Online Health Chat with Phillip R. Schauer, MD
June 17, 2016
Have you tried unsuccessfully to lose weight? Are you severely overweight? Have obesity-related medical issues such as diabetes and high blood pressure held you back from the life you want to lead? If so, Cleveland Clinic can help you take the first step to a healthier you. Join bariatric surgeon and leading expert in the field, Philip Schauer, MD, in a free online chat where he will answer your questions and address your concerns on surgical and non-surgical options for weight loss.
Obesity is defined as having a body mass index (BMI) of 30 to 39. Morbid obesity begins at a BMI of 40. It has been shown that the higher the BMI, the greater the risk for associated illnesses such as diabetes, hypertension, sleep apnea, high cholesterol, coronary artery disease and others. When morbidly obese individuals have one or more of the above diseases, their risk for death increases, and their quality of life is severely diminished.
Gaining weight and becoming obese or morbidly obese has created an epidemic not only in the United States, but also internationally. According to the Centers for Disease Control and Prevention, more than 2/3 of the US population is overweight and nearly 1/3 is obese or morbidly obese.
About the Speakers
Philip R. Schauer, MD, is chief of minimally invasive general surgery and director of the Cleveland Clinic Bariatric & Metabolic Institute. He is also professor of surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. He is immediate past president of the American Society for Metabolic and Bariatric Surgery.
After receiving his medical degree from the Baylor College of Medicine in Houston, Dr. Schauer completed his residency in surgery at the University of Texas, where he served as chief resident of general surgery. He then completed a fellowship in laparoscopic surgery at Duke University Medical Center in Durham, N.C. Prior to joining Cleveland Clinic in 2004, Dr. Schauer served as director of endoscopic surgery, director of bariatric surgery and director of the Mark Ravitch/Leon Hirsch Center for Minimally Invasive Surgery at the University of Pittsburgh Medical Center.
Dr. Schauer's clinical interests include surgery for severe obesity, minimally invasive surgery (laparoscopic) and gastrointestinal surgery. He has performed more than 4,000 operations for severe obesity. His research interests include the pathophysiology of obesity and related diseases; physiologic effects of laparoscopic surgery on postoperative injury and recovery; and outcomes of laparoscopic management of obesity, gastrointestinal diseases and hernias. He has also participated in the development of new minimally invasive, endoscopic and laparoscopic operations.
Let’s Chat About Weight Loss Treatment Options
Considering the Options
shanno2: What are the different types of bariatric surgery?
Philip_Schauer,_MD: If you’re considering surgery, below are the four surgical procedures:
- Roux-en-Y gastric bypass — We surgically create a small stomach pouch, bypassing the lower stomach so less food can be consumed.
- Sleeve gastrectomy — During this procedure, we reduce stomach capacity by stapling the stomach and removing two-thirds of the outer portion.
- Gastric banding — Here, we place an adjustable, inflatable silicone band around the upper stomach, making the stomach smaller. With this procedure, patients are allowed to return to work after about a week.
- Gastric plication — This procedure involves sewing one or more large folds in the stomach, reducing stomach volume about 70 percent. This makes the stomach hold less and may help you eat less.
There is also the intragastric balloon procedure during which intragastric balloon systems are implanted in the stomach via a 30-minute minimally invasive endoscopic outpatient procedure while the patient is under mild sedation. Once in place, the balloon devices are inflated with a sterile solution. The balloons partially fill the stomach to provide a feeling of satiety.
For patients who choose not to undergo surgery, a nonsurgical weight loss option is medical weight loss. Dieticians review each patient’s food and exercise history as an important part of the medical assessment. Psychologists help our patients address issues such as depression, eating disorders, and smoking and other addictions, helping our patients adopt healthy behaviors to achieve a healthy lifestyle. Exercise physiologists can create individualized exercise programs, including stress testing. Medication, such as appetite suppressants, can be prescribed to help with weight loss.
ladyinred: Can you explain what restriction and malabsorption mean in bariatric surgery?
Philip_Schauer,_MD: Restriction means reducing stomach volume. Smaller stomach volume usually results in reduced appetite and a greater sense of "fullness" after a small meal. Malabsorption means reducing the amount of calories that are absorbed from the intestines into the body. Most bariatric procedures today use the restriction concept as opposed to malabsorption. Patients with extreme obesity (more than 200 lbs. overweight) may benefit from malabsorption procedures such as the duodenal switch or biliopancreatic diversion (BPD). These are used in less than 2 percent of all bariatric cases.
Mscats: I am 65 plus, and the only way I can lose weight is to cut my calories to 800 to 1200/day, then I get tired of being hungry and it all comes back on. I have been doing this for 50 years now. I'm fairly active with doggie walking and dancing, but now my knees are starting to bother me.Philip_Schauer,_MD: Patients who are 65 or older may be eligible for bariatric surgery as well as weight loss medications. You may want to consider these options
Pre- and Post-Op
MikeyJames: How do I qualify for bariatric surgery?
Philip_Schauer,_MD: To qualify for surgery, a patient must be overweight and have a body mass index (BMI) of 35 or greater. A BMI of 35 equates to approximately 75 pounds overweight. Usually, patients have another co-morbidity associated with obesity, such as Type 2 diabetes, arthritis, sleep apnea, high blood pressure or a vascular condition. Patients with a lower BMI may also be considered. Just this month, the American Diabetes Association issued a joint statement supporting consideration for bariatric surgery in Type 2 diabetes patients with a BMI of 30 or greater (published in Diabetes Care).
swimmer19: What results should I expect from bariatric surgery?
Philip_Schauer,_MD: In terms of weight loss, patients can lose 50 percent to 90 percent of their excess weight. For sleeve gastronomy, patients typically lose 50 percent to 60 percent of their excess weight. For gastric bypass, there is a 60 percent to 90 percent loss of excess weight. Gastric banding is much less commonly used, and for that procedure we usually see a loss of 25 percent to 30 percent of excess weight. Many other weight-related medical conditions improve as well, including diabetes, high blood pressure, elevated cholesterol, sleep apnea, arthritis, gout, fatty liver disease, polycystic ovary syndrome (PCOS), asthma, migraine headaches and depression. A number of studies show that bariatric surgery can extend life span by reducing the risk of heart attack, stroke and cancer.
O9leo: What types of complications can happen after bariatric surgery?
Philip_Schauer,_MD: Since 98 percent of bariatric surgeries can now be performed using laparoscopic and minimally invasive techniques, complication rates have fallen dramatically. Complications of bariatric surgery are similar to those of gallbladder removal, hysterectomy and appendectomy. Some possible complications include bleeding (1 percent), blood clots (1 percent), minor infections (5 percent), major infections (1 percent) and mortality (0.1 percent). The risk of mortality after bariatric surgery is the same for gallbladder surgery – both are very rare. Patients must take vitamins after bariatric surgery; these include vitamin B12, iron, a multi-vitamin, vitamin D and calcium. If patients do not take these vitamins regularly, they may develop deficiencies including anemia, brittle bones and other less common problems.
JessaJ: What is the recovery time after surgery?
Philip_Schauer,_MD: Patients are usually in the hospital one to two days, occasionally three days for gastric and sleeve surgeries. Most patients are back to work within two to four weeks. We recommend starting an exercise program seven to 10 days after surgery.
Life After Surgery
meme9: What percentage of people gains the weight back after bariatric surgery?
Philip_Schauer,_MD: About 10 percent to 15 percent of patients will either have insufficient weight loss or regain a significant amount of weight. There may be other surgical options for these patients.
JessaJ: What will my diet be like after bariatric surgery?
Philip_Schauer,_MD: Patients start with a liquid diet for about one to two day after surgery. Then, they advance to soft foods such as applesauce and mashed potatoes for one to two weeks. At around four weeks, they may begin solid food such as meat and vegetables. The only foods one should avoid are junk foods with high calorie content, sugars and fat.
MikeyJames: Can bariatric surgery cure my Type 2 diabetes?
Philip_Schauer,_MD: We just published a study showing that approximately 30 percent of patients with Type 2 diabetes can achieve complete remission of their diabetes (STAMPEDE Study). Complete remission is not quite a cure, but very close. Complete remission means that a patient has achieved normal blood sugar for five years without the need for medications. Patients who have bariatric surgery within five years of a diagnosis of diabetes are more likely to achieve remission. Therefore, if a patient wants to achieve remission with surgery, it is important that they get surgery early within the course of the disease. Even in patients who do not achieve remission, many show improvement in not only their blood sugar control, but also cholesterol levels and quality of life. Most patients are able to reduce their medications, especially insulin, after surgery.
O9leo: Are the risks for bariatric surgery higher for someone with diabetes?
Philip_Schauer,_MD: In general, patients with diabetes do have a higher risk with healing issues, particularly if their blood sugar is out of control. However, if their blood sugar is managed well in advance of surgery, these complications can be reduced to a low level.
54558pdc: What is your opinion of HCG or HGH use along with diet and exercise to facilitate large weight loss?
Philip_Schauer,_MD: HCG (human chorionic gonadotropin) has not been shown by careful scientific analysis to produce long-term weight loss.
swolff: What are some techniques I could try for weight loss? I am not interested in bariatric surgery and have tried other weight loss products and have not seen any improvement.
Philip_Schauer,_MD: If you are more than 75 lbs. overweight, unfortunately there are no proven weight loss strategies with success rates greater than 10 percent. A recent study of people participating in the Biggest Loser TV show competition showed that although participants lost 100 lbs. or more, most regained all the weight they lost, or more, within six years. These contestants are the best dieters in the world and they could not keep the weight off, even when most of them continued to exercise one hour or more a day. Why couldn't they keep the weight off? Researchers discovered that when people lose a large amount of weight, their metabolism slows down dramatically. In other words, they burn fewer calories during simple daily actives. With dramatic weight loss, the hormones that control appetite are also revved up in a big way. That's why most diets fail; because over time, patients get very hungry. In a majority of people, the only treatment thus far that has counteracted this cycle of weight loss and regain is bariatric surgery.
jwilson: Do you recommend any over-the-counter weight loss pills?
Philip_Schauer,_MD: The Food and Drug Administration has recently approved several weight loss medications that have shown to be reasonably safe but only modestly effective. These prescription weight loss drugs include Qsymia (phentermine and topiramate extended-release), Contrave (naltrexone hydrochloride and bupropion hydrochloride extended-release tablets), Xenical (orlistat) and others. They generally result in a 5 percent to 10 percent loss of body weight. For example, a patient who weighs 200 lbs. will lose 10 to 20 lbs. on average. The medications must be continued because when they are stopped, the weight usually comes back. They can be helpful for many people, but for those who are extremely overweight, they are usually insufficient. Many over-the-counter "weight loss remedies" have no proven scientific effect.
54558pdc: Do you advocate a mostly plant-based diet for health and longevity?
Philip_Schauer,_MD: There is scientific evidence that a plant-based diet can reduce obesity. However, patients on a vegetarian diet must get adequate protein, which can sometimes be difficult. For some reason, only a small percentage of the population chooses a vegetarian diet, so it might not be a solution for the rest of us.
Cleveland Clinic Specific
ladyinred: Which Cleveland Clinic locations offer bariatric surgery?
Philip_Schauer,_MD: In Ohio, Cleveland Clinic offers surgical weight loss procedures at main campus, Hillcrest Hospital and Fairview Hospital. In addition, pre-surgery evaluation, follow-up and support services for a successful weight-loss journey are offered at Richard E. Jacobs Health Center and Twinsburg Family Health and Surgery Center. In Florida, Cleveland Clinic offers surgical weight loss procedures at Cleveland Clinic Florida – Weston. To learn more about our Ohio locations, visit: http://my.clevelandclinic.org/services/bariatric-and-metabolic-institute/locations.
To learn more about our Florida location, visit: http://my.clevelandclinic.org/florida/departments/digestive-diseases/bariatric.
shanno2: Does Cleveland Clinic offer any support programs for bariatric surgery patients?
Philip_Schauer,_MD: Yes. We have designed support groups for you to attend and resources to guide you through the entire weight loss surgery process. All pre- and post-operative weight loss surgery patients and their family members are welcome to join us.
For more information, please visit: http://my.clevelandclinic.org/services/bariatric-and-metabolic-institute/after-surgery.
Moderator: That is all the time we have for questions today. Thank you, Dr. Schauer, for taking the time to educate us about weight loss treatment options.
Philip_Schauer,_MD: Don't feel bad if you’re struggling to lose weight. It is VERY HARD. If the Biggest Loser champions struggle with regaining weight, then you have to ask yourself if maybe something other than diet and exercise can be an option. Good luck on your weight loss journey!
Moderator: On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.
Start your successful weight loss journey today through our free and convenient informational seminars, either online or in person. To register, visit clevelandclinic.org/firststep, or for questions, call Cleveland Clinic’s Bariatric & Metabolic Institute at 800.339.9829.
For More Information
At the Bariatric & Metabolic Institute, world-class surgeons, physicians, anesthesiologists, psychologists, counselors, dieticians and specialized nurses focus on your long-terms weight loss success, with the #1 bariatric surgery program in Ohio or a non-surgical medical weight loss treatment plan. Our bariatric surgeons perform more than 95 percent of all procedures with minimally invasive (laparoscopic) techniques, improving patients' healing and recovery time. Procedures include the Roux-en-Y gastric bypass, sleeve gastrectomy, gastric banding, gastric plication and the recently FDA- approved intragastric balloon, a non-surgical procedure.
Cleveland Clinic Health Information
Bariatric & Metabolic Institute: http://my.clevelandclinic.org/services/bariatric-and-metabolic-institute
Is Weight Loss Surgery Right for Me? http://pages.clevelandclinic.org/bariatric-weight-loss-program.html
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