Obesity as a chronic disease can be compared to diabetes. Medication will not cure it, and if stopped in a well-controlled patient, the disease will deteriorate. Bariatric surgery is not only the most effective weight loss treatment to date, but also resets the metabolic system. This makes surgery the most powerful treatment for obesity regarding maintenance of weight loss and improvement or cure of obesity-related diseases, such as Type 2 diabetes, cardiovascular diseases including hypertension and high cholesterol, obstructive sleep apnoea syndrome, osteoarthritis, fatty liver disease or polycystic ovarian syndrome.
Among the 800 million adults currently living with obesity, and the number still growing, bariatric surgery is not a first-line treatment option. The standard way people with obesity start their weight loss journey is with a variety of consecutive diets, mostly unsuccessful in the long term and eventually resulting in more weight gain. One of the reasons behind this collective failure of diets has an evolutionary origin; the body fights weight loss to prevent starvation. This same pattern has been used ineffectively for decades, until now.
The power of digital therapeutics
Technology-assisted healthcare aids people in the most important factor in any weight loss treatment, which is understanding their disease process and making sustainable lifestyle changes. These include a healthy diet, daily exercise, good sleep hygiene and mental well-being. GluCare.Health, for example, uses new technologies and Remote Continuous Data Monitoring (RCDM) to help the team understand patients’ individual response to food better and its effect on their weight and chronic disease management.
The monitoring of new digital biomarkers adds a new dimension to motivational coaching, breaking unsuccessful traditional weight loss practices. Under this platform, engagement with patients is continuous. This model is different from traditional, episodic care where engagement stops the minute the patient leaves the healthcare facility. It is well-documented that increased engagement along with the monitoring of personal data leads to significantly better outcomes when it comes to weight loss post-surgery. Our programme is centred around behavioural change over 12 months. This approach significantly increases the success rate of sustained weight loss.
As part of the continuous model of care, patients are equipped with wearables, continuous glucose monitors, and smart weight scales to monitor individualised parameters such as glucose, actigraphy and sleep.
Evaluating patients
The question is which patients qualify for bariatric surgery? There are international criteria developed by healthcare professionals and regulators. A body mass index (BMI) over 40 kg/m2, a BMI between 35-40 kg/m2 with at least one obesity related disease or a BMI 30-35 kg/m2 with uncontrolled diabetes qualify for surgery. In Dubai people with obesity also qualify for surgery with a BMI 30-35 kg/m2 If there are two or more obesity related diseases.
More important, the decision to offer bariatric surgery to a person living with obesity should be made in a multidisciplinary setting where all treatment modalities are offered. When indicated, bariatric surgery should not be unnecessarily delayed by diets and other treatment modalities, as obesity has a significant impact on quality of life. In addition, bariatric surgery has a very strong impact on the prevention and improvement, or cure of related diseases. The positive effect on Type 2 diabetes, for example, is not only because of weight loss, but after surgery patients immediately show improvement of insulin resistance reflected by an immediate reduction or even cessation of their anti-diabetic medication.
The type of surgery that should be performed is also based on individual choice. In general, surgeries can be divided into restrictive (reducing the food intake) or malabsorptive (reducing the food uptake) or a combination of both. A mainstream restrictive procedure is a gastric sleeve resection where around 70 per cent, of the stomach is removed creating a tube-like vessel. Additionally, there is a positive effect on metabolism reflected by the improvement or cure of obesity related diseases as mentioned before.
Types of bariatric surgeries
Previously, adjustable gastric banding, putting a band around the upper part of the stomach that can be adjusted via a connected reservoir under the skin, was hugely popular. This is used to increase or decrease the diameter of the band and so influencing the degree of restriction. Nowadays the procedure is infrequently performed because of disappointing long-term results.
Another mainstream surgery is gastric bypass (GB), a more metabolic rather than restrictive type of surgery. A small pouch of the upper part of the stomach is created by dividing it from the rest of the stomach. Next the pouch is reconnected to the small intestine. The small intestine is only bypassed for a small portion creating the metabolic effect but not malabsorption. The way the small intestine is reconnected results in a standard gastric bypass (Roux-en Y GB, 2 connections) or one anastomosis gastric bypass (Mini GB, 1 connection).
Finally pure malabsorptive procedures in which a large portion of the small intestine is bypassed (such as biliopancreatic diversion with duodenal Switch (BPD-DS) or single anastomosis duodeno-ileal bypass (SADI) should be performed with care as the risk of malnutrition and severe deficiencies are significantly higher than the previously mentioned procedures. Repeat surgeries for weight regain or complications, after previous bariatric surgeries, are an option but should be performed only in experienced settings with the same multidisciplinary pre- and postoperative follow up and lifestyle coaching.
Nowadays bariatric surgeries are performed in a laparoscopic procedure (keyhole surgery) with advanced anaesthesiology techniques enabling early recovery and reduction of complications. Most patients will start oral intake of liquids immediately once fully awake from anesthesia and stay one night in the hospital. Early mobilisation promotes early recovery, after surgery lifelong supplementation of multivitamins and calcium is recommended to prevent deficiencies and weight regain.
Debunking misconceptions
There are several misconceptions about bariatric surgery. One misconception is that it is dangerous. The risk of a major complication (like a bleed or leak) or even death is extremely low; less than 1 per cent and less than 0.1 per cent respectively. For example, a surgery to remove the gallbladder carries the same risk of death and this is considered a routine surgery.
If one balances the risk of bariatric surgery versus the risk of obesity and its related diseases, bariatric surgery is justified. Another misconception is that the surgery should be reversible. As mentioned before, obesity is a chronic disease and treatment should be lifelong. Technically, gastric bypass is reversible, but this is done in exceptional cases of too much weight loss or malnutrition or if complications necessitate reversal. Sleeve gastrectomy is not reversible, as part of the stomach is removed.
One other misconception is that surgery will change one’s lifestyle. Bariatric surgery is a strong tool to lose weight but if lifestyle is not changed or people fall back into old bad habits, patients will regain weight as the body adapts to the new internal situation. Therefore, the process of lifestyle change should be started before the surgery and continued after. The programme at GluCare Health begins before surgery and continues for long afterwards. This lifelong follow up by expert teams is highly recommended to sustain lifestyle changes and prevent vitamin and mineral deficiencies and weight regain.
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Bart A. van Wagensveld, MD, PhD is a Consultant General, Laparoscopic and Bariatric Surgeon at
GluCare integrated Diabetes Center, Dubai
