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Prakash Chandran (Host):   Many of us diet at some point in our lives to lose weight, but for some people bariatric surgery may be a better solution for lasting weight loss. We’re going to talk about it today with Dr. Michael Kia, a bariatric surgeon at McLaren Regional Medical Center. This is McLaren’s In Good Health, a podcast from McLaren. I'm Prakash Chandran. So Dr. Kia, for most people bariatric surgery becomes an option after years of failed attempts at weight loss. So can you tell us a little bit about what may indicate that someone is a good candidate for bariatric surgery?

Michael Kia, DO, FACOS, FACS (Guest):   Sure. When you say years patients that eventually have bariatric surgery have actually been researching it for an average of almost 10 years. That means they’ve been doing research on it, looking at it on the internet, thinking about it, and questioning why can't I lose weight on my own? The real reason that most people can't lose weight on their own is because weight gain and weight loss is actually neurochemical changes that are happening in the brain. When people gain weight, the brain changes, and the body was never really designed to lose weight. When a person attempts to lose weight, the brain frequently fights, and they regain their weight even if they were successful at losing it. People come to chose bariatric surgery many times after they’ve had multiple failed diets. The studies actually show that the success rate for diets is really, really low. There's no right time for patients to come to bariatric surgery. For many of them it could be a new diagnosis like diabetes or heart disease. For others it becomes a physical limitation where they're not able to do things with their children or their family members that they once could, especially as they get older. For most of the patients that I've met, while they’ve been thinking about it for many years there's always something that changed where something got worse. Now it’s time to make that difference for the rest of their life.

Host:   Yeah. I can't believe that the average time is 10 years that people spend researching and considering. I totally understand. It’s a very daunting thing to go through. Ironically I have a close friend that just recently went through this and she’s so happy that she did the surgery. I want to move on to asking about the process leading up to the surgery. Talk to us a little bit about the first appointment, any diagnostics that are needed. Just things that patients should be aware of leading up to the surgery.

Dr. Kia:   Most of the time it begins with meeting with a surgeon. Sometimes people have already met with dieticians for a long time. Here in the United States there are some criteria regarding the average weight that a person needs to be to have insurance cover their procedure. That usually begins at a BMI of 35, which is typically 75 to 85 pounds overweight. Usually they’ve met with their family physician who then refers them to see a bariatric specialist. We meet together and we discuss their health. We go over their life story. It’s usually a very long meeting. Many times the appointments can be an hour or two as they meet with both the surgeon, the dietician. Usually there's other types of counselling that they may meet with either on their first appointment or on future appointments. Most insurances in the United States typically require some degree of weight management meaning that a person has made reasonable efforts through a dietary program for usually about six months without real success in order for them to qualify for coverage through their insurance plan. That’s not true for all insurances, but for most.

So we, on average, spend about six to eight months with each patient before we even come to surgery through education, weight counseling, nutrition, behavioral modification, and physician counselling. It’s so important that patients recognize that the surgery is just one aspect of the changes that’s going to happen to them afterwards. So we spend a lot of time with them, teaching them, getting them to understand what the difference is going to be as they make this positive change in their lives.

Host:   So let’s talk about the different types of procedures? What are they and tell us a little bit about what the recovery time is like for each of them?

Dr. Kia:   So today in the United States the two most common procedures that are performed are the gastric bypass and the sleeve gastrectomy. Both of them are surgical procedures and people undergo general anesthesia, that means that they go to sleep for the surgeries. The surgeries take anywhere from an hour to two hours and people typically stay in the hospital for one to two days after surgery. The surgeries are almost exclusively done laparoscopically, which means through small little incisions on your belly. Recovery time is typically around one week to 10 days. Most people return to work after about two weeks. The general recovery from the surgery is small but the life changes are tremendous. It does take time for people to adapt and adjust to a new way of eating, understanding a different way of thinking about food, and having food as part of their life. For may people, food was a consoling, it was an emotional, it was an overwhelming aspect of their everyday life. After surgery because of the way that the surgery works in changing the biochemistry of how the brain thinks about food, people now have to adapt to these new life changes.

Host:   So let’s get into that a little bit. When you say new life changes, what does that exactly mean? Does that mean that they have to eat a lot less? Does that mean that they have to restrict themselves to certain food? Maybe talk about some of the most common ways that a lifestyle is altered after surgery.

Dr. Kia:   So amazingly the surgery doesn’t work because it makes you eat less. The surgery works because you don’t want to eat anymore. By changing the chemistry of the brain back to how it was before the disease of obesity began, people start to eat again as they used to. Meaning their brain and their body doesn’t crave sweets or large portion sizes. They remember what it feels like to be full again, to feel not hungry. That’s an unusual feeling because for so many years, for so many of the people that go through this disease, their thoughts are always around food because the brain has gotten used to seeing and experiencing food. Afterwards one of the biggest ironies is we have to tell people to remember to eat because after surgery the brain forgets. It’s as if it doesn’t care anymore. So we spend a lot of time reminding people you have to get in a certain amount of protein every day. You have to get in a certain amount of food because people will after surgery for many, many months as they lose weight think, “I don’t even care about eating.” That is really an amazing process that occurs.

Host:   Yeah. It definitely sounds like it. So you mention two different types of procedures. As a potential bariatric surgery patient, how do you determine which one is right for you?

Dr. Kia:   So because many people have done a lot of research on their own, most patients come to the office with some idea of what they believe might be the right procedure for them. Like anything else, it’s a conversation with the surgeon looking at their health conditions, looking at their other what we call comorbidities—their other health problems—and then try to decide what surgery’s the best for them. Both surgeries are very effective. They work in slightly different ways and they both have advantages in certain areas. For instance, if a patient has a lot of heartburn or a lot of reflux, the sleeve gastrectomy may not be the best option for them. If they're a really bad diabetic—and we see a lot of patients coming for resolution of their diabetes—the studies have shown that the gastric bypass is a superior procedure for resolving or reducing the diabetes. For some patients, the sleeve may be a better option especially if their overall weight is a little lower and their significant health issues are not as severe.

Host:   I'm sure that people listening to this are thinking that this sounds like a good option for me, but they might be worried about potential complications. Maybe talk a little bit about the typical complications that arise and what patients can do to minimize the likelihood of them.

Dr. Kia:   One of the most fascinating things about bariatric surgery is that it’s probably been one of the most scrutinized and studied surgeries in all of our departments. Thankfully through the efforts of many, many people over many years, bariatric surgery has actually become safer in the United States than some of the other surgeries that people consider to be the safest like gallbladder removal or having a hysterectomy or even having a joint replacement. Overall, bariatric surgery in the United States is safer than all of those procedures. So that’s a really surprising information for many people because they come to believe that bariatric surgery is inherently risky when in fact the training of the surgeons in the United States and the overall review has led to it becoming one of the safest procedures that we actually perform.

So from a surgical standpoint what we call the time around the surgery is actually very, very safe. Sometimes people think about complications and they talk about late complications. I can tell you in the many years—almost 15 years of doing this—what I see most frequently is that the people that run into problems with bariatric surgery, it’s usually due to failing to continue to follow up with their physician on a regular basis. Bariatric surgery is a life’s decision that’s not made for just one moment. It’s an acceptance that going forward, we’re going to continue to follow up with our family doctor. We’re going to continue to follow up with our surgeon at least once a year. Sometimes life changes and people go out on their own and they're what we call lost to follow up meaning they just disappear into the world. Bariatric surgery is not designed for people that get lost to the world because inevitably problem arise. Without someone, a physician, or someone that they're in contact with to help them through these smaller problems they can become bigger problems.

Host:   Yeah. I can see why the follow up is so important because after the surgery is done, you really want to make sure that you’re following the guidelines to make sure that you're eating healthy and maintaining that weight. Speaking of which, I'm sure a lot of people listening to this are how likely it is that the weight comes back because we’ve all heard of situations where people have gotten these surgeries and then within a year or two they get all of the weight back. So maybe talk a little bit about that.

Dr. Kia: Yes. In the United States what we call the recidivism—the weight regain rate—is about 20%. That means 20% of people that have bariatric surgery will regain a significant amount of weight at 10 years. Now, you have to keep this in perspective. If you compared bariatric surgery to just diets—So if you take a patient or a person that has morbid obesity and you ask them to go on a diet—whatever diet you pick, the best diet you’ve ever heard of—the five year success rate is 3%.   That means only 3% of people that have morbid obesity that go through a diet program will lose weight and keep it off at five years. 3%. The bariatric surgery success rate is 80% at 10 years. So the numbers are tremendously different. If you were to sit down at a slot machine and say, “Well, this machine pays out 3% and that machine pays out 80% of the time,” the answer would be obvious. We tell all of our patients what we’re giving them in bariatric surgery is a start over. An opportunity for the brain, the body to return back to a point before the disease began. We I've them the knowledge, the information, the guidance, the support, the follow up. Everything. Our programs are put in place for a lifetime, but in the end all we’re giving is a redo, a start over. We’re not doing a guarantee. I think that’s one of the most important things we share with our patients now.

Host:   Yeah. Absolutely. When you make that comparison to diet, the numbers are crazy. Just to wrap up here, I know that some of our listeners may be on the fence about getting bariatric surgery. What advice might you have for them?

Dr. Kia:   The first advice I would always tell the patient is put a concerted effort, a real effort, to losing weight. Sometimes we have our patients come to our office and they're not sure if they want to go through with bariatric surgery. I explain to them that we have a tremendous amount of resources from nutritional counselling, psychological counselling, behavior modification, group support. To make use of all of those things and to do those for six or eight months or a year, and in our institute do them for free at no cost. If after a year this isn’t working them let’s sit down again and talk about surgery. Because at that point the person can really look at themselves and say, “I need to make a change. I can't keep going like this. Everything is starting to fall apart. I've really tried.” That’s where I think bariatric surgery fits best into their life.

Host:   Well Dr. Kia, super inciteful conversation today. I really appreciate your time. That’s Dr. Michael Kia, a bariatric surgeon at McLaren Regional Medical Center. Thanks for checking out this episode of McLaren’s In Good Health. To learn more about Dr. Kia or to submit a question, visit mclaren.org/kia. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk next time.