The most common way to measure obesity is by calculating one’s BMI. One is generally considered overweight or pre-obese at a BMI of 25 and higher, while having a BMI over 30 classifies as being obese. The obese weight class is further divided into three classes:

Obese class I: BMI of 30 to 34.9

Obese class II: BMI of 35 to 39.9

Obese class III: BMI equal to or over 40

Class III obesity can also be classified as morbid obesity or severe obesity, and is widely considered a serious health condition. Individuals who are morbidly obese often experience difficulty with basic physical functions, as well as having an extremely high risk of developing several dangerous health complications due to excess weight.

It is important to understand that an individual’s BMI is only an estimate, as there are factors such as muscle mass or visceral fat to consider for certain people. Your BMI may not be at 35, but you may suffer from conditions like type-2 diabetes that still pose a risk to your health. BMI is not perfect as it measures using weight, not fat or muscle mass. Bodybuilders with low body fat may have a muscle mass that contributes to their BMI being calculated as overweight or obese, for example.

A proper assessment or input from a medical professional is advised if you wish to know how your current BMI may affect your daily life.

Obese people build a certain resistance to normal methods of weight loss as they gain more weight, those in the third obese class may find it much more difficult to lose weight compared to people who are not obese. This is why exercising and eating less may not be an effective solution for everyone. Our body types, genetics and hormones can affect the rate at which we lose or gain weight, which is why some of us find it easier to lose weight than others. The reverse is also true, some people may find it tough to lose weight but easy to regain lost weight.

As such, while eating less and exercising more is the common way to treat obesity, for those who cannot achieve a healthy weight despite lifestyle changes: bariatric surgery is an option for you to consider. Remember that bariatric surgery is not a miracle solution for any obese person to lose weight. Obesity can be considered a lifestyle problem, where the person is trapped in a cycle of losing and regaining weight; or their body is at a balance of not losing enough weight. Bariatric surgery breaks that cycle, giving the person a chance to get into a new cycle that involves eating less, getting good exercise and living healthier.

Before surgery, a patient has to go through consultation and evaluation with a surgeon or physician well-versed in bariatrics, like the consultants at Island Hospital. Be prepared to eat in moderation, follow diet plans (as instructed by your doctor) and exercise regularly. Bariatric surgery can help you reach a point where these conventional weight loss methods become effective again. It also causes changes in your hormones that makes you feel full faster and eat less, preventing overeating.

Bariatric surgery should be taken into consideration if you are obese with a BMI over 35, or if your BMI is higher than 32.5 but also have serious health risks such as the aforementioned comorbidities, especially type-2 diabetes. Bariatric surgery is especially effective in causing remission of type-2 diabetes, many patients have stopped or reduced their intake of diabetes medication after bariatric surgery. The change in the body’s hormones and weight loss helps the body regain control over insulin levels without relying on medication as much as before, provided they remain physically active and exercise a controlled intake of sugar.

Apart from knowing your BMI, it is also important to know your waist size. Having excess fat around your waist can also lead to health risks, compared to having fat in other parts of your body. In fact, waist circumference has been shown to correlate with metabolic syndrome more than percentage fat in other areas of the body. Women with a waist size of over 35 inches (89cm) and men with waist size over 40 inches (101cm) may be at a higher risk of developing metabolic syndrome or diseases related to obesity.

Whether it’s your first time reading about bariatric surgery or if you already have an idea of what bariatric surgery is, you should know that at Island Hospital we perform 3 types of bariatric surgery and 1 endoscopic procedure for outpatients.

Bariatric procedures at Island Hospital:

• Sleeve gastrectomy
• Roux-en-Y Gastric Bypass
• One-anastomosis Gastric Bypass

Weight-loss endoscopic procedures at Island Hospital:

• Gastric Balloon

Vertical Sleeve Gastrectomy (VSG) – Is a weight-loss procedure where a large portion of the stomach is permanently removed (roughly 80%), reducing the size of the stomach from a pineapple shape to a banana shape. Limiting the stomach restricts the amount of food consumed, which also causes hormonal changes that assist with weight loss. It differs from gastric bypass procedures as there is no rerouting of the intestines needed. This procedure is permanent and non-reversible. It is a restrictive procedure.

Alternate names for this procedure are laparoscopic sleeve gastrectomy, gastric sleeve or simply the sleeve. Patients and doctors appreciate procedures like VSG as the procedures are laparoscopic, meaning the surgery is done without opening up one’s body. It is instead done through small incisions using tiny surgical instruments.

Vertical sleeve gastrectomy originated as a modification and first part in a bariatric procedure called the duodenal switch, which is a much more complex procedure that involves sleeve gastrectomy and intestinal bypass. It was also used as a safer alternative or first part in two-stage procedures for patients who have specific lung or heart problems that would make it difficult for them to undergo long procedures or anesthesia.

This is due to not requiring any rerouting of organs. For example, if a patient’s heart condition is deemed too weak for long hours of anesthesia (meaning they wouldn’t be able to undergo gastric bypass surgery), VSG can be carried out to help reduce the patient’s weight to a safer level before making the decision to have RYGB surgery. It has since become a procedure of its own, and at Island Hospital most of our patients go through the sleeve procedure. It is faster, safer and capable of producing results on par with gastric bypass procedures.

After-effects

The risk of having a major complication after surgery for sleeve gastrectomy is lower compared to other types of bariatric surgery, as only the stomach is affected and no organs are bypassed. While the chances are extremely low, it is important for you to take note in case symptoms do occur and you are not confused over what is happening to you.

Improvement of comorbidities – Sleeve gastrectomy assists in losing excess weight, and as a result helps to improve comorbidities in patients. Many patients experience remission of type-2 diabetes after sleeve gastrectomy, improving as their weight goes down. Some are diabetes-free a year after surgery. Improvements will continue to happen if one continues to maintain a healthy weight and lifestyle after the surgery.

Leaks and infection – the stapled portion of the stomach may leak, which will cause stomach acid and partially digested food to leak out. This will cause an infection and can be life-threatening. The odds of a leak happening are low, average statistics show only 1 in 200 patients experience an anastomotic leak; however it is best to be on the lookout for any signs or symptoms. Symptoms include fever, vomiting, feeling nauseous, rapid heart rate, stomach pain and bleeding.

Non-reversible – While there are some cases where gastric bypass procedures have been partially reversed, a sleeve gastrectomy is a permanent choice.

Dumping Syndrome – Dumping syndrome is a condition that occurs due to reduced stomach size. Food consumed travels down to the bowel at a faster speed and causes discomfort, caused by a lack of pacing or overeating during meals. Dumping syndrome causes weakness, dizziness, abdominal discomfort or vomiting, occurring immediately after a high-calorie meal, whereas late dumping syndrome occurs a few hours after consuming too much sugar.

One-anastomosis gastric bypass (OAGB) – Is a weight loss procedure that combines certain aspects of the sleeve gastrectomy and Roux-en-Y gastric bypass. The upper portion of the stomach is divided into a tube similar to a sleeve procedure, and then joined to the intestine. It is both a malabsorptive and a restrictive procedure.

This procedure is also known as the Single Anastomosis Gastric Bypass or Mini Gastric Bypass. It is called mini as it involves less rerouting of the intestines and shorter surgery time compared to traditional gastric bypass surgeries.

The primary benefit of the OAGB is that the surgery is shorter and less invasive. The risk of complications is lower as a result, and there is a chance to reverse the surgery to reduce complications should there be post-surgical issues. The weight loss may not be as dramatic as traditional gastric bypass, requiring more time to reach an ideal weight.

After-effects

As stated, the risk of a major complication occurring during or after OAGB is lower compared to traditional gastric bypass. However, the possibility still exists and one should take note of any potential complications.

Improvement of comorbidities – The most prominent side effect of the surgery is of course, the loss of weight. The loss of excess weight allows one to control their blood sugar and blood pressure without their body building up resistances to interfere with the regulating process. Comorbidities will gradually improve as the patient continues to lose weight after surgery.

Leaks and infection – The stapled portion of the stomach may leak, which will cause stomach acid and partially digested food to leak out. This will cause an infection and can be life-threatening. The odds of a leak happening are lower for OAGB patients, as there is only one anastomosis compared to two in RYGB patients (hence, why it is called one-anastomosis). However, it is best to be on the lookout for any signs or symptoms. Symptoms may include fever, vomiting, feeling nauseous, rapid heart rate, stomach pain and bleeding.

Dumping Syndrome – Similar to the RYGB procedure, dumping syndrome can occur in OAGB patients due to the rerouting of the stomach. The food travels down to the bowel at a faster speed and causes discomfort in patients. Dumping syndrome causes weakness, dizziness, abdominal discomfort or vomiting, occurring immediately after a high-calorie meal, whereas late dumping syndrome occurs a few hours after consuming too much sugar. It should be noted that while dumping syndrome can be uncomfortable to go through, it is also an effective deterrent as patients will avoid eating too much or eating too quickly so they won’t have to experience dumping.

Malabsorption – Malabsorption is an after-effect of gastric bypass surgeries, as most gastric bypass are malabsorptive procedures. The malabsorption is a key factor in helping you lose weight because your body does not absorb as many calories as before, but that also means your body absorbs less nutrients.

Nutritional deficiency – Malabsorption leads to nutritional deficiency, requiring you to receive essential nutrients and vitamin supplements. Your doctor will also recommend a specific diet plan or types of food to eat so you can get sufficient nutrients for your day-to-day life.

Roux-en-Y gastric bypass (RYGB) – The Roux-en-Y gastric bypass is a bariatric procedure where a small portion at the top of the stomach is separated from the rest, creating a smaller stomach “pouch” to hold food. With this smaller pouch stapled up, patients will feel full faster and eat less.

The small intestine is then separated and sewed onto this stomach pouch, resulting in food bypassing most of the stomach as it enters the small pouch and directly going into your small intestine. While this causes your body to absorb fewer calories to assist weight loss, it also means absorbing fewer essential nutrients.

Roux-en-Y gastric bypass is a malabsorptive and restrictive procedure, meaning the procedure limits food absorption (malabsorptive) while also limiting food intake (restrictive). It is considered to be the gold standard of weight loss procedures as it is highly successful in terms of weight loss and is the most commonly performed weight loss surgery overseas.

Apart from producing a higher average weight loss in patients as compared to the other procedures, RYGB also improves most of the aforementioned health conditions; such as high blood pressure or diabetes. The risks of conditions related to excess weight decrease as excess weight and fat is lost after the operation.

After-effects and risks

Improvement of comorbidities – Health risks influenced by one’s excess weight such as the aforementioned type 2 diabetes, hypertension and osteoarthritis begin to improve after the surgery. Improvements may continue if one maintains a healthy weight and lifestyle after the surgery.

Weight loss – Weight loss produced by RYGB is significant and perhaps the quickest among the procedures, and can be maintained by following the doctor’s advice. Most patients lose up to 75% of their excess weight after RYGB.

Malabsorption – Bypassing a large portion of your stomach and duodenum means skipping past a large portion of where your body breaks down food and absorbs nutrients. This means you absorb fewer calories and nutrients from food, known as malabsorption. Malabsorption triggers initial weight loss after the procedure and helps you maintain weight loss as your body absorbs fewer calories, but the downside is that your body also absorbs fewer nutrients.

Nutritional deficiency – Similar to malabsorption, nutritional deficiency is one of the side-effects of Roux-en-Y gastric bypass. Because your body doesn’t receive sufficient essential nutrients, vitamin supplements will become a major part of your daily life to avoid suffering from nutritional deficiency.

Dumping Syndrome – Also called rapid gastric emptying, dumping syndrome occurs when food and gastric juices move from your stomach to bowel at an uncontrolled speed or if you consume too much sugar. Dumping syndrome causes weakness, dizziness, abdominal discomfort or vomiting. The odds of this happening increases in patients of the RYGB and VSG procedures, as the reduced size of the stomach pouch causes food to travel into the small intestine at a quicker pace compared to people with a full stomach. You will have to be mindful of the pace you eat as well as how much sugar you consume. Dumping syndrome occurs immediately after a high-calorie meal, whereas late dumping syndrome occurs a few hours after consuming too much sugar.

Leakage or infection – The staples around the stomach pouch may fall apart, causing leakage or infection. The chances are extremely low (approximately 1 in 200 patients experience leakage), but it is best to have your doctor updated on your condition and to be wary of any signs or symptoms. Leakage will require surgery to re-staple the stomach pouch. Symptoms may include fever, vomiting, feeling nauseous, rapid heart rate, stomach pain and bleeding from the surgical wound.

Gastric balloon

A question that might be going through your head is “what if I’m not morbidly obese but I have type-2 diabetes and find it difficult to lose weight?” or “what if I’m not suitable for certain types of bariatric surgery due to health conditions?”. Not everyone may be eligible for surgery, which is why procedures like the gastric balloon exist.

The gastric balloon is also known as the intragastric balloon or endoscopic gastric balloon. This procedure is an outpatient endoscopic procedure. Patients do not need to stay in the hospital, this procedure can be done and the patient returns home after the procedure.

The gastric balloon (some call it the stomach balloon) is a medical device that is placed into your stomach while you are under local anesthesia. As an endoscopic procedure, this balloon is inserted through your mouth. The balloon is only inflated after it is in your stomach, after which you will remain in the clinic to be monitored for a few hours.

The balloon makes you feel full faster after eating, and will remain in your stomach for 6 months. Gastric balloon patients will have to work harder than patients of other bariatric procedures in order to achieve higher weight loss.

The primary advantage of the gastric balloon is that it is quick and done without surgery required. It is suitable for patients who do not meet certain requirements for other surgeries, such as BMI lower than 35, or if it is dangerous for them to go through bariatric surgery due to certain health conditions. Some people have conditions that put them at risk, and they are required to lose some weight before they go through surgery. For them, the gastric balloon is a great alternative to bring their weight down to a level suitable for surgery.

The balloon is removed from the patient’s body after 6 months, restoring the patient’s stomach size back to normal. When considering the gastric balloon, one should treat it as a procedure that helps the patient get used to eating less; preparing them for life after the balloon is removed from their body. If your eating habits are not controlled after the balloon is removed, then there is a high chance you will regain the weight you have lost.

After-effects

The gastric balloon is less complicated compared to other bariatric procedures, but as a result will also require more effort from the patient to produce major weight loss.

Weight loss – The weight loss for this procedure depends on the patient’s efforts. The balloon is responsible for making the person feel full faster, but the patient has to follow the doctor’s diet plan and exercise. After the balloon is removed, patients will regain the weight they have lost if they do not commit to the lifestyle they adopted during their gastric balloon treatment.

Improvement of comorbidities – With the loss of weight also comes the improvement of comorbidities. While not as drastic as the other procedures, comorbidities will still improve as long as the patient loses weight during the period of treatment.

Balloon deflation – Although the chances are very low, there is a possibility that the balloon deflates. If it deflates to a size that is small enough, there is a risk that it will move through your digestive system. This will cause discomfort and blockage that requires surgery to remove the balloon.

Stomach ulcers – Our doctor will prescribe pills for you to take during your treatment, this is to prevent any risk of your stomach developing ulcers or extreme discomfort caused by the balloon.

Stomach discomfort – You may feel discomfort for a while after the balloon is placed, it may take some time to get used to the balloon in your body. If the discomfort persists or you feel worse after a period of time, consider consulting your doctor again to reduce the risk of stomach illnesses developing.

As mentioned, bariatric surgery is often life-changing and brings about permanent results; it will be scary to be put in a position where you have to choose to make changes that you will be stuck with for the rest of your life. The choice is not easy to make, but for some people it may very well be an important consideration if:

Your BMI is over 35

Your BMI is over 32.5 and you experience one or more of the following health conditions:

• Type-2 Diabetes
• Hypertension
• Heart complications
• Sleep apnea
• Frequent soreness or pain in your joints (osteoarthritis)

Your weight causes you to experience difficulty in day to day basic functions such as:

• Breathing
• Walking
• Feeling out of breath after light or moderate physical activity

You are ready for a lifelong commitment

For Sleeve Gastrectomy, One-Anastomosis Gastric Bypass and Roux-en-Y Gastric Bypass, you will have to be prepared to commit to a lifelong habit of a diet given by your doctor; as well as supplements to cope with vitamin deficiency.

For gastric balloon patients, you will have to be ready to make re-visits to the doctor to and be wary of any complications that may arise due to issues with your gastric balloon.

You want to cultivate a healthier lifestyle

Surgery cannot replace healthy habits. Simply controlling food intake is not enough, the proper amount specified by your doctor must be followed to ensure complications do not arise. Physical activity such as exercise or sports for pre-surgery and post-surgery should also be discussed with your doctor.