Let's say you're trying to lose 20 pounds, or boost your immunity,
or increase your ability to fight COVID, or even cancer.
Well, the amazing thing is, with the right diet,
you're well on your way to achieving these vital health goals.
Welcome to the Nutrition Facts Podcast. I'm your host, Dr. Michael Greger.
Today, we have the first in a four- part series on bariatric surgery,
the most common of which are stomach stapling and gastric bypass,
and both of which involve change to one’s digestive anatomy.
So how safe are these procedures,
and how well do they work for weight loss?
Let’s find out.
The treatment of obesity has long been stained by the snake oil
swindling of profiteers, hustlers, and quacks.
Even the modern field of bariatric medicine
(derived from the Greek word baros meaning weight)
is pervaded by an “insidious image of sleaze.”
Beguiled by advertising for fairy tale magic bullets of rapid,
effortless weight loss, people blame themselves for failing
to manifest the miracle or imagine themselves metabolically broken.
On the other end of the spectrum are overly pessimistic practitioners
of the opinion that people who are fat are born fat,
and nothing can be done about it.
The truth lies somewhere in between.
The difficulty of curing obesity has been compared
to learning a foreign language.
It’s an achievement virtually anyone can attain
with a sufficient investment of energies,
but it always takes considerable time and effort.
And of those who do stick with it,
most will regain much of the weight lost.
To me this speaks to the difficulty, rather than the futility.
It may take smokers an average of 30 quit attempts
to finally kick the habit.
Like quitting smoking, it’s just something that has to be done.
As the Chair of the Association for the Study of Obesity put it,
it doesn’t take “willpower” to do essential tasks like getting up
at night to feed a baby; it’s just something that has to be done.
Our collective response doesn’t seem to match the rhetoric or reality.
If obesity is such a “national crisis” “reaching alarming proportions,”
dubbed by the post-9/11 Surgeon General as
“every bit as devastating as terrorism,”
why has our reaction been so tepid?
For example, governments meekly suggest the food industry take
“voluntary initiatives to restrict the marketing of
less healthy food options to children.”
Have we just given up and ceded control?
Our timid response to the obesity epidemic is encapsulated
by a national initiative promulgated by a Joint Task Force
of the American Society for Nutrition, Institute of Food Technologists,
and International Food Information Council:
the “small-changes approach.”
Since small changes are “more feasible,”
suggestions include “using mustard instead of mayonnaise”
and “eating 1 rather than 2 doughnuts in the morning.”
Seems a bit like bringing a butter knife to a gunfight,
but with only one croissant.
Proponents of the small- changes approach lament that
unlike other addictions—e.g. alcohol, cocaine, gambling, or tobacco—
we can’t counsel our obese patients to give up the addictive element
completely, as “no one can give up eating.”
But just because we have to eat, doesn’t mean we have to eat junk,
like just because we have to breathe, doesn’t mean
it has to be through the end of a cigarette.
What about bringing a scalpel to the gunfight instead?
The use of bariatric surgery has exploded from about 40,000 procedures
noted in the first international survey in 1998 to now
hundreds of thousands performed every year in the United States alone.
The first technique developed, the intestinal bypass,
involved carving out about 19 feet of intestines.
More than 30,000 intestinal bypass operations were performed
before “catastrophic,” “disastrous outcomes” were recognized,
including protein deficiency- induced liver disease,
which often progressed to liver failure and death.
This inauspicious start is remembered as
“one of the dark blots in the history of surgery.”
Today, death rates after bariatric surgery are considered “very low,”
occurring on average in perhaps 1 in 300 to 1 in 500 patients.
The most common procedure is stomach stapling, also known as
sleeve gastrectomy, in which most of the stomach is permanently removed.
Only a narrow tube of stomach is left, so as to restrict
how much food people can eat at any one time.
It’s ironic that many patients choose bariatric surgery
convinced that “diets don’t work” for them,
when in reality that’s all the surgery may be—an enforced diet.
Bariatric surgery can be thought of as a form of internal jaw wiring.
Gastric bypass, known as Roux-en-Y gastric bypass,
is the second most common bariatric surgery.
It combines restriction—stapling the stomach into a pouch
smaller than a golf ball— with malabsorption
by rearranging your anatomy
to bypass the first part of your small intestine.
It appears to be more effective than just cutting out most of the stomach.
It results in a loss of about 63% of excess weight
compared to 53% with a gastric sleeve.
But gastric bypass carries a greater risk of serious complications.
Many are surprised to learn that new surgical procedures
don’t require premarket testing or FDA approval
and are largely exempt from rigorous regulatory scrutiny.
In our next story we look at how the extent of risk
from bariatric weight-loss surgery may depend on the skill of the surgeon.
After sleeve gastrectomy and Roux-en-Y gastric bypass,
the third most common bariatric procedure is a revision
to fix a previous bariatric procedure.
Up to 25% of bariatric patients have to go back into the
operating room for problems caused by their first bariatric surgery.
And re-operations are riskier, carrying around 10 times
the mortality rate and offer no guarantee of success.
Complications include leaks, fistulas, ulcers, strictures,
erosions, obstructions, and severe acid reflux.
The extent of risk may depend on the skill of the surgeon.
In a study published in the New England Journal of Medicine,
bariatric surgeons voluntarily submitted videos of themselves
performing surgery to a panel of their peers for evaluation.
Technical proficiency varied widely and was related to the rates
of complications, hospital readmissions, re-operations, and death.
Patients operated on by the less competent surgeons suffered
nearly three times the complications and five times the risk of death.
As with athletes and musicians, some surgeons may simply be more
talented than others, but practice may help make perfect.
Gastric bypass is such a complicated procedure that the learning curve
may require 500 cases for a surgeon to master the procedure.
Complications risk plateaus after about 500 cases,
with the lowest risk found among surgeons
who’ve performed more than 600 bypasses.
The risk of not making it out alive may be double under the knife
of those who’ve done less than 75 compared to more than 450.
So, if you do choose to undergo the operation, I’d recommend
asking your surgeon how many procedures they’ve done,
as well as choosing an accredited bariatric “Center of Excellence,”
where surgical mortality appears to be two to three times lower
than non-accredited institutions.
It’s not always the surgeon’s fault, though.
In a report entitled “The Dangers of Broccoli,” a surgeon described
a case in which a woman went to an all-you-can-eat buffet
three months after a gastric bypass operation.
She chose really healthy foods (good for her!).
She just evidently forgot to chew.
Her staples blew, and she ended up in the ER and then the OR.
They opened her up, and found “full chunks of broccoli,
whole lima beans, and other green leafy vegetables”
inside her abdominal cavity.
A cautionary tale to be sure, but perhaps less about chewing food better
after surgery than about chewing better foods before surgery,
so you can keep all your internal organs intact in the first place.
Even if the surgical procedure goes perfectly,
lifelong nutritional replacement and monitoring are required
to avoid vitamin and mineral deficits.
This includes more than a little anemia, osteoporosis, or hair loss,
but full-blown cases of life- threatening deficiencies,
such as beriberi, pellagra, kwashiorkor, and nerve damage
that can manifest as vision loss years
or even decades after surgery in the case of copper deficiency.
Tragically, in cases of severe deficiency
of a B vitamin called thiamine,
nearly one in three patients progressed to permanent brain damage
before the condition was caught.
The malabsorption of nutrients is on purpose
for procedures like gastric bypass.
By cutting out segments of the intestines you can successfully
impair the absorption of calories, but at the expense
of impairing the absorption of necessary nutrition.
Even people who just undergo restrictive procedures like
stomach stapling can be at risk for life-threatening
nutrient deficiencies because of persistent vomiting.
Indeed, vomiting is reported by up to 60% of patients
after bariatric surgery due to “inappropriate” eating behaviors
(in other words, trying to eat normally).
The vomiting helps with weight loss similar to the way
a drug for alcoholics called Antabuse can be used to make them
so violently ill after a drink that they eventually can learn their lesson.
“Dumping syndrome” can work the same way.
A large percentage of gastric bypass patients can suffer
from abdominal pain, diarrhea, nausea, bloating, fatigue,
or palpitations after eating calorie-rich foods
as they bypass your stomach and dump straight into your intestines.
As surgeons describe it, this is a feature, not a bug:
“Dumping syndrome is an expected and desired part of
the behavior modiﬁcation caused by gastric bypass surgery;
it can deter patients from consuming energy-dense food.”
We would love it if you could share with us your stories
about reinventing your health through evidence-based nutrition.
Go to nutritionfacts.org/testimonials.
We may share it on our social media to help inspire others.
To see any graphs, charts, graphics, images, or studies mentioned here,
please go to the Nutrition Facts Podcast landing page.
There you’ll find all the detailed information you need –
plus links to all of the sources we cite for each of these topics.
For a vital, timely text on the pathogens that cause pandemics
you can order the e-book, audio book,
or hard copy of my latest book “How to Survive a Pandemic.”
For recipes, check out my “How Not to Diet Cookbook”.
Which is my latest-latest book.
It’s beautifully designed, with more than 100 recipes for delicious and nutritious meals.
All the proceeds I receive from the sales of all my books goes to charity.
NutritionFacts.org is a nonprofit, science-based public service,
where you can sign up for free daily updates
on the latest in nutrition research via bite-sized videos and articles.
Everything on the website is free.
There’s no ads, no corporate sponsorship.
It’s strictly non-commercial. I’m not selling anything.
I just put it up as a public service, as a labor of love,
as a tribute to my grandmother,
whose own life was saved with evidence-based nutrition.