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How sustainable is the weight loss from bariatric surgery? Most gastric bypass patients end up regaining some of the fat they lose over the first year or two after surgery, but five years later, three-quarters maintain at least a 20 percent 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 back 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. Eight years out, about half of gastric bypass patients continue 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 [like 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, thoroughly-chewed, small bites. Your stomach goes from the volume of two softballs to down to the size of half a tennis ball in stomach stapling, and half of a ping-pong ball in the case of gastric bypass or banding.
As you can imagine, weight regain after surgery can have devastating psychological effects, as patients may feel they failed their last resort. This may explain why bariatric surgery patients are at a high risk of depression and suicide.
Now severe obesity alone may increase risk of suicidal depression, but even at the same weight, those going through surgery appear to be at higher risk. At the same BMI, age, and gender, bariatric surgery recipients have nearly four times the odds of suicide compared with counterparts not undergoing the procedure. Most convincingly, before-and-after mirror-image analyses show the risk of serious self-harm increases post-surgery among the same individuals.
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 of “undetermined intention.” Bariatric surgery patients also have an elevated risk of accidental death, though some of this may be due to changes in alcohol metabolism. Give gastric bypass folks two shots of vodka, and because of their altered anatomy, their blood alcohol level shoots past the legal driving limit within minutes. It’s unclear whether this plays a role in the 25 percent 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 improves, general mental health tends to significantly deteriorate, compared to pre-surgical levels even among the biggest losers. 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 pounds may not shed the stigma of even prior obesity. Studies suggest that in the eyes of others, knowing someone was fat in the past leads them to always be treated more like a fat person. And there’s a strong anti-surgery bias on top of that, such that those who choose the scalpel to lose weight are rated most 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 has a complication rate exceeding 50 percent, with dehiscence (rupturing of the surgical wound) being the most common complication.
“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 our natural gastrointestinal anatomy as an alternative to better use of feet and forks [(diet and exercise)] 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 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—mal-absorptive—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 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 of 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 consistently frame 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.
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