Weight regain after bariatric surgery can have devastating psychological effects.
How Sustainable Is the Weight Loss After Bariatric Surgery? I explore that issue in my video of the same name. Most gastric bypass patients end up regaining some of the fat they lose by the third year after surgery, but after seven years, 75% of patients followed at 10 U.S. hospitals maintained at least a 20% weight loss.
The typical trajectory for someone who starts out obese at 285 pounds, for example, would be to drop to an overweight 178 pounds two years after bariatric surgery, but then regain weight up to an obese 207 pounds. This has been chalked up to “grazing” behavior, where compulsive eaters may shift from bingeing (which becomes more difficult post-surgery) to eating smaller amounts constantly throughout the day. In a group of women followed for eight years after gastric bypass surgery, about half continued to describe episodes of disordered eating. As one pediatric obesity specialist described, “I have seen many patients who put chocolate bars into a blender with some cream, just to pass technically installed obstacles [e.g., a gastric band].”
Bariatric surgery advertising is filled with “happily-ever-after” fairytale narratives of cherry-picked outcomes offering, as one ad analysis put it, “the full Cinderella-romance happy ending.” This may contribute to the finding that patients often overestimate the amount of weight they’ll lose with the procedure and underestimate the difficulty of the recovery process. Surgery forces profound changes in eating habits, requiring slow, small bites that have been thoroughly chewed. Your stomach goes from the volume of two softballs down to the size of half a tennis ball in stomach stapling and half a ping-pong ball in the case of gastric bypass or banding.
As you can imagine, “weight regain after bariatric surgery can have a devastating effect psychologically as patients feel that they have failed their last option”—their last resort. This may explain why bariatric surgery patients face a high risk of depression. They also have an increased risk of suicide.
Severe obesity alone may increase the risk of suicidal depression, but even at the same weight, those going through surgery appear to be at a higher risk. At the same BMI (body mass index), age, and gender, bariatric surgery patients have nearly four times the odds of self-harm or attempted suicide compared with those who did not undergo the procedure. Most convincingly, so-called “mirror-image analysis” comparing patients’ pre- and post-surgery events showed the odds of serious self-harm increased after surgery.
About 1 in 50 bariatric surgery patients end up killing themselves or being hospitalized for self-harm or attempted suicide. And this only includes confirmed suicides, excluding masked attempts such as overdoses classified as having “undetermined intention.” Bariatric surgery patients may also have an elevated risk of accidental death, though some of this could be due to changes in alcohol metabolism. When individuals who have had a gastric bypass were given two shots of vodka, their blood alcohol level surpassed the legal driving limit within minutes due to their altered anatomy. It’s unclear whether this plays a role in the 25% increase in prevalence of alcohol problems noted during the second postoperative year.
Even those who successfully lose their excess weight and keep it off appear to have a hard time coping. Ten years out, though physical health-related quality of life may improve, general mental health can significantly deteriorate compared to pre-surgical levels, even among those who lost the most weight. Ironically, there’s a common notion that bariatric surgery is for “cheaters” who take the easy way out by choosing the “low-effort” method of weight loss.
Shedding the weight may not shed the stigma of prior obesity. Studies suggest that “in the eyes of others, knowing that an individual was at one time fat will lead him/her to always be treated like a fat person.” And there can be a strong anti-surgery bias on top of that—those who chose the scalpel to lose weight over diet or exercise were rated more negatively (for example, being considered less physically attractive). One can imagine how remaining a target of prejudice even after joining the “in-group” could potentially undercut psychological well-being.
There can also be unexpected physical consequences of massive weight loss, like large hanging flaps of excess skin. Beyond being heavy and uncomfortable and interfering with movement, the skin flaps can result in itching, irritation, dermatitis, and skin infections. Getting a panniculectomy (removing the abdominal “apron” of hanging skin) can be expensive, and its complication rate can exceed 50%, with dehiscence (rupturing of the surgical wound) one of the most common complications.
“Even if surgery proves sustainably effective,” wrote the founding director of Yale University’s Prevention Research Center, “the need to rely on the rearrangement of natural gastrointestinal anatomy as an alternative to better use of feet and forks [exercise and diet] seems a societal travesty.”
In the Middle Ages, starving peasants dreamed of gastronomic utopias where food just rained down from the sky. The English called it the Kingdom of Cockaigne. Little could medieval fabulists predict that many of their descendants would not only take permanent residence there but also cut out parts of their stomachs and intestines to combat the abundance. Critics have pointed out the irony of surgically altering healthy organs to make them dysfunctional—malabsorptive—on purpose, especially when it comes to operating on children. Bariatric surgery for kids and teens has become widespread and is being performed on children as young as five years old. Surgeons defend the practice by arguing that growing up fat can leave “‘emotional scars’ and lifelong social retardation.”
Promoters of preventive medicine may argue that bariatric surgery is the proverbial “ambulance at the bottom of the cliff.” In response, proponents of pediatric bariatric surgery have written: “It is often pointed out that we should focus on prevention. Of course, I agree. However, if someone is drowning, I don’t tell them, ‘You should learn how to swim’; no, I rescue them.”
A strong case can be made that the benefits of bariatric surgery far outweigh the risks if the alternative is remaining morbidly obese, which is estimated to shave up to a dozen or more years off one’s life. Although there haven’t been any data from randomized trials yet to back it up, compared to non-operated obese individuals, those getting bariatric surgery would be expected to live significantly longer on average. No wonder surgeons have consistently framed the elective surgery as a life-or-death necessity. This is a false dichotomy, though. The benefits only outweigh the risks if there are no other alternatives. Might there be a way to lose weight healthfully without resorting to the operating table? That’s what my book How Not to Diet is all about.
Doctor’s Note
My book How Not to Diet is focused exclusively on sustainable weight loss. Check it out from your library or pick it up from wherever you get your books. (All proceeds from my books are donated to charity.)
This is the final segment in a four-part series on bariatric surgery, which includes:
This blog contains information regarding suicide. If you or anyone you know is exhibiting suicide warning signs, please get help. Go to https://988lifeline.org for more information.
