Dr. Cunneen holds a bachelor's degree from the University of Notre Dame, a master's degree in physiology from Georgetown University and a master's degree in human nutrition from the Columbia University College of Physicians and Surgeons. He earned his medical degree from Georgetown University. He served his internship and residency in general surgery at the Cedars-Sinai's Department of Surgery. In 1995 he was named Chief Resident in the Department of Surgery, and is currently Director of Bariatric Surgery at Cedars-Sinai hospital. In his wide-ranging interview, he makes it clear that bariatric surgery, long known as a weight-loss procedure, is now being used to combat major health issues caused by obesity. Dr. Cunneen is also a published author having co-written WEIGHTY ISSUES: Getting the Skinny on Weight Loss Surgery (www.weightyissuesbook.com). He is currently working on his second book, 21 Things to Know About Diabetes and Weight Loss Surgery, to be published in 2016 by the American Diabetes Association.
I'm Dr. Scott Cunneen. I did four years of undergraduate at the University of Notre Dame. I then did graduate school at Colombia in New York doing human nutrition and then I also had another graduate degree at Georgetown in Washington, D.C., in human physiology. I also went to medical school at Georgetown.
Two-thirds of America is either overweight or obese. So it's a problem that's very large and it's been getting larger over the past few decades.
We know genetics haven't changed, so it's probably mostly environment. Work has become more sedentary so people are exercising less; they're moving less at their jobs; they're sitting in front of a computer so they're burning less calories during their day doing their job. We're eating more fast food. Fast food has high caloric density meaning it's a lot of simple sugar. It's a lot of fats. Research seems to indicate that these types of foods make you eat more, you know, so they're kind of addictive, if you will, we won't go so far as to say a Big Mac is addictive but those types of foods trigger you to want to eat more.
And then there's ethnic differences; meaning access to quality foods. It costs a lot more to shop at Whole Foods than it does to go to McDonald's and eat off the dollar menu. So some people just don't have the resources to eat healthy
Some people have two jobs so they don't have time to cook meals so their only access to really healthy food, or food in general, is to stop real quick, see what they can get in 10 minutes and feed their family.
So it's cultural; it's environmental; it's types of jobs we have; and then it's the lack of education. People really don't know what's healthy. They know what tastes good. They know what they see on TV.
Eating's not an addiction, but it's fun. Food is designed to taste good; it does taste good. We have a survival advantage if we find food and don't starve to death. So it's been sort of built into our genetics to not starve and have a very strong drive to find food. It's a strong habit, but it's not an addiction. If I take your food away, you don't withdraw
So we try to create the level playing field so everyone talks using the same language, so body mass index, or BMI, is a way to do that. It takes into account your height; it takes into account your weight; and then it tries to infer just how much fat tissue is on your body. And so body mass index is considered normal if it's somewhere between 18 and 25. When you go from 25 to 30, you're overweight. If it's 30 to 35, you're considered obese. If it's 35 or greater and you're ill, let's say you have diabetes, you're considered morbidly obese. The term 'morbid' just means there's illness with it. So that when you come in, you say I have 50 extra pounds, it's different if you're six feet tall than if you're five feet tall.
There's at least 30 common diseases that go along with being obese. Big ticket items are diabetes, cardiovascular disease, so cholesterol. Atherosclerotic disease so, clogging up the vessels in your heart. People that generate or deposit a lot of fat around their head and neck have trouble breathing and so it's called sleep apnea. Also asthma or wheezing is often associated with being overweight. If you put a lot of extra weight on your knees, your back, your hips, you know, your joint wear out so you get more arthritis. It leads to a lot of endocrine or other types of metabolic problems, meaning infertility, the diabetes, thyroid, even cancers are higher for many of them. So basically it affects your body head to toe.
Traditionally bariatric surgery was weight loss surgery and, you know, people just wanted to lose weight, but more and more that's not the reason we're doing it.
We're giving you a tool and the tool is one component to a life-long change and life-long success and so we want you to understand how the tool works. We want you to understand how to maintenance the tool. And we want you to use it right forever, so we want to make sure that you understand the need to be committed to changing your whole life, not just getting a surgery, in order to get the weight off and keep it off.
We're going to test you to make sure it's safe cause this is an elective procedure.
So we have to talk to the patient, really decide what they think a successful outcome is going to be. Most diets lose about 5 or 10 percent maximum of your total body weight, so if you're 200 pounds, it's 20. Most surgical procedures easily accomplish that and you're looking more at 50 pounds or a hundred pounds of weight loss so you have to decide is it weight loss, maximum weight loss, is this your goal? is it correction of your diabetes?; is it getting off all the medications that you take for your cholesterol and your hypertension and your diabetes? You know, what is your goal first?
And if it's maximum weight loss, surgery is generally better than anything else; it clearly is.
Our practice is generally 80 percent women, 20 percent men. Men come more often for health-related reasons. All of a sudden they need a knee replaced or they need a back surgery, and their doctor says, you have to lose 60 pounds or I'm not going to do it. Same thing with diabetes. You know, they may have a family member that's had it in the past and they know it leads to blindness, kidney failure, amputation, so if they've started insulin, all of a sudden now it's a real thing for them because they want their diabetes to go away.
And as we talked to more doctors and get the message out that these operations really lengthen your life and improve the quality of your life, that's giving it more credence because it's not just weight.
So a lap band is probably the purest model of what we call restriction. It's a band with a balloon on the inside that wraps around the top of the stomach. You wrap it in a position so that you have about a golf ball size of a pouch. So you swallow a bite of food; it goes down your esophagus tube from the mouth into the stomach; the band squeezes on the outside wall so then it stops that bite of food you put in; and the stomach slowly squeezes it through. What this does is this allows that pouch to stretch, which sends nerve signals back to the brain, telling you you're full. And slowing down how fast you can eat allows your body to sample because that food can then go into the lower intestinal tract, sample what you've put in your mouth so that it can say, okay, I'm getting calories; I should stop.
Generally people that are good candidates for bands are people that are pretty savvy about nutrition; pretty willing to eat a healthy diet; solid food; will make a half an hour amount of time to eat that meal, it takes that long and can come back and get adjustments. Because the way a band works is there's a balloon and I have a port underneath the skin and I can add or subtract fluid to fine tune how much it's squeezing on your stomach to create a rate for that solid food to go through.
Usually you peak at about four to six adjustments in the first year and then you're coming back maybe one or two times a year and you're coming back at least once a year to get an assessment, so it's pretty intensive. And for band patients to do the best they're coming back every month, even if I don't adjust.
If you're too tight and it's not completely obvious you'll probably gain weight because you can't eat solid foods. Every time you try to eat solid foods, it gets stuck; you throw up; you're uncomfortable. So then you subconsciously migrate to things that are more lubricated so you use higher fat, break down easier, gain weight, even though you're suffering.
So the best candidate, is someone who is generally younger; more mobile so they exercise; has weight loss of about 10 or 11 BMI points, so meaning less than 40; motivated; have access to taking time off work; coming in to see me often; and is willing to work with it because they're going to be a little bit tighter and they're probably going to be a little bit hungrier than the other operations.
Bypass is the gold standard in the United States. It's been around 40-plus years. It's done laparoscopically so people recover much faster. It's very good at weight loss. People lose about 70 percent on average of excess weight by the first year and a half. And what that means is if you have a hundred pounds to lose, you lose 70.
So, what we're going to do is bypass the stomach so we cut a little egg-shaped piece out of the very top and then we're going to re-route by cutting some small intestine that's below; that's called jejunum. We're going to bring that up and sew it to that little egg and then so the stomach has a place to drain we're going to sew that cut edge, the leading cut edge, back into the intestine, so since you've created a detour over the stomach and the first part of the small intestine, cause food's no longer going there, and so it goes from your mouth into that little pouch; it goes down that limb of intestine we've sewn to it, called the roux limb, and then it finally mixes with the enzymes and chemicals that are going to digest it further downstream.
So it's a small stomach; that's one component. We're bypassing part of the intestine which is contributing to also part of how it functions. And we're delivering food to the distal part of the gut sooner than it's used to seeing it so that signals satiety cause usually the stomach's slowly going to release this food, and if the body sees that food earlier than it normally would, it stops you from eating cause it would usually be later in the day that it would see it.
Pain is there but it's well managed, usually by oral narcotics for a couple days. You're up the same day. Surgery itself is about two hours. We put you on liquids for a couple weeks. So it's more small swallows and sips. You're up and moving the same day.
People take pain medicine usually at night to sleep but usually can be driving by the end of a week. You're a little more tired than usual but a lot of people get back to work two to three weeks. If you're lifting heavy things at work, you're going to be on restricted duty about a month, a month-and-a-half. But you can definitely work from home and get through half days pretty easily after a week or two.
The pattern of eating with the bypass is chew your food, slow down. It's a little less tight than a band, but you still have to take that 15 minutes to half an hour to eat.
One thing that's a little bit different than a band, though, is that if you do high-fat, high-sugar food, say you try to eat a bowl of ice cream, there's something called dumping which is a reaction where all of a sudden you're sweating, you're feeling a little disoriented, your heart's racing, followed by cramps, diarrhea, and then fatigue. So it's not pleasant. Now, it sounds horrible but if your poison is ice cream it stops you from eating ice cream.
And the taste change, also, because there's really hormone changes besides the little stomach and the little openings that also go along with the bypass so you're less hungry; satisfied sooner; can't eat those sweets and don't have the same attractiveness to the sweets; they don't seem as appetizing to you; so you eat less.
And so you lose weight pretty rapidly. Most people are done by a year, year-and-a-half losing weight, and so, you know, if you have 200 pounds to lose, you lose about 140 in the course of the year so that's pretty rapid and it's pretty impressive and it's almost too easy sometimes for the patients.
That's one of the reasons we talked earlier about preparation. We want them to develop all the good habits and think about developing the good habits and realizing they are doing them, not try to recover them three years from now.
The sleeve went from being very few procedures ten years ago to finally surpassing all the other procedures this year
One of the things about the sleeve is that after you get through the first 30 days, you know, it's very hard to hurt yourself with it. You still have to take vitamins but you're not going to get ulcerations around the connections; you're not going to get obstruction or twisting of the intestine that you can get with the bypass. So if you don't take your vitamins, it's going to take longer for you to develop deficiencies, so it's a pretty safe/effective procedure.
We're reducing the size of the stomach. We're going to take that big stomach and we're going to put a calibrating tube down the inside edge and we're going to cut away all the excess.
The calibration tube is about an inch across so think of your stomach being 12 inches long and about an inch across and so we take about 80, 85 percent of the stomach out.
So it limits volume, how fast you can eat, but you know the real reason these operations work is that it changes the signaling, the hormones, and the hormone that's often mentioned with the sleeve is something called ghrelin, and that's a hunger hormone, but there's actually many hormones that are changed.
More ten but five in the making ...
One of the things about a sleeve is it's higher pressure, so if you have trouble with reflux, indigestion, we tend to make that worse unless we can find something to correct hiatal hernia at the same time we do the sleeve. Both of them treat diabetes better than medications, but bypass is definitely better at treating diabetes and keeping diabetes in remission than a sleeve is. And it appears that a bypass even gets stronger as you talk about five years compared to a sleeve.
If someone comes in and they're overweight; they have bad reflux; they're diabetic; I'm going to be pushing him to a bypass cause I know that if I don't, then when they pick a sleeve and I give it to 'em, then I'm probably going to be doing a bypass because all of a sudden their reflux gets so bad they can't lie down flat without sort of suffocating.
So people think there's a lot more going on with a bypass, so they say that looks way too severe. When you look at a band, you just wrap it around the top of the stomach, very simple, you know, it's surgery but you're not cutting anything, so if you believe that that is going to lose the weight you need to lose and it's going to correct your life the way you want to correct it, that sounds like a perfect option because it's reversible; it's simple; you're not cutting; risks are lower. In reality, though, you want to pick something that's going to be effective so if sleeve and bypass is more effective, they look at those two and just cutting stomach versus cutting stomach and intestine. So people just naturally say, give me the one in the middle; looks less invasive I'll take that one.
So you have to restructure your life.
Some people never believed in exercise to begin with but we do everything we can to try to convince them how important it is for the long-term maintenance of their health to exercise more, and we're talking five to seven days. So that's a potential drawback of getting into this program.
Overall, long-term, life expectancy is better; quality of life is better; but you have to take your vitamins; you know, if you choose not to take your calcium, for example, you're probably going to get weak bones, you know, 30 years later. If you don't take your vitamin B12 you can get anemia’s in your iron, so you have to come back to the doctor more. So it requires you to be a little more proactive on maintenance than most people are.
I wish everyone would go out and advertise it cause I know it's a great therapy and it could do so much good but I think people have the right to privacy. There's no compelling reason for you to have to, you know, put a placard on your head that I'm a weight loss patient. And most people don't now. That's just because there's more of a stigma on doing surgery for weight loss than there is having your heart operated on. And it's unfortunate but it's still the case today.
You're talking millions and millions of people that qualify so you really have to approach it as a public health problem, meaning more education when they're young cause we know if you're an obese adolescent, for example, 70-plus chance that you're going to be an obese adult and so we're getting more diabetics at 13 than we've ever had in the past.
The Obama administration when they talked about sort of basic coverage fortunately did put obesity in so there's at least 28 states right now, and including Medicare, that provide bariatric surgery coverage..
Usually they may limit how many procedures you have, meaning if you had a band, you might get a once-in-a-lifetime shot so you better pick the right one first because you're not going to get a second one. And they've also put criteria in for being eligible, meaning you have to go on another diet for six months or you have to go on another diet for three months. Medicare's four months before you can qualify besides seeing the dietician and psychologist and getting all the other testing.
They'll even pay for medically-supervised therapy so not everyone needs surgery; you know, sometimes talking to your doctor, giving meal plans, education, maybe appetite suppressants are you need for that 20, 30 pounds, so they've built in payments for those and that was never really covered before. I mean there's some positive moves but it's clearly not there yet.
Today we have a very effective, safe procedure that can lengthen your life and improve the quality of your life. We've standardized these procedures and developed criteria to ensure the safety from the beginning to the end. So that these are some of the safest procedures out there, and bariatric surgery is actually serving as a model to providing sort of this multidisciplinary care for things like orthopedics, cardiovascular care, so it's one of the safest types of procedures.
It also is a high-value procedure, meaning by treating your weight we're treating diabetes; we're treating your heart disease; we're treating your joint disease. So this procedure, though it's traditionally been weight loss, really treats your whole body and it really allows you to have a longer life and a better quality of life so it definitely should be accessed more.