A 52-Year-Old Woman With Obesity: Title and subTitle BreakReview of Bariatric Surgery

DR TESS: Ms J is a 52-year-old woman with obesity. She has been overweight since menarche and as an adult has attempted to lose weight many times through diet. She now has a body mass index (BMI) of 53, her highest to date.

She first considered gastric bypass surgery 2 years ago but eventually decided against it. She now feels more tired and limited by her weight because of knee pain. She has decided to pursue surgical options again because she wants to improve her quality of life. She has made arrangements to undergo surgery in the near future and is currently beginning the preoperative program.

Her medical history is also significant for hypothyroidism with Graves disease, hypertension, bilateral severe osteoarthritis of both knees with arthroscopy, a benign breast mass, and menometrorrhagia. Her medications include lisinopril, 10 mg/d; buspirone, 10 mg twice daily; levothyroxine, 0.125 mg/d; and naproxen, 500 mg twice daily.

She currently smokes a half pack per day of cigarettes and occasionally drinks alcohol but does not use illicit drugs. She works in finance and is single with parents and siblings nearby.

On physical examination, her weight is 297 lb (134 kg) and her height is 63 in (160 cm). Her blood pressure is 110/70 mm Hg and her pulse is 76/min.

Weight started being an issue for me when I was 13 or 14 years old. I got my period when I was 11 or 12, and after that, I seemed to gain weight over time. I also love to eat and my family loves to force food on me. They always have.

My weight has affected my adult life both personally and professionally. There is a lot of social activity going on around me. I have a tendency to avoid all of that, mostly based on how I physically feel and how I feel about my appearance. Professionally, I hold back in terms of my confidence. I try not to be the center of attention. I don't like presenting. I don't like being in front of a group of people.

My health has been affected in many ways. Mostly, I am tired all the time. Every time I walk, all I want to do is sit down. In addition to other physical problems, I have knee problems and trouble sleeping. I think my weight has definitely affected my depression and my anxiety. I think that's partially because I don't have the confidence that I wish I had. I’m just not happy at all.

I have done all of the different programs that there are: Weight Watchers and others. I’ve even done it on my own. I think that over my lifetime, I’ve gone up and down in weight up to a total of 300 to 500 lb. That is based on gaining 75 lb, losing 100 lb, gaining back 125 lb, losing 100 lb. I always stop at a weight where I’m still overweight, but because I feel well, I figure that's a good place to stop and start feeling good again. So I start to eat again.

I have done some exercise programs in the past but I have never really been on a true exercise regimen. Even when I was feeling better, the most that I really did was walk. I have always been afraid of getting on a treadmill or starting a formal exercise program. Because I have never felt comfortable doing it, I never really put as much emphasis on exercise as on diet.

I started thinking about surgery a couple of years ago. The first time I considered it, I got very nervous about the surgery itself and whether it was really the right thing for me. I ended up back on a diet and lost another 75 or 85 lb. But I got to the end of the diet and I started putting weight back on. So now I’m at the highest weight I’ve ever been.

I just want to be the same person that I am before the surgery. I don't want depression or anxiety to take over because I’ve gone through such a change in my life. The immediate fast weight loss concerns me as well. With my lack of exercise, I’m concerned about how I will look after I have lost weight so quickly.

I’m curious to know how patients who had the surgery 5 or 10 years ago are faring now. I’d like to know if they feel as good as they did years ago and if they are happy with the decision that they made to have the surgery.

What are the benefits of weight loss and when is it appropriate to consider weight loss surgery? What are the options for surgical treatment and how do they produce weight loss? How effective is surgery and how much can one expect to lose from surgery? What are the risks associated with surgery and what is its effect on mortality? What is the effect of surgery on psychological function and overall quality of life? What do you recommend for Ms J?

DR WEE: Ms J is a 52-year-old woman who has been overweight since adolescence. She has lost weight several times through nonsurgical and nonpharmacological means—losing up to 100 lb at one point—but has not been able to sustain weight loss. Eating is a very social activity for her and she finds altering her diet difficult. She has difficulty exercising vigorously because of her arthritis and does not want to take medications to lose weight. She is at her highest weight now, with a BMI of 53 (BMI is calculated as weight in kilograms divided by height in meters squared). In addition to arthritis, her hypertension is a likely consequence of her obesity. She also has depression, anxiety, and hypothyroidism. The stigma of obesity undermines her self-confidence and she has become socially withdrawn. Ms J is considering bariatric surgery and would specifically like to know the long-term outcomes associated with surgery. She is especially concerned about the psychological consequences of the procedure and also how surgery and the resultant weight loss might affect her appearance.

Obesity, defined as having a BMI of at least 30,¹ has more than doubled in prevalence in the last 30 years, and now more than one-third of all US adults are obese.² Obesity's contribution to many life-threatening conditions makes it the second leading cause of preventable death in the United States,³ contributing to more than 300 000 deaths each year.³

Quiz Ref IDObesity is associated with cardiovascular disease, stroke, type 2 diabetes, hypertension (as is evident in Ms J), and, to a lesser extent, dyslipidemia,^{4 - 5} as well as various forms of cancer,⁶ obstructive sleep apnea, osteoarthritis, and gastrointestinal disorders.⁵ Like Ms J, many women who are obese experience menstrual irregularities and uterine bleeding. Not surprisingly, obesity adversely affects quality of life, particularly physical functioning,^{7 - 8} and contributes substantially to high health care costs in the United States.⁹ Furthermore, unlike most chronic health conditions, obesity can be extremely stigmatizing.⁷

Ms J reports having lower self-esteem and avoids socializing outside of her family because of her weight. Furthermore, obese men and women have lower future incomes and are much less likely to be married¹⁰ ; they are also much less likely to achieve educationally, even after controlling for differences in intellectual aptitude and demographic and parental factors.¹⁰ In the health care setting, some obese persons may avoid seeking care.^{7 ,11 - 12} Compared with normal-weight white women, white women who are obese are less likely to undergo screening for cervical, breast, and colon cancer,^{11 - 14} even though they are at higher risk of dying of these cancers.⁶

Several studies have demonstrated that weight loss can reduce many of the adverse consequences of obesity.^{15 - 16} Clinical trials demonstrate that even modest weight loss, such as a 10% loss,¹⁷ can improve cardiovascular risk factors such as diabetes, hypertension, and dyslipidemia^{15 - 16} and improve measures of quality of life.^{15 ,18 - 19}

Behavioral modification with exercise, pharmacotherapy, and surgical or procedural intervention¹⁷ can be used alone or in combination to achieve weight loss. Quiz Ref IDThe National Institutes of Health recommend that bariatric surgery be considered only in those with a BMI of 40 or higher or if they have less severe obesity (BMI of at least 35) but have high-risk comorbid conditions,¹⁷ preferably after trying other nonsurgical approaches. Randomized trials suggest that lifestyle or behavior modification interventions can result in weight loss of at most 4% to 8% of baseline weight,²⁰ although effectiveness depends on the duration and frequency of contact.²⁰ Weight loss is difficult to maintain and requires sustained behavioral changes.²¹ This can be difficult for many patients, including Ms J, and behavioral recidivism results in weight regain.²¹ Ms J has engaged in formal structured programs with some short-term success but ultimately regained weight.

For obese patients, such as Ms J, pharmacotherapy with the 2 FDA-approved drugs sibutramine and orlistat may augment weight loss.¹⁷ As with behavioral modification, the benefits of pharmacotherapy are modest; patients taking sibutramine typically lose 4.3 kg or 4.3% of their initial weight,²² whereas orlistat produces weight loss of about 2.7 kg or 2.9% at 1 year.^{23 - 24} Ms J is reluctant to use weight loss medications and wants to lose more substantial amounts of weight, which leaves surgery as a next option.

The use of bariatric surgery to treat obesity has steadily increased; in 2006, an estimated 200 000 weight loss surgeries were performed in the United States.^{25 - 26} Nevertheless, no more than 1% of eligible patients actually undergo weight loss surgery each year.²⁷ Utilization is even lower in African Americans and Hispanics in the United States.²⁸

Bariatric procedures can be generally classified into their mechanism of action: gastric restriction, malabsorption, or a combination of the 2. The 2 most common bariatric surgeries performed in the United States in recent years are the Roux-en-Y gastric bypass procedure (gastric bypass) and the laparoscopic adjustable gastric banding procedure (gastric banding). Quiz Ref IDThe more established of the 2 procedures, gastric bypass, operates via both gastric restriction and malabsorption. The jejunum is surgically connected to the proximal stomach, “bypassing” most of the distal stomach and the proximal portion of the small intestine; gastric restriction is induced by the smaller gastric pouch and malabsorption is related to the length of the bypass limb. The gastrointestinal tract also secretes multiple hormones that regulate food intake, such as ghrelin, peptide YY, and glucagon-like peptide 1; studies suggest that gastric bypass may alter the secretion of these hormones in a way that reduces appetite and food intake and facilitates weight loss.²⁹

Gastric bypass can be performed laparoscopically or via the more traditional open method. Gastric banding is a purely restrictive procedure performed laparoscopically that compartmentalizes the proximal stomach through the placement of a tight, adjustable prosthetic band around the entrance to the stomach.

Patients who undergo bariatric surgery need to adapt their diet to accommodate the smaller stomach volume. For example, if food consumption exceeds the capacity of the gastric pouch, patients may experience abdominal discomfort, nausea, and vomiting. In addition, individuals who have undergone gastric bypass may experience gas or diarrhea induced by fat intake. Patients can develop micronutrient deficiency after gastric bypass.³⁰

Both procedures produce weight loss and limit the amount of food that can be consumed at a given sitting. However, neither procedure will treat the emotional aspects of Ms J's eating, and she should seek programs that provide more comprehensive behavioral support. She will need to change the way she eats as part of a permanent lifestyle change rather than a temporary diet that she can discontinue once she achieves a desired weight.

Table 1 and Table 2 summarize the best-quality clinical studies and systematic reviews published to date. All found surgical interventions to be superior to a control condition with regard to weight gain; percentage of weight loss, adverse events, and other outcomes vary by procedure.

As with other weight treatments, weight regain is a major concern, and Ms J would like to know how surgery performs in the long term. Several studies suggest that gastric bypass appears to produce a greater degree of weight loss, about twice that of gastric banding.^{15 ,31 ,36} For both procedures, weight loss eventually plateaus and patients regain some of the lost weight over time. Moreover, a sizable proportion of patients do not achieve significant weight loss, especially with gastric banding. For example, in the Swedish Obese Subjects (SOS) study,¹⁵ a prospective, nonrandomized intervention trial in which more than 2000 patients who underwent bariatric surgery were matched with a comparable number of obese patients who underwent nonsurgical treatment, only 28% of gastric banding patients sustained at least a 20% weight loss; 25% sustained less than a 5% weight loss. In that study, gastric bypass performed better, with almost three-fourths of patients sustaining 20% weight loss and 9% sustaining less than a 5% weight loss. Most bariatric studies primarily include patients of European descent, and whether these results generalize to more diverse populations is unclear.

Some observational studies suggest that patients like Ms J, with a BMI greater than 50, may lose a somewhat smaller percentage of excess weight than thinner patients.³⁷ Whether Ms J's depression, binge eating, and physical inactivity will adversely affect weight loss associated with surgery is a concern; however, the literature in this area is sparse and of poor quality and these factors are not considered contraindications to surgery. Although some studies do suggest worse weight loss outcomes in those with binge eating behavior and psychiatric disorders, others show the opposite or no effect.^{38 - 40} Preoperative weight loss and behavioral modification to improve diet and physical activity are often recommended as part of weight loss surgery, although whether these recommendations improve postsurgical weight loss outcomes has not been evaluated.^{41 - 44} Given Ms J's high weight loss expectations, she may prefer gastric bypass to gastric banding.

Weight loss after bariatric surgery has been shown to lead to improvements in many obesity-related comorbid illnesses. Quiz Ref IDIn a systematic review, Buchwald et al³⁵ reported that most patients experience improvement or even resolution of diabetes (80%-91%) and improvement of hyperlipidemia (71%-93%), hypertension (71%-87%), and obstructive sleep apnea (56%-95%). Another systematic review and meta-analysis found improvement or complete resolution of obesity-related liver disease including steatosis, steatohepatitis, and fibrosis.⁴⁵ Case series but no controlled studies suggest that surgery improves symptoms of cardiomyopathy⁴⁶ and pain control in fibromyalgia.⁴⁷ It is likely that Ms J's hypertension would improve or possibly resolve with bariatric surgery.

Two meta-analyses of randomized trials and observation studies published until 2002 estimated short-term perioperative mortality at 0.4% (95% confidence interval, 0.01%-02.1%) for gastric banding and 1.0% (95% confidence interval, 0.5%-1.9%) for gastric bypass (Table 2).^{34 - 35} In general, gastric bypass has higher complication rates, but gastric banding has a higher rate of reoperation, including the need to convert to a gastric bypass procedure because of poor weight loss outcomes; moreover, some of these reinterventions occur later and may not be captured by studies with shorter-term follow-up. The meta-analysis by Maggard et al³⁴ found that after gastric bypass, 17% of patients reported bothersome gastrointestinal symptoms; 17% experienced nutritional problems and electrolyte imbalance; 19% experienced surgical complications including wound infections, incisional hernias, and need for reoperation (2% of all surgeries); and 5% had medical complications such as deep vein thrombosis, pulmonary embolism, and cardiac events. Among patients who underwent gastric banding, 7% had gastrointestinal symptoms and 1% had medical complications. Surgical complications were lower overall (13%); however, reoperations were higher. The Longitudinal Assessment of Bariatric Surgery Consortium recently published 30-day outcomes in 4776 consecutive patients who underwent weight loss surgical procedures performed by 33 experienced surgeons at 10 clinical sites that performed high volumes of such surgeries.⁴⁸ They found that overall 30-day mortality was 0.2%. Mortality was 0% for gastric banding (n = 1198), 0.2% for laparoscopic gastric bypass (n = 2975), and 2.1% for open gastric bypass (n = 437). The composite end point of death, deep vein thrombosis or venous thromboembolism, reintervention, or failure to be discharged by 30 days occurred in 4.1% of patients: 1.0% with gastric banding, 4.8% with laparoscopic gastric bypass, and 7.8% with open gastric bypass.

Several factors are associated with poor patient outcomes. Studies suggest a substantial learning curve for bariatric surgeons in training and that perioperative mortality is influenced by surgeon experience and center-specific volume.^{28 ,49} Quiz Ref IDOne study²⁸ of gastric bypass surgeries at US academic medical centers found that the mortality rate was significantly higher (1.2% vs 0.3%) at low-volume centers (<50 cases per year) compared with high-volume centers (>100 cases per year); complication rates were similarly higher (14.5% vs 10.2%).^{28 ,49} Recent best practice recommendations suggest that surgeons complete 50 weight loss surgery procedures before being granted full privileges and maintain a volume of 25 cases per year.⁵⁰ Several patient factors have also been associated with higher perioperative mortality and complications,^{51 - 54} including male sex, increased age, higher BMI, and higher illness burden. Hence, risks can vary widely—as much as 20-fold—across different patient populations depending on patient and surgeon characteristics.⁵⁵ Ms J's higher BMI places her at higher risk of complications.

Because of the relatively high complication rate, studies have found that rates of hospitalization increase after surgery despite improvements in many obesity-related comorbid diseases.^{27 ,56} One study found that among patients who had undergone gastric bypass, hospitalization rates increased from 8.4% in the year prior to surgery to 20.2% in the first year, 18.4% in the second year, and 14.9% in the third year after surgery.⁵⁶ Approximately 13% were admitted for gastrointestinal tract procedures and surgery-related complications in the first year after surgery, the leading cause of all admissions in the first 2 years after surgery. Elective procedures were the second leading reason for admissions and the leading reason for admissions in year 3 after surgery; nearly 7% were admitted for elective procedures in year 3.

While bariatric surgery is associated with some increased risk of mortality in the short term, several observational studies suggest that patients who undergo bariatric surgery have improved long-term survival. In the SOS study, the adjusted mortality hazard ratio was 0.71 after up to 15 years of follow-up for the bariatric surgery group relative to controls.⁵⁷ Other studies demonstrate similar mortality benefit.^{51 ,58} However, while overall cardiovascular and cancer mortality appeared reduced with bariatric surgery, some studies have shown an unexplained rise in non–disease-related deaths such as suicide and poisonings.⁵⁸ Additional research is needed to better understand what underlies this latter finding.

Observational studies suggest that, at least in the short term, patients who undergo bariatric surgery report improvements in quality of life,^{59 - 61} including better mobility and less pain, and improvements in psychosocial functioning, such as improved mood, self-esteem, social functioning, and sexuality.⁶¹ It is likely that Ms J's pain symptoms from her osteoarthritis and her ability to exercise will improve with weight loss from surgery. Some studies also show increases in patient employment.^{62 - 63} However, these findings are not universal; a review found that patients who do worse psychologically after surgery were more likely to have weight regain, eating disorders, and difficulties coping with the consequences of bariatric surgery.⁵⁹ The SOS study found that while health-related quality of life tended to follow the cycles of weight loss and gain after surgery, 10 years after surgery the surgical group had significantly better health perceptions, social interaction, psychosocial functioning, and depression. Overall, patients who maintained a weight loss of 10% had persistent improvements in quality of life. Mood and anxiety did not differ significantly between groups.⁶⁴ Few studies compare quality of life among different bariatric procedures; however, given that greater weight loss is correlated with positive quality-of-life effects, it is reasonable to assume that long-term quality of life may be more favorable in gastric bypass, but this assumption needs to be tested empirically. Finally, many quality-of-life studies fail to account for loss to follow-up,⁶¹ so the improvements reported may be overestimated.

Ms J is concerned about whether she will be “happy” after surgery and whether she will be satisfied with her appearance. Ms J has depression and anxiety, and eating serves as a coping mechanism for her, with meals being central to her socialization. It is possible that bariatric surgery without concomitant treatment for her psychological issues could worsen her social functioning; much will depend on how well Ms J adapts her eating behavior after surgery. Because most patients have a poor body image before surgery, many patients report positive body image shortly after surgery; however, over time, some patients become discontented in part because they are still overweight and in part because many patients have excess skinfolds after surgery because of the rapidity of weight loss.⁵⁹ Body contouring surgery is sometimes used after bariatric surgery, but few studies have examined the predictors of the need for body contouring and whether physical activity ameliorates the need. A survey of 2501 patients after bariatric surgery found that of the 926 respondents, 84% wished for body contouring after bariatric surgery, particularly women and those who were younger.⁶⁵

Ms J should realize that she may not be satisfied with her postsurgical appearance. She should be aware that body contouring procedures are often not covered by health insurance, except for medical complications of bariatric surgery. Nevertheless, most patients who undergo bariatric surgery say that they would undergo the operation again, even when not all of their goals are met.⁵⁹

Because of Ms J's high BMI and her previous unsuccessful struggle to sustain weight loss through lifestyle change, bariatric surgery is a reasonable consideration for Ms J. Of the contemporary surgeries for which long-term data exist, the Roux-en-Y gastric bypass procedure has better long-term outcomes. Ms J should have this procedure performed by an experienced surgeon who has performed at least 50 gastric bypass procedures and at an institution that handles a high volume (>100 surgeries per year) of such surgeries.⁵⁰

In my opinion, Ms J should receive a thorough preoperative evaluation and ongoing monitoring that includes psychological assessment to ensure that her depression and anxiety are optimally managed before and after operation.⁶⁶ Ms J has indicated that she eats to cope with stressors, and it would be important for her to develop alternative coping strategies and new social outlets. It is unclear how surgery will affect her psychosocially.

It is also important that Ms J be educated about what to expect from surgery, in terms of both the weight loss she can reasonably expect to sustain and the changes that she will need to continue to make, particularly in terms of new eating habits. Best practices for informed consent and patient education are available to guide clinicians,⁶⁷ as are several Web sites that provide credible information, including the Obesity Society (http://www.obesity.org); some academic center-based surgical programs also provide online information and informational sessions. In my opinion, it would be important for her to engage in a multidisciplinary program that provides adequate nutritional education and behavioral support.⁶⁸

QUESTION: There is an epidemic of gastric banding procedure, and yet you showed us very convincing data, even though we internists may quail at the diagram that Roux-en-Y gastric bypass is a more effective procedure. Why should insurers pay for the banding?

DR WEE: While gastric bypass is more effective than gastric banding, gastric bypass is a more invasive and life-altering procedure and, unlike gastric banding, generally not reversible. It also has a higher associated short-term mortality risk and a different risk profile than gastric banding. For patients who are unwilling to undergo gastric bypass for a variety of reasons, gastric banding is still better than most other nonsurgical approaches, and we do have to remember that even a 10% weight loss, while not viewed by most patients as satisfactory, will improve cardiovascular risk factors. So I am not sure that there is no role for gastric banding, but ultimately, health care payers will need to determine based on economic analyses whether they are willing to reimburse for this procedure.