Weight loss surgeries: Golden ticket, Temporary Patch or Ticket to jail?
By Kathryn Fink, MS, RD, CSSD, LD
July 3, 2011
It is imperative to recognize both the physical and emotional deepness that obesity places in a person's life. Weight loss surgeries have done dramatic things for people's health and often seem like the "Golden Ticket". People have been taken off their Diabetes, blood pressure and cholesterol medications, and lowered their risk for many health problems such as heart disease, dyslipidemia, cancer, stroke and even a decrease in overall mortality rates.(1,2 ) Bariatric surgery has been found to be very cost effective for Type 2 Diabetes relative to standard therapy.( 3) Many of these risk reductions are typically because of the loss of weight that puts the individuals in a lowered risk category. Patients who have undergone bariatric surgery have an average excess weight loss of 65 – 70% of their original weight within the first 1 – 2 years, post-op; with 50 – 55% maintaining that weight loss for = 15 years.(4) There are many people who these changes do last, but for how long and at what expense? The physical health problems often times are the only measures used to assess progress and success. However, there is more to examine then just physical health problems and weight loss to determine long term success. Sometimes these procedures provide a temporary patch or ticket to deeper struggles not easily seen initially.
Many individuals think, "This will be it. After this surgery, my life will be miraculously different." Dreams of dotting spouses, well behaved kids, no more hunger feelings, the perfect job and a "will power and control over food" can finally be achieved. This is the illusion many have when going into having bariatric surgery. Bariatric patients have an unrealistic expectation regarding outcome. (5) People do feel better, have more energy and are able to wear a whole new set of clothes. Clients have also described a new attention and focus placed on them, and people recognize them and talk to them more. This attention is often described as overwhelming, some being more comfortable with the attention and others not knowing how to handle the attention. With all this new attention, it makes the old life seem to just slip away and gives hope that this is the "new" you and you will NEVER go back to the way things used to be. No more slave to the scale, measuring, diet books, buffet dinners with the after experience of feeling guilty and overwhelmed and swearing this will never happen again.
A brief synopsis of the currently most performed procedures, as well as some of the issues that are surfacing are the intent of this summary.
There are 3 current procedures most commonly performed: LAP-BAND® or REALIZE® laparoscopic banding, Roux-en-Y gastric bypass or the Sleeve surgery. The Lap Band and REALIZE are brand names of bands that are surgically placed around a person's stomach and contain a port that connects to a person's abdominal wall. This port is used to fill fluid in a person's band and adjust the level of restriction. This procedure is the least permanent and can be removed.
Gastric bypass Roux-en-Y is a procedure where the surgeon creates a small golf ball sized pouch and a Y-shaped section of the small intestine is then attached to this new pouch, allowing food to bypass the remaining stomach, and part of the intestine. This procedure creates a restriction (smaller volume of food fills a person up) and a malabsorption of some nutrients, depending on how much of the intestine is bypassed. This procedure many times has an uncomfortable side effect if an individual eats too many carbohydrates or sweets called "dumping syndrome". This side effect is thought to help individuals restrict the amount of carbohydrates they consume.
The sleeve is the newest procedure being performed. This permanently removes a portion of your stomach. This procedure makes the stomach smaller and with similar restriction to the banding but permanent and similar to restriction to the gastric bypass, but without altering the intestines.
Any surgery carries risks as well as the potential for a degree of complications. In terms of bariatric surgeries, these risks and complications can be categorized into nutritional, physical, physiological, psychological and sociological. Follow- up is imperative for long term success and to initiate and maintain a decrease of complications. Long term dietary advice, evaluation and supplementation are required for all procedures. (3) It is currently recommended that patients be followed by the surgeon for at least two years, with continuing routine checkups and carefully monitored lab values to assess patient nutritional status and deficiencies, as well as medical complications, post-operatively at least yearly for the rest of his or her life. (6,7) An 8 year study showed disordered eating behavior was frequent and recommended successful outcome should take into account problematic eating behaviors. (8) Success with weight loss surgeries should not only look at reductions in health risks and disease states, but their relationship with food.
Reality and Actual Practice
This is where many people fall short. From my professional experience, people think that after the procedure and they are done with their weight loss and typical one year follow up that is provided with the program, this is their new life and they do not need any additional help. However, piece by piece, many of the old habits start to creep back in, as any unrealistic plan is hard to achieve long term. I have often been told," I will just not ever eat sweets again, I‘ve gone this long without them, no big deal". This is often easy to do in the beginning and in the "honeymoon" phase, but long term is unrealistic. Missed indulgences in birthday celebrations, or I'll just have one bite and that will remind me how much I don't like it and then I won't want one. This is often followed by, "gee, that tasted good, might as well go ahead and it eat the whole thing, since after this I will not allow myself this again." However, this is the exact mentatlity that the individual often struggled with prior to surgery. This is where it is essential for continual follow-up with a dietitian and treatment team can help prevent relapses into destructive eating habits. It is crucial to learn effective coping skills to handle increased stressful situations, bumps in the road and comments about their weight loss and change of lifestyle. (9) It is important for clients to learn life style changes and to not label foods as "good" or "bad" foods since that could lead to further destructive eating habits.
For many, the first couple of years can be compared to the first couple of years in a marriage. The new changes and adrenalin from those changes provide lots of excitement and motivation to do this plan right. For many, it is the one hope left that they can lose their weight and make permanent changes in their lifestyle, health and appearance. These changes do often appear, but, do they last? Exercise and activity to help support the weight loss seems to be easier in the "honeymoon" phase, but as many people know, can be a hard commitment to continue, especially if it is done for the wrong reasons. Activity should be a lifestyle change and should be something that you enjoy. If it is not something you enjoy, then it makes it harder to do and continue long-term.
Pipe Dream Smashed?
Many studies talk about the long term weight loss and success of patients. But what about those who are not successful or have some of the complications? Some of the clients end up gaining the weight back and feeling out of control, being admitted to a psychiatric centers after trying to commit suicide, or for detoxification from drugs or alcohol, for their eating disorder or to work on their trauma from their past that resurfaces. These complications can happen for multiple reasons, such as not finding a healthy outlet to handle their emotions. Sometimes when the food gets taken away from them, they turn to a new addiction such as alcohol, shopping or sexual addictions.
Individuals are required to see a psychiatrist and dietitian prior to the surgery, but what is done in that session? Most of the time the evaluation is a brief summary for documentation of the individuals dieting and food behavior history. There is very little time for education about the upcoming surgery or to work on lifestyle behavior changes needed to make such a dramatic procedure successful. Many of the programs do pre-op education, but many individuals have an unrealistic expectation of what the surgery and their behaviors will be like long-term and feel they will not have the complications. There are also programs that offer support afterwards, but typically only for a limited time and this is typically the honeymoon time, when everything is great and no need for support. I find many times the support needed is on a deeper, emotional level, one that a dietitian who works with disordered eating and a therapist who works with emotional eating issues can best understand and help.
Another "surprise" I have heard: "You mean I will still feel hunger? I thought this surgery would take away my hunger and that I will fill up with only bird sized bites of food". While the surgery does produce some hormonal changes that assist with hunger, anatomically make the stomach smaller and produce less feelings of hunger, that often is not enough or as dramatic as was thought it would be. The big concern is that if a person ate outside of physiological hunger and were eating for emotional reasons, the procedures do not remove the emotional hunger nor work well with emotional eating. If emotional eating is a concern and struggle, it is often still a struggle after the surgery. When looking at the band population, Lang et al found per-surgery rates of binge eating patients that discontinued binge eating to be 39.4%, those who binged before surgery to continue to binge after the surgery at 24.2%and 4.5% new binge eating cases after surgery(10). There are reports of binge eating reduced after surgery, some reports of an increase in binge eating and some reports of unchanged amounts of binge eating. When looking at pre-surgical versus two years post-op, pre-surgical eating disturbance predicted post-surgical eating complications.(11) After surgery, patients report less fat intake, external eating, binging and more restrained eating and self-efficacy eating. However, one-third report binging problems. (12)
There may also be additional complications that happen afterwards. For instance, if a person has had a banding procedure, eating too much can cause the food to come out into the esophagus and cause gastrointestinal irritation. Many confuse this as the food gets stuck and feel like they have to get it out. Often the "have to get it out" is done by making a person vomit the contents in order to get relief. Sometimes they just note it to be because they ate just a little too much food and think "I'll do better next time". The problem occurs when they do not find a way to limit the volume they put in their mouth. This could be a failed attempt to binge or a manifestation of a complication from the surgery. In my practice, I have seen this turn into purging episodes that happen multiple times a day. Often this is thought to be normal and not a problem and when they take time to control their intake, this will go away. But with any disordered eating pattern, if left untreated professionally, this disregard for the seriousness of the problem often leads to many more problems.
The body image changes that accompany these procedures are often difficult to predict.
While losing weight, many individuals do feel better about their bodies, yet they are often surprised of how much excess skin is left over. This excess skin is often loose, hanging and difficult to disguise. The only way to get rid of this skin is to have cosmetic surgery, which is not covered by insurance. Not to mention, many people are not comfortable with all the attention given to their bodies and how they look. Many women have described not knowing what to do when they are getting all of this attention. This is another perfect time to work with a therapist.
Long term
Post-op care should include long term nutrition education /counseling provided by a registered dietitian, with specialized training in nutrition medicine. (13) Specific areas dietitians should keep in mind when seeing patients are: post-op nutritional care, emotional eating, supplements, physical activity, support systems, skill building, historical eating patterns and problem solving skills.(14)
One of the big problems I see with this surgery is that the complications do not come until a couple of years after the surgery. This leads people to not equate the problems to the surgery, but just know they are struggling. Often I have heard them say, I thought it was just me and that I should not have these problems or I am too embarrassed to look at these problems. Sometimes their previous surgeons will not see them for follow ups after the initial time period is over, leaving them out there looking for their own support they need, but not knowing where to find the "right" help. One study reported a one year follow up rate of 54% and only 10% at three years. (15)
This is a new group of individuals out there needing the help. Many people do not understand the alterations that happen to a person after such a surgery. If people do not understand the physiological and emotional changes produced by the surgery, this makes it difficult to truly separate out the food intolerances manifested from the procedure, the disordered eating patterns that may have developed from the procedure or the maladaptive behaviors practiced after the procedure. This is where it is important to let people know there is hope. In my opinion, many eating disorder professionals have a better understanding of what is needed then the typical bariatric professionals and general therapists and dietitians. I encourage those I come in contact with to reach out to those who work with emotional issues to gain support. For those who are working with eating disorders, but do not understand all the complications that are out there, training and education and supervised practice can help. Since this is one of my true passions to help individuals out there, these are all services I offer for both professionals and clients.
The main thing is that the word gets out about the potential complications. I am not completely against these procedures, yet I offer a very cautious warning to people.
The research is mixed on long term success and many of the studies reference weight loss and maintenance of the weight loss. Yet, we have to be careful, as the research numbers often do not include those who were too embarrassed to go back in because they were having problems. The true concern is for those people out there with the problems, not realizing it is not another failed weight loss attempt, but a deeper complication that can be addressed, by the right professional.
- Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML. Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J, Guven S. American Association ofClinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity. 2009;17(suppl 1):S1-S70.
- Kolotkin R, Crosby RD, Gress RE. Hunt SC, Adams TD. Two-year changes in health-related quality of life in gastric bypass patients compared with severely obese controls. Surg Obes Relat Dis. 2009;5:250-256.
- International Diabetes Federation. Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 diabetes position statement, March 2011. www.idf.org/idf-releases-position-paper-bariatric-surgery
- ASBS. Rationale for Surgery. http://www.asbs.org/Newsite07/patients/resources/asbs_rationale.htm accessed June 10, 2011
- Rabner J.G., Greenstein R. J. 1991. Obesity Surgery: Expectation and Realty. Interntational Journal of Obesity, 15, 841-845.
- Mechanick JI, Kushner RF, Sugerman HJ, Gonzales-Campoy M, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM,Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. Executive Summary of the Recommendations of the American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the Bariatric Surgery Patient. Endocrine Practice. 2008; 14(13):318-336.
- Aills L, Blankenship J, Buffington C, Furtado M, Parrot J. Bariatr Nutrition: Suggestions for the Surgical Weight Loss Patient. Surgery for Obesty and Related Diseases.2008;Volume 4 (5S); in press
- Kruseman M, Laimgruber A, Zumbach F, Golay A. Dietary, Weight, and Psychological Changes among Patients with Obesity, 8 Years after Gastric Bypass. J Am Diet Assoc. 2010;110:527-534
- Jones-Cornielle L, Wadden T, Sarwer B. Risk of Depression and Suicide in Patients with Extreme Obesity Who Seek Bariatric Surgery. Obesity Management. December 1, 2007, 3(6):255-260.
- Lang T, Hauser R, Buddebery C, Klaghofer R. Impact of Gastric Banding on Eating Behavior and Weight. Obesity Surgery. 2002:100-107.
- Hsu L, Sullivan S. Benotti P. Eating Disturbances and Outcome of Gastric Bypass Surgery: A pilot Study. Int J Eat Disord 1997;21: 385-390.
- Larsen JK, van Ramshorst B, Geenen R, Brand N, Stroebe W, van Doornen LJP. Binge Eating and its Relationship to Outcome after Laparoscopic Adjustable Gastric Banding. Obesity Surgery 2004;14:1111-1117.
- Saltzman E, Anderson W, et al. Criteria for Patient Selection and Multidisciplinary Evaluation and Treatment of the Weight Loss Surgery Patient. Obes Research 2005;13(2):234-243.
- Allied Health Sciences Section Ad Hoc Behavioral Health Committee: American Society for Bariatric Surgery. Suggestions for Pre-Surgery Psychological Assessment of Bariatric Surgery Candidates. October 2004. http://www.asbs.org/html/pdf/PsychPreSurgicalAssessment.pdf Accessed June 10, 2011.
- Warde-Kamar J, Rogers M, Flancbaum L. Laferrere B. Calorie Intake and Meal Patterns up to 4 Years after Roux-en-Y Gastric Bypass Surgery. Obesity Surgery. 2004;14:1070-1079.
