Dr.Chirag Thakkar

Fight against Obesity: Respective roles of Bariatric (weight loss) surgery and Lifestyle Modification

Obesity is a complex disease. It is a difficult problem to understand and even more difficult to fight. For many patients, Bariatric (weight loss) surgery is the only solution for sustained weight loss. But only surgery is not enough. Lifestyle modification is needed for lifelong health. Here is a discussion about the respective roles of surgery and lifestyle modification in the fight against obesity.

Obesity is a complex disease. Complex to understand, occurs due to a complex interplay of multiple causes. Obesity causes a complex set of end-organ damage and is complex in its treatment. I would like to remind you that I am talking about obesity and not overweight.

To make it clear, overweight is the situation where your weight is above the ideal range but not too high. More objectively, overweight individuals have a BMI from 23 to 27.5. For all individuals of Asian origin, BMI > 27.5 is considered obesity. Surgery is not mandatory for all obese individuals. But weight loss surgery is the only option for a large section of obese patients. Why is it so and who will need surgery will follow further in the article. But even for all those who would need a surgery, only surgery is not enough. A healthy lifestyle is a non-negotiable component of an effective strategy to fight obesity. Why is it so and what a healthy lifestyle means is covered further in the article.

Why is Bariatic (weight loss) surgery necessary?

Surgery is necessary because only Bariatric surgery has to date shown a significant and sustained weight loss. The amount of weight loss required to get improvement in obesity related diseases. Obese individuals need to shed a large number of kilos to achieve any significant health benefit. Diet and exercise have failed to achieve these goals even in dedicated and committed individuals. The problem increases if you have knee or spine problems. Or if you have heart or lung condition limiting your exercise capacity. A few individuals, who somehow manage to lose weight are unable to maintain it. Most of these individuals gain back all those shed kilos in a few months. These individuals do not get the health benefits of weight loss.

Reasons for failure of diet and exercise

Our body has a mechanism that tries to maintain body weight even in periods of food scarcity. This ability has been gained as a part of evolution. In the past humans have faced times when the availability of food was not very certain. This happens by a change in the body’s metabolism, various hormonal and behavioral changes.

Now once a person has gained weight and is maintained for a certain period, the body’s metabolism is shifted to maintain that weight. The increased weight is updated as the new normal for that person. And the body’s metabolism itself fights with the person’s efforts to lose weight. Increased hunger, craving for high-calorie carbohydrate food, the feeling of weakness and giddiness with a more healthy diet, tiredness and feeling of lack of energy for physical activity are some of the behavioral patterns by which the body resists weight loss.

Many of the digestive hormones, which are deranged in an obese person are responsible for some of the above behavioral changes. For example, craving for food and giddiness on a normal healthy diet is not due to low blood sugar for low blood pressure. But it is due to an increase in certain digestive hormones including Insulin. And these changes make it difficult for a person to follow the lifestyle modifications that are needed to reduce weight and lead a healthy life.

Why surgery gives sustained weight loss?

Bariatric surgery, creates a long-lasting metabolic, hormonal as wells a behavioral change. This helps not only in weight loss but improves obesity-associated medical problems. It also helps a person to change his diet, physical activity levels and behavior. And thus leading to a healthier mind and body.

All this happens due to multiple changes in the gut secreted hormones and other chemicals. Some of them are also responsible for the improvement in medical problems like diabetes, fatty liver, lipid profile abnormalities. While some are responsible for some of the behavioral changes.

The behavioral changes mainly include decreased hunger and satiety with a small amount of food. There is also preferential change in the liking for healthier food and decreased craving for carbohydrates and sweets. Hormonal changes after bariatric surgery also lead to increased enthusiasm and energetic feeling. This is despite reduced food intake and continuing weight loss. It thus promotes increased levels of physical activity.

Reset the set point for body weight

In a way, we can say that bariatric surgery resets the disturbed metabolic balance of the body. Surgery not just reduces the weight loss, but improves the obesity-associated diseases, improves the behavioral pattern regarding diet and physical activity. Thus it helps achieve a healthier mind and body and ability to lead a healthier lifestyle.

Other factors that affects weight loss

With the above understanding, we also need to understand that each individual is different. Even with these behavioral changes after surgery, there are a large number of other factors that influence the outcome. These include permanent or irreversible damages affecting mobility and physical activity. Family support and the general lifestyle of the family and friends, that has a significant influence on one’s lifestyle. Any long term and significant psychological and behavioral problems that would need additional treatment. Also, the overall motivation of the individual and their commitment to lifestyle change and follow up. This is exactly what we have emphasized in the latter part of the article.

When is Bariatric (weight loss) surgery needed?

Obesity related medical problems

Surgery is the ideal option for those whose BMI is more than 37.5 even if they do not have any obesity associated medical problems. Surgery is also the treatment of choice for individuals having BMI>32.5 and Obesity related comorbidity. Obesity related comorbidities, means the diseases caused by Obesity include Diabetes, Hypertension, Cardiac problems, Acid reflux disease, NASH (Non alcoholic Steatohepatitis or Fatty Liver), Sleep apnoea and Asthma, Knee and spine problems, Infertility, etc. I know the list is long, but this is a fact.

Surgery is also very helpful for lower BMI obese individuals (BMI 27.5 to 32.5) with diabetes, especially if the diabetes is not well controlled with medical treatment. Surgery for the last mentioned indication is also called metabolic surgery. Metabolic surgery means, the surgery done mainly with the intent of improvement in diabetes and not weight loss.

Why just Bariatric surgery is not enough?

Bariatric surgery helps you to achieve what you are unable to achieve with diet and weight loss. That is, a significant and sustained weight loss. It also helps you reset your metabolism and hormonal status. To a certain extent, it also improves your behavior, related to eating habits and activity levels. It thus brings you back to normalcy where you would again be able to control your food and activity and lead a healthy life.  What people fail to understand is that just like any individual can put up weight if they don’t care about their diet and lifestyle, all those who have lost weight by bariatric surgery can also regain the weight.

Various factors that affects the outcome of Bariatric (weight loss) surgery

The outcome of a bariatric or weight loss surgery is dependent on various factors. When we are talking about outcomes, we consider the total weight loss (percentage of excess weight), resolution in medical problems like diabetes, hypertension, kidney problems, breathing problems, varicose veins, etc, overall improvement in mobility and finally how long all these benefits last.

Following are the factors that affect the outcome:

  • Proper selection and execution of surgery
  • surgery-related complications
  • A good follow up
  • A healthy lifestyle and eating habits (lifelong)
  • Family and social support
  • The severity of pre-surgery mobility issues (knee and back problems, paralysis, etc)
  • The severity of medical problems before surgery ( Heart problems, liver failure, diabetes-related kidney failure, major psychiatric problems)

We need to focus on the factors which we can influence to get the best possible outcomes. Hence apart from proper selection of surgery and meticulous surgery, a good follow up and a healthy lifestyle is what will influence your final outcome.

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Importance of Lifestyle modification after Bariatric (weight loss) surgery:

Improving your lifestyle including your diet and activity level is mandatory irrespective of what treatment you undergo. There is no alternative for that. A healthy lifestyle and a good follow up will decide how much benefit you get out of surgery and how long you will be able to maintain it.

To achieve optimum weight loss and health after a weight loss surgery

Bariatric surgery will surely help you lose a large amount of weight. This will range from 70-85% of your excess weight in most of the cases. This means if your weight is say 40 kgs above the ideal weight for your height, bariatric surgery will help you lose about 30-35 kgs of weight. In your case, whether it is 70% or 85 %, it will be decided on your adherence to the advice for lifestyle and diet change. People who improve their physical activity level significantly may lose even more than 85%. And the same way, those who continue a very unhealthy eating pattern and activity restriction may lose less than 70% also.

Hence once surgery selection is proper and it is nicely done, the only thing that is in our control is our efforts to follow a good lifestyle. And once we have experienced the difficulties and problems of obesity, and we are fitting it hard with a bariatric surgery, it is our duty to put our best efforts and achieve the best that is possible for us.

And you must also understand, that not just the maximum weight loss, but all the health benefits and resolution of your diseases go hand in hand with the amount of your weight loss and lifestyle change. So your effort is not just to chase the number of kgs you are losing, but it is to achieve the best of your health.

To maintan weight and health lifelong after a weight loss surgery

Just as efforts are needed to achieve maximum weight loss and best health status, maintaining it also needs efforts. The difference is, maintaining anything needs fewer efforts than what is needed to achieve it. But you need a disciplined and steady effort, in this case for lifelong. Else, there is a small but real chance of regaining weight. Usually, it happens a few years after the stabilization of weight. Also, the weight gain is not significant in most of the patients, but caution is really needed.

You no longer need to do crash dieting, skipping meals and all. But you will persistently, religiously and honestly make sure that you are eating the right things. Mostly after surgery quantity of food is not the culprit for weight regain, but the frequency of unhealthy food is.

Patients start having icecreams, chocolates, chips, pizzas once they forget their struggle with obesity. This usually happens a couple of years after surgery. This is the period when your visits to the bariatric team have reduced. And this happens more to those patients who skip their follow-ups.

The same is true regarding physical activities. You don’t need to hit the gym every morning or run a marathon. Just being physically active, having half an hour to one hour walk daily, going to nearby places by walking, climbing stairs rather than a lift is what is need. Unfortunately, even this is not done and then problems follow.

Lifestyle change needs change of mindset

Living a healthy lifestyle is neither very taxing nor boring. It is a matter of your mindset and your priorities. If your mind is clear and firm about health as your priority, everything else will fall in place. The problem is that we forget about health and are reminded about it by health issues only. This is because everything else in our life has a higher priority than our health.

And the perception, that those who follow a healthy diet and lifestyle live a boring and unhappy life is a big lie. There are a large number of very happening, happy, joyous and full of life people who eat absolutely healthy food and are very strict and rigid about it. In fact, if you observe with an open mind, someone who is having a very unhealthy lifestyle, you will understand how boring and frustrating that lifestyle is.

But once you have a firm conviction in your mind that your health comes at the topmost priority and are conscious about it, nothing seems difficult. In that case, whenever you are offered some unhealthy food either at the workplace or a social gathering or you yourself are tempted, you will remind yourself that your health comes first. And you can choose either to avoid it totally or have in a very small amount depending on how unhealthy that food is. The same applies to exercise and physical activity also. And once you start following it and see the change in your mind and body, you fell “Wow, why I was not doing it till now“.

Lifestyle runs in families

Lifestyle and eating patterns are very very infectious. Whether it is healthy or unhealthy. We tend to adapt to the diet pattern and activity pattern on our parents, partner, spouse, friends, colleagues, neighbors, etc. Anyone with whom we are spending a significant amount of time. And all these people influence our thinking and lifestyle.

Hence, taking efforts in improving the diet pattern and lifestyle of the whole family is very rewarding. What we routinely observe is, those patients who have good family support in adhering to lifestyle change do well for a longer period of time. And certainly, their family members also do get benefitted in terms of a healthy lifestyle and good health. And the same pass on to the next generation. Making changes in isolation has a very higher chance that you will eventually stop it and compromise on your health.

Finally, however harsh it may seem, it is a fact that if you don’t want to do anything about your weight and health, nobody and nothing is going to help you. Bariatric surgery is a great tool that has transformed a lot of lives but it is no magic.

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