Weight Center Offers Multiple Approaches
This article originally appeared in Pathways, a magazine
published for physicians and the community by UMass Memorial Medical
The numbers paint a dire picture. One out of two Massachusetts adults is
either overweight or obese, according to statistics from the Massachusetts
Department of Public Health. And while the Commonwealth has the fourth lowest
level of overweight in the United States, the trend is alarming: the number of
overweight Massachusetts residents increased 30 percent in the last decade.
Nationwide, the numbers are even worse: 64.5 percent of U.S. adults are now
considered overweight (with a Body Mass Index or BMI of 25 or more), and 30.5
percent are obese (with a BMI of 30 or more). Severe obesity - a BMI of 40 or
more - now stands at nearly 5 percent, up from 2.9 percent a decade ago.
Obesity is a complex, chronic disease that involves multiple environmental,
genetic, physiological, metabolic, behavioral and psychological factors. Its
impact is just as far-ranging. Obesity increases the risk of illness from dozens
of serious medical conditions including cardiovascular disease, certain types of
cancer, hypertension and diabetes. And it is the second-leading cause of
preventable death in the United States, just behind tobacco-related deaths.
To combat these troubling statistics, the Weight Center at UMass Memorial
Medical Center offers a multidisciplinary approach for patients with obesity and
weight-related disease. Located on the University Campus, the center is staffed
by nutritionists, behavioral medicine specialists, physicians, surgeons, nurses
and support personnel. The facility is specially outfitted to meet the needs of
adults with significant weight problems. From chairs to examination tables to
scales, the equipment and furnishings are designed to create a comfortable
experience for patients who need guidance in losing weight and dealing with
Most important, programs are tailored to individual patient needs, says
board-certified internist and gastroenterologist Mitchell Gitkind, MD, medical
director of the Weight Center.
"Most patients we evaluate have BMI over 30, although patients with BMI
between 25 and 30 with weight-related risk factors are appropriate for
referral," he explained. "For many patients, a high-intensity weight loss
program involving an experienced multidisciplinary team is recommended.
Behavioral medicine specialists and dietitians evaluate poor eating habits and
counsel patients around developing healthier lifestyles. An internist evaluates
all patients with a BMI over 35, and medically complicated patients with lower
BMI. Triage and management protocols are based on established public health
recommendations including those from the National Institutes of Health and the
U.S. Preventive Services Task Force.
"Patients with BMI over 40, or over 35 with risk factors, are generally
considered to be candidates for bariatric surgery," Dr. Gitkind continued.
"These patients attend a special information session and have evaluations
coordinated by a team including a nutritionist, behavioral medicine specialist
and an internist before seeing a surgeon. This strategy allows optimal patient
selection and preparation for surgery," he adds.
"It's up to the individuals to ‘shine' in these forums and demonstrate their
commitment to making a drastic change in their lives," said John Kelly, MD,
surgical director of the Weight Center and chief of general surgery at UMass
Memorial Medical Center. "A lot of people qualify medically for bariatric
surgery, but they still need to have the psychological and behavioral counseling
to ensure a successful outcome." Moreover, most insurance companies that cover
bariatric surgery require multidisciplinary consultations as part of the
Dr. Kelly explains that there are two bariatric procedures available to
appropriate patients. Both are performed laparoscopically. The first is gastric
bypass, in which a row of titanium staples separates the stomach into a small
upper pouch and a lower, large pouch. The small intestine is separated from the
stomach and cut into two pieces; the intestine is then reattached to the upper
pouch, allowing food to bypass the lower pouch. The small intestine is then
reconnected in the shape of a ‘Y' below the stomach.
"Weight loss occurs through a combination of restriction and malabsorption,"
Dr. Kelly said. The new stomach holds only about a half-cup of food; after a few
bites, the patient feels full. Also, the body cannot absorb as much nutrition
because part of the intestine is not being used, making vitamin and mineral
The second procedure is known as adjustable gastric banding. This is a
relatively new procedure that has been performed for only about three years in
the United States (gastric bypass, on the other hand, has been performed for
nearly 30 years). An adjustable silicone ring is placed around the upper stomach
to create a small pouch with a narrowed outlet. The pouch fills quickly with
solid food and empties slowly to relieve hunger.
"Patients experience satiety and satisfaction with smaller portions," Dr.
Kelly said. He also noted that gastric banding, unlike gastric bypass, is
reversible. At UMass Memorial, Dr. Kelly and his colleagues performed 180
gastric bypass and 40 gastric banding procedures in 2003.
Which procedure is appropriate for which patients? "Most studies have shown
that gastric bypass enables patients to lose more excess weight," he noted. "So
if they have a tremendous amount of weight to lose and they're inactive, they
need the more drastic surgery to change their lives. The gastric banding
generally is best for patients in the lower BMI category who are very motivated
but feel they need some help."
Dr. Kelly also acknowledged that bariatric surgery is not for everyone. Nor
is it the be-all and end-all solution for significant, sustainable weight loss.
"It is long-term change in a patient's behavior that leads to long-term
weight loss," he stressed, which is why the UMass Memorial Weight Center takes a
comprehensive, multidisciplinary approach. "Surgery is a powerful and effective
tool to get certain patients to adopt more appropriate behavior.
"And for morbidly obese patients, surgery currently is the most effective
approach," he noted, pointing out that bariatric surgery enjoys a 70 percent
success rate for sustainable, long-term weight loss in this patient population,
while nonsurgical approaches have a dismal 95 percent failure rate.
The Weight Center holds regular orientation meetings to explain the services
offered and to collect information for triaging patients into appropriate