The Doctors Guide to Weight Loss Surgery . How to Make the Decision That Could Save Your Life

Regarding food choices and diet recommendations Dr. A. Hawasli, one of the most experienced laproscopic GB surgeons in the U.S. makes one diet book a mandatory requirement for his patients. Written by registered dietitian Theresa Malysz, The Duct Tape Diet includes a comprehensive listing of 6200 foods from the USDA database of branded items along with their content of saturated fat, protein, carbohydrates and calories. The book also contains a simple, easy to understand regimen for GB patients to follow so their food selections dont interfere with the intent of the surgery. The title originates from her husbands use of duct tape to wrap up those diet villains that often cause people to fall off the wagon an amusing technique from a book that employs humor to help those afflicted with curse of dangerous excess weight.

Morbid obesity is usually diagnosed when someone is 100 pounds overweight or 150pct. of ones ideal body weight. Dr. Flancbaum refers to this condition throughout the book as a chronic disease and offers a range of surgical solutions, along with the risks and possible complications. For anyone contemplating this route to losing weight, realize that the book leans toward the more invasive Roux-en-y (RNY) gastric bypass surgery. In my opinion, it reflects the 2003 copyright date as well as the experience base of most surgeons, who tend to favor what they know best.

However, RNY surgery is documented as more effective, usually resulting in more weight loss than the less invasive gastric banding (GB) surgery. This is due primarily to the dumping syndrome that causes patients to vomit high fat or sugary foods and the malabsorptive nature of the RNY procedure, which reroutes the small intestine to the new stomach pouch and prevents the normal absorption of nutrients. The book terms this surgery as more radical, since it involves opening the body cavity and re-plumbing the patients innards.

Compare this to GB surgery, which is generally performed laproscopically with thin instruments and a tiny tv camera to guide the surgeon through four or five small incisions in the abdomen. The plastic band is inserted around the upper part of the stomach, forming a small pouch that helps the patient feel full on much less food. The band permits a trickle of food through the small opening, which is adjustable to expand or contract for more or less food to pass through according to the patients weight-loss progress. The book cites some negative issues that occurred early on with this procedure, and tends to write it off. But since the books publication, GB surgery is gaining popularity primarily because it is adjustable, is reversible (rarely done), is far less invasive, does not cause the dumping syndrome, does not affect the absorption of nutrients and has many other advantages.

THE HIGH COST OF OBESITY

The economic cost of obesity is enormous. An estimated USD70 billion is spent annually in the United States on the treatment of obesity and its related conditions. This sum represents about 8 percent of the total health-care budget, or one out of every twelve dollars spent on health care. In addition, another USD33 billion is expended on commercial weight loss programs each year, despite the fact that there is no available evidence suggesting that they are effective in producing long-term weight loss. Annually, the cost of obesity treatment exceeds USD100 billion. At any given time, an estimated 40 percent of women and 25 percent of men are trying to lose weight, with an additional 30 percent involved in weight maintenance.

The significance of obesity as a public-health problem is related to its association with a number of complicating (or co-morbid) medical conditions. Obesity alone is a risk factor for premature death, with risk increasing in direct proportion to weight. Furthermore, obesity is causally related to diabetes, hypertension, coronary artery disease, stroke, sleep apnea, venous disease, gallstones, gastroesophageal reflux (heartburn), osteoarthritis, urinary stress incontinence, menstrual irregularity, infertility, depression, and several types of cancer. Many of these health problems improve or completely resolve with weight loss. Ironically, many insurance carriers and the federal government continue to refuse to pay for obesity treatments (diets, drugs, behavior modification, and surgery) but willingly expend funds to treat diseases that result from obesity.

Obesity takes a social and psychological toll on its victims. Obese individuals face discrimination in school, the workplace, the media, and in the health-care system. Many health-insurance plans do not cover obesity treatment or, if they do, the benefits are severely reduced or restricted. The decisions of insurance and managed-care companies in this regard are often arbitrary and ignore established medical evidence. No other group of individuals is stigmatized to the same degree as the obese and forced to jump through so many hoops in order to receive authorization for the care of a chronic debilitating disease. Morbidly obese people seeking weight loss surgery have to document every diet they have ever been on in addition to undergoing psychological screening to make sure they will comply with the dietary requirements after surgery. Smokers suffering from coronary artery disease in need of open-heart surgery do not need to present letters from their physicians verifying that they have stopped smoking nor do they need to undergo psychological screening to ensure that they will modify their diet and engage in a cardiac rehabilitation program after surgery. Physicians and other health-care practitioners involved in the treatment of obesity are also stigmatized, still often referred to as quacks.

Recently, inroads have been made into the causes and treatment of obesity. Identification of several genes and their corresponding hormones, such as leptin, that are in part responsible for obesity have confirmed that it has a biological basis, helping to reduce the misconception that obesity is a behavioral or psychological disorder. Several promising new drugs and drug classes have been introduced to treat obesity. However, these medications face severe hurdles before they can become available to the general public. They have strict restrictions against long-term use, often based on misconceptions rather than scientific evidence that they are addictive. Safe and effective surgical techniques have been devised that produce long-term weight control for the most severely obese individuals and result in significant improvements in associated medical problems. The beneficial effects of surgery in severe obesity have been evaluated, confirmed, and endorsed by the National Institutes of Health, the World Health Organization, the American Obesity Association, and Shape Up America. Nevertheless, much still remains to be done to improve the treatment of obesity and access to treatment.

Richard L. Atkinson, President, American Obesity Association
A much-needed guide to the most effective treatment for extreme obesity. Takes the mystery out of weight loss surgery. This text refers to the Paperback edition.

Review
Takes the mystery out of weight-loss surgery.
Should be read by all severely overweight people.
From the Foreword by Richard L. Atkinson, M.D., President, American Obesity Association

Ken Meissner, weight loss surgery patient
I wish this book had been available when I had weight loss surgery back in 1995. This text refers to the Paperback edition.

Review
Takes the mystery out of weight-loss surgery.
Should be read by all severely overweight people.
From the Foreword by Richard L. Atkinson, M.D., President, American Obesity Association

Book Description
Whether youre already planning to have weight-loss surgery or are still trying to decide, here is what you need to know about the operation that could save your life

If you are considering weight-loss surgery, you are not alone. Obesity is the most common chronic disease in the U.S. today, affecting one out of every four Americans. In this indispensable resource, Dr. Louis Flancbaum, one of the worlds foremost experts on weight-loss surgery, takes you through the entire process, from presurgical evaluation to postop care. Youll find everything you need to know to get the most out of the latest groundbreaking procedures available that can radically improve your health and your quality of life.

Youll discover.

Why WLS is the safest treatment for patients with clinically severe or morbid obesity
How to determine if youre a candidate for WLS
What to look for when choosing a surgeon
How to choose the surgical procedure thats right for you
What to expect pre-, peri-, and postsurgery
Common side effects and what they can mean for you
Diet and nutritional guidelines after WLS

Plus. what to do if your insurance policy excludes obesity treatment, how to determine when you can resume normal activities and return to work, healthful recipes, patient success stories, support groups and much more

Including detailed charts and tables, helpful resources, and websites, this is the only sourcebook on weight-loss surgery youll ever need.

From the Author
Society is scornful of morbidly obese people. Theyre considered almost sub-human in todays culture. When I see what my patients go through, I feel a strong sense of empathy for them. It gives me tremendous satisfaction to witness the positive transformation that this surgery can make in the lives of patients.

The majority of individuals seeking surgical relief have suffered from obesity for most of their lives. A minority became obese as adults, after childbirth, as a result of an injury that severely limited their physical ability, or in conjunction with an emotionally traumatic event. Virtually all candidates for surgery believe that they have exhausted all available resources before considering surgery. The toll morbid obesity takes on its sufferers is incalculable. In addition to the inevitable health problems that come with severe obesity, those who finally turn to surgery often have heartrending stories of rejection, humiliation and misery. It is a testament to the human spirit that they chose to survive and eventually to thrive after WLS. Unfortunately, obese people are subjected to a unique form of prejudice because our society assumes that we could lose weight if only we tried hard enough.

I wrote this book to help people who are desperate and feel they have nowhere to turn. I want them to know that there is a solution to their problem, there is a way out of the prison of morbid obesity.

Louis Flancbaum, M.D This text refers to the Paperback edition.

From the Inside Flap
Whether youre already planning to have weight-loss surgery or are still trying to decide, here is what you need to know about the operation that could save your life

If you are considering weight-loss surgery, you are not alone. Obesity is the most common chronic disease in the U.S. today, affecting one out of every four Americans. In this indispensable resource, Dr. Louis Flancbaum, one of the worlds foremost experts on weight-loss surgery, takes you through the entire process, from presurgical evaluation to postop care. Youll find everything you need to know to get the most out of the latest groundbreaking procedures available that can radically improve your health and your quality of life.

Youll discover.

Why WLS is the safest treatment for patients with clinically severe or morbid obesity
How to determine if youre a candidate for WLS
What to look for when choosing a surgeon
How to choose the surgical procedure thats right for you
What to expect pre-, peri-, and postsurgery
Common side effects and what they can mean for you
Diet and nutritional guidelines after WLS

Plus. what to do if your insurance policy excludes obesity treatment, how to determine when you can resume normal activities and return to work, healthful recipes, patient success stories, support groups and much more

Including detailed charts and tables, helpful resources, and websites, this is the only sourcebook on weight-loss surgery youll ever need.

From the Back Cover
Takes the mystery out of weight-loss surgery.
Should be read by all severely overweight people.
From the Foreword by Richard L. Atkinson, M.D., President, American Obesity Association

About the Author
Louis J. Flancbaum, MD, Chief, Division of Bariatric Surgery at St. Lukes-Roosevelt Hospital Center in New York City, and Associate Professor of Clinical Surgery at the College of Physicians and Surgeons of Columbia University, is a nationally-recognized authority on the surgical treatment of obesity. Dr. Flancbaum has performed nearly 1,000 bariatric surgical procedures. He has operated successfully on patients ranging in age from 15 to 70, weighing as much as 770 pounds. He has made many international presentations and published more than 100 articles in medical journals, and is board certified in General Surgery, Surgical Critical Care and Nutrition Support. His study, with Dr. Patricia Choban, of patient satisfaction after weight loss surgery, received national attention.

Erica Manfred is a freelance writer and medical journalist whose articles on a variety of medical and psychological topics have appeared in Cosmopolitan, Ladies Home Journal, Parenting, Bottom Line Personal and other publications and websites. She had gastric bypass surgery in January of 1998, which substantially improved both her health and quality of life.

Deborah Biskin is an educator and freelance writer who contributes to Lifestyles, Modern Bride, and Olam magazines. She edited Dr. Flancbaums first book, And You Shall Live by Them. Contemporary Approaches to Jewish Medical Ethics, and profiled him for Lifestyles magazine. This text refers to the Paperback edition.

Excerpt. Reprinted by permission. All rights reserved.
CHAPTER ONE

1

OBESITY. AMERICAS DISEASE

Ive been fat since I was a baby. My entire family is fat. Who knows if its our genes or our eating habits or a combination of both. I just know that being fat is a horrible way to have to live.

When I walk around at the mall with my kids, I have to admit that I look at people who are obese. It reminds me of how I looked and felt before the operation. Its amazing how many people there are out there suffering from this when there is something that can be done about it.

Disease (noun)-a specific illness or disorder characterized by a recognizable set of signs and symptoms, attributable to heredity, infection, diet, or environment. (Mosbys Medical, Nursing, and Allied Health Dictionary, Fifth Edition)

Contrary to popular opinion, obesity is not a personality disorder

resulting from a lack of individual willpower or self-control. Rather, it is a chronic disease characterized by the accumulation of excess body fat, which can be detrimental to health. Obesity is distinguished from overweight, which does not take body composition into consideration. Many athletes are overweight, but because their excess weight is predominantly comprised of muscle, not fat tissue, they are not obese.

SOME FACTS ABOUT OBESITY

The worldwide incidence of obesity is increasing. In 1998, the World Health Organization published Obesity. Preventing and Managing the Global Epidemic, which classified obesity as a growing epidemic. In the United States, obesity is the most common chronic disease, affecting one-third of all Americans, including children, and its prevalence has been steadily increasing for the past twenty years. In Europe, Australia, New Zealand, the Middle East, and the remaining portions of the Americas, the occurrence of obesity appears to be increasing and is now between 10 and 20 percent. The prevalence of obesity is still fairly low in China, Japan, and many countries in Africa.

During the 1970s, the National Center for Health Statistics found that approximately 45 percent of all adult Americans were overweight and 14 percent were obese. These figures stayed relatively constant for over a decade. Armed with this information at the beginning of the 1990s, the Department of Health and Human Resources published Healthy People 2000, a policy statement outlining our national public-health priorities and goals as we entered the new millennium. The initiatives recommended included. reducing the incidence of overweight and obesity by 20 percent. improving the diagnosis and treatment of several obesity-related conditions, such as diabetes, coronary artery disease (hardening of the arteries), hypertension (high blood pressure), and hyperlipidemia (elevated serum cholesterol and blood lipids). and increasing the amount of regular aerobic exercise engaged in by adults and children.

When the National Center for Health Statistics repeated its survey in the mid-1990s, it found that the prevalence of overweight had increased from 47 percent to 54 percent (57 million people), with the prevalence of obesity increasing from 15 to 22 percent (40 million people). Moreover, the prevalence of severe obesity rose from 4.5 percent to 8 percent of the population (Table 1-1). In 1995, the Institute of Medicine, in its publication Weighing the Options, referred to obesity as an epidemic. It is currently estimated that there are approximately 127 million overweight or obese adults in the United States. Of these, 30 million are obese with a Body Mass Index of 30 to 34, 23 million are severely obese, with a Body Mass Index of 35 to 39, and 10 million suffer from morbid or clinically severe obesity, with a Body Mass Index above 40. (We will discuss the Body Mass Index, or BMI, in Chapter 2.)

Among American youth, the prevalence of obesity has sky-rocketed during the past two decades, from just under 4 percent in children (six to eleven years) and 6 percent in teenagers (twelve

to nineteen years) to 15 percent in children and 15 percent in

adolescents. The prevalence of overweight is also extremely high among youth, being 40 percent in Native Americans, 30 percent in African Americans and Hispanics, 25 percent in whites, and 20 percent in Asian-Americans. As with adults, obesity in youth is associated with a number of medical problems, including type II diabetes, hypertension, asthma, sleep apnea, orthopedic problems, psychological problems, and negative social stigmata.

The exact cause of obesity remains unknown, but multiple factors, genetic and environmental, appear to contribute. Afflicting individuals of all ages, genders, races, and ethnic groups, obesity is associated with numerous medical problems and can have a relatively benign or malignant course. Obesity increases steadily with age in both men and women, and it is more common in women than men. It affects African-American and Mexican-American women more than Caucasians or Asian-Americans. A strong genetic linkage exists among the Pima Indians, who live in the Southwestern United States.

Children born to obese parents are more likely to become obese than children born to thin parents. Studies of adopted children have shown that their tendency toward obesity is more related to the weight of their birth parents than their adoptive parents. Furthermore, in studies of twins who were raised separately, the ultimate weight of each sibling tended to be more similar to each other than to that of their nonbiological, adopted family members. Nevertheless, it is likely that these genetic factors merely predispose individuals to obesity but do not guarantee its development. The disease becomes manifest only in the presence of the proper environmental triggers, which are related to several factors, including culture, diet, and physical activity.

Over the past few centuries, Western industrialized societies have placed a progressively greater value on thinness. Television and magazine advertisements equate beauty with thinness. By contrast, the robust bodies of the women glorified in masterpieces throughout the Middle Ages and Renaissance would be considered obese by our standards. On the other hand, in poorer, underdeveloped cultures, where famine is common, obesity is perceived as a sign of wealth and is therefore associated with greater sexual attractiveness.

Diet and exercise also affect the onset and development of obesity. High-fat diets, which are prevalent in wealthier, Western cultures, increase the prevalence of obesity. Modernization of society and the development of ever more advanced technology have led to a progressive decrease in physical activity. Inventions such as the automobile, elevator, escalator, remote control, and wireless communication all decrease the amount of physical activity we perform daily. Similarly, children reared on television, video games, and computers are more likely to become obese than those who exercise regularly.

Table 1-1. Increase in the Prevalence of Overweight and Obesity

in the United States

Weight Number

Category 1976-1980 1988-1994 1999-2000 Americans

Overweight 32 percent 32 percent 34 percent 64 million

Obese 10 percent 14 percent 16 percent 30 million

Severely Obese 3 percent 5 percent 9 percent 23 million

Morbid Obesity 2 percent 3 percent 5 percent 10 million

Total Population 47 percent 54 percent 64 percent 127 million

Classification based upon World Health Organization

American Obesity Association. www.aoa.org/subs/fastfacts/obesityUS.shtml

I am the father of a highly overweight adolescent girl, whose furure may include weight loss surgery (WLS). This book explained the many issues involved not only about the surgery itself, but, importantly, about many basic concepts about obesity (including very useful definitions and formulas about what constitutes obesity). The book also clearly discussed the critically important subject of the co-morbid conditions (diabetes II, high blood pressure, e.g.)that can be caused by obesity. The danger of obesity, as mainifested by the presence of these co-morbid conditions, was dramatically described. These issues, as well as the more technical description of the various types of WLS surgeries, was set forth in a manner that was easily understood by this lay person. I felt as if I was involved with a personal consultation with the physician/author, where the surgery was described, and the potential risks and side effects, and benefits, were being explained to me in a very understandable way. The book also contains an ending chapter of Frequently Asked Questions which provided an excellent review of the entire books contents, and could serve as a condensed version of the book should a reader just wish to address a certain issue, and have the answers presented quickly and directly. The book greatly advanced my understanding of the meaning and problems of obesity, and placed me (and ultimately my daughter)in a substantially more enlightened and informed position to make a potential decision about whether or not my daughter should undergo this surgery.

I depended on Dr. Flancbaum before and after my weight loss surgery in the same way that I depended upon Dr. Spock when my children were small. His book became a dog earred companion on my nightstand--well read and well loved. I would recommend it to anyone considering this surgery.

Dr. Flancbaum writes in a style that is easily understood by the layman. When the topic necessitates using medical language, he takes the time to explain exactly what it means in terms that anyone can understand. I have been researching WLS for about a year and have found this book to be the most helpful. I read the list of reasons to lose the weight and found that I can agree with just about all of them and some I had never even thought of in terms of myself. Thank you Dr. Flancbaum for this wonderful book.

I have read all the books I could find on the subject, since I am having surgery soon. Next to Barbara Thompsons book (Finding the thin person hiding inside you), this is the best. Easily understood, extremely helpful, takes you right through the whole process, and beyond. I love the amount of resources, and the recipes are GREAT. My husband read a lot of it too, so that he is more informed. Great sections to provide info for my employer as well. I got so involved in the reading, was sad when I was done.

This book is a must-read for anyone considering weight loss surgery or just exploring treatment options for morbid obesity. Its well-researched, authoritative and easy-to-read. The authors include one of the top WLS surgeons and a writer who had weight loss surgery, so they know what theyre talking about. Every question a reader might have is anticipated, and ably answered.

Recently, a friend of mine underwent Weight Loss Surgery. I gave her Dr. Flancbaums book as a gift so she could be well informed about the choice she was making. I never gave anyone anything that was so appreciated.

have read this book several times and it is the only book on this subject that you will need. I have read the others but this book has EVERYTHING you will need to know INCLUDING how to select a surgeon, and even how to get approval for your surgery. A MUST HAVE ITEM IF YOU ARE CONSIDERING WLS.

Weight Loss surgery is a tremendously scary subject but this book makes it easy to understand. It was helpful to know that there are different types of surgery that work differently.

The author is one of the leading surgeons in this area and one of the co-authors had the surgery herself.

The best part of the book were the many true-life accounts from real people whove had the surgery and found it changed their lives for the better. And the recipes were great, too.

If you are considering WLS and need to compare operations and get a basic overview, then this is the book for you. It covers pre-surgery questions as well as post-op concerns. I would recommend giving this book to your surgeon or primary care physician to inform them of the surgery. I work as a library assistant and recommend this book to my patrons. It has been the only book I have found that gives good basic coverage of the subject.

For those individuals who are morbidly obese defined as weighing more than 100 pounds above their ideal body weight or with a body mass index of 40 or higher (35 or higher with other illnesses such as diabetes or heart disease) weight loss, or bariatric, surgery can be a lifesaver. It is not, however, a miracle cure. It requires a skilled surgeon, support staff, and the patients lifelong adherence to diet, exercise, and vitamin supplementation. Expert bariatric surgeon Flancbaum (St. Lukes-Roosevelt Hosp., New York, and Columbia Univ.) has written an excellent and reassuring guide for those considering the surgery. He clearly outlines the surgical options, explaining each type along with its risks and possible complications, as well as expected outcomes. He also explains what to expect before, during, and after surgery, discussing selection of a surgeon, insurance coverage, the surgery itself, pain control, diet, and (rarely) reoperation. Resources and recipes are appended. For a nurses perspective on the same subject, see Michelle Boastens Weight Loss Surgery. Understanding and Overcoming Morbid Obesity (FBE Service Network, 2001). For all health collections. Anne C. Tomlin, Auburn Memorial Hosp. Lib., NY

Stedmans Medical Dictionary defines obesity as an abnormal increase in fat and simple obesity as resulting when caloric intake exceeds energy expenditure. Flancbaum, a surgeon with considerable experience in weight loss surgery, refers to obesity throughout as a chronic disease. Erica Manfred, one of his coauthors, had problems with obesity, was operated on by Flancbaum, and became an advocate for this method of treatment. They and their colleagues describe the various types of surgical procedures and counsel the prospective patient in selecting the most helpful one for her or him. They relay what to expect before and after the operation and what complications are possible. They recommend a healthier diet and more exercise after the surgery, and they advise on selecting a good surgeon and getting ones insurance company to pay for the operation. They conclude by listing sources of further information and providing many food recipes. William Beatty