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10/23/18

The Stronger U Journal Club: Bariatric Surgery

It’s that time of the month again, time for the Stronger U Journal Club! Our monthly chance to level up our nutrition knowledge through evidence-based means. This month we learned all about bariatric surgery. Dr. Jessica Bachman and Coach Karina Verespy both led us this month, combining their knowledge of research and real-world application for this often confusing topic.

What was the topic we learned about?

Bariatric surgery has become an increasingly common method of treating obesity. It typically works by reducing the size of the stomach (thereby reducing the amount of food the stomach can hold in any given meal) and/or causing malabsorption of nutrients. These alterations in turn impact gut hormones that encourage favorable changes in both satiety and metabolism.

This significant change in stomach volume and absorption rates also means that many people who undergo bariatric surgery will typically have very different food and hydration needs than those who haven’t undergone this surgery. They will need to eat significantly smaller meals on a daily basis, control their calorie intake more closely, and pay special attention to fluid intake.

Bariatric surgery can be broken down into three different types of procedures:

Roux-en-Y Gastric Bypass

Often considered the “gold standard” wherein a small piece of the top of the stomach is divided from the rest of the stomach, leaving the individual with a stomach that is 1oz, or 30mL in volume.  

This video provides a great example of how the procedure is done:

The downside to the Gastric Bypass is that this is a more complicated procedure than the other two forms of bariatric surgery—which can lead to longer hospital stays. On top of that, there is typically a requirement for lifelong supplementation to help combat vitamin and mineral deficiencies that are associated with this surgery.

Additionally, this procedure will typically require a high degree of adherence both leading up to the surgery, following, and for life afterwards—since the Gastric Bypass typically isn’t reversible.

 

Sleeve Gastrectomy

The sleeve gastrectomy involves removing roughly 80% of the stomach, significantly reducing the size of the stomach pouch, and in turn reducing the amount of food someone that has had this procedure can consume in any given meal.

The Sleeve Gastrectomy works similarly to the Gastric Bypass in that removing a significant portion of the stomach pouch helps to automatically control calorie intake. Additionally, shrinking the size of the stomach pouch in both procedures also shows positive impacts on gut hormones, which can help with satiety, metabolism, and weight management. The gastric sleeve is becoming more and more popular as weight loss and disease remission results tend to be very similar to Roux-en-Y, however, less of the gut is altered and there is an overall lower complication rate than Roux-en-Y procedures.

However, the downside to the Sleeve Gastrectomy is that it’s non-reversible and much like the Gastric Bypass, will typically involve long-term supplementation to help take care of vitamin and mineral deficiencies.

 

Adjustable Gastric Band

In this surgery, an adjustable band is placed around the top of the stomach, which creates a smaller stomach pouch and leaves the rest of the stomach below. The obvious benefit to this is that through the adjustable gastric band someone can get the same benefit of either a Gastric Bypass or a Sleeve Gastrectomy without having a piece of their gut completely removed or re-routed.

The major advantage to this is that it’s a less invasive procedure than either the Gastric Bypass or the Sleeve Gastrectomy, which means that people who receive this procedure typically have shorter hospital stays. Additionally, the band is adjustable, so over time, someone can continue to get their band adjusted as they adjust to a new lifestyle.

The major downside to the Adjustable Gastric Band is that there typically is a slower rate of weight loss, and in the limited research we do have in this area, it seems that fewer individuals who get this procedure reach the mark of 50% of excess body weight lost, post surgery—which is typically considered the benchmark for bariatric procedures.

Along with that, it is important to remember that there is a foreign device in the body and all of the complications that can come along with that. Such as erosion or slippage of the band.

Who is eligible for bariatric surgery?

To be eligible for the surgery, individuals typically need to meet the following criteria (although there can be variations by location):

  • BMI ≥ 40 or more than 100 pounds overweight
  • BMI ≥ 35 and at least one or more obesity-related comorbidities like:
    • Type II diabetes, hypertension, sleep apnea, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders or heart disease
  • Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts

What was the study we went over?

For the actual study that we went over as a group, we reviewed an observational cohort study from 10 US hospitals, with the purpose to describe eating behaviors and weight control behaviors on 3-year change in weight.

Who were the participants?

  • 2,458 adults who underwent Roux-en-Y Gastric Bypass (RYGB; n = 1738) or Laparoscopic Adjustable Gastric Band (LAGB; n = 610) surgery between March 2006 – April 2009
  • They all completed assessments pre-surgery, 6 months, 12 months and annually post surgery
  • They all lost substantial amounts of weight and kept it off 3 years post-surgery

What happened?

  • Those who received the RYGB had a mean weight loss 42kg (31.5% of baseline weight)
  • Those who received the LAGB had a mean weight loss 20kg (15.9% of baseline weight)
  • This study excluded
    • 36 people who had surgery reversed or revised
    • 25 women who became pregnant

What were other takeaways?

Through evaluating the behavioral questionnaires the study participants filled out, researchers were also able to come away with these takeaways about individuals who successfully underwent bariatric surgery and kept it off:

Those who started to:

  • Self-weigh weekly
  • Count grams of fat
  • Eat breakfast regularly
  • Eat 3 regular meals per day

Those who no longer:

  • Had problems with loss-of-control eating
  • Snacked between meals
  • Ate when full
  • Ate when not hungry
  • Ate continuously throughout the day
    • Assessed by the question “During the past 6 months, have you had times when you ate continuously during the day or parts of the day without planning what and how much you would eat?”

How can a Stronger U coach help?

Because there’s no way that I could answer all of this myself, Dr. Jessica Bachman answered this very question for us and here’s what she had to say:

“Some of the biggest challenges that individuals face after bariatric surgery are that they have to maintain a new lifestyle that may be drastically different than the one they led before. Food intake will be altered for life if results are to be maintained. Just like anyone else trying to make changes to their eating habits, individuals who have undergone previous bariatric surgeries can benefit from the expertise, support, and accountability that a coach can provide.

While most bariatric surgery centers do have follow up care for at least a few months post-surgery, that care does eventually end and most centers are not able to offer around the clock support like a Stronger U coach can. Need help approaching eating in your everyday life or how to handle an event, a restaurant meal or eating during the holidays? We can help you develop a plan that will honor the requirements based on your surgery and continue your progress towards your goals no matter how long ago that surgery was.”

What are the final takeaways?

Bariatric surgery is still new in terms of long-term research since the procedure itself didn’t actually gain real popularity until the 1970’s. But despite the relatively short period of time that we can actually study those who undergo bariatric surgery, we do know that the people who see the greatest success tend to:

  • Keep weekly track of their weight
  • Stopped eating when feeling full
  • Stopped eating continuously throughout the day

There’s no doubt that bariatric surgery is the right choice for a number of people to go through, and for a significant number of people, it has dramatically increased their quality and length of life. However, it’s always important to remember that this is a major surgery that will require a significant lifestyle change. There are still people who get bariatric surgery and don’t see the success that they hoped would come. As with all things, bariatric surgery in itself is not a cure-all.

 

Tanner Baze
Director of Content