For some patients, it may be the last resort to improve their health. Anita Courcoulas, MD, Director of the UPMC Bariatric Center, explains who is a good candidate for weight loss surgery and what patients is should consider.

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– [Narrator] This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.

– [Tonia Caruso] For some patients, it may be the last resort to improve their health. So who’s a good candidate for weight loss surgery, and what are some of the things potential patients should consider? Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And joining us right now is Dr. Anita Courcoulas. She’s the director of the UPMC Bariatric Center. Thank you so much for joining us.

– [Dr. Anita Courcoulas] It’s a pleasure to be here today.

– [Tonia] So, in general, there are lots of weight loss surgeries that fall under bariatrics. How would you define for folks what bariatric surgery is in general?

– [Dr. Courcoulas] So, bariatric comes from the Greek word “baros,” which means weight, or burden, or pressure. And “atric” means treatment for. So it’s a treatment for weight options that are surgical.

– [Tonia] And so, in general, who is a good candidate for bariatric surgery?

– [Dr. Courcoulas] Candidates for bariatric surgery can range in age from as young as 14 in adolescent programs all the way up to age 65 or 70, depending upon someone’s particular health conditions. And then the surgical treatment is focused on people based upon their body mass index. And body mass index is a concept that how much of a person is there. The formula is your weight in kilograms divided by your height in meters squared, and there’s calculators for them online. And we, of course, figure it out for patients. But the guide is anyone with a body mass index between 35 and 40, which is class 2 obesity, if they have health conditions like Type 2 diabetes or sleep apnea, they’re candidates for bariatric surgery. Then, people a little higher with a body mass index of 40 and over, they’re candidates for bariatric surgery even if they don’t have any associated health conditions, but many do. And then, finally, in the class 1 obesity, lower body mass index, 30 to 35, there’s now a new indication for bariatric or metabolic surgery in people with class 1 obesity who have Type 2 diabetes that’s not well-controlled because we know now that these operations can treat diabetes as well as weight.

– [Tonia] And so, do you have to prove that you have tried to lose weight in the traditional manners, and it’s just not working? Where does the conversation go from there?

– [Dr. Courcoulas] I always tell patients that we’re the last resort, the surgeons; we’re never the first step. And bariatric treatment services are an entire spectrum, a series of steps that start with lifestyle, behavioral weight control, medications, devices, and then surgeries on the extreme. So, surgery’s at the end after people have tried everything else and it hasn’t worked. And, in fact, most major insurances require that you show that you’ve gone through those steps before surgery would be considered.

– [Tonia] Right. So I know there are lots of different kinds, in theory. And walk me through what some of those are.

– [Dr. Courcoulas] So, once you make the decision that you’re going to have surgery and you’ve already tried and failed nonsurgical options, when you make the decision about surgery, there are several procedures. But right now there are two common operations for bariatric surgery: the gastric bypass and the gastric sleeve. Less common now is the laparoscopic adjustable gastric banding operation. And then there’s a group of more complex operations that we’ll call malabsorptive operations that are done in less than 1% of the population. So, if you go with gastric bypass first, that is considered the gold standard weight loss operation, it’s been studied for more than 20 years. It’s a stomach and intestinal operation. So, with a gastric bypass, we divide the stomach and make a small stomach pouch about the size of an egg. And then we attach the small intestine to that small pouch, and then lower down, we reattach the intestines to itself. So what does that mean? We’re forcing people to eat less; their portion size is controlled. And they’re not absorbing everything that they eat; there’s some modest malabsorption. So that’s the gastric bypass operation. The gastric sleeve operation, which is a bit of a newer operation, more popular in the last eight years or so, is a stomach-only operation. Think of the stomach as a large bag, it’s a big sack that stretches. We all know this. What we do when we do a gastric sleeve is that we staple up the length of the whole stomach and we remove the left side, the so-called greater curvature of the stomach, which is the stretchy part of the stomach. And we leave the residual stomach as sort of a long, narrow tube. It almost looks like a long, banana-shaped stomach. So that operation then just restricts how much people can eat and probably also causes some hormone changes in the gut.

– [Tonia] Right, so that’s kind of the next question. So, when people come to see you, this is an operation not for the faint of heart. Can you talk about the approach at the UPMC Bariatric Center and everything that’s involved in this?

– [Dr. Courcoulas] Right, so it is a very long and involved process to come to have weight loss surgery, and I think that that’s a good thing because that process leads to a lot of education. So, I think step one is determining are you going to go the surgical route or the nonsurgical route? And if patients and their physicians decide that they’re going to be going down the surgical route, then they examine their different health conditions, and then we carry out what I think should be the basis of really all good treatment for procedures like this, which is we do shared decision-making. We explain to patients, like I just did very briefly, what are the operations, what’s involved, and hopefully we’ll cover some of the other changes with eating and other habits. And then we make a shared decision with the patient about which operation might be better for them. And then, of course, we follow through with any medical testing that would be necessary to get them prepared for surgery.

– [Tonia] And is it fair to say there’s a big psychological component to this as well?

– [Dr. Courcoulas] Certainly. It’s a multidisciplinary team that helps take care of a patient with bariatric surgery, and a big part of it is the psychosocial and behavioral aspect. So, everyone who undergoes weight loss surgery is going to have an in-depth psychological evaluation, really to assess their readiness for surgery and readiness for change, and also to make sure that they don’t have any other untreated conditions. And then that help is available to patients after surgery as well because we all know that once you have this kind of an operation, it’s really a lifelong change that has to be carried through.

– [Tonia] So, when folks are going through the psychological evaluation, what are some of the things there that make them not a good candidate?

– [Dr. Courcoulas] So who’s not a good candidate for bariatric surgery, from a psychological perspective? Anyone that has active substance or alcohol use problems should have those problems treated and consider surgery perhaps sometime in the future, when those problems have been well-treated. They could become a candidate, but they’ll be at higher risk for those problems afterwards. Anyone that has major depression with problems with considering suicide or other types of self-harm, those patients should have that treated before they consider bariatric surgery. Eating disorders is kind of an interesting one because one would think perhaps people with eating disorders would not be good candidates. And the data really shows that they are good candidates because it helps them control some of their eating problems, but they are at risk for developing recurrent eating disorder problems over their lifetime and needing additional help. So, there are really very few contraindications from a psychological perspective because, really, we’re there to treat the whole patient. And the prevalence of depression, really, in people that come for weight loss surgery is really quite high, and you can understand that because it becomes this vicious cycle.

– [Tonia] So this is a very serious and complex surgery, and there can be risks involved.

– [Dr. Courcoulas] You’re right. This is major surgery. And no surgical procedure has zero risk. But what’s interesting about these procedures is that because of the advancement of the approach with the laparoscopic or the small-incision approach, the safety of these operations has improved tremendously. So the chance of a major surgical problem after gastric bypass or gastric sleeve is about 1% to 2%, which is as low or lower than other common abdominal operations like having your gallbladder removed or having your appendix removed. So, yes, it’s major abdominal surgery, but the risks are on the low end of the spectrum with a 1% to 2% chance of a serious complication.

– [Tonia] Right, so let’s talk about if someone then does decide. They go through all the testing, it’s time to have the surgery. What happens immediately after surgery? Do you see weight loss instantly? What does that look like? And really, the person has to make some big adjustments.

– [Dr. Courcoulas] Weight loss starts early with these operations. If you look kind of at the trajectory of weight loss after either gastric bypass or sleeve, the slope of the weight loss is fast in the first three to six months. And people keep losing for 12 to 18 months. Most people have reached their lowest weight at around 18 to 24 months, their so-called weight nadir. And for gastric bypass, that would be losing about 35% of their starting weight. And for gastric sleeve, about 27% to 30%. So, big picture, these bariatric operations lead to about 30% weight loss. So I tell patients, one-third of your initial weight is going to come off in about 18 months. And the fastest weight loss is in that first six months.

– [Tonia] Is it fair to say you can’t just have the surgery and then be done? The patient has to put a lot of time and effort and really reshape how they eat, how they think about food, et cetera.

– [Dr. Courcoulas] Absolutely. The changes that are going to be necessary after surgery, we start to work on even before the operation. So, many insurance companies require 6 to 12 months of monitoring, or dieting, or lifestyle coaching before they’ll approve surgery. So that’s an opportunity to make changes: how often you eat, the types of foods that you eat, eliminating beverages with sugar in them, changing really people’s habits. And then immediately after surgery, just to adapt to the new anatomy because we’re changing the anatomy significantly, patients are on a liquid diet for two weeks, followed by a soft diet for a month. And then when they get to solid foods at six weeks, some foods don’t pass through well. So people that like really tough, well-done red meat are going to have trouble eating that. Soft Italian breads and pastas are sometimes difficult to pass through, and no amount of alcohol is considered safe. So, once they get through that postsurgical adaptation to solid food, then what we recommend is that they eat three small meals a day, and one or two healthy snacks if they need, and that they monitor their weight. So, the same philosophy applies to people after weight loss surgery as it does to anyone who’s watching their weight to try to maintain it.

– [Tonia] So alcohol at all, or just no alcohol for those first six weeks?

– [Dr. Courcoulas] So that’s a really good question. So there is data, it actually came from UPMC work, that alcohol use disorders increase after these operations, and about a 3% increase. And the people who are more at risk are people that may have had problems with alcohol before surgery. And it’s interesting because it’s more common after gastric bypass. So, now, there’s clear studies that show that alcohol is absorbed rapidly after gastric bypass, probably after gastric sleeve, such that a single alcoholic beverage after a gastric bypass is like having seven drinks. So we tell patients that no amount of alcohol is safe.

– [Tonia] What are some of these healthy meals that they are having? The three small meals a day: What’s an example?

– [Dr. Courcoulas] We try to keep the meals based on, “Eat your protein first.” Protein is sort of the highest-quality nutrient, it sort of takes up the most room in these small stomachs, so it’s best to eat your protein first. So a good breakfast would be cottage cheese and a little bit of fruit. A good lunch might be some grilled chicken and some vegetables, the same types of things for dinner. So we really stress protein intake and keeping foods kind of well-rounded, staying away from processed foods. Again, very similar to what people would be doing outside of surgery when they’re trying to watch their weight.

– [Tonia] The role of exercise afterwards, is that something that’s mandated for everybody?

– [Dr. Courcoulas] So, we provide guidance about exercise, which is consistent with the national guidance for exercise. And I think that most experts in the field of weight treatment would say that exercise is very, very important for weight maintenance. It’s also important for maintaining your lean body mass. And we know when people lose a lot of weight very rapidly like they do after weight loss surgery, that they do in part lose some of their muscle mass in addition to their fat mass. So, weight training is important for that, and then aerobic exercise is important, really for weight maintenance. So, we get people really starting to exercise immediately after surgery. Just taking a 10-minute walk twice a day is going to be a great way to start right after surgery.

– [Tonia] And as you were talking about that, it got me thinking. So, if you’re losing all this weight, then often you might have excess skin. And what’s sort of that next step for patients?

– [Dr. Courcoulas] Yeah, so there’s a program at UPMC called Life After Weight Loss. And UPMC’s really been a leader in the reconstructive aspects to post-bariatric surgery patients. So I would say that about 40% to 50% of people do decide to pursue some kind of corrective or cosmetic surgery. And where skin becomes a problem is very individually dependent. So, people that carry their weight in their abdomen may have skin in their lower abdomen. And so, it’s common that people about a year and a half to two years after they’ve lost their weight and they’re at a nice plateau, and their weight is stable, and they’re healthy, then they could pursue some of this corrective and cosmetic surgery to sort of remove that extra skin envelope.

– [Tonia] How long would you say it is before someone is their “new normal”? That they’ve gone through the surgery, they’ve gone through the recovery, when is the new normal?

– [Dr. Courcoulas] About two years after surgery. Most people have achieved their lowest weight, they’re working on weight maintenance, they’re pursuing any corrective or cosmetic surgery.

– [Tonia] And they don’t just have their surgery and then say goodbye to you. They’re coming back to you that entire period.

– [Dr. Courcoulas] That’s the nicest thing about what I think we do, which is that we don’t operate on people and then don’t get to see them again. Bariatric patients are lifelong patients with our practice. So, in the year that they have their surgery, we see them about 6 to 10 times. So every month to every other month. In the second year after surgery, we see them twice, and then we should be seeing them every single year after that because it’s really important to monitor them for problems that would come up over time, like micronutrient deficiencies, weight regain, diabetes coming back.

– [Tonia] Can someone self-refer, or do you have to be referred to the center by a physician?

– [Dr. Courcoulas] Patients can self-refer. Insurance may mandate that certain people have a referral, but the vast majority of patients that we see are self-referred.

– [Tonia] You already mentioned, you need to go through all of these steps for insurance to cover it. When you mentioned helping people in case they put the weight back on, how common is that, and what leads to that?

– [Dr. Courcoulas] So if you look at the way people lose weight after bariatric surgery, everybody loses in the same path for about the first six to eight months. And then people diverge. Some people stop losing sooner and lose less; some people keep losing for longer and lose more. Most people are at their lowest weight, or what we call their weight nadir, at around two years. And then between year three and four, about 15% to 20% of people can begin to regain a little bit of weight. Most people regain in the 8- to 10-pound range, and I think that’s a really frightening time for patients that have gone through all this, done everything they’re supposed to do, kept their weight off for the first couple of years, and then feel themselves creeping up. And those are the people that we really want to see back to make sure that we can provide them with all the resources that they need to continue to maintain their weight. So the risk of weight regains starts at about year two to three, and about 15% to 20% of people can regain about eight to 10 pounds.

– [Tonia] What have been some of your biggest success stories? Or do you just find the success that diabetes has gone away and hypertension has gone?

– [Dr. Courcoulas] Right. Well, so, I can think of so many great successes. I operated in one of the largest patients ever many, many years ago, before even the laparoscopic surgical approach. And he was a young man who had a really high body mass index in the 80s. And after his surgery, he was able to do things that he could never do before. He could go to baseball games, he could go to the amusement park. And that’s a very rewarding change, to take a young person whose life is really limited by their physical limitations from their obesity, and see them be able to really, really enjoy their life. But you raised the diabetes issue, and we haven’t talked much about that. The whole field of bariatric surgery a number of years ago was renamed metabolic surgery. And it was in part to bring attention to the fact that in addition to durable significant weight loss of 30%, Type 2 diabetes is improved in 60% to 80% of people after weight loss surgery. So it’s a treatment for Type 2 diabetes, which is phenomenally interesting because there’s something about the operation that we don’t completely understand, but there’s a whole field of work looking at different theories as to why in addition to the weight loss, it’s not only the weight loss that leads to the Type 2 diabetes improvement. It’s probably like a gut hormone change that’s created by the surgery that leads to diabetes improving. So people can come off their diabetes medications. They can reduce the amount of insulin. And then, beyond that, when that happens, people who have weight loss surgery, especially people with diabetes, they have fewer heart attacks and stroke, and they live longer.

– [Tonia] How did you end up choosing this as your field?

– [Dr. Courcoulas] I think the field kind of chose me in a way. I’ve been at UPMC for over 30 years, and I started doing bariatric surgery right at the very beginning of the experience, when it was a really new field and the procedures were sort of untested and very new. And I just found the surgery so challenging technically, and then there were so many unanswered questions about long-term outcomes, benefits and risks in the long term. And how can we make the treatment safer and better? So it became also a research interest of mine. So, it’s been really rewarding to have all those aspects come together.

– [Tonia] And, like everything else, it has evolved over the years.

– [Dr. Courcoulas] If you look at surgical subspecialties, obviously this is my area of expertise. I don’t think a field has evolved as much as this one has in the last 15 years. And by that, I mean, when I started in 1988, there were very few high-quality long-term studies where I could really show you evidence for the statements I just made. Like, we improve survival, we reduce diabetes, we reduce heart attacks and strokes. And now, there are randomized studies, there’s large observational studies. So, the data is really accumulating, and it’s really high-quality. And I think that’s really important when you’re educating patients because I think it’s important to translate that information into what does this mean for me? What are the benefits, and what are the risks?

– [Tonia] And you mentioned, folks who come to see you, not everyone wants or will get surgery. You offer some other weight loss options. Can you talk a little bit about those?

– [Dr. Courcoulas] Correct. So we’re known for our bariatric surgery, but we have a program that enhances the entire spectrum. So, we start with behavioral weight control, coaching, lifestyle. We can add, then, medications. I think another really interesting area of growth in this field is that there’s a whole new class of medications. They were really medications to treat diabetes, the injectable medications. They’re called GLP1 agonists, they’re advertised a lot. Those are also now weight loss medications. And recent studies in the last couple of years have shown that people can lose as much as 15% of their weight with those medications. So, we have a lifestyle program, a medication program, and then we have a device program. So, we have the whole spectrum. So, if someone says, I am not interested in surgery, I don’t want to even consider it, then we have a whole set of services and tools to help people lose weight without surgery.

– [Tonia] What do you want to say to people, someone who might be thinking about this, about, really, you touched on this, there’s really a holistic approach. And what should their mindset be coming in to see you or making an appointment?

– [Dr. Courcoulas] The mindset that I have is that when you come to speak to a surgeon, it doesn’t mean that you’re going to necessarily undergo an operation, right? Surgeons are there to provide information about the surgical options in part, but in our case, we can provide information about nonsurgical options to help people with their obesity. So I would say, gather the information. This is a process. And I tell every patient that I see in my office, this is not a decision that you should take lightly, this isn’t a decision that I should take lightly. It takes time, it takes steps, it takes education, and sometimes it takes trying these steps leading up to surgery before considering surgery. So I think my big message is gather as much information as you can, explore the options.

– [Tonia] What is your favorite thing about your job?

– [Dr. Courcoulas] Oh, boy. That’s a tough one. I mean, I think I said it earlier, I think it’s been tremendous to sort of see the evolution of the field over time, to see how far it’s come in terms of the improvement in the safety of surgery and the improvement in the amount of information we have about the long-term outcomes; that’s been rewarding. Seeing that you can affect people’s lives is really, really rewarding. When patients send a friend or a family member to our group, I think we all feel very content to know that they would trust a friend or family member with us.

– [Tonia] Well, Dr. Anita Courcoulas, thank you so much for coming in and spending time with us today. Some good information, we appreciate your time.

– [Dr. Courcoulas] Thank you so much.

– [Tonia] I’m Tonia Caruso; thank you for joining us. This is UPMC HealthBeat.

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