Putting the word “Cure” into the Management of Obesity-Induced Metabolic Disease

Obesity-induced metabolic diseases (OIMD) such as diabetes, hypertension and chronic fatigue are traditionally thought of as treatable, but not as curable. Lifelong therapy for these diseases is expensive, has numerous adverse side-effects and is only partially effective. The best treatment for obesity-induced disease has always been weight loss, but permanent weight loss is difficult to achieve. Nevertheless, l

ong-term weight loss and improved fitness can result in complete resolution of obesity-induced metabolic disease (OIMD).

The Cost of OIMD

Medications required to treat metabolic diseases are expensive and add up to considerable sums over a lifetime. The annual direct cost of treating the 67 million Americans (CDC, 2011) with hypertension was estimated at $47.5 billion, or about $710 per patient, adding up to more than $21,000 over thirty years. The $21,000 in direct costs does not account for the cost of all the additional diseases, such as kidney failure, stroke and heart disease, that develop as a result of long-standing hypertension.

Direct medical costs for treating the more than 25 million Americans (CDC, 2011) with diabetes is estimated at $176 billion, or $6,800 annually per patient, or over $200,000 per patient over 30 years. And, as a leading cause for stroke, heart failure, heart attack, kidney disease, blindness and amputation, the overall cost of diabetes are astronomical.

All the above costs are alarming, but if we take into account the socioeconomic costs of missed work, lost wages, time commitment of caregivers, and the cost of human suffering, the real price tag for OIMD is staggering.

The Role for Surgery

Metabolic surgery is the specialty of surgery that addresses OIMD as potentially curable. Historically, metabolic surgery has mainly focused on severe obesity and the operations have been primarily targeted towards weight loss. Over the past three decades, however, it has become increasingly apparent that the operations used for weight loss have a significant positive impact on several other metabolic disorders. In fact, the success in resolving hypertension, hyperlipidemia and type-2 diabetes through weight loss surgery has been so profound that new areas of research have developed concerning the role of the gastrointestinal tract in the management of metabolic disease.

The most exciting clinical revelation has been that performing gastrointestinal surgery to treat OIMD can, in fact, result in a cure. The potential for metabolic operations to actually cure these diseases is now an irrefutable fact, and has resulted in a paradigm shift where certain OIMDs should no longer be assumed to be lifelong illnesses. (Many debate this issue, but if a disease is simply not present, by all standard medical testing, then it is by definition cured.)

Published in the Journal of the American Medical Association in 2004, a meta-analysis of 22,049 patients that had undergone traditional bariatric surgery showed an overall 61% sustained excess body weight loss. In terms of OIMD the study showed a 76.8% resolution of type-2 diabetes, a 61.7% resolution of hypertension, and a 79.3% improvement in hyperlipidemia. In a more recent study examining 23,000 patients with metabolic syndrome that underwent bariatric surgery, 36%, 50% and 35% had complete remission of hypertension, diabetes and dyslipidemia, respectively.

The fact that diseases previously thought of as only treatable are now known to be potentially curable is incredibly important. Patients suffering from OIMD should now be counseled that there is an opportunity for cure. In fact, in my professional opinion, if a patient meets the criteria for metabolic surgical therapy, it is now below the standard of care for a physician counseling that patient to fail to make them aware of the possibility for surgical treatment of their disease.

Who Qualifies for Metabolic Surgery?

The National Institutes of Health (NIH) published guidelines for bariatric surgery after a 1991 consensus conference. These guidelines are currently published on their website with a disclaimer (reprinted below) stating that the guidelines are outdated. Despite advancements over the past 25 years resulting in safer bariatric procedures (decreased risk) and a higher level of success (improved benefit), Medicare and commercial insurers have refused to update the guidelines and still refer to the 1991 guidelines when authorizing payment for these surgeries.

The 1991 NIH guidelines were based on an extensive benefit-versus-risk analysis, and are fairly simple; “patients whose BMI exceeds 40 are potential candidates for surgery if they strongly desire substantial weight loss, because obesity severely impairs the quality of their lives. In certain instances less severely obese patients (with BMI’s between 35 and 40) also may be considered for surgery. Included in this category are patients with high-risk comorbid conditions” and patients with “obesity-induced physical problems interfering with lifestyle (e.g., joint disease treatable but for the obesity, or body size problems precluding or severely interfering with employment, family function, and ambulation).”

This disclaimer is included on the NIH website: http://consensus.nih.gov/1991/1991gisurgeryobesity084html.htm

“This statement is more than five years old and is provided solely for historical purposes. Due to the cumulative nature of medical research, new knowledge has inevitably accumulated in this subject area in the time since the statement was initially prepared. Thus some of the material is likely to be out of date, and at worst simply wrong.“

It’s unfortunate that a national agency is unwilling to update their published guidelines on such a widespread disease. The only explanations I can come up with are that there is a concern that up-to-date guidelines would result in an increased demand for weight loss surgery, or simply that ignoring the plight of obese people is still an acceptable bias in our society. The good news is that individual experts and professional organizations have updated their guidelines over time.

Following these 1991 guidelines, the insurance industry will generally authorize payment for bariatric surgery if patients have a BMI>40, or a BMI = 35-40 with significant weight-related disease or disability.

More up-to-date guidelines for metabolic surgery take into account the preponderance of scientific data showing that most patients with a BMI of 30 or greater have a markedly increased risk for OIMD including diabetes, heart disease, cancer and physical disability. They also take into account the lack of adequate alternative treatments for obesity. In fact, the health risks for a BMI of 30 or greater is so well accepted that the FDA approved the Lap-Band device for treating patients with a BMI as low as 30.

In my opinion, based on the safety and success of modern metabolic surgical procedures, it is now reasonable to offer weight-loss surgery for any patient with a BMI>35, and to all individuals with a BMI between 30 and 35 who have failed at long-term weight loss and complain of a significantly decreased quality of life, or who suffer from weight-related disease.

Education: The First Step

The first step in the metabolic surgery process is education of the patient and a reality check. When performed by experts in the field, metabolic surgery has a high degree of success and a low risk of major complications. However, patient willingness to make lifestyle changes is the key to obtaining long-term success. And, because the only reasonable goal for someone undergoing metabolic surgery is to achieve long-term or permanent success, up-front understanding of the patient role in the surgical treatment process is mandatory.

All patients need to be explained that maximum long-term success is dependent on lifestyle changes that they should find to be far easier to achieve with the help provided through surgery. Patients need to have it clear in their mind that, for long-term success, healthy changes in eating behavior need to be embraced. Healthy eating takes understanding and effort whether a person has been overweight or not, and only those patients that use the surgical procedure to assist them in improving their diet will succeed. The scientific literature is also fairly clear on the fact that long-term success is dependent on patients embracing a physically active lifestyle including daily exercise. Studies have shown that the surgical patients that use their surgically induced weight loss to pursue an active lifestyle that includes exercise obtain the best result.

What are the Standard Metabolic Surgical Procedures?

Bypass Operations:

A very brief history of bariatric surgery begins in 1953 with Dr. Victor Hensrikson of Gothenburg, Sweden who performed an intestinal resection to treat obesity, and with Dr. Richard Varco, at the University of Minnesota, who performed the world’s first intestinal bypass to treat obesity. For the next 25 years operations for obesity consisted primarily of malabsorption operations, specifically various kinds of intestinal bypasses; the jejuno-ileal bypass being the most common. These operations resulted in a high degree of malnutrition and fell out of favor in the 1970s. In 1967 a less malabsorptive operation was invented by Dr. Edward E. Mason at the University of Iowa, the Gastric Bypass, and this operation has been improved over the last 50 years to the current Laparoscopic Roux-en-Y Gastric Bypass which is still considered to be the gold standard bariatric operation. However, as a result of the complications seen with intestinal bypass, the term “bypass” came to falsely represent operations with a high risk of severe malnutrition. The gastric bypass involves only a limited intestinal bypass, mainly bypassing the stomach, whereas operations that carry a higher risk for malnutrition are those that bypass of a substantial portion of small intestine. Two operations that involve substantial intestinal bypass, the Biliopancreatic Diversion (BPD) introduced by Dr. Nicola Scopinaro in 1979 at the University of Genoa, Italy, and the Duodenal Switch (DS) designed by Dr. Douglas Hess of Ohio in 1986, are still performed by some surgeons. The BPD and DS operations are remarkably effective operations for treating diabetes and severe dyslipidemia (high cholesterol and high triglycerides), but carry with them a higher risk for malnutrition.

Restrictive Operations:

Around 1979 Dr. Mason also invented the gastroplasty, which carried no risk for malabsorption and was called a “restrictive operation” because it forced patients to eat slowly and chew well. Various forms of gastroplasty (also called “stomach stapling”) were used for about 20 years but, despite successful weight loss, the complications including chronic vomiting were high and the operations fell out of favor. In the 1990s, laparoscopic adjustable gastric banding was started in Europe and in 2001 the FDA approved the Lap-Band System™, for use in the United States. The Lap-Band turned out to be a very safe operation, and surged in popularity for more than ten years, but its popularity has since declined. The popularity of the Lap-Band has been replaced by the popular “sleeve” procedure which has weight loss comparable to the gastric bypass, but with no intestinal bypass so the risk of malabsorption is minimal.

Currently, the most common operations in the world are the sleeve gastrectomy, the gastric bypass and the Lap-Band, all performed using minimally invasive surgery (laparoscopy). The graph below demonstrates some of the differences between these operations. (Data specific to Dr. Quebbemann)

Procedure	Gastric Bypass	Sleeve Gastrectomy	Lap-Band
Average Length of Operation	50-60 minutes	30-45 minutes	30-45 minutes
Typical Hospital Stay	1 day	Outpatient or 1 day	Outpatient
Average Weight Loss	75% of excess(40-100%)	70% of excess(40-100%)	50% of excess(0-100%)
Significant Nutritional Issues	Uncommon	Uncommon	Rare
Nutritional Supplements	Highly Recommended	Highly Recommended	Recommended
Reversibility	Yes	No	Yes

Observations on Metabolic Surgery and Future Directions

Although it may seem like the positive effect metabolic surgery has on diabetes, hypertension and other disease is a recent discovery, the fact is that the use of surgery to treat OIMDs was being studied in the 1960s. As the evidence grew for bariatric surgery as a treatment for high cholesterol, high triglycerides and type-2 diabetes, the physiologic effects of the different operations began to be more closely examined. Due in part to the dramatic improvement in diabetes after gastric bypass, and the dramatic improvement in hyperlipidemia after intestinal bypass, the important role of hormones produced by the stomach and small intestine in the regulation of insulin, blood sugar and metabolism has become apparent.

In September 2008 the first World Congress on Interventional Therapies for Type-2 Diabetes was held in New York. The excitement at this meeting focused on evidence that surgery could be performed safely, on non-obese individuals, specifically to resolve diabetes without weight loss. Interest in these concepts resulted in studies on surgical procedures to treat type-2 diabetes being conducted throughout the world.

With an improved understanding of the role of the gastrointestinal tract in controlling cholesterol, triglycerides, insulin and our metabolism in general, the field of metabolic surgery is evolving. It is now very important for all physicians to understand modern metabolic surgery and its role as a treatment for OIMD, and sometimes as a cure.

References

Buchwald H, Varco RL. Ileal bypass in lowering high cholesterol levels. Surg Forum 1964; 15:289-291

Buchwald H, Varco RL. lleal bypass in patients with hypercholesterolemia and atherosclerosis: Preliminary report on therapeutic potential. JAMA 1966; 196:627-630

Pories WJ. Why does the gastric bypass control type 2 diabetes mellitus? Obes Surg. 1992;2:303–313

Forgacs S, Halmos T. Improvement of glucose tolerance in diabetics following gastrectomy [in German]. Z

Gastroenterol. 1973;11:293–296

Steven Grover S, et al. Preventing cardiovascular disease among Canadians: Is the treatment of hypertension or dyslipidemia cost-effective? Can J Cardiol 2008;24(12):891-898

Inabnet WB, et al. Early Outcomes of Bariatric Surgery in Patients with Metabolic Syndrome: An Analysis of the Bariatric Outcomes Longitudinal Database. J Am Coll Surg, 2012, 214, (4):556-557

Bariatric surgery in class 1 obesity (body mass index 30-35 kg/m2), ASMBS statements/guidelines, September 12, 2012

Buchwald H, et al. Bariatric Surgery, A Systematic Review and Meta-analysis. JAMA. 2004;292:1724-1737

Raul J. Rosenthal, M.D., F.A.C.S., F.A.S.M.B.S.*, for the International Sleeve Gastrectomy Expert Panel Consensus Statement. Surgery for Obesity and Related Diseases 8 (2012) 8 –19

Permanent Fitness Success

Achieving permanent weight loss is one of the most difficult goals in life to achieve. Millions of people buy weight loss products and sign up for commercial weight loss programs every year with promises for amazing success in record time, and every year so many Americans, and much of the world, just keep gaining weight. If you’re tired of ridiculous promises of success with minimal effort, and you are interested in getting to your Best Weight and maintaining that weight over time, then my clinic is here to help.

You aren’t the only one responsible for your excess weight. Billions of people are overweight or obese, and the reasons are many:

• Marketing has made necessities out of non-essential snacks.
• We are eating more low-nutrition, high-fat foods.
• Highly processed foods often contain empty calories in the form of sugar.
• Fewer and fewer people exercise on a regular basis.
• Most diets are ineffective at permanent weight loss.

In short, the odds are stacked against anyone living in the modern world who wants to stay fit. And amazingly, so many people grasp for one quick-fix method after another, knowing that these gimmicks never work. Nevertheless, several of the things on this list are completely under your control, and that’s all you need to succeed.

The fast food industry, our stressful society, the lousy diet advice you’ve been given…all of it has contributed to your long-term weight-loss failure. The biggest problem might be that many “experts” claim to have “the answer” but few of them know much about permanent weight loss. Formula diets give you rules to follow that, once broken, make you feel like a cheater. That’s not what I do in my clinic. My goal is to help you find a lifestyle that you enjoy that keeps you fit.

After over 20 years helping people control their weight, I’ve seen what permanent weight loss looks like, and every time I see it the successful patient has developed a deep understanding of “Why.” They understand and embrace the fact that there is more to it than diet alone. Permanent weight loss requires this understanding, and that’s the main reason almost all diet programs fail long term.

I can line up 20 people that are your same gender, your height, your bone and muscle structure, and your age, that are living at the weight you wish you were at. These twenty people don’t stay at that weight because they are always dieting. If you ask them why they eat the way they do they’ll look at you like you’re a bit slow-minded and say, “Because I like it.” Not only that, but these 20 people all have different eating patterns. So, here are 20 eating patterns that could work for you. On the other hand, if I help you find your own eating pattern that’s enjoyable and leaves you at a healthy weight, then you will become number 21 in this list of people. Simple.

The N.E.W. Fit program is a simple method for losing a lot of weight without sacrificing your health and your sanity. A combination of meal replacements, nutritional supplements and minimal calorie foods are used. We set a target weight loss, plug in a reasonable time-frame, and start the process. At the end of the “weight loss phase” we transition gradually to a maintenance diet and exercise lifestyle. I strongly recommend following my Dietary Rebuild™ Program to identify a new normal diet after you’ve lost the weight.

In the end, successful clients will have reached their Best Weight and identified a lifestyle that will maintain that level of fitness going forward.

• Did you not lose as much weight as expected?
• Have you regained a lot of the weight you initially lost after surgery?
• Have both of these things happened??

If your answer to any of these questions is YES, then getting to your BEST WEIGHT might still be important to you.

Second chances don’t always come along, and when they do, it’s usually smart to jump at the opportunity. If your original weight loss goals have been derailed, Dr. Quebbemann knows how to give you a second chance, how to get you back on track.

To find out if you are a good candidate for getting back on track, you need to answer these questions; Are you committed to achieving a weight where you can live the life you want, and are you willing to work with a program designed to help you meet your goal? If you answer yes to both of these questions, then our clinic can help you.

The first step is to schedule a consultation with Dr. Quebbemann and start the assessment process. Dr. Quebbemann has been correcting anatomic complications, and working with patients to improve their weight loss after surgery, since 1997. (Most of the bariatric surgeons practicing today had not even started medical school in 1997. Read Dr. Quebbemann’s brief professional biography for more information.) At the time of your appointment, Dr. Quebbemann will review your weight history, the surgical procedure you had, the program you followed and the results you achieved. The next steps will be to assess your nutritional status and the current anatomy of your previous surgery. In going through this process, Dr. Quebbemann will make a recommendation on how to achieve your best weight, and discuss a plan.

The evaluation process includes;

1. Initial Consultation
2. Nutritional Evaluation
3. Evaluate Your Anatomy as it is currently
   1. X-Ray testing
   2. Endoscopic Evaluation
4. Second Consultation to discuss results and options

Dr. Quebbemann has performed hundreds of surgical revisions over the past 20+ years; he’s performed revisions after patients have been to several different surgeons and have had more than one unsuccessful surgery. However, he only recommends surgery when there is a clear benefit to be achieved. The above assessment provides the information needed to make this recommendation.

There are times when patients either never received adequate instructions and support to achieve the weight loss they desired, or they were provided excellent support but fell off track. If this is the case, our clinic will still provide the assistance needed to get your weight back on track. Our N.E.W. Fit Program can be tailored for surgical patients to help you finally achieve the weight loss you had originally hoped for. And Dr. Quebbemann’s Dietary Rebuild™ is designed to help you establish a New Normal Diet that you can live with and control your weight going forward.

The N.E.W. Program’s metabolic weight management clinic is geared towards helping you achieve your weight loss goals no matter where you are starting or what you’ve tried before.

Beginning Note from Dr. Q

The unfortunate thing about weight loss procedures is that, when the surgical procedure doesn’t work, the patient takes the blame.

Although bariatric surgery is common these days, and there are quite a few self-declared experts working in the field, I certainly didn’t begin my bariatric surgery program because it was popular or easy. When I first started my weight loss surgery program, it involved a huge amount of work with minimal financial reward.

During medical school, and throughout my surgical training, I was exposed to bariatric surgery. The University of Minnesota, where I attended medical school, was the first surgery department in the world to publish a report about using surgery for weight loss, in 1952. It has always been one of the leading bariatric surgery centers in the world under the guidance of a brilliant surgery professor, Henry Buchwald, who is one of the few, truly world-renowned metabolic surgeons. When I entered medical school, Dr. Buchwald had been a professor at the university for more than 25 years and was completing a landmark study on using intestinal bypass to treat high cholesterol. He was the director of the bariatric surgery program.

The first time I saw bariatric surgery performed was in 1991 when Dr. Buchwald performed a gastric bypass. I had read his research on high cholesterol and to me it was amazing to think that a fairly simple surgical procedure could have such a profound effect on a metabolic disease. The implications seemed profound.

I discussed the effects of Dr. Buchwald’s bariatric operations with some of my classmates, and with several surgical residents, and their response was that the operations were “a joke” because they were being done on “fat, lazy people” that just needed to eat less and exercise. Nobody seemed to want to discuss these operations!

My personal history had included being a fairly intense athlete for most of my life, and I had never been overweight. Since my early school years, I had spent much of my free time practicing sports, and as a result I was rarely around obese people, and had never really thought much about it. Nevertheless, I knew how hard it was to lose 10 or 20 pounds to compete in a sport, so losing 100 pounds seemed like a nearly impossible task. It made sense that, if a relatively safe operation could help a person lose that extra weight, it would be worth doing. The main resident I was working with at the time laughed at me when I mentioned this, and suggested that I consider psychiatry instead of surgery, so I simply stopped asking questions about bariatric surgery.

Two years later when I found myself at the University of Chicago training in surgery and the bariatric surgeon, Dr. John Alverdy, was an excellent clinical instructor with a large number of bariatric patients. Once again, I was exposed to bariatric surgery and this time I learned how to perform the procedures. By the end of my training, I felt comfortable evaluating patients for bariatric surgery and also felt competent in performing the gastric bypass operation. A piece of luck was that a few of the instructors in Chicago were early experts at minimally invasive (laparoscopic) surgery, and I was able to quickly pick up many of those techniques. As a result, I entered private practice with a significant amount of skill in laparoscopic surgery, and with a solid education on bariatric surgery.

In 1997 and 1998 I corrected a number of bariatric operations performed elsewhere that had resulted in patient complications. By 1999 I had assembled the appropriate team and so I started performing primary bariatric procedures myself. Due to my understanding of minimally invasive surgery, I quickly applied laparoscopic techniques to my bariatric surgery practice and began to perform essentially all my bariatric procedures using laparoscopic techniques. According to Ethicon Endosurgery (a surgical equipment manufacturer) my surgical weight loss program was one of approximately 20 surgical sites in America performing essentially 100% of their bariatric procedures with laparoscopic techniques.

At first there was significant resistance to the minimally invasive surgical procedures I began to perform. Very few physicians referred patients to me, and some were openly critical. One general surgeon told me that he had tried to do a laparoscopic appendectomy and that “it doesn’t work” so I was, apparently, wasting my time. When I scheduled the first laparoscopic splenectomy (spleen removal) in Orange County, a surgeon asked me why I was making simple procedures harder by using minimally invasive surgery. Luckily, my first laparoscopic appendectomy took 12 minutes, and my first laparoscopic splenectomy patient recovered so quickly that I discharged him the day after surgery (typical hospital recovery for traditional spleen removal was 3-4 days).

The criticism was even stronger with bariatric surgery, and the Chief of Surgery sent me a letter telling me that I was “wasting a brilliant surgical career” by operating on “fat people that are just going to drink milkshakes all day.” The Chairman of Internal Medicine stopped me in the hospital entrance one day and asked me “Are you still operating on those fatties?” And a senior hospital administrator responded to my complaint about the delay in buying bariatric equipment by saying “we really don’t want a bunch of fat people walking in here every day.”

The discouraging comments simply made me more determined, and when I thought about how much I respected the professors that had taught me bariatric surgery, all the criticism seemed insignificant. The good news is that, over time, the attitude changed and I eventually had very strong support from many physicians at the hospital.

In 2000 I attended the national conference on bariatric surgery in Nashville. I was invited to a gathering at the home of Dr. George Cowan, a past president of the bariatric surgery society, and was happy to meet many highly experienced bariatric surgeons from around the country. All of the surgeons seemed dedicated to improving the treatment for severe obesity, and to developing a better understanding of the disease. The meeting attendance was fairly small, a few hundred surgeons, but the enthusiasm was apparent.

The emergence of laparoscopic bariatric surgery was slow due to the high level of technical skill required. Most bariatric surgeons struggled with laparoscopic surgery and, after attempting the laparoscopic technique for several hours, converted most operations back to the traditional, big-incision, open surgery in order to complete the procedure safely. Then, along came the Lap-Band.

With the Lap-Band System™ there suddenly was an “easy” laparoscopic operation that could be used to treat severe obesity. Despite the growing demand for minimally invasive bariatric surgery, many patients had been dissuaded by the (false) claim that laparoscopic gastric bypass was a very high-risk procedure. Then, suddenly the Lap-Band seemed like the answer to their prayers.

Unfortunately, many unskilled surgeons with little interest in helping obese patients, saw the Lap-Band as a means of quick and easy income, and climbed on board the Lap-Band train. These surgeons promoted the operation as if the only thing needed to lose weight was placement of the band, and the flood gates opened up with patients pouring into inexperienced bariatric surgery clinics with expectations of immediate weight loss. With high patient demand and numerous minimally-trained surgeons jumping into the bariatric field, the quality of bariatric surgery, in my opinion, declined dramatically. During this time several commercial surgical clinics opened up, ran huge marketing campaigns, and hired mediocre “bariatric” surgeons to stick in Lap-Bands as fast as possible. Patients flooded these clinics and the centers made huge profits. Almost nobody was asking the question “What is the quality of surgery and the level of experience?” at these centers.

This is when bariatric surgery “became popular” and new “Experts” (at least according to their marketing) first arrived on the scene.

Fortunately, within a few years the bariatric surgery society adopted an accreditation program that supported the goal of surgical excellence and comprehensive patient support. This Center of Excellence program helped to establish quality of care parameters and enhanced the success of bariatric surgery overall. In my role as Director of Bariatric Surgery at multiple surgical institutions over the past 20 years, I have been personally instrumental in achieving Center of Excellence accreditation at six (6) hospitals.

Although mass marketing clinics still can make huge profits from high volume bariatric surgery despite having little interest in the management of patients (these centers are often not Centers of Excellence), I know of many qualified bariatric surgeons across America with excellent surgical skills and dedication to patient success. Today, awareness of the success and benefits of bariatric surgery has increased, and weight loss surgery enjoys a much higher level of support throughout the medical profession. Excellent clinics exist, staffed by true bariatric experts, and smart patients can find the help they need.

Ending Note from Dr. Q

Be careful who you go to for weight loss surgery! And be careful about signing up for new procedures that promise great weight loss with little or no risk. Many, many procedures have come and gone and few have withstood the test of time. Examples are gastric plication, various gastric balloons, and other devices. Permanent weight loss, and weight loss surgery, is not a no-brainer. The profession of weight loss is a perfect career for fakers and opportunists; after all, if the drug or the procedure doesn’t work, there is always the excuse that the patient just didn’t have enough willpower. So be careful.

Good luck to all patients, and take care.

Brian Quebbemann, MD, FACS, FASMBS

Gastric bypass surgery essentially makes the stomach smaller and reroutes the small intestine, allowing the patient to feel full with smaller portions, absorb fewer minerals, and experience an overall improvement in health as a result of steady weight loss. Not everyone is qualified for this procedure, so it is important to understand what factors into a patient’s candidacy. Below are some of the individuals who may qualify for this life-changing procedure.

• An ideal candidate may have a BMI that is greater than or equal to 40, or more than 100 pounds overweight.
• An ideal candidate may have a BMI that is greater than or equal to 35 and have one or more of the following conditions: type II diabetes, hypertension, sleep apnea, non-alcoholic fatty liver disease, gastrointestinal disorders, or heart disease.
• An ideal candidate may have the inability to achieve a healthy weight loss that is sustainable for a long period of time.

An example of a gastric bypass surgery candidate would be an adult who is 5’11” and weighs 290lbs, with a BMI over 40.

Most patients who have the gastric bypass surgery performed will lose an average of 70% to 80% of excess weight over the course of 2 years after the procedure. Individuals will typically experience the most drastic weight loss results during the first 6 months, though it will taper down in time.

The N.E.W. Program is a state-of-the-art weight loss clinic, which provides a one-of-a-kind opportunity for individuals to finally achieve permanent weight loss. Every scientifically proven and effective tool is here to help you succeed with your weight loss goals. The N.E.W. Program has some of the most extensive experience in performing the gastric bypass surgery in America.

Contact us today at (949) 722-7662 to learn how we can help you start your journey.