Surgical Weight-Loss Solutions (podcast)

Dr. Fujioka: It’s one of those perfect storms. We have a combination of less activity. Our food has changed dramatically. It’s much more processed. Studies show if you just eat less processed food, you can lose weight. But again, the food has changed. Also, we’re hard-wired to keep any weight that we gain. In other words, as humans gain weight, a part of their brain called the hypothalamus is going to try and keep that weight at the highest weight that anyone has ever reached in their life.

This is all brand new stuff. We thought well you just lose some weight and you keep it off. But it turns out no. This is all figured out from the show The Biggest Loser. They would lose weight, 100, 150, 200 pounds some of them. But later they found when they checked them five, six years later, two things had happened. One, they lowered their metabolism inappropriately, way too low, such that the body was trying to gain back weight. And it never readjusted. It always stayed low even though they were doing everything right, exercising and eating right. The other thing is the hormones that also control food intake, hunger, satiety and metabolism, all turned in the wrong direction to try and bring their weight back to what it was before.

Dr. Fujioka: Food has changed for kids a lot. They have much more access to food.

And it turns out that activity level, particularly for young women — especially once girls hit middle school — their activity level drops dramatically. You start to see the weight going up. Boys are a little bit later, but not far. When they hit high school, their activity level goes down. We have all these competitive sports and there is just not enough places for all these kids to exercise.

Dr. Fujioka: We have various definitions. We use a thing called body mass index, BMI. But the short of it is that once somebody is about 30 to 40 pounds overweight, they’re heavy enough that we know their life span is going to be shortened. If they’re 50 or 60 or 70 pounds overweight, their lifespan is going to be dramatically shortened.

Dr. Fuller: Not getting a handle on your weight can lead to serious medical consequences [such as] heart disease, which can lead to heart attacks, diabetes.

There are several consequences of having diabetes that can impact a patient’s life really negatively. Kidney disease can result from that. You can develop vision problems. There is a number of issues that go along with diabetes, which obese patients really struggle with. Stroke can happen. It’s definitely a higher risk factor for patients who are struggling with obesity.

Dr. Fujioka: We’ve gotten a lot of cancers under control except for the ones related to weight. Breast cancer, uterine cancer, colon cancer, all these things are actually rising.

Stroke is the one we can’t seem to get better because it goes up as you get heavier.

Dr. Fujioka: Once somebody gets to a point of being seriously overweight, the costs can double or triple what it would be for somebody who is that same weight and has the same medical problems. But the biggest thing is diabetes. Once diabetes comes in, and it’s clearly weight-related, now you’re looking at a cost that can be 10 times that of someone else.

Dr. Fujioka: It does. It affects it in different ways though. If we look at the minority groups, Hispanic, African-American, Asians, they are actually very much affected even more so than say Caucasians.

We’re not sure if it’s just the socioeconomic factors. Is it cheaper just to get fast food? Maybe not. It could be other factors. Particularity for the Hispanic population, we’re seeing more young Hispanic women get heavy very quickly at relatively young ages. African-American women, it’s the same. The guys though are right behind, and they’re moving up quickly. If you go outside the US, say to Mexico, which is very close to us in San Diego, they’re actually surpassing us in the percentage of people that are overweight.

Dr. Fuller: You have several aspects of your life that are really impacting your ability to exercise as you get older. Your metabolism is slowing down in many regards. Your ability to get out and do exercise and be as active is diminished due to time demands, career demands, family demands.

Dr. Fujioka: If just one of the two parents is overweight, half those kids are going to struggle with weight. If both parents are overweight, 90 percent of those kids are going to struggle with weight. It’s really tough when you have parents that are overweight. Even if you take a child who comes from two parents who are overweight, but you adopt them into a thin family, they’re still going to struggle with weight.

It’s the biology that you’re fighting. It’s particularly rough on women once they hit menopause. Once they hit menopause you see this huge drop in ability to burn calories. That patient is doing everything the same. They’re eating the same. Their activity level actually isn’t that much lower. But all of a sudden, they hit menopause and they’re not burning as many calories and you see the weight creeping up. The good news is that we find that older patients, say those above 60, actually do well with weight loss because they have the time and they understand what it takes to get their weight down. They’re willing to do what it takes.

Dr. Fujioka: The standard of weight loss is still diet and exercise. But we’ve actually gotten a lot better at the diet part. We understand it better, and the exercise. In the past we’ve said you have to eat breakfast. Guess what? You’re wrong. You don’t have to eat breakfast, and you can still lose weight and do fine.

It turns out if you just weigh yourself every day you will do better. You will lose more weight. And then there is the exercise component. It’s real clear now that it isn’t just cardio. It’s just not the number of calories you burn, but rather it’s this combination of doing some resistance training and some cardio.

Dr. Fujioka:The Keto diet is huge right now. Also, intermittent fasting. It turns out they do work. They have to be done appropriately. Keto diet is a little bit on the fence because it does raise triglycerides and you’re adding in fat, which is probably not a good idea. But things like intermittent fasting, where you are getting into ketosis, but you’re not adding additional fat, you can do well.

[What is ketosis?] When you remove carbohydrates from the diet, the body then is literally forced to run off just fat, which is good. But when it runs off fat, it begins to release a byproduct called ketones. In ketosis, it’s clear you’re just burning fat, and you probably save your muscle mass. In other words you don’t burn any of your muscles.You’re just burning fat.

Dr. Fuller: Bariatric surgery is a cumulative name for weight-loss surgery. Weight-loss surgery is essentially at this stage two surgeries that we perform at Scripps, gastric bypass surgery or a sleeve gastrectomy. These are surgeries designed to help patients control appetite, deal with portion sizes and really kind of learn a different, better way to consume food.

Dr. Fuller: Gastric bypass surgery is a procedure in which a surgeon will alter the size of the stomach, reducing it. Along with this reduction of the size of the stomach an intestinal bypass is performed as well.

Dr. Fuller: This a procedure in which a surgeon will also reduce the size of the stomach. But in this case, we are narrowing the stomach to make it a tight conduit, thereby slowing down the passage of food through the stomach, and helping patients to control their portion sizes.

Dr. Fuller: When we talk about minimally invasive surgery, this is surgery which in the past was performed with larger incisions on the abdomen. Now, we do, or use, little, small incisions to perform that same task that we once did with larger incisions. This diminishes the impact of the surgery on the patient, and facilitates their recovery. The abdomen does not have the large incision that we had to do years ago. It is less traumatic for the patient.

Dr. Fuller: Patients are typically relatively pain-free two to three weeks following the surgery. Weight loss results begin immediately, essentially. Some of the metabolic effects, especially with gastric bypass surgery, occur relatively instantaneously once the bypass is done.

Dr. Fuller: We define success in many ways after these procedures. Most patients define success in their quality of life and improvements in daily activities. Being able to get on a plane and not have to take two seats. Being more active with their children. There is a number of measures that patients use to define their success. We as surgeons and physicians define the success based on how much weight patients have lost and reduction in their medical problems. Patients enjoy a large, large amount of success following the surgery, especially when we look at the weight loss, which for most patients is between 60 and 80 percent of their excess body weight.

Dr. Fujioka: To put it in perspective, if you do diet and exercise, you have a 20 percent chance of getting meaningful weight loss. That is one out of five. But if you do, say diet, exercise and meds, it’s 50/50, maybe 60 percent meaningful weight loss. You do bariatric surgery, you’re talking 80-85 percent chance of getting very significant, meaningful weight loss. You can’t eat as much with bariatric surgery. What will happen is the hormones change and they move in the right direction to keep your weight down.

Dr. Fuller: Generally speaking, a patient who is roughly 100 pounds over the clinical ideal weight is a candidate for surgery.

Dr. Fuller: Like any surgery, there are inherent or innate risks with a procedure. Speaking generally, there are risks of gastrointestinal leak, which can lead to infection. There is risk of having a pulmonary embolus, which is a blood clot in the lung arteries. These are some of the more prominent risks. Thankfully, these are very low risks, and generally speaking lower than 1 percent.

Dr. Fuller: Thankfully. the side effects aren’t that plentiful. For gastric bypass patients, there is a number of gastrointestinal type of symptoms they may exhibit. They may have nausea or constipation. Certainly indigestion to certain types of foods. These are more the notable side effects. And similarly so with the sleeve gastrectomy.

Dr. Fujioka: There are certain side effects that can be long term. Once somebody gets bariatric surgery, they really need to at least be seen yearly by somebody who understands what’s going on. I’ll give you an example. Vitamin deficiencies are by far the most common. Vitamin D is number one. We see that the most. But you can also get deficiencies in certain B vitamins, which can be very serious. You can get changes in your meds that you need, particularly for people with diabetes. Usually, we have to rapidly remove their diabetic medications because they get too low in their blood sugars. The side effect would be hypoglycemia. But to make a long story short, all these vitamin and nutritional problems are very well characterized. We know how to fix them. As long as you’re checked regularly, you do well. But you have to take your vitamins.

Dr. Fuller: You need to be psychologically ready. Everyone has a psychological evaluation to ascertain one’s readiness to undergo this massive lifestyle change. You need to be medically fit to undergo the surgery. Your physician needs to okay you to have the procedure. You need to meet with a dietitian so that you can understand the proper ways of eating, especially following a bariatric surgical procedure.

Dr. Fujioka: We used to think binge eating was a psychological problem that probably resulted from when you were a kid and you were put in a closet because you didn’t do your homework and you didn’t finish your Brussels sprouts. Well, it turns out that’s probably not correct. It turns out there is a part of the brain that signals fullness or satiety. It’s a receptor that in about one in 20 people is broken.

What happens is messages come up to tell them to stop eating, but the receptor is broken. These folks, unfortunately, don’t know when to stop eating, and it’s genetic. They just inherit it. Nothing they did. It’s not related to any psychological event. They sit there eating a plate of food, and they’re still not full because the receptor is broken.... Some have no outside cues, so they’ll eat two or three portions. They binge. We need to know about this ahead of the surgery. We know that when they do bariatric surgery they won’t do quite as well. That’s okay because we have certain meds that will help that receptor to work better. Times are really changing in that.

Dr. Fujioka: Bulimia is a big one. If somebody is purging, that’s a big red flag because that can create a lot of problems afterward. The other really common one is cravings. They won’t binge. They won’t eat a large amount, but what they’ll typically do is crave a food that’s very tasty. For most women, it’s chocolate. For guys, it’s savory things like fries, burgers, pizzas, things like that.

Stress is a common producer of this kind of behavior, where you’re going to want to eat that piece of chocolate or you’re going to want to have that burger because it kind of takes you out of that realm for just a split second and you feel good about it. So we need to counsel patients. They need to be aware of that so that they can not reproduce that behavior.

Dr. Fuller: This is a decision that patients and their physician should make in concert. But generally speaking, it’s for patients who have been struggling to lose weight, who are roughly 100 pounds over their clinical ideal body weight, and really feel like they’ve kind of reached the end of the rope with other weight-loss regimens.

Dr. Fujioka: If you look at all the guidelines from the different societies, they’re all going to tell you this. One is you need to be heavy enough. We have a lot of patients like that. It’s hard to imagine that roughly one to two Americans out of just 10, we’re talking 10 percent of the population, meets the criteria for bariatric surgery.

We’re just in a society where it’s tough to lose weight. If they’ve tried medical therapy and failed, they need to actually start thinking about bariatric surgery. I can tell you almost all the women we see, they’ve done Weight Watchers. They’ve done Jenny Craig. They’ve done a lot. They’re good to go. They’ve made a real try. As for the guys, most of them have actually tried, but some have not. They need at least a trial.

The other group that we’re not mentioning is this group where they’re really large. We’re talking over 300 pounds. We get their weight down with medical therapy, but again, we don’t do as well as surgical. We might get them down 20, 30, 40 pounds, but they’re still say 250 or 280 and they need to lose more. Now you start to think about surgery.

Once patients begin to lose mobility, we get scared because we know their lifespans are really going to shorten up quick. I will personally as a physician say “Hey look. We need to start considering bariatric surgery because you’re now not mobile.” We know that really impinges, not just on quality but really big time on health.

Dr. Fuller: One of the primary criteria is that a patient needs to be medically fit to undergo a surgery. If they’ve had medical problems like heart problems or lung problems, that would prohibit them from having a surgery, such as severe, severe congestive heart failure or restrictive lung disease, where their doctor won’t clear them. That’s the one criteria, or one class of patients that would not be candidates for surgery.

There are certain gastrointestinal disorders that may exclude a patient from having a surgery. Certain forms of inflammatory bowel disease, or certainly if the patient has cancer of their intestinal track, or if they’ve had previous significant small bowel surgery. That could exclude them from having gastric bypass surgery.

Dr. Fujioka: One of the bigger issues is can they comply? Can they follow up? If they cannot follow up, they’re going to have problems because they have to take certain vitamins. They can get osteoporosis if they don’t take their calcium or their vitamin D, things like that. They can get some very serious problems in the beginning if they’re not taking their multivitamins. They need to be followed.

The other issue that’s a little bit tougher to distinguish is: Is somebody going to have problems where they can’t have food around? To give you an example, we had one patient for whom food was everything, but after the surgery, they could not eat these large portions of inappropriate foods like they wanted to. They were just so depressed and so unhappy. They went off to a very unhappy world because they couldn’t use food like they used to. That’s why we have these patients see a psychologist before. Sometimes I’ll pick it up, but I can miss it. I’m not trained in psychology. But that’s why they see a psychologist, to make sure that they understand what they’re getting into and that their relationship with food is going to change.