Increasingly, more people are approaching their weight loss efforts with a preventive attitude. Today in my clinic I saw two people who represented what I think is the future for forward thinking people and their doctors. Each of them was significantly overweight with a body mass index between 30 and 40, but neither of them had severe health problems from their overweight or obesity. Yet, that is.
The first patient, a thirty-three year old female whose mom has type 2 diabetes knows that she is committed to losing weight, but has just not had the right tools and knows also that if she is not able to lose the weight, her mother’s health problems will become her own. As she described it to me, there really is no reason for her to wait until she develops type 2 diabetes or hypertension or any of the other obesity related health problems before she moves forward with an aggressive weight loss program. In her case she wishes to undergo Lap-Band surgery and I believe she will be quite successful with it.
The other patient, a forty-one year old male, was told by his doctor he has a condition known as “pre-diabetes”. He wasn’t exactly sure what this meant or if it was even important, but it sounded ominous. I discussed with him the definition of pre-diabetes and we talked about his glucose tolerance test, which showed his body is unable to handle a challenge of ingested oral glucose. This means he has the high likely-hood of progressing to type 2 diabetes, which will require medications. It means that while his blood sugars are not typically out of range, if he eats and has a significant carbohydrate load then the blood sugars to rise into abnormal territory.
By some estimates, seventy-million Americans have pre-diabetes and most of them will progress to type 2 diabetes in their lifetime. Most of these people are also overweight or obese. As this gentleman stated, “Why wait for the diagnosis of full-blown diabetes”.

I saw a patient today who has battled with depression intermittently throughout her life and also struggled with obesity. She wonders if the two are related, but also about how she will manage the depression after her weight loss surgery. Is it still possible to take medications should she need them? Might her depression improve if she undergoes weight loss surgery?
Interestingly, the research on depression and obesity shows it is a two way street: depression leads to more obesity, but obesity itself exacerbates depression. It makes sense, if we think about it. Depressive feelings can lead to overeating and loss of motivation to exercise. Likewise, obesity can lead to feelings of lower self-esteem and lower one’s mood.
Research also indicates some people do experience improvement in their depression after weight loss surgery.
Similar data exists about non-surgical weight loss. Of course it is hard to separate out which comes first, better feelings of self-esteem and higher motivation that lead to successful weight loss or some improvements in weight, leading to better body image and some improvement in mood. Ultimately, this chicken and egg question may be difficult to answer, and the most important advice is to seize the day and to work very hard on both problems. By this, I mean that if you struggle with depressed mood then seek help immediately including psychological counseling and visiting with health professionals who may offer effective antidepressant medications and recommend mood elevating activities like exercise. Likewise, if you are overweight or obese, don’t let another day go by without working on this problem too. Seek professional help. Follow the strategies and tips outlined here and in my books and you will benefit with lower weight and an improved mood.
For my patient today, I also let her know that antidepressant medications can be taken and absorbed after Roux-en-Y gastric bypass surgery. We do believe it is best to change from any extending release formulations (for example Effexor XR) to the standard release formulations that usually must be taken two to three times a day rather than only once a day.
Like so many complex facets of human health, depression and obesity are closely linked. One affects the other, but more importantly one is improved by improving the other

It is not uncommon for me to hear questions along the lines of:
“Will Having Weight Loss Surgery Guarantee That I Won’t Regain the Weight?”
or
“If weight loss surgery is so effective, why do some people need revision weight loss surgery?”

A recent large clinical study found that 89% of people maintained their weight loss after bariatric surgery over an eight-to-ten year time frame. That still leaves at least 11% of people regaining significant weight, and with well over 200,000 procedures performed every year, those with weight re-gain represent a large number of people.

At least five studies, three of them with large samples, have demonstrated a dramatic improvement in life expectancy and reduction in disease over many years among groups of people studied who underwent weight-loss surgery, as compared to people who did not.

But the surgery is far from perfect or a magic cure-all. The same temptations and drives, stresses and human behaviors are still at work, and can lead to weight re-gain in this high carb, high-calorie environment in which we live. Bariatric centers and surgeons have continued to look for ways to help people who re-gain weight.

Some of the new technology to shrink stretched pouches may offer hope to people who have re-gained weight. But my own view is that these attempts to improve, or “revise” the original surgery work best when offered in conjunction with education, coaching, support groups, counseling and a program of physical activity to change the whole way in which a person approaches eating and activity. Clearly the secrets to long term weight loss success lie in making sustained life changes in one’s approach to food and activity levels. Revision procedures can often help, but they represent only a part of the solution to this complex and challenging problem.

Outstanding conference at Scott Becker’s Ambulatory Surgery Center conference in Chicago. Terrific attendance and great questions from the audience about the future of Bariatric Surgery. Scott Becker and I in photo.

One of the most exciting things for people who have transformed their lives and their bodies with a large amount of weight loss is the completion of that transformation with plastic surgery. There are new books and resources appearing that talk about total body lifts and plastic surgery that is performed after very substantial weight loss, usually after bariatric surgery. On the previous blog post I have talked about the optimal timing to undergo a body lift or cosmetic surgery as being eighteen months or more following weight loss surgery. Basically once you absolutely reach your goal weight. But what does a total body lift mean and what will it do for you?

Well, a total body lift has different definitions depending on which surgeon you speak to, but basically some of the key components are: the panniculectomy, which involves removal of the abdominal pannus, as well as other cosmetic surgical procedures on the arms, legs, face and neck to remove excess skin and soft tissue to tighten up the skin and soft tissues to optimize the cosmetic appearance.

Usually health insurance plans do not cover this type of surgery. They view it as cosmetic in nature and therefore not “medically necessary”. With some notable exceptions this is usually, in fact, true. Exceptions to this are instability of the abdominal wall which occur when a large abdominal pannus exists in combination with a hernia stemming from congenital wall weakness or from prior surgical scarring that left the musculature muscle and tendon closure weak. Another exception is when someone has very severe skin disease stemming from the folds of the pannus rubbing together creating an opportunity for breakdown of skin, fungal infections and bacterial infections. Often times though, the insurance company directors will refuse to pay for the panniculectomy, often called a “tummy tuck” even under these circumstances despite good documentation.

I have not seen insurance plans pay for removal of the skin around the upper arms or upper legs, nor have I seen them pay for face lifts or treatment of the skin of the neck. But, there may be some cases out there where this has occurred.

So is the cosmetic surgery “worth it”? Only you as an individual can decide. I am normally quite reluctant to recommend medical and surgical interventions that carry risks for anything other than a purpose that can be scientifically demonstrated as beneficial to health. Many of my patients who have undergone total body lifts or less complete plastic surgical procedures after their weight loss have told me that they viewed it as one of the last stages of their journey toward becoming a healthier new person. Or they have viewed it as a slightly sinful reward to celebrate having reached their goal weight. Certainly many people describe benefits in terms of greater confidence and an improved self image, benefits that are hard to quantify, but none the less individually valuable.

Not infrequently I am asked what is the best timing for removal of excess skin after weight loss surgery.

First of all, lets keep in mind that this is a good “problem” to have. It is not really a matter of excess skin after weight loss surgery so much as a big reduction of the excessive fat. In the years prior the skin will have stretched to accommodate the excess body fat and it often lacks the elasticity to bounce back to a normal, nice shape following big weight loss.

A few factors that determine how much “excess skin” are a persons age, how much weight the person gained prior to weight loss surgery, and the sun exposure over ones lifetime to that skin (ultraviolet sunlight exposure reduces the elasticity of the skin).

Of course the question of whether or not to have the excess skin removed is really a question of whether or not the individual in question is OK with having what is essentially cosmetic plastic surgery. This is definitely a personal decision and one that no two people will look at quite the same. So without a lot of discussion about our body self images and what does and does not really warrant plastic surgery, lets cut to the question as to when is the optimal timing, assuming that you did want to undergo plastic surgery somewhere down the road after your terrific weight loss? (In our practice somewhere around 1/3 of patients do undergo some type of plastic surgery within five years after their bariatric procedure).

The answer, I think, is this: once you have reached your goal weight.

So this means that you must establish a goal weight and then it means that you must stick to that goal, work hard at achieving that goal and once you have achieved it consider that the optimal time frame for undergoing plastic surgery for excess skin. The reasons for this are that you do not want to do it too early before your body has reached its best possible shape lest you would have to do it again. For most people this means waiting a minimum of eighteen months and many times waiting an even longer period of time. If you are like the average person who undergoes Roux-en-Y gastric bypass surgery you may want to wait twenty-four months to reach your best goal weight. If you are undergoing laparoscopic adjustable gastric banding surgery you may want to wait thirty-six months since so many people continue to lose weight between year two and year three. You may want to wait even longer!

But, my bottom line, wait until you have reached your goal weight. If you like to have rewards for yourself and plastic surgery is something that is important to you then consider it a major reward for yourself when you do achieve your goal weight.

An interesting phenomenon I have seen in recent papers reporting long-term outcomes is a disparity between some programs that are heavily devoted to gastric banding and programs that emphasize gastric bypass more. Perhaps predictably, the programs that are very “pro-band” tend to report better weight loss outcomes than centers that emphasize gastric bypass surgery.

There are always multiple reasons for discrepancies in data in any kind of medical studies or scientific trials. But, as our own center has matured over the years and as banding has become an increasingly important component of what we offer, I think there is an important and possibly overlooked explanation for the differences in the long-term weight loss results reported by different studies. And here it is: programs that emphasize gastric banding as a weight loss solution must invest heavily in the long-term follow-up program. For us, this has meant hiring and retaining outstanding nurse practitioners, physician assistants and dieticians who serve on the front lines and see the majority of the patients long-term for their follow-up, band fills, encouragements and coaching. The regular weigh in’s, the accountability this brings, and the opportunity to do ongoing metabolic testing, vitamin testing, counseling and coaching is invaluable in the long-term weight loss success for band patients.

In the future I am confident that our program will be able to demonstrate long-term weight loss results among thousands of gastric band patients that are equal to the outstanding results that we have achieved in the last decade with gastric bypass surgery. I think the infrastructure, personnel and long-term follow-up program will enable those results just as it has for some other centers around the world.

Increasingly we have seen reports in the literature from outstanding centers that demonstrate the long-term weight loss results after gastric banding surgery (Realize band and Lap-band) are equivalent to the long-term weight loss results after gastric bypass surgery.  What occurs is that weight loss is more rapid and greater in magnitude in the first year after gastric bypass surgery, but this gap narrows significantly at the second year of follow-up.  By the third year the difference becomes quite small and may, in fact be indistinguishable.  Then in years four, five and beyond the average maintained long-term weight appears to be the same between the two groups in these studies.

In other studies from programs and centers that focus a bit less comprehensively on long-term band follow-up and care, the results after gastric bypass surgery continue to show a weight loss advantage in favor of the bypass.  The gap at year one is narrowed, but even in the long-term their remains an advantage for the gastric bypass arm and of course this advantage does translate into some improvements or advantages in other health conditions such as obstructive sleep apnea, hyperlipidemia, hypertension and diabetes.

So what accounts for the difference in these studies? While we can’t be certain, and of course there is always variability in any such long-term studies looked at from different centers and different perspectives, I believe the answer may lie in the diligence with which the band patients are followed and the dedication to Lap-band follow-up exhibited by those programs.

What I mean is that patients undergoing gastric banding surgery may have two very different experiences: on the one hand they may go to a center that has outstanding long-term follow-up and have enthusiastic and knowledgeable physicians assistant, nurse practitioners and dieticians  who can coach, council and encourage patients to continue their weight loss journey over the long-term while also skillfully making band adjustments in the office.  The program likely also has support groups and may have other features such as special events, walking groups and celebrations.  All of this combines to create an environment that is conducive to long-term weight loss success.  On the other hand, the patient may go to a center where surgery is performed and very little follow-up is involved.  (An extreme example would be a person who leaves the country to save money in the short-term, but fails to have taken advantage of the long-term follow-up features that lead to success.)  Several studies support this notion that the level of participation in long-term follow-up and the commitment to band adjustments by both the patient and the program, are critical to long-term success.

Our program has fought to enhance its long-term, follow-up features by creating walking groups, special events, support awareness of childhood obesity prevention, a celebratory fashion show, and enthusiastic coaching and encouragement with frequent open access band fills.  In the future I hope that our center might also report data which demonstrates the long-term weight loss results with gastric banding are indeed comparable to the long-term weight loss results after the outstanding results of gastric bypass surgery, which we have previously reported.

An interesting study just released looks at the long-term remission rates of type 2 diabetes mellitus after laparoscopic adjustable gastric banding.  The study reported by Dr. Samuel Sultan demonstrated that after five years of follow-up 40 percent of previously diabetic patients were now off of all diabetes medicines and had normal blood sugars and normal hemoglobin A1c levels.  In a total of 80 percent of patients the diabetes was improved (as defined by a reduction of diabetes medicine) or was totally resolved.

Not surprisingly the patients in the study who maintained the resolution of their diabetes were the same patients who maintained their weight loss over that time period and who exhibited a greater magnitude of weight loss at the five year mark.

I think what this study says about long-term resolution of diabetes after lap-band surgery is that the key is, in fact maintaining the weight loss for the long-term.  We know that the keys for maintaining that weight loss long-term are committing fully and completely to changing, adapting a new life style, participating in ongoing long-term follow-up with the bariatric surgeons office and continuing to have band fills and adjustments on a regular basis.  We also think that coaching, attendance at a support group and more active participation in activities, such as regular walking groups, contribute to the long-term success that leads to total, long-term resolution of diabetes.

The choice of which bariatric procedure on should choose to do is an important one, but it might not be as important as you think.

When faced with deciding upon the right weight loss surgery for you there are many choices to consider. One should try and research every detail they can about them and make the best possible choice for themselves.  I have written a lot on this blog, in books, and articles regarding how to go about choosing the right surgery. I have examined the data very carefully to try and help guide people on this topic.  I also spend a lot of time one on one with my own patients in trying to help them make the best decision should they choose the laparoscopic Roux-en-Y gastric bypass, or perhaps the laparoscopic adjustable gastric band or the laparoscopic sleeve gastrectomy.  Sometimes the choice can be difficult and as we know there is no single, one clear cut right answer for everyone.

But, more important than the choice of weight loss surgery is a much richer, more challenging and more rewarding place to focus our mental energies: on staying prepared and motivated to do the work of losing the weight.  Regardless of what surgery is chosen, the procedure is not going to do the work by itself.  No surgery is going to magically make a person exercise more, decrease the glycemic index of their intake, reduce their portions and begin cutting out full meals and servings of carbohydrates such as: sweets, desserts, potatoes and snacks.  Only you can do that.

So while choosing the proper surgery is important, and some people may do much better with one kind of procedure than another, at the end of the day the variations and weight loss outcome between all the operations is dwarfed by the variations between individuals depending on their motivation level.

Yes, that is right, you could lose far more weight with the less invasive procedure simply by being more motivated and sticking to the regimen more closely.  That means dramatically cutting down carbohydrate intake and increasing the calories you burn with muscle activity.  On the other hand, you can have the most invasive operation that supposedly delivers the highest amount of pounds lost, and find that you don’t lose any weight because you are less motivated and less compliant with the recommended eating regimen.

If the difference between say, the gastric bypass and the gastric banding procedure in terms of average weight loss results is ten percent, the difference between highly motivated and less motivated individuals is 100 percent.

So, research as much as you possibly can.  Read the articles on this blog about the subject, read my book about which operation is right for you.  Read every other source you can, talk to as many people as you can.  But, once you have made a decision about which procedure to undergo, focus all of that mental energy and enthusiasm (and more of it!) on committing 100 percent mind, body and soul to achieving success in your weight loss journey.  This is going to mean sacrifice.  It is going to mean starting a difficult preoperative weight loss diet.  It is going to mean living with hunger.  It is going to mean making painful choices.  It is going to mean cutting down the carbohydrate intake.  It is going to mean reading every label.  It is going to mean increasing your muscular activity through things like: walking, swimming, use of hand weights, etc.  It is difficult, but with a consistent and dedicated effort you can achieve amazing results no matter which type of surgery you have chosen.