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Tag: gastric bypass

  • Weight-Loss Devices to the Extreme | NutritionFacts.org

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    Let’s discuss the safety and efficacy of various weight-loss methods, ranging from Botox and corsets to siphons and tapeworms.

    A moderately obese person doing moderately intense physical activity, like biking or brisk walking, would burn off approximately 350 calories an hour, but most drinks, snacks, and other processed junk are consumed at a rate of about 70 calories (293 kJ) per minute. Therefore, it only takes five minutes to wipe out a whole hour of exercise.

    Enter the AspireAssist siphon assembly.

    It’s a percutaneous gastrostomy device, meaning surgeons cut a hole in a person’s stomach and tunnel a fistula out through the abdominal wall. So, after each meal, the person can attach a suction gadget to the hole and directly drain out their stomach contents, as you can see below and at 0:47 in my video Extreme Weight-Loss Devices.

    This means you could gorge on donuts, spew them out through the hole in your stomach, then gorge on more donuts. Have your cake, and eat it, too…and two, three, and four times!

    It seems to be the quintessential American invention, straight from the land that brought us Jell-O salads, spray cheese, and deep-fried Snickers bars. Patients do lose weight, perhaps in part because the fistula may interfere with the relaxation of the stomach wall during a meal. The process also requires drinking lots of water and thoroughly chewing food, both of which may help with weight loss by increasing hydration and slowing the eating rate. Patients also started making healthier choices to avoid the unpleasant sight of gastric aspirate from unhealthy foods. (The tubing is clear, and, evidently, fried foods look particularly gross as they are pumped out.)

    All patients need to take supplemental potassium, since it’s sucked out in stomach juices. Otherwise, they risk becoming potassium-deficient (a common complication in bulimia), but most side effects are just minor wound complications. Serious adverse effects, like abdominal abscesses, are rare. The big selling point is that the siphon device doesn’t change the gastrointestinal tract’s anatomy. That seems like a low bar, but in today’s Wild West world of weight-loss procedures, you can’t take anything for granted. Take the duodenal-jejunal bypass liner, for example.

    Gastric bypass surgery works in part by cutting out a portion of the small intestine so it’s no longer in the flow of food, thereby helping to prevent the absorption of calories. Instead of major surgery, how about just dropping down a couple of feet of plastic tubing to line the intestinal walls? The problem with the EndoBarrier is that it has to be anchored in the digestive tract. This is accomplished with 10 barbed hooks that cause lacerations, accounting for the majority of the 891 adverse effects reported in 1,056 patients—nearly 9 out of 10 people. Severe penetrating trauma, resulting in esophageal perforation or liver abscesses, is rarer (occurring in only about 1 in 27 patients).

    Concern has been raised about the “palatability” of the AspireAssist stomach pump, but the most cringeworthy endoscopic procedure I discovered in my research was intestinal “resurfacing.” Why cover the inside of your intestines with plastic to prevent absorption when you can just “thermally ablate the superficial duodenal mucosa”? In other words, have your intestinal lining burned off—or rather, “resurfaced.”

    Surgeons have tried injecting Botox into the stomach walls of obese individuals, hoping it would partially paralyze their gastric muscles, slow stomach emptying, make people feel fuller longer, and lose weight. It didn’t work.

    Researchers in Sweden tried randomizing people to wear corsets for 12 to 16 hours a day, seven days a week, for nine months. And it didn’t work. The study participants just didn’t wear the corsets—they were “perceived as uncomfortable.” Duh.

    “Sanitized tapeworms” have evidently been widely advertised as a weight-loss remedy since back in the early 1900s. The fact that living tapeworms have been discovered during bariatric surgery operations suggests that infesting yourself with parasites may not be particularly effective either.

    Speaking of disgusting strategies, how about disgust itself? A study entitled “Harnessing the Power of Disgust: A Randomized Trial to Reduce High-Calorie Food Appeal Through Implicit Priming” tried using subliminal messages to ruin people’s appetite. Just before showing images of healthy foods, researchers briefly flashed happy images—such as a group of kittens—for 20 milliseconds. That’s too quick to consciously register, but the hope was to plant a positive imprint on the brain. Before showing images of high-calorie foods like ice cream, they flashed negative scenes, like a cockroach on a pizza slice, vomit in a dirty bathroom, and a burn wound. Apparently, it worked! Subjects subsequently reported a reduced desire to eat high-calorie foods, though this wasn’t tested directly. The researchers concluded that subliminal revulsion might be “a successful tactic to combat the onslaught of food cues that promote unhealthy eating….”

    The rest of the world looks on, bemused by American machinations, penning commentaries like “Don’t Let Them Eat Cake! A View from Across the Pond.” A paper in the journal Obesity Surgery entitled “What Are the Yanks Doing?” reviewed “The U.S. Experience with Implantable Gastric Stimulation,” inserting electrodes into the muscular layer of the stomach wall. When that didn’t work, colon electrical stimulation was tried.

    Even more shocking were studies like “Repetitive electric brain stimulation reduces food intake in humans.” Though placing deep-brain electrodes is considered a complication-prone operation, scientists have long pondered whether “placing an electrode somewhere in the brain could make people eat less.” Holes were drilled through the skulls of five obese individuals, and wires were pushed into their brains for “electrostimulatory exploration.” Once the researchers poked around and found spots where they were able to elicit convincing hunger responses, they sent in enough juice to fry out electro-coagulatory lesions. It seemed to work in cats and monkeys, but the researchers found that burning holes in people’s brains did not result in weight loss in obese humans. Thankfully, as I explained in my book How Not to Diet, healthy, sustainable weight loss isn’t brain surgery.

    Doctor’s Note

    Check out Is Gastric Balloon Surgery Safe and Effective for Weight Loss?.

    What about drugs? See Are Weight Loss Pills Safe? and Are Weight Loss Pills Effective?.

    So, what’s the best way to lose weight? I wrote a whole book about it! How Not to Diet is focused exclusively on sustainable weight loss. Borrow it from your local library or pick up a copy from your favorite bookseller. (All proceeds from my books are donated to charity.) To whet your appetite, take a peek: Trailer for How Not to Diet: Dr. Greger’s Guide to Weight Loss.

    For more on this topic, check out related posts below.

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    Michael Greger M.D. FACLM

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  • Is Fasting an Effective Treatment for Diabetes? | NutritionFacts.org

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    By losing 15% of their body weight, nearly 90% of those who have had type 2 diabetes for less than four years may achieve remission.

    Currently, more than half a billion adults have diabetes, and about a 50% increase is expected in another generation. I’ve got tons of videos on the best diets for diabetes, but what about no diet at all?

    More than a century ago, fasting was said to cure diabetes, quickly halting its progression and eliminating all signs of the disease within days or weeks. Even so, starvation is guaranteed to lead to the complete disappearance of you if kept up long enough. What’s the point of fasting away the pounds if they’re just going to return as soon as you restart the diet that created them in the first place? Might it be useful to kickstart a healthier diet? Let’s see what the science says.

    Type 2 diabetes has long been recognized as a disease of excess, once thought to afflict only “the idle rich…anyone whose environment and self-support does not require of him some sustained vigorous bodily exertion every day, and whose earnings or income permit him, and whose inclination tempts him, to eat regularly more than he needs.” Diabetes is preventable, so might it also be treatable? If we’re dying from overeating, maybe we can be saved by undereating. Remarkably, this idea was proposed about 2,000 years ago in an Ayurvedic text:

    “Poor diabetic people’s medicine
    He should live like a saint (Munni);
    He should walk for 800–900 miles.
    Or he shall dig a pond;
    Or he shall live only on cow dung and cow urine.”

    That reminds me of the Rollo diet for diabetes proposed in 1797, which was composed of rancid meat. That was on top of the ipecac-like drugs he used to induce severe sickness and vomiting. Anything that makes people sick has only “a temporary effect in relieving diabetes” because it reduces the amount of food eaten. His diet plan—which included congealed blood for lunch and spoiled meat for dinner—certainly had that effect.

    Similar benefits were seen in people with diabetes during the siege of Paris in the Franco‐Prussian War, leading to the advice to mangez le moins possible, which translates to “eat as little as possible.” This was formalized into the Allen starvation treatment, considered to be “the greatest advance in the treatment of diabetes prior to the discovery of insulin.” Before insulin, there was “The Allen Era.”

    Dr. Allen noted that there are clinical reports of even severe diabetes cases clearing up after the onset of a “wasting condition” like tuberculosis or cancer, so he decided to put it to the test. He found that even in the most severe type of diabetes, he could clear sugar from people’s urine within ten days. Of course, that’s the easy part; it’s harder to maintain once they start eating again. To manage patients’ diabetes, he stuck to two principles: Keep them underweight and restrict the fat in their diet. A person with severe diabetes can be symptom-free for days or weeks, but eating butter or olive oil can make the disease come raging back.

    As I’ve said before, diabetes is a disease of fat toxicity. Infuse fat into people’s veins through an IV, and, by using a high-tech type of MRI scanner, you can show in real time the buildup of fat in muscle cells within hours, accompanied by an increase in insulin resistance. The same thing happens when you put people on a high-fat diet for three days. It can even happen in just one day. Even a single meal can increase insulin resistance within six hours. Acute dietary fat intake rapidly increases insulin resistance. Why do we care? Insulin resistance in our muscles, in the context of too many calories, can lead to a buildup of liver fat, followed by fat accumulation in the pancreas, and eventually full-blown diabetes. “Type 2 diabetes can now be understood as a state of excess fat in the liver and pancreas, and remains reversible for at least 10 years in most individuals.”

    When people are put on a very low-calorie diet—700 calories a day—fat can get pulled out of their muscle cells, accompanied by a corresponding boost in insulin sensitivity, as shown below and at 4:43 in my video Fasting to Reverse Diabetes.

    The fat buildup in the liver has then been shown to decrease substantially, and if the diet is continued, the excess fat in the pancreas also reduces. If caught early enough, reversing type 2 diabetes is possible, which would mean sustained healthy blood sugar levels on a healthy diet.

    With the loss of 15% of body weight, nearly 90% of individuals who have had type 2 diabetes for less than four years can achieve non-diabetic blood sugar levels, whereas it may only be reversible in 50% of those who’ve lived with the disease for longer than eight years. That’s better than bariatric surgery, where those losing even more weight had lower remission rates of 62% and 26%, respectively. Your forks are better than surgeons’ knives. Indeed, most people who have had their type 2 diabetes diagnosis for an average of three years can reverse their disease after losing about 30 pounds, as you can see below and at 5:37 in my video.

    Of course, an extended bout of physician-supervised, water-only fasting could also get you there, but you would have to maintain that weight loss. One of the things that has been said with “certainty” is that if you regain the weight, you regain your diabetes.

    To bring it full circle, “the initial euphoria about ‘medicine’s greatest miracle’”—the discovery of insulin in 1921—“soon gave way to the realisation” that, while it was literally life-saving for people with type 1 diabetes, insulin alone wasn’t enough to prevent such complications as blindness, kidney failure, stroke, and amputations in people with type 2 diabetes. That’s why one of the most renowned pioneers in diabetes care, Elliott Joslin, “argued that self-discipline on diet and exercise, as it was in the days prior to the availability of the drug [insulin], should be central to the management of diabetes….”

    Doctor’s Note

    Check out Diabetes as a Disease of Fat Toxicity for more on the underlying cause of the disease.

    For more on fasting for disease reversal, see:

    Fasting is not the best way to lose weight. To learn more, see related posts below.

    What is the best way to lose weight? See Friday Favorites: The Best Diet for Weight Loss and Disease Prevention.

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    Michael Greger M.D. FACLM

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  • The Hidden Costs of Bariatric Surgery | NutritionFacts.org

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    Weight regain after bariatric surgery can have devastating psychological effects.

    How Sustainable Is the Weight Loss After Bariatric Surgery? I explore that issue in my video of the same name. Most gastric bypass patients end up regaining some of the fat they lose by the third year after surgery, but after seven years, 75% of patients followed at 10 U.S. hospitals maintained at least a 20% weight loss.

    The typical trajectory for someone who starts out obese at 285 pounds, for example, would be to drop to an overweight 178 pounds two years after bariatric surgery, but then regain weight up to an obese 207 pounds. This has been chalked up to “grazing” behavior, where compulsive eaters may shift from bingeing (which becomes more difficult post-surgery) to eating smaller amounts constantly throughout the day. In a group of women followed for eight years after gastric bypass surgery, about half continued to describe episodes of disordered eating. As one pediatric obesity specialist described, “I have seen many patients who put chocolate bars into a blender with some cream, just to pass technically installed obstacles [e.g., a gastric band].”

    Bariatric surgery advertising is filled with “happily-ever-after” fairytale narratives of cherry-picked outcomes offering, as one ad analysis put it, “the full Cinderella-romance happy ending.” This may contribute to the finding that patients often overestimate the amount of weight they’ll lose with the procedure and underestimate the difficulty of the recovery process. Surgery forces profound changes in eating habits, requiring slow, small bites that have been thoroughly chewed. Your stomach goes from the volume of two softballs down to the size of half a tennis ball in stomach stapling and half a ping-pong ball in the case of gastric bypass or banding.

    As you can imagine, “weight regain after bariatric surgery can have a devastating effect psychologically as patients feel that they have failed their last option”—their last resort. This may explain why bariatric surgery patients face a high risk of depression. They also have an increased risk of suicide.

    Severe obesity alone may increase the risk of suicidal depression, but even at the same weight, those going through surgery appear to be at a higher risk. At the same BMI (body mass index), age, and gender, bariatric surgery patients have nearly four times the odds of self-harm or attempted suicide compared with those who did not undergo the procedure. Most convincingly, so-called “mirror-image analysis” comparing patients’ pre- and post-surgery events showed the odds of serious self-harm increased after surgery.

    About 1 in 50 bariatric surgery patients end up killing themselves or being hospitalized for self-harm or attempted suicide. And this only includes confirmed suicides, excluding masked attempts such as overdoses classified as having “undetermined intention.” Bariatric surgery patients may also have an elevated risk of accidental death, though some of this could be due to changes in alcohol metabolism. When individuals who have had a gastric bypass were given two shots of vodka, their blood alcohol level surpassed the legal driving limit within minutes due to their altered anatomy. It’s unclear whether this plays a role in the 25% increase in prevalence of alcohol problems noted during the second postoperative year.

    Even those who successfully lose their excess weight and keep it off appear to have a hard time coping. Ten years out, though physical health-related quality of life may improve, general mental health can significantly deteriorate compared to pre-surgical levels, even among those who lost the most weight. Ironically, there’s a common notion that bariatric surgery is for “cheaters” who take the easy way out by choosing the “low-effort” method of weight loss.

    Shedding the weight may not shed the stigma of prior obesity. Studies suggest that “in the eyes of others, knowing that an individual was at one time fat will lead him/her to always be treated like a fat person.” And there can be a strong anti-surgery bias on top of that—those who chose the scalpel to lose weight over diet or exercise were rated more negatively (for example, being considered less physically attractive). One can imagine how remaining a target of prejudice even after joining the “in-group” could potentially undercut psychological well-being.

    There can also be unexpected physical consequences of massive weight loss, like large hanging flaps of excess skin. Beyond being heavy and uncomfortable and interfering with movement, the skin flaps can result in itching, irritation, dermatitis, and skin infections. Getting a panniculectomy (removing the abdominal “apron” of hanging skin) can be expensive, and its complication rate can exceed 50%, with dehiscence (rupturing of the surgical wound) one of the most common complications.

    “Even if surgery proves sustainably effective,” wrote the founding director of Yale University’s Prevention Research Center, “the need to rely on the rearrangement of natural gastrointestinal anatomy as an alternative to better use of feet and forks [exercise and diet] seems a societal travesty.”

    In the Middle Ages, starving peasants dreamed of gastronomic utopias where food just rained down from the sky. The English called it the Kingdom of Cockaigne. Little could medieval fabulists predict that many of their descendants would not only take permanent residence there but also cut out parts of their stomachs and intestines to combat the abundance. Critics have pointed out the irony of surgically altering healthy organs to make them dysfunctional—malabsorptive—on purpose, especially when it comes to operating on children. Bariatric surgery for kids and teens has become widespread and is being performed on children as young as five years old. Surgeons defend the practice by arguing that growing up fat can leave “‘emotional scars’ and lifelong social retardation.”

    Promoters of preventive medicine may argue that bariatric surgery is the proverbial “ambulance at the bottom of the cliff.” In response, proponents of pediatric bariatric surgery have written: “It is often pointed out that we should focus on prevention. Of course, I agree. However, if someone is drowning, I don’t tell them, ‘You should learn how to swim’; no, I rescue them.”

    A strong case can be made that the benefits of bariatric surgery far outweigh the risks if the alternative is remaining morbidly obese, which is estimated to shave up to a dozen or more years off one’s life. Although there haven’t been any data from randomized trials yet to back it up, compared to non-operated obese individuals, those getting bariatric surgery would be expected to live significantly longer on average. No wonder surgeons have consistently framed the elective surgery as a life-or-death necessity. This is a false dichotomy, though. The benefits only outweigh the risks if there are no other alternatives. Might there be a way to lose weight healthfully without resorting to the operating table? That’s what my book How Not to Diet is all about.

    Doctor’s Note

    My book How Not to Diet is focused exclusively on sustainable weight loss. Check it out from your library or pick it up from wherever you get your books. (All proceeds from my books are donated to charity.)

    This is the final segment in a four-part series on bariatric surgery, which includes:

    This blog contains information regarding suicide. If you or anyone you know is exhibiting suicide warning signs, please get help. Go to https://988lifeline.org for more information.

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    Michael Greger M.D. FACLM

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  • Is Surgery Necessary to Reverse Diabetes? | NutritionFacts.org

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    Losing weight without rearranging your gastrointestinal anatomy carries advantages beyond just the lack of surgical risk.

    The surgical community objects to the characterization of bariatric surgery as internal jaw wiring and cutting into healthy organs just to discipline people’s behavior. They’ve even renamed it “metabolic surgery,” suggesting the anatomical rearrangements cause changes in digestive hormones that offer unique physiological benefits. As evidence, they point to the remarkable remission rates for type 2 diabetes.

    After bariatric surgery, about 50% of obese people with diabetes and 75% of “super-obese” diabetics go into remission, meaning they have normal blood sugar levels on a regular diet without any diabetes medication. The normalization of blood sugar can happen within days after the surgery. And 15 years after the surgery, 30% remained free from their diabetes, compared to a 7% remission rate in a nonsurgical control group. Are we sure it was the surgery, though?

    One of the most challenging parts of bariatric surgery is lifting the liver. Since obese individuals tend to have such large, fatty livers, there is a risk of liver injury and bleeding. An enlarged liver is one of the most common reasons a less invasive laparoscopic surgery can turn into a fully invasive open surgery, leaving the patient with a large belly scar, along with an increased risk of wound infections, complications, and recovery time. But lose even just 5% of your body weight, and your fatty liver may shrink by 10%. That’s why those awaiting bariatric surgery are put on a diet. After surgery, patients are typically placed on an extremely low-calorie liquid diet for weeks. Could their improvement in blood sugar levels just be from the caloric restriction, rather than some sort of surgical metabolic magic? Researchers decided to put it to the test.

    At a bariatric surgery clinic at the University of Texas, patients with type 2 diabetes scheduled for a gastric bypass volunteered to stay in the hospital for 10 days to follow the same extremely low-calorie diet—less than 500 calories a day—that they would be placed on before and after surgery, but without undergoing the procedure itself. After a few months, once they had regained the weight, the same patients then had the actual surgery and repeated their diet, matched day to day. This allowed researchers to compare the effects of caloric restriction with and without the surgical procedure—the same patients, the same diet, just with or without the surgery. If there were some sort of metabolic benefit to the anatomical rearrangement, the patients would have done better after the surgery, but, in some ways, they actually did worse.

    The caloric restriction alone resulted in similar improvements in blood sugar levels, pancreatic function, and insulin sensitivity, but several measures of diabetic control improved significantly more without the surgery. The surgery seemed to put them at a metabolic disadvantage.

    Caloric restriction works by first mobilizing fat out of the liver. Type 2 diabetes is thought to be caused by fat building up in the liver and spilling over into the pancreas. Everyone may have a “personal fat threshold” for the safe storage of excess fat. When that limit is exceeded, fat gets deposited in the liver, where it can cause insulin resistance. The liver may then offload some of the fat (in the form of a fat transport molecule called VLDL), which can then accumulate in the pancreas and kill off the cells that produce insulin. By the time diabetes is diagnosed, half of our insulin-producing cells may have been destroyed, as seen below and at 3:36 in my video Bariatric Surgery vs. Diet to Reverse Diabetes. Put people on a low-calorie diet, though, and this entire process can be reversed.

    A large enough calorie deficit can cause a profound drop in liver fat sufficient to resurrect liver insulin sensitivity within seven days. Keep it up, and the calorie deficit can decrease liver fat enough to help normalize pancreatic fat levels and function within just eight weeks. Once you drop below your personal fat threshold, you should then be able to resume normal caloric intake and still keep your diabetes at bay, as seen below and at 4:05 in my video. 

    The bottom line: Type 2 diabetes is reversible with weight loss, if you catch it early enough.

    Lose more than 30 pounds (13.6 kilograms), and nearly 90% of those who have had type 2 diabetes for less than four years can achieve non-diabetic blood sugar levels (suggesting diabetes remission), whereas it may only be reversible in 50% of those who’ve lived with the disease for eight or more years. That’s by losing weight with diet alone, though. For people with diabetes, losing more than twice as much weight with bariatric surgery, diabetes remission may only be around 75% of those who’ve had the disease for up to six years and only about 40% for those who’ve had diabetes longer, as seen below and at 4:41 in my video.

    Losing weight without surgery may offer other benefits as well. Individuals with diabetes who lose weight with diet alone can significantly improve markers of systemic inflammation, such as tumor necrosis factor, whereas levels significantly worsened when about the same amount of weight was lost from a gastric bypass.

    What about diabetic complications? One reason to avoid diabetes is to avoid its associated conditions, like blindness or kidney failure requiring dialysis. Reversing diabetes with bariatric surgery can improve kidney function, but, surprisingly, it may not prevent the occurrence or progression of diabetic vision loss—perhaps because bariatric surgery affects quantity but not necessarily quality when it comes to diet. This reminds me of a famous study published in The New England Journal of Medicine that randomized thousands of people with diabetes to an intensive lifestyle program focused on weight loss. Ten years in, the study was stopped prematurely because the participants weren’t living any longer or having any fewer heart attacks. This may be because they remained on the same heart-clogging diet but just in smaller portions.

    Doctor’s Note

    This is the third blog in a four-part series on bariatric surgery. If you missed the first two, check out The Mortality Rate of Bariatric Weight-Loss Surgery and The Complications of Bariatric Weight-Loss Surgery.

    My book How Not to Diet is focused exclusively on sustainable weight loss. Check it out from your local library, or pick it up from wherever you get your books. (All proceeds from my books are donated to charity.)

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    Michael Greger M.D. FACLM

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  • Bariatric Surgery: Risks in the OR and Beyond | NutritionFacts.org

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    The extent of risk from bariatric weight-loss surgery may depend on the skill of the surgeon.

    After sleeve gastrectomy and Roux-en-Y gastric bypass, the third most common bariatric procedure is a revision to fix a previous bariatric procedure, as you can see below and at 0:16 in my video The Complications of Bariatric Weight-Loss Surgery.

    Up to 25% of bariatric patients have to go back into the operating room for problems caused by their first bariatric surgery. Reoperations are even riskier, with up to 10 times the mortality rate, and there is “no guarantee of success.” Complications include leaks, fistulas, ulcers, strictures, erosions, obstructions, and severe acid reflux.

    The extent of risk may depend on the skill of the surgeon. In a study published in The New England Journal of Medicine, bariatric surgeons voluntarily submitted videos of themselves performing surgery to a panel of their peers for evaluation. Technical proficiency varied widely and was related to the rates of complications, hospital readmissions, reoperations, and death. Patients operated on by less competent surgeons suffered nearly three times the complications and five times the rate of death.

    “As with musicians or athletes, some surgeons may simply be more talented than others”—but practice may help make them perfect. Gastric bypass is such a complicated procedure that the learning curve may require 500 cases for a surgeon to master the procedure. Risk for complications appears to plateau after about 500 cases, with the lowest risk found among surgeons who had performed more than 600 bypasses. The odds of not making it out alive may be double under the knife of those who had performed less than 75 compared to more than 450, as seen below and at 1:47 in my video.

    So, if you do choose to undergo the operation, I’d recommend asking your surgeon how many procedures they’ve done, as well as choosing an accredited bariatric “Center of Excellence,” where surgical mortality appears to be two to three times lower than non-accredited institutions.

    It’s not always the surgeon’s fault, though. In a report entitled “The Dangers of Broccoli,” a surgeon described a case in which a woman went to an all-you-can-eat buffet three months after a gastric bypass operation. She chose really healthy foods—good for her!—but evidently forgot to chew. Her staples ruptured, and she ended up in the emergency room, then the operating room. They opened her up and found “full chunks of broccoli, whole lima beans, and other green leafy vegetables” inside her abdominal cavity. A cautionary tale to be sure, but perhaps one that’s less about chewing food better after surgery than about chewing better foods before surgery—to keep all your internal organs intact in the first place.

    Even if the surgical procedure goes perfectly, lifelong nutritional replacement and monitoring are required to avoid vitamin and mineral deficits. We’re talking about more than anemia, osteoporosis, or hair loss. Such deficits can cause full-blown cases of life-threatening deficiencies, such as beriberi, pellagra, kwashiorkor, and nerve damage that can manifest as vision loss years or even decades after surgery in the case of copper deficiency. Tragically, in reported cases of severe deficiency of a B vitamin called thiamine, nearly one in three patients progressed to permanent brain damage before the condition was caught.

    The malabsorption of nutrients is intentional for procedures like gastric bypass. By cutting out segments of the intestines, you can successfully impair the absorption of calories—at the expense of impairing the absorption of necessary nutrition. Even people who just undergo restrictive procedures like stomach stapling can be at risk for life-threatening nutrient deficiencies because of persistent vomiting. Vomiting is reported by up to 60% of patients after bariatric surgery due to “inappropriate eating behaviors.” (In other words, trying to eat normally.) The vomiting helps with weight loss, similar to the way a drug for alcoholics called Antabuse can be used to make them so violently ill after a drink that they eventually learn their lesson.

    “Dumping syndrome” can work the same way. A large percentage of gastric bypass patients can suffer from abdominal pain, diarrhea, nausea, bloating, fatigue, or palpitations after eating calorie-rich foods, as they bypass your stomach and dump straight into your intestines. As surgeons describe it, this is a feature, not a bug: “Dumping syndrome is an expected and desired part of the behavior modification caused by gastric bypass surgery; it can deter patients from consuming energy-dense food.

    Doctor’s Note

    This is the second in a four-part series on bariatric surgery. If you missed the first one, see The Mortality Rate of Bariatric Weight-Loss Surgery.

    Up next: Bariatric Surgery vs. Diet to Reverse Diabetes and How Sustainable Is the Weight Loss After Bariatric Surgery?.

    My book How Not to Diet is focused exclusively on sustainable weight loss. Check it out from your local library, or pick it up from wherever you get your books. (All proceeds from my books are donated to charity.)

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    Michael Greger M.D. FACLM

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  • Bariatric Weight-Loss Surgery and Mortality | NutritionFacts.org

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    Today, death rates after weight-loss surgery are considered to be “very low,” occurring in perhaps 1 in 300 to 1 in 500 patients on average.

    The treatment of obesity has long been stained by the snake-oil swindling of profiteers, hustlers, and quacks. Even the modern field of bariatric medicine (derived from the Greek word baros, meaning “weight”) is pervaded by an “insidious image of sleaze.” Beguiled by advertising for fairy tale magic bullets of rapid, effortless weight loss, people blame themselves for failing to manifest the miracle or imagine themselves metabolically broken. On the other end of the spectrum are overly pessimistic practitioners of the opinion that “people who are fat are born fat, and nothing much can be done about it.” The truth lies somewhere in between.

    The difficulty of curing obesity has been compared to learning a foreign language. It’s an achievement virtually anyone can attain with a sufficient investment of energies, “but it always takes a considerable amount of time and trouble.” And, of those who do stick with it, most will regain much of the weight lost. To me, this speaks to the difficulty, rather than the futility. It may take smokers an average of 30 attempts to finally kick the habit. Like quitting smoking, curing obesity is just something that has to be done. As the chair of the Association for the Study of Obesity put it, it doesn’t take “will power” to do essential tasks like getting up at night to feed a baby; it’s just something that has to be done.

    Our collective response doesn’t seem to match the rhetoric or reality. If obesity is such a “national crisis” reaching alarming proportions, dubbed by the post-9/11 Surgeon General as “every bit as devastating as terrorism,” why has our reaction been so tepid? For example, governments meekly suggest the food industry take “voluntary initiatives to restrict the marketing of less healthy food options to children….” Have we just given up and ceded control?

    Our timid response to the obesity epidemic is encapsulated by a national initiative promulgated by a Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council: the “small-changes approach.” Since “small changes are more feasible to achieve,” suggestions include “using mustard instead of mayonnaise” and “eating 1 rather than 2 doughnuts in the morning.” Seems a bit like bringing a butter knife to a gunfight. Proponents of the small-changes approach lament that, unlike other addictions—for example, alcohol, cocaine, gambling, or tobacco—we can’t counsel our obese patients to give up the addictive element completely, as “[n]o one can give up eating.” But just because we have to breathe, doesn’t mean it has to be through the end of a cigarette. And just because we have to eat doesn’t mean we have to eat junk.

    What about bringing a scalpel to the gunfight instead? The use of bariatric surgery has exploded from about 40,000 procedures noted in the first international survey in 1998 to hundreds of thousands performed now every year in the United States alone. The first technique that was developed, the intestinal bypass, involved carving out about 19 feet of intestines. More than 30,000 intestinal bypass operations were performed before we recognized “catastrophic” and “disastrous outcomes” resulted from these procedures. This included protein deficiency-induced liver disease, “which often progressed to liver failure and death.” This inauspicious start is remembered as “one of the dark blots in the history of surgery,” as I discuss in my video The Mortality Rate of Bariatric Weight-Loss Surgery.

    Today, death rates after bariatric surgery are considered “very low,” occurring on average in perhaps 1 in 300 to impacting 1 in 500 patients. The most common procedure is stomach stapling, also known as sleeve gastrectomy, in which most of the stomach is permanently removed. Only a narrow tube of the stomach is left so as to restrict how much food people can eat at any one time. It’s ironic that many patients choose bariatric surgery convinced that, “for them, ‘diets do not work,’” when, in reality, that’s all the surgery may be—an enforced diet. Bariatric surgery can be thought of as a form of internal jaw wiring.

    Gastric bypass, known as Roux-en-Y gastric bypass, is the second most common bariatric surgery. It combines restriction—stapling the stomach into a pouch smaller than a golf ball—with malabsorption by rearranging one’s anatomy to bypass the first part of the small intestine. It appears to be more effective than just cutting out most of the stomach, resulting in a loss of about 63% of excess weight compared to 53% with a gastric sleeve. But gastric bypass carries a greater risk of serious complications. Many are surprised to learn that new “surgical procedures…do not require premarket testing and approval by the Food and Drug Administration (FDA)” and are largely exempt from rigorous regulatory scrutiny.

    Doctor’s Note

    I didn’t know there wasn’t some kind of approval process for new surgical procedures!

    This is the first video in a four-part series on bariatric surgery. Coming up are:

    My book How Not to Diet is focused exclusively on sustainable weight loss. Check it out from your local public library or pick it up from wherever you get your books. (All proceeds from my books are donated to charity.)

     

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    Michael Greger M.D. FACLM

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