When a person suffers from morbid obesity and this condition begins to affect their quality of life and health, it is very recommended to consider several options to find a permanent solution to this problem to preserve health and avoid all the diseases that come along with obesity.
In this article we will discuss the various treatment options for morbid and severe obesity in the world so you can make an informed decision on how to deal with this condition.
Before getting into the subject, it would be useful to know the classification of degrees of obesity in the world according to internationally established guidelines to determine the different treatment options to the problem according to the severity of the disease.
It is very common for us at Obesity Free to receive the requests for information on gastric sleeve surgery from persons who do not qualify as candidates for obesity surgery, regardless of the method they wish (gastric sleeve, gastric bypass, duodenal switch, gastric band , gastric plication, etc).
There are well-established guidelines that a serious and professional bariatric practice abides to and define who is a candidate for surgical management of obesity
The classification of different types of obesity is divided as follows:
Classification of Obesity according to BMI
* BMI: BODY MASS INDEX
Patients are candidates for weight loss surgery based on the parameters described in the above table, having certain exceptions based on the type of procedure you are considering and whether there are associated diseases with obesity. You can see more details on this in our section Am I a candidate for weight loss surgery?
Speaking specifically of the procedure's rise and popularity in recent years such as the gastric sleeve, to be eligible, the patient must have a BMI of 35 with associated diseases or 40 with or without associated diseases to obesity.
Having clarified this point, we will focus mainly on discussing the available treatment options for morbid and severe obesity, that is, for those patients who have a BMI of 35 or more, as these patients are at high risk of developing diseases related to obesity threatening their life and its quality.
The benefit of the doubt should always be given to the patient who has not made a real and consistent effort to lose weight and suggest them first try nonsurgical options for treatment of morbid obesity before trying a surgical solution.
Unfortunately, based on experience with our patients and described in multiple studies, 95% of them are people who have been through it (tried to lose with nonsurgical methods) and have struggled with the problem of obesity for years.
There are countless strategies and treatment options for obesity today but most of them are little or no effective at long term. Especially for those patients who are at a body mass index above 35 since their body is "programmed" to not lose weight or to recover it once they stop doing very strict diets and this is the source of frustration of most patients who seek our help.
The statistics of multiple studies show that less than 5% of patients who have a BMI of 35 or greater achieve a significant weight loss and if they manage to lose weight significantly it is quickly recovered once they cease efforts for weight loss which generally consist of the following:
Modifications to the Diet for the obese patient
First of all it is important to make the suggestion that these modifications should be supervised by qualified professionals in the field, mainly nutritionists or bariatric specialists as to customize your diet based on your specific needs. Submission to diets based on what is displayed on a website or on the recommendation of a friend or family member can put you at greater health risk and even cause irreversible damage to your heart, kidneys, liver and other vital organs.
The basis of the diet is subjecting the patient to a low calorie diet which can range from 400 calories to 1000 calories per day, this being a very difficult task for patients with severe or morbid obesity because usually their calorie intake exceeds 3000 calories per day and in some extreme cases that consume up to 10,000 calories per day!
In order for these diets to be considered as an effective and complete treatment should be carried out by the patient for at least six months, a situation that makes it harder for the patient to stick to them.
Modifications to the behavior to treat obesity
The goal of behavior modification therapy is changing eating habits and implement an exercise program to achieve significant weight loss, some examples of strategies to carry out this strategy are:
- Keeping an eating pattern and exercise diary.
- Set realistic weight loss goals for the short and long term.
- Reward of some kind to actions that favor weight loss such as having exercised longer or having eaten less of certain foods.
- Analyze and adopt a realistic perspective on the expected weight loss and body image.
- Develop a support system that includes family, friends and coworkers or join a support group to help them reach the goal together.
As you can see, achieving this is not easy as there are many factors that come into play in the life of each patient that hinder to follow a specific line with many variations, so the patient should focus on these changes and adapt them to their lives. This is definitely not easy to achieve but it is possible if the patient has the required determination.
Exercise to lose weight
Exercise is an essential part to successful weight loss for patients with morbid or severe obesity, especially in the long term, because as mentioned earlier, everyone is able to lose weight if they try, however, the challenge is to maintain those habits for an indefinite time so it can become a new lifestyle and not a temporary effort.
The reason why exercise is so important is because when an obese person undergoes a low calorie diet, their body "protects" by reducing their metabolism so instead of promoting more rapid weight loss it decreases and the exercise allows this metabolism to be accelerated. Thus already there are two factors for weight loss: low calorie intake and increased metabolism due to physical activity.
Here comes into play a very common situation for our patients that is daunting and unfavorable for realization of regular exercise: to submit to an exercise program as a gym or any group activity can be uncomfortable or even intimidating for the person who wants to lose weight, this is because many obese patients suffer from some form of physical limitation due to obesity, whether simply limiting their movement capabilities or to the involvement of one or more joints that causes them pain when trying to exercise.
In these cases the key is to do activities whose actions are initially mild, enjoyable and doable for everyone and as they progress with weight loss and fitness increases the intensity and duration of such exercises can also be increased.
Also as we described in our article on the most common mistakes when making a diet to lose weight, there are simple initial steps which can make the difference gradually, they are listed below:
- Park as far as possible when going to the grocery store to promote easy walks in everyday life.
- Reduce time spent watching television.
- Perform low-impact aerobic exercises like walking and climbing on an elliptical machine or stationary bike.
- Use the stairs instead of the elevator.
- Going for a walk to the park alone or accompanied by your family, partner and / or pet.
Medical treatment for obesity
During decades, many medical treatment options have been searched and tried in order to reduce weight and provide a lasting ultimate solution to the obesity epidemic currently affecting our society and the world. And although there are some recent options that are promising, the truth is that the ideal and fully effective medical treatment for all cases has not been found.
Since for example in the case of the medications and supplements it is sometimes discovered that soon after they hit the market they cause mild to serious health problems or that their effectiveness is limited to a loss of only 10% of the excess weight at best or even if the weight loss is higher it is only temporary, during the period of time in which the the drug is being used by the patient.
The mechanisms of action of these drugs are diverse: from the anorectic (appetite-reducing), which stimulate the metabolism, stimulating the use of body fat, affecting fat absorption from food, even those who seek to change the complex endocrine hormones involved in controlling glucose levels, appetite, etc. and other obesity-related hormones.
There is a huge amount of "options" for medical treatment, prescription and nonprescription therefore we consider impractical to list them all and we mention only the most popular ones, most of them approved by the FDA in the United States:
- Beta methylphenylethylamine (Fatin, USA): Acts as stimulant of fat metabolism.
- Orlistat (Xenical USA, slender d, Mexico): This drug works by blocking the absorption of about 30% of the ingested fat.
- Phentermine: It acts as an appetite suppressant, which a few years ago was combined with fenfluramine but caused adverse health effects.
- Sibutramine: Another appetite suppressant medication for prolonged use.
Some other newer drugs being approved or recently approved as:
- Liraglutide (Saxenda in Europe): Simulates a gut hormone (GLP-1) which causes the satiety sensation to the brain.
- Naltrexone and bupropion (Mysimba in Europe, Contrave in USA): Combines the use Bupropion which is an antidepressant and naltrexone used for drug addiction, experts say it causes a decrease in appetite attacks or hunger pangs. Although the mechanism by which it achieves this effect is not well known.
- Phentermine and topiramate (Qsymia in USA): Phentermine is an appetite suppressant and topiramate is an anticonvulsant or antiepileptic.
- Locaserin (Belviq in USA): It is also an appetite suppressant, belongs to the group of serotonin agonists.
As it can be inferred, the reason why there is a long list of drugs with the same goal (here we show only a minority) is because unfortunately none of them has shown an overall, lasting and/or safe effectiveness for obese patients.
However as adjunctive management to other measures and modifications it is feasible as well as for patients without severe obesity, usually for a short or medium term; however, when the medication is discontinued the effect is lost and weight regain happens so the medications do not represent a definitive solution in most cases.
These medications must be prescribed by a health professional to avoid severe consequences.
Bariatric Surgery and other procedures as a treatment for morbid obesity
Bariatric surgery is sometimes misinterpreted as some people misjudge those who have opted for this treatment option thinking this decision as an easy way out for not having willpower or wanting a quick and "simple" solution to their obesity problem.
The truth of the matter is that all or nearly all patients who choose to opt for this solution to their problem of obesity is a brave and determined person that has decided to change the course of their lives once and for all because this surgery is no magic option and requires a high level of commitment and discipline from the bariatric patient.
It is a fact that obesity surgery is not a treatment option for all cases, since some patients suffering from severe or morbid obesity are not good candidates, either because their added diseases make a bariatric procedure a risky solution for their health (it is the minority of cases) or because they do not understand the concept of what surgery constitutes and expect surgery to do everything for them. But we dare to say that in over 95% of the cases it is about patients who have done all possible efforts during long periods of time and have not achieved the goal, so they have certain discipline that make them ideal candidates for the procedures.
It is clear, based on what we show in previous sections, that so far, effective medical treatment options for morbidly have not been found either because a sufficient weight loss is not obtained to reach a healthy weight or because that lost weight, a few or several pounds, is recovered quickly and easily once the multidisciplinary management is suspended. That is why bariatric surgery is an excellent option when treatment is done in conjunction with other medical measures, especially those that are focused to change the behavior and feeding habits of the patient.
As we have described in other articles, obesity surgery should be considered a last resort and when performed, the patient must be aware that this is a very good and effective tool that will help them achieve their goal; but it depends on the patient the degree of success obtained from surgery. When it comes to highly effective procedures such as the gastric sleeve or gastric bypass, weight loss occurs invariably, however the amount of weight lost and the maintenance of a healthy weight depends on a good measure on the patient.
At present, there is an infinity of bariatric procedures that are offered to the public as a treatment option for morbid or severe obesity, it depends on the patient in conjunction with the bariatric group of their choice, the procedure they select for each individual case.
What is described below could be considered it is a bit biased observation because we are dedicated to perform the gastric sleeve procedure in most cases but this is not only because of our preference but also the patient’s based on the risk/benefit obtained with this procedure. Having said this we consider the gastric sleeve surgery is the best initial and definitive treatment option for most patients with morbid obesity.
Although it is true that there are several other methods that are effective for the same purpose (malabsorptive procedures), but with aspects or consequences that go beyond the perioperative risk of any surgery and they include long-term risks that never disappear. Situations that with the gastric sleeve (restrictive procedure) do not happen once you have passed the period of risk of serious complications such as a gastric leak.
Current surgical options to treat obesity
Finally, there are other procedures whose effectiveness and validity are in doubt whether because of lack of experience worldwide (few cases to have reliable statistics) or because they are simply procedures that despite being offered in various parts of the world it is known that do not give favorable results or have a high complication rate.
The classification of different bariatric procedures as a treatment option for obesity can be done in several ways, either by their effectiveness and acceptance, by the type of procedure (restrictive, malabsorptive or mixture of both), for the low experience worldwide or how recent they are. We will try to list these procedures and place them on the different categories comprising them.
Below we list some of the most popular of their kind: (Note that the procedures listed are for different degrees of obesity and are not necessarily treatments for morbid obesity and some are not widely accepted as being unsafe)
RESTRICTIVE BARIATRIC PROCEDURES
- Adjustable Gastric Band (Lapband)
- Non- adjustable gastric band
- Sleeve Gastrectomy
- Gastric plication
- Intragastric balloon
- POSE procedure (Primary Obesity Surgery Endoluminal)
- Procedure TOGA® (transoral gastroplasty)
MALABSORPTIVE/RESTRICTIVE BARIATRIC PROCEDURES
- Gastric bypass
- Mini gastric bypass
- Duodenal Switch (BPD)
- FOBI Procedure (Gastric Bypass with ring)
- SADI-S (duodenal switch with a single anastomosis and gastric sleeve)
EXPERIMENTAL BARIATRIC PROCEDURES
- POSE procedure
- MAESTRO System
OUTDATED OR NOT WIDELY ACCEPTED BARIATRIC PROCEDURES
- Vertical banded gastroplasty
- Non- adjustable gastric band
- Gastric Sleeve with Gastric Band
- Gastric Bypass with Gastric Band
- Gastric plication
- POSE procedure
- MAESTRO System
* It should be noted that several of the procedures in this particular list are poorly or not widely accepted by bariatric societies probably due to ignorance in the technique and little or no personal experience of the surgeon with each procedure. The only ones who are unanimously considered obsolete or "banned" are the vertical banded gastroplasty and non-adjustable gastric band.
FULLY ESTABLISHED BARIATRIC PROCEDURES
- Sleeve Gastrectomy
- Gastric Band (downward tendency)
- Gastric bypass
- Duodenal Switch
As you can see from these lists, there are numerous surgical treatment options for obesity today and as the decades pass new procedures appear and others disappear. The only procedure that withstands test of time above the rest is the gastric bypass, the gastric sleeve however, despite being a "new" procedure with under 15 years of being performed for the first time, has been so successful and effective that has positioned alongside the bypass and other procedures that have been performed for longer periods of time, which speaks of the great success of this procedure between different bariatric societies in the world and among the population of patients and potential patients.
At present the two most frequently performed bariatric procedures worldwide are precisely gastric bypass and gastric sleeve over any other procedure. In the last year more gastric sleeves were performed in the world than any another bariatric procedure surpassing the gastric bypass for the first time.
Finally it is important that if you are considering having any of the procedures described here you get it done by a bariatric group that has extensive experience in that specific procedure and should keep in mind what the tool will have much greater success if the management of obesity is multidisciplinary.
Your turn, tell us what you are considering bariatric procedure and why? Already you made any of them?, tell us your experience.
Written by: Gabriel Rosales
Dr. Gabriel Rosales is a highly skilled, board certified surgeon in constant pursuit of learning the latest innovations in the weight loss surgery field to give his patients the best care possible.