Wednesday 13th April 2011 must have been “Free PR for bariatric surgery day”. I could not read a paper, watch the TV, listen to the radio, or even scan twitter without seeing stories about how marvellous bariatric surgery is and how we should be doing far more of it. The spokespeople in the numerous media reports were invariably bariatric surgeons who stand to make even more money the more of these operations that they do. They are certainly gaining £’s in their single minded effort to convince the world that the only way to lose lbs is by allowing them to operate on the obese people that mankind made fat and sick in the first place.
This article, therefore, is a summary of what we all may like to know about bariatric surgery: What exactly is it? How is it supposed to work? What are the risks/side effects? Is there an alternative that we haven’t considered? Not least if this seems a bit scary and extreme.
What is Bariatric Surgery?
Bariatric surgery is the collective term given to a number of different procedures all designed to ‘interfere’ with a person’s digestive system.
The main different types are:
1) A Gastric Bypass (also called the Roux en Y Gastric Bypass procedure). This operation was first done in 1967 in the USA. In 2008 there were 200,000 such procedures done in the USA. It was originally always done as an open operation (cutting the stomach open) and sometimes still is done in this way. More commonly nowadays, however, it is done “laparoscopically”. This means it is a less invasive operation – small cuts are made (usually 0.5-1.5cm) and then the surgeons can use cameras to pin point the area they want to work on without having to open up the whole stomach area. This reduces time spent in hospital to 2-3 days and there is a shorter recovery time also. Most people still need 2-3 weeks off work and can’t drive for a couple of weeks.
Gastric Bypass is a very accurate name for what is happening here – the stomach is literally bypassed – so that food doesn’t go where it used to go – and where it should go. All you need to know, from a nutrition and health perspective, is that the majority of nutrients (vitamins and minerals, vital for life and human health) are absorbed in the small intestine. In the pictures above, you can see that the small intestine is bypassed and nutrients can not, therefore, be absorbed properly. This surgical procedure is irreversible.
2) A Gastric Band is less invasive than Gastric Bypass surgery. This is done through key hole surgery, with four small incisions. An adjustable band is placed around the top of the stomach, as shown in the diagram, and it can be adjusted after the procedure. The operation is done under general anaesthetic, taking about an hour and the person can be released in 24 hours and be back to normal activities within a week or two. Unlike gastric bypass surgery, banding is reversible although this is not advised as weight gain is likely to occur.
Anne Diamond and more recently Vanessa Feltz have had Gastric Band surgery. Sharon Osbourne is probably the most well known example of a reversal of this procedure. Sharon had a Gastric Band fitted in 1999 and then had it removed in 2006. Sharon’s reason for having it removed was “I keep wanting to eat more and more….I’m a pig”! She was being physically sick every time she ‘overate’ (probably normal amounts for someone without a gastric band) and this can’t be pleasant. No matter how much we want to be slim – Sharon obviously found that some things are just so intolerable and uncomfortable that she made a decision that may seem unimaginable to some of us.
3) A Gastric Balloon is a soft silicone ‘balloon’ that is inserted into the stomach ‘deflated’. The c. 20 minute operation doesn’t need a general anaesthetic, mild sedation (whatever that is) is induced instead. The balloon is inserted through the mouth and guided down to the stomach where it is then inflated until it takes up a big part of the stomach area. The balloon needs to be removed after 6 months because of the risk of erosion from stomach acid. The removal takes about the same time – 20 minutes – and, again, can be done under mild sedation.The idea is then that the person has had 6 months to improve their ‘eating behaviour’ and doesn’t need a band. Yeah, right!
Often a balloon is used to try to help someone lose some weight before they then have a band or a bypass. This may happen with someone who is dangerously obese and the surgeons don’t want to risk a general anaesthetic until the person has lost some weight.
There are other procedures, which fall under the collective term ‘bariatric surgery’:
– A Sleeve Gastectomy removes 85% of the stomach. Effectively a new ‘sleeve’ or tiny stomach is created. It is alleged that this enables some of the nutrients to be absorbed, because a stomach of sorts is still there. However, the key thing to find out is what they plan to do with your small intestine. The small intestine is actually more than 6 metres long and this is where the majority of nutrients are absorbed. I’d want to know what they were planning to do with my 6 metres! This is obviously irreversible.
– A Duodenal Switch. I have absolutely no idea why someone would opt for this procedure. The full name is “Biliopancreatic diversion with sleeve gastretomy”. You’ve got the idea of the Sleeve Gastrectomy above – so this procedure involves having 85% of the stomach removed. Then you get clear direction on what is planned for your small intestine. The procedure makes a new pathway from the end of the new small stomach to the colon (also known as the large intestine). The colon is where food should end up after digestion and from there it is evacuated from the body as faeces. In this procedure, food bypasses the majority of the small intestine (the duodenum particularly), which limits the amount of food that can be absorbed.
– Stomach Stapling used to be quite common – this involves pretty much stapling the stomach (as if you were stapling paper, to give you the imagery) so that the stomach is made smaller. It is simply less favoured now and the bypass and band options are preferred instead, having similar and apparently safer outcomes to stapling. Staples had an unfortunate habit of becoming infected or tearing another part of the person’s inside and causing internal bleeding etc. I wouldn’t put a staple in my finger, so why would we think putting a few inside our body is a good idea?!
And those are pretty much the surgical options available under the term ‘bariatric surgery’.
How are they supposed to work?
1) A Gastric Bypass has a pretty direct way of making the person consume less food than is needed for energy and health (and that’s the right way to describe what’s happening – the individual will have insufficient energy and nutrition from food permanently after the operation). One of the private weight loss surgery information sites says “Over-eating causes abdominal discomfort and vomiting.” You may still feel like overeating (most likely you will), but, if you do so, you will regret it very quickly and violently.
Some people become scared to eat and this will be quite an effective way of losing weight, health and energy from that point onwards. For others, the temptation and cravings are too great and they do try to eat their craved foods and they will feel terrible very quickly. Many will put up with feeling so ill because of the power that their fix has over them.
2) A Gastric Band works literally by making the stomach so small that the person can hardly eat anything before they feel full (very temporarily). If they eat more than the tiny area above the band can hold they are likely to be sick and throw back up the food that they have tried to eat.
This is a pretty drastic way of trying to get people to eat less.
3) A Gastric Balloon is intended to work in a similar way to the Gastric Band – by making the stomach area smaller so that the person feels full sooner and stops eating. (Yeah, right, again!) The person will also feel sick and will actually vomit if they eat ‘too much’.
The literature for Gastric Bypasses and Bands admits that mal-absorption of vitamins and minerals is a problem (that’s a bit of an understatement) and that people need to take vitamin supplements and be regularly tested for anaemia and that iron, B12 and calcium deficiency are especially common. All fat soluble vitamins are likely to be compromised – vitamins A, D, E and K – just as they are when Orlistat/Alli/Xencial is taken in tablet form to try to stop fat being absorbed by the body. Messing around with the entire digestive system has a similar disruption to the body’s ability to be able to absorb fat.
The National Obesity Forum produced a booklet, written by Dr David Haslam, Colin Waine and Anthony R Leeds. At the end of the booklet, Haslam declared an interest as a consultant for Lighter Life and Leeds declared an interest as an employed medical director for the Cambridge Diet. The booklet was funded by the Cambridge Diet. This is a conflict of interest as liquid only diets are advised for a couple of weeks before surgery and many people will find they can only consume liquid diets for a period of time after the surgery.
The bit that is interesting to note in this booklet is the admission: “The risk of complications is dependent on the nature of the surgery and the degree of bypass… All are likely to develop vitamin B12 and iron deficiency. Many UK patients have low or deficient vitamin D status pre-operatively due to low exposure to sunlight, low dietary intake and effects of their previous experience of weight loss regimens. Vitamin D status and bone health therefore need to be watched. Serum trace elements such as Zinc, Selenium and Copper levels have been shown to fall in the majority of patients post-bariatric surgery.”(my emphasis)
There are so many interesting comments to make about just this short passage:
a) Note the admission that vitamin D intake in the UK is deficient and the admission that diet has played a part in this. What are the best sources of vitamin D? Eggs and dairy foods. So dieticians tell us to avoid eggs and have low fat dairy foods (when fat soluble vitamins, like vitamin D, need fat to accompany the vitamin or it is pretty useless);
b) Note that word “All” – I added the emphasis – not the authors. All bariatric surgery patients are likely to develop vitamin B12 and iron deficiency. What does that mean? Anaemic, extreme tiredness, pale skin, low energy, palpitations, breathlessness, pins & needles, confusion, depression, poor concentration and so on. And that’s just 1 vitamin and 1 mineral. There are 13 vitamins and c. 16 minerals that will be seriously affected by effectively removing the ability to absorb nutrients vital for life.
c) How would we like selenium deficiency? It can cause heart arrhythmias and loss of heart tissue, deterioration of muscle tissue, muscle pain and weakness etc. Or maybe zinc deficiency? Dandruff, eczema and hair loss if we’re lucky and inflammatory bowel disease, growth retardation, pre-eclampsia (serious complication in pregnancy) and loss of sex drive if we are not so lucky.
We talk and act as if vitamins and minerals are optional and it doesn’t matter if we take away the body’s ability to absorb them. Vitamin comes from the Latin word “vita” meaning life. They are literally life or death substances.
Risks and side effects:
What are the risks and side effects of the most common procedures: Gastric Bypass and Gastric Banding?
1) Nutritional deficiencies (and all the minor and serious and even life threatening conditions that come with deficiencies in any individual vitamin and mineral) are not risks – they are virtually guaranteed. The ‘prescription’ following gastric bypass is “lifelong vitamin supplementation required.”
2) The post-operative information, which can be found on private surgery web sites, has a number of FAQ’s. Here are a couple of the most Frequently Asked Questions:
Q Will I lose my hair after surgery?
A) Yes there is a possibility
Q) Will I have baggy skin or stretch marks?
A) Unfortunately you are likely to be left with a large amount of loose skin.
Q) Will I lose weight straight away?
A) Following a bypass you can expect to lose a stone a month for the first year. Following banding a loss of 3kg per month is normal. (My comment – this is hardly different to what calorie counting promises, but doesn’t deliver. Weight regain is documented to occur in 98% of cases following calorie deficit diets (Stunkard & McLaren-Hume 1959). Whether the person manages to eat less/do more through willpower, or because they have had surgery, matters little. The only difference being that the gastric options make it less possible for people to eat the fuel that they actually need – because they will be sick and/or ill if they do).
3) The ‘complications’ list for Gastric Bypass includes: infection (an estimated 1 in 20 patients); internal bleeding (an estimated 1 in 50 patients); leakage from stapled sites (one of the biggest causes of fatalities resulting from the surgery); blood clots; deep vein thrombosis (DVT); breathing difficulties; pain; vitamin and mineral deficiencies (they’re a given); heartburn and bowl obstruction. The private weight loss surgery sites themselves admit that about 1 in 50 patients need corrective surgery because something has gone wrong.
I’ve got a 1 in 14 million chance of winning the lottery and I still think it might happen – I’m not sure a 1 in 50 chance of internal bleeding is worth gambling on. The ‘complications’ list for Gastric Banding includes: band slipping/twisting and stomach obstruction; infection; erosion into stomach and injury to stomach and nearby organs.
4) There are then what the patient may consider to be complications: not being able to eat normally; serious bodily responses if they succumb to a binge (even a ‘small’ one); not being able to join in at family meal functions and celebrations; feeling hungry all the time; having to eat little and often and all the blood sugar swings that go with this; having little or no energy, as you can no longer put fuel in your petrol tank in effect; stomach pain and all the health complications that go with just not feeling well and nourished.
5) Life may never be the same again. When I first saw this headline I thought “there’s just no pleasing some people”. If you read the whole story and not just the headline, it is quite upsetting. Tim Daily can no longer eat any solid food. He is literally wasting away and is suffering from malnutrition and is now fed through a tube into what is left of his stomach. If he does eat any actual food the pain is so excruciating he needs to take morphine.
This has literally ruined the man’s life and I suspect he will be dead in a few years from effective starvation. He has a one in four chance of death if he tries to have corrective surgery. That is one heck of a rock and a hard place and one heck of a ‘side effect’ .
6) Finally death itself. Some private web sites promoting bariatric surgery will admit that death rates for Gastric Bypass operations are 1 in 200. Try 1 in 50 said a CBS report into a Washington study. One of the most comprehensive reviews that I found was in the Journal of the American Medical Association (2005) – an extremely prestigious journal. This article found that, from a total of 16,155 patients who underwent bariatric procedures (mean age, 47.7 years; 75.8% women), the rates of 30-day, 90-day, and 1-year mortality were 2.0%, 2.8%, and 4.6%, respectively. Men had higher rates of early death than women (3.7% vs. 1.5%, 4.8% vs. 2.1%, and 7.5% vs. 3.7% at 30 days, 90 days, and 1 year, respectively). Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% vs. 1.7% at 30 days, 6.9% vs. 2.3% at 90 days, and 11.1% vs. 3.9% at 1 year). So, according to this study, up to 11% of patients for ’stomach’ surgery weight loss operations are dead within a year.
My view on bariatric surgery:
You can probably tell that I am not a fan and these are the main reasons why:
1) The most important one is that it is not necessary. I am shocked at the idea that we would rather remove 85% of someone’s stomach, than have people return to eating what we used to eat before we became so obese that we needed to invent bariatric surgery. There is another option, which can be used as a first resort as well as a last. It is healthy and is likely to lead to lost weight and gained health. However, I am considered radical for suggesting it. Surgeons who want to remove our digestive systems are welcomed onto the breakfast TV sofa and I am ostracised for daring to suggest that we just need to eat real food, as provided by nature. The excuse given will be that nature is ‘out to get us’ and put real, essential, fats in real meat, fish and eggs with the intention of killing us and so we must not eat what nature provides – we must eat what food manufacturers provide instead. You would not think that humans would be so stupid as to believe this, but, when PepsiCo alone is worth $44 billion and is larger than 60% of the countries of the world (comparing revenue with GDP) – there is no place for truth. There is no money to be made pushing Mother Nature’s natural products. The profit to be made by food & drink companies, pharmaceutical companies and/or bariatric surgeons is the real issue here.
The first/last resort should not be surgery. The first resort should be 1) eat real food 2) three times a day and 3) manage carb intake to manage weight. The last resort should be to take these 3 rules to the extreme of a virtually ‘zero’ carb diet. Then the body cannot store fat and it has to use its own fat for fuel. My recommendation would be the best of Harcombe/Atkins. “Only eat real food” (Harcombe) has to be the fundamental guiding principle for any healthy eating/weight loss plan and then the very low carb/ketosis principle of Atkins is a very useful one, which we have known about for over 150 years (since Banting et al).
Hence – the last resort should be to eat unlimited real meat and eggs from grass reared animals (nothing processed); real fish (meat, eggs and fish can be cooked in butter, lard or olive oil) and then 20 grams of carbohydrate a day. The carb intake can include dairy from grass reared animals, vegetables (not potatoes) and salads, but there will be no room for fruit, whole grains or large portions of dairy.
People would be better off using the carb allowance for green vegetables and salads (this would approximate to one coffee mug of green veg/salad at each of two main meals and the third meal would be carb free – (non-processed) bacon & eggs for example). This will just make meals feel more ‘normal’ and filling. There is no need to be hungry, no need to suffer ill health, vitamin or mineral deficiency, no need to be low energy (it may take a while for the body to get used to using fat for fuel and not carbohydrate) and there is no need to die from having your entire digestive system completely compromised. Surely that is a far better ‘last resort’?
2) Another issue I have with bariatric surgery is that it fundamentally believes in the ‘eat less’ principle (the person won’t be able to do more as they will have no energy). Everything we know about ‘eat less’ studies – the 80 studies from the outstanding review (Franz et al 2007) in that famous chart in the club ( http://www.theharcombedietclub.com/forum/showthread.php?1686-The-evidence-for-low-calorie-diets&highlight=franz) – says that the weight returns and the body will continually adjust to lower calorie intake. All the evidence for the past 100 years also supports this.
You will find many studies on line and I have come across clients who have had surgical procedures only to regain the weight. I give an example in “The Obesity Epidemic” book of a man I sat next to at dinner at an obesity conference. He had had a Gastric Bypass and had lost a reasonable amount of weight (never got a BMI below 30, so stayed technically obese). He was steadily regaining the weight when I met him.
One of the main reasons for this is that, after bariatric surgery, people are invariably only able to digest the things that we avoid. He could eat bread, potatoes and the pudding quite easily – he couldn’t digest the lamb and no doubt fish would also have been problematic. People who have had surgery will be living on carbs, little and often, continuously throughout the day and will be horribly hungry and their likelihood of developing type 2 diabetes must be high.
3) The third point that I would like to make about bariatric surgery (and many supporters of these operations make this point also) is that it does nothing to change the underlying problem that caused the obesity in the first place. It does not give people the understanding about food addiction and cravings that we have. It does not address the mind games and emotional connections with food that we have made. The poor person who has their stomach reduced to the size of an egg will still have all the food addiction and immense cravings that we all know only too well. Can you imagine having that incredible desire to eat and knowing that you would feel horribly physically ill if you gave in to it?
There is a term called ‘dumping’ used to describe a situation that people who have had bariatric surgery can experience. If you have ever fainted and had that most indescribably awful feeling when you come round (your blood sugar is on the floor; you feel sick/nauseous; hot and cold; you feel an urgent need to poo; you feel like you have died or wish you had – I faint at blood tests most times and I know this dreadful feeling only too well). If someone who has had bariatric surgery eats a small bar of confectionery they may well experience all of this and then some. That would terrify me on a daily basis.
Contrary to commonly held beliefs, people who have bariatric surgery rarely reach normal weight. They are lucky to even get into the overweight category and regain is likely.
The final point should not need stating, but clearly does, as the bariatric surgeons will be at pains to play this down. How can I support the mutilation of the human body? (the definition of mutilation is to deprive one of a limb or essential body part – I would consider my digestive system fairly essential). Do we have any idea of the long term effects of bariatric surgery? Dr Natasha Campbell McBride, a world authority on the gut, calls the gut “our second brain”. What would she say about effectively removing our second brain? If mutilation really were the last resort then maybe we would have no alternative but to consider this option – but we are far from at that point yet.