Fighting the Stigma: Bariatric Surgery
“It’s cheating” “You’re giving up.” “That’s the easy way out.” These are all common phrases that bariatric patients hear on a regular basis, after battling obesity for what may have been their entire life (1)(2)(13). Unfortunately these hurtful words are more commonly used than one would think; in 2016 over 93 million Americans were considered obese according to the CDC National Center for Health Statistics data brief, and there were 216,000 bariatric surgeries performed that same year (3)(4).
Many people are aware of the health consequences of having obesity; these include diabetes, hypertension, sleep apnea, depression, anxiety, GERD, asthma, heartburn, and joint pain (7). What most people don’t know is that bariatric surgery can be used as a tool to help alleviate the symptoms or eliminate some of these conditions. After bariatric surgery, patients may see advances in their physical health such as remission of type 2 diabetes, improved blood pressure, and reduction of sleep apnea symptoms, as well as a higher quality of life with more energy, improved fertility, and the ability to do normal day-to-day things that many people take for granted such as fitting into the seat of a roller coaster or having the ability to tie their own shoes (5)(8).
Every person has their own journey, and it is up to each individual to decide whether bariatric surgery is the right option for them. It is both a physical and mental journey for a patient to undergo bariatric surgery, and it is important to understand what this process entails in order to help eliminate bias in the future.
WHAT IS BARIATRIC SURGERY?
Bariatric surgery, also known as weight loss surgery, is an operation that helps a patient lose weight by making changes to the stomach and/or small intestine (11). It restricts the amount of food the stomach can hold, causes malabsorption of nutrients, or a combination of both (12). Bariatric surgery may also cause hormonal changes, which can in turn decrease a patient’s appetite (12)(13).
TYPES OF SURGERY
There are currently five popular types of bariatric surgery procedures, among some other lesser known procedures. They are designed to be as minimally invasive as possible, and most patients can return home from the hospital after one or two nights (14).
Adjustable Gastric Band:
The Adjustable Gastric Band is a restrictive procedure. An inflatable band is placed around the upper portion of the stomach, creating a small pouch (12). When a patient eats, this small pouch fills with food faster than the larger normal-sized stomach, making him or her feel fuller, faster. The patient’s bariatric surgeon can adjust the size of the opening from the pouch to the rest of the stomach by injecting or removing saline solution to and from the band, thus increasing or decreasing the patient’s feeling of restriction (11). This restriction leads to portion control, which contributes to weight loss (12).
2. Vertical Sleeve Gastrectomy:
The Vertical Sleeve Gastrectomy is a restrictive procedure (12). A large outer portion of the stomach is removed, changing the size and shape of the stomach from about a small pineapple to the size and shape of a banana (11). This new, smaller stomach holds about ¼ of the volume that the stomach could hold pre-operatively (15). The amount of the hunger hormone, grehlin, is also decreased, therefore decreasing appetite (12). Patients choose this procedure for its decreased portion control and lowered appetite, and it is an increasingly popular surgery in the United States.
3. Roux-en-Y Gastric Bypass:
The Roux-en-Y Gastric Bypass is both a restrictive and malabsorptive procedure. A small stomach pouch is created by dividing the top of the stomach from the rest of the stomach, leaving this outer ‘remnant stomach’ in the body. Then, the first portion of the small intestine is divided, and the bottom end of this divided small intestine is brought up to connect to the small stomach pouch. The top portion of the newly divided small intestine is connected to itself further down, creating the ‘Y’ shape that gives this surgery its name (12). Due to the smaller pouch and intestinal rerouting, this surgery is both a restrictive and malabsorptive procedure.
4. Biliopancreatic Diversion with Duodenal Switch:
The Biliopancreatic Diversion with Duodenal Switch, sometimes abbreviated as BPD/DS, is essentially the Vertical Sleeve Gastrectomy with fat malabsorption; therefore it is both a restrictive and malabsorptive procedure. It is the most absorptive bariatric surgery that exists, and is becoming increasingly popular, likely due to its high rate of weight loss and resolution of some diseases such as hypertension and diabetes (6). To create fat malabsorption, the stomach is divided and a portion of the distal small intestine is brought up and connected to the newly created stomach pouch, causing food to bypass about 75% of the small intestine when eaten (12).
5. Intragastric Balloon:
Intragastric balloons are a newer weight loss procedure and are non-permanent, typically staying in the body for a period of about 6 months. A silicone balloon is filled with saline or air and placed into the stomach, limiting portion size and causing a quicker feeling of satiety (16). It is a purely restrictive procedure and can sometimes be done in an outpatient setting where a patient does not have to stay overnight.
CHOOSING THE RIGHT SURGERY
Choosing a bariatric surgery procedure is a personal decision that should be made in congruence with individual goals discussed with the advice of a medical team that includes a primary care physician and bariatric surgeon (6). There are multiple factors that play a role in the decision to choose one surgery over another. These factors include age, BMI, medical history, post-operative goals (i.e. diabetes resolution, a BMI <40 to allow a hip replacement surgery), and the patient’s decision of how invasive of a procedure they would like (9). All of these factors are discussed until the patient and surgeon ultimately make a decision together that will best benefit the patient’s overall health.
THE WORK UP PROCESS
In order to be cleared for bariatric surgery, a patient oftentimes has to go through an extensive workup process. Each insurance company has different requirements, but most patients have to go through several months of medical visits and clearances prior to the surgery itself. The workup process is done pre-operatively to help identify if it will be safe for the patient to undergo a gastrointestinal surgery, if the patient is ready and willing to comply with post-operative lifestyle changes, and to determine which bariatric surgery is the best option for each patient’s individual health. A workup often includes some or all of the following (6) (10):
Preoperative laboratory evaluation: this may include a full vitamin panel, a complete blood count, liver function tests, thyroid function tests, lipid profile, urinalysis, and any other labs the surgery center sees fit
Imaging studies on the chest, gallbladder, etc.
Diagnostic procedures such as an upper gastrointestinal endoscopy
Nutrition education and clearance
Surgical weight loss visits
Appointments with a case manager or social worker
LIFE AFTER SURGERY: DIET AND EXERCISE POST OP FOR SUCCESS
Life after surgery can be a new beginning for many patients—a new beginning to learn the importance of reading Nutrition Facts Labels, a new beginning with decreased joint pain that allows the ability to go for a long walk, or a new beginning to find the confidence to engage in new social activities. Although this new life can seem very exciting, a patient must also put forth a lot of effort to ensure they are safe and successful after surgery.
First and foremost, a patient must follow a specific diet for the first few months after surgery to ensure safety. Although clinics have different protocols, many clinics will start their patients on fluids only, graduate to a pureed texture, move on to soft foods, and eventually regular-texture crunchy foods such as nuts or celery (18). Patients also have specific protein and hydration goals to ensure they do not become malnourished or severely dehydrated, and also to promote healing (17).
Vitamin and mineral repletion is essential after bariatric surgery. Because patients are no longer getting all of the nutrients they need from food, a bariatric-formulated vitamin is needed to give the patients what they are missing. Most clinics will give vitamin recommendations based on the American Society for Metabolic and Bariatric Surgery (ASMBS) national guidelines (18).
Physical activity is a key component in maximizing success following surgery. For the first 4-8 weeks after surgery, it is advised that patients lift no more than 15 pounds; however after this time frame, there are no general exercise restrictions (19). The national recommendation for physical activity in the first year post-op is 150 minutes of moderate-intensity aerobic activity (or 75 minutes of vigorous activity) per week, and 250 minutes of moderate-intensity aerobic activity after the first year (20).
LONG TERM FOLLOW UP
Long term follow up with an interdisciplinary team is recommended for patients to have optimal success. A patient will follow up with a surgeon or physician assistant every few weeks to few months to discuss medical needs. They may also follow up with a Consultant Registered Dietitian to discuss post op dietary protocols, with a psychologist to help navigate their new life, and with any specialist (i.e. gastroenterologist) deemed necessary.
All in all, bariatric surgery can be a life-changing, and in some instances, life-saving procedure. By knowing the facts and spreading awareness, people may learn to accept these surgeries as a tool to success and not as a quick fix.
RD Nutrition Consultants LLC, is the industry leader in Consultant Dietitian Services & Bariatric Dietitians Nationwide. We specialize in providing contract Registered Dietitian services in a wide variety of healthcare and wellness organizations.
Goyanes, I. (2016, May 25). Weight Loss Surgery Is the Easy Way Out. Retrieved from http://miaminewtimes.com/restaurants/weight-loss-surgery-is-the-easy-way-out-6577058
K. (2018, April 16). Is weight loss surgery cheating? Retrieved from https://bariatric-surgery-source.com/weight-loss-surgery-cheating.html
Estimate of Bariatric Surgery Numbers, 2011-2017. (n.d.). Retrieved from https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers
Overweight & Obesity. (2018, June 12). Retrieved from https://www.cdc.gov/obesity/data/adult.html
21 Reasons To Have Weight Loss Surgery. (2017, January 24). Retrieved from http://www.obesityhelp.com/articles/21-reasons-to-have-weight-loss-surgery
Choosing The Right Bariatric Surgery Procedure. (2014, May 28). Retrieved from http://www.surgerync.com/2014/06/choosing-right-bariatric-surgery-procedure/
Ferreira, L. M. (n.d.). Obesity Comorbidities: What You Need To Know. Retrieved from https://obesitynewstoday.com/obesity-comorbidities/
Digestive Health Team. (2017, August 10). 7 Bariatric Surgery Benefits Besides Helping You Lose Weight. Retrieved from https://health.clevelandclinic.org/7-bariatric-surgery-benefits-besides-helping-you-lose-weight/
Frey, M. (n.d.). Questions to Ask Before Choosing Bariatric Surgery. Retrieved from https://www.verywellfit.com/is-it-time-to-choose-the-weight-loss-surgery-option-3496412
Bariatric Surgery Workup: Laboratory Studies, Imaging Studies, Diagnostic Procedures. (2018, June 12). Retrieved from https://emedicine.medscape.com/article/197081-workup#showall
Definition & Facts for Bariatric Surgery. (2016, July 01). Retrieved from https://www.niddk.nih.gov/health-information/weight-management/bariatric-surgery/definition-facts
Bariatric Surgery Procedures – ASMBS. (n.d.). Retrieved from https://asmbs.org/patients/bariatric-surgery-procedures
Bariatric Surgery Misconceptions. (n.d.). Retrieved from https://asmbs.org/patients/bariatric-surgery-misconceptions
What to Expect After Weight Loss Surgery. (n.d.). Retrieved from https://www.webmd.com/diet/obesity/what-to-expect-after-weight-loss-surgery#1
Gastric Sleeve Illustrations. (n.d.). Retrieved from http://surgery.ucla.edu/bariatrics-gastric-sleeve-illustrations
Intragastric balloon. (2018, January 13). Retrieved from https://www.mayoclinic.org/tests-procedures/intragastric-balloon/about/pac-20394435
Life After Bariatric Surgery. (n.d.). Retrieved from https://asmbs.org/patients/life-after-bariatric-surgery
Nutrition Guidelines: Before, During, and After Weight Loss Surgery. (n.d.). Retrieved from http://www.surgerync.com/nutrition-portal/nutrition-guidelines.php
Weight-loss Surgery and Fitness - The Do's and Don'ts for a Successful Exercise Program - Obesity Action Coalition. (n.d.). Retrieved from https://www.obesityaction.org/community/article-library/weight-loss-surgery-and-fitness-the-dos-and-donts-for-a-successful-exercise-program/
King, W. C., & Bond, D. S. (2013, January). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529741/