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Bariatric Surgery: A Realistic Look at the Risks and Rewards

Sometimes the risks may outweigh the benefits

Bariatric surgery has made headlines in recent months for its effectiveness in improving type 2 diabetes, sleep apnea and high blood sugar compared to conventional medical treatments. These results aren’t surprising. In many areas of medicine, costly and invasive surgeries yield more dramatic results than medication and behavioral strategies. What concerns me is the one-sided nature of the current dialogue about this high-risk surgery.

An increasing number of obese individuals are undergoing weight loss surgery. The American Society for Metabolic and Bariatric Surgery estimates that 220,000 Americans had bariatric surgery in 2008, up from just 16,000 in the early 1990s. Yet little research has been done to educate the public about the long-term risks and how people should go about deciding whether or not surgery is right for them.

Current guidelines suggest that an individual is a candidate for bariatric surgery, which includes gastric bypass and other surgical procedures that change the stomach and digestive system, if they have tried to lose weight unsuccessfully, have a body mass index (BMI) of 40 or higher, or if they have a BMI of 35 or higher (or even 30 or higher for certain procedures) along with a weight-related problem such as diabetes or high blood pressure. The goal of surgery is to limit the amount of food a patient can eat, which prompts dramatic weight loss.

Weight loss surgery may be the best option for some obese individuals. There are indeed clear medical benefits when it is reserved for only the most severe cases of obesity. But the decision shouldn’t be made lightly without a clear understanding of what the patient is signing up for.

Nutritional Deficiencies

While the medical community widely touts the benefits of weight loss surgery for diabetes management, many of the risks have been minimized, including the serious risk of nutritional deficiencies. Bariatric surgery restricts the absorption of nutrients by bypassing the part of the intestinal tract where they’re normally absorbed. This can result in deficiencies in iron, protein, folate, vitamins A, B12, D, E and K, calcium, and micronutrients like zinc, magnesium and selenium.

To counteract these deficiencies, patients need to follow a lifelong vitamin regimen. Because it can be burdensome and expensive, many people stop taking their vitamins, and doctors become lax over time in monitoring their patients. Even among those who comply with supplementation, studies have found that as many as half of patients still have deficiencies. This number may be even higher given that nutritional deficiencies go unrecognized in approximately 50 percent of patients. These deficiencies can have dramatic effects on patients’ health and quality of life. For example:

• Folate and vitamin B12 are critical for the production of serotonin, dopamine, epinephrine and norepinephrine, neurotransmitters that affect mood and appetite. Vitamin B12 deficiency can lead to anemia, neuropathy and cognitive difficulties.

• Vitamins E and A are antioxidants that aid in immune system function and protect against oxidative stress, which can cause degenerative diseases.

• Protein contains amino acids, the precursors of neurotransmitters. Protein deficiency can lead to hair loss, weakness, anemia and problems with mood.

• Iron deficiency can cause anemia, which produces fatigue and irritability.

• Calcium and vitamin D have a significant effect on bone health.

Cross-Addiction

Research increasingly shows that food can become a compulsion similar to drugs or alcohol because of its impact on the pleasure centers of the brain. Just as it is common for drug addicts in drug rehab to gain weight, it is common for people undergoing bariatric surgery to turn to drugs, alcohol, sex, gambling, and other addictive substances and behaviors to cope with the emotional issues that food helped them soothe.

Having a person undergo bariatric surgery who has not addressed trauma, abuse, neglect or other painful psychological issues does not solve the problem. In Kaiser Permanente’s Adverse Childhood Experiences study, people with morbid obesity had a high incidence of severe trauma, such as abuse, neglect, domestic violence, or living with an adult who abuses substances, is mentally ill or in jail. Taking away the food doesn’t address the addictive behavior or the emotional pain that these behaviors are covering up, leaving patients at high risk for cross-addictions.

Long-Term Lifestyle Change

Before getting bariatric surgery, medical professionals advise patients that long-term success depends on the individual’s ability to make permanent lifestyle changes – changes that most obese individuals have tried to make for years without success. Some of the changes that are important even with bariatric surgery include:

1. Following a strict eating plan for life

2. Addressing how you will deal with your home environment. What type of emotional support will you have? How will you stay on a strict diet when others in your home are not?

3. Can you commit to taking supplements for life?

4. Can you commit to exercising regularly for life?

5. Do you fully understand the possible risks that surgery poses, including bleeding, infection, bowel obstruction, ulcers, gallstones and death?

People who undergo bariatric surgery may indeed experience significant improvements in diabetes and other health measures. But while making progress in one area, there’s a very real risk that they’re developing other serious medical problems, including threats that we already know of and long-term risks that the medical community has yet to document.

Weight Loss Surgery Alternatives

In America, the country of the quick fix, more than 60 percent of American adults are now overweight or obese. For those searching for a magical solution, weight loss surgery should be the exception rather than the rule. The answer for most is the same as it has always been: sustainable lifestyle change. Even modest changes in weight (5 to 15 percent weight loss) can result in dramatic improvements in health.

Weight loss surgery is overused and its benefits overblown. At the same time, more effective approaches such as the Health at Every Size movement haven’t built the following they deserve. Rather than focus on the number on the scale, which is not the best indicator of health,

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Carolyn Ross, M.D., specializes in Integrative Medicine and developed the eating disorder treatment program at The Ranch in Tennessee. You can follow Dr. Ross on Twitter.

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