Metabolic Surgery should be offered to all obese people with diabetes. The evidence for this recommendation is now irrefutable.

In 2016, the American Diabetes Association, the International Diabetes Federation, and 43 other medical groups published guidelines, in the journal Diabetes Care, recommending surgery as treatment for people suffering from obesity and Type 2 diabetes. The guidelines state that people with Type 2 diabetes and a body-mass index (BMI) equal to or over 40.0, or a BMI from 35.0-to-39.9 and poorly controlled Type 2 diabetes, should be advised to undergo surgery, and people with poorly controlled diabetes and a BMI of 30.0-to-34.9 should “consider” surgery.

The STAMPEDE Trial followed three groups of patients, about 150 people, with poorly controlled diabetes and obesity. One group underwent gastric bypass; one got sleeve gastrectomy; and one group was placed on an intensive medical weight loss program, including counseling and medications. After five years, half of the patients who had surgery had a HbA1c level less than 7.0%, while less than a quarter of those in the medical therapy group had similar success. One in five patients that underwent surgery had complete remission of their diabetes (HbA1c of 6.0% or less, without medications) while there were no cases of diabetes remission in the medical therapy group. Surgical patients also lost a lot more weight and required fewer heart medications after 5 years. The surgical patients even scored higher on quality-of-life measures.

Only skilled surgeons with low complication rates should perform these technically demanding procedures. Risks include infections leaks and blood clots early after surgery, and ulcers, reflux, gallstones, and malnutrition months to years after surgery. People that have undergone gastric bypass surgery need to take supplemental vitamins and minerals for the rest of their life.

So you think that weight loss surgery is expensive?  Well, staying fat is more costly than you may realize!  Economic experts tell us that we are spending outrageous amounts of money treating obesity-related conditions like diabetes, heart disease, and cancer.  In fact, America spends more than $147 billion annually on obesity and this is projected to reach close to $1 trillion annually by 2030!

At the personal level, for people with just 50lb of excess weight (a BMI~30), the lifetime medical cost related to diabetes, heart disease, high cholesterol, hypertension, and stroke is $10,000 higher than it is for the average person at a healthy weight.

So, how does this relate to your daily personal finances? First, it’s a fact that your health is your most important asset. The cost of weight loss surgery pales in comparison to the long-term costs of obesity-related health problems.  In 2006, obese patients (BMI of 30 or greater) spent $1,429 annually more for their medical care than people in a normal weight range. A very significant study published in the American Journal of Managed Care reported that patients pay $900 per month less for healthcare just one year after bariatric surgery compared with similar weight people who don’t have surgery.

Even day-to-day living is more costly when you’re overweight. Plus-sized clothing costs 10% to 15% more than regular sized apparel.  Food is expensive and some experts estimate foods savings alone at more than $3000 per year after bariatric surgery.  Of course, you need to include how much money you are going to spend on another failed diet program. You won’t lose weight just because Jenny Craig’s wallet gets fatter.  One study broke this last fact down further by showing that for each pound of weight loss at Weight Watchers you will spend about $400!  That’s $4000 to lose ten pounds!

If you wonder if you can afford weight loss surgery, it’s time to ask yourself the real question.  Can you afford to stay fat?

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.