Broward County

Weight-loss surgery: Changing behavior is key

FOR THE MIAMI HERALD

Lynnette Marrero tells the story of a conversation she had with another woman while she was waiting for a gym class. She mentioned in passing her recent weight loss. The woman responded that her aunt, too, had just lost a lot of weight — only she had cheated, the niece said, by undergoing weight-loss surgery.

“I don’t think that’s cheating,” Marrero told her. “There’s no magic pill, there’s no magic surgery. You still have to work for it.”

Marrero didn’t say she was a case in point. After battling weight issues since she was a child, the 39-year-old mother of three underwent a sleeve gastrectomy — one of the three major bariatric procedures — in January through Memorial Healthcare System’s Weight Loss Surgery Program in Broward.

Like most people who undergo bariatric surgery, Marrero had tried everything to keep a healthy weight. A self-described “poster child” for Weight Watchers — she had been in the program since her teen years, she says — and an avid kickboxer, Marrero at one point lost up to 65 pounds.

She gained it all back, and while each of her pregnancies added more pounds, her cesarean sections — which cut into abdominal muscle — made shedding them even more difficult.

“Being a mom — my primary goal was to be healthy for them. It wasn’t about numbers on a scale, it was about being healthy,” said Marrero, who has lost 85 pounds since her surgery. “It was finally time for me to take charge of my life and my health.”

Popular assumptions surrounding bariatric surgeries obscure how woefully ineffective nonsurgical interventions into severe obesity have been — most studies put their long-term success rate at around 5 percent — and how good bariatric procedures have been at getting patients to both lose weight and improve their general health.

“The effectiveness is truly amazing — when you look at the effect on these chronically ill, obese patients, we actually can put [type 2] diabetes into remission 82 percent of the time. There are similarly good results for blood pressure and sleep apnea,” said Dr. John Morton, president-elect of the American Society for Metabolic and Bariatric Surgery (ASMBS). “There are studies that show that having the surgery versus not having it decreases your overall risk of mortality by 40 percent.”

Since the introduction of laparoscopic methods, the mortality rates for bariatric procedures have also plummeted, making weight-loss procedures among the safest surgeries today.

“Our mortality rates are on par with hip or knee replacements,” said Morton.

Like all surgical procedures, weight-loss surgery does carry a slew of potential complications; about 1 in 25 patients experiences major problems. Marrero herself had to go back to the hospital twice for dehydration, a typical complication.

But bariatric patients must also commit to healthy habits after the surgery. Bariatric procedures control the quantity of food patients can eat before feeling full — but not the food’s quality.

“It all starts before surgery — with setting correct expectations. What the operation can do for them and what it can’t do for them,” said Dr. Anthony Gonzalez, medical director of South Miami Hospital’s weight-loss surgery program. “They have to understand that the operation is really only a tool, and they have to change all other aspects of their life.”

To be accredited by the ASMBS and the American College of Surgeons’ joint program — the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program — bariatric centers must report their outcomes, follow up with patients, have specialized surgeons and the right equipment, and the staff and program on hand to help patients adopt and maintain new habits.

That means having nutritionists, psychologists and exercise physiologists on staff to guide patients before and after the procedure. Accredited centers also must host regular support groups led by a healthcare professional, where post-op patients — as well as those thinking about the procedure — can talk through questions, both psychological and physical.

Both Memorial and Baptist, which are accredited, also offer special bariatric personal-training programs. Memorial Healthcare System recently instituted a policy of letting bariatric patients use its fitness facilities at no charge for up to three months.

Bariatric procedures are considered successful if at least 50 percent of a patient’s excess weight is lost and not regained up to five years after the procedure. In that regard, success rates vary across surgeries.

“For a laparoscopic [adjustable gastric] band, there’s a 50 percent success rate. Something like a sleeve [gastrectomy], you’ll have something like a 20 to 30 percent failure rate. And something like a gastric bypass will have a 5 to 10 percent failure rate,” Gonzalez said.

Gastric bands typically require adjustments after surgery, depending on weight lost, eating habits and symptoms. Dr. Brett Cohen, chief of bariatric surgery at Memorial Regional Hospital in Hollywood, argued that sometimes poor patient care after surgery at non-specialized centers might be to blame for greater rates of failure with gastric bands.

“Bands are based on ... how well you follow patients after surgery. So if you have a formal bariatric program, not one of these plastic surgery places, but a formal bariatric program, those patients can do just as well, although the rate of weight regain tends to be a little higher with a band than a bypass or sleeve,” said Cohen. “It’s a very frustrating situation for those of us in formal bariatric programs, because it’s not a problem with the band. It’s a problem with the care the patient is getting.”

Another uphill battle for bariatric patients: cost and access. Although bariatric procedures have been shown in studies to pay for themselves in the long run through reduced medical expenses and increased productivity, the upfront cost of the procedures — between $11,000 and $26,000 — is typically too much for most people to pay out of pocket.

Insurance coverage for bariatric surgeries has expanded greatly in the past decade — Medicaid and Medicare cover it, as do most states, including Florida, for their employees. But there are gaps. Major insurers usually cover the procedure, but many employers opt out in order to keep premiums lower. And Florida is one of 28 states that do not include bariatric surgery as an “essential health benefit” in its state health exchange.

“With all the surgeries being done in America — which is about 175,000 a year — we need to understand that we are only taking care of 2 percent of [potential candidates for surgery],” said Dr. Raul Rosenthal, director of the Bariatric and Metabolic Institute at Cleveland Clinic Florida. “Why? A lack of understanding — patients don’t see themselves as candidates, second of all is fear, and third of all is ignorance on the side of the physicians that don’t recommend the operation. And insurance coverage, obviously.”

Who qualifies for bariatric surgery?

The National Institutes of Health considers candidates those with a Body Mass Index of 40 or greater, or a BMI of 35-39.9 with additional obesity-related medical conditions.

For a complete list of bariatric centers in Florida accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, visit www.facs.org/quality-programs/mbsaqip.

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