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Kalamazoo, MI

As gastric bypass and other bariatric surgeries are becoming more popular for weight loss and as minimally invasive surgical techniques are developed, some health professionals worry that the procedures may be overused.

“I think it’s wrong to do it on people who are minimally overweight,” said Dr. Jerome Cooper.

Cooper is the medical director of the Medical Weight Loss Clinic, a Southfield-based business that has 34 locations in Michigan and northern Ohio, including one in the Kalamazoo area.

“Bariatric surgery is a last resort, as I see it,” said Cooper, who was trained as a bariatric physician but has not done bariatric surgery.

He was raising his concerns in response to a recent Los Angeles Times report saying that new, incisionless techniques that are now in human trials at major hospitals may end up broadening the use of bariatric surgery to people who are only moderately overweight or on the lower end of the obesity scale.

“I think 100 pounds overweight or more with co-morbidity (another health condition such as diabetes) is a good rule to follow,” Cooper said.

The clinics that Cooper oversees are devoted to medically supervised weight loss through diet, exercise and medication. “We do some referrals for bariatric surgery” when it’s appropriate, he said.

“Bariatric surgery does offer the best results of any weight-loss treatment available today,” Cooper said, “but it’s not without the possible recurrence of weight gain, and there are post-surgical issues” such as the risks of leakage, bowel obstruction and dumping syndrome, which is involuntary vomiting or defecation.

“The risks of bariatric surgery must be weighed against the risks of being morbidly obese (overweight by 100 pounds or more or with a body mass index of 40 or greater), diabetes, arthritic problems, heart problems, certain cancers,” Cooper said. “It’s appropriate for the right people.”

Divided opinions

Health professionals at major medical centers who were quoted in the L.A. Times report — and in a similar Chicago Tribune story — were about evenly divided on using bariatric surgery in those who are not extremely obese.

Some said the surgery is underused as a way to deal with Type 2 diabetes and other obesity-related health problems, while others said the surgery carries the risk of long-term complications and that diet changes, exercise and medication should be recommended instead for the overweight or moderately obese.

The L.A. Times noted that statistics from the American Society for Metabolic & Bariatric Surgery show bariatric surgery rates have doubled in the United States in the past six years, with 220,000 of the procedures done in 2008.

Diabetes, though, is on the rise, too, and studies show bariatric surgery is achieving good results in controlling that disease in patients with BMIs between 30 and 35, said Dr. Stuart Verseman, who has been medical director of bariatric surgery at Borgess Medical Center since October 2005 and does bariatric surgery at both Borgess and Bronson Methodist Hospital.

“They’re finding a marked improvement in their diabetes after bariatric surgery and a decreased usage of medication,” Verseman said.

An example of someone with a BMI of 30 would be a person who is 5-foot-9 inches tall and weighs 203 pounds. That person would be 35 pounds above the normal weight range for that height, according to the U.S. Centers for Disease Control and Prevention.

While that example might not strike some people as a case of obesity, Verseman said that “even people with BMIs of 30 are considered clinically obese.”

Verseman, following National Institutes of Health guidelines, does bariatric surgery only on those with a body mass index of 35 or more and certain related medical conditions or 40 or more without those conditions.

But he said he finds it “very exciting to think about offering that to a larger population, especially with the number of diabetics increasing astronomically every year.”

Verseman is the only surgeon in Kalamazoo currently doing bariatric operations. Dr. Alan Saber, who had been the main physician doing bariatric surgery at Bronson, left in November and now works at Case Western Reserve University Hospitals, in Cleveland.

Verseman, like Cooper, said bariatric surgery should never be the first choice for weight loss. But he is much more open to the potential of its use in the moderately obese who have diabetes, high blood pressure or other weight-related conditions.

Krista Hampton, a registered dietitian who is Bronson’s bariatric coordinator, sees the value of bariatric surgery for the extremely obese, but she expressed reservations about using it in people who are overweight or moderately obese.

“Coming from my background, I would want someone to exhaust all other weight-management options first,” she said.

Surgery and support

Bariatric surgery is on the rise at Borgess and Bronson, as it is nationwide. In the fiscal year ending June 30, 2004, there were 14 bariatric surgeries at Borgess. From July 2008 through June 2009, there were 187 at Borgess, and in the last six months of 2009 there were 110, according to Rebecca Blades, a registered nurse who leads the Borgess bariatric program.

Bronson, which started its bariatric program in 2007, did 47 surgeries that year, 99 in 2008 and 112 in 2009, said public-relations specialist Erin Smith.

Verseman said his bariatric surgeries have had a major-complications rate of 2 percent, while the national average is 3.5 percent.

Representatives of both hospitals emphasized that they carefully screen those interested in bariatric surgery and offer continued support to those who get the surgery, trying to help them avoid overeating and stay active.

Borgess, for example, offers support groups, both in person and online, and offers classes in active living, Blades said.

“None of these operations are cures,” Verseman said. “They’re tools to help patients. And it’s a team approach we take, involving a dietitian, a psychotherapist, the primary-care physician. Patients need to follow guidelines afterward to improve their medical conditions.”

“If you start grazing, over time you can get a lot of calories in even after surgery,” Verseman said.

But if people getting bariatric surgery have to learn to make dietary and behavioral changes and stick with those changes to lose weight, why not instead work closely with people to support new eating habits and more exercise without doing bariatric surgery?

“I wouldn’t have somebody undergo bariatric surgery who has never attempted anything else before,” Verseman said. “Almost every patient (who undergoes bariatric surgery) has completed numerous diets” but has not succeeded in losing enough weight to improve their medical condition, he said.

“You don’t just wake up one morning and say, ‘I want to have gastric bypass surgery.’”

The surgery helps people feel full and therefore have less of an urge to eat, Verseman said. One type of surgery he does — a sleeve gastrectomy — takes out 75 percent of the stomach and gets rid of the hormone that causes hunger, he said.

Even without bariatric surgery, though, people can learn to ease feelings of intense hunger, Hampton said, by increasing the protein and fiber in their diets and decreasing the kinds of high-carbohydrate foods that cause blood sugar to spike and then drop.

She said some people who enter a weight-management program at Bronson with the idea of getting bariatric surgery decide not to have it once they learn to cook and eat differently, get more exercise and overcome some behavioral issues.

“We need to get back to the basics of how to cook and how to meal plan,” she said. “Convenience food is way too easy to get our hands on.”

Verseman expressed a similar sentiment but said he is glad he can help improve people’s lives through bariatric surgery.

“To see people get over medical conditions and get their lives back ... is really gratifying,” he said.