graphical intervention on David , by Michelangelo / Laura DaviñaIn the course of 2001, Olívia no longer saw the 85 kilograms that were appropriate for someone as tall as she – she is 1.80 meters tall – on the scales; she gained weight until at one point she weighed 167 kilos. She felt terrible hunger pangs because of the drugs she was taking to control an illness that caused her excruciating pain, depression, and made it impossible for her to walk. She no longer fitted into the medical exam equipment and four years after the onset of her health problems, the neurologist predicted that she would not survive for more than six months because she was so overweight. The team of psychologists responsible for her medical evaluation gave her permission to undergo bariatric surgery, a stomach reduction procedure used as a last resource to treat obesity. Seen by many as a form of vanity, this surgical procedure has been proven to provide major benefits, in addition to weight loss. For example, the procedure cures type 2 diabetes and reduces the propensity to cancer. But it is not an easy solution. On the contrary – it condemns the patient to deal with permanent life style changes.
Morbid obesity, where the Body Mass Index or BMI (weight divided by the height squared) is higher than 40 increased by 255% in Brazil from 1974 to 2003, affecting 0.64% of the adult population. This is a modest percentage when compared to the 4.9% found in the United States; however, over 600 thousand Brazilians are so overweight that this results in complications such as type 2 diabetes, and serious orthopedic and cardiovascular problems. This evaluation is included in a study conducted by Isabella Oliveira, under the coordination of Leonor Pacheco, a researcher from the University of Brasília (UnB). The study showed that the prevalence of obesity – BMI higher than 30 – increased from 4.4% in 1974/1975 to 11.1% in 2002/2003. The proportion of obese people is higher among women (13% according to the latest survey, conducted in 2002/2003) than among men (8.8%), but the BMI grew at a faster pace among men in the last three decades. Olivia’s weight – at one point her BMI was equivalent to 51.5 – became so unbearable that she broke her ankle. She went on a very strict diet and managed to lose 20 kilos, which was not enough to lessen the damage to her health, caused by the obesity.
Bariatric surgery has proven to be the most efficient weight loss option for people who have unsuccessfully tried all the other ways to lose weight. Brazil ranks second, after the United States, in terms of the number of bariatric surgeries. In Brazil, bariatric surgery was regulated by the Brazilian National Health System (SUS) in 1999, in compliance with international guidelines. Surgical intervention is recommended for morbidly obese patients and for obese ones (BMI between 35 and 40) with severe complications associated with obesity, such as breathlessness, diabetes, and high blood pressure. Leonor and Isabella’s article, published in Obesity Surgery, was co-authored by Lilian Peters, from the Ministry of Health, and by Wolney Conde, from the Department of Nutrition of the University of São Paulo (USP). The article states that more than 10 thousand bariatric surgeries were conducted in the period from 1999 to 2006 under the SUS, and half of these surgeries took place in the Southeast Region. The number of these surgeries has increased every year, but so far only 0.29% of the estimated number of morbidly obese patients in Brazil have undergone the procedure.
The long waiting list of patients to be operated under the SUS means that they might have to wait for years, but even the number of patients who can afford to pay for the surgery – a procedure that costs an average of 20 thousand reais for surgical material alone – is limited. According to Dr. José Carlos Pareja, from the Laboratory for Studies on Metabolism and Diabetes/Limed, of the State University of Campinas/Unicamp), Brazil now has some 600 officially accredited surgeons trained in this procedure. Even when one adds up the public and private surgical care, only approximately 1% of the obese who need to undergo surgery have access to the 25 thousand procedures done every year. In his opinion, waiting lines are not the issue. “We used to have a waiting line at Unicamp and between 3% and 4% of the patients died while waiting in line”, he says; “now, our mortality rate is zero”. The latest strategy is to set up preparatory groups in which patients have to go to the university every week and lose weight during this period. In the course of three to four months, they get information, lose weight and have the guarantee that they will undergo the surgical procedure at the end of this period.
The most common type of bariatric surgery, with proven successful results over many years, focuses on the separation of the stomach into two parts. The smaller part, corresponding to approximately 5% of the total size, maintains the function of taking in the food. The bigger part of the stomach remains in the abdomen and produces the digestive juices, which are then taken to the intestine – which is slightly shortened. After undergoing the surgery, patients have to change their eating habits: they have to eat smaller portions and chew their food very well. Rebellious patients suffer, because a silicone ring limits the food intake into the reduced stomach.
Some patients who undergo the surgery have a lack of essential nutrients like iron, zinc and potassium, because their stomach has become smaller and the intestines shorter. Other serious complications can also appear, such as gall bladder stones and problems in the isolated part of the stomach, because it becomes more difficult to examine the stomach by using commonly used techniques such as laparoscopy. This is why doctors prefer to use a less traumatic procedure on patients already debilitated by obesity: vertical gastrectomy, which only removes approximately 60% of the stomach. Prior to deciding on the surgical procedure, surgeon João Luiz Azevedo, from the Federal University of São Paulo (Unifesp), decided to compare it to the established technique to see whether the vertical gastrectomy was indeed safer. “Most of the published findings in this field are reports on series of cases”, he criticizes. “Science demands that controlled clinical tests be conducted”.
His group conducts a draw to decide which kind of procedure each patient will undergo; this allows the team to compare the risks and benefits of each procedure. “This is the only clinical investigation in Brazil of surgeries systematically compared by the same surgical team”, states the physician. The preliminary results indicate that vertical gastrectomy is not as inoffensive as had been heralded. After the surgery, pressure splits the suture that surrounds the new stomach in 7% of the patients. This happens because the technique preserves the pylorus, the constriction that retains food in the stomach. The group from Unifesp is working on mice to detail the anatomic and physiological effects of both surgical procedures. In the opinion of surgeon Otávio Azevedo, who is the son and assistant of the professor from Unifesp, if vertical gastrectomy proves to be more hazardous during immediate post-op, it will not be recommended for the more debilitated patients – the ones who supposedly should resort to it.
Olívia went through a number of serious complications and her stomach had to be re-opened four times in a little over one year: first, to undo a loop that had formed in the intestines; next, to extract secretions that had accumulated in the gallbladder – this obliged the medical team to redo the sutures of the stomach, remove the accumulated pus from the abdominal cavity and finally remove the silicone rings that controlled the flow of food and enzymes into both parts of the stomach. The silicone rings had merged, causing her excruciating pain. In spite of complications, the study conducted by Leonor Pacheco showed that only seven out of every one thousand patients die after surgeries conducted under the SUS program, a death rate comparable to those in other countries.
This is why doctors feel that this surgical procedure is quite safe and efficient. “It is successful for 90% of the morbidly obese patients, who lose approximately 70% of their excess weight”, says Pareja. A study conducted by his group, published in July in Obesity Surgery, monitored 782 patients for at least 2 years after surgery and found that approximately 50% had regained approximately 9% of the lowest weight they had achieved – which does not jeopardize the success of the procedure. However, the authors feel that this indicates a need for long-term studies to understand what is so different about the metabolism of people who are not able to maintain weight. So far, the study has shown that, of the patients who regained weight, 60% had not followed through on their nutritional program and 80% had not seen a psychologist after the surgery. The SUS requires that all bariatric surgery teams offer these specialties, but there is no way to ensure that patients see these specialists year after year, especially when they are under public health care. Pareja points out that in big countries such as Brazil, it is very difficult to re-evaluate patients year after year, especially those who rely on public health care. “In my clinical practice, I am able to keep track of approximately 70% of the patients because I have an employee who is dedicated exclusively to sending e-mails to patients summoning them for their periodical doctor’s appointments.”
In the opinion of surgeon João Ettinger, from the Escola Baiana de Medicina e Saúde Pública medical school, the difficulty of post-surgery follow-up is the most serious issue. “We have already examined approximately 1,300 operated patients, and the ones who do not follow the advice of the physician and the nutritionist gain weight again and suffer consequences such as osteoporosis and nutritional deficiencies”. The surgery-associated problems that he has seen are not caused by the surgery itself but by excess weight – which can lead to muscle injuries when the patient spends several hours in the same position under the effect of general anesthesia.
Caused by multiple behavioral and physiological factors, such as compulsions and hormone imbalance, obesity is one of the biggest challenges faced by current medicine; obesity rates have been increasing, especially in developed countries and in countries whose culture includes a sedentary way of life and easily absorbed industrially processed foods.
Such a complex illness requires a medical team comprised of psychologists, nutritionists, surgeons and endocrinologists. In 2007, a group from the U.S. showed a drop in the incidence of diabetes, cardiovascular problems and cancer, following bariatric surgery, thus reducing the mortality rate by 40% in comparison to obese patients who had undergone clinical treatment only. But the mortality rate caused by accidents and suicide increased by 58% among operated patients, which is a clear indication of the need for psychological care.
graphical intervention on Venus of Melus, by Praxiteles/ Laura DaviñaNiraldo de Oliveira Santos, who is part of the team of psychologists coordinated by Mara de Lucia, treats obese patients at USP’s Hospital das Clínicas hospital. He says that patients must have psychological care before and after bariatric surgery. He and Mara coordinated a survey, a Portuguese version of a questionnaire prepared in the United States, to evaluate weight levels and life style of the obese. The study detected eating compulsion in nearly half of the patients and depression in 64% of them, which is approximately three times higher than in the population in general. This shows that, in most cases, weight gain is mostly linked to family or love relationships, such as deaths and break-ups. The results also revealed that the biggest problem does not stem from eating highly fattening food or sweets, but from eating huge quantities of food. “We showed that the eating reality in Brazil is quite different from what is seen in the United States, hence the importance of not only translating but also adapting the questionnaire to what we see here”, Niraldo explains.
Part of the psychologist’s work is to verify whether the patient has the conditions to improve if he undergoes surgery. If the patient is a compulsive eater, he will certainly have problems: if he eats too much, he will feel pain, will vomit or cause serious damage to his new stomach. Finding that eating is impossible, many patients substitute food for some other compulsion, such as drinking, drugs or gambling. This is why the ideal thing to do is for the patient to go to psychotherapy prior to surgery, to deal with the psychological factors. “There is no consensus yet, but we believe that symptoms of schizophrenia, attempts at suicide, drug consumption and IQ deficiencies that cause comprehension difficulties are factors that enormously increase the risk of failure”, adds Niraldo, who does not advise surgery in these cases. But sometimes it is impossible to wait, as was the case with Olívia. In these situations, Niraldo emphasizes the need to follow up on the patient for as long as necessary after the operation.
Prior to surgery, psychologists, nutritionists and groups of obese and operated patients try to show the patient what this surgery means: if everything goes well, he will have to spend the next month after surgery taking liquids and the rest of his life carefully controlling what he eats. “I have more problems now than I did before”, Olívia said after a therapy session. She takes several dietary supplements, needs to eat every two hours and her meals are limited to two spoonfuls of rice, a spoonful of beans and red meat – which has more protein than other meats. She has to eat very slowly and chew her food very well. And her body has not adapted to the new nutrition yet: Olívia still loses a lot of hair and her complexion still has a greenish undertone.
More than the body, it is the mind that takes longer to get accustomed to new circumstances. “The body image only changes after five years of stable weight, and sometimes it takes even longer”, says Adriano Segal, a psychiatrist from USP. He explains that obese people go on successive diets, they gain and lose weight off and on, and this creates havoc on the brain mechanisms involved in body image. “Ever since I started gaining weight, I haven’t looked at myself in the mirror. I just use a hand mirror to put lipstick on”, says Olívia. She still sees herself as obese. This is why, when she concluded the long string of surgeries, she kept losing weight and ended up weighing 70 kilos, getting visibly too thin. She had to go through intensive treatment with a nutritionist to gain back the necessary 15 kilos to have a healthy body. “Weight loss always happens quickly, so it is inevitable for the body and the mind to be out of synchrony”, adds Segal. The doctor can show how the patient is physically better.
Psychologists and psychiatrists have to work in the dark, so to speak: according to Segal, there are no studies that detail the mental problems associated with obesity and there is no way of predicting how each patient will react to the surgery. This is why he argues that there are no scientific grounds to limit access to surgery because of psychiatric disturbances. “Based on current evidence, what we can say is that it is enough for the patient to be able to understand the procedure”, says the psychiatrist, “so that he can make the decision about the surgery”.
In his opinion, patients who need post-surgery follow-up are the ones who had prior psychological or psychiatric disturbances. “Some patients go into depression or have other mood swings after surgery, but they are the exception”, he says. In general, the opposite situation happens: people who suffer from depression when they are obese tend to feel better after the surgery.
Recent studies have shown that losing weight is not the only benefit from the surgery. Stomach reduction and changing the way food travels through the intestines increases the production of insulin and controls diabetes. “Approximately 80% of the diabetic patients leave the hospital cured of their diabetes”, says endocrinologist Bruno Geloneze, a colleague of José Carlos Pareja’s at Unicamp. This is a glimmer of hope for this condition, which afflicts 200 million people around the world, approximately 8 million of them in Brazil. Based on these results, Geloneze and Pareja proposed in 2006 in the Arquivos Brasileiros de Endocrinologia & Metabologia journal, that a metabolic surgery be developed to cure type 2 diabetes. This form of diabetes is one of the first problems caused by excess weight, and that is why it can affect a person before this person can be qualified as being obese: 75% of diabetics have a BMI lower than 35, which characterizes slight obesity.
The race is on to develop metabolic surgery. Based on a model developed on rats, the team headed by Geloneze and Pareja conducted a procedure on 15 non-obese diabetics. This procedure leaves the stomach intact, but creates a small shortcut: when leaving the stomach, the food does not go through the duodenum. When detecting an unexpected volume of food, the intestine induces the secretion of the hormones responsible for stimulating the production of insulin and generating a feeling of fullness. The results, presented in June at the congress of the American Society of Diabetes held in San Francisco, USA, are preliminary, although promising: 6 months after surgery, only one of the 15 patients still needs to take insulin injections to control the diabetes. “We have to wait for more results before we present this to the SUS and change the rules”, predicts Pareja.
The race is currently headed by surgeon Áureo Ludovico de Paula, from the Hospital de Especialidades in the city of Goiânia. In 2002, he developed a surgical procedure that focuses only on the treatment of type 2 diabetes. His team transfers part of the ileum, at the tip of the small intestine, to the jejunum. The ileum cells produce the hormones that stimulate the pancreas to produce insulin, as insulin deficiency is the origin of diabetes. To function properly, these cells depend on getting undigested food, which does not happen in diets that contain excess industrially processed food, which the organism absorbs with greater ease. Transferring part of the ileum to the jejunum might solve the problem. “This is an entirely new procedure which we developed on the basis of physical-pathological principles”, says the surgeon. In an article published this year in the journal Surgical Endoscopy, he reports a success rate of 95% in 60 patients followed up over the course of 7 months on average. So far, the surgeon has operated on approximately 400 patients.
João Luiz Azevedo, from Unifesp, argues that surgical procedures must go through tests on animals and controlled clinical studies on human beings must be conducted before patients are submitted to such surgeries. In addition, it is necessary to keep track of patients for a number of years, to evaluate whether the effect persists. Based on this reasoning, his team is testing Áureo de Paula’s procedure on rats. The work is still in its early days, but João Luiz and Otávio Azevedo report that when the cells of the transplanted ileum die, the tissue produces new cells according to the instructions of the environment – which after surgery happens to be the jejunum. This is why these cells, when seen under a microscope, resemble the jejunum cells and their architecture no longer includes the cells that secrete the essential hormones for the metabolism. At the moment, the researchers from Unifesp are skeptical about the possibility of an efficacious metabolic surgery for non-obese patients. Alfredo Halpern, an endocrinologist from USP and a colleague of Áureo de Paula’s, challenges this: “The transposed ileum resembles the jejunum, but it is common knowledge that the secretion of the hormones remains the same.” This debate will continue.
Another promising side effect of obesity surgery was a highlight at the congress of the American Society of Endocrinology in São Francisco, held right after the scientific conference dedicated to diabetes. Alfredo Halpern and Cristiane Moulin, his doctoral student, noticed that natural killers, the cells of the immune system, have little activity in obese people, and this deficiency is reverted by bariatric surgery. “This is important because these cells are an innately important line of defense in the battle against infections and cancer”, explains Halpern. The result fits in with the reports published in the Scandinavian Obesity Survey, or SOS, a Swedish study that followed patients for a long period after surgery and is considered by specialists as being the world’s benchmark in this field. The team’s latest article, published in 2007 in the New England Journal of Medicine, reported a much lower incidence of cancer in patients who had undergone the surgery in comparison to those who had not.
Halpern and Cristiana explain why. In a pioneering approach, she analyzed the substances that stimulate the activity of the natural killers and detected three that are produced in higher quantity after the sudden loss of weight that comes in the aftermath of the surgical procedure. “This might be the mechanism that is behind the report of the SOS”, says the endocrinologist enthusiastically, in whose opinion the results are a strong point in favor of the surgery. “There are risks, but the benefits are much greater”.
Even when it is successful, the surgery is still a drastic and expensive solution for a problem that is increasing all over the world and which, up to a certain point, could be avoided. “It is necessary to plan cities in a way that will promote life style changes, such as encouraging people to walk or ride bicycles. The health care system bears the burden of the final result of a problem that can only be prevented in an integrated manner”, ponders Leonor Pacheco. In addition to making the body move, a low calorie diet that includes more fruits and vegetables would significantly reduce the obesity problem. But when metabolic disturbances prevent the body from working properly, surgery becomes the only option.
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