When It Comes to Losing Weight, Surgery Is 'Not the Ultimate Solution'

Weight-loss Drugs, Procedures Have Drawbacks, Say FPs

May 17, 2010 08:40 am David Mitchell

When a patient who is obese can't shed pounds through diet and exercise, other options exist. However, family physicians interviewed by AAFP News Now said weight-loss medications aren't a long-term solution, and surgery has its risks.

"I've found that medications might work for a month or two," said Andrew Pasternak, M.D., of Reno, Nev. "(Patients) lose some weight, but if (they) don't change their behavior, as soon as they stop taking the medication, the weight comes back."

Pasternak said he's reluctant to expose patients to possible side effects of weight-loss medications without hope for long-term benefit.

For example, sibutramine, which is marketed as Meridia, can increase heart rate and blood pressure, and orlistat, which is marketed as Xenical, can decrease absorption of fat-soluble vitamins and cause loose stools and anal leakage. That's according to the National Heart, Lung and Blood Institute's Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults(www.nhlbi.nih.gov), which also notes that net weight loss attributable to pharmacotherapy generally ranges from 4.4 pounds to 22 pounds.

Vance Blackburn, M.D., of Birmingham, Ala., told AAFP News Now that medication can help "kick-start" a patient who is attempting to lose weight. But, like Pasternak, he said the weight typically comes back when treatment ends.

According to Blackburn, part of the problem is that inexpensive weight-loss medications -- such as phentermine, which is marketed under multiple brand names -- are not approved for long-term use. Sibutramine and orlistat can be taken for longer periods of time, but they cost more, he said, which limits their usefulness.

"I think the best thing physicians and their staffs can do for patients is to focus on brief fitness-related interchanges with patients during every visit, linking their problems to their excess weight, challenging them to visualize a functional reason they want to get healthier and encouraging small, progressive, lifelong changes," said Blackburn.

Overall, said Thomas Marshall, M.D., of Lincoln, Mich., the reputation of weight-loss drugs was damaged by the market withdrawal of "fen-phen" (fenfluramine-phentermine) in 1997. (Fen-phen was shown to cause potentially fatal pulmonary hypertension and heart valve problems.) And the short-term nature of many available products doesn't help, he added.

"I don't think there are any that work," Marshall said. "And I don't mean you won't lose weight on them. People will lose weight on anything they have to pay for. Even if they lose 40 or 50 pounds in a year, three years later they're back in the same boat, and you haven't done them any favors except waste their money."

Surgery: Pros and Cons

According to Marshall, if a patient is so incapacitated by excess weight that his or her diabetes, cholesterol or other problems are out of control, then surgery may be necessary.

Surgery By the Numbers

According to the Journal of the American Dietetic Association, the number of bariatric procedures performed in the United States increased from 13,386 in 1998 to 121,055 in 2004. More than 220,000 bariatric operations are expected to be performed this year.

"That's where you bring behavioral health into it and make sure they've tried everything they can," he said. "Make sure they're ready for the risks involved. Play the risk-benefit game: What are the odds of complications in surgery versus what (is likely to happen) if we don't do anything, and this patient stays at 400 pounds the rest of his life?"

A study(www.amjmed.com) published last year in the American Journal of Medicine assessed the quality of life of patients with obesity who had gastric bypass surgery and compared it with that of a group of matched patients who did not have the surgery.

Researchers said the operative patients showed "remarkable improvements in overall quality of life and functional status" after bariatric surgery. Patients' comorbid conditions improved, and they needed fewer medications to experience a better quality of life.

In the April issue(download.journals.elsevierhealth.com) of the Journal of the American Dietetic Association, researchers from Northwestern University's Feinberg School of Medicine, Chicago, advocate initial treatment by a multidisciplinary team -- including physicians, exercise specialists, behaviorists and registered dietitians -- with a focus on lifestyle modification to help patients lose weight, with or without pharmacotherapy.

If this approach fails to achieve significant weight loss, authors Robert Kushner, M.D., a professor in the school's division of general internal medicine, and Lisa Neff, assistant professor of endocrinology, write in their editorial that bariatric surgery should be considered for patients with a body mass index, or BMI, greater than 40 or, for patients with significant comorbidities, a BMI greater than 35.

Pasternak said that although several of his patients have done well after gastric bypass surgery, he also has had a few who suffered from complications. In addition, he noted, some patients have had the surgery, lost weight and later regained it.

"I try to explain to patients that it's not the ultimate solution," he said. "It's actually much better if you make lifestyle changes first."

Also in the April issue of the Journal of the American Dietetic Association, a study that tracked a group of 80 women who had gastric bypass surgery found that the average weight loss eight years after surgery was 30.7 kilograms, and nearly 60 percent of the women lost 50 percent or more of their excess weight.

However, many of the patients continued to struggle with poor eating habits, the study revealed, with 51 percent reporting episodes of binge eating or night-eating syndrome. A review article in the same journal issue focused on the role registered dietitians can play in helping patients stay on track.

Yet another recent study(www.annallergy.org), this one in the Annals of Allergy, Asthma & Immunology, found that patients cut their use of prescription breathing medications in half after bariatric surgery.

Access to Care

Despite the potential benefits, however, some patients face hurdles when trying to obtain bariatric surgery.

"Insurance companies want to see that they're in a weight-loss program," said Pasternak, who added that exercise is difficult for many obese patients because of joint pain and other limitations. He gives patients six months to make progress in such a program before referring them for surgery.

Kathleen Dunckel, M.D., of Harrisville, Mich., said her practice has a large Medicaid population and that those patients have to meet certain criteria to have the procedure covered.

"They have to have the comorbidities -- the diabetes that's not being controlled, sleep apnea, osteoarthritis -- before their insurance will even consider it," she said.

According to Dunckel, bariatric surgery centers in Michigan carefully screen patients interested in surgery, which helps improve outcomes.

"They've lost different amounts, but the weight that they've lost they've generally kept off," Dunckel said of her patients who have had the surgery.

"By the time they get to that point, they've been through everything else and are pretty motivated. It's not easy to get insurance to pay for it, so they've been through all the other options before they get to bariatric surgery."