A bid to expand eligibility for weight-loss surgery

Esther Eppler was deemed not heavy enough for weight-loss surgery.
Esther Eppler was deemed not heavy enough for weight-loss surgery.
Posted: January 03, 2011

After years of trying - and failing - to lose weight with diet and exercise, Esther Eppler decided last summer she was ready to take a more extreme step: surgery.

But Crozer Chester Medical Center gave Eppler, 46, of Boothwyn, some disappointing and ironic news.

At 5 feet tall and 174 pounds, she wasn't fat enough.

Her Body Mass Index (BMI) of 34 fell just short of what doctors and insurers usually require for weight-loss surgery.

Eppler, who has high blood pressure and a family history of diabetes, now has reason to hope she may yet get the procedure.

A Food and Drug Administration advisory panel last month recommended allowing doctors to use the Lap-Band, a less drastic form of weight-loss surgery, in somewhat thinner, but still obese patients. Those with BMIs of 30 to 35 and medical complications of obesity would qualify. People who are 5-foot-5 and weigh 180 to 210 fall in that range.

Currently, the FDA has approved the device only for people with higher BMIs: 40 and up, or 35 to 40 if they have other complications. The agency usually follows advisory committee recommendations, though it's unclear when a decision will come.

"That would be completely awesome," said Eppler, who sees her weight as both a health and self-esteem problem.

The Lap-Band, a saline-filled silicone band that a surgeon wraps around the upper part of the stomach, restricts how much people can eat at one time and makes them feel full faster.

According to Allergan, the company that makes the Lap-Band system, 64 million Americans are obese and 27 million of those - 42 percent - have BMIs of 30 to 35 and at least one other weight-related medical problem.

Noel Williams, director of bariatric surgery at Penn Medicine, said many doctors think the weight limits should come down for all types of weight-loss surgery. The procedures have gotten safer, he said, and they're more effective than drugs or diet.

But surgeons also said such changes would have little impact unless insurers agree to pay for the procedures, which cost from $14,000 to more than $26,000.

Insurers now typically require weight-loss surgery candidates to complete six months of a medically supervised diet and exercise program before surgery.

Leon Katz, director of bariatric surgery at Crozer Chester Medical Center, said he doubted insurers would hurry to offer the surgery to close to 30 million more people. "I think they will do absolutely anything and everything in their power to stall the process," he said.

Allergan also expects slow change. "We are anticipating upwards of two years for full reimbursement to be in place," spokeswoman Cathy Taylor said.

Don Liss, senior medical director at Independence Blue Cross, the Philadelphia region's dominant insurer, said his company would evaluate all the published data on surgery in thinner patients as well as guidelines from surgical groups and the National Institutes of Health after the FDA makes a decision. Typically, that process takes three to six months, he said.

Most Blue Cross plans cover weight-loss surgery, he said, though some employers decide to exclude it.

Liss said Lap-Band surgery was not to be taken lightly.

Though deaths are rare, about 1 percent of banding patients and 5 percent of bypass patients have serious complications during the first 30 days, according to the American Society for Metabolic and Bariatric Surgery.

The bands can slip, requiring further surgery. And patients can still overeat. "The lifestyle changes that one needs to adhere to to make it work are pretty significant," Liss said.

Tom Wadden, director of the Center for Weight and Eating Disorders at the University of Pennsylvania, said he supported the idea of giving more obese people the option of surgery. But, he said, the cost could be high for a country already struggling to pay its health-care bills.

"There's just no question that we can't treat our way out of the obesity epidemic," he said. Preventing obesity makes more sense, he said.

According to the bariatric surgery society, 220,000 morbidly obese people had bariatric, or weight-loss, surgery in 2009. Fifteen million people are morbidly obese.

Samuel Wasser, a bariatric surgeon at Lourdes Medical Center Burlington County, said he sees a patient a week who wants surgery but is too thin to qualify. Crozer hears from two or three a month.

Area surgeons said gastric bypass remained the most common weight-loss procedure and the one that gets the largest, longest-lasting results. It reduces the stomach from the size of a football to a golf ball, the surgery society says. The smaller stomach is attached to the middle of the small intestine, bypassing its first two sections.

An advantage of adjustable gastric banding is that it's reversible, but a downside is that it requires frequent adjustments. Patients lose less weight with this procedure and gain more of it back, but they still lose enough to improve health, surgeons said.

A procedure growing in popularity is vertical-sleeve gastrectomy, which uses staples to make a smaller stomach. It now constitutes up to 20 percent of bariatric procedures at Penn and about 10 percent at Lourdes.

Last month, an FDA panel also recommended approval for Contrave, a new diet drug with modest results. Wadden thinks Qnexa, a more effective drug that the FDA rejected in October, still has a shot at approval. There are concerns about side effects with both, said Wadden, a consultant to the makers of both drugs.

Wadden and colleague David Sarwer are studying chemical changes in the body after bariatric surgery. Wadden said there was evidence that changing the path food takes with bypass surgery created chemical changes in the body that affected appetite and insulin production. Surgeons report almost immediate improvement in blood sugar for diabetics, even before much weight is lost. Because they lose weight, Lap-Band patients also see improvement in diabetes but don't report the appetite change.

According to the surgery society, stomach bypass resolves Type 2 diabetes in almost 90 percent of patients, compared with 73 percent for band surgery.

In one study, Wadden's group will look at how patients with diabetes and lower BMIs respond to diet and exercise, Lap-Band surgery, and bypass surgery.

Debra Jenkins, a 58-year-old Philadelphia woman with a BMI of 33, had Lap-Band surgery as part of that study on Dec. 23.

She is on seven medicines for diabetes, sleep apnea, high cholesterol, high blood pressure, and acid reflux.

"Hopefully, this diabetes will just dissipate and I will be a happy camper," she said. "I will stick to my diet. I am so excited about this."

Contact staff writer Stacey Burling at 215-854-4944 or sburling@phillynews.com.

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