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.

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Why this blog?

Bild 2013-05-31 kl. 09.27 #2

I guess it’s part excitement and part frustration behind my decision to start communicating much more directly with real people interested in obesity and weight loss, and not just other academics and media. Let’s start with the frustration and then round off with the happy bits.

The lack of progress in both prevention and treatment outcomes is quite frankly staggering. Sure, the epidemic appears to be slowing down in more affluent segments of the population, but it is still more or less a runaway train in poorer areas of the US and Europe, and this also goes for countries in the middle of the nutrition transition, such as China and India. There are in fact very few places in the world where the epidemic is not doing very well. This is a public health failure of monumental proportions.

Despite this, most of the obesity experts continue to advocate more of the same tired old strategies, i.e. increased dietary control and exercise, and the outcomes are very predictable: more failure.

Then the experts seemingly got desperate and started to drastically scale up the use of bariatric surgery with minimal follow-up afterwards, as a kind of advanced quick fix. This very large increase in bariatric surgery volumes is a bomb waiting to explode if you ask me, since the safety of such drastic procedures are far from fully understood. A review I am working on with former student Filippa Juul has so far identified 32 separate nutritional deficiencies after bariatric surgery, some of them quite serious. And this is just one type of safety concern.

Another major source of frustration is the almost total lack of balance in the media. Every day they keep pumping out the same tired fad diets, or similarly ineffective measures. And on the next page you can read up on recipes for all kinds cakes and sweets, complete with glossy photographs and smiling photoshopped models. It’s quite absurd, but we apparently fall for it, and so they keep doing it.

The media is nothing if not cynical when it comes to weight loss, and it has now basically gotten to the point where public health nutrition and lifestyle advice is largely controlled by the media. These are some of the biggest frustrations for me as an obesity academic.

So, what are the happy bits? Well, just over a year ago, I started to become very interested in some of the deeper underlying psychological and emotional reasons behind overweight and obesity. And what I have discovered so far has got me pretty excited. I guess I feel a little like Howard Carter when he was exploring the unknown parts of the pyramids.

If you are anxious to read more in-depth information right now you can read a conceptual review paper I just published (Hemmingsson E. A new model of the role of psychological and emotional distress in promoting obesity: conceptual review with implications for treatment and prevention. Obesity Reviews, 2014, epub 16 June).

I am expecting to publish many posts on the topics covered in the review, for example how the very earliest years of our lives continue to affect our health as adults. I genuinely think that this type of information can be a concrete help for anyone wanting to lose weight permanently.

I actually think we are getting close to a genuine breakthrough in how we help people lose weight that actually works long term, and also in terms of preventing new cases of overweight and obesity. Sure, much more research needs to happen before the epidemic is confined to the history books. And that is why I go to work each day. Stay tuned of you want to find out more.

 

Sincerely,

Erik Hemmingsson