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Recently I started writing a series on training obese clients that has evolved into much more than I had expected.  In Part I of this series I described the categorization and classification of obesity, in Part II I shared some resources and very important concepts about obesity management, in Part III I discussed how I could go about training those with a BMI greater than 35.  In Part IV I talked about the training I would use for those with a BMI below 35, but still above 30.

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Today I want to begin talking about nutrition for those suffering with obesity.  However, discussions about nutrition and the obese client would be lacking without at least a brief mention of gastric bypass surgery.  So today I will cover that, and then I should have only one more post on nutrition related stuff that should wrap things up.

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Now before you tune out because you think gastric bypass has nothing to do with you or your clients, trust me when I say you need to hear this.  Even if you are not a believer in this type of surgery, chances are that if you train obese clients long enough you’ll run across one that is considering or has had some form of bariatric surgery.  If or when that happens, you should be informed with the best possible information so that you can provide appropriate guidance and support.

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And even if you never happen to personally train someone who has had this surgery or wants to have this surgery, it will help to inform you that this surgery is by no means “the easy way out” that some may perceive it to be.  I feel that fitness professionals should make an effort to at least understand the basics bariatric surgery as this is part of weight management for many (even if you don’t agree with it).  So…let’s get at it!

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Laproscopic Banding

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The first and least invasive type of bariatric surgery is simply called laproscopic adjustable banding (popularly known as the Lap-Band).  With this surgery, a small adjustable band is inserted through very small incisions and placed laproscopically around the top of the stomach.  This limits the amount of food that can enter the stomach and thereby causes people to lose weight.  This is called a restrictive surgery because of this limitation.  People that have had this surgery also have a port below the skin in the abdomen that allows them to have saline added or removed to make the band tighter or looser depending on their needs.  Of all of the bariatric surgeries available, this is the least invasive and it has the smallest surgical risk.  It is also removable so if some decides it isn’t right for them, the band can be removed.

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From the data I’ve seen at conferences and from hearing surgeons talk about this procedure, it seems as though the weight losses seldom meet the expectations of the patient, weight is almost fully regained in many cases, and the band is frequently removed.  As a result, it seems that gastic banding is losing favor in some circles.  One of the things that strikes me as most interesting about banding is that we’re basically providing a removable (temporary) treatment for what I’ve suggested is a chronic condition.  If removing treatment results in the return of the condition, it might be wise to question the use of temporary solutions.  Of course, I’m not saying that there isn’t a place for banding (they often use them when they feel such a surgery is warranted in children – don’t even get me going here), but the data I have seen on them is generally not promising.  I won’t ignore that some have great success with these, but I think this is the exception rather than the rule.

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Sleeve Gastrectomy

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The sleeve gastrectomy is also a laproscopic procedure in which part of the stomach is actually cut off and removed.  The remaining section of the stomach is actually quite small which limits the amount of food a person can consume and allows them to lose weight.  This too qualifies as a restrictive procedure and it is only slightly more risky than the laproscopic band, but it is permanent.  This surgery generally has greater weight losses than laproscopic banding and (from what I’ve seen) is better in terms of preventing weight regain.  However, the results aren’t as great as with the “gold standard” gastric bypass surgery we’ll talk about next.

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Roux En Y Gastric Bypass

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While there have been many versions of this surgery over the years, the roux en y gastric bypass is now the gold standard against which all bariatric surgical procedures are compared.  In this surgery, like the sleeve gastrectomy, part of the stomach is removed to limit the amount of food that can be consumed except that with the sleeve the stomach can hold 150ml of food while this procedure typically limits food to about 30ml (two tablespoons).  Then, the small intestine is cut part of the way along and attached to the new stomach pouch.  This prevents much of the food that is ingested from being absorbed by the body resulting in even greater weight loss.  For this reason, this procedure is classified as a restrictive and malabsorptive procedure.  It is obviously not reversable.

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The highlights of this procedure is that the weight loss is typically greater than the two previously mentioned.  It also does have some greater weight loss maintenance than the other two as well.  What is more important though (and probably why this procedure gets so much appreciation from physicians and patients) is that it can be an almost instant cure for Type 2 Diabetes.  In other words, you could be a Type 2 Diabetic today, get the surgery, and then you’re pretty much off your meds.  There is even some talk about doing this procedure on non-obese Diabetics whose disease is really difficult to control, but I’m not sure whether this will pan out.

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I want to be clear here with my own perspective in that I don’t think the data on this is 100% reliable as the follow up isn’t the best in many of these studies and some are not randomized controlled trials.  The big issue with follow up is that the people that are probably most likely to make themselves available for this are those that are doing well.  Those who aren’t probably don’t want to be followed up.  For this reason, I think that perhaps this surgery may be good for some Diabetics, but I’m cautiously optimistic.

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I also want to be clear about some of the downsides.  First, the surgical risk is higher with this than the other surgeries I’ve mentioned.  I don’t think it is terrible, but worth noting.  And because the surgery is malabsorptive, there are some major nutrient deficiencies that occur with many patients.  Of course, they are typically told to take certain vitamin and mineral supplements for the rest of their lives following surgery, but some are non-compliant with this and they end up with serious issues.  There are also other issues like increased rates of suicide, divorce, addiction, and other issues following this surgery that make it important to weigh the risks and rewards of this procedure.

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Biliopancreatic Diversion with Duodenal Switch

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This procedure is the most intensive procedure of them all and it is only usually considered for the very obese patient.  Generally it begins with the restrictive component where the stomach is reduced very much like the sleeve gastrectomy.  From there, it becomes difficult for me to describe so I’ll just use a video to illustrate for those who are interested.

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This procedure can be done in two parts with more severely obese patients.  In the first procedure, the restrictive part is done to reduce the size of the stomach.  Then, after the patient has lost some weight and is less of a surgical risk, the surgeon can go back in and add the malabsorptive element to continue the weight loss.  While the roux en y is the gold standard, the duodenal switch can also be used for those who have regained weight after this procedure as it is pretty much the only thing left in the surgical arsenal.

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As you might guess, the risks for this surgery are higher than those associated with any of the previous, but the results are also usually pretty darn good too.  Ultimately, the more risky the surgery, the greater the potential weight loss.  However, with all surgical procedures you really have to look at the pros and potential cons of this operation.  Similar to gastric bypass, there are many possible issues that can present.

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I honestly can’t tell you what to do in the case of a client that has had any of the above surgeries because they’ll all present differently.  My primary goal with this post was to bring a basic understanding of surgical weight management to the fitness world in the hopes that it will begin to build a bridge between fitness and physicians as we attempt to understand each other’s methods.

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I can tell you that without lifestyle modification any of the above surgeries can result in weight regain and the reappearance of obesity related issues like Diabetes, hypertension, and so on (remember what I said about obesity being a chronic condition?).  So even if we don’t agree with the methods, it is important that we be prepared to partner with people that have had them (and their physicians) because many family doctors are at a loss for what to do with these patients.  By having at least some understanding, you will be in a position to help.

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If you want more information on this topic I would highly recommend you take the time out to read Dr. Sharma’s series called Why I Support Bariatric Surgery.

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There are 5 parts and they are all fantastic.  They can be found here. 1, 2, 3, 4, 5.

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But before you think I’m totally going to allow only the positives to be highlighted here, Dr. Sharma wrote a 5 part follow up series called Why Bariatric Surgery Can Fail which I think is also solid and provides more information than I can possibly cover here in this single post.

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You can read this series here. 1, 2, 3, 4, 5.

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In the end, I guess I didn’t teach you much about how to handle these clients, but being aware of them, what they’ve had done, and the potential issues can only point you in the right direction.  If nothing else, you probably just learned something you never thought you’d learn in this industry. 

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If this article helped you in any way or you think it may help others you know, please share it on Facebook, Twitter, Google+, or whatever social media outlet is your addiction.  Or if you’re lazy like me just hit the “like” button or +1 button.  Thanks.

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PS: I know I possibly covered a lot of unfamiliar ground here so if you’ve got questions, drop ‘em below.

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PPS: Check out Part VI of this series HERE.

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Yesterday I attended the 6th Annual McMaster Bariatric Conference put on by the Centre for Minimal Access Surgery.  The topic was obesity management and talks ranged included those discussing the risks associated with obesity as well as lifestyle, pharmacological, and surgical management of this condition.

 like myself so interested in the topic of obesity?  For me, body weight is more of a continuum than a distinct divide between lean and obese.  All of us are somewhere on that continuum and (based on statistics) most of us are more towards the obese end than the other.   

Moreover, almost 95% of people who lose a significant amount of weight by the usual commercial weight loss practices (i.e., get ripped in 12 weeks) will gain it back plus some additional pounds leading us closer and closer to being la rger and larger throughout our lives.  And I still believe that whether you’re 20 pounds away from your fat loss goal or 100 we are all subject to the same environment, marketing, and dieting practices.  While surgery (if we use it at all) might be used for the most severe cases, conservative management can probably benefit anyone looking to lose body fat permanently.

Here are a few notes I took at the conference that I’ll likely expand upon in an upcoming post:

- If your BMI is over 25 you are considered overweight.  If your BMI is over 30 you are considered obese (Class I).  OVer 35 is Class II obesity.  Over 40 is Class III.

- BMI does not account for muscle mass so lifters may not be truly obese.  However, if they are carrying excess fat around their midsection, there is still reason for concern.

- The total number of obese people in North America is levelling off.  However, the number of people with class 3 obesity is growing.

- Current statistics on obesity likely underestimate the number of obese because people with normal weight obesity (normal body weight, but high fat percentage) is not included.

- Normal weight obesity results in metabolic issues similar to having a BMI over 30.  These are the people we call “skinny-fat”

- The only group in North America in which obesity rates are still climbing is 6-9 year olds.

- Studies have shown that parents and phsyicians are unable to accurately determine when a child is obese.  In some studies as few as 18% of parents thought their children had weight problems when they were clinically obese.  Doctors didn’t fair much better.  You can’t treat what you don’t diagnose. 

- The best predictor for adult obesity is childhood obesity.

- 90% of obese kids have a lipid abnormility (high cholesterol or triglycerides) and 50% have hyperinsulinemia.

- 20% of obese children are likely to have a heart attack and 15% will have Diabetes by age 38.

- Obesity is second only to smoking as a risk factor for Cancer.

- Some people have now created the term “Diabesity” because of the strong link between Diabetes and obesity.

- Obesity is a chronic condition very much like hypertension.  When treatment is stopped, the condition reappears.

- Body weight is related more to “screen time” than to the amount of exercise you do.  In other words, turn off the computer and television.

- Frequency of activity breaks is related to weight loss more than total amount of activity time.

- A 5-10% body weight reduction shows improvements in lipid profiles, blood sugars, and various other obesity related disorders.  This should be the goal when health is the primary outcome.

- 50% of people on a suitable lifestyle plan (exercise + diet + behaviour modification) can maintain 5% loss at one year.  In other words, you need to treat only two people to achieve this result with one.

- 20% of people on lifestyle plan can maintain 10% at one year.  Need to treat 5 people to get one who does this.

- Lifestyle alone tends to maintain 5% weight loss, lifestyle + pharmacology allows 15%, and gastric bypass around 50% weight loss.

- People who do not lose weight while following a 900 calore per day VLCD (very low calorie diet) will likely not lose weight effectively with surgery.  Possibly due to genetics?

- Although many blame obesity on genetics, the number of genetic mutations that actually occur to cause such conditions likely only accounts for 5% of obese people.

- The most common form of weight loss surgery is the Roux en y Gastric Bypass.  The stomach is reduced to a small pouch (about 2 tablespoons) and the pouch is attached at a point further down to bypass the first part of the small intestine.  The procedure is restrictive (small stomach) and malabsorptive (bypassing absorption in the intestine).

- Gastric banding is an alternative type of surgery where an inflatable band is placed around the stomach.  This surgery is reversible, but gastric bypass is not.

- Gastric bypass is significantly more effective for weight loss than banding.

- Bypass surgery results in an almost immediate remission of Type II Diabetes in most patients.

- Pregnancy is discouraged for 2 years after weight loss surgery.

- After surgery a patient must never consume carbonated beverages again.

- Bariatric surgery requires supplementation to prevent nutrient deficiencies although they are still common.

- Depending on where the surgery is done, 3-40% of bands require removal (usually due to weight regain).

- In patients with BMI over 40 gastric bypass has a 20-35% failure rate at 10 years (again due to weight regain)

- Effectiveness of revision surgery is equally as high, but complications (leaks, infections, etc) are 2.5 times more common.

- Gastric bypass is also more effective than banding in children.  The youngest to date was age 9.

- Craniopharyngioma is a condition of the pituitary that can cause uncontrollable eating in children.  Surgery helps maintain weight.

- One presenter said that gastric bypass was “the real solution to childhood obesity because nothing else really works”.  He was a giant dink.

- Bariatric surgery is the most studied surgery in history.  The screening for this surgery is intense and includes surgeon, nutritionist, social worker, and phsychiatric consults to ensure suitable mental status to maintain weight loss.  Tests for obstructive sleep apnea and other issues are common as well.  Heart and brain surgery has much less screening.

- Patients who are not compliant with managing blood sugars or taking meds probably won’t follow post surgical instructions.

- ADHD has a strong relationship to obesity.  Sometimes treating ADHD causes patients to lose weight.

- Binge Eating Disorder is now officially a diagnosis in the DSM.

- Depression can cause cravings for carbohydrates which increase serotonin.  Screen and treat for depression when necessary.

- The incedence of previous sexual abuse is very high in obesity.

- The higher the BMI, the greater chance of having a history of mental health issues.

- There are increased rates of divorce after bariatric surgery.  Assessment makes sure support systems are secure prior to sugery.

My hope is that these points will make for a great discussion.  Thoughts?