By Jamie Friedlander
Tony Gambee, the CEO of a software company in Boulder, Colorado, used to be able to eat an entire slab of ribs in one sitting at his favorite barbecue joint.
Now, it’s two ribs and he’s full. His secret is gastric bypass, a type of weight loss surgery that promises dramatic results, but often involves a lot of maintenance afterward and some difficult side effects at first, such as vomiting.
Known as bariatric surgery, procedures to induce weight reduction include gastric bypass, which creates a small stomach pouch; sleeve gastrectomy, which reduces the stomach to 25 percent of its size; lap band surgery, in which a device is placed around the stomach to slow down eating; and duodenal switch surgery, in which 70 percent of the stomach is removed and a large portion of the small intestine is rerouted.
All of these surgeries have the same goal: to help severely obese patients lose weight quickly and effectively by restricting how much they can eat as well as how many calories they absorb. Bariatric surgery also helps obese patients control their related conditions, such as diabetes, high blood pressure and sleep apnea.
Recent research from the University of Cincinnati and a research institute in Seattle shows bariatric surgery improves life expectancy in most obese patients in comparison to obese patients who do not have surgery. However, one study suggests a small subset of very obese, diabetic patients may not see increased life expectancy after surgery.
Gambee falls into the group with increased life expectancy because of surgery. After contemplating the procedure for a few years, he finally decided to have gastric bypass in July 2014.
He weighed 331 pounds.
Now, in March 2015, he weighs 228 pounds. Gambee partially decided to have surgery for personal reasons.
“I’m 39, I have two teenagers, and I just want to be active and have fun with them and my weight was slowing me down,” he said. “I was like, if I just keep failing at doing this on my own, I’m going to be 50 and look back and say, ‘Geez, I wish I had done something more drastic ten years ago when I could’ve enjoyed this time more.’”
Gambee wrote a list of goals prior to surgery unrelated to the number of pounds he lost. He wanted to walk 18 holes of golf with his son, be able to mountain bike with his other son and have his wife be able to hug him and touch her hands behind his back.
New Research Shows Improved Life Expectancy
One study published recently in the Journal of the American Medical Association (JAMA) followed 2,500 patients for 14 years after they had bariatric surgery in Veterans Affairs hospitals from 2000 to 2011. The study, by Dr. David E. Arterburn of the Group Health Research Institute in Seattle, compared them to 7,462 obese control patients who did not have bariatric surgery. The majority of the surgical patients (74 percent) had gastric bypass. In addition, 74 percent of the surgical patients were men.
The study found at the end of the 14-year period, the mortality rate for control patients was 10.4 percent at 5 years and 23.9 percent at 10 years, while the mortality rate for surgical patients was 6.4 percent at five years and 13.8 percent at 10 years. Control patients had an average age of 53 with a BMI of 46 and surgical patients had an average age of 52 with a BMI of 47.
In addition, the study showed the safety of bariatric surgery has improved over the years.
“I think one of the important take home points of the study was that they looked at the mortality risk for patients who had surgery in the early part of the study versus the second half of the study and found that the overall safety of the operation has actually significantly improved over time,” said Dr. Vivek Prachand, a bariatric surgeon and the Director of Minimally Invasive Surgery and Surgery Quality Chief at the University of Chicago Medicine.
However, another recent study has shown that in a very small group of people – diabetics with a body mass index over 62 – bariatric surgery may not actually increase life expectancy. Body mass index, or BMI, is a measure of the correlation between height and weight.
The study, done by a group of researchers at the University of Cincinnati and published in The Annals of Surgery, analyzed data for approximately 200,000 patients to look at life expectancy. Of 159,000 severely obese diabetic patients, 4,185 had bariatric surgery. The researchers looked at data from the Nationwide Inpatient Sample and the National Health Interview Survey, as well as data from three HMO Research Network sites.
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The study found that while life expectancy improved in most diabetic obese patients who underwent bariatric surgery, it might actually reduce life expectancy in “super super” obese patients, which is a category of obesity that applies to people with a BMI over 60, for example a person who is 5 feet 8 inches tall and weighs about 400 pounds. The researchers got these results by using a model that compared severely obese diabetic patients who had bariatric surgery to those who didn’t.
More specifically, the study found that a diabetic, 45-year-old woman with a BMI of 45 gained around 6.7 years of life expectancy upon having bariatric surgery, but once the same woman’s BMI hit 62, life expectancy went down. The researchers reported that they saw similar results for men and women in all age groups.
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“We were not surprised that most obese diabetic patients benefitted from surgery,” said Dr. Daniel Schauer, an author of the study. “We were surprised though that the most severely obese didn’t.”
“Less than 3 percent of [the people in the study] actually had an initial BMI greater than 60,” said Prachand, who believes it was somewhat misleading to lead the reporting of this study with the finding that applies to 3 percent of patients instead of the finding that applies to 97 percent of patients. “So the confidence upon which you can make those sorts of generalizations is a little bit limited given that it represents a relatively small percentage of the overall sample.”
In addition, both Schauer and Prachand noted the study didn’t account for patients’ quality of life.
“I think it’s fair to say that the benefit [of surgery] as far as life expectancy decreases as the BMI goes up,” said Schauer. “But there are other reasons to have bariatric surgery. It improves quality of life and it improves other obesity-associated conditions, like arthritis, diabetes and hypertension.”
Schauer said he and his colleagues are still unsure as to why they got these results. They hypothesize that it could be because patients in the super super obese category had diabetes longer or because they had much more weight to lose in the end, so they were still obese even after weight loss. With the added risks, they may not have achieved all the true benefits of bariatric surgery.
Schauer believes the take-home message from this study should be that the vast number of obese patients actually do benefit from bariatric surgery.
Deciding to Have Surgery
For most people, it isn’t the number on the scale that drives them to surgery.
“I think the public has the perception that most people who seek obesity surgery do so because they don’t like the way they look,” said Prachand. “But when we ask patients ‘Why are you seeking surgery?’ appearance and self esteem tend to be maybe fifth, sixth or eighth on the list. The most common thing is a loss of functional ability and the second most common thing is a newly diagnosed medical problem.”
Before surgery, Gambee was on medication for diabetes and used a machine at night because of his sleep apnea, a condition in which one’s breathing stops in short spurts while sleeping. Now, Gambee no longer needs the diabetes medication or the machine to correct his breathing.
Blanca Ramirez, a secretary at Loyola University, ultimately decided to have weight loss surgery for health concerns. Her brother had a heart attack at 35, her father had diabetes, high blood pressure and congestive heart failure and her mother has a pacemaker.
“That always stayed in the back of my mind, [whether] I would possibly be the next one with some heart condition or some heart issue,” she said.
Ramirez had a sleeve gastrectomy at age 41 in August 2012. At the time of surgery, Ramirez, who is 5 feet 3 inches tall, weighed 215 pounds and had weighed as much as 235 pounds. Now, she maintains an average weight between 150-159 pounds.
Some people have trouble adjusting after bariatric surgery. People can experience side effects that include difficulty swallowing from eating too quickly, dehydration, gallstones, indigestion, nausea and vomiting. Many people also experience dumping syndrome, which is when patients who have had surgery experience nausea, vomiting, cramping, diarrhea, dizziness and lightheadedness shortly after eating.
“You can’t wake up and get off the operating table and say okay, voila! You have to work at it. Nothing in life is that easy.”
While neither Gambee nor Ramirez said they had any serious side effects after surgery, they both pointed out that it’s not as simple as having surgery and being done. Even after weight loss surgery, people need to eat healthfully and be active to prevent gaining weight and getting sick.
“You can’t wake up and get off the operating table and say okay, voila!” said Ramirez. “You have to work at it. Nothing in life is that easy.”