Background for obesity

Morbid obesity – about the disease

Obesity is measured by body mass index (BMI). Morbid obesity is defined when BMI is over 40 or between 35-40 with accompanying obesity-related diseases, the common in them being: type II diabetes, hypertension, heart diseases, sleep apnea, deficient fertility and more. Likewise, there’s a direct link to increased mortality. Obesity has been defined as a plague whose causes are many and complex: improper diet, genetics, environment, psycho-social, economic. The disease’s complexity determines the treatment’s complexity. It’s been proven that the most effective long term treatment is surgical treatment. A multidisciplinary staff significantly improves the results and reduces the risk of complications and increases the chances for success after the surgery and for the long term.

1. It can be generally said that a positive balance of energy and regulating the energy is a very complex mechanism, in which organs and tissues participate: the brain, inner-stomach fat tissue, digestive system organs.
2. Disease prevalence: about 5% of the adult population in Israel suffers from Morbid obesity. For comparison, about 8% of the population in the US suffers from the disease, and about 4% of kids suffer from extreme obesity.

Population features

1. Abnormal eating habits such as: ravenous eating, emotional eating associated with mood, nocturnal eating, addiction to sweets, high volume eaters with very high satiation threshold or without satiation at all, and snackers in between meals – often the patients note that their meals aren’t big, and they don’t know why they gain weight.
2. Nutritional deficiency in the fat patient (before surgery): lack of B12 mostly in older patients, and in patients taking H2 blocker or PPI’ss, iron/ferritin deficiency – mostly in women, also in the general population, vitamin D deficiency – very common in fat patients, zinc deficiency.
3. Psycho-social features: experiencing social and occupational discrimination against them, low daily quality of life, hygiene, sitting places and more, high frequency of eating disorders, depression, anxiety and frequent mood swings, chronic surrender to the situation, lack of hope, desperation, apathy, impotence, passivity, lack of faith in the ability to change the situation as a result of repeat failures to lose weight, internalizing getting fat as part of the identity.
4. Medical/physiological features: about 80% of this population suffers from type II diabetes in various severities. About 30% suffer from hypertension. There is a high frequency of many other accompanying diseases including increased chances of various cancers and damaged fertility in women.
5. Mortality risk without surgery: the risk for death from accompanying diseases and future risk without surgery is 9 times higher than in patients undergoing the surgery:

Surgeries to treat the disease

All bariatric surgeries are included in the health basket. In general, success is defined when there’s a reduction of 65% of the excess weight (the weight above the ideal weight). The minimally invasive technique is mostly performed:

• The surgery is performed thought about 5 small openings, without full opening of the side of the stomach
• Quick recover – quick return to normal.
• Reducing the amount and degree of pain. Most patients need a simple analgesic such as Acamol or metamizole after the surgery.
• Reducing surgical incision complications (wound infections, hernias).
• Mortality: studies show that the risk of death is about 0.3%, no higher than gallbladder resection or joint replacement. For comparison – mortality in cardiac bypass is about 3.5%

Review of surgeries in Israel and the world

In Israel, bariatric surgeries have been performed in Israel for many years, since 2005, centers in Israel began performing laparoscopy of gastric bypass and sleeve gastrectomy, thousands of bariatric surgeries are performed a year in Israel. In the world: more than 300,000 bariatric surgeries are performed every year in the world today, 220,000 of which in the US alone. The most common surgery in the US is a gastric bypass, compared to Australia – band surgery is the most common.

The bariatric center Herzliya medical center

The center operates in the multidisciplinary frame with a professional and leading staff comprised of 3 doctors, 4 psycho-social and 4 dietitians, a physiologist and a clinical pharmacist, convening assessment committees to approve the surgery in accordance with the ministry of health regulations, but most resources and attention are directed at patient follow-up and escort after the surgery within personal and group meeting over time in order to provide a comprehensive surrounding for the patients and aid in a permanent success of the surgery and changing the patients’ lifestyle.

Surgery follow-up:

After the surgery, support and escort follow up must be made to help change the lifestyle and aid in ensuring surgery success over time and thus preventing repeat weight gain.  Within the follow-up, the Herzliya bariatric center staff will examine the data below:

• BMI Calculation  excess weight reduction
• Reminder – goals, current status versus goals, the importance of gradual weight loss.
• Dietary progress according to stages and surgery type.
• Importance of physical activity.
• Diagnosis and treatment – digestive system phenomenon – diarrhea, constipation, gas, changes in taste.
• Compliance with taking dietary supplements.
• Prevention of dehydration.
• Going over blood test results – adjusting supplements.
• Exercising new eating habits, awareness for satiation.
• Preventing vomiting
• Dealing with special situations – mental and dietary
• Giving motivation
• Aid in dealing with the prevention of repeat weight gain.
• Acquiring tools for the rest of the road.

Meetings with the patient:

First meeting – assessment and preparation for the surgery (committee): in this meeting, the staff assesses the patient’s fitness for the surgery in the clinical, psycho-social and dietary aspects and preparing the patient for surgery. During the meeting, introduction and making contact will be emphasized and the reasons to have the surgery – how the patient feels, what are the challenges in his life, difficulties, pleasures, reasons for weight gain (identification – focusing internal/external control, taking responsibility), events in the past that affected weight (diets, births, traumas and so on), evaluating quality of life – self evaluation, physical, social difficulties, employment, sex life, financial evaluation, evaluating addiction tendency, expectations – what is the expectation from the surgery, required behavioral changes, target weight, evaluating the time for weight loss, family support system, resistances, selecting and recruiting a chaperon/confidant, preparing the home for the recovery period.

Personal follow up meetings: the first follow up meeting is done at the Herzliya bariatric center after 10 days from the surgery, where the patient will meet for the second time the 3 staff members who saw him before the surgery, then the patient will be reexamined by them to assess his condition in terms of his physical feeling during the hospitalization and the recovery process and returning to routine, motivation and satisfaction from the results so far, comparing to goals set at the start of the process (a progress graph can be shown), evaluating the new quality of life – self evaluation, physical, social difficulties, employment, sex life, changes in the workplace and intimacy, family support, evaluating addiction, encouraging participation in support forums and groups, compliance with taking dietary supplement according to the financial condition.