Losing it

Bariatric surgery’s impact on remedying weight conditions

A recent print advertisement for Baptist Health Bariatric Center refers to a "weight condition" that keeps a barrel racer from doing the thing she loves the most. "In order to win, you might first have to lose," reads the headline.

Bariatric surgery, which makes changes to a patient's digestive system that limit food intake, is used to treat obesity. And obesity, as of June 2013, is considered a "multi-metabolic and hormonal disease state" by the American Medical Association. "Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans," said AMA board member Patrice Harris, M.D.

Why bariatric surgery? Is it really the only solution for some?

"This is a difficult question," says Dr. Eric Paul, a surgeon with Arkansas Bariatric Surgery and Surgical Clinic of Central Arkansas, both in Little Rock. "Multiple facets of our lives here in America help lead to obesity. We have an overabundance of resources and a paucity of ethics by our food industry. For the first time in our history, socioeconomic status and weight have flipped. Healthy foods are now quite expensive, and cheap foods that are cheap to make are incredibly calorie dense, with little nutritive value. A large fountain drink at a gas station that costs 99 cents or lower can have as many as 500 to 700 calories, which for most people is about one fourth of their recommended daily allowance.

"Bariatric surgery is obviously not the only option, but it is usually a more permanent solution for people, who can diet and lose weight. But recidivism is very high with dieting--near 98 percent. Bariatric surgery is a tool, intended only to facilitate a lifestyle change. When you alter the capacity of someone's stomach to the point that reduction of intake is a necessity, most patients don't have a choice but to lose weight. You combine that initial weight loss with a wellness program, and you now have a lifestyle which is drastically different from the one they led before."

More questions for Dr. Paul, and his answers:

What's your philosophical approach to bariatric surgery? In residency, I had little exposure to bariatric surgery, so I didn't have much of a philosophy about it at all. I completed a fellowship in minimally invasive surgery at Emory University in Atlanta to learn techniques in reflux surgery, something that I was and still am interested in. As part of that fellowship, you also were required to learn bariatrics, something that I was at first not terribly excited about.

As I continued through the fellowship, however, I saw the dramatic benefits to the patients that underwent these surgeries, not only the diminution of their medical conditions associated with their obesity [such as diabetes, high blood pressure, sleep apnea, back pain, and heart disease], but behavioral differences, exercise, depression, etc. When I watched multiple people escape from the grip of diabetes following the surgery, I was convinced that bariatric surgery was and is a worthwhile endeavor.

What makes a good candidate for bariatric surgery? Someone who is motivated to change their life. They realize that their weight is causing a decrease in their quality and, ultimately, quantity of life. I do not make people thin and beautiful. I want to treat/cure the diseases that cause people to have to visit their doctors 80 percent more than people of normal weight.

A poor candidate is someone who looks at the surgery as a magic bullet--something that will allow them to lose weight without being an active participant. I always tell everyone at my seminars that if they have the surgery and do not utilize it correctly, i.e., making good food choices and increasing their activity level, they will fail in their weight loss goals.

People that have uncontrolled psychological conditions, smokers, and the unmotivated in general are not good candidates or are ineligible for surgery. There are requirements put forth by insurance companies and the government that regulate who is a candidate as well. This is based on the patient's body mass index, or BMI, which must be greater or equal to 35 with a significant health condition associated with obesity, also called a comorbidity, or greater or equal to 40 without a comorbidity qualifies for surgery.

What are the patient's expectations? I really try to mold patients' expectations. They might think that everything will be amazing and they will lose 100 pounds in three months and be healthy and happy. I typically tell patients that they should look at 18 to 24 months in the future as to where they will likely stabilize in their weight loss. Rarely do I give a patient a number of pounds that they should try to lose.

I always try to educate my patients that this is a drastic change to their bodies, and although most patients do exceedingly well, there might be some bumps in the road, and their lives and their families' lives can change in a very real way.

Of course patients have second thoughts. In those instances I talk to the patients in the clinic for an extended period, but if they are not sure they want this, I do not try to talk them into it. This is a difficult choice that these people are trying to make, and if they're not sure, they are not candidates for surgery.

I have not yet had a patient that has regretted a decision to pursue bariatric surgery.

Will these patients need to learn to adjust their eating and exercise habits after surgery? Absolutely. They really have no choice. With the gastric bypass and the sleeve gastrectomy types of bariatric surgery, a patient's stomach capacity has changed to the point that they can only take in between 50 and 150 cc of food, which is almost the equivalent of a small banana. What types of foods people take in is certainly under their control, and no operation can be performed that cannot be undone by people making poor food choices.

As far as exercise habits, I encourage my patients to be more active and educate them on specific types of exercise which would be most beneficial for their age, weight, body, etc.

How busy are you? Getting busier. It takes time to build a bariatric practice as the surgeries are all elective. I have to screen probably 20-30 patients prior to having one that is able to have surgery either secondary to insurance reasons or health concerns. I would say now it is approximately 10 percent of my practice, the rest of which is broad-based general surgery--gall bladders, colon surgery, endocrine surgery, and advanced laparoscopic and endoscopic surgery.

What is the medical profession's opinion concerning the future of bariatric surgery? Currently there is a plateau of the numbers of bariatric surgeries performed in the United States. I wish that this was indicative of the fact that obesity rates are going down, which unfortunately they certainly are not. With the AMA classifying obesity as a disease, one would think that the treatment of obesity in any form is becoming more of a priority to our country.

I would like to see the medical profession take more of a leadership role in the prevention of obesity and the diseases that accompany being overweight. I feel that our country will continue to get heavier and less healthy unless policies regarding food availability and physical education are not altered.

Many urban areas are "food poor" in terms of adequate access to nutritious, wholesome fruits and vegetables. Physical education is no longer mandatory, and in some school districts does not exist after elementary school.

We have many ambitious people taking on these tasks. Little Rock Urban Farming is a group that is doing a great job here in the city bringing organically grown produce to the people. Girls on the Run of Central Arkansas is bringing an education-based curriculum incorporating running to young girls in the third through fifth grade.

I think that our philosophy should be to get them while they're small, and keep them that way.

Perspectives on 05/11/2014

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