http://www.cnn.com/2005/HEALTH/diet...y.ap/index.html

Study: Obesity surgery riskier than expected

Tuesday, October 18, 2005; Posted: 7:19 p.m. EDT (23:19 GMT)

CHICAGO, Illinois (AP) -- Obesity surgery, which is fast becoming a popular way to battle the nation's weight crisis, may be a lot riskier than most patients realize.

New research found a higher-than-expected risk of death in the year after surgery, even among young patients.

"It's a reality check for those patients who are considering these operations," said University of Washington surgeon Dr. David Flum, lead author of a Medicare study that analyzed the risks.

The findings appear in Wednesday's Journal of the American Medical Association.

Some previous studies of people in their 30s to their 50s -- the most common ages for obesity surgery -- found death rates well under 1 percent.

But in a study of 16,155 Medicare patients who underwent obesity surgery, more than 5 percent of men and nearly 3 percent of women aged 35 to 44 were dead within a year. And slightly higher rates were found in patients 45 to 54.

Among patients 65 to 74, nearly 13 percent of men and about 6 percent of women died. In patients 75 and older, half of the men and 40 percent of the women died.

There are several types of operations to lose weight, most generally involving surgically shrinking the stomach and usually restricted to "morbidly" obese people more than 100 pounds overweight.

Those patients often have medical problems brought on by their girth, including heart trouble, diabetes and breathing difficulties -- problems which obesity surgery can sometimes resolve but which can also contribute to making the surgery risky.

Patients studied underwent surgery between 1997 and 2002.

"This is a major operation in a high-risk population. "When you do a complicated operation in a complicated population, we should expect to see adverse outcomes" occasionally, Flume said.

Dr. Neil Hutcher, president of the American Society for Bariatric Surgery, said that Medicare patients are probably sicker than the general U.S. population and that complication rates have declined as surgeons' expertise has increased.

But Flum argued that some previous research showing lower risks came from "reports from the best surgeons reporting their best results," while the new study is more of a real-world look.

A JAMA editorial said even if Medicare patients do face higher risks, they should not be denied obesity surgery.

"These patients may also represent the potential greatest benefit associated with major lasting weight loss given their associated disease burden," the editorial said.

The surgery may be lifesaving when done on the right patients, by experienced surgeons, the editorial said.

The study offered no breakdown on causes of death, but obesity surgery's potentially deadly complications can include malnutrition, infection and bowel and gallbladder problems. Also, surgery in general can be a deadly shock to the system, especially in older patients.

The American Society for Bariatric Surgery predicts obesity surgery will be performed more than 150,000 times this year in the United States. That is more than 10 times the number in 1998, according to a second JAMA study. The increase parallels a surge in the portion of U.S. adults who are at least 100 pounds overweight, from about 1 in 200 in 1986 to 1 in 50 in 2000, that study said.

Flum said the new study suggests that in many cases, obesity surgery may not be right for an older person "who already has the burden of 60 years of obesity on their heart" and other organs.

Medicare covers obesity surgery if it is recommended to treat related conditions such as diabetes and heart problems. The government is considering whether to cover surgery to treat obesity alone.

Medicare is for younger Americans with disabilities and for patients 65 and older. Flum said most of the patients he studied were under 65 and probably qualified for Medicare because of obesity-related ills, including heart and joint problems.

Flum's study lumped together data on different operations, but the most common U.S. obesity surgery, gastric bypass, involves creating an egg-size pouch in the upper stomach and attaching it to a section of intestine.

Researchers said one reason men may have higher post-surgery death rates is that they tend to wait longer than women to seek medical help and may be sicker at surgery.

Hutcher said patients should seek experienced surgeons, should be thoroughly evaluated before and after surgery, and should receive long-term follow-up care.

Most patients "will receive a good outcome," Hutcher said. "A good outcome does not mean there's no risk for complications or mortality."

For those who are interested in this issue, check out this NPR radio programme:

http://www.npr.org/templates/story/...storyId=4777030

The main problem I have with Gastric Bypass is that it does not address the main problem -- consumption of high glycemic foods.

Being overweight is not the root problem. Being overweight is like a warning light on your dashboard like "check engine".

The main problem I have with it is I don't want to die, and I don't want to spend the rest of my life with a Frankensteinian intestinal tract even if the surgery doesn't kill me.

One thing that interests me about this article is the implied pessimism of the bariatric people. Yes, they say, the surgery might kill you, but it's still the right thing for lots of people. They clearly do not believe that permanent weight loss is a realistic expectation for most people without surgical intervention, which is depressing.

LOL I love that first sentence Kwikdriver! Too accurate and too funny!

Also, it is sad, isn't it? It makes you feel like the bariatric professionals have just given up on the overweight/obese population. Just chop and dice and presto!! Instant thin!!

October 19, 2005

BY JIM RITTER Staff Reporter

Three new studies are documenting just how popular -- and risky -- weight-loss surgery is becoming.

One study found the number of Americans who get stomach-reduction surgery has increased tenfold in just seven years. In two other studies, researchers reported that during the year after the operation, nearly 1 in 5 patients were hospitalized and nearly 1 in 20 died.

The mortality rate "provides a reality check of the risk of these procedures," said Dr. David Flum, lead researcher of a University of Washington study that found 4.6 percent of patients died within 12 months of surgery.

BY THE NUMBERS

*Operations in 1998: 13,365
*Projected in 2005: 130,000
*Projected in 2010: 218,000
*Female: 84 percent
*Average age: 41.7
*Younger than 18: 0.3 percent
*Older than 64: 1 percent
*Household income below $25,000: 2 percent
*Family income higher than $45,000: 59.7 percent
*Average hospital stay: 3.3 days
*Mortality rate 30 days after surgery: 2 percent
*After three months: 2.8 percent
*After one year: 4.6 percent

SOURCE: JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION

Flum added that weight-loss surgery usually is the only thing that works for extremely obese patients, and that the benefits generally outweigh the risks. Nevertheless, patients should go into surgery "with their eyes open."

Increase in obesity

The studies are reported in the Journal of the American Medical Association.

Surgery is recommended for people with a body mass index higher than 40, meaning they are roughly 100 pounds or more overweight. (Less obese patients can qualify for surgery if they have obesity-related conditions such as heart disease and diabetes.)

Several surgical techniques restrict how much people can eat by shrinking the stomach. The most common technique is known as a gastric bypass. Patients typically lose 60 percent to 70 percent of excess body weight the first year, though many eventually gain some of it back.

The rise in weight-loss surgeries has paralleled the rapid increase in obesity. Between 1986 and 2000, the percentage of people with BMIs of 40 or higher quadrupled.

Most patients who undergo weight-loss surgery have family incomes higher than $45,000. Only 16 percent are men and only 2 percent have incomes under $25,000, reported University of Chicago researcher Dr. Heena Santry and colleagues.

A study of gastric bypass patients in California found that 19.3 percent were hospitalized during the next 12 months, mostly for surgery-related complications such as infections, hernias and bowel obstructions. That is more than double the 7.9 percent hospitalization rate during the 12 months before the operation.

However, the mortality rate in the California study was only 0.9 percent -- less than one-fifth the mortality rate in Flum's study.

Flum's study included Medicare patients. Most were under 65 but qualified for Medicare because they were disabled by their obesity. Experts said this population likely was less healthy to begin with than patients in the California study.

Weighing the risks

Flum said many patients have a good understanding of the hazards of weight-loss surgery, while others are heedless of the risks. "They say, 'Doctor I feel like I'm going to die if I don't have the operation,' " Flum said.

Dr. Michael Kohrman, a pediatric neurologist, said he carefully weighed the risks before he underwent weight-loss surgery in August 2004 at the University of Chicago. Kohrman weighed 283 pounds and had a family history of heart disease. He figured the risk of dying from a heart attack was greater than the risk of dying from the operation. He's now down to 159 pounds.

Kohrman's wife, Mary Hayes, had undergone weight-loss surgery a year earlier. Her weight has dropped from 274 pounds to 160 pounds.

"It's been absolutely life-changing for both of us," she said.

It's a very crude surgery.
Cutting out one's intestines so they are forced to under eat is not a solution to a complex endocrine, neurological, and psychological disease.

Physically, eating very low calorie and low carb allows for weight loss and a restoration of integrity to endocrine system. The diet helps control the true obesity. However, so does a low carb diet.

What makes the surgery the runaway success it is, is it's powerful psychological, and behavior-modifying effects. A low carb diet addresses just a tiny factor of obesity (the true physical condition). Unfortunately most people's obesity is so much more complex - psychologically, emotionally, behaviorally - these factors prevent the physical cure from working. We are an anomaly. Most people, even carb sensitive people, do not make this work. WLS fills the gaps that a diet does not.

Psychologically, the surgery is a huge benefit.
One is given volumes of support. Their perception of themselves change after the surgery - they feel they can succeed. The WLS patient has strong conditioned responses between self hatred/shame, failure, and dieting. The WLS patient has engaged in ill fated weight manipulation attempts so many times prior. It is so that the WLS patient engages in self undoing when starting a diet, simply because they anticipate failure.
WLS is different. There is a fresh association in their minds between surgery and weight manipulation. They are eager to try and really commit this time. They find, unlike other diet attempts, it's easy and automatic, because they aren't killing themselves doing something unnatural that is an every day effort like self starvation and too much exercise. (That's why I never did more than I had to - I did the bare minimums to keep loses going and it never felt labored. Thinking about it that way made it easier to actually do the big changes that are required of weight loss.)

Another factor is eating disorders. Carbohydrate sensitivity pretty much means food has an above average drug-like effect on the body. When food is withheld we go into withdrawals due to a suppressed capacity to generate energy from body fat & stored sugar. Physically the body goes into withdrawal. Emotionally, one tends toward negative feelings such as anxiety, panic during a sugar low. Speaking personally, when my sugar starts to decline - even before I reach the obvious "panic stage" when my body is pouring out adrenaline and doing nasty things to my mind and body - I start to feel a inner "jumpiness" and nervousness that is very unpleasant. That's just the mind-affects of a sugar low which is transient withdrawal; let's also not forget carbohydrate is strongly related to chronic bi-polar form depression because of what it does to blood sugar (which then affects serotonin & other chems). I alternate between bouts of feeling "not too horrible" and "extremely horrible" on carbs (lucky bastards who get the sugar high grumble grumble).
On the other hand, eating has a curative effect for mood. When food is consumed, our blood sugar spikes rapidly, which encourages the body to change neurochemicals so as to produce relative feelings of pleasure and stress relief.
We know morbidly obese people are carb sensitive which means they are more sensitive to the ups and downs of food. Morbidly obese people, also, tend to get into shame spirals about the symptoms of their disease (weight, eating) or other things in life.
The combination means many morbidly obese people are binge eaters and compulsive eaters. Food is their drug.
The pains and difficulties with trying to cure obesity is more than simply physical withdrawals from carbohydrate; the emotional withdrawal is significant, too. They get used to looking at food this way - as something that will make EVERYTHING feel better. It becomes a friend, a companion.

The basis for seeking food-high may be related to carbohydrate (which is now controlled) but emotionally the urge is still there. This is why controlling carbs isn't enough to fix food addiction; it takes a conscious awareness of the problem and an effort to develop alternate coping mechanisms & look at food differently.
Past diets failed to help them control psychological impulses for "food high". Many were even unaware of why they kept failing even when diet worked (e.g. Atkins or another LC program).

The WLS forces the patient to develop coping mechanisms and to break the bad habits of food addiction. It is no longer an option when eating sugar causes you to vomit, and your stomach is the size of an egg. It's not pleasant - many go through much agony over the process (they don't really have a choice and are given no practical guidance on how to deal with it). As with the whole surgery, it's a messy ordeal.



Anyway what I guess I'm saying is that WLS, physically, is not necessary.
Psychologically & behaviorally, it fills the gap that a diet does not. For someone with a long history of failed diets, and significant food addiction, it's very effective.
Speaking personally, I did not need it. With absolutely no negative association between failure and weight manipulation, and with emotional eating making the much smaller part of my weight problem... all I needed was to figure out the carb diet is poison to my body. I am lucky to find it so young. If I found this when I was in my 30s, it's possible that I'd be psychologically ruined by a history of dieting & depending more and more on food addiction.

It does address the problem since after WLS you need to become very selective about what you eat. You need to prioritize nutrient dense food or you will become malnourished. When you can only eat small amount of food, you can't afford to make it nutrient-poor filler food.

And there are many things you simply can no longer eat under pain of "dumping"

My across the street neighbor had gastric bypass and now she is at here goal weight and can not stop loosing. If she eats anything with carbs in it she gets sick. So basically the surgury was a forced low-carb diet for the rest of her life. Sad that she could not just do the low-carb without the surgery.

I agree. When regular food nauseates you, and you vomit it, you become happy not to eat it. But the "food" they eat, at least initially, nauseates me.

Lets face it, without behavior (food choice ) modification this surgery is still a failure even if you survive it.
A girl I work with had it done some years ago, lost a tremendous amount of weight, also had blood clots threaten her life during and after the surgery as well as a truckload of problems such as anemia, other blood disorders, and nutritional deficiencies. She had to have a tummy tuck which created infections and skin failure so now she doesnt have a belly button (which would be really odd way of going thru life to me. )

End result.. she's apparently stretched her stomach back out and has gained 40 lbs and brings a huge sack of chips and candy with her to work as well as eating several meals during a 12 hour shift. I used to notice that she only ate half or less of whatever meal she had.. now I very rarely see leftover food from her plates in the fridge like I used to.

Im not condemning her, just observing that spending nearly $200,000.00 (surgeries plus complications ) does not fix the problem without addressing the underlying compulsory / emotional eating patterns.

What would the medical community's response be to a successful weight-loss diet that had these mortality rates? Or a weight loss drug? I'm sure that there would be universal condemnation of the diet and massive lawsuits. Why does the medical community allow these surgeries to take place? Where is the national outrage?

I think it was Mark Twain that said there were three types of lies - lies, damn lies and statistics.

The mortality rate for weight loss surgery is not 4.6% after one year. The mortality rate for weight loss surgery performed on a specific subset of obese patients, specifically obese patients that not only qualify for Medicaid but additionally meet Medicaid's requirements for weight loss surgery. These Medicaid requirements include other dangerous medical conditions in addition to obesity, generally diabetes or heart problems. If the study were to have been more representative of the actual population of obese patients getting weight loss surgery, those stats for mortality would drop.

Anybody got the stats for the average shortening of a lifespan of an obese patients with BMIs greater that 35 (the average you need to get weight loss surgery) that is untreated? I bet that more than 5% of those people have their lifespan cut significantly short due to disease/health issues related to obesity. And that is the topic of national outrage at the moment.

I'm not saying WLS is the right answer, but I would bet if it's an either/or proposition, the stats for WLS beat the stats for untreated obesity.

actually, not only does the gastric bypass make your stomach so tiny that you are full with a small amount of food, but it also removes a length of intestines that prevents the absorbtion of some of what you actually DO eat.
so even physically, it is pretty different than LC.

I have to say, my MIL had this done a few months ago and has done very well. Not that I'm happy she chose this path, I really tried to convince her of LC, including giving her Dr. Bersteins book but she never could seem to grasp its concepts. She is one of these that had so many problems that she needed to do something, and has since gone of the vast majority of her meds. Still she doesn't get what eating is, to her a potato is a vegetable, so she eats potato. She still eats what she wants for the most part, and doesn't care. She does try to focus on proteins, and her shakes, but she eats very little fat, and her skin looks it. I try to tell her she needs some fats in her diet, but for a nurse she just believes what she is told by the dieticains, so yeah she is eating much less than what she did in the past, but it is still a very poor balance of food, and I fear greatly for the long term effects of poor nutrition, and lack of activity. It is very sad for me to see, even though she has done so well otherwise, I don't think it will be the permanant fix that she wants it to be.
Tanya