When Dieting and Exercise Just Aren’t Enough – All You Wanted to Know about Weight Loss Surgery

According to a 2019 study by the CDC, almost half of U.S. adults weigh much more than they should and those extra pounds carry the risk of causing issues that go beyond aesthetics.

When a person decides to embark upon a weight loss journey, it can often be triggered by that person not liking how they look, the improper fit of their once-beloved clothing, slow or sluggish feelings related to weight gain, or more seriously, that their health is at risk and dependent upon them reaching healthy weight levels. For some people, healthy eating and living an active lifestyle comes easily and they may see the results of their labor within a reasonable time frame. Thankfully, in the case of my fitness journey, my triggers were more of the simple type. I modified my eating and began a training routine, and with consistency, I’ve seen the results.

But what happens when the path to weight loss isn’t as straightforward? What happens to the people whose health is at risk because they’ve tried everything and they’ve had no success? What happens to the person who has reached the point of “morbid obesity”? Is there hope?

I recently got the chance to partner with NJMOM and interview Dr. Naveen Ballem, Medical Director of Bariatric Services and Chief Clinical Effectiveness Officer at Clara Maass Medical Center, an RWJ Barnabas Health facility in Belleville, NJ. As a fitness enthusiast and registered nurse, this was such an appropriate pairing. However, I must say that even I held my own biases and misconceptions regarding weight loss surgery and interviewing Dr. Ballem was enlightening and eye-opening, and it allowed me to understand weight loss (or bariatric) surgery from a whole new lens.

Dr. Ballem greeted me with a friendly smile and a warm demeanor. Immediately upon initiating the conversation about what he does, it was very apparent that Dr. Ballem is truly a force to be reckoned with regarding his knowledge of weight loss surgery, the bariatric population, and their multifactorial special needs. He has a background in general surgery, endocrine surgery, advanced laparoscopic surgery and robotics, scientific research and education, and he’s published articles related to his area of expertise.

Despite the sometimes chaotic nature of a typical day in healthcare, Dr. Ballem stated that he tries to keep some structure to his days, strictly performing surgeries two days a week, and using the other days to see patients in the office for pre-operative and post-operative appointments, and to ensure that Clara Maass is doing their part in delivering quality care to patients. He’s also furthering his education and is currently enrolled in Harvard University’s Master’s of Healthcare Management program.

Just hearing these things alone made me very eager to hear more about what Dr. Ballem had to share about weight loss / bariatric surgery, so let’s hop right to the Q&A that Dr. Ballem and I exchanged.

What is the gender demographic breakdown of your patients? Do you tend to see an equal number of males and females who seek your services?

The demographic breakdown of our practice is generally about 2/3 female and 1/3 male. When we look at the national utilization of bariatric surgery, it is significantly higher in women than in men. However, if you look at the data on obesity rates for men and women, they’re both equally high. So the question becomes why are women coming to get surgery while men are not? What is that barrier to treatment men have that women don’t? So, to sum it all up, we do see more women than men in our practice, but it’s not necessarily because they suffer from obesity more than men.

Do you feel that the reason for this is that women, in general, or from a societal standpoint, tend to be more concerned with body image, while it’s more acceptable for men to be overweight?

That psychology definitely plays into it. Men, generally speaking, tend to be less concerned with body image as a whole. However, while psychology and body image do have some role in the decision-making process related to weight loss surgery, the process one must go through before undergoing surgery is very rigorous and potential patients get plenty of pre-operative education. Because of this, the vast majority of our patients do weight loss surgery for health as opposed to body image – to improve comorbidities, quality of life, etc.

As an outsider who isn’t well-informed about bariatric surgery, it’s easy to see that as a “cop-out” or easy way out for a person who is overweight as opposed to just a healthy diet and exercise. What are your thoughts on this?

Bariatric surgery is absolutely not a cop-out. There are various ways that a person can lose weight. However, once the body mass index is significantly high (i.e. greater than 35), most people are about 50 to 60 lbs. overweight. The average diet, exercise program, or even medication that exists on the market helps people lose, on average, 5-10% of their excess weight. So if a person needs to lose about 20 lbs. to be healthier, diet and exercise are ALWAYS the answer. By the time people come to me for weight loss options, they’ve pretty much tried everything that exists. Most people truly don’t consider surgery as a first option. Most of them can lose weight for about a month or two… perhaps even six months, but maintaining that weight loss long-term is a challenge. These patients’ weight will yo-yo over time, but with every weight loss and gain, the weight gain will be higher than they’ve ever experienced. Another part of the challenge is that many of the commercial weight loss programs are unrealistic. In the short-term, or for a few months, it’s feasible to eat food via a point system, but it can’t be done for a lifetime. It’s feasible to order meals from a company, but that, too can’t be done for a lifetime. The bottom line is to create a healthy lifestyle that goes beyond any diet or exercise program.

How do you go about teaching your patients about creating a healthy lifestyle?

The key to it is creating a truly individualized approach for every single patient that is REALISTIC for where that patient is in life. It’s easy for a person who lives a fit and active lifestyle to tell someone suffering from obesity that they simply need to diet and exercise for an hour. However, for a patient who is carrying an extra 150 lbs., they may not be able to stand for more than a few minutes because of the amount of pressure that exerts on their knees or back. So the best approach is to address each person’s individual needs and encourage them to get up and just do some type of physical activity (e.g. 15 minutes every morning and 15 minutes every evening). This approach is more empathetic and ultimately, more realistic, for someone who is morbidly obese. As that weight comes off, they’ll have more energy, they experience less pain, and they organically will get to that point where committing to an hour of exercise won’t be as daunting. But to start with that from the beginning is impossible.

How do you address the psychological aspect of morbid obesity? After surgery is complete, the patient’s body will undergo significant change. How do you address the mindset change that must occur for a person to maintain their weight loss and health goals?

Obesity is a multi-factorial, complex problem. To be successful in the long term, it’s necessary to address all of the things that got a patient to that point in the first place. Surgery is only one tool to assist a person in obtaining their weight loss goals by allowing them to reduce the volume of food intake or the absorption of certain foods, but we also need to assist patients in developing healthy and continually improved eating habits. We need to counsel patients on the importance of exercise and active lifestyle. If any of these components are missing, the surgery is bound to fail. I tell my patients up front, that surgery is only the first step in a long process. Here at Clara Maass, we have a great team approach in supporting our bariatric surgery patients. We have post-operative support groups that meet monthly. We have dieticians and psychologists who work collaboratively to create individualized plans for each patient to assist them with developing a healthy relationship with food, making better food choices, and dealing with life stressors. We cannot ignore the psychological component of obesity.

How does the decision to have bariatric surgery affect women who are already suffering from obesity and trying to conceive? Can bariatric surgery affect a woman’s fertility?

As a bariatric surgeon, I have the unique opportunity to work with practically every type of physician or specialty out there. I work with a large group of OB/GYN’s and see a lot of women who are overweight and having trouble getting pregnant, largely because of PCOS (Polycystic Ovarian Syndrome), which is a combination of increased androgen production by the fat cells as well as cysts in the ovaries. With weight loss surgery, there is significant improvement in the ability to get pregnant – fertility rate increases. If you’re trying to conceive, you should definitely try to improve your health by ensuring that you’re at a healthy weight. You don’t need to be at an ideal weight, but losing 5-10% of excess weight improves many of the risk factors, diseases, and morbidity associated with pregnancy, delivery, and the overall health of the newborn child. It is also recommended that if a woman has undergone weight loss surgery, she should not get pregnant for at least 24 months after, as it is unknown how the rapid weight fluctuations that the surgery causes will affect an unborn child.

At what point do you decide that it’s time for a person to self-manage post-operatively? When do you decide?

Never (Dr. Ballem laughs)! Literally never. My protocol is as follows: I see patients one week after surgery to ensure that they’ve gone through the risks of surgery without any complications and that they’re doing well. I see them every 3 months for the first year, every 6 months for the second year and then once a year for life. I don’t replace their primary care doctor – they will continue to see their primary care doctor. However, as I mentioned, being severely overweight is a multifactorial problem. So to think that just because a person has one surgery that will cure it is erroneous. We support our patients once we operate on them and address any sort of issue that arises over time. Morbid obesity is a disease, a complex, systemic disease that we would treat in the same way as any other complex, systemic disease, like, for instance, Cancer. If a patient has a treatment or surgery to remove a cancerous tumor, it’s not a one-shot deal. That patient is monitored very closely to ensure that there isn’t a recurrence, or in the event that recurrence is on the horizon, the entire health care team is proactive in planning treatment options. Morbid obesity should be looked at the exact same way, and the team here at Clara Maass is vigilant with follow up.

What is the likelihood of developing excess skin weight loss surgery and how can a patient deal with that?

Funny enough, that is probably the most recurrent question I get from patients in every education session. I will say this – I can’t predict who will have excess skin after surgery and who won’t. I will also say that there are some patients who do develop excess skin afterward and for others, it isn’t even an issue. The likelihood of developing excess skin is a combination of how old you are, your genetic make-up, skin elasticity, just to name a few. Diet and exercise, particularly with cardio and resistance training, can minimize the amount of excess skin a person develops. However, to be quite honest, if a patient develops excess skin after surgery, that will probably be the happiest problem they’ve ever had. It just means they’ve lost weight and hit weight loss numbers that they probably have never seen. If it gets to a point where loose excess skin becomes particularly bothersome, there is also a means by which we can refer patients to a plastic surgeon if that would make them more comfortable.

Do you have any final insight to give our readers regarding the bariatric services department at Clara Maass Medical Center?

The bariatric services department here at Clara Maass is truly amazing. We are a Center of Excellence as designated by the American College of Surgeons. After surveying our site, they called our program “exemplary.” We have a full complement of dieticians who are fluent in Spanish and Portuguese. Actually, we are the only hospital in New Jersey that has full bilingual support for bariatric patients.

Speaking with Dr. Ballem was truly an enlightening experience. Even as a healthcare professional myself, there was still so much that I did not know and was misinformed about. I even learned that insurance companies will cover the cost of bariatric surgery to offset the cost of managing health problems that arise later on in life as a result of remaining obese for too many years.

Dr. Ballem was definitely a breath of fresh air, especially in a climate where it seems that, at times, patients can be taken advantage of for the sake of making money. He genuinely cares about his patients’ well-being and long-term success after his job is complete and he truly takes satisfaction in seeing and hearing their joy once they become able to do things that were, prior to surgery, impossible for them. Once I heard that he follows his patients FOR LIFE, that really threw me for a loop!

So if you’re considering having weight loss surgery and are on the fence about it, or if you simply want to learn more about the options that are available to you, take comfort in knowing that the team of doctors, nurses, and staff at Clara Maass Medical Center will make see to it that you’re well supported on your journey.

This post has been compensated by NJMOM and its advertiser. All opinions are mine alone.

Photograph of Clara Maass Medical Center and RWJ Barnabas logo provided by RWJ Barnabas Health