Why Aren’t All the Cool Kids Doing It?

Despite widespread acceptance in the medical community, bariatric surgery doesn’t seem to have received the same embrace from the general public

Recently, I was reading an opinion piece in the New York Times by an author named Julia Holloman, entitled “Don’t Keep Bariatric Surgery a Secret.” (link: http://www.nytimes.com/roomfordebate/2013/12/26/when-beauty-is-not-exactly-truth/dont-keep-bariatric-surgery-a-secret) In the article, Holloman, herself a bariatric surgery patient, discusses the importance of the support from others in achieving and maintaining success. She also briefly discusses what she feels is her responsibility to be open about her experience so as to help others overcome their fears and/or misconceptions about bariatric surgery and decide to take definitive action. She powerfully summarizes the dilemma:

For most, the path of escape is fraught with secret shame, looming failure and a fear of dying, while remaining obese holds the same deadly consequences. This is why it’s so important for there to be an open dialogue about weight loss options, no shame attached.

As a bariatric surgeon, nothing in her piece was surprising to me. She eloquently describes her difficulty with the emotional component of obesity as a separate struggle apart from just the physical aspects of the surgery. This is very familiar to those of us who treat patients with morbid obesity regularly, and the reason why our program, not unlike most effective bariatric surgery programs, emphasizes thorough psychiatric evaluation and counseling, pre- and post-operatively through our support groups and dieticians.

What did surprise me were the comments in response to the article. As a long time denizen of various forms of social media, I probably should not have been caught off guard by these comments, but I was. Given the experience we have with our patients, and seeing first hand how bariatric surgery changes their lives for the better, as well as the extensive clinical research confirming the benefits of weight loss surgery, it had not really occurred to me that there could be people who could objectively look at it and be so philosophically opposed to what we do for our patients every day. We do know that currently, less than 1% of patients who meet the criteria undergo bariatric surgery. This number has always puzzled us, given that it’s hard to imagine any other disease, which obesity has now been classified by the AMA, for which so few people afflicted with it would seek medical treatment. We have always assumed that this number remained as low as it has based on a combination of economic factors, lack of awareness, and a reluctance of primary care physicians to refer patients to be evaluated for weight loss surgery.

I decided to do a quick search for other articles on bariatric surgery to see what those comment sections contained to see if this modern voxpopuli might further enlighten me as to why so relatively few people seek out bariatric surgery. I came across an article on the Huffington Post entitled “New Year – Same Old Nonsense About Obesity” written by a woman named Angela Meadows. (link: http://www.huffingtonpost.co.uk/angela-meadows/obesity-weightloss-new-year-same-old-nonsense_b_2395273.html) Before I even made it to the comment section I was amazed to see the following sentence in print in the year 2014:

No intervention for obesity has been proven to produce clinically significant and sustainable weight loss in the medium- to long-term. Not diet, not exercise, not behavioural interventions, not even bariatric surgery.

While the author is correct in her assertion regarding diet, exercise, behavior changes, and even pharmacotherapy had she included that, she is simply wrong with regard to bariatric surgery. She continues:

Evidence is mounting that weight regain following bariatric surgery is common, and even the much-touted benefits in terms of diabetes ‘remission’ show high rates of relapse within five years.

Again, the author is partially correct. Weight regain after bariatric surgery is common. On average, we expect patients to lose weight for the first 18 to 24 months following a weight loss surgery. Depending on which surgery they choose, we expect the average patient to lose between 50 to 80 percent of their excess weight. While some patients are able to maintain their weight loss achievement, a significant percentage of patients do regain 10 to 15 percent of their excess weight. But this still puts them in a much better and healthier place than where they started! As for her claims regarding diabetes, she is again dangerously misinformed. The body of evidence supporting weight loss surgery for the treatment of diabetes has convinced the AmericanAssociation of Clinical Endocrinologists (link: http://www.guideline.gov/content.aspx?id=13022) to formally include referral of patients for bariatric surgery for patients with diabetes and a Body Mass Index over 35 into their official guidelines for clinical practice. This marked a monumental shift from a powerful group of physicians who had not advocated weight loss surgery for many years. Meadows further displays a disconnect with the current state of weight loss surgery:

The health costs of the surgery itself, the complications, the malnutrition, the increased risk of severe depression, do not disappear that readily. Oh and death. That’s pretty permanent too.

A debate about health care economics is outside the scope of this article, but suffice it to say there are many who would fiercely disagree with her assertion given the vast health care resources (as of 2008 an estimated 147 Billion dollars in the US alone) spent on treating obesity and its many comorbidities. As surgeons have gained more experience with these procedures the complication rates have continued to decrease, and as the Laparoscopic Sleeve Gastrectomy has become the predominant procedure malnutrition has become a far less significant sequelae of weight loss surgery. Depression, which is often related to obesity, may not be cured by surgery and the subsequent weight loss, but its risk is certainly not increased in these patients. Of all of the aspersions she makes, the most blatantly uninformed is the comment regarding death. As a result of the standardization of surgical techniques and the extensive work-up bariatric surgery patients receive, the mortality rates are now lower for bariatric surgery patients than for somebody who has their gallbladder removed. Later in the article she also claims that there is no evidence to support treating people simply based on their size, and that the obese are at no higher risk of developing health related problems like cardiovascular disease and diabetes than less overweight people. I would encourage anyone who believes this to do some research and see if they come to the same conclusion.

What I found truly disturbing about this article is that it was published on a mainstream web site. Some of the comments did challenge the author as I have above, but manydefended the author’s position. As I looked at the comment section from other articles on the subject I noticed several recurrent themes.People still question the efficacy (both short and long-term), safety, and extent of the side effects or bariatric surgery and are largely influenced by experiences of patients they know who have had the surgery. Some people question our motives as physicians and believe that we are performing these surgeries purely for financial gain. Another frequently cited concern about weight loss surgery is that is doesn’t address the food addiction and emotional issues that may had contributed to the obesity in the first place. My hope is that over time, as we gather and publicize larger amounts of data that we will help educate more people about the true risks and benefits of bariatric surgery. We do not underestimate the significance of the psychological aspects of obesity and its surgical treatment and that is why we believe so strongly in our support groups and psychological counseling.

I’m interested to hear from those of you who have had, those that are considering, and those that have decided against weight loss surgery. What was it that convinced you to have (or not have) surgery?

Michel Gunn

Michel Gunn