WL&S Support

What Could Be Done – A Simple Solution, If Only!

The statement that Morbid Obesity Kills is a statement of fact. It is not an exaggeration. Morbid obesity may lead to many medical conditions that increase the likelihood of an early death. These conditions include diabetes and kidney failure, heart problems, strokes, joint problems, fatty liver degeneration, an increased incidence of malignant tumours, sleep apnea and so on.

There are several types of surgical intervention, such as constricting the stomach with an adjustable constriction, removing a portion of the stomach or disconnecting most of the stomach from the esophagus and relocating portions of the small intestine to reduce digestive efficiency (Roux-en-Y). All are effective, and the choice of procedure is often personal preference made with medical advice. The Roux-en-Y in particular has garnered a lot of interest as the relocation of the small intestine helps bring type 2 diabetes under control without medication, effectively “curing” about 80% of patients. This procedure is now being recommended for the treatment of type 2 diabetes by many physicians.

Surgery does not end the emotional dysfunction that morbidly obese patients have. It does cause a loss of weight, the speed and amount depending on the type of surgery. A patient weighing 400 pounds who has a Roux-en-Y could lose 100 pounds the first year and another 50 pounds the second, but if they do not deal with the underlying dysfunction, that weight will eventually be put back on. Surgery gives an opportunity to “start over”, but the patient must take advantage of it and address the eating disorder. That is why counselling and help groups are necessary along with the surgery.

Despite considerable evidence that surgical intervention is the appropriate treatment for morbidly obese patients, few hospitals in British Columbia offer it as a service. There are many reasons for this – attitudes of the public and some physicians towards obesity and surgical intervention, lack of the equipment and skills necessary to deal with very heavy patients, lack of funding by the Ministry of Health Services, lack of surgeons trained to perform the surgery – all combining to restrict access to a necessary service. Could you imagine the outcry if there were the same lack of availability for those with tobacco induced lung cancer?

VIHA Complaints

At present (December 2009) bariatric surgery in British Columbia is performed at the Royal Jubilee Hospital by just a few surgeons. The Vancouver Island Health Authority has just announced a reduction in such surgeries of about 60%, and there is now only one per week being done on average. Other jurisdictions are increasing the number of surgeries, Ontario being a good example, where the target is to triple the number being done over the next few years. Our opinion is that this surgery should be offered at centres throughout B.C. – Prince George, Kamloops, and Vancouver as well as Victoria.

It is now well known that there is an increase in obesity among Canadians, young and old. There are many factors involved, but a change from an active to an inactive lifestyle is certainly one of them. We now have advertising campaigns directed at young Canadians to increase their physical activity, and educate them in nutritional diets. The aim is to decrease the numbers of obese Canadians. That is a positive step, but it does nothing for those already morbidly obese. For this group, an increase in the availability of surgery is essential.

Surgery is expensive both in direct costs for the supplies and equipment and for fees. So is not doing surgery, if not in lower productivity due to the restrictions on physical activity that morbid obesity imposes on its victims, then most certainly in the costs of medication for the diseases that obesity of this degree invariably causes, some of which cost hundreds of dollars monthly. Pharmacare absorbs significant amounts of these costs, as do private prescription insurers. One way or the other society pays – in money and human distress.

Once a morbidly obese patient has had Roux-en-Y surgery they can never again eat a full meal, and the food they do eat does not provide the same nutrition as it did before the surgery. The relocation of the small intestine results in a less efficient digestion than before. After surgery the patient usually has to take vitamin and mineral supplements for the rest of their life, along with medication to reduce the production of stomach acid, but they will almost certainly stop needing the numerous and expensive other medications they required before surgery.

Plastic surgery is done for several reasons – cosmetic purposes, reconstruction after accidents or surgery, correction of excessive natural growth, removal of disfiguring material, etc. All but the first may be covered by the Medical Services Plan. An exception is reconstructive surgery following weight loss after bariatric surgery. The removal of excess skin is not covered, with the exception of some breast reconstructions in women and a minor allowance for the lower abdomen. The majority of necessary skin resection must be covered privately by the patient.

Surgically modifying the stomach is only part of the job. For the patient to obtain maximum benefit, when they have reached their target weight there should be a means of restoring their bodies to a close approximation of that of a healthy person. That means plastic surgery to remove any sagging skin and correct any obvious problems caused by the rapid weight loss. A person is not just a body, a person also has a mind and emotions, they are a whole being. Treating only part of the being is doing only part of the job. The job should be complete.

When determining the cost to the medical system of providing this surgery, the direct costs are not the only consideration. Savings obtained by Pharmacare due to less medication being prescribed should be included. In addition, costs of surgery for other obesity induced conditions, such as knee replacements that will no longer be required, should be estimated as savings and included in the calculations. It should also be acknowledged that there will be savings by third party insurers which may have a positive impact on employers since the cost of employee benefits may be reduced.

The Challenge – All About Obesity

Morbid obesity is a medical condition in which patients have a BMI (Body Mass Index) greater than 40. It is an eating disorder in which the patient has a compulsion to overeat, usually for emotional reasons, often made worse by a genetic predisposition to store fat. Simple dieting is ineffective in this group and a more radical approach is necessary – surgical intervention.

Some members of the public believe that the morbidly obese are just fat people who won’t stop “stuffing their face”, and if they would stop doing that they would get thinner. In fact, morbidly obese people do not want to be that way and many diet constantly with little effect. In the same way that bulimic patients have great difficulty making themselves eat more to increase weight, so morbidly obese patients have great difficulty controlling their urge to eat. Both illnesses are rooted in dysfunctional emotional states causing self harmful behaviour ending in premature death.

Walk down the main street of any reasonably sized town in Canada and your senses are assaulted with the smells of cooking food – hamburgers, fried chicken, pizza, roast beef and much more. Restaurants of all kinds blow their exhaust into our streets, advertising their products through our sense of smell. Morbidly obese patients respond to this exactly the same way as anybody else, but do so more strongly from a heightened desire to eat. Cigarette advertising is banned to help smokers control their urge to smoke, but morbidly obese patients are left to fend for themselves from this daily assault on their senses.

Imagine telling alcoholics that they could stop being alcoholics if they would only drink half a bottle of beer a day, or a cigarette smoker should inhale only three puffs on a cigarette each day. Neither alcoholics nor smokers can limit themselves like that. Morbid obesity is the same with the same limitation, except that the focus is on food instead of alcohol or tobacco. The only way alcoholics can control themselves is to stop consuming alcohol completely, and smokers must stop smoking completely. Can a morbidly obese patient stop eating completely? No, and that makes their problem more difficult to deal with.

A patient who is 200 pounds or more overweight obviously will find it difficult to do much exercise, especially if they have knees, ankles and spines that have been damaged by supporting the excess weight. Nevertheless, morbidly obese patients must commit to increasing their physical activity. They must strengthen their muscles in order to retain some mobility. Simple walking helps enormously, and doing so also predisposes the patient to increased exercise post-operatively as part of a changed lifestyle. Do what you can, then increase it.

It is far easier to become obese than it is to lose excess weight. There was a time when people walked everywhere, now we drive. Our food availability has increased and the cost has remained reasonable. Fast food is available almost everywhere and almost continuously, and contains a high proportion of high fat, meat products. Advertising on billboards, in print media and on television bombard us with the message, “Eat! Eat! Eat!” Is it any wonder that those with a compulsive eating disorder become morbidly obese?

Is weight loss surgery the easy way out to lose weight? Many think so, but none of those have any personal experience. Those who have had the surgery say it is not. They say it completely changes the way they interact with food, and not always pleasantly, if the stories of vomiting, dumping of fluids into the intestines and pain from swallowing incompletely chewed food are anything to go by. Despite that, just about all of them say they would do it again in a heartbeat because it gives them a new life, despite the adjustment problems.

Patients who are extremely large physically and who lose the excess weight that makes them so large, often are left with a smaller body in a large covering. This is because the skin may not retract completely as the fat is consumed, causing the excess epidermis to sag. This is frequently found in the areas of the lower abdomen, buttocks, breasts and upper arms. Since this skin may trap perspiration and bacteria, it is not only a nuisance, it can become infected. At the least, it requires constant attention and care. The best treatment is to remove it.

Morbid obesity is often found in patients with emotional problems, invariably involving some degree of poor self image, self deprecation or inferiority. That is why so many are “comfort eaters”, patients who eat as a means of obtaining some sort of satisfaction from being full. It is a self defeating behaviour, though, as the increasing weight merely increases the perception of low self esteem. After surgery, self esteem may rise as weight is lost, but the sagging skin works against it, inhibiting the maximum benefit that could be obtained.

Once the excess weight has been lost, what then? Surveys show that the majority of patients keep the weight off. They clearly understand the possibility of returning to a morbidly obese state if attention is not paid to the underlying conditions causing it. That is why selection of patients for this surgery is made after careful medical evaluation and counselling. A lifetime’s commitment to a changed lifestyle is essential for long term success. The proverb, “Once bitten, twice shy” is appropriate, as previously obese patients have no desire to return to that condition.

Author:
Bryan Llewellyn
Pre-op Patient – waiting 4 years & still holding on.
To read more about Bryan and our other authors on WLS Support, goto “About Us”

To contact Bryan, you can email him at – llewllew@shaw.ca

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