Though bariatric surgery can be done second and even third time, the outcomes are not the same. The complications are higher, and so you want to get the right operation the first time. And so though the patient comes in with a preconceived notion, we try to sway them in the best medical surgical opinion based on all these factors that we take into account.
Dr. Fialkow:
Again, we're flying through this. The information's great. In the interest of time I'm going to take some questions from the viewers. We got some good ones. To Dr. Gonzalez, Tony, is it possible to regain the weight that was lost after bariatric surgery?
Dr. Gonzalez:
Yes. I alluded to that and you alluded to that as well, and that's why it's important to educate the patients preoperatively. It's important that they change their lifestyle, because, remember, these operations are operations that are trying to change a behavior. And, as Carmen will tell you, the behavior is not in the stomach, it's in the brain and if you don't help them reprogram their behavior they can regain weight. So the chance of failure or the chance of significant weight regain varies by procedure. The laparoscopic adjustable band has a 50, 5-0 percent chance of weight regain. The sleeve gastrectomy has a 10 to 20% chance of weight regain and the bypass has a five to 10% chance of weight regain. So you could see the operations have different chances of failure, and it really depends on educating the patient, and putting them in the right operation and obviously give them the correct education preoperatively.
Dr. Fialkow:
So I'm going to ask this one of Carmen but I'd ask you both the weigh in and I'm going to paraphrase it a little bit. If someone has a bariatric surgery which makes their stomach smaller, do they eat less but they're hungry all the time or does it actually affect cravings and hunger? Carmen, can you speak to that? Is that a fair question to ask you?
Carmen Barresi:
I think I can speak on the term as far as the food relationship we make and I think having this conversation, it's important to think about. Sometimes it's the first time individuals start to really pay attention that the relationship they have with food sometimes can be used to cope with certain emotions and then that's where the craving factor comes in. So you may be craving sugary food. You may be craving high calorie food and what is the purpose and what is it that you're fulfill? So looking at that relationship with food is important and at this point after surgery you may begin to examine, and analyze and then start picking up on triggers and cues as to what is fullness, and what is stress and how can I cope with that in a healthy way that isn't related to food?
Dr. Fialkow:
Thank you. Tony, anything you want to add to that?
Dr. Gonzalez:
Yeah, no doubt. I think that's important because I hear patients all the time tell me, "In my mind I'm still an obese individual, but because of the bariatric surgery now I eat as a thin person." But yes, these operations can control satiety and can control hunger. For our viewers, satiety is the sense of fullness. You may have hunger when you get to a point in the day, but with a sleeve gastrectomy you're going to feel full very rapidly and that's early satiety.
Dr. Gonzalez:
The sleeve controls hunger in the first few years because a hormone called ghrelin is removed from the body and ghrelin drives hunger. But God is a lot smarter than us and ghrelin is produced in other parts of the body afterwards, and so hunger comes back as a survival mechanism. The bypass does deal with hunger long term, but patients can have hunger as well, but it really has to do with educating them preoperatively and making sure that they don't use other mechanisms to deal with the stresses that they have in their life. That's something that we have seen in regard to going from food to obviously other types of addictions to deal with the stresses in their life.
Carmen Barresi:
And Tony, that actually reminds me of even the visual cue, like afterwards you see a plate and it could be disorienting because your diet and the amount of food you're eating changes. So even visual cues like that is something that can be worked on post surgery.
Dr. Gonzalez:
Yes.
Dr. Fialkow:
Carmen, we know that depression is associated with obesity and obesity is associated with depression. Do we see any improvements in depressive symptoms in patients after bariatric surgery or, quite frankly, any worsening? Can you comment on your experiences in that area?
Dr. Gonzalez:
With lifestyle changes, as you move after in recovery and if you continue a healthy lifestyle when it involves going out, going back to those factors that put you at greater risk, such as a sedentary lifestyle. So if you change your lifestyle, one that involves more activity and you feel comfortable there is a way of combating and decreasing the depression symptoms. One thing to also keep in mind is that if you're in a relationship it's important that as your body changes, as you make this change, to also kind of analyze the relationships that you've formed with individuals and keep those that you feel are important and helpful for you, because that can also impact your mood and also your progress.
Dr. Fialkow:
Tony, quick question. How long after weight loss surgery can one get pregnant?
Dr. Gonzalez:
Yeah, so obviously your body is going through a catabolic state, which is you're breaking down all this fat in the first year, and so we recommend several forms of contraception based on the surgical procedure for at least 18 months and then after 18 months it's very safe. For our viewers' knowledge, becoming pregnant when you're morbidly obese at this level of obesity is very dangerous and most of your obstetricians will tell you that and recommend weight loss even before pregnancy. But the moment you have bariatric surgery, you should not get pregnant for 18 months, and then at that point it's super safe and multiple studies have demonstrated that.
Dr. Fialkow:
That's good to hear. Carmen, here's an interesting question. If a couple, both of whom are obese, and one decides to get the surgery and the other doesn't, have you seen that affect the relationships at all between the individuals and the psychological journey of change for that individual?
Carmen Barresi:
Yeah, there's actually a term called bariatric divorce and there's studies that show that after the procedure divorce rates actually spike. And going back to the importance of really identifying and monitoring your relationships and the purpose they serve, it's important that in all aspects, but that you're in a healthy relationship and that includes communicating, supporting each other. So to answer your question, yes.
Dr. Fialkow:
Tony, here's a question that I'm surprised took so long to come up. How safe is the surgery?
Dr. Gonzalez:
Yeah, today with the advancement of laparoscopic surgery and robotic surgery these operations are very safe. Studies have demonstrated that these operations have complication rates similar to a gallbladder removal, a hysterectomy, a hernia repair and, as our viewers know, these are everyday operations. So the days of where these operations had risk of dying, a mortality, a death with these operations is a rarity.
Dr. Gonzalez:
Obviously, the age of the patient, the core morbidities, the medical problems the patient has changes their risk and that's why the individualized evaluation is very, very important. We have enough data and a quality collaborative that we participate with many hundreds of programs around the country. We can calculate your perioperative risk of bleeding, infection, death, so we can give you that to the number. But yeah, these operations are very safe today.
Dr. Fialkow:
To our listeners, remember that you can send us your comments and suggestions for future topics at Baptist HealthTalk at baptisthealth.net. That's Baptist HealthTalk at baptisthealth.net. On behalf of everyone at Baptist Health, thanks for listening and stay safe.
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