SWLC is proud to announce the publication of our 2^nd clinical research report in the prestigious “Obesity Surgery Journal” in September of 2011.  This study shows that the Lap-Band procedure can be safely performed in out-patient facilities – even for patients who would otherwise be considered high risk due to sleep apnea or respiratory problems. If you are a health care professional or you would like more information about this research report, please go to the SWLC HCP section.

This study documented that Laparoscopic Adjustable Gastric Banding (LAGB) can be safely performed in an outpatient facility in a group of patients at high risk for sleep apnea. This review was conducted in association with Dr. M. Kurrek, Dr. A. Kiss and Dr. S.L. Dain & Dr. Z. Wojtasik and myself from the Surgical Weight Loss Centre (SWLC). We reviewed 2,370 patients who undergone Lap-Band surgery between 2005 and 2009 who were classified as high risk for sleep apnea or met at least three STOP-BANG criterias.

A total of 746 of the 2,370 patients (31%) met criteria for or were at high risk for sleep apnea. There were no deaths and no cases of respiratory failure or re-intubation. The 30 day anesthesia related morbidity was less than 0.5%.

This clinical report was conducted due to the controversy that exists regarding perioperative management of patients at high risk of sleep apnea.

For more information on the clinical study, tables, figures and references, visit http://bit.ly/p2Vh5p.

Happy reading!

Dr. Cobourn

Written by: Jeannine Stein

WEDNESDAY, September 16th, 2011 (LA Times)—–Diabetes isn’t just a problem in the U.S.–about 366 million people worldwide have the disease, says the International Diabetes Federation.

In addition, 4.6 million deaths are attributed to diabetes, and healthcare spending has grown to a staggering $465 billion.

The figures were released Tuesday in Lisbon, Portugal, at a meeting of the Assn. for the Study of Diabetes, in advance of the United Nations Summit on Non-Communicable Diseases Monday and Tuesday in New York. The IDF, an umbrella group of more than 200 national diabetes associations in over 160 countries, will release its Global Diabetes plan this weekend, outlining steps to combat the diabetes epidemic. The entire Diabetes Atlas, which includes breakdowns by region, will be available in November.

“IDF’s latest atlas data are proof indeed that diabetes is a massive challenge the world can no longer afford to ignore,” said IDF President Jean Claude Mbanya in a news release. Mbanya, professor of medicine and endocrinology at the University of Yaounde I in Cameroon, added: “In 2011, one person is dying from diabetes every seven seconds. The clock is ticking for the world’s leaders — we expect action from their high-level meeting next week at the United Nations that will halt diabetes’ relentlessly upwards trajectory.”

There is reason to be concerned. Last month the journal the Lancet released a study that used past obesity trends in the U.S. and the U.K. to predict what could happen if rates continue to climb. By 2030 there could be more than 8 million cases of diabetes in the U.S., along with a 50% obesity rate.

Another 2011 Lancet study reported that the rates of Type 2 diabetes have more than doubled worldwide since 1980, going from about 153 million cases to about 347 million in 2008. Researchers attributed about 70% of the growth to population aging, and the other 30% to the increase in obesity.

Written by: Ted Michaels

WEDNESDAY, Sept 7th, 2011 (Sports Network)— Mike Jovanovich knew exactly when it happened.

The former offensive lineman, who graduated from Boston College, signed as a free agent with the Seattle Seahawks in 1992. He joined the Hamilton Tiger- Cats after being released by Seattle, and also played for the Toronto Argonauts, Ottawa and Montreal.

Like many of his peers, Jovanovich waged a running battle with his weight, during and after his playing days.

“My first year as a freshman at Boston College, I weighed 300 pounds,” he told Inside the CFL. “At the end of my playing days there, I weighed 285 pounds. In my CFL days, I played around 300-305 pounds.”

Then, he admits, the problems started.

“I left football in 1996, got married and started having kids. After all the years of lifting weights and maintaining my weight, you get to a stage in life where other activities become more important. I wasn’t as active as when I was playing, so in the first three years or so after I retired, I probably ballooned up to 340 or 350 pounds. It took me around three years to finally get motivated enough to go back into the gym and resume some sort of the grind, similar to when I was playing.”

However, as he points out, when you battle a weight problem, it’s not a matter of just exercising.

“My defining moment was in February 2009,” said Jovanovich. “I went for a physical. We did the usual tests, cholesterol, blood pressure and so forth. I was as healthy as a 6-foot-5, 250-pound person. But one of the comments from the doctor was ‘Mike, you’re in fantastic shape, but as you get older, as you carry this excess weight, it’ll start to put a toll on your body.’ I had the exercise part down, but the eating in moderation part wasn’t working. I’d go to the gym in the morning, and come home and eat three bagels.”

So, he decided to resort to a drastic measure: Laparoscopic band surgery.

“Dr. Chris Cobourn, my bariatric surgeon, is a pioneer in the field,” Jovanovich said. “In essence, in layman’s terms, they put a throttle on the gas tank. They put a band on the top of the stomach, and create a little pouch. It tricks your brain into thinking you’re fuller, faster, so it reduces the caloric intake. The band can either be constricted or you can fill it up. It’s not invasive surgery at all.”

The Toronto native says the decision wasn’t too difficult to make.

“A friend of mine had it, and had great results. I talked it over with my wife, and because I wanted to coach my daughters’ hockey team and we had travel plans, I just decided, I didn’t want to be big anymore.”

Jovanovich also knows he was a good candidate for the surgery, because, even though he weighed well over 300 pounds, he didn’t suffer from any long-term effects from playing football.

“I was pretty fortunate that I didn’t have serious injuries. I had pulled muscles, but never had reconstructive surgery on the knees or my back or shoulders. I was healthy bone-structure wise, but getting into my 40s, I thought I should do something about it.”

Once he had the surgery, he noticed the difference in his diet.

“I could eat a whole pizza for lunch, but now, I have a slice of pizza maybe once a month. I just know the volume of breads, starches and carbs that I consumed was a vast amount, and now, it’s 10 percent of what I used to eat.”

The reaction he gets from ex-teammates and friends is one of amazement, and concern.

“The first thing people ask me, is ‘Jovo, are you sick?’” he chuckled. “Normally you don’t see a lineman drop that much weight. I know it is a cause for concern for some O-linemen, because most of the guys I played with are now in their late 40ss.”

While he doesn’t recommend the surgery for everyone, he says, the numbers show that, for him, it’s a success.

“When I stepped on the scale prior to the surgery, I was 348 pounds and today, I’m about 257,” he said. “My waist size went from 50 to 40.”

THURSDAY, July 14th, 2011 (www.drsharma.ca) — That overweight and obese individuals face weight-bias and discrimination is no secret. It is also no secret that individuals who lose weight often experience significant positive changes in how they are treated by family, friends, colleagues and perfect strangers.

Interestingly, however, it turns out that these ‘positive’ attitudes to people, who lose weight, may very much depend on how these individuals actually managed to do so.

Thus, a study by Jasmine Fardouly and Lenny Vartanian from Sydney, Australia, just published in the International Journal of Obesity, suggests that knowing how the weight loss came about significantly determines the changes in weight bias following weight loss.

Participants (N=73) were first shown an image of an obese woman or a thin woman and asked to indicate their perceptions of the target with respect to the target’s behaviors (for example, how often she exercises), as well as some personality characteristics (for example, lazy, sloppy and competent).

Participants were then shown a more recent image of the obese target in which she had lost weight, and were informed that the target had lost weight through diet and exercise or through surgery, or were not provided with any explanation for the weight loss.

Regardless of the method of weight loss, all targets were rated as eating more healthily, exercising more, and being more competent and less sloppy after having lost weight.

However, participants also rated the target as less lazy when they learned that she had lost weight through diet and exercise, or when no information was provided about the method of weight loss, than if they were informed that the target had lost weight through surgery.

Or, as the authors point out:

“Weight-loss surgery patients may not be able to overcome the obesity stigma as surgery may be perceived as the lazy weight-loss option because of an assumption that it does not require effort and discipline that losing weight through exercise and dieting does. Thus, despite choosing to undergo weight-loss surgery to reduce weight stigma, obese individuals may continue to be viewed as conforming to the obesity stereotype, and hence be considered lazy and lacking in willpower.”

This certainly explains why many, who have successfully lost weight with bariatric surgery, will often not mention this to even their closest friends and why it may be awhile before gastric bypass surgery becomes to be viewed as as acceptable a treatment for severe obesity and its complications, as coronary bypass surgery is viewed as an acceptable treatment for heart attacks.

AMS
Edmonton, Alberta

FRIDAY, May 27th, 2011 (www.drsharma.ca) — Yesterday’s post was a brief overview of how bariatric surgery works and why it helps most people sustain weight loss by affecting key determinants of ingestive behaviour (hunger, appetite, satiety, reward, etc.).

Today, however, I want to look at why surgery is anything but a ‘quick fix’ or an ‘easy way out’ and why, despite all of its potential benefits on quality of life, comorbidities and mortality, surgery is by no means a ‘guarantee’ for success.

While ’success’ with bariatric surgery is certainly not guaranteed (and for some patients, as with any drastic treatment, things can sometimes go horribly wrong), most patients do remarkably well, including – and this may surprise readers – patients with emotional eating or eating disorders.

Thus, as presented by Tom Wadden, Professor of Psychology, University of Pennsylvania School of Medicine, at the 18th European Congress of Obesity, which I am currently attending in Istanbul, Turkey, even patients with classical ‘Binge-Eating Disorder’ (BED) surprisingly benefit from surgery (OBESITY).

In this prospective case-control comparison of cognitive behavioural therapy, lifestyle intervention and the use of meal relacements vs. bariatric surgery in patients diagnosed with BED, the surgical patients did twice as well as the ‘lifestyle’ group in terms of weight loss with significant improvements in cardiovascular risk factors.

Perhaps, even more importantly, the frequency of binge episodes dropped as dramatically in the surgical BED patients as in the non-surgical BED patients. Although the study published only one-year results, Wadden reported that even extended follow-up appears to confirm these results. Similar results have been reported by others.

I only bring up these studies, as it is widely assumed that because bariatric surgery does not address the psychological drivers of overeating (as the surgery is on the gut and not the brain), it may be far less effective or even futile in patients with severe eating disorders.

This is not to say that failure rates may be somewhat higher in people who are more predisposed to emotional eating or eating disorders – but on average, these patients appear do just as well.

So how can these findings be explained?

One reason may well be that although bariatric surgery primarily affects the homeostatic system of hunger and satiety, it indirectly also affects the hedonic system.

As regular readers may recall, hunger can markedly activate the hedonic (reward-seeking) centres of the brain, which I have previously described as the reason why “hunger makes you eat crap“. Thus, experiments, in which volunteers were given ghrelin (the hunger hormone), not only reported increased hunger, but also had increased neuronal activity in the reward centres of the brain.

This (indirect?) role of ghrelin in ‘emotional’ or ‘hedonic’ eating behaviour may explain why BED patients and emotional eaters do better after sleeve gastrectomies or bypass operations than with gastric banding – the former reduces ghrelin levels, the latter increases them.

This discussion should make it clear that bariatric surgery is not simply about creating an ‘obstruction’ (as suggested by the terms ‘banding’ or ’stapling’) but actually induces quite intricate and complex neuronal and hormonal changes in the gut-brain axis that determines ingestive behaviour.

Despite these changes, bariatric surgery is certainly neither a ‘magic bullet’ nor a ‘quick fix’.

Indeed, to be successful, patients have to make substantial and long-term changes in their lifestyles to get the maximum benefit of surgery. Even though the positive effects of surgery on hunger, satiety and appetite make it substantially easier for patients to sustain a rather low caloric intake (usually only about 1400 KCal) without experiencing constant hunger or cravings, patients do have to follow rather strict dietary recommendations (that can vary according to the type of surgery).

One obvious reason that bariatric patients have to substantially change their diet after surgery, is due to the simple fact that anyone, who eats only 1400 KCal per day, will have to eat a much more balanced and nutrient-rich diet to fully meet daily energy, macro- and micronutrient requirements than someone eating 2000 or 3000 KCal. The lower the quantity of food you eat – the greater the quality has to be!

In fact, this would apply to ANYONE trying to live off 1400 KCal, irrespective of whether or not this person has had surgery or not.

Eating as little as 1400 KCal (or less), without careful attention to adequate nutrient intake, carries the inherent risk of severe malnutrition that can include all the typical symptoms of ’starvation diets’ including vitamin and mineral deficiencies that can result in anemia, hairloss, osteopenia, nerve damage, memory loss, lack of energy, and in the case of severe protein malnutrition, even sypmpoms of Kwashiorkor.

The point here, is that there is nothing specific about these symptoms to bariatric surgery, even if the risk for such deficiencies may well be higher in surgical patients, who do not follow the nutritional recommendations.

It may also be important to note that one reason why severe deficiencies are perhaps more often seen insurgical patients, than say in someone who goes on the cabbage-soup diet, is due to the simple reason that without surgery, patients would find it very difficult to stick to such a low caloric intake long enough to develop severe deficiencies.

Indeed, ensuring that a 1400 KCal diet meets all of the body’s protein, vitamin and mineral needs can be challenging for anyone – and even non-surgical patients on such a low caloric intake may need protein, vitamin and/or mineral supplements.

Thus, some of the commonly described nutritional deficiencies seen in patients with bariatric surgery, have little to do with the surgery itself, but rather with the fact that any such drastic reduction in food intake makes it far more challenging to meet the daily nutrient requirements. For this reason, simply eating less of an otherwise crappy diet will not work and will ultimately result in marked deficiencies.

Remember, patients with gastric banding and sleeve gastrectomies do not develop any maldigestion as their small bowel is left completely intact – so nutritional deficiencies in these patients cannot be explained by any maldigestion or malabsorbtion after surgery but rather result simply from the fact that these patients are now eating substantially less than before and therefore need to eat a much healthier and nutritionally sound diet than prior to surgery.

On the other hand, because bypass surgery does involve a maldigestive component, these patients do have to be even more ‘obsessed’ about meeting their nutritional needs and may indeed have to resort to regular protein and/or nutritional supplements.

Fortunately, however, the types of nutritional deficits in these patients are largely well understood and proper assessment and supplementation will avoid nutritional deficiencies in the vast majority of patients if they follow the nutritional guidelines. Indeed, regular readers may recall the previous post on the bariatric-surgery food pyramid that clearly lays out the need for dietary changes.

Thus, the idea that undergoing bariatric surgery would allow someone to simply eat less of the same diet as before will not work – indeed, most patients will need to make considerable changes to their diets – not just in quantity (that part is easy after surgery) but particularly in quality – there is simply no longer any room for nutrient-poor foods (or for that matter liquid calories, which would simply defeat the whole purpose of having surgery in the first place).

But nutritional recommendations after surgery are not just limited to quality of the diet. There is an other important aspect of eating that bariatric surgical patients have to follow: meal planning and regular eating.

This is not difficult to explain. Normally, most people can easily skip a meal or two – or even go several days without food. For e.g. during Ramadan, devout muslims will go all day without eating, only to feast after sunset. This is possible when you have a stomach the size of a small football – in fact, this is exactly why the size of the stomach is what it is – to fill up on food, when food is available (or allowed).

This, however, is no longer possible after bariatric surgery. When the capacity of the food that can be eaten at a single meal is reduced to a few ounces, gorging or overeating is no longer possible (and will often result in vomiting – which only makes things worse). This means that patients, who have had surgery, can no longer afford to skip a meal and simply eat twice the amount at the next one. A missed meal – unfortunately remains missed!

Put this in the context of the need to maximise nutrient content of each meal and things get even more difficult. Thus, even if a bariatric patient instead of skipping a meal, simply eats a rather ‘un-nutritionous’ meal (say for lunch), the next meal would need to be even more nutritionous if the patient is to meet her daily requirements. This can be challenging even at the best of times.

This alone, should make it clear that avoiding nuritional deficiencies after surgery requires considerable planning and optimisation of food intake. Skipping meals or eating nutrient-poor foods is no longer an option. Patients, who do not understand this or cannot adhere to such dietary recommendations will need to take supplements – people who do not stick to these recommendation and refuse to take supplements will inevitably develop serious nutritional problems.

Unfortunately, as discussed in previous posts, many bariatric patients start out with pre-existing nutritional deficiencies that should be corrected prior to surgery, which is why we invest so much effort into getting our patients eating healthier even before consideration for surgery. Patients, who are unable to eat healthy balanced diets, will find it hard to do so after surgery and will be far more likely to develop nutritional complications.

None of this is ‘rocket science’ or in anyway ‘mysterious’ or in anyway specific to bariatric surgery (similar rules apply to all patients who may be restricting their nutritional intake for other reasons or have undergone gut surgery for reasons other than obesity.

Thus, one of the prerequisites for surgery in our program is that patients demonstrate both their understanding and ability to adhere to regular eating patterns (absolutely essential after surgery) and improving the nutritional quality of their diets (even more important).

It should therefore not come as a surprise, that from a dietary perspective, surgery is clearly not the ‘easy way out’ or in any way a ‘quick fix’. The notion that you can simply have your stomach ‘banded’ or ’stapled’ or your gut rerouted and not have to also very substantially change your diet is nonsense and short sighted.

Remember, as quantity decreases, quality has to increase!

Fortunately, regular use of dietary protein, vitamin and mineral supplements can make this somewhat easier.

So while changing both nutrition quality and pattern are certainly important aspects of post-surgical management, other issues can be as, if not more, important determinants of success.

More on these, perhaps lesser known, aspects of bariatric surgery, which can often make all the difference between failure and success, in next week’s posts.

AMS

Istanbul, Turkey

THURSDAY, May 26th, 2011 (www.drsharma.ca) — In previous posts this week, I discussed the risk and potential benefits of bariatric surgery and explained why for someone with severe obesity and significant comorbidities, current evidence comes down heavily on the benefit side, whereas for someone with obesity but no complications, the risk/benefit ratio may not be all that positive.

In today’s post, I would like to look at why bariatric surgery works and hopefully dispel some common misconceptions about what bariatric surgery actually entails.

However, to fully understand why bariatric surgery should even be considered an option, we need to first understand why it is so difficult to lose weight and keep it off.

Readers will recall last week’s discussion on how any weight loss results in a ‘hypometabolic’ and orexogenic state – in short, weight loss drastically reduces the number of calories burnt while increasing hunger and appetite.

This is exactly what makes keeping weight off so difficult – as metabolism slows down and appetite increases, keeping weight off becomes a daily battle – a battle that lasts forever (the more weight you lose, the greater the struggle). This is why only a dedicated few, for whom weight management becomes nothing short of a daily obsession, manage to keep substantial amounts of weight off.

Everyone else, eventually gives in – most people can simply not endure constant restrictions or hunger forever.

Remember we are not talking about simply expecting someone who weighed 300 lbs to lose 50 lbs and from now on live on the same amount of food that a never-obese 250 lb person would normally eat.

No! To sustain the 50 lbs wieght loss, the formerly 300 lb person would need to perhaps survive on the amount of food that a never-obese 200 lb person would normally eat (or less!).

So expecting someone, who normally would have eaten 2500-3000 KCal a day (or more) to, from now on, survive on 1500 KCal a day or less, is a pretty hard sell – especially, as this person, thanks to the orexogenic response to weight loss, would be constantly hungry and thinking of food.

To make this kind of weight loss possible (even in the short-term), virtually all popular diets resort to certain ‘tricks’ to reduce hunger and increase satiety.

Increasing protein intake while drastically reducing carbs is one common variation (e.g. Atkins diet) – this approach takes advantage of both the satiating effect of protein and the anorexic effect of ketosis. This strategy, of course works fine as long as you can stick with it – but adding even a few more carbs or reducing the amount of protein immediately brings back the hunger and you fall off. Very few individuals manage to walk the fine line between hunger management and falling off – many simply get bored.

Another popular trick is to bulk up the food with lots of fruit, vegetables, or simply adding fibre supplements with plenty of fluids. The idea here is that these foods will expand in the stomach and hopefully fill it enough to create a sense of fullness despite eating fewer calories. This may well work for some people, but remember, the stomach is the size of a small football – it takes a lot of food to fill it.

Also, eating large quantities of fruits, vegetables, legumes, high-quality protein and complex carbs, rather unfortunately, given today’s nutritional landscape, is not only impractical, inconvenient, and expensive – it also requires a substantial time commitment and other changes in lifestyle (e.g. regular shopping for fresh ingredients and home cooking).

The third trick is to simply avoid high glycemic index (HGI) foods (especially refined sugars and other carbs), which (at least theoretically) reduces the ‘eat-crash-and-crave’ and ‘antilipolytic” response to the hyperinsulinemic surge that comes from ingesting readily digestible carbs. However, evidence that this is a viable long-term weight-loss or maintenance strategy, is rather limited.

So the bottom line is that sustaining weight loss with dietary restrictions alone requires both subtantial dedication and some clever and sometimes drastic modifications of your dietary intake to make it sustainable.

For the sake of brevity, I do not want to go into a discussion about the rather important role of exercise in all of this, as I am trying to get to the issue of how bariatric surgery works.

But before I get to the surgery bit, here is one last important piece of information regarding how these dietary strategies affect ingestive behaviour.

Most of the above dietary strategies focus on the homeostatic system, i.e. hunger and satiety. Only the Atkins diet, which also allows chocolate and other high-fat goodies as long as they are low in carbs, also caters to the hedonic system, i.e. appetite and reward – which is perhaps why some people find it somewhat easier to stick with.

So here in short is the problem that every obese person, trying to maintain a significant amount of weight faces: losing weight activates both the hemeostatic system (more hunger – less satiety) and the hedonic system (greater appetite, especially for highly palatable energy dense foods that are especially ‘rewarding’) – two systems that will eventually wear down even the most determined dieter.

This is where bariatric surgery can provide help.

In principle, there are two mechanisms by which bariatric surgery can work:

a) Reducing the size of the stomach or otherwise slowing the passage of food, thereby eliciting a stronger and longer-lasting feeling of satiety.

b) Bypassing a significant proportion of the gut to create maldigestion, which means that a proportion of the eaten calories will not be digested and absorbed.

These two principles are referred to as ‘restrictive’ and ‘maldigestive’ surgery, respectively.

Although this sounds simple enough (and variations of both principles have been around for over 50 years), the actual biology of how these operations really work is only now being understood.

Thus, contrary to popular belief, restrictive surgery (formerly referred to as ’stomach-stapling’ or ‘vertical gastric banding’ (VGB) and its modern cousin, the adjustable gastric band (AGB)), does not work by simply making it difficult to eat.

If this was the case, you would see the same results from simply wiring your jaw.

The real reason restrictive surgery works is because it sends powerful neuronal and hormonal signals to the brain to create an early and strong sense of satiation, thereby reducing the need to eat large portions.

In other words, restrictive surgery tricks the brain into thinking that you have eaten a 12 ounce steak, when all you have eaten is 4 ounces. Suddenly, those tiny serving sizes shown to you by the dietitian is really all you need to feel completely full and satiated – portion control is no longer a problem. Wiring your jaw does not produce that sense of fullness but putting a band around the upper part of your stomach does – this is why banding works while jaw wiring does not.

A variation of this approach is the increasingly popular vertical sleeve gastrectomy (VSG), which essentially reduces the size of the stomach to that of a small banana. Once again, this operation works because, it no longer takes a 12 ounce steak to feel full.

In addition, VSG also removes a large part of the stomach that produces the hunger hormone ghrelin. This is why many patients with VSG no longer feel as hungry as before (some patients literally say that this is the first time in their life that they have never felt hungry).

Thus, VSG has two modes of action: it significantly reduces hunger while increasing satiation with smaller portions. Suddenly, eating less is no longer that difficult – imagine losing weight without being hungry and not having to eat huge portions to feel full anymore.

The mode of action of the ‘gold-standard’ Roux-en-Y Gastric Bypass (RGB) is even more complicated. Not only is the size of the stomach reduced (greater satiety), the remaining detached stomach secretes less ghrelin (less hunger) but the food also bypasses part of the gut, which affects food digestion and absorbtion (maldigestion).

But even this ‘triple whammy’ is not the full story. It turns out that the way in which this operation redirects food by bypassing the duodenum also has a profound effect on the secretion of gut hormones like GLP-1, which control insulin secretion and other metabolic responses.

In fact, experiments with devices that simply prevent this part of the gut from coming in contact with food (as in the endoluminal sleeve or ‘duodenal condom’), lead to an almost instant improvement in type 2 diabetes, even without any appreciable weight loss (although in the long-term, improvement in glycemic control generally tends to be proprtional to the degree weight lost). This mechanism of action is commonly referred to as the ‘foregut hypthesis’.

In addition, it may also be that this operation, by allowing more undigested food to rapidly enter the large intestine, leads to a release of gut hormones like PYY-36, which delivers a potent satiation signal to the hypothalamus. This effect is referred to as the ‘hindgut hypothesis’.

Thus, each of these bariatric operations, by different means, tricks the ’starving’ brain into thinking that it is still getting all the calories it needs thereby ‘accommodating’ the hypometabolic response by allowing the ingestion (or absorbtion) of fewer calories, while at the same time ‘overriding’ the orexegenic response to weight loss.

This is what allows patients to survive on as little as 1400 KCal per day without feeling hungry – a feat that takes an almost inhuman amount of willpower to do otherwise.

So why do some people fail with surgery?

The short answer would be because surgery, primarily affects the homeostatic system (hunger and satiety) of ingestive behaviour and not so much the hedonic system (appetite and reward).

In other words, bariatric surgery deals well with the issue of ‘being hungry all the time’ and ‘never feeling full’ (especially after weight loss) but not so well with the issue of emotional eating or food-addiction.

The latter is not always true, because not being hungry and feeling full (not to say ’stuffed’) also affects the hedonic system – but only indirectly – certainly not enough to fully stop emotional eating (see tomorrow’s post for more on this issue).

And of course, any form of surgery can be ’sabotaged’ by not following the recommended diet – you can always still drink your calories or graze all day and and gain all the weight back – no bariatric surgery will stop that.

Fortunately, ’self-sabotage’ is the exception and not the rule and needs to be dealt with in a very different manner – remember, the surgery is on your gut and not your brain.

So what exactly do patients have to do to ensure success of their surgery? Why is surgery anything but a quick or simple fix? And, what are the potential long-term complications of surgery?

More on this in coming posts.

AMS
Istanbul, Turkey

WEDNESDAY, May 25th, 2011 (www.drsharma.ca) — So now, that we have extensively discussed the issue of risk in previous posts, let us turn our view to the benefits of bariatric surgery.

In this discussion let us be very clear about the following:

1) Bariatric surgery does not, nor is it intended to, address the many ‘root causes’ of obesity. Its only raison d’être is to help patients with weight-related health problems sustain a degree of weight loss that is, for the vast majority of people (i.e. 19 out of 20), simply impossible to sustain with diet and exercise alone.

2) To be honest, bariatric surgery is not even about weight loss! To put it bluntly, the real reason to even consider bariatric surgery is because of its positive impact on comorbid conditions (which is why I refuse to call it weight-loss surgery or WLS). While many patients appreciate the fact that bariatric surgery may help them attain and sustain a lower body weight – the real benefit, at least from a medical perspective, can only be measured in improvements in health and quality of life. In fact, if ‘bariatric’ surgery only improved health (with no weight loss), it would still be a worthwhile intervention.

3) I have already addressed the issue or surgical risk vs. the risk of not having surgery in previous posts. Thus, readers will recall that even the surprisingly small risk of undergoing laparoscopic bariatric surgery, may exceed the risk of not having surgery in obese people, who are otherwise healthy. These are NOT the folks who should be strongly considering surgery. On the other hand, the more obesity-related complications the patient has, the smaller the relative risk of undergoing surgery. So, I am by no means advocating for simply operating on anyone who is obese. In any obese patient without comorbidities or significant impairment of quality of life, even the rather small risk of surgery is clearly not worth taking.

4) Surgery is not for everyone. As pointed out in previous posts, we turn away many patients, who may meet both the BMI and medical criteria for surgery because we do not think that they will be able to make or sustain the considerable lifestyle changes that are required for surgery to ’succeed’. Some patients may slip through the ‘cracks’ because they manage to convince (I will not say intentionally mislead) us to think they will cope, when they clearly will not. But we certainly do our very best to try and identify such patients and turn them away from surgery.

5) Surgery is invasive and traumatic! It impacts dramatically on normal gut anatomy and function. Whether it just restricts normal passage of food through the gut (as in adjustable gastric banding), reduces the size of the stomach (as in sleeve gastrectomy), or additionally reroutes food through the gut (as in gastric bypass or biliopancreatic diversion), surgery has a profound, and in most cases, permanent impact on the anatomy and functioning of the digestive system. Tampering with an essentially ‘healthy’ gastro-intestinal system should never be considered trivial. This amazingly complex system has evolved through eons of human evolution to serve one of the most important biological functions – to digest and assimilate our food and drink – our only source of nutrients and calories. The expectation that this system can simply be surgically tampered with, without some very significant and sometimes dramatic consequences, is both naive and irresponsible. Of course bariatric surgery entails risk and there are very real consequences – the only question is whether or not these risks and consequences outweigh the risk and consequences of leaving things as they are – a question that I will address in the following.

With these caveats out of the way, let us look at the potential benefits of surgery (and, please remember, I AM NOT A SURGEON!).

I will limit my discussion to people who have higher BMIs and do have significant comorbidities, because this is the population that we see in our clinic.

One of the most common comorbidities (about 30% of patients) is diabetes mellitus.

Let us look at what it means for a 40 year old (the average age of our patients) to be told they are diabetic.

The diagnosis diabetes means, that this patient will now have to begin medical treatment, usually metformin, which she will hopefully tolerate without the often significant intestinal adverse effects (cramps and/or diarrhea) and will hopefully help lower her HBa1c levels to below 7, a level that should ward off the many complications of this disorder. She will also now need to regularly check her blood glucose levels and quite substantially change her diet and lifestyle to try and keep her diabetes under control. In addition, she will have to start seeing her doctor or nurse several times a year and perhaps go for annual checkups of her eyes and feet.

Unfortunately, given that diabetes is a chronic progressive condition, she may soon belong to the rather large number of patients where metformin alone is not enough to control their diabetes. The next step would be to consider sulphonylureas or even daily insulin injections, treatments that not only carry a small but important risk of hypoglycemia as well as an almost obligatory risk of further weight gain. Of course, these treatments also mean even more daily checking of blood glucose levels (perhaps even several times a day) and more visits to the nurse or doctor (I am not even mentioning cost here).

Although diabetes is a condition for which we have relatively good medical treatments, the annual risk of dying for a patient with diabetes is about 1 in 100. As none of these medical treatments are curative, treatment will continue over the next 10 to 15 years, by which time chances are that she will begin experiencing significant retinopathy, nephropathy, neuropathy and of course the almost obligatory atherosclerosis that accompanies this disorder.

Eventually, after about 20 years (remember that our patient is now still only in her 60s), she will have a substantial risk of losing her eyesight and/or kidney function, begin developing sores and ulcers on her feet that could lead to amputations, and of course, at any time, could experience a fatal heart attack or stroke.

This, unfortunately, is the natural course of type 2 diabetes, a condition that now affects 6 million Canadians and, in young people like this patient, is almost entirely accounted for by excess weight (or the lifestyles that leads to excess weight). There is no known medical treatment that can cure diabetes – once you are diabetic, treatment is for life.

Let us now consider the surgical alternative. Let us imagine, that this patient, at age 40 with her BMI of 47 meets a physician, who suggests she should perhaps consider the option of bariatric surgery. The doctor advises her that bariatric surgery, a relatively safe 45 to 90 min operation, offers an 80% chance of her diabetes going into complete remission for 5 to 10 years if not longer. During this time, she would still need to go for annual checkups, would need to follow a diet and take daily protein and vitamin supplements, but would be off her daily diabetes tablets and injections and, as one may expect, have virtually no risk of experiencing any diabetes-related complication for however long her diabetes remains in remission. In fact, there are studies showing an over 90% reduction in diabetes-related mortality upto 15 years following bariatric surgery. In addition, there is also a good chance that this operation would get her off her blood pressure pills, her CPAP machine, reduce her fatty liver disease, ease the pain in her hips and knees, improve her urinary incontinence and sex life, and reduce her risk of dying of cancer by 60%.

I am not making this scenario up or painting a too rosy picture because my surgical colleagues have somehow managed to brainwash me.

At least two highly credible non-surgical organisations have recently come out with positive recommendations on bariatric surgery – the American Heart Association and the International Diabetes Federation – no reasonable person would accuse either organisation to be involved in some secret conspiracy to drive more business to our surgical colleagues.

But these organisations are by no means alone. There are now countless position papers and detailed analyses from institutions like the UK National Institute for Health and Clinical Excellence (NICE) or the Canadian Agency for Drugs and Technologies in Health (CADTH) that have carefully evaluated the evidence – both the pros and cons – and come down heavily in favour of bariatric surgery as a treatment of choice for individuals with severe obesity, especially for those who also have significant comorbidities.

None of these reports depict bariatric surgery as being harmless or without risk. They all strongly recommend that patients are carefully selected, well prepared and receive long-term follow up for nutritional and other complications. Yet, they all recommend surgery as being a better alternative in terms of warding off complications, improving quality of life, and monetary savings compared to non-surgical treatment.

So unless, you want to believe in some major global ‘conspiracy theory’ that involves all of these government and non-government organisations, which for some unknown reason are now in cahoots with bariatric surgeons the world over, you would have to assume that modern bariatric surgery has some very strong evidence to support it.

Having myself worked closely with some of these organisations, I can assure you that these folks are not known to make rash recommendations or off-the-cuff decisions without carefully weighing the evidence.

So until someone comes up with a better or even equally effective (hopefully non-surgical) treatment for severe obesity, that delivers all of the same health benefits of surgery, I will have to continue discussing and, in most cases, recommending surgery to my patients.

But how exactly, does bariatric surgery deliver on this promise? How does it work? What are the real problems that any patient considering surgery must be aware of?

More on this in tomorrow’s post.

AMS

Istanbul, Turkey

TUESDAY, May 24th, 2011 (www.drsharma.ca) — Yesterday’s post was about the widespread misconceptions around the risk of having bariatric surgery compared to the risk of not having surgery.

I pointed out that for a severely obese person with clinically significant end-organ damage, the risk of death without surgery within 1 year is about 10 times that of dying of the surgery itself.

Having looked at the risks, today, I wanted to discuss the ‘benefit’ side of the equation – after all, no one would consider even the safest surgery, if there was no benefit to having it.

But before I go into the discussion of benefits, I thought it may be worthwhile to discuss how we (both experts and non-experts) tend to perceive risk and why we are so easily bound to kid ourselves, even when we know the numbers.

The fundamentals of how human psychology tricks us into falling widely off the mark, when it comes to interpreting risk was described in a classic paper by Daniel Kahneman and Amos Tversky published in Science in 1974 (Kahneman went on to get the Nobel Prize for economics in 2002).

As pointed out in this seminal paper, based on a remarkably solid body of empirical psychological research (consistently replicated ever since), we all tend to make ‘gut’ decisions according to the following three principles:

1) Representativeness (or as Dan Gardner calls it, “the rule of Typical Things”)

2) Availability or recall of instances (”Example Rule”)

3) Anchoring

We tend to use all three rules to assess risk or judge probability – even when we know the numbers and statistics.I have previously described the Anchoring Rule, so I will not discuss this again – suffice it to say, that our judgements are often clouded by (random?) numbers that we have heard somewhere, irrespective of whether they are even remotely true or not.

If someone (anyone) were to simply say 89.7% of patients struggle after surgery (a number I just made up), people will think that surgery is a risky business, even if I then tell them that I just made up this number and it is probably a wild exaggeration (and never mind that the actual number is probably well below 20%). They would just be obeying the Anchoring Rule.

The Rule of Typical Things is even trickier and leads us to believe more in stories that sound reasonable and ‘typical’ than stories that sound ‘non-typical’. Interestingly, what we perceive as ‘typical’ may not be at all ‘typical’ – we just think it is because it makes a good story and sounds highly plausible.

Here is how the ‘Rule of Typical Things’ works:

Stephanie is a 45 year old Canadian woman with severe Vitamin D deficiency.

Which of the following is most likely to be true:

a) Stephanie lives in Alberta

b) Stephanie has had bariatric surgery

c) Stephanie lives in Alberta and has had bariatric surgery

Pick one before you read on!

Let’s do the math:

Based on population distribution and assuming that Vit D deficiency is distributed equally across Canada, the chances that Stephanie lives in Alberta is 1 in 10.

Assuming that well under 5,000 45-year old Canadian women will have had bariatric surgery and assuming that perhaps 20% of bariatric surgery patients may have severe Vit D deficiency, chances that Stephanie may have had bariatric surgery is about 1 in 250.

So the chances that Stephanie both lives in Alberta AND has had bariatric surgery turns out to be only about 1 in 2500.

Yet, if you picked option (c), you would not be alone – this is what most people (around 80%) will pick – just because it tells a better story – the rule of ‘Typical Things’.

In short – if we associate a certain event (severe Vit D deficiency) to be ‘typically’ related to another event (bariatric surgery) we are far more likely to think that the likelihood of the combination of these two events occurring together is greater than the likelihood of either event occurring alone – despite the fact that probability theory tells you that this is impossible.

But, no doubt, when it comes to our ‘intuitive’ assessment of the risk of bariatric surgery, the third “Example” rule is perhaps the most pervasive and powerful.

According to this rule, our ‘gut’ tells us that something we have experienced, heard of, or can otherwise readily recall, is much more likely than something we do not remember (or know of) – in other words, the easier it is to recall something, the more we assume this to be a common occurrence.

It is of course human nature, to pay more attention to and remember the outliers than the typical instances. We do not remember every car that ever drove by us at the pedestrian crossing but will never forget the car that almost hit us – even if this only ever happens once, we will, from then on, always be extra careful when crossing the road and will likely warn all our friends and family to be extra careful because of this experience.

Translate this to the issue of bariatric surgery: we will always recall and remember the one case that sadly died of surgery or had some other horrible complication (the rarer – the more likely we are to vividly remember it) but remain quite unaware of (or forget) the many instances where things went well – in fact, the better things go in general, the more ’spectacular’ and ‘memorable’ we find the rare cases that go wrong.

The reverse is also true: many, who enthusiastically decide to have surgery, remember the ’spectacular’ case of the person they recall meeting or reading about, who lost 50% of their initial weight and changed their lives forever, but forget (or are unaware of) the not-so-spectacular ‘typical’ cases of those who only lost the usual 25% of their initial weight and just quietly went on with their lives.

Incidentally, Kahneman & Tversky also demonstrated the psychological phenomenon of Prospect Theory or “loss aversion“, which states that people value losses much more harshly than gains (Note the asymmetry of the curves in the Figure). So if you lose a $100 bill you will lose more satisfaction than you would have gained from finding a $100 bill. Similarly, a patient, who develops a new complaint from bariatric surgery (e.g. dumping syndrome), will find this far more distressful (even if it can be easily controlled by avoiding certain foods) than the relief from seeing his original problems (having to inject insulin and to sleep with a CPAP machine) getting better.

Not unexpectedly, all of these psychological phenomena readily explain some of the comments that readers leave on this site: I am of course far more likely to hear from readers who had a remarkable (but atypical) negative or positive experience, than from readers, where everything simply went its unremarkable and unspectacular usual course, which is exactly, why they do not leave comments (or even read this blog) – because everything went just the way it should – nothing special to write home about!

Sadly, perhaps, these heuristics (experience-based techniques for problem solving), which we all apply in so many judgements every day, are remarkably resistant to both data and common sense.

All of this brings us back to the discussion of risk and benefit, which underlies any clinical decision making.

In my own work as a physician, these heuristics are present every day. I am fully aware that my own judgements are subject to rules of ‘Typical Things’, ‘Examples’, and ‘Anchoring’ and it is often with great effort that I have to remind myself that ‘outliers’ (both good and bad), which will always happen, are thankfully (or sadly) just that – outliers. I will also always distress more about the ‘problems’ that any treatment may have caused my patients, than celebrate their improvements from that treatment

In real life, taking chances means placing your bets – this is best done, when you fully understand your odds of winning or losing. Great wins may justify large bets, even when the odds of losing are substantial. On the other hand, even a small chance of losing your shirt (no matter how big the jackpot), would make many decide to walk away from the table.

Hopefully my readers will forgive me for this brief excursion into the psychology of risk, before delving into the benefits of bariatric surgery tomorrow.

For anyone further interested in this topic, I highly recommend Dan Gardner’s immensely readable bestseller ‘Risk: Why We Fear The Things We Shouldn’t – and Put Ourselves In Greater Danger‘.

AMS
London, UK

MONDAY, May 23rd, 2011 (www.drsharma.ca) — Let me start this post with a few disclaimers:

1) I am not a surgeon and do not get paid based on whether any of my patients decides for or against surgery.

2) The average BMI of patients seen in our program is 49.7 kg/m2 – the average patient is just below 40 years of age. Most have substantial health problems – many cannot work or perform even simple tasks of daily living because of their weight – most have tried every commercial diet or pill they could lay their hands on – they are all ‘experts’ on weight loss.

3) Many have significant psychosocial problems and mobility issues that may have contributed to their weight gain – these are dealt with by an interdisciplinary team of psychiatrists, psychologists, occupational and physiotherapists, nurses and dietitians – treatments that start months before any patient is considered a candidate for surgery.

4) I do not for once believe that bariatric surgery addresses any of the ‘root causes’ of severe obesity and I am sure that none of my surgical colleagues believe it does. As I often tell my patients, “the surgery is on your gut and not your head”.

5) Our program regularly talks patients, who come to us wanting surgery, out of surgery, if we feel that it is not in their best interest or unlikely to have a successful outcome – to these patients we offer the best non-surgical care we can – but of course, many are disappointed.

And yet, our program regularly performs bariatric surgery and prepares patients for it in a process that can often take 6 months or longer. We proactively discuss surgery with all patients, who meet the criteria for surgery – both the pros and the cons. We offer comprehensive dietary, psychological and medical support to all patients who decide to undergo surgery but make it very clear that surgery is not a ‘cure’ and that patients have to make substantial lifestyle changes in order to be ’successful’ (we measure ’success’ in improvement in comorbidities and quality of life – not in pounds lost!).

With these caveats out of the way, I would today like to dispel some common myths about bariatric surgery and discuss why for many patients with severe obesity, it is in fact a very realistic and successful option.

The first common and pervasive misconception relates to risk – both short-term and long-term risk.

Let me begin by paraphrasing the concept of risk according to Seth Godin’s Poke the Box:

“Risk, to some, is a bad thing, because risk brings with it the possibility of failure. It might be only temporary failure, but that doesn’t matter so much if the very thought of it shuts you down. So for some, risk comes to equal failure (take enough risks, and sooner or later, you will fail). Risk is avoided because we’ve been trained to avoid failure. I define anxiety as experiencing failure in advance…and if you have anxiety about initiating a project, then of course you will associate risk with failure.”

So, why do people with cancer opt to expose themselves to sublethal doses of radiation, radical surgery, or deadly chemotoxins? Because they reckon that the risk of these aggressive treatments is probably less than the risk of simply living with their cancer (even if the cancer grows slowly and may never kill them).

In many cases these patients are just ‘buying’ a few months of additional life – much of it spent in hospital or dealing with the often considerable adverse effects of treatment – yet they perceive the ‘risk’ of undergoing treatment to be lower than the ‘risk’ of not being treated – because they are ‘hoping’ for success.

Readers, who find this comparison to cancer seemingly far fetched, may be interested in noting that the reported quality of life of many patients (both kids and adults) with severe obesity is comparable or worse than that of people living with cancer. Add the social stigma of obesity and every day becomes a struggle with zero sympathy from family and friends. And I am not even mentioning the potential health and economic risks of severe obesity.

So what is the risk of being severely obese? Interestingly, for some people not much.

In our program we see a significant, albeit small proportion (~15%) of severely obese individuals, who have no detectable health problems – they feel good about themselves – eat healthy diets – are physically very active – have been weight stable for years – have great jobs and families – all power to them, I say!

But for the other 85% the picture is not all that rosy. Here we see everything from fatty livers, severe sleep apnea, intractable back and joint pain, urinary incontinence, diabetes, lymphedema, and countless other health problems, which get worse with progressive weight gain (stable weights in this population are the rare exception) and so much better with weight loss (although not in every case).

All of these conditions have some very real risk – our own research shows that when obesity (even moderate obesity) is associated (note the use of the word ‘associated’!) with a single comorbidity with clinical signs of end-organ damage (e.g diabetic kidney disease), 20-year life expectancy drops to 50% in absolute terms. And this is in patients receiving all the usual conservative treatments for whatever comorbidity they may have.

A 50% chance of dying in the next 20 years is an annual risk of about 2.5% per year. This means that out of 100 obese patients WITH end-organ damage, statistically speaking, 2.5 will die every year. This is a 1 in 40 risk of death per year or a 1 in 2 risk of death in just 20 years.

Obviously, for someone with obesity, who has a comorbidity (e.g. diabetes) but does not (yet) have end-organ damage (e.g. no kidney damage), the risk of dying is substantially lower – only about 20% over 20 years or about 1 in 100 per year or 1 in 5 over 20 years.

Without any sign of obesity-related comorbidity (irrespective of BMI), the risk of dying is less than 5% over 20 years – only about 1 in 400 per year or 1 in 20 over 20 years.

So, if risk of dying was your only criteria for deciding for or against surgery, you would need to first understand the risk of not having surgery. As explained above, this risk is very much dependent on whether or not there are any comorbid health problems – the more existing health problems and the more severe these are, the greater the risk of simply sticking with what you are doing and hoping for the best.

This makes all the difference when considering the risks of surgery – both in the short and long term – because any discussion about the risk of surgery is meaningless without first fully understanding the risk of not having surgery.

As previouslt blogged, a recent analysis of over 15,000 cases of laparoscopic bariatric surgery found a mortality risk of less than 0.04% of laparoscopic adjustable gastric band, 0.0% sleeve gastrectomy, and 0.14% of the gastric bypass patients.

Even if we assume the worst and say that surgical mortality risk is as high as 0.2% – this translates to a risk of 1 death in 500 patients undergoing surgery – a risk of 0.1% would be 1 in 1,000 – a risk of 0.05% would be 1 in 2,000.

Compare this to the annual risk of not having surgery in an obese patient with end-organ damage of 1 in 40 and that of an uncomplicated obese patient of 1 in 400.

So if risk of death is all that you care to consider, let us be clear that an obese patient with end-organ damage is over 10 times more likely to die within one year without surgery than from having surgery.

In contrast, an uncomplicated obese patient is just about as likely to die within one year without surgery as from surgery!

Thus, amazing as it may seem to some readers (given all the talk about the apparent ‘riskiness’ of bariatric surgery), the risk of not having surgery actually substantially exceeds the short-term risk of having surgery in patients with comorbidities and end-organ damage and may even have a slightly favourable risk in uncomplicated patients – this, perhaps goes to show just how safe modern bariatric surgery has actually become.

But of course, the risks of bariatric surgery are not limited to simply the actual risk of surgery – there is no doubt that even after recovering from the surgery itself, there may well be an increased risk of nutritional, psychological, and other complications that may result from having had surgery.

But one can make very similar calculations as I have made for mortailty, and in every case, the risk (even the long-term risks) of surgery come nowhere close to the risks of not having surgery (just take a minute to compare the very real risks of hypoglycemic shock from insulin treatment or falling asleep at the wheel due to sleep apnea to the risk of having to have annual blood tests and taking daily protein or vitamin supplements).

Of course, any discussion of risk is meaningless without also discussing the possible benefits – after all, no one wants to have surgery simply because it is relatively safe unless it also provides some very real benefits (or at least has a statistically substantial chance of delivering such benefits).

So tomorrow, we will look at the data on the benefits of surgery compared to ‘conventional’ treatments – without which, even the safest bariatric surgery would be useless.

For today, let me leave you with this advice from Harvard Business Review:

“Every important decision inevitably involves a trade-off. Knowing what you can’t pursue is as valuable as articulating what you will. But how do you know which trade-offs are acceptable and which are losing propositions? Here are three ways to help make the distinction:

- Get input on pros and cons. List advantages and disadvantages and ask others for their perspective on which carries the heaviest weight [sic].

- Balance short term with long term. Determine what you’d be willing to give up in the long run for some important short-term gain — and vice versa.

- Gauge support. While weighing alternatives, think about who will support a particular idea and who will oppose it. Ask whose support you can live without, and whose backing and buy-in you absolutely need.“

AMS
Edmonton, Alberta

TUESDAY, June 14th, 2011 (www.newscanada.com) — A new survey from the Canadian Obesity Network–Réseau canadien en obésité (CON–RCO) found that 84 per cent of Canadians with severe obesity are motivated to lose weight and eight–in–ten respondents say their main motivating factor is to improve their overall health. This is not surprising given that 75 per cent report having one or more accompanying conditions, including high blood pressure, high cholesterol and diabetes.

Lucille Bisignano is familiar with the motivation to lose weight to improve her overall health. “In addition to being severely obese I was also living with diabetes and high blood pressure, taking countless medications. I had seen a number of doctors and dietitians about my weight but nothing worked for me. I knew I needed to make a change and that’s when I decided to undergo the gastric banding procedure. Since having the procedure, I’ve lost over 190 pounds. As a result of my weight loss, my blood pressure has stabilized, my diabetes is in remission and I no longer have to take any medication.”

Many Canadians face the same struggles that Lucille did in achieving sustained weight loss. Sixty-one per cent of Canada’s severely obese population report that weight loss is an uphill battle for them as they have too much to lose, and four in 10 feel discouraged about trying another weight loss program for fear of failing again.

Dr. Christopher Cobourn is the medical director and surgeon at the Surgical Weight Loss Centre. He sees hundreds of patients each year who want to lose weight, but struggle.

“Many patients who come into my office are frustrated and depressed with their repeated failure to sustain weight loss,” says Dr. Cobourn. “It’s critical that these patients understand that there is no ‘one–size–fits–all’ approach to weight loss. Only after understanding all the treatment options, including surgery and medically–assisted weight loss procedures, can these patients make an informed decision. This allows them to feel empowered to live their life without being controlled by their weight issues.”

In Canada, there are different medically–assisted weight loss procedures available, including: the gastric balloon, laparoscopic adjustable gastric banding (or gastric banding) and gastric bypass. You can learn more about these procedures online at www.yourmomentoftruth.ca.