Are There Risks to Bariatric Surgery for Severe Obesity?

severe obesity

See the Whole Picture Before Choosing Weight Loss Surgery

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’re scared.

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.

Despite recommendations, risks to the mother and baby following surgery may actually be less over the long-term when compared to becoming pregnant while obese or morbidly obese (13; 14).

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).

Thiamine (B1) deficiency is associated with bariatric surgery at a potentially higher rate than previously thought (22; 23).

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.

Metabolic Surgery?

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.

 

4 Comments

  1. Diane Kress, RD CDE June 12, 2012 at 10:37 am - Reply

    It didn’t take long. Not so long ago gastric bypass surgery was promoted as a “cure” for type 2 diabetes. Slowly but surely, the truth is coming out.

    Posted on my Blog on http://www.themetabolismmiracle.com on February 3, 2012

    I take a much different position when it comes to gastric bypass surgery and long-term benefits for those with type 2 diabetes. I’d like to start by saying that those who have ridden the metabolic syndrome train from overweight with elevated blood pressure, cholesterol, midline fat deposits, and blood glucose progressing to pre diabetes and finally progressing to type 2 diabetes have a common denominator: this train ride is fueled by insulin imbalance.

    Insulin is a fat gain hormone…excesses will cause increased fat stores on the body and in the blood (cholesterol/triglycerides). Over time, fat cells expand in size from excess insulin release and insulin resistance occurs. At this time, plenty of insulin is being released, but has lost its effectiveness. At the very same time, a person with pre diabetes has excess insulin AND excess blood sugar.

    As time passes, the pancreas gradually fatigues and cannot keep up with increased insulin needs. This is the onset of type 2 diabetes. But…along this entire trainride…during which time the person with insulin imbalance (I call this uncontrolled Metabolism B) is getting “fatter”. It is not a matter of excess calories and inadequate activity alone that got him here…the underlying weight gain’s precursor was and is insulin imbalance.

    Fast forward to the day the person has gained over 150 excess pounds, can’t succeed on a 1200 calorie low fat diet (remember, his main issue is not calories!) and opts for gastric bypass.

    For 1 1/2 to 2 years after the surgery, he will lose weight. This is because his stomach (which once held 8 cups) holds 2 ounces after surgery. (At the end of 2 years, it holds only 1 cup.). As if that were not enough, his GI tract has been cut in two, and reconnected, but leaves the area of the small intestine that absorbs vital nutrients rendered null and void. During these 2 years, he may lose 125#….but……

    BUT……when the stomach pouch stretches to hold about 1 cup, his carb intake can be substantial enough to trigger that darn insulin release and he will stop losing weight. Not only stop…he will then begin to regain weight!!!!! Why? Not because he’s doing anything wrong…but because gastric bypass does not bypass the pancreas!

    The answer…If weight is causing immediate health danger and there is no time to wait until an effective weight loss program takes effect, the person may consider bypass. When 1.5 years pass, he/she will need to follow a diet protocol that targets insulin release. (The Metabolism Miracle or Diabetes Miracle).

    If weight is not causing an immediate life threatening situation…he/she should consider not rerouting their GI tract, slicing their stomach in half and stapling it together, and malabsorbing nutrients forever….when in the end they will need to “diet” anyway….but to follow the diet protocol in The Metabolism Miracle or Diabetes Miracle and lose weight permanently…without surgery.

    • admin June 12, 2012 at 6:19 pm - Reply

      Thanks Diane for such a detailed response, I agree as well that insulin is the main factor involved and that an oral glucose tolerance test is a much better measure of blood sugar management than fasting blood sugar alone. Unfortunately the oral glucose tolerance test is technically not a “benign” test…as you are recreating the stress so you can measure the body’s ability to respond. But millions of Americans are doing this to themselves every day and not reaping the consequences until 10, 15, even 20 years later. It’s a sick twist in a dangerous game of weight management, and it’s definitely more than calories in vs. calories out as you mentioned. Thanks again for reading and sharing your insights.

  2. Angela June 21, 2012 at 2:48 pm - Reply

    DOnt takek the risks of the bariatric surgerym use roca labs and lose weight naturally.

  3. carole starr June 26, 2012 at 1:42 am - Reply

    Risks
    By Mayo Clinic staff
    As with any major surgery, gastric bypass and other weight-loss surgeries pose potential health risks, both in the short term and long term.

    Risks associated with the surgical procedure can include:

    Excessive bleeding
    Infection
    Adverse reactions to anesthesia
    Blood clots
    Lung or breathing problems
    Leaks in your gastrointestinal system
    Death (rare)
    Longer term risks and complications of weight-loss surgery vary depending on the type of surgery. They can include:

    Bowel obstruction
    Dumping syndrome, causing diarrhea, nausea or vomiting
    Gallstones
    Hernias
    Low blood sugar (hypoglycemia)
    Malnutrition
    Stomach perforation
    Ulcers
    Vomiting
    Death (rare)
    How you prepare

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