Morbid Obesity and Treatment Options
What is morbid obesity?
Morbid obesity is a Body Mass Index (BMI) of 40 or more. The disease of morbid obesity interferes with basic physical functions such as breathing or walking. Long-term effects of the disease include shorter life expectancy, serious health consequences in the form of weight-related health problems (co-morbid conditions) such as type 2 diabetes and heart disease, and a lower quality of life with fewer economic and social opportunities.
What causes morbid obesity?
The causes of morbid obesity are multiple and complex. Despite conventional wisdom, it is not simply a result of overeating. Research has shown that, in many cases, significant, underlying causes of morbid obesity are genetic, environmental, and social. Studies have demonstrated that, once the problem is established, efforts such as dieting and exercise programs have a limited ability to provide effective long-term relief.
What is a co-morbid condition?
There are two definitions for a co-morbid condition: the presence of one or more disorder or disease in addition to a primary disorder or disease; or, the presence of a disorder or disease that is caused by or otherwise related to another condition in the same patient. The primary disease of morbid obesity can lead to several co-morbid conditions.
What is bariatric surgery?
Bariatric surgery is a procedure designed to make the stomach smaller so the patient feels satisfied with less food. It is intended for people with a Body Mass Index of 40 or greater, and who have not had success with other weight loss therapies such as diet, exercise, medications, etc. A person with a Body Mass Index (BMI) of 35 or greater and one or more co-morbid condition also may qualify for bariatric surgery.
What is Body Mass Index (BMI)?
BMI is a measure used to index a person’s height and weight. BMI allows healthcare professionals and patients to better understand health issues associated with a specific weight classification (classifications such as obesity and morbid obesity).
How do I know if I qualify for bariatric surgery?
Patients should have:
- 45kgs or more of excess weight; or a BMI of 40 or greater
- A BMI of 35 or greater with one or more co-morbid condition
Other common guidelines include:
- Understanding the risks of bariatric surgery
- Committing to dietary and other lifestyle changes as recommended by the surgeon
- Having a history of weight loss treatments having failed the patient
- Undergoing a complete examination including medical tests
Is bariatric surgery right for me?
- Bariatric surgery is not cosmetic surgery.
- Bariatric surgery does not involve the removal of adipose tissue (fat) by suction or surgical removal.
- The patient must commit to long-term lifestyle changes, including diet and exercise, the key to the success of bariatric surgery.
- Problems after surgery are rare, but corrective procedures may be required.
What are the complications and risks associated with bariatric surgery?
As with any surgery, there are immediate and long-term complications and risks. Possible risks can include, but are not limited to:
- Complications due to anaesthesia and medications
- Deep vein thrombosis
- Dehiscence (separation of areas that are stitched or stapled together)
- Leaks from staple lines
- Marginal ulcers
- Pulmonary problems
- Spleen injury
- Stenosis (narrowing of a passage, such as a valve)
What are the possible side effects of bariatric surgery?
Side effects include:
- Dumping syndrome
- Nutritional deficiencies
- Need to avoid pregnancy temporarily
- Nausea, vomiting, bloating, diarrhoea
- Excessive sweating, increased gas, and dizziness
What is the difference between minimally invasive and open surgery?
Open surgery involves the surgeon creating a long incision to open the abdomen and operating with “traditional” medical instruments. Laparoscopic, or minimally invasive, surgery is an approach that allows the surgeon to perform the same procedure using several small incisions, a fibre-optic camera, video monitor, and long-handled instruments. Learn more about the differences, as well as why your surgeon may recommend a minimally invasive technique but switch to an open one.
Why would I have an open procedure?
The decision to perform minimally invasive or open surgery is made by your surgeon before the operation. For some patients, the laparoscopic, or minimally invasive, technique cannot be used due to dense scar tissue from prior abdominal surgery. Also, the inability to see organs and/or bleeding during the operation can cause your surgeon to switch from minimally invasive to open surgery during your operation.
What is Roux-en-Y gastric bypass surgery?
Roux-en-Y (pronounced ROO-en-why) gastric bypass surgery is the most popular bariatric surgery in the United States. In this procedure, the surgeon creates a small stomach pouch and then constructs a “bypass” of some of the small intestine. The smaller stomach pouch restricts the amount of food the patient can comfortably eat, and the bypass decreases the number of nutrients and calories absorbed.
What is a gastric banding procedure?
Gastric banding is a purely restrictive surgical procedure in which a silicone band is placed around the uppermost part of the stomach. The band is adjustable and can be periodically tightened or loosened depending on the patient’s needs.
What is sleeve gastrectomy or tube gastrectomy?
Sleeve gastrectomy is a surgical weight-loss procedure in which the stomach is reduced to about 25% of its original size, by surgical removal of a large portion of the stomach along the greater curvature. The result is a sleeve or tube like structure. The procedure permanently reduces the size of the stomach, although there could be some dilatation of the stomach later on in life. The procedure is generally performed laparoscopically and is irreversible.
Sleeve gastrectomy was originally performed as a modification to another bariatric procedure, the duodenal switch, and then later as the first part of a two-stage gastric bypass operation on extremely obese patients for which the risk of performing gastric bypass surgery was deemed too large. The initial weight loss in these patients was so successful it began to be investigated as a standalone procedure.
Today sleeve gastrectomy is the fastest growing weight loss surgery option in North America and Asia. In many cases, but not all, sleeve gastrectomy is as effective as gastric bypass surgery, including weight independent benefits on glucose homeostasis. The precise mechanism(s) that produce these benefits is not known.
How successful is bariatric surgery?
Studies show that bariatric surgery can effectively improve and resolve many co-morbid conditions. A review of more than 22,000 bariatric surgery patients showed improvement in or complete resolution of conditions including type 2 diabetes, hypertension, and sleep apnoea as well as a 61.2% reduction of excess weight
What are the routine tests before bariatric surgery?
Certain basic tests typically are performed:
- Full Blood Count (FBC)
- Blood Urea, Creatinine and Electrolytes
Other tests that may be requested include:
- Blood glucose test
- Pulmonary function testing
- GI evaluation
- Cardiology evaluation
What impact do my medical conditions have on the decision for bariatric surgery, and how can my medical problems affect risk?
Medical problems, such as serious heart or lung problems, can increase the risk of any surgery. On the other hand, many serious medical conditions may improve or resolve after successful bariatric surgery.
What can I do to prepare for surgery?
Bariatric surgery is like other major abdominal surgery. You can best prepare by knowing the benefits and risks of surgery, and by closely following your doctor’s instructions. Understand the surgical process and what to expect afterward. Keep in mind that you’ll never be able to eat the way you did before and that you’ll have to watch what and how you eat for the rest of your life.
- Talk to people who have had bariatric surgery.
- Write down your reasons for having bariatric surgery
- Outline your plans to maintain your weight loss after surgery.
- Practice the post-op diet, including the transition from an all-liquid diet, to pureed food, to a normal diet of smaller portions with 115 grams of protein.
- Start a journal. Record how you feel now, the challenges you face, and the things you hope to be able to do after bariatric surgery.
- Ask your family and friends for their support. Talk to them about why you want to have bariatric surgery. It helps to have people behind you, waiting to help
What is a co-morbid condition?
There are two definitions for a co-morbid condition: the presence of one or more disorder or disease in addition to a primary disorder or disease; or, the presence of a disorder or disease that is caused by or otherwise related to another condition in the same patient.
What is type 2 diabetes and how is it affected by bariatric surgery?
Type 2 diabetes is a long-term metabolic disorder where the body produces insulin, but resists it. Insulin is necessary for the body to utilize sugar.
- 83.8% of patients who had gastric bypass surgery experienced complete resolution of type 2 diabetes.
- 66% of patients who had sleeve gastrectomy surgery experienced complete resolution of type 2 diabetes.
- 47.8% of patients who had gastric banding surgery experienced complete resolution of type 2 diabetes.
Patients who had bariatric surgery had lower insulin resistance, and their risk for metabolic syndrome, high blood pressure, and high amount of fats in the blood also decreased.
What is high blood pressure (hypertension) and how is it affected by bariatric surgery?
Excess body weight is associated with an increased risk of heart disease, elevated cholesterol, and high blood pressure. These conditions can lead to heart attacks, strokes, and heart and kidney damage. Bariatric surgery reduces excess body weight over time, which decreases strain on the heart.
- 75.4% of patients who had gastric bypass surgery experienced complete resolution of high blood pressure.
- 62% of patients who had sleeve gastrectomy surgery experienced complete resolution of high blood pressure.
- 38.4% of patients who had gastric banding surgery experienced complete resolution of high blood pressure.
- Changes in diet and exercise after surgery can lead to significant improvement of cardiovascular problems.
What is high cholesterol and how is it affected by bariatric surgery?
High cholesterol is a disorder of lipids—the fat-like substances in the blood. A common form of dyslipidaemia is hyperlipidaemia (or high cholesterol), the condition that exists when someone has too much of certain lipids in the blood. As these lipids build up inside the artery walls, harmful scar tissue and other debris begin thickening and hardening the walls. Long-term, this can lead to heart disease and high blood pressure.
- 95% of patients who had gastric bypass surgery experienced improved cholesterol health.
- 75% of patients who had sleeve gastrectomy surgery experienced improved cholesterol health
- 78.3% of patients who had gastric banding surgery experienced improved cholesterol health.
What is sleep apnoea and how is it affected by bariatric surgery?
Obstructive sleep apnoea is when breathing suddenly stops because soft tissue in the back of the throat collapses and closes during sleep. Morbid obesity can cause sleep apnoea and other respiratory problems that may result in chronic fatigue.
- 86.6% of patients who had gastric bypass surgery experienced complete resolution of sleep apnoea.
- 60% of patients who had sleeve gastrectomy surgery experienced complete resolution of sleep apnoea.
- 94.6% of patients who had gastric banding surgery experienced complete resolution of sleep apnoea.
What is acid reflux or gastroesophageal reflux disease (GERD) and how is it affected by bariatric surgery?
Acid reflux, also known as gastroesophageal reflux disease, is injury to the oesophagus caused by chronic exposure to stomach acid. It is a serious disease that can cause esophagitis, Barrett’s oesophagus, and oesophageal cancer (adenocarcinoma).
- 98% of patients who had gastric bypass surgery experienced complete resolution of acid reflux/GERD.
- 25 % of patients who had sleeve gastrectomy surgery experienced complete resolution of acid reflux (33% had progression)
- 32.3% of patients who had gastric banding surgery experienced complete resolution of acid reflux/GERD.
What is the relationship between morbid obesity and cancer?
Morbid obesity may put you at a higher risk for several types of cancer, such as colon, breast, and kidney cancer. In 2003, an article in the New England Journal of Medicine estimated that obesity could account for:
- 14% of all deaths from cancer in men
- 20% of all deaths from cancer in women
What is depression and how is it affected by bariatric surgery?
Depression is an illness that involves the body, mood, and thoughts. It affects the way a person eats, sleeps, thinks, and feels. There are many reasons people with morbid obesity experience depression. Emotional health goes hand in hand with physical health. Lifestyle improvements and renewed health can help resolve depression. Weight loss, combined with counselling, can be very helpful in improving mental health. 47% of patients who had gastric bypass surgery experienced improvement of depression symptoms.
What is osteoarthritis and how is it affected by bariatric surgery?
Osteoarthritis is one of the most common forms of arthritis. Known as the wear-and-tear kind of arthritis, osteoarthritis is a chronic condition in which there is a breakdown of joint cartilage. For anyone who is living with morbid obesity, the excess body weight placed on joints, particularly knees and hips, results in rapid wear and tear, and pain caused by inflammation. Bariatric surgery can reduce much of this weight over a long period of time and can be very effective in treating osteoarthritis. 41% of patients who had gastric bypass surgery experienced complete resolution of osteoarthritis.
What is stress urinary incontinence and how is it affected by bariatric surgery?
Among women, morbid obesity is a risk factor for stress urinary incontinence, or uncontrollable urine loss. A large, heavy abdomen and relaxation of the pelvic muscles due to morbid obesity may cause the valve on the urinary bladder to weaken, leading to leakage of urine with coughing, sneezing, or laughing. Bariatric surgery has been found to improve stress urinary incontinence. Less weight is placed on the bladder, and other physical changes take place to improve this condition. 44% of patients who had gastric bypass surgery experienced complete resolution of stress urinary incontinence.
What is reproductive health and how is it affected by bariatric surgery?
Reproductive health can be a concern for women struggling with morbid obesity. Issues such as infertility (the inability or reduced ability to produce children) and menstrual irregularities may occur due to morbid obesity. Fertility issues include possible miscarriage, reduced success with fertility treatments, and polycystic ovarian syndrome (PCOS). Additionally, women living with morbid obesity are more likely to have children with certain birth defects. A recent study of women following gastric bypass surgery showed improvement of multiple clinical problems related to infertility and PCOS. 100% of patients who had gastric bypass surgery experienced complete resolution of menstrual dysfunction due to PCOS.
- 79% of patients who had gastric bypass surgery experienced complete resolution of excess hair due to PCOS.
- Patients who had gastric bypass surgery experienced restored ovulation and fertility.
How can I deal with my fear of surgery?
The fear of surgery is not irrational or abnormal; in fact, it’s very common. Bariatric surgery creates a smaller stomach pouch and, depending on the procedure, may shorten the digestive tract—all while the patient is under general anaesthesia. If you have concerns, consider the following:
- Share your concerns and fears with your surgeon.
- Attend a support group and speak with patients who likely share the same fears.
- Understand the complication rates and mortality rates of surgery.
- Listen to bariatric surgery patients share their own fears and concerns.
And remember, you’ll have a team of healthcare professionals dedicated to your best possible care.
How does bariatric surgery change my body?
For people who have spent years living with morbid obesity, bariatric surgery can transform their lives. However, it’s important to be prepared for all aspects of the treatment. Surgery changes your body by creating a smaller stomach pouch. Learn more about the different types of bariatric procedures.
How long do I have to stay in the hospital?
It varies from person to person. Generally, the hospital stay (including the day of surgery) can be one to two days for a gastric band, two to three days for a laparoscopic sleeve gastrectomy and gastric bypass, and five to seven days for an open gastric bypass.
After the surgery, what support will I receive in adjusting to new daily habits?
A typical comprehensive bariatric program will consist of a combination of the following healthcare professionals: a program coordinator, psychologist, dietician, exercise physiologist, and other healthcare professionals. Each expert is dedicated to providing support for bariatric patients both before and after surgery. Check with your program to find out about support groups that can be helpful in adjusting to new daily habits.
Can I get pregnant after bariatric surgery?
Most doctors recommend that women wait at least one year after the surgery before a pregnancy. Approximately one year postoperatively, your body should be fairly stable (from a weight and nutrition standpoint), and you should be able to carry a normally nourished foetus. Consult your surgeon as you plan for pregnancy.
What about postoperative pain and discomfort?
Many people think bariatric surgery will be followed by a long and painful recovery period. However, most patients report experiencing discomfort and soreness rather than pain. Recovery does, however, vary from patient to patient. Click here for more information about recovering from bariatric surgery.
How long is recovery?
As with any major surgery, there will be a recovery period. Remember that this is a necessary step, and the better care you take during recovery, the more quickly you’ll return to normal activity.
Recovery time varies from patient to patient.
One study found laparoscopic gastric bypass patients spent an average of two days in the hospital and were able to return to work after 21 days.
What is the long-term success of bariatric surgery?
For people suffering from morbid obesity, bariatric surgery can be a powerful tool. For the surgery to be effective long term, it must be used properly. Through lifestyle changes, such as regular exercise and a healthy diet plan, many patients are able to make a long-term change for better health.
What will my life be like after the surgery?
Bariatric surgery is not a quick fix. It’s an ongoing journey toward transforming your health through lifestyle changes. After surgery, you will feel satisfied and fuller with less food. Positive changes in your body, your weight, and your health will occur, if you maintain the diet and exercise routines recommended by your bariatric program.
How often will I be able to eat?
After the initial recovery period, most patients are instructed to eat 1/4 cup, 65 grams of food per meal. As time goes on, you can eat more (as instructed by your medical team). Most people can eat approximately 1 cup of food per meal (with 115 grams of protein) a year or more post surgery.
When can I go back to my normal activity level?
Your ability to resume pre-surgery levels of activity depends on your physical condition, the nature of the activity, and the type of bariatric surgery you had. Many patients return to normal levels of activity within three to six weeks of surgery.
How much exercise is needed after bariatric surgery?
Exercise is an important part of success after surgery. You may be encouraged to begin exercising, limited only by discomfort, about two weeks after surgery. The type of exercise depends on your overall condition, but the long-term goal is to get 30 minutes of exercise three or more days each week.
Is there any difficulty in taking medications?
Most pills or capsules are small enough to pass through the new stomach pouch. At first, your doctor may suggest that medications be taken in crushed or liquid form. As a general rule, ask your surgeon before taking any medication.
What is “dumping syndrome?”
Eating simple sugars (such as sugar, honey, and corn syrup) or high-fat foods can cause dumping syndrome in patients who have had gastric bypass surgery. This occurs when these products, which have a small particle size, are “dumped” from the stomach into the intestine at a rapid rate. Water is pulled into the intestine from the bloodstream to dilute the sugar load. This flush of water causes symptoms that can include diarrhoea, rapid heart rate, hot flashes or sweating and clammy skin, and dizziness.
What is the long-term follow-up schedule?
Band patients need to work with their surgeons to have their band adjusted several times during the first 12 to 18 months after surgery. Sleeve & Bypass patients typically see their surgeons for three to five follow-up appointments the first year, then once per year thereafter. Over time, gastric bypass patients will need regular checks for anaemia (low red blood cell count) and vitamin B12, folate, and iron levels.
How can I find a support group?
Support groups give patients an excellent opportunity to talk about personal issues. Most patients learn, for example, that bariatric surgery will not resolve personal relationship issues. Most bariatric surgeons who frequently perform bariatric surgery will tell you that ongoing support after surgery helps to achieve the greatest level of success for their patients. Patients help keep each other motivated, celebrate small victories together, and provide perspective on the everyday successes and challenges that patients generally experience.