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In the larger discussion around long-term weight management, bariatric surgery, or weight-loss surgery, it’s clear that it has become a topic that seems riddled with misconceptions. Here to speak to those misconceptions is the founder and medical director of the Bariatric Medical Institute, Dr. Yoni Freedhoff, who gave us a crash course in all you need to know about bariatric surgery, and dispelled some of the myths surrounding it.
Bariatric surgery is not just one surgery. It’s rather a catch-all term used to describe surgeries which are used in the treatment of obesity. Amazingly, these surgeries don’t simply work by way of making the stomach much smaller, but rather their main mechanisms of action are metabolic whereby they have a huge impact on the body’s production of hunger hormones, peptides, and even our microbiome in a way that not only leads to long term weight loss and the resolution of many weight-related medical conditions.
Bariatric surgery is not just ‘stomach stapling’, as many people might think it is. Twenty years ago, these surgeries were open surgeries with big scars. Nowadays, they are done laparoscopically, consisting of 5 small holes.
AN ‘EASY WAY OUT’
Many patients view merely considering bariatric surgery to be a personal failure. They believe that if they simply tried harder or had more self-efficacy, they’d be able to lose the weight without the surgery. While it’s true that weight management is about eating less and exercising more, that truism is about as useful to long term success as ‘buy low, sell high’ is to becoming a millionaire. A patient’s job is to do their best, to live with the healthiest life that they can enjoy. If that best effort doesn’t afford them sufficient success to reduce medical comorbidities and/or improve their quality of life then we might consider medications, and if behaviour plus medications didn’t do the trick, thankfully, we have a surgical option.
Right now, the requirements for bariatric surgery include a body mass index of 35 or higher with weight responsive medical conditions, such as high blood pressure, type 2 diabetes, sleep apnea, etc., or a BMI of 40 regardless of medical issues. While BMI is relative, to give you an idea of what these numbers look like in real life – for a person who is 5 foot 6, a BMI of 35 would come at a weight of 210 pounds and a BMI of 40 would put them at 240 pounds.
The procedure presents no more risk than a gallbladder removal, with mortality rates ranging from 2% to 0.2%. It would be important for you as a clinician to check with your local surgical site and ask them if they could provide you with their statistics, but generally, surgical centres of excellence say that bariatric surgical mortality is comparable to any other intra-abdominal surgery. Most patients are off of painkillers, aside from acetaminophen, within three to four days.
THE ULTIMATE CURE
Though bariatric surgery can help patients achieve dramatic and sustained weight losses, it’s not curative. For surgery to be a long term success, behavioural effort is required. While not the effort of classic dieting, if a patient ignores their surgery’s required nutrition guidelines and dietary recommendations, over time, they risk regaining all of the weight they’ll lose through surgery, and that once weight lost through surgery is regained, it’s very unlikely there will be the option of a second surgical procedure to help.
DOES IT AFFECT HUNGER?
One of the most common patient concerns is that following surgery they will be faced with the scenario of being constantly hungry and yet unable to eat. Bariatric surgery does affect hunger hormones – but it actually decreases their production. Much more often than not, bariatric surgery patients find themselves with far less hunger post-operatively, and on those rare occasions that a post-operative patient does struggle with a resurgence of hunger, early experiences with liraglutide suggest that it may be a very useful drug in its management.
Generally speaking, post bariatric surgery patients are encouraged to eat multiple smaller meals throughout the day with an emphasis on the inclusion of protein. Part of the reason for this is that due to the small stomach, they fill quickly, and so if you’re not eating frequently, you may not be able to meet nutritional needs.
We also discourage eating and drinking at the same time in part because it may lead to those small stomachs to fill quickly and actually hurt. The first 3-6 post-operative months can be especially difficult in terms of patients learning how to eat again. That said, with time, patients will learn how to manage their new anatomies and they will find their new normals in terms of what, when, and how much they can eat. The other major caution is to alcohol consumption, which post-surgically, affects people very differently than prior and actually increases the risk of dependency and alcohol use disorder.
Nutritional deficiencies are the main side effect of bariatric surgery. Deficiencies post-surgery depend in part on which surgery is performed. Consequently, patients who have surgery must be prepared to take supplements and regularly (at least annually) have their blood drawn and analyzed. Speaking to the most common bariatric surgery, the roux-en-y gastric bypass, part of the deficiencies are a consequence, in part, to the sort of intestines that are bypassed, and in part due to decreased dietary consumption. Risk, and consequently, surveillance, is for life. That said, we monitor for deficiencies and we replace them with supplements if need be.
THE EMOTIONAL TOLL
At least in the early weeks and months post-surgery, patients should expect a bit of an emotional ride. From days where they wish they had done the surgery years earlier, to days where they feel they made the biggest mistake of their lives, because it’s quite challenging. It’s relearning how to eat in terms of pace. Often palates change. If you eat too quickly a person can experience pain or nausea. It’s just a great deal of change quickly and that’s challenging to take in at times.
Reassuring them that this rollercoaster is normal, and pointing them in advance towards the myriad of online resources that they can access for peer support (ask your patients who have had surgery already if there are any local Facebook groups and also you can steer patients to obesityhelp.com) can help them weather their surgical journeys.
Studies on post-bariatric surgery pregnancy demonstrate that the pregnancies are actually safer for both mother and baby than pregnancies with pre-bariatric surgical weights. There’s no data to suggest it’s more difficult to get pregnant post-bariatric surgery. In terms of wait times post-surgery, in Ontario we recommend a woman wait 18 months post-surgery to conceive, but of course if it happens sooner, we simply manage those pregnancies.
The benefits of the surgery are staggering. We see long term remission of type 2 diabetes in 75-85% of patients, we see resolution of high blood pressure, sleep apnea, and reflux. We often see pain decrease consequent to decreased mechanical loads on joints, we know that the risk of many different cancers decrease and we know too, that it extends life’s quantity and also, dramatically, life’s quality – so many patients express the sentiment that they’re finally able to live the lives they want to live – running marathons, travelling, playing and keeping up with their kids and grandkids, taking on challenges that they felt, fairly or not, were not within the realm of possibility when they were heavier.