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• Highlights
• Introduction
• Biologic and Medical Causes
• Cultural and Emotional Causes
• Risk Factors
• Complications
• Weight Loss and Maintenance
• Weight Management
• Medications
• Other Treatments
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Weight control and diet

Description

An in-depth report on losing and managing weight safely for health benefits.

Alternative Names

Dieting; Obesity; Weight loss

Other Treatments

Surgical procedures for obesity may be appropriate for some dangerously obese people and may reduce heart problems and many of their risk factors, including high blood pressure, sleep apnea, and diabetes. In fact, some evidence suggests that surgery may provide much greater control of weight and diabetes than nonsurgical weight-loss methods. Studies are reporting significant reductions in diabetes and need for diabetic medications. Other medical conditions that often improve after surgery include heartburn, arthritis, and other joint and circulation problems.

Bariatric surgeries produce weight loss through one of two approaches:

• Restrictive Banding Procedure. These procedures restrict the amount of food by closing off parts of the stomach with bands.
• Malabsorptive Bypass Procedures. This approach restricts the amount of food and also reduces absorption by using a bypass of parts of the intestine.

The malabsorptive procedures are more successful in achieving weight loss than the banding approach, but they carry a greater risk for nutritional deficiencies.

Benefits of Bariatric Surgery

Most people who have bariatric surgery lose about two-thirds of excess weight within 2 years. In addition, diseases associated with obesity (such as diabetes, high blood pressure, sleep apnea, joint pain, and incontinence) often improve.

Researchers at the Mayo Clinic looked at records from patients who had the surgery between 1990 and 2003. They found that those who had bariatric surgery reduced their risk of cardiovascular events such as a heart attack much more than those who lost weight without surgery. The findings were published the September 2005 Mayo Clinic Proceedings .

Other studies have shown that even though most patients maintain significant weight loss, the majority regain about to 10% of their weight. Patients must still develop a healthy life style and be calorie conscious after the operation. Follow-up must be life long.

Candidates for Bariatric Surgery

Any surgical candidate must have failed consistently in losing weight through less invasive methods. Experts recommend bariatric surgery only for the following:

• Those whose BMI is above 40 (about 100 pounds overweight), and or
• Those with BMIs of over 35 who have type 2 diabetes or serious obesity-related medical problems at least 35 or more or whose weight is about 85 to 100 lb. more than ideal, and or
• Those with severe obesity that interfered with employment, normal physical activity (e.g., walking), and important relationship.

Restrictive Banding Procedures

About a third of people who undergo these procedures achieve normal weight and 80% experience some weigh loss. They are less successful than the bypass procedures but cause a lower risk for nutritional deficiencies.

Vertical Banded Gastroplasty. Vertical banded gastroplasty (VBG) was the most common restrictive procedures. It involves creating a hole through both stomach walls and sealing the edges with a staple. This narrows the stomach, similar to a funnel, and allows only small amounts of food to pass through.

Laparoscopic Gastric Banding. Laparoscopic gastric banding (the Lap-Band) usually does not require a major incision and avoids some of the major complications of gastric bypass:

• It employs an adjustable silicone band that is placed around the upper part of the stomach.
• A small balloon-like reservoir attached to the band under the abdominal skin contains saline, which can be added or removed to tighten or loosen the band.
• The procedure restricts the amount of food a person can eat and gives the feeling of fullness.

The band is removable, if necessary. Studies to date indicate that the intestinal tract returns to normal afterward. Some studies have reported significant weight loss and improved quality of life with the procedure, including in the elderly. A 2001 analysis of eight U.S. centers where it was performed, however, reported a very high failure rate after 2 years. Experts concluded that it is not, at this time, an effective procedure for severe obesity. Nevertheless, increasing surgical experience could improve these results.

Malabsorptive Bypass Procedures

Malabsorptive procedures produce greater weight loss than restrictive procedures. They generally achieve about two-thirds of their weight loss within 2 years. Furthermore, in a 2003 study, after standard bypass surgery, 83% of patients with type 2 diabetes experienced normal blood glucose levels and the rest had significant reductions.

Roux-en-Y Gastric Bypass Procedure. This is the most common and successful malabsorptive surgery in the United States. It involves creating a small stomach pouch that serves as a reservoir and restricts food intake. The pouch eventually holds up to 3 ounces of food and has a small outlet that delays emptying and causes a feeling of fullness. Then the surgeon creates a Y-shaped section in the small intestine that attaches to pouch and allows food to bypass the lower stomach and upper part of the intestine. One 2003 study reported that it was associated with significant weight loss, and furthermore 80% of patients with type 2 diabetes were able to reduce their medications. A more recent study, published in the March 14, 2006 Archives of Surgery , found that gastric bypass surgery also helps lower the blood pressure of very obese patients.

The procedure produces greater and more sustained weight loss than banding procedures, but also it is more complicated and carries a higher risk for nutritional deficiencies. Laparoscopy techniques, which are less invasive, are showing promise for possibly reducing complications.

Biliopancreatic Diversion. This procedure is more complicated and removes portions of the stomach. The pouch that is created attaches directly to the lower part of the small intestine. It poses a higher risk for nutritional deficiencies than other procedures and is not used as often.

Side Effects and Complications

General Side Effects and Complications. Side effects and complications of bariatric procedures are common, and up to 25% of patients require corrective or repeat procedures. After any of these procedures people must chew all their food carefully and cannot eat large amounts of food at one time or they will experience nausea, abdominal distress, or both.

Complications from any bariatric procedure includes the following:

• Vomiting is the most common, with banding procedures causing a greater risk.
• There is a strong risk for nutritional deficiencies, particularly with malabsorptive operations. This can lead to anemia and increase the risk for bone loss and osteoporosis. Sufficient mineral and vitamin supplements are important.
• There is a significant risk for deep-vein thrombosis (blood clots) .
• Abdominal hernia is a common complication. (Newer, laparoscopic technique can avoid this problem, but not all individuals are candidates for this less invasive approach.)
• Rapid weight loss after surgery puts people at high risk for gallstones.
• Women who wish to be pregnant should wait until their weight has stabilized. Rapid weight loss and nutritional deficiencies can harm the fetus.

People at highest risk for complications are those with heart or lung problems, severe obesity, and a history of abdominal surgeries. Mortality rate from bariatric surgeries is 0.2%, which is lower than the morality rates from morbid obesity itself. Other variations and less invasive techniques using laparoscopy are being developed.

Specific Complications of Restrictive Banding Procedures. Nausea, vomiting, or both in half the patients and severe heartburn in a third. Device-related complications include band slippage, pouch dilation, or both in nearly a quarter of patients and obstruction in 12%. Very serious complications are rare, but include blood clots, bleeding, infection, pneumonia, and perforation of the stomach.

Specific Complications of Malabsorptive Bypass Procedures. Vomiting often occurs. Nutritional deficiencies occur more often in these procedures. The so-called dumping syndrome is a common unpleasant side effect that occurs when food waste moves too quickly through the intestine. Symptoms include nausea, weakness, sweating, and faintness (particularly after eating sweets).

Spot Reduction Spot Exercising. Anyone seeking to lose weight must expect that the results may not be as cosmetically satisfying as one would wish. Spot exercising, training particular areas of the body, is ineffective in reducing fat in specific locations because exercise draws on fat stores throughout the body. Gimmicky devices such as bust developers, vacuum pants, and exercise belts do absolutely nothing to reduce fat in specific locations or, in the case of the bust developer, to add bulk. Electrical pads wrapped around the waist, arms, or thighs were reported to cause burns and fires. Cellulite-Removal Creams. Many women try to reduce fat in their thighs (cellulite) with creams that contain aminophylline (Skinny Dip, Thermojetics Body Toning Cream, Smooth Contours). Studies provide no evidence that these creams are effective. Their apparent effect on fat may simply be from constricting blood vessels and forcing water from the skin, which could be dangerous for people with circulation problems. Endermologie. Endermologie uses motorized rollers and regulated suction to smooth out cellulite. In one study, about 28.6% of patients reported improved appearance after using it. Liposuction. Liposuction eliminates fat in specific areas, such as the abdomen, thighs, buttocks, or knees. Special instruments are inserted through the skin into the pockets and suction is used to move the fat, break it up, and remove it. Small tubes may be used to drain blood and fluid during the first few days. The pain after the operation can be severe and often the skin does not contract, resulting in a flabby look. Complications can include burns from the vibrators, bruising, blood clots, and bleeding. Weight gain generally tends to develop in other locations after the operation. Some doctors are using this procedure in overweight people with diabetes to remove abdominal fat. Although there is no proof that it has an effect on diabetes, some experts believe it warrants some attention.

• Review Date: 3/29/2006
• Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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