It has been six weeks since you started that New Year's Resolution Diet (again). And it's not working (again). How do you know if you should consider bariatric surgery instead?
For the answer, we interviewed Dr. Thomas E. Lavin, bariatric surgeon, Clinical Assistant Professor of Surgery Tulane University School of Medicine and founder of The Surgical Specialists of Louisiana, which has offices in Covington, Slidell, Metairie and Lafayette. Lavin's group also performs the new POSE (Primary Obesity Surgery Endolumenal) procedure, which he describes in more detail below.
Q: How can someone know when to try weight-loss surgery instead of just dieting?
A: We are laparoscopic surgeons that help people lose weight, but we’re all about wellness and fitness. We work with people who want to lose weight just by changing their habits. They might want to lose 20 to 30 pounds and that group really needs to look at their whole lifestyle as far as what they eat, what exercise they do. I recommend that they sit down with someone who specializes in weight loss and look at their exercise and eating habits and start making a plan to change it and do it one day at a time. Change your eating patterns and start planning your meals. People have a very difficult time changing their lifestyle patterns. But once you do something for a month, it becomes a new lifestyle. They need someone to help them get to that point.
We work with three groups of people. This first group, they have to change everything in their food environment at home and go on a new eating plan. We make a plan for them that involves simply getting processed foods out, bringing in more fruit and vegetables and more of a protein-based diet.
The second group, those who want to lose 30 to 70 pounds, they have a significant amount of weight to lose, but they don’t quite quality for laparoscopic surgery. With these patients, I always check to see if they’ve made good efforts in the past to lose weight through diet and exercise and if they have, we have an endoscopic procedure we offer.
On a side note, I don’t like to use the word “diet.” It implies that you can’t eat this. We like to talk about lifestyle change through a new eating plan, so you just replace what you’re eating. It’s the processed foods and high-carb foods that are mostly at fault for our obesity problem. These are easy foods to find and eat when you didn’t plan your meal. You’re busy running around, you didn’t plan and all of a sudden you’re extremely hungry. You look up in search of something to satisfy your hunger quickly and there’s McDonald’s, Taco Bell, or a convenience store with chips and candy.
Once we see they have a history of dietary failures, we offer them a POSE. The procedure is ... endoscopic, outpatient, incision-less. Basically, I go down though the mouth and I shrink the stomach. I sew it endoscopically, from the inside. What that does then is decrease the patient’s capacity, so they’ll fill up sooner when they eat and second, it will decrease their hunger drive and cravings.
As another side note – and this goes for both the POSE and the laparoscopic bariatric surgeries – everything we do decreases capacity, which everyone understands. We decrease the stomach size. The thing that people don’t understand, the second thing that happens when a patient has a procedure, is it decreases their hunger and cravings.
Q: How do these procedures accomplish that?
A: This is what people do not understand: the gastrointestinal tract, meaning the stomach and intestine, are an endocrine organ that produces hormones. The gastrointestinal tract produces hormones just like a lady’s ovaries, pituitary gland or your thyroid gland (does). These hormones do a lot of things, but what pertains to weight loss is they create hunger and cravings at the hypothalamic level of the brain. The hypothalamus in the brain is the hunger center, and the hormones from the stomach and intestines create this hunger-drive and cravings. When we do a procedure, these hormones are changed so patients have less of a hunger drive and less cravings.
Q: How are the hormones changed?
A: There are a lot of pathways from the stomach and there have been tens of millions of dollars put into this research to look into the different pathways. They’re very complex. I actually went to a whole weekend presentation a couple of months ago, and this is all cutting-edge research, on why these hormones create cravings. All of these hormones are changed when we do procedures, whether it’s a POSE or the laparoscopic procedures, which are sleeve and gastric bypass.
Q: What about the third group of people?
A: The third group of people are 80 pounds overweight up to, our patients are as much as, 500 pounds overweight. With the third group, it is very clear that their chances of losing weight to a healthy range and keeping it off are less than one percent. So that group of patients I recommend that they look into laparoscopic bariatric procedures.
Q: And why does this group have so much trouble losing weight? Is it just the sheer amount of weight they need to lose?
A: A lot of research has gone into why certain people can’t lose weight and other people live their life thin and they can’t understand why people are 100 pounds overweight. The theory today is called “Set-Point Theory.” You can take any patient based on their genetics and their environment and they will have a curve that will trend up over time. And what it means is there’s going to be a weight for any person where they feel comfortable. My weight is 175 pounds and I feel very comfortable. If I tried to lose 10 pounds, my hunger hormones would increase, and my hunger drive and cravings would make me live my waking hours consumed with all the food that I cannot eat because I am trying to live 10 pounds below my set point. And eventually I would go back on that curve which is my set point, which is where my body says I should live. This is really cutting-edge, this is hot off the presses.
Q: Is the set point totally mental?
A: No. It’s a combination of genetics and environment. And some people’s set point at age 35 might be 220 pounds, so they could lose 40 or 50 pounds, but when they’re in that weight-loss mode, they are consumed every waking moment with all of the things they can’t have to eat which eventually drives them off of their “you can't eat that” diet. This puts them back on their curve which is their set point.
This even works in reverse. If a Hollywood actor, a John Travolta, weighs 220 pounds and he gets that great role for a person that is 260 pounds, it becomes very uncomfortable for him to get there and when he quits trying to eat all that food, his body will go back to that set point of 220 pounds.
Also, everybody's set point trends up year to year.
What we do with bariatric procedures is we drop that set point. So a 300-pound person after the procedure now has a new set point of 200 pounds where they feel comfortable. So over the year, they’re gradually going to go down to 200 pounds and that’s where they’ll live. So the body goes down to this new set point and so that’s where they live and that’s where they feel comfortable.
Q: How does the procedure lower the set point?
A: Because set points are hormonally and neurally modulated, meaning the hormones I talked about earlier from the gastrointestinal tract, and there are also nerves that go to the brain from the gastrointestinal tract. Those hormones change and once again, our brain is the center that determines everything in our existence, so now our body wants to live at a lower weight because these hormonal and neural inputs to the brain have changed. So patients after a procedure, say after a laparoscopic sleeve gastrectomy, one of the most popular procedures, have very little hunger drives or cravings after the procedure.
The world thinks that hunger is emotional because of Dr. Phil and Oprah and all the books written on emotional hunger, but the reality is hunger is mostly hormonal. And the way I like to help people understand it is, think about going grocery-shopping when you’re starving and think about that behavior. And then think about going to the grocery store after you’ve had a very large lunch and you are very full. Your behavior is totally different. There is nothing emotional about that; it’s hormonally-driven behavior. After a laparoscopic sleeve gastrectomy, it’s like grocery-shopping after a big meal. You’re not driven to buy those foods.
Q: What are the best ways to avoid surgery?
A: The best way is to not get to the point where you’re 100 pounds overweight, but then you say, “I’m already there.” So if you’re already 100 pounds overweight, you look at your lifelong history of weight-loss attempts. It’s usually what we call a yo-yo diet.
My patients have a lifelong history of this yo-yo diet, where they’re 100 pounds overweight, they might lose 30 pounds over six months or four months on some diet, but then over the next two months they regain their 30 pounds plus 10. It is very common in all my patients to have this yo-yo weight loss over their life until they get to a point where they’re really emotionally defeated because they can’t get the weight off and keep it off. These patients may be extremely successful in every area of their life except for weight. And that gets back to the Set-Point Theory – they can overcome it for three months or four months but lifelong, to overcome your set point is virtually unheard of. In fact, Jason with Subway is the only one I have heard of to do it and he gets paid a lot to do it. It’s still impressive that he’s been able to do it. But it’s extremely uncommon for people say 100, 200 pounds overweight to lose that excess weight and keep it off long-term through diet and exercise. A diet is a temporary solution to weight loss. I mean you can’t go on a water diet, a cookie diet, whatever diet for the rest of your life.
With that weight comes a whole host of medical problems, such as diabetes being the worst, but also high blood pressure, sleep apnea, joint problems, heart disease and cancer. Many of the cancers like breast and colon cancer, the risks are greatly increased by being 100 pounds overweight. And infertility. Infertility is a big problem in ladies in their childbearing years. When you’re 100 pounds overweight, your infertility problems will be markedly greater than if you lost the weight. Because of those medical problems, we do the laparoscopic weight-loss procedures, which take about an hour and involve a one-night stay and low risk in our hands, relative to the risks of living 100 pounds or more overweight. And most of the medical problems will resolve themselves, including frequently, the diabetes. It will improve or resolve with the weight-loss procedure.
Q: What reasons would the second group have for losing weight? Does the weight contribute to medical problems in their case as well?
A: You can imagine if you’re 30 to 70 pounds overweight, you would rather be thinner. There’s a cosmetic, quality-of-life improvement with losing the weight in addition to the resolution of medical problems like diabetes and high blood pressure.
Q: Tell me about the POSE procedure. What’s new or different about this procedure?
A: First, I make it clear to everyone that these procedures are not magic and they still involve people working with our team to take responsibility in their own lives. I don’t see it as an easy way out. Results can appear magical when people are responsible and work with us. It’s a two-way street. We’re going to give you a tool to help you lose weight and that tool will do two things – decrease your capacity and cravings, but you will have to take responsibility in your own life to make good choices. You have to be responsible and make good choices. We take care of over 1,000 patients a year and for the most part, they are very responsible, knowledgeable people that understand we give them the tool but they still have to use the tool to lose the weight and become healthy.
Q: What are the most common misconceptions about these procedures?
A: I think the biggest misunderstanding is that it’s only an anatomic restrictive procedure and they don’t understand the hormonal aspects. They don’t understand the patient’s hunger drive and cravings are decreased, which is ultimately the most important thing to help them lose weight.
The three procedures that I’ll get into are the lap sleeve, gastric bypass, and the lap band. Those are the three procedures we offer.
Q: How does body type affect weight loss?
A: There are two basic body types. There’s more the central obesity, which is the male-pattern obesity, where patients wear their weight in the middle – and that is the dangerous kind, which leads to diabetes, high blood pressure and heart disease. And that’s more the male pattern, although women can have that pattern of obesity also. Now the female kind of obesity is more the pear, where most of the weight is in the legs and buttocks. That weight actually doesn’t affect diabetes, but it still leads to musculoskeletal problems like lumbar disc disease or osteoarthritis of the knees which leads to knee replacement. Female pattern obesity, they don’t get as much of the serious medical problems like diabetes, high blood pressure and heart disease.
Q: So do you recommend different diet plans for each body type?
A; That’s still a pretty debatable thing. There are so many different kinds of diets – low-carb, low- fat. Once again, we encourage getting away from all the high-carb and processed foods like chips and Fritos and candy and fast foods, the Taco Bells and all the brightly lit signs that appear when we’re hungry, and getting to more planned meals with fruits and vegetables and foods that you would buy at the grocery store and prepare.
Q: Is there anything you would like to add?
I think everyone needs to really look at their overall health and their whole lifestyle to really live healthy, and so it’s not, I don’t want to be looked at as just a surgeon. We’re concerned with people’s health and wellness and that involves people’s choices that they make every day. The group that is 100 pounds overweight is best served by a laparoscopic bariatric procedure. The people that aren’t, that don’t need it, they’re either going to use the endoscopic procedure or just get with a healthcare professional or someone trained in weight loss and just make a plan as far as changing their lifestyle and their approach to eating as well as exercise.
One more misconception is that exercise is the solution to losing weight. Exercise is great for overall health but if you want to lose weight, you need to change your overall consumption of calories, as for the amount and type.
Read this article:
How can you tell if it's time to ditch the diet and consider bariatric surgery?
