Weight loss surgery extends lives, study finds | CNN


Weight loss surgery reduces the risk of premature death, especially from such obesity-related conditions as cancer, diabetes and heart disease, according to a new 40-year study of nearly 22,000 people who had bariatric surgery in Utah.

Compared with those of similar weight, people who underwent one of four types of weight loss surgery were 16% less likely to die from any cause, the study found. The drop in deaths from diseases triggered by obesity, such as heart disease, cancer and diabetes, was even more dramatic.

“Deaths from cardiovascular disease decreased by 29%, while deaths from various cancers decreased by 43%, which is pretty impressive,” said lead author Ted Adams, an adjunct associate professor in nutrition and integrative physiology at the University of Utah’s School of Medicine.

“There was also a huge percentage drop — a 72% decline — in deaths related to diabetes in people who had surgery compared to those who did not,” he said. One significant downside: The study also found younger people who had the surgery were at higher risk for suicide.

The study, published Wednesday in the journal Obesity, reinforces similar findings from earlier research, including a 10-year study in Sweden that found significant reductions in premature deaths, said Dr. Eduardo Grunvald, a professor of medicine and medical director of the weight management program at the University of California San Diego Health.

The Swedish study also found a significant number of people were in remission from diabetes at both two years and 10 years after surgery.

“This new research from Utah is more evidence that people who undergo these procedures have positive, beneficial long-term outcomes,” said Grunvald, who coauthored the American Gastroenterological Association’s new guidelines on obesity treatment.

The association strongly recommends patients with obesity use recently approved weight loss medications or surgery paired with lifestyle changes.

“And the key for patients is to know that changing your diet becomes more natural, more easy to do after you have bariatric surgery or take the new weight loss medications,” said Grunvald, who was not involved in the Utah study.

“While we don’t yet fully understand why, these interventions actually change the chemistry in your brain, making it much easier to change your diet afterwards.”

Despite the benefits though, only 2% of patients who are eligible for bariatric surgery ever get it, often due to the stigma about obesity, said Dr. Caroline Apovian, a professor of medicine at Harvard Medical School and codirector of the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston. Apovian was the lead author for the Endocrine Society’s clinical practice guidelines for the pharmacological management of obesity.

Insurance carriers typically cover the cost of surgery for people over 18 with a body mass index of 40 or higher, or a BMI of 35 if the patient also has a related condition such as diabetes or high blood pressure, she said.

“I see patients with a BMI of 50, and invariably I will say, ‘You’re a candidate for everything — medication, diet, exercise and surgery.’ And many tell me, ‘Don’t talk to me about surgery. I don’t want it.’ They don’t want a surgical solution to what society has told them is a failure of willpower,” she said.

“We don’t torture people who have heart disease: ‘Oh, it’s because you ate all that fast food.’ We don’t torture people with diabetes: ‘Oh, it’s because you ate all that cake.’ We tell them they have a disease, and we treat it. Obesity is a disease, too, yet we torture people with obesity by telling them it’s their fault.”

Most of the people who choose bariatric surgery — around 80% — are women, Adams said. One of the strengths of the new study, he said, was the inclusion of men who had undergone the procedure.

“For all-causes of death, the mortality was reduced by 14% for females and by 21% for males,” Adams said. In addition, deaths from related causes, such as heart attack, cancer and diabetes, was 24% lower for females and 22% lower for males who underwent surgery compared with those who did not, he said.

Four types of surgery performed between 1982 and 2018 were examined in the study: gastric bypass, gastric banding, gastric sleeve and duodenal switch.

Gastric bypass, developed in the late 1960s, creates a small pouch near the top of the stomach. A part of the small intestine is brought up and attached to that point, bypassing most of the stomach and the duodenum, the first part of the small intestine.

In gastric banding, an elastic band that can be tightened or loosened is placed around the top portion of the stomach, thus restricting the volume of food entering the stomach cavity. Because gastric banding is not as successful in creating long-term weight loss, the procedure “is not as popular today,” Adams said.

“The gastric sleeve is a procedure where essentially about two-thirds of the stomach is removed laparoscopically,” he said. “It takes less time to perform, and food still passes through the much-smaller stomach. It’s become a very popular option.”

The duodenal switch is typically reserved for patients who have a high BMI, Adams added. It’s a complicated procedure that combines a sleeve gastrectomy with an intestinal bypass, and is effective for type 2 diabetes, according to the Cleveland Clinic.

One alarming finding of the new study was a 2.4% increase in deaths by suicide, primarily among people who had bariatric surgery between the ages of 18 and 34.

“That’s because they are told that life is going to be great after surgery or medication,” said Joann Hendelman, clinical director of the National Alliance for Eating Disorders, a nonprofit advocacy group.

“All you have to do is lose weight, and people are going to want to hang out with you, people will want to be your friend, and your anxiety and depression are going to be gone,” she said. “But that’s not reality.”

In addition, there are postoperative risks and side effects associated with bariatric surgery, such as nausea, vomiting, alcoholism, a potential failure to lose weight or even weight gain, said Susan Vibbert, an advocate at Project HEAL, which provides help for people struggling with eating disorders.

“How are we defining health in these scenarios? And is there another intervention — a weight neutral intervention?” Vibbert asked.

Past research has also shown an association between suicide risk and bariatric surgery, Grunvald said, but studies on the topic are not always able to determine a patient’s mental history.

“Did the person opt for surgery because they had some unrealistic expectations or underlying psychological disorders that were not resolved after the surgery? Or is this a direct effect somehow of bariatric surgery? We can’t answer that for sure,” he said.

Intensive presurgery counseling is typically required for all who undergo the procedure, but it may not be enough, Apovian said. She lost her first bariatric surgery patient to suicide.

“She was older, in her 40s. She had surgery and lost 150 pounds. And then she put herself in front of a bus and died because she had underlying bipolar disorder she had been self-medicating with food,” Apovian said. “We as a society use a lot of food to hide trauma. What we need in this country is more psychological counseling for everybody, not just for people who undergo bariatric surgery.”

Managing weight is a unique process for each person, a mixture of genetics, culture, environment, social stigma and personal health, experts say. There is no one solution for all.

“First, we as a society must consider obesity as a disease, as a biological problem, not as a moral failing,” Grunvald said. “That’s my first piece of advice.

“And if you believe your life is going to benefit from treatment, then consider evidence-based treatment, which studies show are surgery or medications, if you haven’t been able to successfully do it with lifestyle changes alone.”

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New Guidelines for Kids With Obesity: What Parents Should Know

Jan. 13, 2023 — The American Academy of Pediatrics last week issued their first new guidelines in 15 years for evaluating and treating kids and adolescents with overweight or obesity. 

If you only saw the headlines, you might think that when a youngster is a few pounds overweight, their pediatrician will prescribe a weight loss drug or bariatric surgery. The reality is much less alarming. The guidelines take a deep dive into evidence-based treatments at various levels.

“It’s a misunderstanding, it’s being sensationalized,” says Lori Fishman, PsyD, a child psychologist who specializes in pediatric weight management. “There’s so much more to the process. It’ll be a small percentage of kids who’ll even qualify for these treatments.” 

Treating the Whole Child

Before writing the guidelines, the AAP’s Subcommittee on Obesity spent years analyzing and synthesizing information from nearly 400 studies. 

“We now have more information than ever that supports that obesity is a chronic, complex disease that requires a whole-child approach,” says Sarah Hampl, MD, one of two lead authors of the guidelines. “And many kids will not outgrow it, so it’s important to identify children with obesity early and offer them evidence-based treatments.”

In the new guidelines, treatment of overweight and obesity doesn’t mean putting a kid on a diet and expecting their parents to manage it. Instead, multi-pronged approaches might include nutrition support, physical activity specialists, behavioral therapy, medications for adolescents 12 and up, and surgery for teenagers with severe obesity. 

Before starting any of these evidence-based treatments, the guidelines remind pediatricians to consider each child’s individual circumstances — their living situation, their access to healthy food, and more.

“As pediatricians, we ought to be especially mindful of the influences that child and family are surrounded by,” Hampl says. “We should help guide them, whether it’s to local resources for healthy food or support for a child who’s being bullied.”

Because obesity is often stigmatized, the pediatricians’ group also included guidance for pediatricians to help them examine their own biases. It calls on them to acknowledge the myriad genetic and environmental factors that contribute to obesity and treat children and their parents with respect and sensitivity.

The Rise of Childhood Obesity

For kids 2-18, obesity is defined as having a BMI at or above the 95th percentile for a child’s age and sex. Rates of pediatric obesity have more than tripled since the 1960s, from 5% to nearly 20%. Just last month, the CDC released updated growth charts to take into account how many more children and adolescents now have severe obesity, well beyond the 95th percentile. By 2018, more than 4.5 million kids qualified, but the old charts didn’t go high enough.

If these trends continue, researchers estimate that 57% of children aged 2 to 19 will have obesity by the time they hit 35. And the pandemic has only made things worse.

“It’s about much more than what we eat and drink or how physically active we are,” Hampl says. Risk factors for obesity include genetics, socioeconomics, race and ethnicity, government policies, a child’s environment, neighborhood, and school, and even their exposure to unhealthy food marketing. Because each child is so different, these factors combine in unique ways.

You can see an example of the variability in Jill’s family. She’s a New Jersey mom with two teenage sons. For privacy reasons, we’re using only her first name. 

“I have two children who I raised the same way, who were offered the same foods, and yet one weighs 80 pounds more than the other,” she says. “My 16-year-old is happy to choose fruit over a cookie. He’s able to stop, to not eat another bite. The 14-year-old will eat cookies until they’re gone.”

No More Watch and Wait

The last set of guidelines, from 2007, called for pediatricians to monitor kids with obesity via “watchful waiting.” It would give children a chance to outgrow their excess pounds before being treated. Research conducted since then shows that’s not effective. 

“The risk of watching and waiting, in my experience, is that a 10-pound-overweight child a year later might be 30 pounds overweight,” says Fishman. “That’s a lot harder to tackle.”

In the new guidelines, the AAP stresses the urgency of treating children with overweight and obesity as soon as it’s diagnosed. Instead of hoping a growth spurt might take care of the problem, pediatricians should move quickly, “at the highest level of intensity appropriate for and available to the child.”

By guiding children and their families to adopt healthier habits early, it may help to reduce some of the weight-related health issues that have also increased in the last few decades. Just within the 21st century, diabetes rates for children and teenagers have skyrocketed — between 2001 and 2017, the number of kids with type 2 went up an astonishing 95%.

“Now we understand the consequences of untreated obesity, especially severe obesity,” says Mary Ellen Vajravelu, MD, a doctor-scientist at the Center for Pediatric Research in Obesity and Metabolism in Pittsburgh. “That includes type 2 diabetes, fatty liver disease, high blood pressure, high cholesterol. It’s important to treat obesity in childhood to avoid the complications we’re seeing in young adults.”

Also important: Reversing the trend while a child is young can help them avoid the emotional impact of growing up with obesity. 

“I saw the recommendations and thought, ‘How different would my life have been for the past 35 years if they had treated my obesity when I was a child?” says Heather, the mother of a 10-year-old in Florida. She’s been carrying shame and limiting herself since childhood, for instance by avoiding activities where her size might prove embarrassing. “For kids who are struggling, I think it’ll be life-changing.”

What the Guidelines Really Say

In a world where fat-shaming is rampant, parents often want to protect their children by encouraging them to lose weight — but parental pressure adds another layer of bad feelings. The AAP advises against putting a child on a diet or restricting their access to food without professional help. Guidelines recommend that pediatricians:

  • Treat obesity as a chronic disease. That calls for long-term care strategies and ongoing monitoring.
  • Implement a model known as the “medical home.” It takes treatment beyond the exam room to shape behavior and lifestyle changes. Pediatricians should build partnerships with families in their care and serve as a care coordinator, working with a team that may include obesity treatment specialists, dietitians, psychologists, nurses, exercise specialists, and social workers.
  • Use a patient-centered counseling style called motivational interviewing. Rather than a doctor prescribing changes for a child’s family to figure out, the process guides families to identify which behaviors to adjust based on their own priorities and goals — that might mean cutting back on sugary drinks or walking together after dinner. Research has shown it takes less than 5 hours of motivational interviewing with a pediatrician or dietitian to help bring down BMI.
  • Opt for an approach called intensive health behavior and lifestyle treatment (IHBLT) whenever feasible. As the name suggests, it’s an intense treatment that calls for at least 26 hours of face-to-face, family counseling on nutrition and exercise over a period of 3 to 12 months. More sessions produce larger reductions in BMI, with 52 hours or more over the same duration having the greatest impact. Unfortunately this treatment program isn’t available everywhere, and for many families the time and financial demands put it out of reach.
  • Offer approved weight loss drugs to adolescents 12 years and older who have obesity. Medication should always be used together with nutrition and exercise therapies.
  • Refer adolescents 13 and up with severe obesity for possible weight loss surgery. That referral should be to a surgical center with experience in working with adolescents and their families, where the teen would undergo a thorough screening process.

Medication and Surgery

Those last two recommendations have garnered most of the headlines, and it’s understandable. Medicating a child — or performing an operation that would permanently change their body — might seem extreme. But the research shows that for children with obesity and severe obesity, these treatments work.

“This isn’t for a kid who’s a little overweight,” says Fishman. “It’s obesity that’s limiting this child’s ability to function. When we face something this disabling, we want to attack it from every direction we can.”

Right now, only a handful of medications are approved to treat obesity in adolescents. Some are taken orally, while others, like the recently approved Wegovy, are injected. 

Jill, the New Jersey mom, is using Wegovy herself. 

“The fact that I’ve had success with it makes me more comfortable about approaching it as an option for my son,” she says. “And ultimately, it’s his choice. If he wants to see if he can just do things differently first, we’ll try that. A nutritionist’s guidance will be part of this for him regardless, so he can understand what’s involved. It’s not like he’ll get the shot and all of a sudden magic happens.”

Losing weight with medication can help remove some of the shame that often comes with obesity. Heather, the Florida mom, is also using an injectable drug.

“It’s all the morality stuff like, if you had more self-control, if you worked harder and really tried, if you just made the choice,” she says. “This pulls all the morality out of it. Obesity is a medical condition. It’s so clear. In the same way I take thyroxin because my thyroid doesn’t work well, this makes my insulin receptors work properly.”

For kids 13 and older with severe obesity — a BMI over 35, or 120% of the 95th percentile for age and sex — metabolic or bariatric surgery may be recommended. Of course, surgery is much more invasive than medication, with a greater risk of complications. The guidelines acknowledge this and stress the need for thorough screening before proceeding.

“The pediatrician would refer a child for evaluation. They wouldn’t say, ‘You definitely need to have surgery,’” Hampl says. “They’d say, ‘As your pediatrician, I feel that you would benefit from a comprehensive evaluation at a pediatric bariatric surgical center.’ These types of centers do a very thorough pre-op evaluation over at least 6 months, and then careful monitoring is done for years afterward.”

Weight loss surgery for adolescents does have certain drawbacks. Any surgery has the risk of complications, and some surgical patients do gain back a significant amount of weight. Some research suggests that adolescents who have the surgery are more likely to have alcohol problems later in life.

Even with those risks, for some teens surgery may prove life-saving.

“We know much more about the complications of obesity in adults, we know those are devastating,” says Hampl. “If we can prevent heart attacks, stroke, sleep apnea, diabetes, and other really serious medical complications, that in itself is a huge benefit to the person’s health.”

The Question of Equity

The guidelines point out that obesity has inequities baked into the condition. Risk factors increase depending on your economic status and your race. Access to treatment is lopsided. Some of the most effective treatments, like intensive health behavior and lifestyle treatment, aren’t available everywhere. Providers may not be in-network or even accept insurance. 

If the family of a child with overweight can’t access effective programs to help them build healthy habits, the child’s odds for developing obesity grow. As they get older and their BMI reaches the level of obesity or severe obesity, treatments like medication and surgery become an option. But they’re even more costly, which leaves many families with no help at all.

That’s why the guidelines also include policy recommendations aimed at covering comprehensive obesity prevention, evaluation, and treatment. They call attention to the ways unhealthy food is marketed, the effects of limited resources on a community, how socioeconomic and immigration status factor in, and the challenges posed by food insecurity.

“We hope the guidelines will serve as impetus to help improve access to care for all children with obesity,” Hampl says. “That includes everything from infrastructure and policy to systems change as well.”

For parents who struggle to help their children with overweight and obesity, having such an authoritative resource can pave the way to getting real help.

“It’s good that they issued these guidelines. I’m hoping, for my son and all the kids out there who are struggling, that it will help to have it recognized as something worthy of clinical, medical management,” Jill says. “It’s validating.” 

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