Research aims to better understand weight-loss surgery

You probably don’t know Nancy Douglas but you see people like her every day—at least the way she used to look in her former life. They are the ones who gasp for breath as they struggle up stairs, cram themselves miserably into too-small airline seats, and try to make themselves appear smaller as they block the aisle of a city bus. They are the 44.3 million American adults classified as obese by the Centers for Disease Control.

About 60 percent of the American adult population is overweight with 25 percent of those fitting into the obese category. Public health officials expect obesity to grow to 40 percent by 2020.

Obesity in America has gotten so bad that in 2002, the Internal Revenue Service classified it as a disease, making expenses related to its treatment — exercise programs, stomach surgery and commercial weight-loss programs — tax-deductible.

Douglas was part of this epidemic. The 42-year-old nurse at the UW Medical Center came from a family cursed with obesity. Douglas’ problems didn’t start until her early 20s, when she started packing on the pounds after college. By the time Douglas turned 40, she had been carrying an extra 100 pounds around for 15 years. More health problems — Type II diabetes and high blood pressure — followed.

“I tried Weight Watchers, Fen-Phen, Atkins and a liquid diet called Optifast. I did Optifast three times and it cost several thousand dollars every time, but I gained the weight right back,” she recalls.

In desperation, she turned to a radical procedure that once rested on the fringes of standard medical care: surgery to reduce the size of her stomach. Once dismissed as “stomach stapling,” this gastric bypass technique is now gaining acceptance among doctors and insurance companies.

Called bariatric surgery, its use is skyrocketing. Members of the American Society for Bariatric Surgery performed 63,100 operations in 2002, triple what they did just three years before. Since many non-member surgeons also do the procedure, health officials estimate 120,000 stomach bypasses were done last year.

When she turned to bariatric surgery, Douglas (in photos at top, before and after the surgery) joined the ranks of celebrities such as NBC Today weatherman Al Roker and TV sitcom star Rosanne Barr. She now weighs 130 pounds and has no food cravings. She hikes and bikes and said goodbye to diabetes medication two years ago. Shopping is finally a pleasant experience. “I remember going to Nordstrom and bawling in the dressing room. I went from a size 3X to a size 6. Now I’m in the petite section,” she says.

The loss of 100 pounds from the surgery has been what she calls “the hugest gift in my life.”

While the number of these procedures is rapidly rising, much about the effects of the surgery is still a mystery. Researchers say having a smaller stomach is only part of the reason for the loss of weight.

A new research project at the University of Washington, fueled by a five-year, $1.5 million federal grant, may help explain why the surgical treatment of obesity works on people like Douglas, determine who should be a candidate for the surgery and how the surgery affects chemicals in the body that suppress or stimulate appetite.

The National Institute of Diabetes and Digestive Diseases tapped the UW to lead the research effort in part because Surgery Professor E. Patchen “Patch” Dellinger has been performing bariatric surgery since 1978, when the procedure was in its infancy.

Dellinger takes an unusual tact when he meets his obese patients for the first counseling session — he tries to talk them out of the procedure. Because they are so eager to solve the problem, they don’t have a realistic view of the risk, he says.

Although the methods of performing bariatric surgery vary somewhat, all stomach surgery is major and carries risk. Fifteen to 20 percent of bariatric surgery patients develop complications, 10 percent develop a wound infection, and 15 to 20 percent experience psychological problems such as depression.

The official U.S. death rate is 0.5 percent or about 1 out of 300 surgeries. However, Dellinger says the death rate in Washington state is 2 percent or about 1 out of 50 surgeries. He believes that’s a more realistic national percentage as well.

Surgery Professor David
Flum.

Because of the risk, bariatric surgery is not a choice for the faint of heart. “Bariatric surgery is behavior modification with a hammer,” says David Flum, assistant professor in the UW Department of Surgery and principal investigator for the research project.

Not everyone with a weight problem qualifies for bariatric surgery. Only adults who are “morbidly obese” — more than 100 pounds overweight — are eligible.

Another way to understand obesity is to look at a patient’s Body Mass Index (BMI), which assesses your weight compared to your height. If you are 5 feet 8 inches with a weight of 150 pounds, you have a 22.8 BMI. A healthy adult BMI generally falls between 18.5 and 25.

If your BMI is more than 25, you are probably overweight. If it is 30 or higher, you are considered obese, and 40 or higher, you are “morbidly” or “super obese” and a candidate for surgery. Douglas had a 41.7 BMI prior to her surgery.

In a gastric bypass, the surgeon divides the stomach into a smaller upper section and a larger bottom section using staples that are similar to stitches. The top section of the stomach (called “the pouch”) continues to hold food. After the stomach is divided, the surgeon connects a section of the small intestine to the pouch so that the food bypasses the rest of the stomach.

Gastric bypass surgery can now be done with a laparascope, a slender, illuminated optical or fiber-optic instrument that functions like a camera when it is inserted through an incision in the abdominal wall. The surgeon watches through a lens and video monitor. A laparascopic procedure is less invasive and allows for smaller incisions, a lower risk of large scars and hernias and a quicker recovery. This is the reason behind the skyrocketing number of bariatric surgeries in the U.S. However, this technique may not be available to the super obese because the large amount of fat and tissue prevents the use of a tiny instrument and smaller incisions.

Douglas resorted to this radical surgery because, after her initial dieting success, she couldn’t maintain her ideal weight. Everyone who has ever gone on a diet knows that weight loss is hard, but keeping the pounds off is where the battle is really won or lost. “Ninety-five percent of the people who lose 5 to 10 percent of their body weight don’t keep it off. Why are they so incapable? What else is there?” asks Flum.

The answer doesn’t lie in poor character or lack of personal discipline, according to Flum. He and his colleagues already know that there are chemicals in the body that are designed to help keep weight on. Flum theorizes that there are good evolutionary reasons for the human body to resist weight loss. Over the centuries, people who survived famine were those who were most efficient at storing body fat, so natural selection favored this body type.

“When you lose weight by dieting, every signal in your body tells you to bring in more calories. Your body is essentially working against you when you lose weight. Is obesity the product of sloth or disease? That debate may be irrelevant. What underlies that debate is that there is a complex system in our bodies to help put the weight on and keep it on,” says Flum.

By studying bariatric surgery patients, Flum and his colleagues hope to learn more about how the body’s chemicals suppress or stimulate appetite. While the size of the “new” stomach made in gastric bypass surgery is vital in reducing the calories consumed, Flum and his colleagues believe that body chemicals, called peptides, also play a big role in successful weight loss and maintenance.

Even when stomach surgery is not tied to weight loss — such as surgery due to stomach cancer — doctors still find it results in a profound lack of appetite. “These patients aren’t hungry. You’d expect they would be really hungry. This is the most intriguing aspect of bariatric surgery. If we can understand what makes people hungry and what takes hunger away in people who have gastric surgery, maybe we can find a nonsurgical solution to obesity,” Flum says.

It’s a strange twist of science that the quest for the ultimate diet pill might start with stomach surgery. Researchers speculate that gastric surgery, which bypasses most of the stomach and the duodenum (the first, shortest, and widest part of the small intestine), interferes or suppresses the production of ghrelin, a hormone that increases food intake in humans.

One of those researchers is UW Medicine Professor David Cummings, an expert on ghrelin. In a recent New England Journal of Medicine article, Cummings compared hormone levels of people who had lost weight through a gastric bypass to those at obese and normal weights. He found that the bypass group, who experienced a 36 percent weight loss, had ghrelin levels 77 percent lower than those at normal weight.

While it would seem logical that significant weight loss would trigger higher ghrelin levels, this is not what happens in people who have gastric bypass surgery. “There are many hormones involved in appetite control, any one of which could be affected by surgery. Our goal is to understand the nonsurgical mechanisms of weight loss,” says Cummings.

The researchers hope that their work may lead to a ghrelin-blocking drug that will produce the effects of gastric bypass surgery without a scalpel. A drug is preferable to surgery not only because it would eliminate most of the risk, but also because bypass patients have a hard time absorbing iron, calcium and vitamin B-12.

The positive health effects of dramatic weight loss are profound. Obesity is related to lung disease, heart disease and diabetes. “But if you lose the weight, you can lose the diabetes. In 85 percent of people who have the surgery, their diabetes disappears. Sometimes it disappears in a matter of days. Like appetite, it points to a chemical mechanism in which food exposed to the gut promotes appetite — and problems with insulin. If appetite can be suppressed and diabetes can be eliminated, maybe we can do this without surgery,” Flum says.

Another goal of the research is to pinpoint who should have bariatric surgery and when it is a success. Currently, there are 10 million adult Americans eligible for the surgery, but there is no clear data about which patients will be successful at weight loss and maintenance and which will not.

Bariatric surgery pioneer Dellinger says that despite the growing number of surgeries, nobody has a proven system for predicting success or failure.

“There are many definitions of success: total weight loss, percent of excess weight loss, etc. I view the surgery as a success if the patient doesn’t have a prolonged hospitalization, prolonged disability or infection, and loses enough weight to improve the medical conditions that led them to want the operation,” he says.

While bariatric surgery may be effective for some, it’s not for everyone. So what is the solution for the millions of overweight and obese Americans who face the daily struggle of losing weight and keeping it off?

Every researcher interviewed says that massive behavioral change is the first step. It boils down to lifestyle choices: Diet and exercise. Our sedentary life — along with other factors like “supersizing” meals and eating high-fat, calorie-dense foods — makes us fat. Once we become overweight, we are stuck on the merry-go-round of weight loss and weight gain, and it is very hard to get off.

“Without doubt, sedentary behavior is contributing. Nowadays people drive to a job and sit at a computer, so the same amount of caloric intake that would have produced a healthy weight 50 years ago will now make you obese,” says Dellinger.

The good news about weight loss is that, in terms of health, a fairly small loss can have a large effect on conditions such as high cholesterol, high blood pressure and even a diabetic’s level of medication.

“If you weigh 300 pounds and you drop to 285 pounds, you have a modest weight loss of 5 percent, but the benefits are not proportionate. The benefits are large where these co-morbid (conditions that often accompany obesity) conditions are concerned,” says Cummings. “You really can have a positive effect on your health with even a modest loss.”

‘Patch’ work

Surgery Professor E. Patchen “Patch”
Dellinger.

In 1978 when E. Patchen “Patch” Dellinger performed his first bariatric surgery, one of the first in Washington state, the patient weighed more than 600 pounds and the surgery was viewed with suspicion by most of his medical colleagues. Times sure have changed. In November the New York Times reported that more than 100,000 morbidly obese Americans underwent some form of bariatric surgery, or gastric bypass, in the last 11 months — four times as many as in 1998.

At the time, Dellinger was working as a trauma surgeon at Harborview Medical Center, but wanted to have a relationship with patients beyond emergency care. He decided to pursue bariatric surgery because no one was serving morbidly obese patients. But the surgery was so rare then that very few surgeons knew how to do it.

“I went to the University of Iowa and watched what they were doing. And I learned on the job,” he says. One of the things Dellinger has learned is that when a person hits 400-plus pounds, even with gastric bypass surgery, dietary modifications and exercise, it is unlikely that normal weight will ever be achieved. He is very frank with his patients about the surgery’s limits.

“One of the first things I tell them is, ‘This operation does not cause weight loss. Diet and exercise cause weight loss and the operation assists dieting,’ ” he says. Even though there is no silver bullet, many obese patients are wait-listed for the surgery at the UW because they are so desperate for change.

After 25 years of performing bariatric surgery, Dellinger speaks with passion about what these patients endure. “Some people are so heavy they can’t stand up. They’re in wheelchairs because of their weight. We get people who can barely breathe. Some don’t leave their homes because they are too embarrassed,” he says. “Obese people in the United States are one of the last groups of people about whom most people make uncensored rude remarks.”

Dellinger points out that accommodations have to be made in order to care for obese patients properly. Obese patients often can’t sit on a hospital toilet without breaking it. They’re too heavy to have surgery on a regular operating table because it won’t sustain their weight. Often X-rays and MRI images are inadequate because the technology can’t “see” past the fat. Some regular surgical instruments don’t work because they’re not long enough.

The UW Medical Center has taken steps to improve services to patients who are obese. Equipment is being upgraded, nursing unit rooms are being remodeled so obese patients can get through widened doorways and new beds are more comfortable.

As the UW’s “father of bariatric surgery,” Dellinger believes the day will come when the super obese no longer need surgery and hospitalization. “We are going to learn how to help these people,” he says, “It will come.”

Julie Garner is a Seattle-area free-lance writer