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Confidence rises in weight-loss surgery

Every year, about 250,000 people in the United States undergo surgery to lose weight, paying — or having their insurance companies pay — tens of thousands of dollars for procedures that essentially restrict how much food they can take in.

But are the surgeries safe? Do they work? And can they help treat diabetes, hypertension and other conditions caused or made worse by obesity?

Increasingly, the answer in the medical community is yes, yes and yes.

Doctors and others are bolstered by studies like one this month that showed improved outcomes and lower complication rates among Type 2 diabetes.

And they're encouraged by the endorsements of groups like the American Society for Nutrition and the Obesity Society, which called bariatric surgery "the most effective weight-loss therapy for obesity." Or the American Diabetes Association, which last year for the first time recommended bariatric surgery as a treatment option.

"We would not have imagined that day 10 years ago," Tampa bariatric surgeon Michel Murr said of the Diabetes Association's endorsement. "We've seen quite a shift of attitude."

Such acceptance likely will lead to a continued increase in surgeries, but also place greater pressure on public and private insurers to cover more of them.

Still, Murr and others caution that bariatric surgery is a major medical procedure and isn't for everyone, such as children and adolescents, or adults who are overweight but not considered obese. They also don't consider surgery a magic bullet for curing the country's obesity epidemic.

"We only operate on about 250,000 patients a year from a population of 30 million in the U.S. who are obese," Murr said. "In that regard, what are we going to do with the other 29,750,000?"

• • •

Most patients choose either a gastric bypass, which involves cutting and stapling the stomach, or gastric banding, which places an adjustable silicone ring around the top portion of the stomach. In both cases, a smaller pouch is created — the idea being that with less food filling a smaller stomach, patients lose weight.

Acceptance among the medical community has come slowly. Though the first procedures were performed in the 1960s, it was relatively uncommon even through the early 1990s.

"It was a very narrow field," said Murr, who started the bariatric surgery program at Tampa General Hospital in 1998. Primary care doctors weren't referring their obese patients for surgery. And most insurance wasn't covering it.

Murr said a number of factors helped shift the landscape. For one, more Americans were becoming obese. And second, the surgeries became safer and less invasive with the introduction of the laproscopic approach in the 1990s, which used several smaller abdominal incisions instead of a large one. Another major advance was the introduction of adjustable gastric bands in the past decade.

Then came the studies that showed the procedures were safer, had better outcomes and helped reduce or even eliminate chronic conditions associated with obesity. The most recent study appeared this month in Archives of Surgery, which showed lower complication rates and shorter hospital stays for Medicare beneficiaries who had the procedure after Medicare implemented certain criteria for prospective patients.

Medicare covers the procedures for people who are severely obese (body mass index of 35 or higher) and have a condition associated with obesity such as diabetes.

How much has the landscape changed?

"About half of the patients sent to my practice are directed by physicians," says Dr. John Baker, president of the American Society for Metabolic & Bariatric Surgery, who performs about 240 procedures a year at his Little Rock, Ark., practice.

• • •

But what about losing weight through diet and exercise?

Other studies have shown it is possible. The Louisiana Obese Subjects Study released this past month showed successes when placing participants in a structured medically supervised program.

And then there are the morbidly obese contestants on the popular TV show The Biggest Loser, who season after season lose large amounts of weight through improved diet and an intense exercise regimen.

Baker says those successes tend to be few and far between. Plus, "not all of us have a trainer that's going to push us to the limit every day."

• • •

Murr says people like Jackie Chandler are becoming a more typical obesity success story. The 51-year-old Hillsborough County school bus driver struggled with diabetes and sleep apnea and carried 300 pounds on her 5-foot-8 frame before deciding last year to have a gastric bypass surgery. Her BMI was 44.

Her insurance company, Humana, covered the procedure, which Murr said typically costs about $27,000 (gastric band procedures cost about $17,000).

Since Murr performed the surgery last September, Chandler has lost 65 pounds, no longer has trouble sleeping and is taking one medication for diabetes, instead of five.

Though the results so far have been positive, Chandler knows the surgery was just a tool to help her lose weight. The rest, she says, is up to her.

"I can't eat as much as I'd like to," she says. "Can't eat spaghetti anymore. Can't eat ice cream or chocolate." Patients have some dietary restrictions after surgery, and some experience nausea with certain foods.

And it's early. Studies suggest that bariatric patients can regain a significant amount of their lost weight. One 2004 study in the New England Journal of Medicine found that the percentage of weight lost for gastric bypass patients decreased from 38 percent after one year to 25 percent after 10 years.

But, the study notes, the improvement in their chronic conditions such as diabetes mitigated the fact they regained some weight.

Studies have also found that gastric bypass patients can suffer from vitamin and mineral deficiencies if they don't carefully manage their diets.

• • •

Surgeons say there's still a long way to go toward addressing the nation's obesity problem.

The percentage of obese people having bariatric surgery is small. And though surgery is covered for Medicare beneficiaries who meet certain criteria, insurance coverage for the general population is limited.

Humana, for example, doesn't offer it as a standard benefit; rather, it's offered as a buy-up option for employer groups with more than 3,000 members, said Dr. Jill Sumfest, the company's market medical officer for Central Florida. Currently, five groups in Central Florida offer it.

Members need to meet certain age and BMI requirements, and must have participated in a physician-directed weight management program for at least six months in the last two years.

Murr feels that's too restrictive. After all, he says, you don't tell someone that they have to have breast cancer or heart disease for a minimum period before you cover them.

He says Medicare has led the way for coverage; now it's up to private insurance companies and employers to recognize the benefits.

"There are enough studies now that the operation will pay for itself in two to three years . . . with the reduction of costs associated with other illnesses like hypertension, sleep apnea and diabetes," Murr said.

Both Murr and Baker say the real solution lies in comprehensive obesity management programs that include surgery as a choice. They say programs should include ways to curb the rising obesity rates among children and adolescents, such as better nutrition in schools and increased physical activity.

So, is the goal to get people to manage their weight so they don't get to the point where they need surgery?

"That's too ideal," Murr said.

Richard Martin can be reached at rmartin@sptimes.com or (727) 893-8330.

Confidence rises in weight-loss surgery 01/30/10 [Last modified: Monday, February 1, 2010 1:00pm]
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