Size Does Matter: The Role of Metabolic Surgery in the Obesity Epidemic

Obesity poses as a major public health challenge. It is rampant in all facets of society and has negative clinical implications on almost every organ of the body. Indeed, these pernicious effects can be increasingly prevalent among the morbidly obese, straining not only individuals but healthcare systems and the society as a whole. This enlarging problem of obesity has led the World Health Organization (WHO) to declare that it is an epidemic. In a global perspective, the WHO estimates that there are about 2 billion overweight or obese people in the world and about two-thirds of which reside in the developing nations. In the ASEAN region, the Philippines ranks fourth among the “overweight” countries, following Malaysia, Singapore and Thailand. The latest local information we have comes from the Food and Nutrition Research Institute where in 2014, have estimated that three out of 10 Filipinos are either overweight or obese.

But the problem is not just the overweight person tipping the weighing scale. It involves a variety of changes in the body, forming interplay of biochemical, hormonal, and physiologic interactions. Insulin release is higher among the obese than among normal weight individuals. This high insulin levels may eventually lead to insulin resistance and diabetes, as well as impair the effects of leptin, a hormone secreted by fat cells that signals the brain that energy storage is adequate. Research has shown that the gut bacteria transform after being subject to high-energy processed foods. These modulated bacteria produce lipopolysacharrides, complex chemicals that enter the blood stream and induce the white blood cells to release chemical factors that put the body in a state of constant stress through inflammation. The diversity of the human race also plays its part in the disease. Fat distribution and adiposity across races vary greatly. Patients of Mongolian descent have an increased propensity at developing diabetes at a lower weight class as compared to Caucasians.

In almost every aspect of medicine, there is an inherent need to control weight. An obese woman wanting to be pregnant will be told by her obstetrician to shave a couple of pounds because obesity increases the risk for polycystic ovarian syndrome, causing infertility. An internist would strongly advise weight loss to minimize the risk of heart disease and diabetes. Having a large waistline is a critical component of the metabolic syndrome, a cluster of conditions that raises the risk of heart disease, diabetes and stroke. This syndrome also includes elevated triglyceride levels, high blood pressure, low high density lipoprotein (good cholesterol) and high fasting blood sugar. Research has shown that losing about 10-20% of excess weight can significantly improve the parameters that increase the risk of obesity-related disorders.

Weight loss for a better health has always been a battle of attrition, a battle of wills if you will. There are four major options that can be used to address the issue: diet, exercise, medications, and surgery. All of these options assist a patient in their weight loss journey but the will to sustain each of them is there should the desire to maintain proper weight loss is a concern. Diet and exercise aids the patient to control weight loss through the reduction of calories consumed and increase physical activity to “burn” calories. This method is the first line in treating obesity, unfortunately very few people people are able to maintain proper diet and exercise and some encounter the phenomenon of “yo-yoing”, losing weight then gaining weight then losing it again and etc. Weight loss can also be achieved through medications. Drugs that reduce hunger urges and help control cravings such as Naltrexone HCl/bupropion HCl, or glucagon-like agonists (GLP-1), that increase insulin release and decrease gastric emptying, or gastrointestinal intestinal lipase inhibitor (orlistat), preventing triglyceride absorption at the gut level have all produced results in significantly reducing weight to affect clinical outcomes. However, these medications also have varying side effects ranging from nausea and vomiting, to increased urgency of bowel movement and psychiatric effects.

Surgery is another viable option to the obesity problem. For decades, the role of bariatric surgery has been mostly to address obesity itself. However, studies have been done to review the effects of surgery on the diseases associated with obesity itself. Meta-analyses have shown that surgery can significantly reduce weight among obese patients, with excess weight reduced by 75% (bariatric-metabolic surgery) versus 11% (diet, exercise and medical management). Diabetes resolution is seen in 63% of patients in the surgery group versus 11% in the conservative group. The growing evidence of the metabolic effects of surgery has increased dramatically over the past 10 years. These new evidence has been recognized by the International Diabetes Federation and the American Diabetes Association, wherein the 2017 guidelines recommend metabolic surgery for patients with body mass index (BMI) of 35 and above, if the patient has other obesity related diseases that is not responding well to medical management. The BMI category for surgery is even lower if the patient is of Asian descent.

Though it is true that the effects of surgery for obesity and its comorbidities have been proven effective, ensuring the durability of its effects is another hurdle in itself. Obesity is a multifaceted disease and the treatment should be multidisciplinary. Studies have shown that desirable long term outcomes are seen in centers where a team approach is done. The cooperation between the Nutritionist, Endocrinologist, Cardiologist, Psychiatrist, Physical Therapist, and Surgeon produces best results.

For more than ten years, the Weight Management and Bariatric-Metabolic Surgery Center of St. Luke’s-Quezon City has a group of in-house medical and paramedical staff who specializes in Weight Management programs ranging from medically-supervised diet regimens, tailor-made exercise routines, and a multidisciplinary, evidence-based approach in the medical and surgical treatment of obesity and its comorbidities. The Center holds regular lay forums to help in the awareness of the obesity epidemic. This integrated team approach helps ensure that the weight loss and health goals of the patient are sustained and lasting.

Dr. Jose Paolo Porciuncula is a General Surgeon at St. Luke’s Medical Center – Quezon City. He specializes in Minimally Invasive Surgery (MIS) focusing on Bariatric and Metabolic Surgery. He finished his fellowship training for MIS in the same institution and trained in Yotsuya Medical Cube in Tokyo for Bariatric and Metabolic surgery. He is currently the Secretary of the Philippine Society for Metabolic and Bariatric Surgery and is a member of the International Federation for the Surgery of Obesity and Metabolic Disorders, Asia-Pacific Chapter.