Weight loss surgery reduces the risk of premature death, especially from such obesity-related conditions as cancer, diabetes and heart disease, according to a new 40-year study of nearly 22,000 people who had bariatric surgery in Utah.
Compared with those of similar weight, people who underwent one of four types of weight loss surgery were 16 per cent less likely to die from any cause, the study found. The drop in deaths from diseases triggered by obesity, such as heart disease, cancer and diabetes, was even more dramatic.
"Deaths from cardiovascular disease decreased by 29 per cent, while deaths from various cancers decreased by 43 per cent, which is pretty impressive," said lead author Ted Adams, an adjunct associate professor in nutrition and integrative physiology at the University of Utah's School of Medicine.
"There was also a huge percentage drop — a 72 per cent decline — in deaths related to diabetes in people who had surgery compared to those who did not," he said. One significant downside: The study also found younger people who had the surgery were at higher risk for suicide.
SUPPORTS EARLIER RESEARCH
The study, published Wednesday in the journal Obesity, reinforces similar findings from earlier research, including a 10-year study in Sweden that found significant reductions in premature deaths, said Dr. Eduardo Grunvald, a professor of medicine and medical director of the weight management program at the University of California San Diego Health.
The Swedish study also found a significant number of people were in remission from diabetes at both two years and 10 years after surgery.
"This new research from Utah is more evidence that people who undergo these procedures have positive, beneficial long-term outcomes," said Grunvald, who coauthored the American Gastroenterological Association's new guidelines on obesity treatment.
The association strongly recommends patients with obesity use recently approved weight loss medications or surgery paired with lifestyle changes.
"And the key for patients is to know that changing your diet becomes more natural, more easy to do after you have bariatric surgery or take the new weight loss medications," said Grunvald, who was not involved in the Utah study.
"While we don't yet fully understand why, these interventions actually change the chemistry in your brain, making it much easier to change your diet afterwards."
Despite the benefits though, only 2 per cent of patients who are eligible for bariatric surgery ever get it, often due to the stigma about obesity, said Dr. Caroline Apovian, a professor of medicine at Harvard Medical School and codirector of the Center for Weight Management and Wellness at Brigham and Women's Hospital in Boston. Apovian was the lead author for the Endocrine Society's clinical practice guidelines for the pharmacological management of obesity.
Insurance carriers typically cover the cost of surgery for people over 18 with a body mass index of 40 or higher, or a BMI of 35 if the patient also has a related condition such as diabetes or high blood pressure, she said.
"I see patients with a BMI of 50, and invariably I will say, 'You're a candidate for everything — medication, diet, exercise and surgery.' And many tell me, 'Don't talk to me about surgery. I don't want it.' They don't want a surgical solution to what society has told them is a failure of willpower," she said.
"We don't torture people who have heart disease: 'Oh, it's because you ate all that fast food.' We don't torture people with diabetes: 'Oh, it's because you ate all that cake.' We tell them they have a disease, and we treat it. Obesity is a disease, too, yet we torture people with obesity by telling them it's their fault."
BOTH MEN AND WOMEN CAN BENEFIT
Most of the people who choose bariatric surgery — around 80 per cent— are women, Adams said. One of the strengths of the new study, he said, was the inclusion of men who had undergone the procedure.
"For all-causes of death, the mortality was reduced by 14 per cent for females and by 21 per cent for males," Adams said. In addition, deaths from related causes, such as heart attack, cancer and diabetes, was 24 per cent lower for females and 22 per cent lower for males who underwent surgery compared with those who did not, he said.
Four types of surgery performed between 1982 and 2018 were examined in the study: gastric bypass, gastric banding, gastric sleeve and duodenal switch.
Gastric bypass, developed in the late 1960s, creates a small pouch near the top of the stomach. A part of the small intestine is brought up and attached to that point, bypassing most of the stomach and the duodenum, the first part of the small intestine.
In gastric banding, an elastic band that can be tightened or loosened is placed around the top portion of the stomach, thus restricting the volume of food entering the stomach cavity. Because gastric banding is not as successful in creating long-term weight loss, the procedure "is not as popular today," Adams said.
"The gastric sleeve is a procedure where essentially about two-thirds of the stomach is removed laparoscopically," he said. "It takes less time to perform, and food still passes through the much-smaller stomach. It's become a very popular option."
The duodenal switch is typically reserved for patients who have a high BMI, Adams added. It's a complicated procedure that combines a sleeve gastrectomy with an intestinal bypass, and is effective for type 2 diabetes, according to the Cleveland Clinic.
A SERIOUS COMPLICATION
One alarming finding of the new study was a 2.4 per cent increase in deaths by suicide, primarily among people who had bariatric surgery between the ages of 18 and 34.
"That's because they are told that life is going to be great after surgery or medication," said Joann Hendelman, clinical director of the National Alliance for Eating Disorders, a nonprofit advocacy group.
"All you have to do is lose weight, and people are going to want to hang out with you, people will want to be your friend, and your anxiety and depression are going to be gone," she said. "But that's not reality."
In addition, there are postoperative risks and side effects associated with bariatric surgery, such as nausea, vomiting, alcoholism, a potential failure to lose weight or even weight gain, said Susan Vibbert, an advocate at Project HEAL, which provides help for people struggling with eating disorders.
"How are we defining health in these scenarios? And is there another intervention — a weight neutral intervention?" Vibbert asked.
Past research has also shown an association between suicide risk and bariatric surgery, Grunvald said, but studies on the topic are not always able to determine a patient's mental history.
"Did the person opt for surgery because they had some unrealistic expectations or underlying psychological disorders that were not resolved after the surgery? Or is this a direct effect somehow of bariatric surgery? We can't answer that for sure," he said.
Intensive presurgery counseling is typically required for all who undergo the procedure, but it may not be enough, Apovian said. She lost her first bariatric surgery patient to suicide.
"She was older, in her 40s. She had surgery and lost 150 pounds. And then she put herself in front of a bus and died because she had underlying bipolar disorder she had been self-medicating with food," Apovian said. "We as a society use a lot of food to hide trauma. What we need in this country is more psychological counseling for everybody, not just for people who undergo bariatric surgery."
Managing weight is a unique process for each person, a mixture of genetics, culture, environment, social stigma and personal health, experts say. There is no one solution for all.
"First, we as a society must consider obesity as a disease, as a biological problem, not as a moral failing," Grunvald said. "That's my first piece of advice.
"And if you believe your life is going to benefit from treatment, then consider evidence-based treatment, which studies show are surgery or medications, if you haven't been able to successfully do it with lifestyle changes alone."
