West Virginia Uncovered

Clarksburg resident chooses gastric bypass surgery to manage health.

By Shay Maunz

Nancy Robinson was always a bit ”chunky,” even as a kid.

“I didn’t really care,” she said. “I was always a free spirit and dressed cute anyway. I didn’t really care if my skirt was a little too short, or if I was a little too big.”

She played sports in school and “ran around the neighborhood playing all year.”

But 20 years later she cringes looking back on her childhood eating habits: mid-day snacks that should have qualified as meals, and butter-slathered vegetables at every dinner table.

By the time she reached her 20s, those eating habits had caught up with her. At 28, Robinson, of Clarksburg, was morbidly obese – with severe diabetes and sleep apnea, among other obesity-related health problems.

She knew she needed to do something about her weight. But for years, she depended on fad diets – she lost and then regained 30 pounds more times than she can remember.

Then she and her husband decided to have a baby.

”The doctor said if I got pregnant taking so much insulin it would probably kill me,” “she said.

“I looked at my husband and realized that food was ruining my life, and I had to do something drastic.”

Nancy was not unlike most chronically obese individuals. A recent study done by researchers at the University of Pennsylvania and published in the New England Journal of Medicine, suggests that for most chronically obese patients, behavioral changes alone may not cut it.

Researchers compared different types of medical therapy involving “weight loss coaches “and measured their effectiveness on weight loss. They found that, even with the help of a coach, only about one-third of patients achieve long-term, clinically meaningful weight loss.

Nancy had tried to lose weight before: she’d seen trainers and doctors and tried to take a proactive approach. But with her weight somewhere upwards of 300 pounds, the amount she needed to lose was daunting, and she couldn’t seem to make enough meaningful changes.

Then, her dad died of obesity-related causes – both her parents are also obese – and the emotional toll caused her to eat even more. She was heavier than she ever had been and she didn’t see any other way out.

She underwent roux en-Y gastric bypass surgery, a common type of weight-loss surgery in 2011.

In 2009, around 250,000 people in the United States had weight-loss surgery, according to the American Society for Metabolic and Bariatric Surgery, and the number of people having such surgeries has grown since.

The number of bariatric surgeries in the United States has doubled in the past decade. But more than 20 million Americans are morbidly obese, so only around 1 percent of the clinically eligible population have bariatric surgery.

Doctors generally use body mass index, an index for relating weight to height, to determine eligibility. Guidelines from the National Institute for Health recommend bariatric surgery when a patient has a BMI of 40 or above – the threshold for severe clinical obesity – or a BMI of 35 with at least one co-morbidity, like diabetes or sleep apnea.

Patients often lose between 62 and 70 percent of excess weight following gastric bypass, and related health problems usually clear up as well. According to the Agency for Healthcare Research and Quality, diabetes disappeared in almost 77 percent of patients.

It isn’t magic, though.

“A lot of times people kind of give me flack for taking ‘the easy way out,’” Robinson said.

“I’m here to tell you it’s not the easy way out.”

Immediately after the surgery, the pouch in Robinson’s stomach that was able to accept food was so small that she was struggling to get 600 calories a day.

For Robinson and many other patients, over-eating after gastric bypass often leads to “dumping syndrome.” They feel nauseous and vomit or defecate because their small intestine has come into contact with too much food at once.

They’re also prescribed a daily regimen of vitamins to make up for what their body isn’t absorbing through food, and about 10 percent of patients develop a lactose intolerance after the surgery and can’t digest milk or milk-products.

This has prompted a national debate among experts over the efficacy and safety of weight loss surgery- a debate that has a direct impact on the well being of the millions of obese Americans who qualify for the surgery.

“It’s a big step,” said Holli Neiman-Hart, residency director in family medicine at WVU’s Health Sciences Center.

“I’m very cautious in who I recommend it to. There are a handful I’ve seen personally who are doing the right things and keeping the weight off, but I think a lot of us who are overweight just want a quick fix, and it’s really not that.”

The most common type of bariatric surgery, gastric bypass, involves two steps: first, the stomach is stapled into a small pouch that can hold only a fraction of what it previously could. Then, the pouch is connected to the small intestine further downstream so food doesn’t get absorbed as easily.

The procedure was first described in the 1950s, and it was performed through an open incision until the early 2000s.

“You can imagine, with the health risks associated with (the people seeking surgery) that it was often very risky,” said Robin Blackstone, president of the American Society for Metabolic and Bariatric Surgery.

Around 2000, surgeons began to perform the surgery laproscopically – using tiny cameras and incisions less than a centimeter long—and the death and morbidity rate has steadily declined ever since.

Now, around 93 percent of bariatric procedures are done laproscropically, and the death rate is less than .1 percent.

Still, in 2004, 230 patients died during hospital stays when bariatric surgery was performed. For many people, that means the risk is still too high for an elective procedure.

“Usually when you have surgery, something bad has happened to you,” Blackstone said. “The times people elect to go in to have elective surgery they’re weighing individually the risks and benefits.”

Other, non-fatal risks related to the surgery include infection, ulcers, heart attack, hernias and wound reopening.

“The biggest problem with it is our inability to predict who is going to do well and who is not,” Neiman-Hart said. “It’s not a decision that I encourage my patients to take lightly.”

When Robinson had gastric bypass surgery in 2011, she paid $16,500 out of pocket for the surgery; her insurance would not cover the procedure.

“It nearly broke us,” she said. “I mean, we were digging into places we didn’t even know were there looking for money.”

In the end she even extended the required pre-surgery liquid diet – only liquids and protein shakes – from the mandatory two weeks to three weeks, to save on food costs.

“I had to make up that extra cash somewhere,” she said. “There was nowhere else left to find it.”

Nearly all major insurance payers include provisions for weight-loss surgery in their guidelines, but in practice, they rarely cover the procedure.

Aetna’s guidelines, for example, include a note saying that certain Aetna plans exclude coverage of bariatric surgery altogether, and that “most” plans require that the procedures be “approved by Aetna.” Cigna and United Health Care – Robinson’s povider—include similar notes.

Blackstone said that around half of large-employer health care insurance plans cover bariatric surgery, but smaller employer plans rarely do so.

In the end, Robinson and her husband decided to spend the money on the procedure.

“I said we couldn’t afford it,” Robinson said. “But my husband just said ‘We can’t afford not to’.”

Without the surgery, they reasoned, they wouldn’t be able to live out the lives they had planned for themselves. They wanted children and the mobility to travel.

“We decided that we had to do it, spend the money,” Robinson said. “But, it was so hard for us.”

They decided to look at it as an investment in their future.

“I always tell my patients that if you can lose 100 pounds and you keep it off, that’s the holy grail, it’s just that a lot of people can’t do that without the surgery,” Blackstone said.

“They need tinkering.”

A study published last month in the New England Journal of Medicine compared the effects of weight loss surgery on diabetes – one of the most common and serious obesity comorbidities – to the impact of medical therapy with a “weight-loss coach” focusing on diet and exercise.

The study, done by researchers at the Catholic University of Rome, assigned 30 patients to receive gastric bypass surgery, and 30 to receive conventional medical therapy for diabetes.
After two years, 75 percent of patients with gastric bypass surgery had seen their diabetes go into remission. No patients who received medical therapy saw their diabetes disappear.

“In the old days of bariatric surgery, ten years ago, we told patients that the way these surgeries work is they restrict the amount of food you can eat and the amount of food your body can absorb,” Blackstone said.

“It turns out that couldn’t be farther from the truth.”

Instead, experts now realize that gastric bypass and other types of weight loss surgery are effective mainly because they affect the body’s metabolic processes.

“They actually change things. They change the way your hormones work with the brain They change your preference for food.”

Since her surgery, Robinson’s lifestyle has seen a major overhaul. Her diet and exercise habits have improved substantially – partly because of a change in taste, she said, but also because of a lot of hard work.

She weighs the portions of everything she eats, and exercises six days a week.

“I needed the surgery,” she said. “But it didn’t end there. I still had a lot of work to do, and a lot of adjusting to do to this new lifestyle.”

Just as weight-loss surgery wasn’t a cure-all for Robinson, Blackstone admits that it isn’t a silver bullet for the country’s obesity epidemic overall.

“At the end of the day there has to be a different answer to obesity,” she said. “But for now, we’re using obesity surgery as a window to figure this all out, and it’s really exciting.”

“There may always be people who need this kind of surgery, but I’m hoping it will just be in very extreme cases.”