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All the Options for Serious Weight Loss

The first thing Santa Monica weight-loss physician and surgeon Carson Liu, M.D. will tell you is that the desire to lose serious weight, and how one chooses to go about it, is a deeply personal journey. Sometimes diet and exercise efforts are not enough to shed unwanted pounds—as any woman who has battled her hormones can attest, it’s often a much more complicated formula. With more than twenty years’ experience on the front lines of the obesity epidemic, Liu is an expert on all forms of weight-loss treatment options, from highly involved procedures to simpler diet and lifestyle changes. Below, he explains what is currently available, and offers advice for navigating the choice.

A Q&A with Carson Liu, M.D.

When do you recommend someone undergo a weight-loss procedure?

It’s of course ideal if you can get to a healthy weight by making changes to your diet and exercise routine, but for someone who has tried this over time and still cannot get to a preferable weight, I recommend considering a procedure. There are so many options today: Even people who only need to lose 25 to 60 pounds have procedures available that didn’t exist three years ago, although most are designed for people who have significantly more weight to lose. I’ve found that many people are deterred from seeking weight-loss procedures because they think, “I am not there yet,” or, “It’s too dangerous.” But there’s a lack of education around weight-loss procedures, and knowing and understanding the available options can help. Procedures range from non-invasive to very invasive (surgery). I like to start with the least invasive and go from there. I have seen many people succeed at losing weight with minimal help from an intervention, so it’s worth trying.

What makes a person a good candidate for weight loss procedures?

Most procedures are geared toward people who have a Body Mass Index (BMI) of 30 kg/m2 or higher. BMI is your body weight in kilograms divided by your height in meters squared. It’s a mathematical computation, and taken alone, it’s not always the best way to categorize people, as it tends to misrepresent muscle mass. For instance, body lifters may be determined to have an unhealthy BMI, even though they have lean muscle. In my office, we calculate fat percentage through bioimpedance–a test that conducts a low voltage through the body to measure the body’s resistance to conduction–and then use it with a patient’s BMI information to guide our recommendations for each individual. The combination of BMI and bioimpedance gives us a clearer picture of how unhealthy a person may be, as compared to just measuring weight and height as we do with a BMI calculation.

What are the types of weight-loss procedures, and how does each one work?

Procedures can be grouped into the following: Non-invasive (diet modifications, appetite suppression); minimally invasive (gastric balloons, AspireAssist, lap band); and surgical (stapling the stomach).

NON-INVASIVE

Diet Modifications: I highly recommend diet modification with meal replacements for all patients, regardless of other procedures or interventions they pursue for their weight loss: It invariably makes weight loss both quicker and easier. Seeking the expertise of a medical nutritionist will help to tease out what in your diet is causing you to gain weight and/or what is inhibiting meaningful weight loss. I also recommend support groups, such as Overeaters Anonymous, to help hone any emotional issues linked to the inability to lose weight. The important thing is to speak up at these group meetings.

Appetite Suppression: The next level of intensity includes pharmacological agents for appetite suppression. Patients can pursue these, but they have to understand that side effects come with every medication. These range and can include palpitations, sleepiness, agitation, or debilitating headaches. In the last five years, multiple appetite suppression drugs have received FDA approval for weight loss. There are four different, newer drugs on the market, including: Qsymia, Contrave, Belviq, and Lomaira. Qsymia and Contrave are combination drugs that work on the brain, with the the most common side effect being sleepiness. Belviq is a Serotoinin subtype 2 receptor agonist, so the drug binds to the brain’s receptors. Side effects for this include sleepiness or headaches. And Lomaira is an old drug, Phentermine, packaged in a very small dose to be taken immediately before a meal; it is the lowest cost of all the new drugs available.

MINIMALLY INVASIVE

Gastric Balloons: The new gastric balloons occupy space in the stomach, as well as disrupt the motility of the stomach and confuse it so that patients feel full and eat much less, depending on its position and size. The procedure takes less than ten minutes with twilight sedation, excluding the Obalon, which is done while awake (patients need to be able to swallow a pill the size of a small olive). The balloons are usually left in for a maximum of six months and retrieved with endoscopy. There are no surgical scars, as we place these balloons through the mouth and retrieve them with an endoscopic procedure under twilight anesthesia—a procedure that takes 20 to 30 minutes. It’s a safe procedure, but can cause nausea and vomiting.

I recommend gastric balloons to people who have as little as 25 pounds and as much as 60 pounds to lose. Patients must know they will have to continue to work on weight loss after the balloons are removed.

There are three FDA-approved balloons for weight loss: Orbera (single balloon), Reshape (dual balloon), and Obalon (three swallowable pills that turn into gas-filled balloons). Each balloon comes in various sizes, and patients choose the one that makes sense for their lifestyle: The Orbera is a single saline balloon that is usually 600 cc to 650 cc (that is about a third of most people’s stomach) in size; the Reshape balloon is a two-balloon system with 450 cc in each balloon (occupying a total space of 900 cc in the stomach); and the Obalon system is three separate gas filled balloons (250 ccs each) that are swallowed by the patient in pill form on three separate visits to the doctor.

Aspire Assist: Aspire Assist is a minimally invasive, reversible surgical procedure, which means it can be removed and the body’s anatomy restored. It’s a newer procedure, designed for patients who don’t typically chew their food well, which can contribute to digestion and weight issues. Between 15 and 40 minutes after a meal, the patient connects a drainage device to a disc on the outside of their abdomen. If the patient chews their food well, they will see more food draining from the device (up to 25 percent). If they eat quickly without chewing, all the food will be absorbed and weight loss will not occur. This tube doesn’t have a time limit, and patients can leave it in for six months, twelve months, two years, or longer. This is an amazing procedure that seems to work in all patients who are willing to try this tool—but it is important for patients to know they need to chew more and drink more water (which I tell patients for all procedures). There is no set time length, which is a particularly appealing aspect of this procedure.

“The most important thing to remember is anyone who elects to undergo a weight-loss procedure must change their lifestyle in order to help keep weight off in a permanent way.”

Lap Band: Another minimally invasive, reversible procedure is the lap band. It remains one of the safest surgical interventions—it is also covered by most insurance if patients qualify by their weight. It is FDA-approved for patients with a BMI greater than 30 kg/m2, and insurance companies will cover it if a patient’s BMI is 35 or greater and they have a co-morbid condition such as high blood pressure, diabetes, or sleep apnea. If they don’t have a co-morbid condition, insurance covers the procedure if the patient has a BMI greater than 40 kg/m2. The procedure entails placing an adjustable balloon around the outside of the upper stomach, near the junction of the esophagus and stomach. It’s an outpatient procedure, placed laparoscopically under general anesthesia. Patients can have the lap band for years, but a concerted effort needs to be made to change the diet within the first two to five years, or the weight loss will slowly creep back on.

SURGICAL

Stapling the Stomach (sleeve and gastric bypass): The stapling procedure on the stomach entails the sleeve gastrectomy and the gastric bypass. These are the most popular procedures, as insurance covers them. The sleeve gastrectomy requires stapling off and removing approximately 80 percent of your stomach, leaving a “sleeve” of stomach, approximately the size of a hot dog, behind. This is the only non-reversible procedure and presently, the most popular with patients.

The gastric bypass creates a stomach pouch the size of a golf ball and bypasses the beginning of the small intestine. The gastric bypass and the sleeve can stretch over the years, and if patients don’t change their eating and exercise behaviors, weight can creep back on.

The gold standard in surgical weight loss is the Gastric Bypass Roux en Y. This procedure has been proven to result in more weight loss—that stays off over time. The stomach is left at lower capacity for food (so people eat less) with minimal malabsorption of nutrients.

What should patients know before considering a weight loss procedure?

The most important thing to remember is anyone who elects to undergo a weight-loss procedure must change their lifestyle in order to help keep weight off in a permanent way. Weight loss is elective, and can be timed. Surgeons prefer to operate when a patient has lost a few pounds, rather than when they are at their highest weight or at their sickest, for that matter, especially if there is a threat of diabetes or high blood pressure.

There’s a pre-procedure phenomenon called the “last meal syndrome”— which happens to many patients, regardless of the procedure they’ve chosen—where people eat and eat, feeling as if they will never be able to eat again after their procedure. The reality is that you will be able to eat after your procedure, but just smaller amounts.

What are some of the risks to the more-involved surgical procedures?

With surgery, we always worry about complications of bleeding, infection, or injury to adjacent structures, but the minimally invasive surgeries are more accurate and much safer.

Any tips for recovering after undergoing a surgical weight-loss procedure?

Stay hydrated by taking small sips of water, and walk every hour, even just a few steps. These two things can help prevent almost all of the possible problems we see after surgery.

What lifestyle changes are most important following a weight loss procedure?

Over the past two decades observing patients, I have found a low-carbohydrate diet and daily walking will melt off almost all the weight people might lose with any of the procedures. Whether a person undergoes a lap band, sleeve, or balloon procedure, they can likely achieve weight loss by adjusting their diet and walking for 30-40 minutes every day.

Are there payment options if insurance doesn’t cover a procedure?

Payment options are always available through Care Credit or Lending USA. The gastric balloons, Aspire Assist, and Lap Band are FDA-approved, but insurance companies don’t generally cover them, with the exception of the Lap Band in patients with a BMI above 35 kg/m2 with a medical illness or a BMI above 40 kg/m2.

Carson Liu, M.D., is a leading bariatric surgeon in Santa Monica and Tustin, CA. He is a recognized expert in both weight-loss surgery and medical weight-loss programs, and is experienced in multiple surgical weight-loss techniques and methods. After earning his Bachelor’s degree in chemistry from the University of Chicago, Liu completed his M.D. at University of Chicago Pritzker School of Medicine, followed by his residency, internship, and fellowship at UCLA Medical Center, Department of Surgery, where he also served as Administrative Chief Resident.

The views expressed in this article intend to highlight alternative studies and induce conversation. They are the views of the author and do not necessarily represent the views of goop, and are for informational purposes only, even if and to the extent that this article features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment, and should never be relied upon for specific medical advice.