James “Butch” Rosser, Jr. MD FACSProfessor of SurgeryMorehouse School of Medicine
Billions are spent each year treating millions of patients around the world suffering from diseases such as diabetes, hypertension, heart disease, sleep apnea, cancer, asthma, reflux, infertility, low back pain, and osteoarthritis. What if there was a treatment that could prevent, cure or give better control to all of them and very few people were using it? This is the case with lifesaving obesity surgery such as gastric banding and the gastric bypass procedure. So, why are they the most underutilized treatments in health care?
A Surgeon’s Personal Journey
I have a very unique vantage point: I am one of the millions of people that lost the nutritional challenge and fell victim to morbid obesity. How does a surgeon reach a weight of 450 pounds with a BMI of 55, suffering from sleep apnea, and chronic back pain? With all my knowledge as a physician, I was not able to succeed in sustaining weight loss on my own. I tried every diet, every exercise program, even going to a fat camp. But, like so many others, I would lose significant weight and, within a period of time, the weight would come back – plus more. This took me on an upward spiral until I reached over 210 pounds above my ideal body weight. At this point, my life became threatened with the likelihood of an early death. Frankly, I was frustrated and disgusted with myself. When you reach this point, perpetual self-disappointment clings to you like the stench of a battlefield. Then you began to believe what the general public believes. You are an individual that is a mental and physical aberration with capabilities and work ethnic below others. Finally, I faced reality; I was over 100 pounds above my ideal body weight and I had become a victim of a disease called morbid obesity. Now, I had to do the right thing to save my life and the right thing was to undergo gastric bypass surgery.
Obesity: Public Enemy #1
For those of you facing this problem every day, you are not alone. Over 91 million people (78 million adults and 13 million children) in the US are obese. One billion adults and 28 million children under the age of 6 are stricken with this condition around the world. Five to ten percent (50-100 million) suffer from morbid obesity as I did.
Most of the public thinks that the face of obesity is the grotesque physical appearance of the victim brought on by deposition of layers of fatty tissue. But, obesity is not a cosmetic issue; it causes medical co-morbidities that decrease the quality of life (increased incidence of diabetes, hypertension, heart disease, sleep apnea, cancer, asthma) and a patient’s ability to sustain a productive existence (reflux, infertility, low back pain, osteoarthritis).
It is not just the person with the condition that suffers; the loved ones of the nutritionally challenged are victims also. Spouses, family members and friends live in a unique and often secretive world that no one seems to want to address. As a loved one, there are so many emotions they experience, but keep secret because they are afraid or ashamed to admit their feelings for fear of hurting the one they love. Whether the issue is concern for their health, intimacy, quality of life, self-esteem or any other life situation, loved ones often tread through the issues softly and quietly. They sing a song that no one hears.
These are the facts and as our second president John Adams once said, “Facts are stubborn things.” I know these facts all too well because as a 6’4”, 450 pound surgeon, the doctor could not save himself. Disease and death are the true face of obesity. In view of the facts I just gave, obesity should be labeled public enemy number one.
A Matter of Balance: Energy In (Food)/ Energy Out (Calories Burned)
The cause of obesity is very complex but based on a simple concept. It is the result of a person taking in more energy in the form of calories (food) than they burn off from physical activity and maintaining proper body function (metabolism). Because of this, I have used the word obesity less and less in general conversation. I refer to patients stricken with this struggle as being nutritionally challenged. Even though the energy side of the equation is extremely important, I stress nutrition because the other side of the equation has so many elements that are beyond our control. Nutritionally challenged is an accurate description and carries less of a stigma of misconception and discrimination. We all are in a war each day with our environment and way of life to attain a nutrition profile that helps us to successfully balance what we take in with what we burn off.
The Obesity Yardstick: The BMI
How do you know when your weight is starting to become a problem? You have to know your number. You cannot just look in the mirror and judge your health status in relation to weight.
The BMI (Body Mass Index) is the official weight measurement device. It is based on your weight (kilos) and height (meters square). There are calculators, websites and even phone apps that will do the math for you. For instance, if your height is 5’4” and your weight 120 pounds, your BMI is 20.6. If you are 6’ and weigh 200 pounds, your BMI is 27.1. When you go to the doctor, there are certain measurements that are collected at every visit such as blood pressure and pulse. These are called vital signs. I believe that the BMI should be the new vital sign and everyone must know their number.
At this point, you have to ask what do the numbers mean? You are underweight if your BMI is less than 18.5. You are normal weight if your BMI is 18.5-24.9. You are overweight if your BMI is 25-29.9. You are obese if your BMI is over 30. Now, it does not end there.
All obesity is not created equal. There are different levels or stages of obesity. Stage I is 30-34.9, Stage II is 35-39.9 and Stage III is 40-49.9, and a BMI of 50 or greater is considered to be super obese. To put this in context, there is an obesity elevator and each stage is a new floor. An alarm bell should ring as you go up each floor to warn you that you are in danger. The higher the floor, the higher the stage, and the more your life is in danger. My BMI was 55 and the alarm was ringing like crazy.
Obesity Surgery: The Most Underutilized Treatment in Health Care
Why is this option for treatment so underutilized? First of all, the decision to have any surgery is not an easy one to make. Surgery carries risks and – let’s face it – having a surgeon entering your body is not exactly on your bucket list. But the risk associated with this treatment is very low when done with great surgeons at great Centers of Excellence (COE) that focus on this treatment.
As a patient you must realize that the risk to continue to suffer from the disease far outdistances the risks from surgery. The patient has to overcome the feeling that they are copping out and withstand the criticism from others who feel the same. Furthermore, you have to get passed the “there has got to be another way that will let me do this on my own” syndrome. It haunts every step of your decision-making journey. Doctors unfortunately can be part of the problem. Unless it is their specialty, most doctors lack the awareness of the science behind this treatment, and they suffer from the same prejudices about the nutritionally challenged and obesity surgery as the general public. So, therefore they do not suggest it to their patients.
Let’s make this very simple. The reason and the only reason you should undergo weight-loss surgery is too improve your health. There are guidelines to help you make a decision that can relieve you of the mental gymnastics. If you are a BMI of 40 or greater (usually at least 100 pounds above your ideal body weight), you are suffering from morbid obesity and obesity surgery will allow you to regain and sustain your health. If you are a BMI of 35 or greater and you suffer with co-morbidities, especially diabetes, you should have obesity surgery. It is the only treatment that can offer sustained disease control or cure. Once I accepted that my condition was a disease, the decision was straightforward. The overwhelming academic evidence directed me to a surgical solution.
Gastric Band and Gastric Bypass
There are two main types of obesity surgery that are practiced today: The gastric band and the gastric bypass procedure. The gastric sleeve procedure is gaining popularity but it will not be covered in this article.
The gastric band is a device that is placed around the upper part of your stomach to make it smaller and restrict the flow of food into the rest of the intestine. It makes you feel full very quickly and you do not want to eat anymore. You can expect to lose 40-50% of your excess body weight. If you are 100 pounds overweight, you can expect to lose 40-50 pounds.
The gastric bypass reduces the size of the stomach and decreases the absorption of calories by diverting food from a large part of the small intestine. This results in a reduction of calories brought into the body and you lose weight. In addition, there is an incompletely understood impact on certain hormones that affect your hunger and satiety center, which also helps you to control your weight. If you choose the gastric bypass you can expect to lose 60-70% of your excess body weight or 60-70 pounds.
A word of caution: there are trade-offs to both procedures. The gastric band is safer and is not permanent but it gives less weight loss and is more prone to failure. The gastric bypass has a slightly higher serious complication rate but has more durable weight loss and is more appropriate for patients who have a higher BMI (>50) and diabetes.
Regardless of the operation you choose, these procedures help you to put food into a proper perspective. You are not hungry all the time and you do not miss food as a friend. Obesity surgery should be used as a tool to help you help yourself by achieving nutritional balance with your energy expenditure.
Be aware that you have to practice all those things that you learned with medical weight loss! The operation allows you to adhere to those things, where before you faced forces that caused you to fail. If you do not, no matter what operation you choose, you will ultimately not be successful. There is no free lunch. The operation only puts you in a position to help yourself.
A New Day for a New Me
It has been 10 years since my gastric bypass procedure and today I am 6’ 4”, 290 lbs: an amazing sustained weight loss of 160 pounds. My BMI is now 35. Hey, I am still a “big unit” but a healthier “big unit.” From no longer suffering from sleep apnea to shooting baskets with my children to hiking with my wife in the rain forest to completing three 5K runs, my existence has changed for the better. And I am determined to protect my investment by consciously shaping my living to win the challenge of balancing nutrition with exercise to maintain a healthy lifestyle.