In 2008, at only 17 years old, Lindsay Green* decided the only way she’d get her weight down was through surgery.
At the time, Green was 6 feet tall and 215 pounds — “overweight,” by medical standards, but not “obese.” Still, she heard about the laparoscopic gastric band operation, one of several common weight loss surgeries, on the radio in Phoenix, Arizona, and was intrigued. “I was a young person and pretty susceptible,” she said. “All I wanted was to lose weight.”
After the $16,000 operation, her weight slowly dropped to a “normal” BMI of about 180 pounds. But she now had an eating disorder to contend with. The band made eating painful; she’d often feel like someone was screwing her rib cage closed after meals. To relieve the pressure, she’d vomit.
“I thought if I’m going to throw up no matter what, I might as well eat what I want, and eat as much as I want,” Green, who’s now a corporate wellness worker, said. She’d often opt for bags of Goldfish crackers or bowls of cereal; they hurt less than vegetables with fiber, like broccoli. “That’s the opposite of what you’d hope of trying to create someone with healthy eating habits,” she added.
After going into the doctor’s office to get her band adjusted four times, Green finally had the device taken out last year. Her weight has settled at around 205 pounds. She’s relieved she no longer has the band inside her.
Green’s story, it turns out, is more the rule than the exception. As the obesity epidemic has surged across America, more and more people with weight struggles are turning to weight loss, or bariatric, surgeries as a treatment. But ever since the lap band entered the mix in 2001, it’s gone from being one of the most common bariatric surgeries to the least. Mounting, longer-term research has emerged showing that lap bands too often lead to medical complications and that they’re inferior to other obesity surgeries when it comes to weight loss.
Still, of the nearly 200,000 weight loss operations each year, some 11,000 of them still involve gastric bands. Researchers are increasingly arguing that’s too many.
How the lap band works — and how it fails
First, a quick primer on the three major types of weight loss surgery:
- The first involves restricting the size of the stomach, like the lap band. The procedure involves placing an inflatable band around the upper portion of the stomach to create a small pouch, and the idea is that people will feel fuller faster, eat less, and lose weight.
- The second kind interferes with how the body absorbs calories, like the small bowel bypass, which doctors don’t do anymore.
- The third are combination procedures that are both restrictive and cause calorie malabsorption or hormonal changes that affect hunger and satiety, like the gastric bypass and gastric sleeve operations. These operations make the stomach smaller by cutting out part of it (and in the case of the bypass, rerouting the intestines). They are now the most popular weight loss surgeries.
When the lap band operation was first approved by the Food and Drug Administration in 2001, it was met with a lot of hype: The device seemed like a safe option for weight loss surgery that could be adjusted or removed at the patient’s behest. Unlike the gastric bypass or sleeve operations, it didn’t involve cutting the stomach or rerouting the intestines — and it could be reversed (which helps explain the band’s enduring, albeit more limited, appeal).
“It looked like it was going to be great,” said University of North Dakota School of Medicine obesity researcher Jim Mitchell. “Nobody expected it was going to be problematic.”
That ease and perception of relative safety is part of what drew Green to the procedure, she said — a quick fix for a difficult problem.
But over the years, obesity researchers have been learning that the lap band is anything but: It’s now clear that a large number of patients suffer medical complications and require additional surgeries after their initial operation. “That’s one of the reasons you need long-term outcome data [in medicine],” Mitchell said.
In the best study we have on just how problematic lap band surgeries can be, published in JAMA in May, researchers from the University of Michigan looked at 16 years of Medicare data to see how common “re-operations” were after the first lap band procedure. These involved everything from removing the band to replacing it, fixing it, or following the initial procedure with another weight loss operation (i.e., the gastric bypass). They found 20 percent — or one in five — of the 25,000 lap band patients needed an additional procedure. That’s much higher than the 3 to 9 percent re-operation rate for the gastric bypass and gastric sleeve surgeries.
Between 2006 and 2013, Medicare paid $470 million for these procedures. What’s more, the average number of procedures per lap band patient was a staggering 3.8.
Because the band doesn’t cause any physiological or hormonal changes like other bariatric surgeries, patients often struggle with weight loss afterward. They feel the same hunger sensations they did before the surgery, but they can’t eat the same amount of food. So they find ways to compensate — like Green throwing up after eating. Other doctors told me they’ve seen patients who routinely drink milkshakes, eat mashed potatoes, or soften their biscuits with gravy so they’ll go down more easily.
In this 2016 JAMA study, looking at the four-year weight change in veterans who underwent weight loss surgery, the bypass patients lost 27 percent of their original bodyweight, the gastric sleeve patients lost 17 percent, and band patients lost only 10 percent. This systematic review pooled together the results of many studies on different weight loss operations, and also found the same trend: Band patients fared the worst when it came to weight loss, and gastric bypass patients the best.
“If I were a patient,” the University of Michigan’s Andrew Ibrahim, who studied the re-operation rate of the lap band operation, told me, “and those were the numbers presented to me, I would have a hard time accepting that risk [with lap band operations] when there are two other alternatives that we know well can be done.”
That’s why some doctors don’t refer patients to lap bands anymore. “I would never recommend it,” said Yoni Freedhoff, an obesity doctor based in Ottawa. “I wouldn’t wish one on my worst enemy.”
Other weight loss surgeries are more effective, but doctors will still keep doing the lap band
Fewer and fewer patients are asking for the device, and fewer and fewer doctors are performing the lap band procedure these days. But despite the concerns about the safety and effectiveness, the lap band still accounts for about 6 percent of all weight loss operations: 11,000 of these devices were implanted in patients in 2015, according to the American Society for Metabolic and Bariatric Surgery.
That’s still too many, Freedhoff says. He noted that the single-payer health system in Ontario, Canada, doesn’t cover the band procedure — though it funds other bariatric operations — and he thinks other payers could move in that direction. (The authors of the May JAMA paper on the lap band’s rate of re-operations, including Ibrahim, also concluded that insurers should consider discontinuing coverage for the lap band.)
But as long as there are patients who will pay, doctors will probably keep doing them, Freedhoff said.
Green wishes more people contemplating the lap band were aware of its risks and downsides. She had wanted to remove her band for several years, but had to wait for insurance coverage that could help foot the $5,000 bill for the operation.
Today she’s worried that the heartburn medications she was using to counterbalance the effects of throwing up may have an effect on her bone density. She’s also worried about whether all those years of being sick and not getting the nutrients her body needed will carry long-term health consequences.
“I’m still settling back in to a normal body,” she said, “that doesn’t have a weird plastic contraption in there fouling everything up.”
*Lindsay’s name was changed because she was concerned about her professional image.