Joint replacement surgery is common–even very common in the U.S., with more than 700,000 major joint replacements performed annually.  It’s also very expensive, with total costs exceeding $10 billion.  It’s highly successful in most patients and dramatically improves their quality of life.  However, complications can be disastrous and very costly.

Recently, a study was published in the journal Clinical Orthopaedics and Related Research identified the medical conditions that predispose patients to complications after joint replacement surgery.  For a single disease process, these researchers found that patients with obesity had the highest risk for post-surgical complications with the incidence of complications increasing by more than 40%.  Furthermore, the percentage of patients requiring admission to a rehabilitation center after surgery increased 45% when a patient was obese.

As a result of this study and other studies like it, “Some surgeons are now refusing to operate unless an obese patient first loses a significant amount of weight,” according to an article in the Wall Street Journal (February 28, 2006).  Another article from The Boston Globe, July 18, 2006, quoted Dr. Richard Scott, chief of joint-replacement services at Brigham and Women’s Hospital, as telling high-risk, obese patients “If you lose so much weight . . . then I will fill my end of the bargain, and we’ll go ahead with your surgery. If you don’t do it, you’re telling me you’re not motivated.”  The problem here, of course, is that many obese people simply can’t lose the weight.

This dilemma is obvious since obesity itself is rapidly becoming the main cause of chronic joint disease.  One study from Canada found that 90% of patients undergoing knee replacements and 70% who had hip replacements in 2004 were overweight.  Clearly, obesity is a substantial additional risk for patients undergoing joint replacement and significant weight loss in an obese patient will lower the risk of complications.  For severely obese patients, delaying joint replacement for 6-to-12 months in order to permit them to undergo bariatric surgery and lose their excess body weight may be the difference between a rapid, uncomplicated recovery and a disastrous outcome.  Coordination between orthopedic surgeons and bariatric surgeons in the management of severely obese patients may be the best answer.

Orthopedic surgeons, rheumatologists and physicians specializing in rehabilitation medicine know that the knee joint has to support the force of three to six times one’s weight.  The impact of extra weight is also multiplied on other joints, including those of the back, hips and ankles.  The results of this increased wear and tear are impressive; for example, men who are just 40 pounds over their ideal body weight have a five-fold increase in osteoarthritis (1).  This close link between obesity and osteoarthritis is well documented (2).  Of course, the incidence of severe osteoarthritis in people that are one hundred or more pounds overweight is exponentially higher, and the age of onset is much earlier.  As always in medicine, unless patients and their doctors attack the root cause of their disease, in this case arthritis, medications and other therapy will only temporarily alleviate the pain and allow for permanent injury to the bone and cartilage.

For patients who do not yet require surgery to replace damaged joints, substantial weight loss has been shown to alleviate the debilitating symptoms of osteoarthritis.  Schauer, et al, documented that seventy percent of patients that were taking medications for joint pain had no pain and were off all arthritis medications after weight loss surgery (3).  Another published study documented that 58 percent of patients undergoing weight loss surgery complained of chronic low back pain, but this number decreased to only 20 percent after surgery (4).

Unfortunately, not everyone will have resolution of his or her knee pain after weight loss since joint cartilage lost after years of obesity will never regenerate.  This damage may result in the need for surgery to repair or replace the damaged joint.  Of course, recovery from joint replacement is more difficult in obese patients and many orthopedic surgeons will not perform joint replacement surgery in severely obese patients because of the significantly higher risk of complications.  A patient who is unable to undergo joint replacement due to excess weight is a prime example of a person who needs surgical weight loss.

To evaluate the impact of surgical weight loss on patients requiring joint replacement therapy, the Mayo Clinic followed 20 patients who had hip and knee replacements after weight loss from gastric bypass.   This recent study found a significant improvement in physical rehabilitation after joint replacement in patients who had previous weight loss due to gastric bypass.   In fact, not only did the recovery from joint replacement improve, the re-operation rate due to complications after surgery was dramatically lower (5).

Everyone is aware that osteoarthritis will often improve with good weight control.  For those people who are severely obese and are suffering from chronic joint pain, surgery for permanent weight control may be the best option to help your physician or surgeon improve your treatment results.

1- Annals of Rheumatic Disease; Felson, 1996

2- Amer. Jour. of Public Health; Sahyoun, 1999

3- Schauer 20004

4- Melissas, 2004

5- Parvizi, 2000

The gastric bypass surgery typically results in only a minor amount of malabsorption of nutrients. Proteins, for instance, are absorbed normally after a gastric bypass. However, patients who are not followed well, or who are not educated about the importance of some vitamins and minerals, can develop mineral deficiencies. Iron is an especially important mineral supplement to follow after a gastric bypass. Iron is vital to the healthy exchange of oxygen from your lungs to your body. Iron atoms are incorporated in hemoglobin, the major oxygen carrying protein in the body, and account for the red color of blood. Iron is present in many foods and absorbed by the body. Without iron, the body cannot make healthy red blood cells and a condition called iron deficiency anemia results. This anemia, when severe, can cause fatigue.

After some weight loss operations, iron pills are helpful to prevent iron deficiency anemia. Anemia, which only occurs in a minority of patients, may take years to develop. Therefore, monitoring of iron and hemoglobin levels is important. One helpful key is that if you take iron with acidic foods, or vitamin C, the iron absorption improves. Although some evidence suggests that different formulations of iron (Iron sulfate, Feosol, So-Fe, Iron fumarate) result in different absorption, the real clinical differences are not known. Some people experience minor side effects to iron pills such as constipation. So if you are taking iron supplements, find the cheapest, tastiest formulation that doesn’t cause GI upset. Take these supplements as directed and follow-up regularly with your physician.

Foods that are very high in iron include clams, tofu, steak, shrimp, black beans, chickpeas, turkey, and chicken. Other foods such as eggs, spinach, potatoes are also high in iron.

Researchers are taking a closer look at a previously rare disease that is now on the rise as obesity in children increases. Non-Alcoholic Steatohepatitis (NASH), more commonly known as Fatty Liver Disease, occurs in approximately 15% of obese children.

Fatty Liver Disease (FLD) is when excess fat accumulates in the liver.  While not life threatening by itself, it can lead to cirrhosis of the liver over time, sometimes requiring transplantation by adulthood.  Today, the most common causes of cirrhosis requiring transplantation are chronic alcoholism and hepatitis.  Within one generation, FLD secondary to obesity is expected to move to the top of the list, surpassing both alcoholism and hepatitis.

Approximately one third of children and teens in the United States are overweight, and 15% of children and teens are obese.  Estimates indicate that FLD may exist in 15% or more of obese children, or one out of every 40 children.  Children are routinely tested for conditions that have a much lower incidence, such as scoliosis, due to the severe physical and social implications.  Despite its dramatically increasing incidence, and the huge potential impact on society, there are no guidelines to screen for liver disease in children.

The American Liver Foundation currently estimates that 10-20% of Americans have Fatty Liver Disease.  This means that there are currently between 30 to 60 million overweight Americans with ongoing damage to their livers as a result of excess weight.  The huge concern is that many of these people will progress to cirrhosis and eventual liver failure.

Until now, the treatment for Fatty Liver Disease has been to offer dietary and exercise counseling, but this is often not effective.  Only a significant and maintained weight loss can improve, and possibly reverse, this disease process and significant weight loss with these methods is difficult to achieve and harder to maintain.  If caught early enough the liver is the only internal organ that can regenerate after an injury, but once significant scarring or cirrhosis has set in, it’s too late.  Currently, a national multi-center research network is looking at Vitamin E and a diabetes drug called Metformin, as possible therapy for FLD.  But, as of today, the best and only reliable way to prevent the damaging effects of obesity on the liver is to lose the excess body weight.

At The N.E.W. Program we screen all patients for FLD prior to surgery.  A simple, non-invasive ultrasound test of the abdomen can detect excess fat in the liver as well as enlargement of the liver.  If this disease process is discovered by ultrasound, further testing may be required.

Several recent studies have shown the positive benefit of surgical weight loss on Fatty Liver Disease.  In one study, obese patients had liver biopsies taken both before surgery and again 15 months after surgery, when significant weight loss had been accomplished.  Many patients showed dramatic improvement, and some had complete resolution, of the excess liver fat as well as the inflammation and fibrosis that was seen before surgery. These results highlight the important role that obesity plays in liver disease and reinforce the benefits of surgical weight loss in severely obese adolescents.

We all have a huge number of bacteria and other living organisms in our intestines and most of these organisms support the healthy functioning of our bodies. The organisms that live inside our intestines, and the intestinal environment they thrive in, is called our “Gut Microbiome.” This gut microbiome is unique for everyone, and the balance of bacteria within our intestines is different than everyone else.

Several decades ago, doctors recognized that intestinal bacteria played an important role in our immune system and that certain disease processes were affected by our intestine’s ability to maintain a healthy balance of all organisms. Since then, diseases such as arthritis, heart disease and metabolic disorders have been found to be affected by this intestinal community of organisms, and a lot of interest has developed in determining whether certain drugs, foods, and dietary supplements that alter this balance can possibly improve or even cure certain disease.

When it comes to obesity, research has shown that the balance of intestinal bacteria is different for obese people and healthy weight people. However, so far nobody knows the reason for this; does our intestinal balance of organisms cause weight gain, or dos weight gain cause a change in our intestinal balance? In other words, which is the cause, and which is the effect?

Probiotics are living microorganisms that, when eaten in a significant amount, provide us with certain health benefits. Certain types of food are packed with probiotics; examples are yogurt, buttermilk, tempeh, kimchi, sauerkraut, and pickles. The fact that we might be able to benefit from eating foods that have a high concentration of certain types of bacteria has led many people to assume that we can control our gut microbiome, and thereby control our health, by eating certain specific probiotics. Unfortunately, when it comes to excess weight and obesity, there is no evidence that our intestinal balance can be altered in a way that will improve our ability to control our weight.

Despite this lack of evidence, there is no law that restricts companies from defining probiotics any way they want, and from selling them as ways to improve your health. A huge industry has rapidly arisen where “experts” recommend certain probiotic dietary supplements as treatments for everything from Alzheimer’s to asthma and obesity. In fact, a survey in 2012 showed that probiotics were the third most common dietary supplements purchased after vitamins and minerals.

While there is a lot of research underway to determine how we can use probiotics to prevent and possibly treat certain diseases, there is currently no good scientific evidence that any probiotic can prevent or treat obesity.