Is Bariatric Surgery for You? - Woman to Woman - Harvard Commentaries

From time to time, a friend or colleague will ask me what I think of bariatric surgery. Formerly often called "stomach stapling," the procedure done now is more likely to be gastric bypass or lap-band surgery. Too often, those asking about it clearly are not appropriate candidates for this surgical method, which can lead to substantial weight loss. There are misconceptions about what it's for and what life will be like afterward.

I think there is no way to properly prepare someone for the seriousness of this type of surgery and the life changes that will follow.

The biggest myth is that bariatric surgery will make it easy to lose weight and keep it off. Celebrity examples of successful weight loss, Carnie Wilson and Al Roker, are walking advertisements of how you could look after having surgery. This makes bariatric surgery seem like plastic surgery or a more involved cosmetic procedure.

But the truth is that this operation is far more serious than a tummy tuck. This is major surgery, sometimes cutting your bowel and rearranging it. And what you don't see behind the smiles of those who have had it done are the big changes they had to make in their diet and lifestyle.

The reality about bariatric surgery is that your life will never be the same again. You will be limited to eating small portions because of the small size of your stomach after the surgery. You also may have diarrhea and difficulty absorbing important nutrients. Aside from the small but still concerning risk of death, the risks of surgery include potentially serious infections in the abdomen, difficulty with wound healing, and hernias.

Bariatric surgery includes two main types. Each type basically involves cutting down the size of your stomach. A lap-band is the simplest type of surgery, which in some cases is reversible. However, it may be less successful in terms of weight loss. Gastric bypass surgery involves cutting down the size of the stomach you can use and rerouting part of the intestine.

The truth is, bariatric surgery should be used only in select cases. The National Institutes of Health created guidelines for bariatric surgery based on available study evidence. Most insurance providers follow these guidelines before approving payment for this surgery.

Are morbidly or significantly obese (body mass index, or BMI, greater than 40)
Are moderately obese, with a BMI between 35 and 40, with more than one high-risk condition such as severe diabetes or poor functional status
Are between ages 16 and 65
Have an acceptable operative risk
Are psychologically stable with realistic expectations
Are committed to prolonged lifestyle changes
Have a supportive family and social environment
Have no active alcohol or substance abuse problem
Do not have active schizophrenia or untreated severe depression
Have documented failure at losing weight long-term through nonsurgical methods — this usually means evidence that you have enrolled in a program to incorporate diet and exercise
Are well informed and motivated
Are able to participate in the treatment, follow-up and diet

The definition of success in studies of bariatric surgery is weight loss of 50% of excess body fat. Who gets the most benefit? People with diabetes and obesity.

Some studies suggest that people who are somewhat less obese but have high blood pressure, high cholesterol or diabetes might benefit more from the surgery than people of similar weight who don't have any of these medical problems. Additional studies are underway to help determine who, if anyone, is a surgical candidate when BMI is not greater than 40.

So my usual short answer to friends' questions is that surgery is a pretty serious way to treat obesity given its risks. In general, I am more likely to recommend it if the person has diabetes, high blood pressure or very high cholesterol in addition to being obese.

Even then, it's important to be sure that you understand the life-changing aspects of this surgery. I always recommend that any potential surgical candidate talk to someone who has had the surgery.

Second, you should do a risk assessment with the help of your health care provider. Is your health endangered enough by your weight to make it worth risking your life now to potentially add years to your life in the future?

Alice Y. Chang, M.D. is a former instructor in medicine at Harvard Medical School. She is currently associated with University of Texas Southwestern Medical Center. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine and patient education.