bariatrics

Bariatrics is the branch of medicine that deals with the causes, prevention, and treatment of obesity.^[1] The term bariatrics was created around 1965,^[2] from the Greek root bar- ("weight," as in barometer), suffix -iatr ("treatment," as in pediatrics), and suffix -ic ("pertaining to"). The field encompasses dieting, exercise and behavioral therapy approaches to weight loss, as well as pharmacotherapy and surgery.

Overweight and obesity are rising medical problems of pandemic proportions.^[3][4] There are many detrimental health effects of obesity:^[5][6] Specifically, individuals with a Body Mass Index or BMI exceeding a healthy range have a much greater risk of a wide range of medical issues.^[7] These include heart disease, diabetes, many types of cancer, asthma, obstructive sleep apnea, chronic musculoskeletal problems, etc. There is also a clear effect of obesity on mortality, though this is not so clear for those who are overweight.^[8]

Diagnosis

Although not a direct measure of body fat, the Body Mass Index is widely adopted and promoted as a marker for excess body weight.^[9] However, it is not flawless: a very muscular person may be assessed as obese, and an elderly person with low body weight but high body fat (this can happen due to low muscle mass and bone density) may be assessed as healthy. Other markers for the evaluation of obesity include waist circumference (associated with central obesity), and a patient's risk factors for diseases and conditions associated with obesity.^[10] Besides these indirect methods, body fat can also be measured directly.

General aspects of treatment

People may find it difficult to lose weight on their own.^[11] Indeed, it is common for dieters to have tried a variety of fad diets only to find that they return to their original weight or potentially see a weight gain after a period of time.^[12]

Although diet, exercise, behavior therapy and anti-obesity drugs are first-line treatment,^[10] medical therapy for severe obesity has limited short-term success and almost nonexistent long-term success.^[13] Weight loss surgery generally results in greater weight loss than conventional treatment, and leads to improvements in quality of life and obesity related diseases such as hypertension and diabetes.^[14] The combination of approaches used may be tailored to each individual patient.^[15].

Weight-loss programs

Dietary counseling

Dietitians and nutritionists can advise patients as to what foods they should be eating to help ensure they are receiving enough vitamins and minerals. It is also important for a meal program to be formulated that satisfies the patient's caloric requirements to maintain good health while continuing to promote weight loss ^[16] . The diet cannot be so restrictive that the patient cannot maintain their efforts for the long term. Regular adjustment of diet plans to meet the changing needs of the patient is a key component ^[17].

Exercise

Exercise is important to any weight-loss program. Ramping up the patient's metabolism, burning calories, and improving the overall health of the body are all achievable through exercise ^[18] . Patients meet with Fitness Trainers and Exercise Physiologists who design custom programs to encourage safe exercise for each patient. As the patient progresses in physical capability these programs continue to be modified to promote maximum effectiveness without endangering the patient. Vigorous exercise is essential in helping an individual reduce the size of fat cells and to retain lean muscle mass.

Psychological approaches

Investigating and addressing a patients psychological state is a key component ^[19] . If there are psychological issues that are coming into play regarding the patient's health, they must be taken into consideration when customizing a weight loss plan for them. A positive attitude and mental focus are seen as essential to successfully achieving one's weight loss goals. Mental issues that lead a patient to engage in emotional eating or other negative behavior must be addressed. Eating behaviorists and health coaches will work with patients to help give them the tools they need to navigate this process. Occasionally, a more in depth psychological intervention is necessary. In these cases, the patient may require the help of a psychologist or psychiatrist (with the possibility of prescription drug therapy for treating mental health issues which may affect the patient's ability to adhere to the program.) ^[20] . Mental health is treated with equal important to physical health and they both play a role in a medical weight loss program.

Behaviorist therapy

Patients need to learn a new set of behaviors to encourage healthier choices in their daily routine ^[21]. Everything from lifestyle changes to the way a patient performs seemingly basic activities such as grocery shopping, cooking, and food planning are key to the long term success of the medical weight loss program. These sustainable and rewarding new behaviors lead to a healthier body and better quality of life.

Anti-obesity drugs

If diet and exercise are ineffective alone, anti-obesity drugs are a choice for some patients.^[22] Prescription weight loss drugs are recommended only for short-term use, and thus are of limited usefulness for extremely obese patients, who may need to reduce weight over months or years.

Surgical procedures

Before someone can become eligible for bariatric surgery, certain criteria must be met.^[13] The basic criteria are an understanding of the operation and the lifestyle changes the patient will need to make, and either:^[23]

• a body mass index (BMI) of 40 or more, which is about 45 kg (100 pounds) overweight for men and 35 kg (80 pounds) for women; or
• a BMI between 35 and 39.9 and a serious obesity-related health problem such as type 2 diabetes, heart disease, or severe sleep apnea (when breathing stops for short periods during sleep)

Past studies found that 10 percent to 20 percent of bariatric surgery patients had complications while they were in the hospital. In 2006, federal researchers found that 39.6 percent of patients had complications within 180 days of surgery. The most common complications are

• a composite of gastrointestinal symptoms including vomiting, diarrhea, dysphagia, and reflux (20%)
• anastomotic leaking (at the surgical connections between the stomach and the intestine) (12%)
• abdominal hernia (7%)
• and "infections" (6%).

About 7% of patients were readmitted to the hospital within 6 months to treat complications specific to the bariatric procedure.

There were 212 in-hospital deaths out of an estimated 104,702 adults who underwent obesity surgery in 2003, or a rate of 0.2 percent.^[24][25]

The prevalence of extreme obesity (body mass index > or = 40 kg/m²) in the United States in 2003-2004 was 2.8% in men and 6.9% in women.^[26] This suggests millions of people are in the weight range for potential therapy with bariatric surgery. Laparoscopic surgery has become an important addition to this field of surgery, and demand soars, amidst scientific and ethical questions.^[27] The number of Americans having weight-loss surgery more than quadrupled between 1998 and 2002—from 13,386 to 71,733—according to a study by the Agency for Healthcare Research and Quality.^[28]

There are a number of surgical options available to treat obesity, each with their advantages and pitfalls. In general, weight reduction can be accomplished, but one must consider operative risk (including mortality) and side effects. Usually, these procedures can be carried out safely.^[29] Procedures can be grouped in three main categories:^[30]

• predominantly malabsorptive procedures: although also reducing stomach size, these operations are based mainly on malabsorption.
  • Biliopancreatic Diversion (Scopinaro procedure - rare)
  • Jejuno-ileal bypass (no longer performed)
• predominantly restrictive procedures: this kind of surgery primarily reduces stomach size
  • Vertical Banded Gastroplasty (Mason procedure, stomach stapling)
  • Laparoscopic Adjustable Gastric Band (LAGB)(REALIZE Band - Lap Band)
  • Sleeve gastrectomy
  • Transoral Gastroplasty
• Mixed procedures: applying both techniques simultaneously
  • gastric bypass surgery, like Roux-en-Y gastric bypass
  • Sleeve gastrectomy with Duodenal Switch
  • Implantable Gastric Stimulation

References

External links

• VIDEO: How Bariatrics Has Changed Our Understanding of Type II Diabetes Dr. Daniel McKenna speaks at the University of Wisconsin School of Medicine and Public Health, 2008.
• MedLinePlus Portal on Weight Loss Surgery
• American Society for Metabolic & Bariatric Surgery
• American Society for Bariatric Physicians
• UCLA Metabolic and Bariatric Surgery Program