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Yesterday’s post was a brief overview of how bariatric surgery works and why it helps most people sustain weight loss by affecting key determinants of ingestive behaviour (hunger, appetite, satiety, reward, etc.). Today, however, I want to look at why surgery is anything but a ‘quick fix’ or an ‘easy way out’ and why, despite all of its potential benefits on quality of life, comorbidities and mortality, surgery is by no means a ‘guarantee’ for success. While ‘success’ with bariatric surgery is certainly not guaranteed (and for some patients, as with any drastic treatment, things can sometimes go horribly wrong), most patients do remarkably well, including – and this may surprise readers – patients with emotional eating or eating disorders. Thus, as presented by Tom Wadden, Professor of Psychology, University of Pennsylvania School of Medicine, at the 18th European Congress of Obesity, which I am currently attending in Istanbul, Turkey, even patients with classical ‘Binge-Eating Disorder’ (BED) surprisingly benefit from surgery (OBESITY). In this prospective case-control comparison of cognitive behavioural therapy, lifestyle intervention and the use of meal relacements vs. bariatric surgery in patients diagnosed with BED, the surgical patients did twice as well as the ‘lifestyle’ group in terms of weight loss with significant improvements in cardiovascular risk factors. Perhaps, even more importantly, the frequency of binge episodes dropped as dramatically in the surgical BED patients as in the non-surgical BED patients. Although the study published only one-year results, Wadden reported that even extended follow-up appears to confirm these results. Similar results have been reported by others. I only bring up these studies, as it is widely assumed that because bariatric surgery does not address the psychological drivers of overeating (as the surgery is on the gut and not the brain), it may be far less effective or even futile in patients with severe eating disorders. This is not to say that failure rates may be somewhat higher in people who are more predisposed to emotional eating or eating disorders – but on average, these patients appear do just as well. So how can these findings be explained? One reason may well be that although bariatric surgery primarily affects the homeostatic system of hunger and satiety, it indirectly also affects the hedonic system. As regular readers may recall, hunger can markedly activate the hedonic (reward-seeking) centres of the brain, which I have previously described as the reason why “hunger… Read More »
In previous posts this week, I discussed the risk and potential benefits of bariatric surgery and explained why for someone with severe obesity and significant comorbidities, current evidence comes down heavily on the benefit side, whereas for someone with obesity but no complications, the risk/benefit ratio may not be all that positive. In today’s post, I would like to look at why bariatric surgery works and hopefully dispel some common misconceptions about what bariatric surgery actually entails. However, to fully understand why bariatric surgery should even be considered an option, we need to first understand why it is so difficult to lose weight and keep it off. Readers will recall last week’s discussion on how any weight loss results in a ‘hypometabolic’ and orexogenic state – in short, weight loss drastically reduces the number of calories burnt while increasing hunger and appetite. This is exactly what makes keeping weight off so difficult – as metabolism slows down and appetite increases, keeping weight off becomes a daily battle – a battle that lasts forever (the more weight you lose, the greater the struggle). This is why only a dedicated few, for whom weight management becomes nothing short of a daily obsession, manage to keep substantial amounts of weight off. Everyone else, eventually gives in – most people can simply not endure constant restrictions or hunger forever. Remember we are not talking about simply expecting someone who weighed 300 lbs to lose 50 lbs and from now on live on the same amount of food that a never-obese 250 lb person would normally eat. No! To sustain the 50 lbs wieght loss, the formerly 300 lb person would need to perhaps survive on the amount of food that a never-obese 200 lb person would normally eat (or less!). So expecting someone, who normally would have eaten 2500-3000 KCal a day (or more) to, from now on, survive on 1500 KCal a day or less, is a pretty hard sell – especially, as this person, thanks to the orexogenic response to weight loss, would be constantly hungry and thinking of food. To make this kind of weight loss possible (even in the short-term), virtually all popular diets resort to certain ‘tricks’ to reduce hunger and increase satiety. Increasing protein intake while drastically reducing carbs is one common variation (e.g. Atkins diet) – this approach takes advantage of both the satiating effect of protein… Read More »
So now, that we have extensively discussed the issue of risk in previous posts, let us turn our view to the benefits of bariatric surgery. In this discussion let us be very clear about the following: 1) Bariatric surgery does not, nor is it intended to, address the many ‘root causes’ of obesity. Its only raison d’être is to help patients with weight-related health problems sustain a degree of weight loss that is, for the vast majority of people (i.e. 19 out of 20), simply impossible to sustain with diet and exercise alone. 2) To be honest, bariatric surgery is not even about weight loss! To put it bluntly, the real reason to even consider bariatric surgery is because of its positive impact on comorbid conditions (which is why I refuse to call it weight-loss surgery or WLS). While many patients appreciate the fact that bariatric surgery may help them attain and sustain a lower body weight – the real benefit, at least from a medical perspective, can only be measured in improvements in health and quality of life. In fact, if ‘bariatric’ surgery only improved health (with no weight loss), it would still be a worthwhile intervention. 3) I have already addressed the issue or surgical risk vs. the risk of not having surgery in previous posts. Thus, readers will recall that even the surprisingly small risk of undergoing laparoscopic bariatric surgery, may exceed the risk of not having surgery in obese people, who are otherwise healthy. These are NOT the folks who should be strongly considering surgery. On the other hand, the more obesity-related complications the patient has, the smaller the relative risk of undergoing surgery. So, I am by no means advocating for simply operating on anyone who is obese. In any obese patient without comorbidities or significant impairment of quality of life, even the rather small risk of surgery is clearly not worth taking. 4) Surgery is not for everyone. As pointed out in previous posts, we turn away many patients, who may meet both the BMI and medical criteria for surgery because we do not think that they will be able to make or sustain the considerable lifestyle changes that are required for surgery to ‘succeed’. Some patients may slip through the ‘cracks’ because they manage to convince (I will not say intentionally mislead) us to think they will cope, when they clearly will not.… Read More »
Yesterday’s post was about the widespread misconceptions around the risk of having bariatric surgery compared to the risk of not having surgery. I pointed out that for a severely obese person with clinically significant end-organ damage, the risk of death without surgery within 1 year is about 10 times that of dying of the surgery itself. Having looked at the risks, today, I wanted to discuss the ‘benefit’ side of the equation – after all, no one would consider even the safest surgery, if there was no benefit to having it. But before I go into the discussion of benefits, I thought it may be worthwhile to discuss how we (both experts and non-experts) tend to perceive risk and why we are so easily bound to kid ourselves, even when we know the numbers. The fundamentals of how human psychology tricks us into falling widely off the mark, when it comes to interpreting risk was described in a classic paper by Daniel Kahneman and Amos Tversky published in Science in 1974 (Kahneman went on to get the Nobel Prize for economics in 2002). As pointed out in this seminal paper, based on a remarkably solid body of empirical psychological research (consistently replicated ever since), we all tend to make ‘gut’ decisions according to the following three principles: 1) Representativeness (or as Dan Gardner calls it, “the rule of Typical Things”) 2) Availability or recall of instances (“Example Rule”) 3) Anchoring We tend to use all three rules to assess risk or judge probability – even when we know the numbers and statistics. I have previously described the Anchoring Rule, so I will not discuss this again – suffice it to say, that our judgements are often clouded by (random?) numbers that we have heard somewhere, irrespective of whether they are even remotely true or not. If someone (anyone) were to simply say 89.7% of patients struggle after surgery (a number I just made up), people will think that surgery is a risky business, even if I then tell them that I just made up this number and it is probably a wild exaggeration (and never mind that the actual number is probably well below 20%). They would just be obeying the Anchoring Rule. The Rule of Typical Things is even trickier and leads us to believe more in stories that sound reasonable and ‘typical’ than stories that sound ‘non-typical’. Interestingly,… Read More »
Let me start this post with a few disclaimers: 1) I am not a surgeon and do not get paid based on whether any of my patients decides for or against surgery. 2) The average BMI of patients seen in our program is 49.7 kg/m2 – the average patient is just below 40 years of age. Most have substantial health problems – many cannot work or perform even simple tasks of daily living because of their weight – most have tried every commercial diet or pill they could lay their hands on – they are all ‘experts’ on weight loss. 3) Many have significant psychosocial problems and mobility issues that may have contributed to their weight gain – these are dealt with by an interdisciplinary team of psychiatrists, psychologists, occupational and physiotherapists, nurses and dietitians – treatments that start months before any patient is considered a candidate for surgery. 4) I do not for once believe that bariatric surgery addresses any of the ‘root causes’ of severe obesity and I am sure that none of my surgical colleagues believe it does. As I often tell my patients, “the surgery is on your gut and not your head”. 5) Our program regularly talks patients, who come to us wanting surgery, out of surgery, if we feel that it is not in their best interest or unlikely to have a successful outcome – to these patients we offer the best non-surgical care we can – but of course, many are disappointed. And yet, our program regularly performs bariatric surgery and prepares patients for it in a process that can often take 6 months or longer. We proactively discuss surgery with all patients, who meet the criteria for surgery – both the pros and the cons. We offer comprehensive dietary, psychological and medical support to all patients who decide to undergo surgery but make it very clear that surgery is not a ‘cure’ and that patients have to make substantial lifestyle changes in order to be ‘successful’ (we measure ‘success’ in improvement in comorbidities and quality of life – not in pounds lost!). With these caveats out of the way, I would today like to dispel some common myths about bariatric surgery and discuss why for many patients with severe obesity, it is in fact a very realistic and successful option. The first common and pervasive misconception relates to risk – both short-term… Read More »