The fight against fat

A leading US cardiologist and preventive medicine expert finds in joint research with Israelis that bariatric surgery is safe and preferred for the morbidly obese.

By
February 11, 2018 03:15
Overweight man

Overweight man [Illustrative]. (photo credit: INGIMAGE)

 
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In America, fast-food restaurants and donut shops are so ubiquitous that even many medical centers have outlets where people can gorge themselves with unhealthful food.

Ironically, this makes those hospitals one-stop-shops that contribute to the number of people with morbid obesity and then treat those suffering from it by performing bariatric surgery.

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Israelis may laugh about this, but while Americans are the fattest population in the world, we are also getting heavier from junk food; the number of stomach-shortening operations we undergo is the highest per capita in the world. A number of well-known people here in fields such as entertainment and government have halved their girth with the procedure.

The reason that this type of surgery for the morbidly obese is so popular in Israel is that it is covered by the health funds – those with a body-mass index of 40 or more, or 35 and above if the patient suffers from hypertension, diabetes or related chronic conditions. In the US, not all private health maintenance organizations are willing to pay for the surgery, which costs at least $10,000, and there are also people without health insurance. .

That is the appraisal of cardiology and preventive medicine Prof. Philip Greenland, director of the Institute for Public Health and Medicine Center for Population Health Sciences at the Feinberg School of Medicine at Northwestern University in Chicago.

A frequent visitor to Israel, Greenland recently published in the Journal of the American Medical Association (JAMA) a study he conducted with the Clalit Research Institute on the relative risks of bariatric surgery vs. morbid obesity.

Greenland, who is straight and thin, exercises regularly at home on his elliptical machine and stationary bicycle. “I use them every day. We live in Skokie, where there are no sidewalks because people go everywhere by car.”



A modern Orthodox Jew, Greenland and his wife have four adult children. Their son is a rabbi and the international director of the National Council of Synagogue Youth, a modern Orthodox Jewish youth group, while each of their three daughters are married to modern Orthodox rabbis.

Titled “Association of Bariatric Surgery Using Laparoscopic Banding, Roux-en-Y Gastric Bypass, or Laparoscopic Sleeve Gastrectomy vs Usual Care Obesity Management with All- Cause Mortality,” the study would have been impossible to carry out in the US. In an interview with The Jerusalem Post during one of his visits to Jerusalem recently, Greenland said that long-term follow-up of patients is possible in Israel because most people remain members for decades – and even a lifetime – of one of the four public health insurers and there are excellent digital records. Clalit Health Services, which is the largest of the insurers here, has less than a 1% annual turnover of members.

There is no such thing in the private American health insurance system.

ABOUT 5,000 Israelis undergo bariatric surgery in an average year. His own hospital in Chicago performs about 500 such procedures annually.

“Bariatric surgery is an effective and safe approach for weight loss and short-term improvement in metabolic disorders such as diabetes,” the research team wrote.

“However, studies have been limited in most settings by lack of a nonsurgical group, losses to follow-up, missing data, and small sample sizes in clinical trials and observational studies.”

The team concluded that the death rate in obese patients who did not have surgery was 2.3% compared to 1.3% for those who had surgery – meaning they have a 50% lower death rate for up to 10 years after the operation. The research was reportedly the first to follow the benefits and possible risks of the surgical procedure over the long term.

“We showed that a long-term effect of bariatric surgery is a longer life for very obese patients,” said Greenland. “They had half the death rate, which is significant.”

Greenland worked with Prof. Ran Balicer, a founding director of the Clalit Research Institute and Dr. Dror Dicker, director of the department of internal medicine D, head of the obesity and hypertension clinic for at the Rabin Medical Center – Hasharon Campus in Petah Tikva and former head of the Israel Obesity Society.

The team analyzed deaths from any cause among obese Israeli patients (65% women and 35% men) who had bariatric surgery and compared them with 25,155 obese people who did not have the surgery.

In the US, the majority of people who have bariatric surgery are women, but those long-term studies that have been performed in the US were done almost solely in Veterans Administration hospitals, where 95% of patients are men.

The average age of those in the study was 46 with an average body mass index of 40, the equivalent of being 1.7 meters tall and weighing 120 kg. The new research illuminates the real-world experience of patients having bariatric surgery.

Greenland noted that while the operation is highly effective in promoting weight loss if the patient changes his lifestyle, eats less and exercises, it is also invasive and can lead to short- and long-term complications.

So the study was needed to help doctors make informed decisions, based on long-and-short-term benefits and risks of the procedure.

Some of the complications of the surgery include malabsorption of nutrients, vitamin deficiency, anemia and protein deficiency. But Greenland and colleagues found there was no higher rate of anemia, vitamin or protein deficiency among those who were studied.

While it is preferable to lose weight by proper diet and regular exercise, for many obese people, this proves to be impossible, he said. Surgery is a radical approach to managing obesity that many people reject because it seems risky, but it is actually less risky than not having the surgery.

There are three main types of bariatric surgery plus a few other possible procedures.

In the laparoscopic adjustable gastric band procedure, the surgeon places a ring with an inner inflatable band around the top of the stomach to create a small pouch.

This makes you feel full after eating a small amount of food. The band has a circular balloon inside that is filled with salt solution. The surgeon can adjust the size of the opening from the pouch to the rest of your stomach by injecting or removing the solution through a small device called a port placed under your skin.

In gastric sleeve surgery, also called vertical sleeve gastrectomy, the surgeon irreversibly removes most of the stomach, leaving only a bananashaped section that is closed with staples. Like gastric band surgery, this surgery reduces the amount of food that can fit in your stomach, making you feel satiated sooner. Taking out part of your stomach may also affect gut hormones or other factors such as gut bacteria that may affect appetite and metabolism.

Gastric bypass surgery, also called Roux-en-Y gastric bypass, has two parts. First, the surgeon staples your stomach, creating a small pouch in the upper section. Then he cuts the small intestine and attaches the lower part of it directly to the small stomach pouch. Food then bypasses most of the stomach and the upper part of your small intestine so the body absorbs fewer calories. The surgeon connects the bypassed section farther down to the lower part of the small intestine. This bypassed section is still attached to the main part of your stomach, so digestive juices can move from your stomach and the first part of the small intestine into the lower part of your small intestine.

The bypass also changes gut hormones, gut bacteria, and other factors that may affect appetite and metabolism. Gastric bypass is difficult to reverse, although a surgeon may do it if medically necessary.

Greenland noted that because of possible complications, this type is not carried out much anymore, but there are many Americans and Israelis who have had the surgery done in the past. The band and sleeve techniques are much less invasive, so the possible complications are also much lower.

Recovery after bariatric surgery is usually rather quick. You may be kept in the hospital for just one day, especially after laparoscopic surgery.

Returning to your ordinary routine and full recovery take a few weeks.

Yet, even with stomach reduction, if you eat enough you can still end up stretching your stomach, just like a fetus stretches a woman’s uterus.”



GREENLAND IS a cardiologist, not a surgeon and does not perform bariatric surgery.

“Most of the research I have done is in the field of heart disease and how to prevent it. Obviously, obesity is a major factor.”

He recalled that bariatric procedures were developed three decades ago, but they have become popular around the world only in the last 15 years.

“Both here and in Israel, there are opportunities to eat fattening food everywhere. Most people have very sedentary jobs. Even construction jobs that used to require a lot of moving around today involve sitting in a tractor or a crane and just pushing buttons and moving sticks.”

According to the most recent data, adult obesity rates exceeded 35% in five states, 30% in 25 states, and 25% in 46 states. Colorado had the lowest adult obesity rate at 22.3% and West Virginia and Mississippi had the highest at almost 38%. Some 30% of Americans are morbidly obese.

Losing weight by observing a healthful diet and exercising regularly is, of course, the optimal way to shed kilos, “but so few people have the willpower to do it. So there is the option of the operation, even though one should not undertake surgery lightly,” he said.

“Tobacco is the number-one preventable cause of heart disease.

Smoking is something you either do or don’t. Obesity is more complex, as obese people look for an easy fix,” Greenland continued. Losing a lot of weight is not simple. We can’t just give patients pills to take. You can lower cholesterol levels with a pill, but not make them drop kilos.

Surveys show that exercising in the US is stable, meaning low. And there is more child obesity than ever.

“When I studied medicine, there was juvenile diabetes (Type 1) and adult-onset diabetes (Type 2), but today there are obese children with ‘adult-onset’ diabetes.”

Efforts to reduce obesity are spotty in the US, because each state does different things.

“In Illinois, where I live, physical education in schools is mandatory, but there are other states where this has been canceled due to budget constraints. The city of Chicago enacted a tax on sugar-sweetened beverages. It was supported by the American Diabetes Association, the American Heart Association and other groups, but the food industry lobbyists and the general public opposed it, and it was canceled.

There are societal things outside of doctors’ control.”

The government of Finland recognized some 40 years ago that their population had the highest rate of coronary disease in world. It turns out that they ate an incredibly large amount of high-fat dairy products and that many smoked tobacco.

“The government stepped in and instituted and anti-smoking programs and dietary measures. Butter became more expensive, for example.

In the long term, there were huge reductions in health issues such as high blood pressure, smoking and obesity.”

There are prescription drugs aimed at reducing weight without surgery, but they produce only very modest weight loss, up to 5%, so users get discouraged. These medications are also not very popular because of their unpleasant side effects, including oil diarrhea.

“Pharmaceutical companies say they have various experimental drugs in the pipeline, but significant weight loss is very complicated because they involve multiple hormones or neurotransmitters.”

Greenland was not surprised to hear that an effort by the Health Ministry in Jerusalem to require food manufacturers and importers to label their products with red or green icons for healthful or unhealthful products and teaspoons for their sugar content were pruned and delayed due to pressure by companies.

“A multi-pronged effort and political will are needed to promote governmental regulations and reduce obesity,” Greenland declared.

“There must also be more individual responsibility in which people recognize their duty to improve their health,” the cardiologist concluded.

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