Obesity Week 2014: Medications and Surgery to Treat Obesity
Obesity is often tagged with a discussion about willpower. Recent research and obesity trends seem to indicate that more is at play than just the ability to say no to food. Society does seem to value the person who loses weight and keeps it off without any use of medications or surgery. But current science suggests that if you have diabetes in the presence of obesity, bariatric surgery can help to resolve the diabetes, with minimal weight loss. Patients, and the health professionals who treat obesity, have to be willing to evaluate the possible benefits of using medications, even temporarily, and consider weight loss surgery.
If you have a BMI of 30 or greater, or a BMI of 27 and obesity-related disease (high blood pressure, diabetes, heart disease) you should consider the pros and cons of using medications in conjunction with diet and exercise. Orlistat (Xenical) is sold over-the-counter as Alli, and helps to block a percentage of fat that you eat from being absorbed by your body. If you overeat fat at any single meal, side effects can include gas, diarrhea and even oily stool leakage. For the person who needs a strong deterrent, it may be a good fit.
Currently there are three other by-prescription drugs on the market: Contrave, Qysemia, and Belviq. A fourth drug may be approved shortly. Belviq (Lorcaserin) acts on serotonin receptors in the brain. It has a number of symptomatic side effects. Qysemia, a combination of phentermine and topiramate, suppresses appetite, may make you feel fuller, and possibly change the way foods taste. Contrave, the most recent drug to join the list of weight management drugs, combines Wellbutrin (buprion) an antidepressant, with naltrexone, an anti-addiction drug. It has a boxed warning for suicidal thought risks.
There are some other drugs (phentermine, benzphetamine, diethylpropion, and phendimetrazine) that can be used short term and all have somewhat unpleasant side effects that can range in intensity. Let’s also remember that obesity has long list of quality of life issues and raises the risk for a number of serious chronic diseases. A person needs to balance the benefits or edge that a drug may offer, versus any unpleasant side effects. You can always try a drug to see if you can tolerate any downside, and the prevailing thought is that if a weight loss drug works, you will experience the bulk of weight loss in the first three months of use. Doctors who work in this field do believe drugs have an important role, but they are by no means a magic bullet, nor are they a good fit for every patient.
A very recent study does suggest that the many supplements and over-the-counter options that promise weight loss (which are not regulated by the FDA) are actually creating significant problems, and even fueling obesity further. Certainly, too many consumers believe that drugs can be a magic answer. Just taking a drug can fuel over-eating because you believe the pill is somehow magically blocking calories and weight gain. This behavior is not just isolated to obesity. Many patients who take cholesterol-lowering statins continue unhealthy eating habits because they somehow believe the drug will completely block the impact of a poor diet. You have to choose the right medication and add a lifestyle program for a successful outcome.
The American Society for Metabolic and Bariatric Surgery presented a number of sessions discussing current surgical interventions for weight loss. Guidelines to qualify for weight loss surgery include:
- BMI of 40 or more
- A lower BMI in the presence of serious health-related disease (diabetes, heart disease, severe sleep apnea, high cholesterol and others)
- Individuals who are severely overweight and have tried other weight loss therapies unsuccessfully
Weight loss surgery will not singularly resolve obesity. There’s a lot of work that has to be done, lifestyle-wise and behaviorally, prior to surgery, and that work doesn’t stop after surgery. Ongoing support is also crucial. Current available surgeries either shrink the stomach and slow digestion, or they give you a smaller stomach and “bypass” part of your digestive tract affecting how you absorb calories. All the surgeries will result in weight loss, sometimes dramatic weight loss, but there's a risk of re-gaining some or all of the weight. All surgeries have certain side effects, some of which may be untenable for patients. A short synopsis of the current surgeries:
Gastric banding, which uses an inflatable band to create two sections, a smaller upper pouch and a larger lower section, still connected by a very narrow channel. You will eat significantly less (about a cup of food) because of the very slow emptying of the upper pouch.
Sleeve gastrectomy involves removal of about 75% of the stomach. Remaining is a narrow “sleeve” or tube which connects to the intestine. It’s associated with less weight loss, less risk, but it is irreversible unlike banding.
Gastric bypass or Roux-en-Y surgery, essentially creates a bypass from the stomach to the small intestine, so the body absorbs less calories. Weight loss is usually swift and dramatic. This surgery has some pretty dramatic long term side effects including dumping syndrome, when you consume high carb meals. It’s a more complicated, riskier surgery.
Biliopancreatic diversion is a more drastic version of gastric bypass surgery, and there is a less extreme version called biliopancreatic surgery with duodenal switch (which has a lower risk of dumping syndrome).
Ongoing research may propel better surgical techniques, better preoperative recommendations to help limit complications, a better design for follow up care post-surgery to avoid malnutrition or vitamin deficits (somewhat common due to poor compliance or financial constraints), and better assessments so that the right patient is matched to the most optimal surgery.
Clearly the decision to use drugs or surgery involves a detailed assessment of your weight situation. Some individuals seek surgical intervention thinking it’s a quick fix. The surgery only works if you sustain lifestyle changes. Otherwise you’ll probably regain much if not all your weight back. During ObesityWeek2014 experts discussed whether weight loss medications could be used in conjunction with surgical options. In the future we will more than likely see more pharma options, and possibly newer versions of current surgeries.
Next Up: Can We Dramatically Limit Childhood Obesity?
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