Dr. Kohli on the Life-Saving Benefits of Bariatric Surgery

Obesity is a true epidemic in the United States. Data show that among US adults, the prevalence of severity obesity has doubled since the start of the new millennium, when it was at 4.7%, to 9.2% in 2018. Studies have shown that patients with severe obesity incur a greater risk of heart-related diseases and death. While bariatric surgery is the most successful treatment available for this population, it remains an underutilized solution. DocWire News Medical Lead Payal Kohli, MD, FACC, discussed a recent study, published in Obesity, which demonstrates that bariatric surgery significantly reduces all-cause mortality in obese patients, suggesting that it should be used more often.

DocWire News: For the laymen, what exactly is bariatric surgery, what patients are eligible for it, and what are some pros and cons typically associated with it?

Dr. Payal Kohli: Bariatric surgery is really surgery targeted to help an individual lose weight. The individuals that are eligible for it, usually those that have significant morbid obesity, so generally a body mass index, or BMI, greater than 40, and that’s calculated based on your height and your weight. Or, if you’re between 35 and 40 and have other obesity-related health conditions such as severe sleep apnea, diabetes, high blood pressure, high cholesterol, heart disease, other types of things that may be contributing to your overall health as a result of your obesity.

Bariatric surgery is something that’s been around for quite some time, but it’s been underutilized tremendously because there’s often the stigma against having surgery for obesity almost as if it’s kind of a failure of your willpower, or what have you. But what individuals across society, and particularly those that are struggling with managing their weight and with obesity need to understand is that it’s actually part of a comprehensive treatment program for obesity. So we really need to think about it just like we think about medications or we think about lifestyle changes for obesity. It’s not a failure of willpower.

In fact, once you have bariatric surgery, what it can often do is actually rewire your brain so that you’re much more able to sustain a diet, exercise, and lifestyle changes because you feel better, you eat less, and therefore you have that need to eat less as well. So, it rearranges the structure of those neurons in your brain that lead to some of those eating patterns that can often lean to obesity.

There’s many different types of bariatric surgery. There’s gastric sleeve, there’s gastric bypass, there are laparoscopic approaches, open approaches. They all have their advantages and disadvantages. But in general, it’s a very good procedure as part of a comprehensive weight management program.

Now, once you have bariatric surgery, you have a rearrangement of the plumbing, so to speak, of your stomach or your intestines. It’s a lifelong commitment because it can create situations like changes in the way that your body absorbs nutrients. Dramatic weight loss can often have psychological impacts as well. It can change the way your face looks as well. And then, a lot of people can have chronic issues that they struggle with, such as nausea, changes in their bowel habits, constipation, diarrhea, those types of things. So, it’s a commitment that you make once, but it is something that really stays with you for life.

Talk to us about the recent study published in Obesity which showed bariatric surgery reduces all-cause mortality.

Yes, fascinating. This was a large study of 22,000 people done over many, many years. What it shows is that those individuals that got bariatric surgery, they were associated with a lower risk of dying by 16%. Then, if we actually broke it down, the results were even more robust when it came to the risk of dying from heart disease, the risk of dying from cancers, or their risk of dying from conditions like diabetes. So, very, very compelling data that tells us that this kind of an intervention, it doesn’t just change the way you feel about your body, it doesn’t change your appearance, but it actually can change your risk of mortality.

Now, keep in mind this was an association, not a causation study. So it was not a randomized trial of bariatric surgery, but it was more just following people over time that had had the surgery and seeing how they fared. But to me, as a physician and a provider, it tells us that since only 2% of people are getting bariatric surgery across the country. And if this association study, this large study with a long follow-up is really showing these types of signals, perhaps we as healthcare providers ought to be using this intervention more frequently, more aggressively, and offering it to more of our patients as part of a comprehensive obesity management plan.

What are the key takeaways of this analysis?

I think the key takeaways of this analysis are really the bigger philosophical shift that we’re seeing in our society, which is that obesity is not a lack of willpower. Obesity is not a personal failure that you have sustained. Obesity is a medical condition. And for reasons that are complex and not well understood, somehow bariatric surgery doesn’t just change your weight. It also changes your set point of your body, with respect to your eating patterns and other such conditions that can contribute to obesity.

One other thing that I definitely want to highlight with this study, however, is the fact that the younger age population between 18 to 34 that got bariatric surgery had a slightly higher associated risk of suicide. There was about a 2.4% higher risk of suicide. Now, this is a flag. This is a red flag that we have to pay attention to. It’s hard to know whether the younger individuals that ended up signing up for surgery had something different about them coming in that led to that higher risk of suicide. Or, whether something about the surgery somehow was associated with that higher risk of suicide. So it’s hard to know which was the chicken or the egg. Were they different people, the ones that were younger, and that’s why they were associated with a higher risk? Or, was it something about getting surgery early that somehow was associated with the higher risk?

But regardless, I feel like in this particular age population, we have to be exceedingly careful when we think about bariatric surgery as an option. And we also have to screen more aggressively for mental health conditions in the obese population in general because we know… Again, it’s the chicken or the egg. Is it that they have low self-esteem and that drives part of their eating behaviors, perhaps, and their relationship with food, and that could be contributing to their obesity? Or, vice versa? Is it that the obesity is driving a low self-esteem, which can then increase risk for comorbid psychiatric conditions? But to me, mental health is a big part of treating somebody with obesity. And we have to make sure that as we’re treating their physical health, we also remember to treat their mental health, particularly as they undergo these types of interventions, which can completely change the way their body looks, they can change their self-esteem, their self-perception, and really their relationship with food moving forward.