Transcription:
Bariatric Surgery, Obesity, Weight Loss

Caitlin Whyte: Bariatric surgery is a term that encompasses several procedures, each with its own benefits to different types of patients. Today, we're chatting with Dr. Robert Catania to talk about surgery options who makes a good candidate and managing obesity as a whole. He is the Director of Metabolic and Bariatric Surgery at the Southern New Hampshire Medical Center. This is the Solution Health Podcast from Solution Health. I'm your host, Caitlin Whyte. Dr. Catania, what got you interested in the management of obesity?

Dr. Catania: I sort of stumbled upon obesity as an interest. I was completing a fellowship in advanced laparoscopic surgery and started doing bariatric surgery as part of that training. And when I saw the success that the patients were having and the really life changing effect that the surgery had on people, I became more and more interested in it. I studied it more and ultimately found that it was a really a great way to help patients and to have an enjoyable career.

Host: And why should we care about the treatment of obesity?

Dr. Catania: Well, obesity is a chronic disease and it's a progressive disease, and it's also a very prevalent disease. The number of patients with obesity in the country continues to grow. And the medical problems that develop from obesity include diabetes, hypertension, sleep apnea, obesity can increase your risk of cancer. So by treating obesity, we are able to effectively lower your risk for cancer. We're also able to effectively treat some of those other chronic medical conditions that people will develop such as diabetes and hypertension.

Host: Now let's talk about the difficulty of treating and managing obesity. Why is it so hard?

Dr. Catania: Basically, is a really complex disease. Part of the problem is we really haven't treated obesity like a disease in the past. It's only in the last few years that we've recognized it as such. We don't really understand why some people develop obesity and some don't. We know that there are behavioral characteristics associated with obesity. There are some genetic predispositions toward obesity. We also know that some medical treatments such as medications for blood pressure or depression can lead to obesity. So since we don't fully understand what causes obesity, it's kind of hard to design treatments to specifically attack those problems. What we do know is that when you treat obesity as a disease, and when you use counseling, dietary alterations, exercise programs, medications, and surgery, all in combination, we're much more effective in having success and achieving long-term weight loss.

Host: So, if someone wants to start treating their obesity, what kind of options are available to them?

Dr. Catania: Depending on what degree of disease the patient has. There are different options. Patients who are just overweight. So that means their body mass index is somewhere between 25 and 30. Oftentimes can be successfully managed just with some nutritional education, with some exercise programming, and also a look at their medication lists to see if there are any medications that they're taking that are causing them to be prone to obesity as your body mass index increases and goes above 30. That puts you in the obese category when your BMI is above 35, that puts you in the severely obese category. And when it's over 40, that puts you in the morbidly obese category. As you get into the obese, severely obese, and morbidly obese categories, what we use to treat the disease changes. And so we'll go from counseling and education, then add medications to that. And there are several effective weight loss medications available right now. And then for really severe disease, that's when we would consider using surgery.

Host: So, let's talk about surgery, how effective is bariatric surgery?

Dr. Catania: So right now, bariatric surgery is the most effective treatment for obesity. In general patients, depending on which operation they choose will lose somewhere between 50 and 80% of their excess body weight using surgery. And approximately 60% of patients who undergo surgery will maintain long-term weight loss. That does mean that 40% of the patients who have surgery will gain some or all of the weight back that they have lost after surgery. And that's why I say it's a very complex disease and there's no one treatment that is right for everybody, for patients who have had surgery and are successful. Then generally what we ask is that they continue to follow up with us carefully and we can monitor their weight, any changes and intervene earlier if there's a problem. So patients who are not successful, who either didn't lose enough weight initially, or who regained a lot of their weight after surgery, then we have to add other layers of treatment.

Host: Now let's talk about the safety of bariatric surgery. That's always a concern. How safe is this type of surgery?

Dr. Catania: Bariatric surgery is actually one of the safest surgeries that you can undergo. There were historical problems going back 20 or 30 years. And there was a time when bariatric surgery was largely done with open surgery and where the complication rates and the mortality rates were high. Over the years, we've actually refined the techniques of surgery, and we've shifted almost entirely to laparoscopic surgery when we deal with bariatric surgery. So that means smaller incisions, quicker, recoveries, less pain, less complications, and most importantly, a much lower mortality rate. So right now the risk of mortality or dying from bariatric surgery is 0.1% or one in 1000 operations. So that means it's safer than a lot of very common operations that are done today, including gallbladder removals and hip replacements.

Host: With all this talk of the different kinds of surgery and the safety who makes the best candidate for bariatric surgery?

Dr. Catania: The best candidate for bariatric surgery would be a patient who has committed themselves to making good dietary choices, who is able to perform some degree of exercise. And then who is willing to make the long-term changes that are necessary to accommodate the surgery that they have. So what we find after surgery is that most patients can eat pretty much anything they want. They just end up eating much smaller portion sizes, depending on the operation that you choose. You may also find that there are certain things, particularly high carbohydrate foods that you're not able to eat, but in general, if a person has obesity, particularly if they have obesity and they're starting to find they're developing other metabolic problems like high blood pressure or diabetes, that's a good candidate for surgery.

Host: Let's get into the nitty gritty. How does this surgery work?

Dr. Catania: How does bariatric surgery work is a great question. And the answer is, we don't really know. So interestingly, when we started doing bariatric surgery, you know, 30 or 40 years ago, we designed the operation to do a couple of things. One is we designed to be very restrictive so that patients couldn't eat very much. And then we also designed it to be malabsorptive that is preventing some of the nutrients from being absorbed into your body. It turns out that we came up with the right operations, particularly with the gastric bypass and the sleeve gastrectomy, but they turned out to be right for the wrong reasons. So it seems like the restriction and the malabsorption are less important than some of the other metabolic changes that are created by the surgery. So the reconfiguration of the GI tract causes some of the hormone levels in your body to change. And that seems to actually lower the set point that your body wants you to weigh. We all have this little area in the brain that is responsible for maintaining our weight. And it's sort of like the set point in your brain that maintains your temperature. You can't really change your temperature just because you want to, you can't diet your temperature up or down. Same thing with weight. You really can't change your weight just because you want to, we have to manipulate that set point in your body. And the surgery seems to lower the weight set point. We still don't know exactly how. So, I like to say, we kind of found the right operation for the wrong reason.

Host: For someone who's listening, who may have tried to lose weight for years and just never found the success they wanted. How is this route any different?

Dr. Catania: One of the problems with obesity is that it is a chronic and progressive disease. And another of the problems with obesity is it's an neurologic disease. It's a disease of the brain. Your brain decides it wants you to weigh something greater than what we think is a healthy weight. And there's a lot of reasons why that weight set point seems to climb in patients, but you can't wish it away. And you really can't diet or exercise it away. And a lot of people say, Oh, all you got to do is eat less or exercise more and you'll lose weight. And if you need to lose five or 10 pounds, that's probably true. If you need to lose 50 or a hundred pounds or more, that's probably not true. You've reconfigured your brain somehow. So that now once you weigh more, so diet and exercise alone is never going to get you there. And that is why surgery actually comes into play. And some of the weight loss medications available as well. Cause they go to the root of the problem. They help lower that set point so that you can bring your weight down. Now it does mean that you still have to make good food choices and it does mean that you still have to be active. So good, good nutrition and good exercise are always part of a weight loss program. But in most cases they're not sufficient. You actually have to have that extra help to lower that set point. So when you combine diving plus exercise plus surgery, you're much, much more likely to be successful.

Host: Now I've seen stories of people who have even had this bariatric surgery and then they regained the weight. Why does that happen?

Dr. Catania: Success rates after bariatric surgery are approximately 60%. So that means the majority of people who have weight loss surgery will actually go on to maintain a lower, healthier weight. About 40% of people will see some degree of weight gain, or they won't lose as much weight as we had hoped for at the time of surgery. And that sort of speaks to the multidimensional cause of obesity, because there are so many things that contribute to the raising of that weight set point in your brain. Sometimes surgery alone is not enough to get you success. We do see some people who have behavioral issues like eating disorders that cause them to regain weight. And if that's the case, then we need to obviously work on them with behavioral modification. We do see some patients who have complications of the surgery, although those are really, really rare. And if that happens, then we can treat those surgically. But a lot of patients’ surgery just is not sufficient to get the weight loss that they need. And we need to combine surgery with something else. And in the last few years, what we started to do is add weight loss medications after weight loss surgery. And so the surgery gets you some degree of success and then the medications get you more success. And what that probably means is we're probably targeting different pathways with surgery and medicine, and some people just need all of those pathways treated simultaneously to really achieve success.

Host: So, if we're really thinking about having bariatric surgery, where do preexisting conditions come in? I mean, my first question is if I have diabetes or hypertension, can I still have this type of surgery?

Dr. Catania: Absolutely. In fact, if you treat diabetes or hypertension, some of those medications are likely to cause weight gain. So you may see that by treating your diabetes or your hypertension alone, you're causing yourself to gain weight. Paradoxically weight gain contributes to diabetes and hypertension. So you may actually be making yourself worse off by being on some of the medications available today. On the other hand, if you treat obesity first, often the diseases that co-mingle with that such as diabetes, hypertension, or sleep apnea will get better just from weight loss alone. So if you have high blood pressure, or if you have diabetes, you're actually a perfect candidate for weight loss surgery, because the weight loss will actually improve those other diseases as well.

Host: Now, wrapping up here, my last question kind of bouncing off the last one. What if I've had abdominal surgery like a hysterectomy or gallbladder operation? Can I still have bariatric surgery if I've had those in the past?

Dr. Catania: In almost all cases, the answer is yes, there are very few patients I've encountered over the years who have had so much surgery that it's made it impossible to do the weight loss surgery. And I honestly, in several thousand patients, it may be one or two people that we couldn't complete the operation. It does make it a little bit more difficult because sometimes we have to work around scar tissue or other obstacles created by the previous surgery. But in general, unless you've had multiple major surgeries, there's no reason why we couldn't consider weight loss surgery for you at the moment.

Host: Well, Dr. Catania, thank you so much for your time and for this discussion. For more information, visit solutionhealth.org and check out our full podcast library for other options that may interest you. This has been the Solution Health Podcast from Solution Health. I'm your host, Caitlin Whyte, stay well.