For some people, losing weight and keeping it off takes more than just diet and exercise. Obesity can be secondary to another condition, or it can be a stubborn condition that is much harder to get rid of. Global obesity¹ rates have tripled since 1975. In 2016, 39% of adults aged 18 years and over in the US were overweight, and in recent years the obesity epidemic has only gotten worse.
Weight loss surgery is recommended as an option for some people with obesity that does not respond to lifestyle changes, or for people who are unable to make the required changes.
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Weight loss surgery is more specifically termed bariatric surgery. It covers a range of medical procedures, with the same goal of limiting the amount of food you can eat in one sitting. The most common type of bariatric surgery performed in the US is sleeve gastrectomy, in which a large portion of the stomach is removed, leaving a tube-like sleeve.
Reducing the size of the stomach causes you to feel full a lot faster, limiting the amount you can eat. It is not a treatment in itself but may be recommended as part of an overall treatment plan which includes nutrition, exercise, and mental health.
There are also two other forms of weight loss surgery² that are sometimes performed:
Gastric bypass surgery – This type of surgery connects part of the stomach to the middle part of the intestine to decrease the amount of fat the body can store.
Gastric banding – This is a procedure in which a band is placed around the upper part of the stomach to reduce its size.
Not every person who is obese qualifies for weight loss surgery³. To qualify, you must feel the following basic criteria:
BMI over 40, or more than 100 pounds overweight.
BMI over 35 with at least one obesity-related comorbidity, which includes type II diabetes, hypertension, lipid abnormalities, heart disease, etc.
Inability to achieve sustained, healthy weight loss through other means.
In other words, surgery is considered for people who are extremely overweight, who have a medical condition that is aggravated by their weight, and/or who have unsuccessfully tried everything else to treat their obesity. For many patients, surgery is the last resort. Before undergoing surgery, many surgeons expect patients to lose some weight through diet and exercise. You will also be asked to quit smoking or start a program to help you quit.
Some conditions will make you ineligible for weight loss surgery. You may also be asked to work on or correct certain health issues before you become eligible.
Typically, you are not eligible for surgery⁴ if you have:
A blood clotting disorder
Heart disease is severe enough to impact the safety of anesthesia
Any condition that increases the risk of anesthesia
Your care team will also want to address whether you have an appropriate motivation for seeking weight loss surgery. You can't get the surgery then return to your previous lifestyle – you need to be committed to making this a lasting change.
If you have any of the following issues, these will need to be worked on prior to surgery:
Irregular eating behaviors or an eating disorder
Mood disorders such as depression and anxiety
Alcohol and drug use
Since alcohol and drug issues are associated with poor outcomes following weight loss surgery, you will likely be expected to go through a substance abuse program before getting surgery, as well as comply with mental health treatment.
Therapy is generally recommended for anyone undergoing weight loss surgery to help them deal with body image and self-esteem issues before and after surgery. There is sometimes also an increased risk of suicide after surgery, especially if you have a preexisting mood disorder or substance use disorder.
Typically, you would talk to your primary care doctor first, and they would refer you to a specialist or directly to the surgeon⁵. As a minimum, you will also be referred to a nutritionist and a psychiatrist, as both nutrition advice and therapy are recommended for everyone receiving surgery.
Your care team will decide, as a whole, if you are qualified and ready for surgery. This typically means meeting certain requirements, such as medically supervised weight loss attempts for a period of time. Insurance companies often also require you to have attempted this before undergoing surgery, usually for a period of three to six months. A specialist will work with you on your weight loss attempts with tailored exercise plans depending on your needs (for instance, if you have mobility issues).
To prepare for surgery, you should continue with your diet and exercise plan and follow any suggestions from your care team.
Generally, you will need to participate in talk therapy, especially if you have a mental health condition. You should do your best to quit smoking and you should stop smoking six weeks before surgery.
Your surgery may be delayed or canceled if the team thinks you are not ready or if you have instead gained weight during the evaluation process.
Weight loss surgery is a relatively routine procedure, but there are still risks. If you do not qualify as a candidate for surgery because your state of health makes it unsafe or indicates a poor outcome, then you should talk to your doctor about alternatives. These might include weight loss medication, which can help to increase weight loss together with lifestyle changes.
Your doctor will also continue to work with you on making the necessary lifestyle changes to help you lose weight. Crash diets generally do not work and can backfire. Instead, you should work towards building healthy eating habits.
Engaging in a regular exercise regime also provides many health benefits. If you have mobility problems that make it hard to exercise, ask your doctor for a referral to a physical therapist who can design an exercise program that works within your limitations.
If you do not enjoy exercising, find an activity you enjoy and plan to do it with a friend, family member, or spouse to make it more fun. Having an exercise partner improves accountability.
If you do not qualify as a candidate for weight loss surgery because your obesity is not severe enough, then you may need to work on addressing body image problems, which often affect overweight people. If you think you are more overweight than you really are, a therapist can help you work through this, which can also help you to lose weight.
Weight loss surgery is a permanent treatment for obesity. It is generally recommended only as a last resort or for people whose weight is significantly impacting their health and they have exhausted all other options, such as diet, and exercise.
If you are obese and your weight loss attempts to date have not been successful, you could talk to your doctor about whether you would be an eligible candidate for surgery. Whether or not you qualify, you will need to continue with your weight loss attempts.
Obesity and overweight | World Health Organization
Overweight and Obesity | NIH: National Heart, Lung, and Blood Institute
Who is a Candidate for Bariatric Surgery? | American Society for Metabolic and Bariatric Surgery
Weight-loss surgery: Is it an option for you? | Mayo Clinic
Bariatric Surgery Requirements and Evaluation | University of California San Francisco Health
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