Options for Treatment

For anyone who has considered a weight loss program, there is certainly no shortage of choices. In fact, to qualify for insurance coverage of weight loss surgery, many insurers require patients to have a history of medically supervised weight loss efforts.

Most non-surgical weight loss programs are based on some combination of diet/behavior modification and regular exercise. Unfortunately, even the most effective interventions have proven to be effective for only a small percentage of patients. It is estimated that less than 5% of individuals who participate in non-surgical weight loss programs will lose a significant amount of weight and maintain that loss for a long period of time.

According to the National Institutes of Health, more than 90% of all people in these programs regain their weight within one year. Sustained weight loss for patients who are morbidly obese is even harder to achieve. Serious health risks have been identified for people who move from diet to diet, subjecting their bodies to a severe and continuing cycle of weight loss and gain known as "yo-yo dieting."

The fact remains that morbid obesity is a complex, multifactorial chronic disease.

For many patients, the risk of death from not having the surgery is greater than the risks from the possible complications of having the procedure.

That is the key reason that in 2000, approximately 40,000 weight loss surgical procedures were performed and why the American Society for Bariatric Surgery estimates that 50,000 weight loss surgical procedures will be performed in 2001. Patients who have had the procedure and are benefiting from its results report improvements in their quality of life, social interactions, psychological well-being, employment opportunities and economic condition.

In clinical studies, candidates for the procedure who had multiple obesity-related health conditions questioned whether they could safely have the surgery. These studies show that selection of surgical candidates is based on very strict criteria and surgery is an option for the majority of patients.

Weight Loss Surgery:

Weight loss surgery is major surgery. Its growing use to treat morbid obesity is the result of three factors:

• Our current knowledge of the significant health risks of morbid obesity
• The relatively low risk and complications of the procedures versus not having the surgery
• The ineffectiveness of current non-surgical approaches to produce sustained weight loss

Surgery should be viewed first and foremost as a method for alleviating debilitating, chronic disease. In most cases, the minimum qualification for consideration as a candidate for the procedure is 100 lbs. above ideal body weight or those with a Body Mass Index of 40 or greater. Occasionally a procedure will be considered for someone with a BMI of 35 or higher if the patient's physician determines that obesity-related health conditions have resulted in a medical need for weight reduction and, in the doctor's opinion, surgery appears to be the only way to accomplish the targeted weight loss. In many cases, patients are required to show proof that their attempts at dietary weight loss have been ineffective before surgery will be approved. More important, however, is the commitment on the part of the patient to required, long-term follow-up care. Most surgeons require patients to demonstrate serious motivation and a clear understanding of the extensive dietary, exercise and medical guidelines that must be followed for the remainder of their lives after having weight loss surgery. (see Life After Surgery).

Diet & Behavior Modification 
There are literally hundreds of diets available. Moving from diet to diet in a cycle of weight gain and loss - yo-yo dieting - that stresses the heart, kidneys and other organs can also be a health risk.

Doctors who prescribe and supervise diets for their patients usually create a customized program with the goal of greatly restricting calorie intake while maintaining nutrition.
These diets fall into two basic categories:

• Low Calorie Diets (LCDs) are individually planned so that the patient takes in 500 to 1,000 fewer calories a day than he or she burns.
• Very Low Calorie Diets (VLCDs) typically limit caloric intake to 400 to 800 a day and feature high-protein, low-fat liquids.

Many patients on Very Low Calorie Diets lose significant amounts of weight. However, after returning to a normal diet, most regain the lost weight in under a year. Ninety percent of people participating in all diet programs will regain the weight they've lost within two years.

Behavior modification uses therapy to help patients change their eating and exercise habits. Like low-calorie diets, behavior modification, in most patients, results in short-term success that tends to diminish after the first year.

If diet and behavior modifications have failed you and surgery is your next option, it is important to understand that diet and behavior modification will be instrumental to sustained weight loss after your surgery. The surgery itself is only a tool to get your body started losing weight - complying with diet and behavior modifications required by most surgeons would determine your ultimate success.

Exercise 
Starting an exercise program can be especially intimidating for someone suffering from morbid obesity. Your health condition may make any level of physical exertion next to impossible. The benefits of exercise are clear, however. And there are ways to get started.

A National Institutes of Health survey of 13 studies concludes that physical activity:

• results in modest weight loss in overweight and obese individuals
• increases cardiovascular fitness, even when there is no weight loss
• can help maintain weight loss

New theories focusing on the body's set point (the weight range in which your body is programmed to weigh and will fight to maintain that weight) highlight the importance of exercise. When you reduce the number of calories you take in, the body simply reacts by slowing metabolism to burn fewer calories. Daily physical activity can help speed up your metabolism, effectively bringing your set point down to a lower natural weight. So when following a diet to attempt to lose weight, exercise increases your chances of long-term success.

Examples to get you started:

• Park at the far end of parking lots and walk
• Take the stairs instead of the elevator
• Cut down on television
• Swim or participate in low-impact water aerobics
• Ride an exercise bike

Overall, walking is one of the best forms of exercise. Start out slowly and build up. Your doctor, or people in a support group, can offer encouragement and advice. Incorporating exercise into your daily activities will improve your overall health and is important for any long-term weight management program, including weight loss surgery. Diet and exercise play a key role in successful weight loss after surgery.

Over-the-Counter & Prescription Drugs 
New over-the-counter and prescription weight loss medications have been introduced. Some people have found them effective in helping to curb their appetite. The results of most studies show that patients on drug therapy lose around 10 percent of their excess weight and that the weight loss plateaus after six to eight months. As patients stop taking the medication, weight gain usually occurs.

Weight loss drugs can have serious side effects. Still, medications are an important step in the morbid obesity treatment process. Before insurance companies will reimburse/pay for weight loss surgery, you must follow a well-documented treatment path.

"Since many people cannot lose much weight no matter how hard they try, and promptly regain whatever they do lose, the vast amount of money spent on diet clubs, special foods and over-the-counter remedies, estimated to be on the order of $30 billion to $50 billion yearly, is wasted." (New England Journal of Medicine)