Losing Weight Through Surgery

Angie Keith.

Baptist Health offers three surgical procedures to lessen appetites and decrease the amount of food absorbed. But it’s not a simple fix. Heavy lifting is ahead.

Story by Steve Kaufman

Photos by Andrea Hutchinson

Angie Keith was always active and athletic. The Starlight, Indiana, wife and mother had thrown the discus and put the shot in high school along with playing basketball and volleyball. She even played volleyball at Saint Mary-in-the-Woods College in Terre Haute.

Yet, she had a lifelong battle with weight gain, phasing in and out of diets, and by the age of 40 she weighed 250 pounds.

Two years ago, she signed up for the Medical Group Weight Loss program at Baptist Health Floyd in New Albany. Two years earlier, her husband Chris had gone into the program weighing 400 pounds and lost 150 of that.

Like her husband, Angie Keith had a procedure called the gastric sleeve performed by bariatric surgeon Dr. Lanny Gore.

“The sleeve involves removing about 85 percent of the stomach,” Gore explained, “leaving a long, narrow stomach about the size of a banana and the shape of a sleeve – thus the name.”

While Gore also performs two other surgical weight-loss procedures – gastric banding and gastric bypass – the sleeve has become his procedure of choice. “It simply works better than the others and is simpler to perform,” he said.

All three procedures are offered at Baptist Health Floyd – as well as at Baptist Health Louisville in St. Matthews by bariatric surgeon Dr. John Oldham – and there may be times when one over the other is recommended.

For example, said Gore, “For patients with severe insulin-dependent diabetes and other multiple medical problems associated with obesity, I might recommend bypass because it’s better at resolving insulin-dependent diabetes.”

However, he said, gastric bypass has some complications associated with it. Bypass is the technique of stapling the stomach, thus keeping foods from being completely absorbed. “Because of this malabsorption, some patients may be susceptible to malnutrition and vitamin deficiency – or more susceptible to ulcers – so it’s important for them not to smoke or take steroids or ibuprofen (Advil, Aleve, Motrin), and to be monitored for those things.”

At the end of the day, though, he said, “No bridges are burned. The patient can have a sleeve and, if there’s not enough weight loss, can be converted to a bypass.”

Dr. Lanny Gore.

Less Ghrelin

The sleeve not only reduces the size of the stomach, it also changes some of the hunger hormones in the body. “A hormone called ghrelin is secreted by stomach tissue, signaling to the brain that you’re hungry,” Gore said. “If you have less stomach, you have less ghrelin. That adds to the weight-loss success. You’re less hungry and have less of a drive to eat.”

Surprisingly, eating less is only one of the objectives. Another is getting patients off their medications. “Certain medications that treat diabetes, heart disease, depression and anxiety actually put on weight,” said Gore. “Insulin, for example, causes weight gain.”

No Magic Bullet

So did Keith simply show up on the morning of the procedure and walk out with a smaller stomach and less hunger-signaling hormones, off her meds, on her way to an easy 90-pound loss?

Not even close. There’s nothing easy about the process. To think of any of these procedures as some kind of a magic bullet that melts all of your excess weight and leaves you model-thin is to vastly underestimate the amount of energy, effort and motivation you have to put into the process. There are challenges that test patients’ determination, willpower and willingness to make lifestyle changes.

As Keith herself said, there’s a reason some people are so overweight. Eating has become an obsession with them. An 85 percent-smaller stomach is just the start.

“You’re less hungry,” she explained, “but people who are that overweight never before stopped eating just because they felt full. The triggers to eat don’t go away. Your appetite doesn’t go away.”

Or, as Gore put it, “After this surgery, you’ll want fewer donuts. But the objective is to eat no donuts.”

A New Mindset

Keith said it’s all part of the mental process that accompanies the surgery. “Your new mindset becomes that you can enjoy that bite of food without having to eat the whole thing,” she said. “You learn to actually enjoy what you’re putting in your mouth instead of just eating it because it’s there.”

She knows this because, prior to surgery, all patients have to undergo an extensive process of monthly seminars, educating themselves about the causes of overeating and obesity. They learn about the value of food and then undergo a period of supervised weight loss with a dietician and nurse. There are also extensive physical and even psychological exams.

“We want to make sure people understand this is a life-changing process,” said Gore. “The operations are great, but they won’t be successful if lifestyle changes aren’t made.”

“Pure diet alone has a 97 percent failure rate,” said Dr. Oldham. “The majority of those ‘Greatest Losers’ gained their weight back.”

In fact, even before surgery, Gore likes to see that there’s an understanding of what’s required and some minimal weight-loss progress. These measures aren’t only for the doctor’s sake. “Sometimes, insurance companies won’t pay for the operation if they see the patient is gaining weight during the supervised weight-loss period,” said Gore.

Candidates for the surgery also have to undergo a psychological evaluation to see if there are any issues that might interfere with their success – depression, anxiety, stress, bipolar disorder and coping problems.

Insurance Coverage

Some of this also has to do with the elephant that’s always in the medical room: insurance coverage. According to Gore, most insurance companies will only pay based on a patient’s body mass index (BMI), a simple calculation of height and weight.

“There generally has to be a BMI of 40 or greater to qualify for coverage,” he said. “Sometimes, they’ll cover a 35 BMI if there are ‘comorbidities’ – other obesity-related health problems.”

For context, Gore said that a “normal” BMI is 18.5 to 24.9; “overweight” is 25 to 29.9; and “obese” is more than 30. “If they’re over 40,” he said, “that’s considered ‘morbidly obese.’ ”

These numbers must be taken seriously since it often means related diabetes, heart disease, high blood pressure or greater-than-average orthopedic issues are at play.

“We call it weight-management,” he said, “but it’s really managing all of these medical problems associated with obesity.”

Insurance also requires the pre-surgical regimen of education, counseling and examination. Insurance coverage notwithstanding, however, the education and counseling become powerful pillars of success in the weeks and months after surgery.

“Getting prepared to change my eating habits was so important,” said Keith. “It’s hard to smell food and know you shouldn’t eat it.”

In addition to eating less, post-op patients abide by a rigid program that involves eating certain amounts of vegetables, fruits and proteins.

The Cravings Remain

“I can’t think of anything I still don’t crave,” said Keith, two years after her procedure. “But I know that if I take even a bite of bread, it will fill me up. Then I can’t eat the proteins I’m supposed to be having. Since you’re limited to only those little bits, you have to get in the proteins, fruits and vegetables. You won’t have room for the chips and donuts and chocolate. Junk food messes up your system in so many ways.”

In the successful procedures, which Gore said far outweigh the unsuccessful ones, a patient can expect to lose 70 percent of his or her excess weight with a sleeve or bypass. But, he said, that’s only a secondary goal.

“We’re upfront with people,” he said. “Don’t necessarily expect to get down to an ideal body weight. What you can expect is to live a healthier, fuller life and get off your medications. Play with your kids. Do your job better. Feel better about yourself.”

Angie Keith agreed.

“I went from a size 20 to a size 10,” she said. “People who’ve lost a lot of weight know that other people respond differently to you. They’re nicer, friendlier, complimentary. You just want more of that feeling good about yourself.”

Now, she said, “I carry myself differently, care more about myself, I’m not exhausted all the time, it’s not upsetting to go out somewhere. I don’t feel I have to hide in the house anymore.” VT

Baptist Health

Baptist Health Floyd

2125 State St., New Albany, 812.949.7151

Baptist Health Louisville

4000 Kresge Way, Louisville, 502.897.8100