ADVANCES IN TREATMENT OF OBESITY
An interview with Dr. George R. Merriman II
An interview with Dr. George R. Merriman II
Dr. Merriman, you have been a specialist in bariatric surgery for the last 20 years. What would you say is the biggest change in the treatment that you have seen over the life of your career?
Currently, the biggest change lies in our understanding that the basis of the obesity problem is not what we thought. When I started my training in the early 1980s, I was taught that a gastric bypass was curative of morbid obesity. We had a woefully inadequate understanding of the problem. We understand today that obesity is a multi-factorial problem, based not only on genetics and behavioral issues, but also on environmental influences and psychological factors. We also now know that early intervention is very important. We don’t want to wait to treat and manage the problem until a patient is morbidly obese with significant comorbidities (associated health problems). A truly modern program treats the obesity epidemic as a chronic, incurable problem that fortunately can be well managed and in many cases driven into remission. Because obesity is such a widespread problem today, we are seeing significantly more research, funding and entrepreneurial efforts geared toward finding the best solutions to managing the problem.
We have been hearing about the newest non-surgical procedure for weight loss called the gastric balloon. Can you tell us how this works?
The device comes as a deflated silicon balloon that is placed through the esophagus into the stomach with an endoscope (the same tool used to look for ulcers, etc.) and is done with sedation rather than general anesthesia. Once placed, the balloon is inflated with saline solution and can remain in the stomach for up to six months. Following the balloon removal, the patient participates in a support program for an additional six months.
The main mechanism by which the intragastric balloon works is by profoundly delaying the speed at which food empties from the stomach. This maintains a prolonged sense of fullness and therefore inhibits hunger. Also, by occupying space in the stomach, the balloon reduces the amount of food a patient can eat at one sitting, significantly reducing daily calorie consumption. This new device is a powerful tool to jumpstart a patient’s weight loss and transition into a lifestyle and support system which can manage their problem long-term.
I understand that you were the first doctor in the area to be chosen and trained to place both the Orbera and ReShape gastric balloon systems. What is the difference between the two balloons on the market, and how have your patient results been with balloon?
The Orbera is a single-balloon system, and ReShape is a dual-balloon system. There are factors which would guide a patient to one system or another, and I discuss these in detail with each patient. I have been very pleased with our results so far, as they are profoundly better than what was achieved during the FDA trials of both devices. We know the average amount of weight loss with a traditional, medically managed sixmonth diet and exercise plan is about 5 percent of total body weight. Our average balloon patients are achieving 15-20 percent of total body weight loss prior to balloon removal.
If a person is not a good candidate for the gastric balloon, what other options can you offer for treatment?
There are three treatment pathways in my program to manage obesity: medical management (nutritional education, individualized simple exercise protocol, and any of the four new FDA-approved weight loss medications); devices (surgical lap band or non-surgical intragastric balloon); and permanent surgeries (sleeve gastrectomy, gastric bypass, SIPS/SADI). In some cases more than one pathway will be used at the same time to achieve optimum results. Determining which pathway or combination of pathways is best for a patient is a highly individualized decision. We spend time both in group educational meetings and in one-on-one consultations educating the patients about their problem and the options.
What is the cost of these treatments and does insurance cover them?
Insurance does not cover the intragastric balloon procedure. Cash-pay prices vary significantly based upon the pathway chosen, so we consult with each patient individually on what their cost will be. Many insurances cover the surgeries and medications, but it varies widely based upon the patient’s insurance company and employer.
What is the most surprising data you have seen in recent studies about the actual causes of morbid obesity?
The model I use to teach patients based on the most current research is that the origin of the obesity epidemic comes from the meeting of genetic predisposition with environmental influences. We used to think the environment played no role and the problem was purely genetic. In the past, we have believed our genetics was “hardwired” and unchangeable, and it either promoted or inhibited obesity (like a switch). Now we understand that our genetics are “software,” like the operating system on your computer or an app on your smartphone. When hooked to the Internet, this software may be exposed to viruses, malware and hackers. Your body’s “software” is constantly being altered by your environment, meaning obesity- promoting switches that had been turned off may get turned on. This explains why so many environmental factors beyond calories consumed play a role in the obesity epidemic, such as stress, chemicals, lack of sleep, depression, “gut microbiome” and hormone imbalance (i.e., pregnancy, menopause). This is why it is such a complex and difficult problem to treat. Many of these insights defy what we have believed to be commons sense. We were wrong.
For more information about these topics, we recommend www.freedomfromobesity.com, www.bariatric-surgery-source.com.