Search Results for "why i support bariatric surgery"
Post-Surgery Weight Regain: Nutritional Factors
One of the key reasons why bariatric surgery is so much more effective for treating severe obesity than non-surgical approaches, is because of its profound effect on food intake. Thus, bariatric surgery significantly affects hunger and satiety and may even have important effects on “wanting” and “liking” of high-caloric foods. However, this effect on ingestive behaviour is neither “guaranteed” not are these effects consistent between individuals. As I tell my patients, “The surgeons operate on your gut, not your brain”. Thus, it can only be expected that a certain proportion of patients will struggle to control their food intake despite surgery, thereby either losing less weight than expected or putting the weight back on. In an article, published in Obesity Surgery, we systematically reviewed the published evidence on the role of dietary factors in this issue. As may be expected, patients reporting “loss of control” of eating behaviour post-surgery lost less weight or had a higher risk of gaining back any weight they may have initially lost. Thus, individuals with self-reported “high-adherence” scores tended to lose and sustain greater weight loss than those who did not. Given that bariatric surgery may limit the amount of food that can be eaten at a single meal, some patients resorted to grazing behaviours (defined as consumption of smaller amounts of foods over extended periods of time) leading to subsequent weight regain. In addition, it was reported that poor diet quality, characterized by an excessive intake of calories, snacks and sweets, as well as oils and fatty foods, was statistically higher in patients experiencing weight regain. Interestingly, even short-term dietary “indiscretion” (or falling off) can result in very rapid weight regain. This is not surprising as, in this regard there is little difference between someone who has lost weight through surgery or simply through diet and exercise. Irrespective of how the weight is lost, the body appears to retain its ability to rapidly regain lost weight if allowed to do so. Thus, as we discuss in our article, “The existing literature strongly suggests that nutritional and lifestyle compliance is crucial to weight management post- bariatric surgery.” “Comprehensive weight management programs must therefore provide improved patient education and promote adherence to post-bariatric surgery diets in order to ensure success. These programs must take action to support patients towards a long-term goal of healthy and appropriate dietary choices with active monitoring (journaling) and reinforcement (review of… Read More »
Interdisciplinary Bariatric Care
Yesterday, I gave a key note talk on why bariatric surgery should not be seen as a ‘quick fix’ for obesity at the 5th Annual Obesity Symposium hosted by the European Surgical Institute in Norderstedt (just outside Hamburg). I also participated in an interdisciplinary panel discussion of six interesting cases that were presented to us for comment. While all panelist agreed that surgical treatment is currently the most effective treatment for patients with severe obesity, several of us were also quick to point out that this does not make obesity a surgical disease. In fact, there was general agreement among the panelists that this is a condition that is best managed in a multidisciplinary setting which includes internists and psychiatrists as well as nurses and other allied health care providers. As one panelist pointed out, while the surgery may help the patient sustain weight loss, the many medical and psychosocial problems that patients often face before and after surgery need to be addressed in order for them to get the maximum benefit from the procedure. It was interesting, but not surprising, to note that surgeons from all three countries (Germany, Switzerland and Austria) universally complained about the fact that they often had nowhere to send their operated patients for follow-up leaving them with the burden of trying to provide what little support they could after surgery. While the surgeons fully realized that the underlying problems in cases where patients struggled or faced complications were seldom ‘surgical’, they often found it difficult to direct these patients to appropriate providers better qualified to deal with the psychosocial or mental issues that caused these problems. Thus, surgeons reported often finding themselves reoperating on ‘unsuccessful’ patients in the hope that a more drastic operation would fix the problem (which in most cases it didn’t). This speaks to the importance of ensuring that any increase in bariatric surgical capacity must be matched by an increase in capacity of other providers to assist in the care of these often complex patients. Unfortunately, in many setting, such services are either not available or significantly under funded, often leaving patients abandoned and struggling. This issue is certainly by no means unique to these countries. Rather it appears to be rather universal experience that, while attracting surgeons to do the operations is rather straightforward, finding competent physicians willing to work in this field is far more difficult. AMS London,… Read More »
Role Of GLP-1 In The Resolution of Diabetes After Gastric Bypass Surgery
Yesterday, I discussed the strong interest in trying to understand why exactly bariatric surgery leads to an often dramatic improvement (if not resolution) of type 2 diabetes. Additional insights into this topic comes from Marzieh Salehi and colleagues in a paper just published in Diabetes. The paper takes advantage of the fact that some patients undergoing gastric bypass (GB) surgery experience significantly increased insulin secretion following a meal, sometimes even resulting in clinically significant hypoglycaemia. In order to test the hypothesis that this increase in insulin secretion is in part mediated by the incretin glucagon-like peptide 1 (GLP-1), asymptomatic individuals with previous GB, 10 matched healthy nonoperated control subjects, and 12 patients with recurrent hypoglycemia after GB were examined with and without administration of the GLP-1 receptor antagonist exendin-(9-39). Blocking GLP-1 significantly reduced postprandial insulin secretion in GB patients than in the non-surgical controls. However, in the hypoglycaemic GB patients, GLP-1 appeared to account for about 45% of increased insulin secretion, not much more than in the non-hypoglycemic surgical subjects. Glucagon was suppressed similarly by hyperglycemia in all groups but rose significantly after the meal in surgical individuals but remained suppressed in nonsurgical subjects. GLP-1 receptor blockade increased postprandial glucagon in both surgical groups. As the authors conclude, “Increased GLP-1-stimulated insulin secretion contributes significantly to hyperinsulinism in GB subjects. However, the exaggerated effect of GLP-1 on postprandial insulin secretion in surgical subjects is not significantly different in those with and without recurrent hypoglycaemia.” This means that additional factors are probably involved in the hypoglycaemic response seen in some GB patients. As pointed out in an accompanying editorial by Jens Juul Holst, however, these findings may be more difficult to interpret due to several features of the study design used by Salehi and colleagues. Thus, without going into too many methodological details, there are questions about whether or not the approach used in this study fully explored (or rules out) the role of GLP-1 in the hypoglycaemic response. Nevertheless, the study certainly supports the notion that increased secretion of GLP-1 following GB surgery, together with other mechanisms including secretion of other enteric hormones, quicker passage of food through the small bowel, reduction in liver fat, and weight loss in general, may all play a role in the substantial glycemic improvements seen with GB surgery in patients with type 2 diabetes. Thus, while administration of GLP-1 analogues can potentially mimic some of… Read More »
Bariatric Surgery: It’s More Interesting Than You Think
Regular readers of these pages, will by now know that bariatric surgery is by far the most effective and reliable treatment for severe obesity. However, how exactly bariatric surgery works, continues to be an intense field of medical and experimental research. Last year, this was the topic of the 13th Bariatric/metabolic International Symposium of the Merck Frosst/CIHR Research Chair in Obesity at Laval University, the proceeding of which have now been published in a supplement to the International Journal of Obesity. As pointed out by Keith Sharkey, from the University of Calgary, in an accompanying editorial, “surgeries are remarkably effective in reducing weight over a sustained period of time, and they also have significant beneficial effects on glucose homeostasis. Interestingly, the metabolic benefits of these surgeries frequently occur before significant weight loss.” Studies in this supplement use animal models to reveal the neurohumoral mechanisms underlying weight loss and improved glucose homeostasis after experimental bariatric surgery. Not only do these rodent models of bariatric surgery show that food reward is altered and that the proximal gut is important in the control of energy balance and glucose homeostasis, but these studies provide important insights into the molecular and neuronal mechanisms of these effects. Of course, from my perspective, the hope is that there findings will eventually lead to pharmaceutical approached to treating severe obesity that will eventually put bariatric surgeons out of business. Till then, we must accept that surgical treatment is far more effective for managing severe obesity in patients, who urgently need treatment, than any conservative ‘Eat-Less-Move-More’ approaches have to offer. Of course, preventing the obesity in the first place would be even better, but that certainly does not solve the problem of the tens of thousands, who cary 100s of excess pounds and have few, if any, other options to deal with their considerable excess weight and related health problems. AMS Edmonton, Alberta Sharkey KA (2011). Animal models of bariatric/metabolic surgery shed light on the mechanisms of weight control and glucose homeostasis: view from the chair. International journal of obesity (2005), 35 Suppl 3 PMID: 21912385
Impact of Bariatric Surgery on Romantic Relationships
Regular readers may recall previous posts in which I commented on the significant impact (both good and bad) that undergoing bariatric surgery can have on personal relationships. This topic is extensively dealt with in an article by Katherine Applegate and Kelli Friedman (Duke University) published in Bariatric Nursing. As the authors point out patients can encounter diverse relationship issues as they consider, undergo, and live with bariatric surgery. These problems can stem from the patients’ and their partners’ expectations, the patients’ increase in energy, their enhanced confidence, and changes in appearance. Other common concerns include changes in sexual intimacy and beliefs about the stability of the relationship and risk of divorce. Although overall, there is considerable research showing that most patients will report improvements in relationship satisfaction and weight-related sexual quality of life after surgery, problems can occur and health professionals should certainly be aware of and well able to counsel their patients on these issues. As always, it is best to communicate these issues professionally and accurately and help patients recruit support and obtain psychological counseling when needed. I’d certainly like to hear from any of my readers on how they have dealt with such issues or have counselled their clients about these problems. AMS Hamburg, Germany