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case records of themassachusetts general hospital

The

new england journal of

medicine

n engl j med 351;7

www.nejm.org august 12, 2004

696

Founded by

Richard C. CabotNancy Lee Harris, m.d.,

Editor

Jo-Anne O. Shepard, m.d.

,Associate Editor

Stacey M. Ellender,Assistant Editor

Sally H. Ebeling,Assistant Editor

Christine C. Peters,Assistant Editor

Case 25-2004: A 49-Year-Old Womanwith Severe Obesity, Diabetes,

and Hypertension

Janey S. Pratt, M.D., Susan Cummings, M.S., R.D., Deborah A. Vineberg, Psy.D.,

Fiona Graeme-Cook, M.D., and Lee M. Kaplan, M.D., Ph.D.

From the Weight Center (J.S.P., S.C.,D.A.V., L.M.K.), and the Departments ofSurgery (J.S.P.), Psychiatry (D.A.V.), Pa-thology (F.G.-C.), and Medicine (Gastro-intestinal Unit) (L.M.K.), MassachusettsGeneral Hospital; and the Departments ofSurgery (J.S.P.), Psychiatry (D.A.V.), Pa-thology (F.G.-C.), and Medicine (L.M.K.),Harvard Medical School.

N Engl J Med 2004;351:696-705.

Copyright 2004 Massachusetts Medical Society.

A 49-year-old woman was evaluated at this hospital for the management of obesity. She

had been overweight since childhood; at the age of 10 years she weighed 45.4 kg, at theage of 18 she weighed 88.5 kg, and throughout most of her adult life she weighed be-tween 108.9 and 129.3 kg. She was able to lose weight on more than 10 occasions with

diet and exercise but always regained it within two to three years. Dexfenfluramine wasprescribed for weight loss when she was 40 years old, and she lost 11.3 kg but gained

22.6 kg after she stopped taking the drug.Ten years earlier, diabetes mellitus had been diagnosed; it was controlled with met-

formin hydrochloride and glyburide. Twice within the 12 years before the evaluation,the woman had noted intermittent, sharp pain radiating down her left leg. Plain radio-graphs showed that there was narrowing of the disk spaces between the second and

third and the third and fourth lumbar vertebrae and first-degree spondylolisthesis ofthe fifth lumbar vertebra. Despite several courses of physical therapy and the intermit-

tent use of ibuprofen, intermittent pain persisted.An episode of exertional chest pain had occurred five years before the evaluation; ra-

dionuclide scanning of the heart revealed a large anterior defect suggestive of ischemia.Coronary-artery angiography demonstrated 50 percent occlusion of one coronary ar-tery. Aspirin and pravastatin were prescribed.

Three years earlier, treatment with insulin had been started because of inadequatecontrol of blood glucose. At the same time, hypertension was diagnosed (blood pres-

sure, 164/114 mm Hg), and treatment with lisinopril was started. An ophthalmologist

diagnosed diabetic retinopathy. Two years earlier, the patient had reported the sensa-tion of burning on the soles of her feet that awakened her at night. Gabapentin was pre-scribed. She had experienced episodes of depression intermittently for 11 years; theyhad been treated first with bupropion and for the past 3 years with fluoxetine.

The patient (gravida 2, para 2) had delivered both her children by cesarean sectionand worked as a registered nurse for a health care agency. A tonsillectomy had been per-

formed when she was 14 years old. She was allergic to penicillin. She had been divorced

pres en t at i on of cas e

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tidisciplinary, long-term approach. Members of

this patients multidisciplinary clinical team willdiscuss aspects of her assessment and care.

medical evaluation

Dr. Lee M. Kaplan:

The medical evaluation of this pa-

tient with obesity was focused on identification ofthe causes and complications of the excess weight

and on treatment to reverse them or prevent their

progression. Therapeutic decisions in a case such as

this one are guided by the degree of obesity and theseverity of the medical and psychological compli-

cations. For the majority of persons with obesity, aspecific cause cannot be identified.

2

Even when en-docrine disorders such as hypothyroidism or Cush-

ings disease are present, they are rarely the causeof the obesity. In an increasing number of patients,

the onset or exacerbation of obesity correlates withthe use of medications that cause weight gain as a

side effect. When I first saw this patient, she wastaking insulin, which is commonly associated withweight gain, and fluoxetine, which causes weight

gain in a minority of patients. However, she hadbeen severely overweight since late childhood, be-

fore those medications were administered.The common disorders associated with obesity

can be divided into five major categories: metabolic,structural, degenerative, neoplastic, and psycholog-

ical (Table 2).

2

Several of them (obstructive sleep ap-nea, thromboembolism, and degenerative arthritis)result from both structural and metabolic dysfunc-

tion. The relationship of each complication to thebody-mass index varies widely, with the risk of dia-

betes and other metabolic complications increas-ing at a body-mass index as low as 23 to 25 and therisk of anatomical complications increasing most

strikingly in persons with severe obesity. Among themany complications of obesity, obstructive sleep

apnea, fatty-liver disease, gastroesophageal refluxdisease, fungal skin infections, and nutrient defi-

ciencies are the most commonly undiagnosed or un-

dertreated complications in patients presenting forcare at a specialized obesity center.

2

This patient

had diabetes, hypertension, and hyperlipidemia. Aspart of the initial evaluation, a sleep study was con-

ducted, which showed that she had sleep apnea. Al-though it was not among the symptoms she initial-

ly described, she later reported that she had snoredand had had difficulty sleeping for many years.

People with obesity have an elevated risk of all

the diseases for which patients are most commonlyscreened: hypertension, hyperlipidemia, diabetes

mellitus, and cervical, breast, prostate, and colorec-tal cancers. Ironically, however, several studies have

shown that they are less likely to undergo screen-ing for these disorders than are people of normalweight.

1,2

In this patient, screening was complete

and up to date. The strongest medical contraindica-tions for weight-reduction surgery are severe lung

disease, unstable cardiovascular disease, uncon-trolled clotting disorders, portal hypertension with

Table 2. Complications of Obesity.

MetabolicType 2 diabetes mellitusHypertensionHigh cholesterol levelPlatelet dysfunctionThromboembolic diseaseFatty liver disease (nonalcoholic steatohepatitis)GallstonesPancreatitisReproductive dysfunctionCentral hypoventilation syndromeAsthmaNutritional deficiencies

StructuralObstructive sleep apneaGastroesophageal reflux diseaseAsthma associated with gastroesophageal reflux diseaseVenous insufficiencyVenous thrombosisPseudotumor cerebriSkin infections and ulcersStress incontinenceInjuries

DegenerativeAxial arthritisVertebral disk diseaseAtherosclerotic cardiovascular diseaseComplications of diabetesLeft-ventricular hypertrophyRight-sided heart failureCirrhosis associated with nonalcoholic steatohepatitisAlzheimers disease

NeoplasticEndometrialBreastOvarianCervicalProstateColorectalEsophageal adenocarcinoma (secondary to gastroesophageal reflux

disease)

GallbladderPancreaticRenal cell

PsychologicalDepressionAnxiety and panicBinge eatingReactive bulimia



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699

gastric varices, pregnancy, and ongoing substance

abuse. This patient had none of these disorders.

nutritional evaluation

Susan Cummings:

This patients comprehensive nutri-tion evaluation included the assessment of anthro-

pometric data and social, nutritional, and behavior-al factors. Our objectives were to assess her risk for

complications of obesity, to identify factors con-tributing to her obesity, if possible, and to provide

baseline data to assess the outcomes of treatment.The measurements of height, weight, and waist

circumference provide an indication of a patients

risk for complications of obesity (Table 3).

1,2

Calcu-lations based on the patients height, weight, and

age are used to estimate energy expenditure (Table4).

3

This patients weight put her at extremely high

risk for complications. Her energy needs were esti-mated to be 2500 kcal per day to maintain her cur-

rent weight, but her reported intake was approxi-mately 3000 kcal a day 500 kcal more than hernet energy needs.

The patients weight history and that of her fam-ily may give some indication of a genetic predispo-

sition. In this patient, the weight history revealedthat the onset of obesity was in late childhood andthat her highest weight as an adult was 129.3 kg, the

weight at the time of her presentation to us. Herlowest adult weight was 79.4 kg, immediately after

dieting. Her dieting history included four commer-cial programs and many self-directed diets. She had

lost as much as 38.5 kg at one time through dieting,

but like many people she always regained moreweight than she had lost from each diet, and she

had gained more than 45.4 kg overall during

adulthood. Her family history revealed obesity inboth parents and three brothers.

The nutrition evaluation included a 24-hour re-call of total food intake and the frequency of foodintake, as well as inquiry into hunger, satiety (how

frequently she experienced hunger and what madeher feel satiated), and behaviors such as binge eat-

ing, grazing (eating not related to hunger), night-time eating, eating in restaurants, and alcohol con-

sumption. This information helped to determinethe patients usual food intake and provided an in-dication of the environmental influences on her eat-

ing patterns. Most of her calories were consumedat meals with large portions of calorically dense

foods. She ate three meals a day but occasionallyskipped lunch and had a planned snack in the mid-

afternoon. She often ate in fast-food restaurants.The assessment of physical activity included in-

formation about the activities of daily living, physi-cal limitations, and structured exercise. This patientwas sedentary and did not engage in a structured

program of exercise because of her chronic backpain. The patients expectations concerning ideal

weight were also addressed, as were her self-efficacy(confidence in the ability to make the necessary be-havioral changes), motivation, readiness for weight

loss, and potential barriers to treatment. This pa-tients primary motivation to lose weight was to im-

prove her overall health and well-being.

psychological evaluation

Dr. Deborah A. Vineberg:

Psychological assessment ofpatients with obesity was once thought to be impor-

* The risk of disease is calculated for type 2 diabetes, hypertension, and cardiovascular disease. The information is fromthe National Institutes of Health.

1

NA denotes not applicable.

An increased waist circumference can denote increased disease risk even in persons of normal weight.

Table 3. Assessing Obesity: Body-Mass Index, Waist Circumference, and Risk of Disease.*

Category Body-Mass Index Obesity ClassDisease Risk Relative to Normal Weight

and Waist Circumference

Men, 102 cm,or Women, 89 cm

Men, >102 cm,or Women, >89 cm

Underweight 40 III Extremely high Extremely high



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tant in identifying the cause of the obesity, whichwas believed to be related to a lack of self-control or

to a psychological addiction to food. The currentunderstanding is that the most important reasons

for this evaluation are to diagnose and treat psycho-logical disorders that result from the obesity, com-

pound the existing weight problem, or interfere

with effective treatment. Pretreatment evaluation ofthis patient included screening for psychiatric dis-

orders that could interfere with the management ofobesity. Axis I disorders in the Diagnostic and Statisti-cal Manual of Mental Disorders

, fourth edition (psychi-atric disorders that are clinical in nature,

4

such as

depression or anxiety) and eating disorders (suchas binge eating or bulimia) can complicate medicalmanagement unless they are treated adequately.

This patient reported poor self-esteem and a pro-found sense of inferiority that she attributed to be-

ing overweight. She reported that stressful events,including the births of her children and her divorce,

had exacerbated her weight problem. At the time ofher evaluation she identified her job, single parent-hood, and her declining health as stressful factors

in her life. At the initial evaluation her Beck Depres-sion Inventory

5

score was 19, which corresponds

to mild-to-moderate depression. Obesity is strong-ly associated with depression. Persons over 50 years

of age who are obese are twice as likely to become

depressed within five years as those who are notobese,

6

but when followed for five years, those

who are depressed are not at increased risk of be-coming obese. Thus, obesity is a risk factor for de-pression, but the converse is not true.

Psychological complications associated withgastric bypass are similar to those associated with

other major surgical procedures; transient postop-erative depression is the most frequent complica-

tion. Exacerbation of preexisting psychiatric anxietyor depression is rare, and more than 90 percent ofcases of depression and 50 percent of cases of anx-

iety disorders improve.

7

Depression before weight-loss surgery does not worsen outcomes

8

; in fact,

one study found that patients with higher Beck De-pression Inventory scores lost more weight after

surgery than those with lower scores.

9

This patient described neither binge eating nor

inappropriate behaviors such as self-induced vom-iting or the use of laxatives or diuretics. She demon-strated good insight into the psychological function

of her weight, which she characterized as providingher with a sense of safety and a form of protection.

She admitted to being fearful of substantial weightchange, and she worried about her potential forself-sabotaging behavior. She was provided addi-

tional sessions with a psychologist to address theseconcerns.

The presence of an Axis II disorder (a personalitydisorder or mental retardation) can lead to difficul-

ties in management or can be a contraindication to

surgery and should be addressed before surgery isundertaken. This patient did not have an Axis II dis-

order, and she had no family history of psychiatricdisorders. Thus, she did not have psychiatric con-

traindications to surgery.We also discussed her personal support system,

since the involvement of family or friends in medicaland surgical treatment of obesity can improve theoutcome.

10

She reported that both her family and

her friends were supportive of her efforts to loseweight.

weight-loss surgery

Dr. Pratt:

A clinical-team meeting of the obesity-medicine specialist, nutritionist, and psychologistconcluded that this patient was a suitable candidate

for bariatric, or weight-loss, surgery. The term bar-iatric comes from the Greek word baros, meaning

weight, and refers to the treatment of weight dis-orders. Many different surgical procedures have

* The resting metabolic rate is derived from the HarrisBenedict formula.

3

Table 4. Estimating Energy Expenditure.

Resting Metabolic Rate (RMR)

*

For men:66.5+(13.75weight in kg)+ (5.003 height in cm)(6.775agein years)

For women:

655.1+ (9.563 weight in kg)+ (1.850 height in cm) (4.676 age in years)

Activity Factors

Sedentary little or no exercise

Daily calorie expenditure = RMR1.2

Lightly active (light exercise or sports 13 days/wk)


Moderately active (moderate exercise or sports 35 days/wk)


Very active (hard exercise or sports 67 days/wk)


Extra active (very hard daily exercise or sports and physical job or twice-a-daytraining)




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been tried during the past 50 years, but there are

three major categories in current use: restrictive op-erations (gastroplasties with the use of adjustable

gastric bands), malabsorptive operations (biliopan-creatic diversions), and gastric bypasses. Each canbe performed either laparoscopically or in an open

fashion. The standard types of gastric bypass do notcarry the risk of clinically significant protein mal-

nutrition that is associated with biliopancreatic-diversion procedures.

Weight-loss surgery provides the best long-termresults for patients with moderate (class II) or severe(class III) obesity who have not responded to more

conservative approaches.

11,12

It is generally reservedfor patients with a body-mass index greater than 40

or for those with a body-mass index greater than 35whose obesity is complicated by one or more major

diseases. This patient met the criteria for this ap-proach, since she had a body-mass index of 52 and

several major complications and was unable tomaintain weight loss by other means.

The overall morbidity and mortality associated

with gastric bypass surgery are approximately 10percent and less than 1 percent, respectively.

13,14

Early postoperative complications of laparoscopicgastric bypass surgery include wound infections (in-cidence, 3 percent), anastomotic leak (2 percent),

bowel obstruction (2 percent), gastrointestinal hem-orrhage (2 percent), and pulmonary embolus (less

than 0.5 percent). Late complications include bow-el obstruction (3 percent) and stomal stenosis (5 per-

cent)

13

; both of these problems are more common

after laparoscopic procedures than after open pro-cedures. Although reported in less than 1 percent of

cases,

7

anastomotic ulcers have been one of themost common late postoperative complications in

my experience. In patients who have gastric bypasssurgery, there is often improvement or resolution

of coexisting diseases such as diabetes,

15

hyperten-sion, hyperlipidemia, and sleep apnea,

12

as well asimproved quality of life.

7,14

For this patient, my col-

leagues and I believed that the risks of continuedobesity outweighed those of bariatric surgery and

its potential complications.Laparoscopic Roux-en-

Y

gastric bypass was rec-

ommended, because this procedure is associatedwith the best long-term outcomes.

14,16

This opera-tion includes a restrictive procedure and a short-

limb gastroduodenal bypass (Fig. 1). It does not re-sult in protein-calorie malabsorption, but it appears

to induce neurohumoral effects that result in de-creased hunger, accelerated postprandial satiety,

and diminished emotion-based or reward-based

eating.

2

The physiological and molecular mecha-nisms of these effects remain poorly understood.

In the current case, preparation for surgery in-volved the full multidisciplinary team. The preoper-ative nutrition program included an individual ses-

sion of nutrition counseling with a dietitian and agroup education session to familiarize the patient

with the postoperative diet protocol. The diet to befollowed after gastric bypass surgery is advanced in

a staged approach (Table 5). Psychological counsel-ing was instituted to assist the patient in making

Figure 1. Roux-en-Y Gastric Bypass Surgery.

This operation includes a restrictive procedure, creating a small proximal gas-

tric pouch, followed by the creation of a jejunojejunostomy in a Y configura-

tion to allow an end of the jejunum to be brought up and anastomosed to thisproximal pouch.

Gastric pouch

Gastrojejunostomy

Jejunojejunostomy

Loop of jejunum

Retrocolic, retrogastricetrocolic, retrogastricpassage of loopassage of loopRetrocolic, retrogastricpassage of loop



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the behavioral changes that would be required after

surgery. The preoperative medical evaluation includ-

ed a thorough assessment of the operative risks andthe need for perioperative management of coexist-

ing diseases, with discussion among the obesity-medicine physician, anesthesiologist, and surgeon

to optimize her care.The operation took about three hours. The sur-

gical team first gained access by placing two 12-mmports and three 5-mm ports through the abdominalwall in the upper abdomen one for a camera, one

for the liver retractor, one for stapling devices, andthe other two for graspers to manipulate the stom-

ach and intestines. The stomach was first dividedby staplers across the cardia, creating a 30-ml prox-

imal gastric pouch (Video Clip 1 in the Supplemen-tary Appendix, available with the full text of thisarticle at www.nejm.org). We then created a 100-cm

Roux limb by dividing the intestines, stapling a je-junojejunostomy (Video Clip 2 in the Supplementary

Appendix), and passing the limb behind the colonand stomach (Video Clip 3 in the Supplementary Ap-

pendix). Finally, this limb was stitched to the pouch

in a double-layer anastomosis 1.5 cm in diameter(Video Clip 4 in the Supplementary Appendix). Be-

cause the liver appeared fatty, a wedge-biopsy spec-imen of the liver was obtained. Postoperatively, anamidotrizoic acid (Gastrografin) swallow examina-

tion confirmed that the gastrojejunal anastomosiswas intact and without leak. The patient was dis-

charged on the third hospital day while following astage 1 diet (Table 5).

Dr. Fiona Graeme-Cook:

The specimen obtained byliver biopsy revealed hepatocellular steatosis with a

very few foci of ballooning degeneration; the portaltracts showed slight proliferation of the bile ductules

with minimal chronic inflammatory infiltrate (Fig.2A). Glycogenated hepatocellular nuclei were scat-

tered. These findings are consistent with the pres-ence of nonalcoholic fatty liver disease, without ev-idence of steatohepatitis, fibrosis, or cirrhosis.

In the presence of insulin resistance, high levelsof circulating insulin lead to high levels of free fatty

acids within the liver, increasing the synthesis oftriglycerides. Although the mechanism is not com-pletely understood, hepatocytes accumulate fat,

manifested as hepatocellular steatosis. This is themost common finding in the liver in patients with

severe obesity, present in more than 75 percent ofcases. The additional feature of glycogenated nuclei

is also a marker for insulin resistance and hypergly-

cemia. Steatohepatitis may complicate steatosis,possibly as a result of excessiveb

-oxidation of fatty

acids by hepatocellular mitochondria. The resultantoxidative stress is thought to lead to peroxidation of

lipids, resulting in hepatocyte necrosis, an influx ofmononuclear inflammatory cells, and eventually, fi-

brosis and cirrhosis (Fig. 2B).

17,18

Dr. Kaplan:

During the early postoperative period,

the patients most prominent symptom was consti-pation, which was probably a result of mild dehy-

dration. The mobilization of stored fat by lipolysisconsumes prodigious amounts of water, and fluidrequirements are high during the first several

months after surgery. During the first few weeks, pa-tients are closely monitored for dehydration, which

may be manifested as constipation, lethargy, orlight-headedness. The use of diuretics or other an-

pat h olog i cal di s cus s i on

di s cus s i on of out com e

Table 5. Protocol for Diet after Gastric Bypass Surgery.

Stage 1

12 days after surgeryConsume no-calorie, noncarbonated, decaffeinated, clear beverages

Stage 2

12 wk after surgery

Consume 600 ml (minimum) of stage 1 liquids plus 600 ml (minimum)full liquids (skim or 1% milk with Instant Breakfast with no sugar added,blended low-fat yogurt, diet pudding made with skim or 1% milk, tomatosoup made with milk, soy-protein powder mixed with milk), and no con-centrated sweets

Stage 3

324 wk after surgery (a transitional phase, with advancement to a solid-fooddiet as tolerated)

Soft, moist foodsBegin with cooked, moist, protein-rich foods (eggs, fish, poultry) diced

smallAdd cooked vegetables; avoid raw vegetables until 1 mo after surgeryAdd whole-grain starch to diet gradually

Guidelines:Do not drink fluids with mealsTake very small bites, chew very well, stop when comfortably full

Plan 3 meals a day, no more than 5 hours apart, with protein at eachmealGradually add vegetables, fruit, and starch; take 23 bites of protein

before eating vegetables, starch

Stage 4

(24 wk after surgery, or as tolerated)Solid-food diet

Avoid carbonated beveragesPlan all meals and snacksAvoid eating when not hungry, eating high-calorie soft foods, and

drinking beverages with meals



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tihypertensive agents often must be reduced orstopped altogether in the immediate postoperative

period. This patients blood pressure remained nor-mal, and the lisinopril was discontinued without ad-

verse effect. Her blood sugar levels became normalwithin two days after surgery, despite the discontin-uation of insulin and metformin. This rapid im-

provement in insulin sensitivity within several daysafter surgery is typical, and many patients require

little or no therapy for their diabetes during thistime. To avert potentially life-threatening hypogly-

cemic episodes, her blood glucose levels were mon-itored frequently and insulin and sulfonylureas wereavoided.

Ten days after surgery, she had lost 9.1 kg. Threemonths after the operation, she was eating three

meals and two snacks daily and had lost 27.2 kg.Six months after surgery, she had lost 37.2 kg and

was eating most foods without having symptoms.

Participation in postoperative programs of nutritioneducation and cognitive behavioral therapy appears

to minimize both short-term complications relat-ed to nutritional issues and subsequent weightgain.

10,11

Beginning six months after surgery, the

patient participated in a monthly program for sur-gical support and education, which provides ongo-

ing support and counseling. Her weight decreasedby 54.4 kg, to 70.3 kg, during the first 12 months

after surgery. Excess skin with ptosis in the lower ab-domen was treated with abdominoplasty 15 monthsafter the weight-loss surgery. She later regained ap-

proximately 4.5 kg, and her weight then stabilizedat 74.8 kg for the next year.

nutritional outcome

Two years after surgery, the patients body-mass in-dex was 30, down from 52, and her energy expen-

diture was estimated to be about 1800 kcal per day,down from 2500 kcal per day. She ate three meals aday and did not routinely eat snacks. She experi-

enced satiety with half-normal portions of food, andher hunger returned about five hours after each

meal. She tolerated all types of food, although sheavoided concentrated carbohydrates at the begin-ning of each meal as a way of preventing the dump-

ing syndrome (i.e., rapid gastric emptying). She didnot have any change in her food preferences. She

walked 4.8 km a day and reported enjoying exercisefor the first time.

medical outcome

Two years after surgery, the patients diabetes im-

proved but did not completely resolve. She no long-er required insulin, and her metformin dose de-

creased from 850 mg taken three times daily to 500mg taken twice daily. Her levels of hemoglobin A

1

c

and urinary microalbumin fell (Table 1). Her dia-betic retinopathy did not progress. Her sleep apnea,hypertension, and folliculitis resolved. Her lumbar

back pain and sciatica improved substantially. Herhyperlipidemia remained well controlled with the

use of a lower dose of atorvastatin than she was tak-ing before the surgery, and there was no progres-

sion of her coronary artery disease.A deficiency of micronutrients is common after

gastric bypass surgery. We regularly assessed the

patients levels of iron, calcium, vitamin B

12

, vita-min D, and vitamin K. Iron deficiency developed ap-

proximately 10 months after surgery (Table 1). Itwas treated successfully with oral ferrous bisglyci-

Figure 2. Liver-Biopsy Specimen (Hematoxylin

and Eosin).

Hepatocellular steatosis with small-droplet and large-

droplet fat is apparent, with glycogenated nuclei (Panel A,

arrows). Panel B shows a liver-biopsy specimen from an-other patient with nonalcoholic steatohepatitis, with ste-

atosis, ballooning degeneration, and portal and lobular

mononuclear infiltrates.

A

B



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nate and polysaccharide iron supplementation. Be-

fore surgery, she had been found to have a vitaminB

12

deficiency, which occurs in a small number of

patients with obesity who have followed many dietprograms. Intranasal vitamin B

12

supplementationwas begun before the operation and was continued

afterward, and two years later she had normal levelsof vitamin B

12

(Table 1). Secondary hyperparathy-

roidism from malabsorption of calcium and vita-min D occurs in more than 60 percent of patients

after gastric bypass. Metabolic bone disease is com-mon and must be screened for and treated. This pa-tient took prophylactic supplementation with an

oral calcium preparation (1000 mg of elemental cal-cium per day), and her levels of calcium, vitamin D,

and parathyroid hormone have remained normal.

psychological outcome

Six weeks after the operation, the patient recognized

feelings of loss related to being unable to overin-dulge in food. She commented, You fixed my stom-ach, but I need to fix my head, alluding to the need

to focus on psychological triggers for eating thatcould no longer be satisfied by food. Twelve weeks

after surgery, she reported feeling great. She wasexcited about her increased energy, and the BeckDepression Inventory score fell to 3, within the

range of minimal depressive symptoms, and it re-mained at that level thereafter. She stopped taking

fluoxetine.Two and a half years after the gastric bypass sur-

gery, both her self-confidence and her self-esteem

have increased. She is more assertive in her relation-ships, with positive results.

Dr. Pratt:

This case illustrates the importance ofa multidisciplinary team that includes an obesity-

medicine specialist, a nutritionist, a psychologist,and a surgeon to ensure optimal medical and psy-

chological results from weight-loss surgery.

1,10,19

Although this patient was able to initiate exercise onher own, it is important to include a physical thera-

pist or trainer when needed. Although her obesitywas not cured, since her body-mass index remained

elevated (at 30), the team viewed this case as havinga successful outcome.

Dr. A. Benedict Cosimi (Surgery): How would youassess whether the patients psychological issues

were solved or complicated by the surgery? This pa-

tient considered her weight a protective shield. Howdid she feel when this shield disappeared?

Dr. Vineberg:

Instead of using the weight as a pro-tection, she worked to establish appropriate bound-aries with people in her life, so that she could main-

tain appropriate emotional distance that did notdepend on the physical or emotional distance

caused by her size.

Dr. Kaplan:

It is not clear whether the protection

that she felt the excess weight provided was a pri-mary or a secondary event. If you are shunned in so-ciety because of obesity, you may then use the weight

as an excuse not to interact with people.

Dr. Carlos Fernndez-del Castillo (Surgery): The ad-

justable gastric band has been approved by the Foodand Drug Administration for use in the United

States. I anticipate that its application is an easieroperation than bypass. Why was it not used here?

Dr. Pratt:

The early experience with the adjust-able gastric band in the United States showed a highrate of reoperation,

20

and definitive studies of long-

term outcomes are not yet available. To achieve anoptimal outcome, the band has to be adjusted every

two to six months by the addition or removal of sa-line. This dependence on frequent follow-up visitssuggests that success with this procedure may be

more dependent on voluntary behavior than thesuccess observed after gastric bypass.

Dr. Jay Vacanti (Pediatric Surgery): Can you com-ment on the use of surgery in the management of

pediatric obesity?

Dr. Pratt:

Obesity in adolescents is being treatedsurgically in several centers around the country, in-

cluding the Weight Center.

21

Although the pediat-ric program here focuses primarily on behavioral

and medical approaches, gastric bypass surgery hasbeen used to treat a few teenagers with severe obe-

sity and obesity with medical complications, suchas type 2 diabetes mellitus or obstructive sleep ap-nea, who have not been responsive to other inter-

ventions. Recent studies have shown that resolu-tion of diabetes is most likely in patients who have

had it for less than five years, so waiting to performsurgery in children with type 2 diabetes may be more

dangerous in the long term than performing thesurgery.

22



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18. Neuschwander-Tetri BA, Caldwell SH.Nonalcoholic steatohepatitis: summary ofan AASLD Single Topic Conference. Hepa-tology 2003;37:1202-19. [Erratum, Hepa-tology 2003;38:536.]19. Blackburn GL, Greenberg I. Multidisci-plinary approach to adult obesity therapy.Int J Obes 1978;2:133-42.20. Ren CJ, Horgan S, Ponce J, et al. US ex-perience with the LAP-BAND system. Am JSurg 2002;184:46S-50S.21. Sugerman HJ, Sugerman EL, DeMariaEJ, et al. Bariatric surgery for severely obeseadolescents. J Gastrointest Surg 2003;7:102-8.22. Schauer PR, Burguera B, Ikramuddin S,et al. Effect of laparoscopic Roux-en-Y gas-

tric bypass on type 2 diabetes mellitus. AnnSurg 2003;238:467-85.Copyright 2004 Massachusetts Medical Society.

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