There has got to be a better way

GaryLarson_2001

I have seen many times how bariatric surgery can help people with severe obesity have a better and healthier life, at least in the short term. The benefits of surgery over other methods such as diet and exercise programs are also quite clear – in the short term. Does this mean I support surgery over other methods? No, it most certainly does not.

Here are some of my personal issues I have with bariatric surgery. It has become clear that there are serious risks to your health involved with the surgery. Examples include increased risk of alcoholism, depression and many forms of malnutrition. There is also likely to be an increased risk of suicide. I think you will agree that these adverse events are quite serious, and these are just examples. If any type of drug or other form of treatment was associated with such serious risks, it would probably never be approved.

The majority of people and colleagues I speak with also appear to have this notion that surgery is the only method that does not lead to long-term weight regain. This is wrong. I would argue that the long-term effectiveness of bariatric surgery to maintain a very large weight loss is very poorly understood. The landmark publications on the effectiveness of surgery have mostly come from Sweden as it happens (the SOS study). Slightly less than 300 individuals underwent gastric bypass in this study but the follow-up of body weight development some 15 years later was only done in 13 individuals, i.e. less than 5% of all starters, meaning a dropout rate of 95%.

And when you do a study of this kind, who do you think drops out? Those who generally do worse of course. So, by now I hope you realize that there are some pretty dark clouds hanging over bariatric surgery, including a very large risk of weight regain. Indeed, many patients who have had the surgery are now coming back having regained all their weight loss. And yet bariatric surgery has increased exponentially in Sweden and elsewhere in the last 5 years: it went from about 2000 per year to 8000 within 2 years.

I understand that people are frustrated and need more effective methods than what we currently have in the non-surgical arena, but this does not mean that there is a license to go overboard with a very drastic method with serious safety issues. Moreover, we also know that there is minimal screening before surgery, for example of factors like drinking habits and mental health. But surely, you think, there must at least be a massive follow-up after surgery to make sure that the patients are all right, coping well and not malnourished? Unfortunately no, apart from a tiny minority of centers. Many patients are left more or less completely on their own.

So what do I mean by saying that there has got to be a better way? I mean it’s time we invested some time and effort into understanding more about what caused the weight gain to begin with – this is obviously unique to each individual – and then try to reverse the situation through much safer means. This is likely to include counseling, therapy, diet, exercise, stress management, mindfulness or whatever is needed to steady the ship.

Who knows what will happen to all those patients who suffer long-term damage after 10, 20 or 30 years down the line as a result of their surgery. And bear in mind that, if you do suffer adverse events, that this surgery is not easy to reverse.

Yes, I still think surgery is called for in extreme cases, but this calls for much enhanced screening and follow-up, not to mention many more long-term safety studies, including a proper intention-to-treat analysis of body weight. But the current thinking, at least here in Sweden, is to start operating younger and lighter individuals, even children.