Bariatric surgery: Resources and story ideas for reporters

By Robyn Shelton
Orlando Sentinel

Background

There is no lack of coverage of the obesity crisis. Many newspapers have explored the causes of obesity and prevention/treatment efforts. The Orlando Sentinel runs a Health & Fitness section on Tuesdays that devotes much of its space to dieting and exercise topics.

But what about the reality? Anybody can lose weight, yet the majority regains their lost pounds and a few more. In desperation, more Americans are looking for help from the operating room. We decided to take a new look at bariatric surgery, which got a lot of attention in the early 2000s because of high rates of complications and deaths.

We found that the landscape for bariatric, or weight-loss, surgery has changed dramatically in recent years. More than 200,000 Americans are expected to undergo surgical procedures in 2008 to alter their anatomies and lose weight – up from slightly more than 16,000 in 1992.

The purpose of the stories was to explore the dangers, the advantages, the insurance challenges and the limitations of “America’s new weight-loss program.”

The stories

We ran a two-day series with photos, graphics and videos online of interviews and a surgical procedure carried out on a patient featured in one of the articles. The first day’s main story focused on the overall trend, documenting the rise in surgeries, complications and concerns raised by medical ethicists. The main bar featured Monica Ramos, a 26-year-old nurse who lost more than 200 pounds after gastric bypass surgery. Two short profiles of other patients also were published the first day. There was a secondary story that looked at the discrepancy in quality from one hospital to another, according to a group called HealthGrades.

The second day’s main bar focused on the insurance industry’s reluctance to pay for bariatric procedures, and a secondary story looked at gastric banding – an increasingly popular alternative to gastric bypass surgery.

Resources

The only Orlando hospital that offers bariatric surgeries refused to participate in the stories. I approached them in early 2007 to see if I could observe a surgery and follow a patient afterward to document the results. The hospital didn’t give a reason, saying only that it preferred not to be included.

The Sentinel had previously covered a 500-pound man married to a nurse who worked at the hospital, which offers its own health plan to workers. The hospital health plan refused to cover the man’s surgery, even though it offers the procedure and markets it heavily in the community.

In any case, I contacted a doctor in nearby Melbourne who was willing to bring us in on a surgery and connect us with patients. During the ensuing months, the reporting included interviews of physician experts nationwide, patients, the insurance industry, psychologists, medical ethicists, an advocacy group for the obese and others.

Several patients had their procedures years ago; others had them just prior to my meeting them. I checked back every few months with the recent patients to hear about their struggles, successes and ongoing progress.

There are good resources for covering bariatric surgery:

• Many hospitals and outpatient centers offer bariatric procedures. But most do not have the expertise needed to reduce complications and support patients afterward. What to look for? Hospitals that have received accreditation for bariatric surgery from either the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery. These “bariatric centers of excellence” have high volumes and reduced complication rates. They also offer ongoing services such as nutritional counseling, support groups and psychological care. Either organization can provide you with hospitals in your region that fit the criteria.

• The American Society for Metabolic and Bariatric Surgery also can provide data and offer experts from their organization. Phone: 352-331-4900.

• Some of the nationally recognized leaders in bariatric surgery are the Cleveland Clinic,University of Pennsylvania Hospital, University of California at Los Angeles and University of Texas Southwestern Medical Center.

• HealthGrades Inc. rates the quality of bariatric surgery at hospitals nationwide. The group issued a report in 2007 that described wide variance in complication rates among hospitals offering bariatric surgery. You can get data on your local hospitals. Just go to the HealthGrades site, select “free hospital ratings,” and then choose your state. Click on “Bariatric Surgery” and follow the prompts. You can also reach HealthGrades’ communications office at 720-963-6584. [See more about HealthGrades' ratings.]

• The federal Agency for Healthcare Research and Quality maintains data on bariatric procedures. Phone: 301-427-1364. You can access some statistics online. I find it helpful to get someone from the press office on the phone while navigating the Web site to ensure that you find the most recent data.

• Insurance industry. I interviewed the largest private insurer in Florida and then spoke with America’s Health Insurance Plans, an industry lobby in D.C., for a national perspective. America’s Health Insurance Plans phone: 202-778-3200.

• Obesity Action Coalition is an advocacy group for the obese. The organization’s leaders are well versed on insurance issues, patient access to bariatric procedures and impact on patients. It’s a national group based out of Tampa at 813-872-7835.

• Medical ethicists can provide good insight on the broader issues with bariatric surgery. Is it moral/responsible to subject people to the risks of surgery when alternatives exist? Conversely, is it moral to keep people from what could be a life-saving procedure? What does the growth in bariatric procedures say about our society? Have we gotten so obese that only drastic measures can save us? Is bariatric surgery the easy way out for patients?

• Nutritionists and psychologists: Most hospitals with bariatric accreditation have nutritionists and psychologists on staff who can answer questions about post-surgery diets and mental health issues.

• Patients are crucial for the stories and, fortunately, very easy to find. I met one patient through a physician’s office. The gentleman allowed us to watch his gastric banding procedure. The others came through varying means, but the Obesity Action Coalition also helped by sending out an e-mail to its membership. Several Orlando patients responded to me as a result.

• A search in PubMed will reveal numerous articles on bariatric surgery. Coincidentally, Archives of Surgery published several studies in October 2007 on bariatric surgery, complication rates and increasing use of the procedures. This provided me with very current, up-to-date data on complication and death rates.

Issues to explore

There are many topics worth examining. Here are the main issues I explored in the Sentinel’s two-day series:

• The surgical options. Gastric bypass surgery remains the most common weight-loss procedure in the United States. It is a complicated operation that involves multiple cuts in the small intestines and stapling of the stomach to reduce it to a tiny pouch. Less invasive options are becoming more popular, including having a band tied around the stomach to limit food (gastric banding) and having most of the stomach permanently removed (sleeve gastrectomy). The surgeries are usually done laparoscopically, which has led to lower complication rates and improved patient recovery.

• Risks and complications: The early days of bariatric surgery had a wild-west flavor. A lot of hospitals and surgeons were offering the procedures without much experience, often cutting patients loose with no ongoing support or follow-up. In an early analysis of complication rates, the Agency for Healthcare Research and Quality found up to 40 percent of patients had complications after surgeries. New data suggest that a sizeable portion of patients – 18 percent – still experience complications. But the vast majority of problems are usually minor in nature and resolve themselves before the patient leaves the hospital.

• Results: Bariatric surgery does not magically transform people from fat to thin. It is a long, painstaking process that can be demanding. Gastric bypass patients must balance liquids, food and supplements. The first year is especially daunting, and many can end up in the hospital with dehydration or potassium deficiencies if they’re not careful. The bottom line: Bariatric surgery is not a free ride. It requires ongoing diligence and effort by the patients.

• Impact on patients: Weight loss stories can’t ignore the dramatic impact that weight reduction has on peoples’ lives. The Sentinel’s stories included separate profiles of patients, who talked about how their lives have changed since losing weight. These included video interviews online.

• Insurance industry: Insurers are reluctant to pay for bariatric surgeries because of the mixed results that they’ve seen in the past. Some doctors and advocates say this is an outdated view. Lots to cover there.

My stories didn’t explore the following, but these are relevant issues that I would have investigated if space had allowed:

• Many people are going out of the country, mainly to Mexico, for gastric bypass or gastric banding. This is a direct result of the fact that most insurers aren’t paying for the procedures and people have to come up with the money themselves (roughly $30,000 for gastric bypass or $15,000 for gastric banding). It’s much cheaper to go to Mexico. But is it safe? [Read more about "medical tourism."]

• Long-term complications. This topic has been explored in recent years, but it’s worthwhile. After some lose weight, they develop new addictions such as drinking, gambling or compulsive shopping. Another possible problem: Sagging skin. Some patients actually suffer greater self-esteem problems as a result of surgery, when they are left with long, hanging folds of skin after losing 100 or more pounds. Cosmetic procedures to remove the skin aren’t covered by insurance in most cases, and the $10,000 or so for the operations is out of most patients’ reach.

• Teens. There are special considerations when teens undergo bariatric surgery. Are they old enough to understand the risks and accept the lifelong changes that must be made to keep the weight off?

Response

After the stories run, be prepared for an onslaught of callers who want to share their experiences with bariatric surgery. You might also receive a number of pleas for help in paying for the surgeries. The most touching request I received was from a 17-year-old girl who has dropped out of high school because of her weight. Her parents’ insurance plan will not pay for her surgery.

Also, a warning. If your paper allows readers to post comments about stories online, you may find hateful responses from the community. One day soon after the series ran, I was startled by a phone call from a distraught woman who had been featured as a successful gastric bypass patient. She was crying about some of the comments made about her. The online staff quickly went through them and removed the offensive ones. Just be prepared for callous and immature remarks.