Tom Saridis, chief executive officer and founder of the CIBO clinic, poses for a photograph with an old 80-inch belt that he used to wear when he was 500-plus pounds. The Toronto man lost nearly 300 pounds after bariatric surgery and exercise.Tom Saridis, chief executive officer and founder of the CIBO clinic, poses for a photograph with an old 80-inch belt that he used to wear when he was 500-plus pounds. The Toronto man lost nearly 300 pounds after bariatric surgery and exercise. (Nathan Denette/Canadian Press)In Canada, the fatter you get, the slimmer your chances of regaining control of your weight. Some experts estimate that a million Canadians are morbidly obese - most have high blood pressure, diabetes, bad joints and increased risk of heart disease. It's not about laziness and lack of self-control. They're unable to take off the pounds for a variety of physical and psychological reasons.

Now, medical science shows that what was once considered a vanity surgery is a medical necessity for hundreds of thousands of people. Bariatric surgery - or weight-loss surgery - has proven to be an effective way for the morbidly obese to lose weight.

The most common form is stomach stapling - gastric bypass surgery - which is now done safely as a laparoscopic surgery. Its success rate is high as patients who go through it claim they've regained a quality of life they thought they'd never see again. The upfront costs of the surgery and the support are high, but doctors argue the long-term costs of morbid obesity will be much higher.

While all provincial health insurance programs pay for gastric bypass surgery, the procedure is not available in all provinces. Some people have to travel to get it. The waiting list varies across the country from several months to as long as 12 years. The average wait is about five years.

A study published in the Canadian Medical Association Journal in March 2009 concluded that the waiting times for bariatric surgery are the longest of any surgically treated condition. The journal called that unacceptable, noting that people who undergo the procedure see their risk of death drop by between 40 and 89 per cent.

Demand for the procedure is high. A 2005 report from Ontario's Medical Advisory Secretariat estimated that the province must do 3,500 obesity-related surgeries a year just to keep up with demand. Ontario was averaging about 500 surgeries a year. The Ontario Health Insurance Plan also paid to send 394 people to approved hospitals in the United States to have the surgery.

In February 2009, the province announced it would increase funding for bariatric surgery by $75 million over three years. By 2011/12, hospitals in the province are expected to be capable of performing 2,000 surgeries a year.

In B.C., the only hospital that is equipped to perform bariatric surgery and provide the follow-up care cut the budget for the program. The Vancouver Island Health Authority announced it would limit the number of bariatric surgeries to 52 per year, focusing on the most urgent cases.

What is gastric bypass surgery?

In gastric bypass surgery - Roux-en-Y gastric bypass - a surgeon reduces the capacity of your stomach to hold food. The surgeon will create a small pouch at the top of your stomach by sealing it off from the rest of your stomach with surgical staples. The pouch is about the size of a golf ball and can hold about 30 grams of food.

Obesity surgery.The surgeon will cut part of the small intestine and attach it to the new pouch, so food bypasses the rest of the stomach and the first section of your small intestine - the duodenum. The food goes directly to the second section - the jejunum. This limits your body's ability to absorb calories.

While food no longer enters the rest of your stomach, it still continues to secrete digestive juices that mix with the food in your small intestine.

After the surgery, you are unable to eat as much food as you ate before surgery. It is critical to eat the right kinds of foods to ensure that your body gets the proper nutrients. You may also need to take supplements so that you get all the vitamins and minerals you need.

What are the benefits of gastric bypass surgery?

The key benefit to gastric bypass surgery is dramatic weight loss. You can expect to lose up to 60 per cent of your excess body weight within two years. And if you stick with your recommended diet and exercise program, you can expect to keep that weight off for the long term.

But it doesn't end with weight loss. You will also likely find significant improvement in other conditions associated with obesity, such as: · Type 2 diabetes. · High blood pressure. · High blood cholesterol. · Sleep apnea. · Acid reflux. Improving those conditions will also likely reduce your risk of developing - or exacerbating - cardiovascular disease.

What are the risks of gastric bypass surgery?

Treating adolescents

Toronto's Hospital for Sick Children has set up the first bariatric surgery program for pediatric patients. Teens with severe obesity due to complex medical conditions can be approved for laparoscopic band surgery, which is more easily reversible than gastric bypass surgery.

Patients will work with a medical team including doctors, a nurse practitioner, a dietitian, a psychologist and an exercise therapist. The hospital notes that severe obesity is difficult enough for teens to deal with, but the situation is even tougher when it's complicated by another serious medical condition.

A study published in the journal Pediatrics suggested that bariatric surgery could be considered for adolescents but only under very strict conditions.

As with any major surgery, there is a small chance you could die while undergoing gastric bypass surgery. The risk is estimated at one death for every 200 or 300 surgeries. The risk varies according to the patient's age and overall health.

Other risks include: · Blood clots in the legs for extremely overweight people. · Leaking at one of the staple lines in the stomach (treated with antibiotics). · Weakness in the incision. Most gastric bypass procedures can now be done laparoscopically, using a small opening which reduces the risk of incision complications. · Dumping syndrome, in which the contents of the stomach pass too quickly through the small intestine, causing nausea, dizziness and vomiting. · Intolerance to certain foods. · Gallstones.

Who is a candidate for gastric bypass surgery?

Before you are considered for gastric bypass - or any other weight loss surgery - you will undergo a complete physical as well as a psychological evaluation to determine whether you are ready to commit to a healthier lifestyle.

The U.S. National Institutes of Health has set other guidelines to determine eligibility for weight-loss surgery. They include: · A body mass index (BMI) of 40 or more. A BMI of 40 or more means you are at least 45 kilograms over your recommended weight. A normal BMI is between 18.5 and 25. · A BMI of 35 or more along with a life-threatening illness that can be made better with weight loss, such as sleep apnea, type 2 diabetes, and heart disease. Canada follows similar guidelines.

What are other weight loss surgery options?

The most common alternative to gastric bypass surgery is laparoscopic banding (lap band surgery). In this procedure, a surgeon places a donut-shaped device, with an inflatable balloon on the inside, around the upper part of the stomach. The intent is similar to gastric bypass surgery: the upper part of your stomach is turned into a small pouch that can handle much smaller quantities of food.

Why dieting fails

  • The more muscle mass your body has, the more efficiently you burn calories. Muscle uses a lot of energy. Initially, weight loss inevitably implies muscle loss. The greater the restriction or the more unbalanced the diet, the greater this loss will be.
  • Less muscle mass means a slower basal metabolism. Food is more efficiently absorbed to keep the body in its natural weight zone. The weight put back on after a diet is mainly fat and not muscle, which can lower energy needs, making further weight gain easier.
  • Ending a diet or suddenly relaxing strict dieting rules can lead people to eat compulsively and to overeat.
  • The self-esteem and confidence that comes with successfully controlling weight diminishes as the weight returns, and people become increasingly obsessed by weight and food.
  • A balanced diet coupled with exercise remains your best option for weight management.

The major difference is that there is no bypass to the second section of the small intestine. The device can be tightened or loosened by a saline injection.

The surgery takes less time and recovery is quicker than for gastric bypass, which can involve a hospital stay of a few days and weeks of recovery at home before resuming a normal lifestyle.

Weight loss with the lap band is more gradual than with gastric bypass surgery. Because it is adjustable and more easily reversible, lap band surgery is safer and easier to accommodate life changes like pregnancy.

Lap band surgery involves fewer possible complications during surgery but does present other potential problems afterwards. There have been cases of band erosion, where the band goes through the gastric wall and into the stomach's cavity. There have also been complaints that the band can sometimes slip out of place.

Not every province covers the cost of lap band surgery and some provinces that do won't cover the cost of the band, which can mean an out-of-pocket expense of about $5,000 for the patient.

A less used option is biliopancreatic diversion with duodenal switch. In that, the surgeon removes about 80 per cent of the stomach. Most of the intestine is bypassed by connecting the end of the intestine to the duodenum near the stomach.

This type of surgery offers substantial weight loss but an increased risk of malnutrition and vitamin deficiencies. It is generally recommended only for people with a BMI of over 50. Patients who undergo this procedure require close monitoring.