Medical Risks of Bariatric Surgery

The newest clinician to treat obesity is the surgeon. Although Bariatric procedures can have startling short-term benefits for obese patients and their medical co-morbidities, there's not much reliable data about the long term risks of surgery. I have written frequently about the difficult road to curb overeating and binging, and the decision to have drastic surgery can be liberating. It feels like the magic cure after years of struggle. But the surgeon, without sufficient knowledge of the life and trials of the obese person, typically is not equipped to assess suitability of the patient or inform patients of the real risks of surgery. Instead, they paint a rosy picture of weight loss without any reality check at all and proceed accordingly.

Unlike all other interventions for binging and overeating, surgery is permanent. The goal is to create a physical impediment that will stop someone from eating too much. The surgeon can explain the various procedures and risks during the surgery well, such as the possibility of infection or the risks of anesthesia, but has little knowledge of what happens afterwards. Much of the pre-screening is completed during a psychological evaluation which appears to be a part of the pre-op checklist rather than weeding out patients who shouldn't move forward. The only true impediment is cost, largely based on insurance coverage. After that, almost anyone who meets criteria can have it done.

Changing the anatomy of the gastrointestinal tract has significant medical consequences. This post will not thoroughly review the risks but rather point out some important things to consider. The long term effects of Bariatric surgery are still largely unknown.

After surgery, a much smaller amount of food enters the digestive system, by design. The body adapts by slowing down digestion in response to the decreased need. Over a long period of time, slowed digestion is no longer an adaptation but a permanent change called gastroparesis or delayed gastric emptying. The symptoms are chronic indigestion, limited diet and abdominal pain and, in its severe form, can be debilitating with minimal effective treatment. This condition can lead to permanent gastrointestinal disability.

Medical science is still learning about the complicated interplay between hormones in hunger and digestion. There is a lot of current research into endocrine involvement in the gastrointestinal system to devise weight loss medications. Some Bariatric surgeries take out parts of the stomach that produce these hormones. Since doctors don't know the exact mechanism of hormones in digestion, no one knows what long-term effects low levels of digestive hormones may have.

Bariatric surgery also affects absorption of nutrients, vitamins and minerals in the stomach and small intestines, yet once again it's not clear how or why this happens. Years after surgery patients can have rare deficiencies of micronutrients that humans need in very small quantities of for our bodies to function. Since its so uncommon to see signs of these deficiencies in today's world, most doctors don't check these blood tests and the syndrome goes undiagnosed.

In addition, Bariatric surgery is not a cure for eating disorders. People who binge or manage emotions by overeating find that the drive to use a behavior can outwit any physical impediment. It's too easy for people who have had one of these surgeries to adapt their symptoms and find themselves trapped again but having also undergone an ineffective, painful procedure. A thorough psychological screening needs to identify patients with eating disorders and direct them for treatment before even considering surgery.

It's telling about the current reaction to the obesity epidemic that as drastic an option as surgery is so popular. The misdirection in advertising by agribusiness, the processed food industry and the diet industry has successfully placed blame on the individual. Even the government believes the solution to this public health issue is education and individual choice despite growing evidence that we are powerless to resist the current world of delectable food. All signs erroneously place the blame squarely on the individual. Diets are ineffective and medications supposedly in the pipeline, so for many surgery appears to be the best alternative. The medical literature of the consequences of Bariatric surgery can't slow down the growth of this branch of the health care industry. 

It strikes me that only another part of the medical field can inform the public about these risky surgeries. Doctors only sporadically see patients with severe consequences of surgery because there are no sub-specialists at this point. The surgeries are still new enough that medicine doesn't yet have enough evidence to challenge such a radical approach to obesity. Pooling data among clinicians, a difficult task without centralized medical records, would be very effective. The hope is that the medical system will recognize the risk of Bariatric surgery and respond appropriately in the very near future. 

Sanctioned Chronic Undereating: One Factor in the Obesity Epidemic

The principle that starving can actually cause an eating disorder is, from much of the feedback to a recent post (The Biology of Starvation), eye-opening to many, especially since dieting is commonplace in today's world. The modern drive for thinness, in its many guises, fuels our collective desire to lose weight and helps us not bat an eye at the crazy schemes to do so. The concept that our bodies will adapt, mostly negatively, to being starved, is shocking to many. It's not obvious how society condones and even encourages such reckless and dangerous behavior. Although recent posts in this blog have increased awareness that there is a biological response to starvation, they haven't reviewed the many ways starving is sanctioned in the modern world.

Dieting is the most obvious example. The diet industry is a multi-billion dollar business that takes many forms. Health-oriented programs such as Weight Watcher's, Jenny Craig and Overeaters Anonymous provide supportive therapeutic environments for weight loss. Normalized eating may be the long term goal of these programs, but they never shake their emphasis on weight loss as a lifestyle.

Self-help or "healthy eating" cookbooks encourage undereating as a daily life choice, as if it were a choice, while not admitting the meals are just very low in calories and not sufficient. Many diet programs now include meal order services which make it even easier to see starvation as a daily goal. Juice cleanses excuse total starvation to rid the body of "toxic elements" and have even become a point of envy in certain social circles.

Bariatric surgery provides medical interventions that can make anyone capable of starving--a physical impediment diet. And so we are surrounded by facets of every day life that inure us to the concept of not eating. But never is it pointed out that starvation has serious medical consequences.

Advertising and fashion business concepts give a visual representation of the same message. Clothing advertisements continue to show women and men who are underweight with very low body fat. Companies such as Abercrombie and Fitch experience few repercussions for celebrating that they won't make clothes past a certain size. Any media presence of a person, especially a woman, of a more typical size is still noted as an anomaly. Again modern life normalizes starvation and encourages us all to want to look underweight.

Another means to starvation a reader recently pointed out is athletics. Many sports or physical activities demand starvation either to reach or maintain very low weights. Gymnastics, wrestling and ballet all focus on weight loss as a critical part of the sport, and much has been written about the connection between these endeavors and eating disorders. Competitive athletes or dancers often link the onset of the eating disorder to enforced starvation but find themselves unable to get better afterwards.

We live in a world focused on obesity and the overabundance processed food. Needless to say, these are public health problems of a large magnitude. The counterbalance to obesity is dieting, undereating and supposedly "healthy eating." As government, regulators and prominent writers tackle obesity, the solutions tout tried and true methods of regulating our intake, cooking, whole foods and knowledge about food choices, but it's not clear this advice can affect the population at large. The experts ignore the fact that starvation plays a more insidious role in daily life--the unidentified yin to obesity's yang--and the community at large still tolerates messages promoting undereating as a solution to our larger problems of being overweight.

The connection between starvation and obesity won't be obvious to people without knowledge of eating disorders. The biology of starvation is only one of the basic principles of eating disorder treatment. A second, just as relevant principle about eating disorders from this blog is that undereating promotes overeating. Not only does starvation often trigger an eating disorder but it also cycles into overeating, weight gain and obesity. Serial dieters show escalating weight gain over time. After a period of starvation and weight loss, we are biologically programmed to experience intense hunger and overeat to compensate, hoarding reserves for the next enforced famine. A simple equation emerges from these two principles of eating disorders: without addressing starvation, obesity won't go away. And that needs to be an obvious point to prominent people facing the obesity epidemic.