AtlantiCare’s Dr. Onopchenko talks weight loss surgery
Life during the novel coronavirus (COVID-19) pandemic has brought with it a number of changes, both positive and negative. Dr. Alexander Onopchenko, a bariatric surgeon and the medical director of the Surgical Weight Loss and Wellness Center at AtlantiCare, said that one of those changes is weight gain.
Onopchenko attributes the cause as “the enormous amount of stress that COVID-19 has produced in all of us, disrupting our lives.”
“For kids, we’re seeing increased incidents of overweight and obesity in kids, for the amount of time that they’ve spent outside of school, learning remotely. Inactivity, stress, poor eating during the pandemic—and also the additional intake of alcohol during the pandemic due to all those things—has resulted in the increase in weight that almost all of us are experiencing,” Onopchenko told The Gazette.
Onopchenko said that the lack of access to medical care has been another factor.
“I think what has happened is—I don’t want to overuse the term, but—a perfect storm, a combination of suspending elective surgeries, it is the fear of getting appropriate medical care during the pandemic. Some of the things we’ve addressed, like the care problem; even during the pandemic, we very quickly pivoted to telemedicine, and the increased use of it was very significant during the height of the pandemic, and will be continuing to be a part of our armamentarium,” Onopchenko said.
With restrictions being eased in the state and across the nation, Onopchenko said that now is the time to “come out of our homes and get back to a more healthy lifestyle.”
“Thankfully, the CDC [Centers for Disease Control and Prevention] has said that masks are no longer necessary in doing outdoor activities, and it’s really a nice time, as the weather starts to change, to get outside and at least go for a walk every day ... As far as eating habits, it’s time to get back on track. It’s time to make sure that, yeah, we learned how to bake, but we should be making healthy foods. We should be avoiding high-carbohydrate, high-fat foods, concentrating on our protein and getting back to work. Remote work and remote learning has all contributed to the increase in inactivity, so we’ve got to start going back to normal in a lot of different ways,” Onopchenko said.
However, Onopchenko acknowledged that, for most, weight loss is a difficult process; for some—those classified as morbidly obese—it is nigh impossible.
Onopchenko outlined the differences in weight classifications in relation to the Body Mass Index (BMI), which he said is “your weight, in kilograms, divided by your height in meters-squared.”
“A normal BMI is 19 to 24. Overweight is 25 to 29.9. Obesity is 30 to 34.9, without co-morbidities. The difference between obesity and morbid obesity—and, again, the name doesn’t sound very nice, because it carries connotations. When someone gets that heavy, that their health is affected, that is morbid obesity, and that can be defined as a BMI of 40 or greater, or a BMI as low as 35 to 39.9 if the patient also suffers from medical comorbidities that tag along with the weight—the biggest ones being hypertension, diabetes, obstructive sleep apnea, hyperlipidemia, asthma, reflux disease, joint and back problems,” Onopchenko said.
Onopchenko said that morbid obesity is a chronic, incurable and recidivistic disease that needs lifelong care.
“Unfortunately, there is no cure for this highly recidivistic disease, but the only acceptable and effective treatment that we currently have is bariatric surgery in the guise of a full-fledged, bariatric program that supports patients with education for what they need to do preoperatively, and then lifelong support postoperatively,” Onopchenko said.
Onopchenko said that, besides three bariatric surgeons and a fulltime bariatric program coordinator, AtlantiCare has a full team of specialists at their Surgical Weight Loss and Wellness Center.
“We have a psychologist that does all our preoperative evaluations; that is a part of the program, and certainly there is support, psychologically speaking, afterwards, if it is required. We have a dietician attached to us only, that is responsible for preoperative education and postoperative, ongoing education and support. Certainly, we utilize all the other resources that AtlantiCare brings to bear, including our primary care docs, our specialty care docs like cardiology and pulmonology, both for preoperative evaluation of patients and postoperative follow-up. Our life center provides an excellent opportunity to get the exercise piece in, which will be important in maintaining weight loss—with the help of bariatric surgery—and avoid significant weight regain,” Onopchenko said.
According to Onopchenko, candidates for bariatric surgery are those with a BMI of 40 or greater, or those with a BMI of 35 to 39.9 with any of the aforementioned comorbidities.
“Once you reach those milestones in BMI, this is the only effective treatment out there. To get into our program, it’s very easy. You go on the AtlantiCare website and click onto the Center for Surgical Weight Loss and Wellness, and there’s a webinar there. All three of our surgeons, myself included, are featured in their own webinars, discussing the state of morbid obesity and what needs to be done in terms of preparation for surgery, the surgeries themselves and the lifelong aftercare that is necessary,” Onopchenko said.
The next step, Onopchenko said, is to go to the center for a complete medical history and physical by one of their surgeons. Then, patients will by guided step-by-step as they go through the preoperative evaluation process to the day of surgery.
“The operations that we offer are sleeve gastrectomy, gastric bypass and duodenal switch. For sleeve gastrectomy, usually it’s a 23-hour stay. For bypass and switch, it’s usually a 48-hour stay. Recovery from all three of them is usually about two weeks, in terms of returning to work and returning to normal activity. The most important part is the lifelong follow-up in the office for support, reinforcement of the education that you got preoperatively and to make sure that these are positive changes in your life and no complications from the operations have occurred,” Onopchenko said.
Determining the proper procedure for each patient, Onopchenko said, is the “holy grail of bariatric surgery.”
“Unfortunately, there is no software yet available so that I can put in all the patient data and it spouts out the answer. In general, the most popular operation right now is the sleeve gastrectomy. It’s a very ubiquitous operation that is applicable to a wide range of patients, but, again, there may be other factors, and that’s why it’s so important to sit down with the surgeon after you get all the information on the webinar to decide which operation is best for you ... The differences are discussed in the webinar. The patients need to have a baseline amount of knowledge before they come to the surgeon’s office. Certainly, the surgeons discuss with the patients the advantages and disadvantages of each operation, in terms of the patient’s own profile in order to get to the right answer,” Onopchenko said.
There is no right or wrong answer when it comes to choosing the procedure, Onopchenko said, but he was also quick to caution that there is “really no operation that someone can’t out-eat.”
“They all work, and they all can fail. It’s more important to identify what the patient has to do with the help of the operation in order to change their lifestyle, change their eating habits, change their exercise habits that, without the operation, it’s impossible to do, but they still need to make those changes, even with the operation, to be successful,” Onopchenko said.
Onopchenko also noted that changes in diet need to be lasting and lifelong, not quick fixes.
“I like to tell folks that there are two types of diets: there’s Diet—and that’s Atkins, Weight Watchers, Nutrisystem—and there’s diet, and it’s diet that you need to make happen for you. I never tell folks that they need to completely eliminate one entire food group, because that is absolutely impossible. Going on a no-carb diet is absolutely absurd. That’s why it’s important to have a dietician as part of our program,” Onopchenko said.
What the Surgical Weight Loss and Wellness Center advocated for the average person, Onopchenko said, is a 1,200 to 1,500 calorie, high-protein, low-fat, low-carbohydrate diet.
“That’s what it’s about. Of those three components—protein, carbs and fat—I tend not to tell people to eat less fat or eat less carbs; it’s psychologically damaging. Instead of that, I tell people to eat more protein. The average person does not eat enough protein in order to be able to decrease those other components. If you eat an adequate amount of protein, the carbs and the fats almost take care of themselves, especially postoperatively, where there’s only room for that much food in their newly fashioned stomach, regardless of the type of operation that they get,” Onopchenko said.
The change in diet, Onopchenko said, is for the initiation of weight loss. Concurrently with that, patients need to increase activity.
“I try to say ‘activity’ rather than ‘exercise,’ because, for a lot of folks, ‘exercise’—even though it’s not—is a four-letter word. Federal guidelines call for an hour of extra activity above and beyond your activity of daily life, daily, just to maintain weight. Once you diet it off, then it’s very important to blend in your exercise piece to prevent weight regain,” Onopchenko said.
Without increased activity, Onopchenko said that there will come a time when patients “plateau and slowly start to regain.”
“That’s the way our bodies are built; we’re built as calorie-conserving machines. You do need to add the exercise piece to be able to do the equation correctly. That will keep your basic metabolic rate high, and allow you to maintain the weight loss that you’ve worked so hard to attain,” Onopchenko said.
Besides the obvious benefits, Onopchenko said that bariatric surgery can help patients with comorbidities like Type II Diabetes. One in three of his patients are Type-II Diabetics, he said.
“With Type II, you’re hyperinsulinemic before you become Type II Diabetic. So why do you become Type II if you have lots of insulin? There’s a block at the receptor site that’s important for transferring sugar glucose from the bloodstream to the tissues for utilization, and there’s a block at releasing that extra insulin from the pancreas. Even before any weight loss is accomplished, because all three of these operations deliver food somewhat faster downstream in your GI tract, there are reflex increases in certain gut hormones that reverse the effects of Type II Diabetes, meaning they unblock the receptor in the periphery and promote insulin release from the pancreas, and someone who has been on metformin or one of the new antidiabetic medications come in on day one, have their bypass, and by the time they leave on post-op day two, be no longer requiring any medication to regulate their blood sugar because of the almost immediate hormonal effects of these operations,” Onopchenko said.
Additionally, bariatric surgery can greatly reduce the risks of COVID-19.
“Morbid obesity was the most significant risk factor for COVID-19, not just in contracting the virus, but in having a serious disease due to the virus, the chance of ending up on a ventilator due to the virus and, ultimately, the higher risk of death. Morbid obesity alone—not just because of the comorbidities—does that, because it is a chronic, inflammatory state. Ventilation becomes much more difficult, especially when lungs are affected by this virus. If nothing else should be motivating us to get back to normal and get back to a good diet and exercise, with the next epidemic—if we haven’t learned our lesson—we’re going to repeat the significant mortality that we’ve seen because of morbid obesity when it’s combined with a virulent virus like COVID-19,” Onopchenko said.
For more information, visit www.atlanticare.org/services/bariatric-surgery/.