You’ve tried everything.
The weight just won’t come off.
It haunts you. Stalks you.
And you just want it to go away.
Your doctor tells you that there is a surgical option that can help reduce cravings and get rid of the extra pounds, fast.
He tells you that the excess weight you're carrying is life-threatening - putting you at high risk for diabetes, heart disease, and cancer.
You want to know the risks, and what effects surgery may have on your nutritional health.
Will the weight return long-term?
Am I making the right choice?
Everyone you talk to wants to give you their opinion.
You hear it the most from those close to you. "Do this!", "Don't do that!", "What you really need to do..."
But it's your decision to make, not theirs.
The Appeal of Bariatric Surgery:
Surgical options are increasingly being seen as the most effective form of treatment for the morbidly obese (1).
Although traditionally seen as a last resort for weight loss, rates of bariatric surgery are rapidly increasing and continually being seen as one of the few options that lead to long-lasting weight loss for the severely obese (as defined by a BMI greater than 35 kg/m2) (2).
For these individuals, type 2 diabetes may progress in as little as five years. Severe pediatric obesity is also on the rise - signaling doctors to seek more aggressive options like bariatric surgery earlier than ever before (3).
On the surface, the results look promising.
Bariatric surgery is associated with a loss of 50% of excess body weight, with 30-40% of that total loss being sustained.
It’s also associated with a 73-80% remission of type 2 diabetes (4).
Other fringe benefits may be early detection of other co-existing complications such as renal cell carcinoma (5).
These are life-saving statistics and potent enough to bring the attention of doctors
But there’s more to discuss.
Risks of Bariatric Surgery
On the downside, bariatric surgery has been associated with a a <0.5% mortality rate (<1 in 200 procedures), multiple micronutrient deficiencies, hypoglycemia (6) and an ultimate relapse of weight gain in as high as 20% of cases (7; 8; 9).
In one review published in Obesity Surgery in May 2010, at six months following their bariatric surgeries, clients still did not fall into healthy BMI ranges and saw no improvement in inflammatory markers despite having achieved significant weight loss (10).
The rate of complications is as high as 16%, with nutritional complications making up the vast majority of problems (11).
Those undergoing bariatric surgery are at high risk of a general reduction in metabolic rate and protein malnutrition which may put surgical candidates at risk to bone and muscle health, particularly those already diagnosed with type 2 diabetes (12).
Should Women Looking to Become Pregnant Have Bariatric Surgery?
Women who wish to become pregnant following bariatric surgery are recommended to wait 12 months before trying in order to give time to replenish micronutrient deficiencies and decrease the likelihood of potential complications.
What Supplements Should I Take Before or After Bariatric Surgery?
Ensuring adequate micronutrient levels prior to weight loss surgery may decrease risk of follow-up complications (15).
Calcium, iron, zinc, selenium, copper, thiamine, folic acid, vitamin B12, vitamin C, vitamin A, vitamin D, and vitamin K are recommended as their absorption may become significantly decreased (16; 17; 18; 19; 20; 21).
At its worst, B1 deficiency may cause Wernicke’s syndrome, a neurological disorder associated with confusion, tremors, loss of memory and poor muscle coordination typically associated with chronic alcoholism.
Lastly, the amino acid leucine may be particularly important due to its stimulating role in muscle growth (24).
How Does Bariatric Surgery Compare with Lifestyle Change?
In comparison, other weight loss interventions such as calorie control and exercise lead to 5-10% loss of excess weight for successful individuals, but have a high rate of relapse and the losses are rarely maintained over long periods of time.
The underlying conclusion is still the same for both surgical and non-surgical candidates - the adoption of regular physical activity, healthy food choices, portion control and other lifestyle changes is still essential (25).
But for those choosing bariatric surgery, nutritional preparation and follow-up is essential to increase the likelihood of high-quality outcomes.
Some now refer to bariatric surgery as “metabolic surgery” reflecting insights into the short-term and long-term endocrine effects on the body, especially with hormone signaling in the gut (26).
Bariatric surgery may work in part by disrupting brain reward pathways controlled by hormones secreted by the gut, as well as changing the body’s “set point” of energy balance (27).
In English, that means that those who received the surgery report less preoccupation with food, as well as more satisfaction with small meals and low calorie foods (28). They are "tricked" into thinking they are fuller faster, and do not crave foods like they have in the past.
Because of its effect on appetite and weight control hormones, the increase in bariatric procedures are spurring exciting discoveries in the relationship of the gut and the brain (29).
As the mechanisms of weight loss with bariatric surgeries are being discovered, the hope is that the results may be achieved with less aggressive and invasive means.
Raising Insulin and Other Mechanisms of Bariatric Surgery
Bariatric surgery may increase the release of insulin from the pancreas by improving the release of “incretins” (such as glucagon like peptide 1 [GLP-1] and glucose dependent insulinotropic polypeptide) by as much as 300-500%, an effect not seen with traditional weight loss strategies (30; 31).
Currently, the rate of eating, stomach emptying, nutrient absorption and monitoring, bile acid metabolism, and changes in gut bacteria may all play important roles (32).
Additionally, those with high body fat tend to release high amounts of estrogen which can disrupt the delicate balance of sex hormones as we age.
When you lose excess weight, levels of estrogen will drop as well.
Both men and women who have lost weight with bariatric surgery may see improvements in the balance of estrogen and testosterone (33)
But listen to this...
These proposed mechanisms may all be achieved by alternative means other than surgery that are potentially safer and more cost-effective than bariatric surgery.
Reading Between the Lines
Many complications due to obesity and type 2 diabetes (now called “diabesity), are due to chronically high levels of insulin, often present well before elevations in blood sugar and weight gain occur.
Bariatric surgery definitely leads to weight loss, but does it lead to key improvements in inflammatory profile of a patient?
So far, the research I’ve reviewed says no.
Metabolically, the weight loss from bariatric surgery appears to be partly related to increased release of insulin, which improves sugar management and provides an alternative to problematic prescription drugs.
A class of drugs known as thiazolidinediones (Avandia, Actos, Rezulin) have been used similarly in the past to raise insulin sensitivity, but have been associated with potentially serious risks to cardiovascular and liver health and urged off the market and may only still offer benefit to those individuals with type 2 diabetes who have already suffered a heart attack (34).
So if the secret mechanism of bariatric surgery is to increase insulin levels, you may have a client with improved blood sugar levels and a significant loss of weight, but who is still inflamed and at high risk for further complications that you are looking to prevent in the first place.
Putting Bariatric Surgery in Perspective
If you have been diagnosed with morbid obesity or are at serious risk of health problems due to the excess weight, you want to review all of the options in front of you before making a decision.
My bias is toward lifestyle interventions is clear, but I agree that there are certain cases where surgical intervention is necessary to at least jumpstart the process.
But surgical options are not without their complications, their medical costs, and are associated with some strict dietary changes leading up to and directly following the procedure that you need to take in to consideration.
You want to be prepared for what's ahead of you. The surgical process is not always as easy as it sounds.
Behaviorally, losing that weight initially may be the momentum needed to finally jumpstart lifestyle change for good.
This is the mindset you need to approach any decision with - there is no magic procedure to substitute necessary lifestyle change.
If the same results can be achieved without having to go under the knife (or the laparoscope), it would be in the best interests of your health to seek out more conservative and less costly interventions first.