Surgery for Weight Loss: Am I Too Old to Benefit?

By Mohammad El-Rifai, MD

The problem of obesity, which is defined by having a body mass index (BMI) – calculated as weight (in kilograms) divided by height (in meters) squared – equal to or greater than 30, is increasing around the world. In the U.S. alone, approximately one-third of the population fit the definition of being obese.

And age in no way protects from being obese: the obesity rate is also increasing in adults aged 65 or older, with a prevalence that is similar to the general population.

Obesity is a major health problem and a well-known risk factor for type 2 diabetes mellitus, high blood pressure and high cholesterol, with a resultant decrease in quality of life as well as life expectancy.

Obesity increases the chance of developing heart disease, as well as the risk of developing many cancers. Beyond physical disease, mood disorders are also more likely to be present in someone who is obese: research studies suggest that those who are obese are about 25 percent more likely to have issues such as depression when compared to those who are not obese. And low self-esteem and self-image are common in the obese, as is social isolation.

Given the negative impact of obesity in health and quality of life, weight loss is medically recommended to reverse the negative impacts. In addition to lifestyle modifications with diet control and increased physicial activity, other therapeutic options include weight-loss medications (see story on page 4) and bariatric (weight-loss) surgeries.

What is bariatric surgery?

Bariatric surgery is one of the fastest-growing surgical procedures performed in the U.S., with an estimated 196,000 operations performed in 2015 alone. There are several different types of bariatric surgeries available including, but not limited to:

  • Adjustable gastric band, in which a band containing an inflatable balloon is placed around the upper part of the stomach, which creates a small stomach pouch above the band, with a very narrow opening to the rest of the stomach. The procedure is intended to slow consumption of food and thus reduce the amount of food consumed.
  • Sleeve gastrectomy is the most commonly performed gastric bypass surgery, and involves part of the stomach being separated and removed from the body, with the remaining stomach shaped into a tube or sleeve-like structure. Patients are unable to eat as much food, so fewer calories are absorbed into the body.
  • Bypass surgery is achieved through several different surgical methods. During this type of bariatric surgery, the stomach is divided into two parts, with the outside section of the stomach being removed permanently. Then the GI tract is reconstructed to bypass some of the small intestine, which leads to less absorption of calories and nutrients.

Regardless of the type of procedure used, bariatric surgeries continue to produce greater weight loss and improvement in weight-associated medical conditions when compared to non-surgical interventions.

But in older individuals, concerns regarding the possibility of increased surgery complications have often led to a reluctance on the part of doctors to offer the surgery to those over 65 years of age even though the National Institutes of Health (NIH) removed age limitations on the surgery in 2006. That reluctance, in turn, has resulted in a lack of information regarding the true risks vs. benefits of these surgeries in the elderly.

When is bariatric surgery indicated in adults, especially the elderly?

In adults, candidates for bariatric surgery include those with a body mass index (BMI as kg/m2) greater than or equal to 40, or a BMI of 35.0 to 39.9 kg/m2 with at least one additional medical condition present, such as type 2 diabetes mellitus, obstructive sleep apnea (OSA) or high blood pressure. Individuals with a BMI of less than 35 typically require additional criteria for coverage of weight-loss surgery.

For older individuals, guidelines should be clearly followed when weight-loss surgery is being considered. Recommended guidelines typically include:

  • Body mass index equal to or greater than 40, with additional medical conditions present, such as: uncontrolled blood sugars in the setting of diabetes mellitus; high blood pressure; high cholesterol; severe to moderate sleep apnea; venous stasis disease, a condition in which there is slow blood flow in the veins, usually from lower leg venous varicosities; and reflux esophagitis, an inflammation that damages the tube running from the throat to the stomach (esophagus).
  • BMI 35.0 to 39.9 kg/m2 with more severe conditions such as uncontrolled diabetes despite aggressive medical therapy; severe high blood pressure, despite maximum medical therapy; and moderate to severe sleep apnea.

However, given that we tend to have more medical issues and problems as we age, and consequently are at increased risk of complications after surgery, each person considering undergoing weight-loss surgery should be considered individually — both in terms of benefits as well as risks. Understanding which surgery is going to be performed, what to expect during recovery and ongoing follow-up, the amount of weight loss to expect, and what could be the shortterm and long-term complications related to the planned procedure should all be discussed with your treatment team, including your surgeon, your surgeon’s support team, your endocrinologist and you endocrinologist’s support team. Make sure that you know who you will be seeing after the procedure, as weight-loss surgery requires lifetime, ongoing medical care.

What should be expected after surgery?

As stated previously, there is a lack of information about outcomes of weight-loss surgery in elderly patients as compared to younger patients. In the few studies that exist, younger patients tended to have better results when looking at the impact the surgery had on their health, losing more weight and showing more improvement in specific, weight-loss-associated conditions as well as overall health. However, elderly patients did benefit from the surgery: select studies showed that weight loss and improved health in those older than 55 might be just as good as in younger patients who underwent gastric surgery.

In a study published in 2011, data was culled from more than 48,000 adults in a national registry who had open or laparoscopic bariatric surgery procedures performed between 2005 and 2009. The research found that adults over 65 were not at a significantly greater risk of a major adverse event as compared to those in their 30s and 40s. While seniors were more likely to face longer stays, they did not appear to be at any increased risk of having surgery associated heart attacks, strokes, or serious infections following their weight-loss surgery.

Thus, age alone should not be an absolute deterrent to bariatric surgery. Indications should be carefully evaluated in the light of routine preoperative tests and discussed with the patients knowing that there are some risks, and that the results might not be as good as they might expect.