As new statistics reveal an alarming rate of obesity in the U.S., more and more people are opting for weight loss surgery to combat this disease. However, there are myriad side effects to be concerned about other than weight regain that range from addiction to possible suicide risk.
Last month, the Centers for Disease Control released updated statistics on adult obesity in the U.S. One statistic in particular that raised eyebrows and grabbed headlines – the prevalence of obesity was as much as 35% or more in seven states (Alabama, Arkansas, Iowa, Louisiana, Mississippi, Oklahoma, and West Virginia).
This again points to the continuing obesity epidemic in the U.S., and while most experts say more people are becoming obese because of increased calorie intake and increasingly sedentary lifestyles, obesity is a physiological disease, and it’s often more complicated to control than “eat less and move more.” Lifestyle changes remain the first line of treatment, but for many patients, bariatric surgery is the most effective for long-term weight loss.
But weight loss surgeries – Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (most centers no longer perform laparoscopic adjustable gastric banding [LAGB] because it’s not as effective) – are procedures that carry both short-term and long-term effects, some of which can be harmful without proper treatment. And while most obesity experts are aware of what’s at stake for patients undergoing bariatric surgery, it’s important to keep in mind the physical and psychological toll these surgeries can have on these patients.
People with obesity are at a higher risk for several comorbid conditions, including diabetes and heart disease, and the short-term benefits of bariatric surgery are marked improvements in these conditions. Bariatric surgery can even mean remission of pre-diabetes and type 2 diabetes. The surgery can help resolve hypertension and let patients discontinue the medications they take for high blood pressure. And that’s not to mention the weight loss itself.
“Bariatric surgery is highly effective and although there is weight regain, the weight loss associated with bariatric surgery still surpasses weight loss with other conventional methods and the weight regain that is reported is usually 10% to 15% (although we see more weight recidivism post sleeve and it’s occurring earlier on post-surgery),” says Amy E. Rothberg, MD, PhD, associate professor of internal medicine in the Division of Metabolism, Endocrinology and Diabetes (MEND) and director of the MEND Investigational Weight Management Clinic at the University of Michigan in Ann Arbor. “But any interval of diabetes remission is good since it will provide a longer interval of the potential to avoid complications related to T2DM. The short-term improvement in metabolic effects may be related to markedly reduced caloric intake and hepatic insulin sensitivity.”
But this weight loss can invite a lot of unwanted attention from family and friends and acquaintances of the patient, according to Kasey Goodpaster, PhD, a psychologist in the Bariatric & Metabolic Institute at Cleveland Clinic. It’s very common for patients to be asked invasive questions after they lose weight. The patient might have to field questions about how much weight they lost, what they weighed before, and other questions they may not want to answer, especially if they are embarrassed that they had to “resort” to surgery to lose weight. Other social reactions depend on whether they had been open beforehand about their decision to pursue surgery. If they kept it private, they are more likely to hear questions about how they lost weight and concerns about whether they are eating enough. If they had shared their decision to pursue surgery, they are more likely to hear questions about the surgery itself and whether they “should” be eating certain foods.
“For many, bariatric surgery is considered the ‘last resort,’ and if it does not result in the quality of life improvements one expected, it could lead to despair. It is crucial to educate patients about these risks and monitor them postoperatively.” – Kasey Goodpaster, PhD, psychologist, Bariatric & Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
“Behavioral health professionals help patients role-play how they will handle these interactions using assertive communication skills,” Goodpaster says. “For patients who are embarrassed that they needed to resort to surgery, we help break down this internalized stigma by educating them about the biological forces resisting weight loss and why the majority of diets fail. Bariatric surgery allows patients’ bodies to work with them to lose weight, rather than battling against them.”
Any patient who undergoes surgery is usually prescribed some sort of opioid to help cope with the post-operative pain, but new research suggests that bariatric patients are more likely to develop chronic opioid use, and this occurs more often in patients who had postoperative complications or lost less weight. Bariatric patients are also more prone to abuse and are at risk of becoming addicted to alcohol. Studies have shown that drugs, alcohol, and food trigger similar reward responses in the brain, and binge eating can be construed as an “addiction.” Alcohol and drugs could substitute for overeating following bariatric surgery.
“Some have attributed increased rates of alcohol and opioid addiction to ‘addiction transfer’ (i.e., when some bariatric patients can no longer use food to soothe negative emotions, they may turn to another substance that provides a numbing effect),” Goodpaster says. “However, this theory is difficult to prove, and the majority of bariatric patients do not feel addicted to food before or after surgery. However, if patients feel as though addiction transfer did occur, behavioral health professionals help patients grieve the loss of food and develop alternative, healthier coping mechanisms. We refer to substance abuse specialists when needed.”
Rothberg explains the physical mechanisms for increased alcohol abuse following bariatric surgery. Alcohol is easily consumed and digested and leads to disinhibition and impulsivity. “There are also changes in absorption as the alcohol dehydrogenase is primarily in the stomach and since the stomach is significantly reduced, so is the enzyme,” she says. “Patients may more rapidly absorb alcohol and have greater acute and longer response to the effects of alcohol, leading to other negative behaviors, like suicide.”
In July 2016, Backman et al., published a paper in the British Journal of Surgery titled “Alcohol and substance abuse, depression and suicide attempts after Roux-en-Y gastric bypass surgery.” The researchers examined data from a Swedish registry who had undergone RYGB between 2001 and 2010 and found that these patients were almost three times more likely to attempt suicide than a general population reference group. Rothberg says that the rate may be even higher. “This included only those who had been hospitalized so it probably underestimates the risk because it did not include those who had thoughts of suicide or who did not seek treatment,” she says. “He also published another study looking at self-harm emergencies, including suicide attempts and found that these increased by 50% after RYGB. Again, this looked at individuals who were seen in a hospital, so the actual rate is probably higher.”
But Rothberg also points out that 93% of the people in this study who had engaged in self-harm had a prior mental health diagnosis. “Although many centers do a psychological assessment, this can be rather perfunctory and many patients, in retrospect, had mental health diagnoses or behaviors that should have precluded them from undergoing surgery,” she says.
Goodpaster says that Cleveland Clinic does more thorough assessments, as do most comprehensive bariatric programs with psychologists embedded in the multidisciplinary team.
In 2010, The American Journal of Medicine published a paper by Tindle, et al., titled “Risk of suicide after long-term follow-up of bariatric surgery.” The researchers examined bariatric records on Pennsylvania residents between 1995 and 2004 and matched the data to reference population from the Division of Vital Records in the Pennsylvania State Department of Health, and found an overall suicide rate of 6.6 per 10,000 (13.7 per 10,000 among men and 5.2 per 10,000 among women). Thirty percent of the suicides occurred within the first two years following surgery and almost 70% occurred within three years. Comparable sex matched U.S. suicide rates among those aged 35 to 64 were 2.4 per 10,000 for men and 0.7 per 10,000 for women. These authors concluded that there was a substantial excess of suicides among patients who had undergone bariatric surgery.
“A number of psychosocial issues that might be involved are discussed in those papers,” Rothberg says, “including inadequate weight loss or weight regain, potentially superimposed on a unrealistic expectations, lack of improvement in quality of life after surgery, continued or recurrent physical mobility restrictions, persistence or recurrence of sexual dysfunction and relationship problems, low self-esteem, and a history of child maltreatment including sexual abuse.”
Bariatric patients have more psychopathology than the general population even before surgery, and Goodpaster says they have higher rates of depression and past suicide attempts, which are a major risk factor for suicide. Mood does improve immediately after surgery, but depression re-emerges two to three years after surgery and could possibly be worsened by body image disturbance, psychiatric medication malabsorption, and disappointment in the extent to which life improved after surgery. “For many, bariatric surgery is considered the ‘last resort,’ and if it does not result in the quality of life improvements one expected, it could lead to despair,” she says. “It is crucial to educate patients about these risks and monitor them postoperatively.”
“Recurrence of medical problems, especially if initially the conditions resolved, may contribute to a sense of failure and disappointment, which theoretically may increase suicide risk,” Rothberg says. “Also, suicide rates are known to be elevated in those with diabetes.”
But while these findings are concerning and even alarming, for patients with severe obesity who are well selected, bariatric surgery offers a myriad of benefits. “But, ironically, those who derive the greatest benefit are indeed those who adhere to the prescription for low calorie diet, regular physical activity, and other behaviors that are part of a comprehensive intensive lifestyle program (that may have resulted in weight loss success without surgery),” Rothberg says. “Still bariatric surgery can offer leverage over lifestyle alone in that it facilitates early and robust weight loss (a motivator) and changes in some of our neurophysiology around weight regulation and reward such that patients may experience an earlier sense of fullness, less hunger, and even changes in taste making the previous “yummy” foods less palatable. Those changes can help reduce food intake leading to continued weight loss or longer weight loss maintenance.”
“Although many centers do a psychological assessment, this can be rather perfunctory and many patients, in retrospect, had mental health diagnoses or behaviors that should have precluded them from undergoing surgery.” – Amy E. Rothberg, MD, PhD, associate professor of internal medicine, Division of Metabolism, Endocrinology and Diabetes (MEND); director, MEND Investigational Weight Management Clinic, University of Michigan, Ann Arbor
“I always tell my patients that bariatric surgery is a ‘stomach surgery,’ not a ‘brain surgery,’ and much of eating is triggered by thoughts, feelings, and situations which will remain after surgery if not tackled proactively,” Goodpaster says. “Loss of control eating before surgery is likely to re-emerge, but it manifests differently.”
For example, she says, one study indicated that over 60% of patients who met criteria for binge eating disorder before surgery developed graze eating (i.e., eating small/modest amounts of food continuously throughout the day) after surgery. Graze eating is particularly problematic because the post-operative stomach does not preclude it, and it can contribute to weight regain. “For patients with pre-surgical eating disorders, it is vital to provide treatment before surgery and to educate patients about how to prevent relapse,” Goodpaster says. “Treatment and monitoring should be ongoing after surgery.”
And that’s the problem with bariatric surgery – the follow-up. It is imperative for patients who undergo bariatric surgery to have long-term follow-up. “Bariatric surgery does not take away the requirement to implement and continue lifestyle modifications and to ensure ongoing success,” Rothberg says. “They must have ongoing management (just like any chronic disease).”
- Bagley is the senior editor of Endocrine News. In the September issue, he wrote about how a diet rich in seafood could potentially help couples get pregnant.