Bariatric Surgery: A Treatment, Not a Cure, for Obesity




“If you go with the flow in America today,” says Thomas Frieden, M.D., director of the Centers for Disease Control and Prevention, “you will end up overweight or obese.”

Frieden hits on the crux of the issue when it comes to excess body weight. It’s not just that we eat too much and don’t get enough exercise. Urban design and our car culture, desk-bound jobs and nonphysical leisure pursuits all lead us to be about as active as the elderly or infirm. Making things worse, the marketing of convenience food reinforces the general idea that no one with any kind of a life today would take the time to cook a meal. Food marketers want you to believe you are limited to microwave or order-in or eat-out foods because to actually spend 15 minutes assembling six or eight healthy ingredients (lower in fat, salt and sugar) is simply unthinkable.

That’s the flow in the developed world. It is a river that leads to a single consequence: obesity. Now considered itself a disease, obesity contributes significantly to higher rates of diabetes and heart disease and a higher mortality rate with certain cancers.

So what’s the solution? After the problem was determined to be untreatable — “diet and exercise just don’t work” — hundreds of thousands of people resorted to bariatric surgery. The procedure costs about $30,000 and eliminates the patient’s ability to eat more than a teacup of food at any sitting.

Is this radical surgical procedure inevitable for increasing numbers of people? As higher rates of obesity arrive in future years, will more and more people choose to have their digestive systems permanently altered?

Bariatric surgery: the facts

The original concept of bariatric surgery is for persons who are dangerously overweight, often referred to as “morbidly obese.” The surgery is meant to be lifesaving and is based on a simple idea: Reduce the size of the stomach such that the individual can ingest only small amounts of food at any one time.

While there are multiple approaches to this method of weight loss, two methods are used most often. Gastric banding (“lap band”) uses a silicone device to restrict the size of the stomach; it is reversible through removal of the band; however owing to several factors (including higher rates of infection and product failure), it is used much less frequently than the second method. Sleeve gastrectomy (“stomach stapling”), more commonly used, reduces the size of the stomach by about 85 percent. It is irreversible.

Both procedures are effective at dramatic weight loss. The Obesity Society, a professional membership, nonprofit organization, states that bariatric surgery “clearly is the most effective treatment for persons with extreme obesity who have failed to lose weight using less intensive interventions.” Of note, the Society lobbies for accreditation of bariatric surgery centers, in part because there has been a high rate of complications and even deaths associated with both procedures. The implication is that some surgery centers are operating at lower levels of competency.

Nonetheless, bariatric surgery is effective for the vast majority of patients. Some simple facts from peer-reviewed research conducted in the United States, Europe and Australia follow:

  • Mortality rate is now 2 percent of procedures. In other words, about 1 out of every 500 people receiving the procedure dies as a result.
  • In 2008 about 220,000 people underwent bariatric surgery, twice the number for 2002.
  • The number of obese teenagers getting the procedure (which is controversial but meets medical guidelines) doubled between the years 2000 and 2003.
  • On average, patients who undergo bariatric surgery can expect to lose 30 to 50 percent of excess body weight over 6 to 18 months following the procedure. The literature does not state that the loss is solely of adipose tissue (fat); rather, it may include some reduction of muscle tissue as well.
  • Type 2 diabetes disappeared in 22 out of 29 patients who took part in a landmark Australian study in 2008.
  • Minor complications (gastric dumping syndrome, which includes bloating and diarrhea; internal leaking; infections and pneumonia) affect 30 percent of patients.
  • More severe complications (bleeding, blood clots, bowel blockage, incisional hernias) occur in 3 percent of patients.
  • About 10 percent of patients experience unsatisfactory weight loss or regain the weight over time, largely by eating high-calorie/high-fat foods.

Of note, while stomach volume is reduced, it does not signal individuals to eat particular types of food. They might fill that teacup space with broccoli, or ice cream, or whatever they choose (after a period of adjustment, when pureed and liquid foods are eaten). Consuming excess amounts of food induces nausea and vomiting. Nutritional deficiencies are often evident, as seen in the high rate of hair loss in the first year after undergoing the operation.

The medicalization of health

Studies on postoperative success* with bariatric surgery very clearly show a reduced mortality rate for the morbidly obese. In very severe cases it works as a lifesaving technique. But the fact that obese individuals, particularly younger patients, are now using it as a weight loss strategy suggests a slippery slope. It fits the idea that medicine is the path to health, which is disturbing to many who subscribe to other points of view, that lifestyle behaviors are the first line of defense against disease.

Surgery advocates such as Marc Ambinder, a political writer for The Atlantic magazine who himself underwent bariatric surgery in 2009, takes a nuanced view. He lost 85 pounds (down from 235 pounds), and his diabetes disappeared. He acknowledges that because many insurance companies refuse to consider footing the bill for the procedure, it is largely a tool of the middle and upper classes, perhaps missing the people who may need it the most. He says that attempts to diet and exercise didn’t work for him, and he thinks that the high failure rate of diets in general spell an inevitable need for an increasing use of medical approaches in the future.
Ambinder is someone who knows how life was as an exceptionally overweight person and now is experiencing it as a normal-weight individual. He understands the stigma an obese person faces and says such attitudes are misplaced. He thinks the manufacturers of sugary cereals sold to children, and other high-fat, high-calorie fare everywhere else, should instead be the targets of scorn. It is hard to disagree with that.

But the causes of obesity, as well as its cures, are many and varied. It would be wrong if the inexorable flow of our sedentary, bad-diet society were toward the operating room. And yet it’s easy to see how it — we — may just end up there.
* L. Sjöström, K. Narbro, C. D. Sjöström, et al., “Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects,” N. Engl. J. Med. 357, no. 8 (2007): 741-752. doi:10.1056/NEJMoa066254. PMID 17715408.
T. D. Adams, R. E. Gress, S. C. Smith, et al., “Long-Term Mortality after Gastric Bypass Surgery,” N. Engl. J. Med. 357, no. 8 (2007): 753-761. doi:10.1056/NEJMoa066603. PMID 17715409.
Paul E. O’Brien, John B. Dixon, Cheryl Laurie, et al., “Treatment of Mild to Moderate Obesity with Laparoscopic Adjustable Gastric Banding or an Intensive Medical Program,” Annals of Internal Medicine 144 (2006): 625-643.