Gut Check: the Complexities of Bariatric Surgery

Weight-loss surgery isn’t a panacea, or a quick fix.

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Alfred Day almost had weight loss surgery in 2012. At 360 pounds, he qualified for gastric bypass, one of the four main types of bariatric (weight loss) surgery performed in the United States. After the orientation session at his bariatric surgery center, he changed his mind. Learning that he’d be forced to say goodbye to all the foods he loved, along with the unnerving details of what the surgery itself entailed — cutting open the stomach, making an egg-sized stomach pouch, moving the small intestines down and connecting a piece of small intestine to the new pouch — left him, as he puts it, “really freaked out.”

But over the following four years, his weight didn’t stabilize. He began battling a laundry list of medical issues: osteoarthritis, an umbilical hernia, pre-diabetes and more. Alfred’s weight peaked at 398. He called his doctor, and restarted the approval process. Now 47 years old, he’ll go under the knife, and have his surgeon bypass a portion of his stomach and intestines, this week.

Obesity is a disease that now afflicts over a third of adults and one in six children in the United States. As America’s second leading cause of preventable death, it comes with a host of medical conditions, referred to by bariatric surgeons as “comorbidities,” including heart disease, diabetes, sleep apnea, liver disease, arthritis, hypertension and high cholesterol, along with higher risk for several kinds of cancers, heart attack and stroke. Genetics and family history play a role, as do income disparity and certain medical syndromes, but so too do poor diet and inactivity. It’s a complex issue.

So is the surgical remedy.

“I was, for a very long time, anti-surgery,” says Taunia Soderquist, a 44-year-old professional musician from Los Angeles who eventually underwent gastric bypass nearly nine years ago. “I was one of those people that was like, ‘I want to do it on my own. I want to feel proud that I did it on my own.’ I said surgery would be the easy way out. But all of that was really just based on fear. I was afraid of the surgery.”

There were approximately 196,000 bariatric surgeries performed in the U.S. last year, which accounts for about 0.2% of American adult cases of obesity. Although women are no more likely than men to be obese, women account for 80% of all bariatric surgeries performed here. The average patient waits until age 42 to seek surgery. Mortality rates associated with bariatric surgery in accredited centers have decreased over the years to 0.01% — and are higher among the morbidly obese who do not undergo surgery. The procedure isn’t a walk in the park, though. The challenging recovery and drastic lifestyle shift force people like Alfred and Taunia to consider the choice very carefully.

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Each pea on this plate represents 1,000 of the 196,000 bariatric surgeries performed in the U.S. last year.

Gastric bypass is the bariatric surgery that’s been used the longest (1960s onward), and the procedure that Alfred and Taunia’s doctors advised. However, sleeve gastrectomy is now far more common. Both surgeries are performed laparoscopically, meaning, through small incisions using a minimally invasive technique. While gastric bypass reroutes part of the small intestine to, in part, keep patients from absorbing all the calories they eat, sleeve gastrectomy cuts out 70 to 80% of the stomach and fashions the remainder into a long tube to achieve the same goal. Eliminating that much of the stomach also decreases ghrelin, the hormone that tells us we’re hungry.

The popularity of another “go-to” bariatric surgery, the laparoscopic adjustable gastric banding — aka lap-band — is waning. Weight loss results are not nearly as successful with the lap-band as they are with gastric bypass and the sleeve. Plus, the band itself is a foreign object that can slip on the stomach or erode the stomach wall.

“Now we probably take out more bands than we put in,” says New York Bariatric Group’s founding surgeon Shawn Garber, adding that he might recommend them for patients with lower BMIs. Most patients must either have a BMI of 40, or between 35 to 40 with at least one comorbidity, to qualify for surgery. Garber’s practice doesn’t perform the fourth option, biliopancreatic diversion with duodenal switch (BPD/DS), noting that the vitamin deficiencies and risks associated have made it the least frequently practiced nationwide today.

Surgeons make recommendations for one procedure over another based off of patients’ BMIs and health histories, and most bariatric surgery centers require a number of medical screenings, mental health screenings and preparatory classes over the course of anywhere from four to eight months leading up to surgery. And yet, there’s no way to fully know what the whole process — pre-surgery, post-surgery and beyond — will entail, until you’re in it.

“To be honest, no one is prepared,” says Iscarelys Espinal, a 29-year-old private security officer from York, Pennsylvania. Iscarelys, eight months out from her gastric bypass and down 111 pounds so far, adds that she knew what she was getting herself into in terms of dietary requirements and expectations for recovery, thanks to the classes required. Still, she says, “This is something that everyone experiences individually. It’s very raw, very unique for each person.”

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The number of hoops that bariatric surgery patients must jump through as pre-ops cannot be overstated. There’s no nationally standardized pre-op protocol, and every center operates differently, but there are patterns.

“The process was very rigorous, and I’m actually very glad about that,” says Taunia of the program at Boston Medical Center, where she had her gastric bypass in 2008. “They want to make sure that you really are prepared for what you’re about to embark on.”

First, there’s the comprehensive pre-op workup. At Garber’s practice, for instance, patients must see a cardiologist, a pulmonary and lung specialist, a nutritionist and a psychologist, and complete both a sleep study to check for sleep apnea and a set of blood tests to check for undiagnosed diabetes and thyroid issues.

Taunia adds that smokers were barred from surgery at her bariatric center. Iscarelys had to keep a food diary and hand it in every month throughout her six-month pre-op period, and reports that her insurance was so strict that she would’ve been disqualified from surgery if she’d gained one pound.

Insurance coverage varies from state to state. Some states, like New York and Massachusetts, require insurance companies to cover bariatric surgery, viewing surgery as preventative. Neither Taunia nor Iscarelys paid a penny out-of-pocket. Alfred’s will cost him a $250 co-pay, something he’s grateful for considering that the uninsured cost of bariatric surgery averages between $20,000 and $30,000.

“You hear stories of people getting second mortgages on their house or going to Mexico, and that’s a really frightening prospect,” says Alfred. “But I understand the impulse. […] I’m definitely seeing it as a component of my being able to survive.”

Pre-op dietary requirements and the level of nutritional education offered vary among programs, too. Alfred has adopted a diet similar to what he’ll need to commit to post-surgery — high-protein, low-carb, low-fat and very low calorie, dropping all fast food, soda and most processed foods. Taunia, meanwhile, acknowledges that she “ate everything in sight” for fear that she’d never be able to eat anything she loved ever again, right up until the two-week liquid diet necessitated immediately pre-surgery.

“A lot of people think [the liquid diet exists] because they’re testing your willpower,” says Taunia, “and to see if you can handle your life after surgery, which is not true.” The liquid diet shrinks the liver, explains Garber, and allow the surgeon easier access to the stomach beneath it.

“It’s also a good test of your willpower,” adds Taunia.

Willpower is but one small piece of the psychological puzzle that will determine whether, in the end, the surgery will trigger long-term health improvements bolstered by permanent lifestyle changes. Due to the lack of standardization across programs, content runs the gamut here as well. Taunia’s classes functioned a lot like a support group. Pre-ops go for camaraderie, and to meet post-ops to learn more about what to expect. Alfred’s pre-op coursework, on the other hand, included an entire session devoted to relationships, citing the high rate of divorce post-surgery, a phenomenon so frequent it’s been coined “bariatric divorce.”

There’s a lot of emotion tied up with food and eating. The classes Alfred’s taking are meant to teach him coping mechanisms and techniques for what to do when an emotional need to eat presses down on him. But, he says, that’s not the half of the classes’ value. “More than anything, at least for me, is just acknowledging that you’re going to have that experience.”

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Iscarelys didn’t realize how painful waking up from surgery would feel. “[My doctor] told me he had to blow up my belly with gas like I was five months pregnant,” she says. Doing so is routine for patients like her with “problem areas” other than the stomach. “I woke up terrible from that surgery. It took me four hours to recover.”

Taunia doesn’t point to pain post-surgery, but to initial weight gain. “You’re pumped full of liquids, and you gain 20 pounds immediately.” Soon, though, the pounds come off easier than either Taunia or Iscarelys expected, thanks to their new small stomach pouches and the rules that accompany them.

Post-op patients must stick to a mushy, pureed diet for six weeks. Once solids are reintroduced, portions must remain small. Garber advises that meals must be four to six ounces in total. Consider that daily caloric intake after the first two months need remain under 1,000 calories, compared to the 2,000 daily calories that the FDA recommends to the population at large, for a sense of how little post-op patients can eat. Vitamin supplements become necessary after surgery to safeguard against malnutrition. Iscarelys takes nine a day.

One of the bigger challenges for Iscarelys, though, is remembering to not drink anything, including water, for thirty minutes before eating and thirty minutes after eating. When liquids are in the stomach at the same time as food, the food becomes soft, which leads to extra space in the pouch, allowing you to eat more. Eating more expands the pouch. “That’s how people start gaining [post-surgery],” she adds.

As you might imagine, the toll such stringent dietary restrictions take on mental health can be instantaneous — and emotionally debilitating. Taunia recalls that one of her friends came to visit her after surgery, and brought her own dinner over. “It was killing me,” says Taunia. “I was like, ‘Oh my god, I can’t believe you did this to me. You’re eating in front of me and I can’t eat.”

Eat something you shouldn’t, like greasy food or chocolate, and the physical reaction is severe. “I thought I was having a heart attack,” says Taunia of the time she consumed something in the soft food stage that she shouldn’t have. “I called my mom. I was really scared.” Iscarelys likens the experience of having one piece of chocolate to severe food poisoning: diarrhea, vomiting, chills and sweats.

The reaction is called dumping syndrome, and it’s one of the intentions of gastric bypass: to make it physically impossible to eat non-nutritive food, especially sugar.

Over time, patients can eat larger quantities of food without risk of putting strain on surgery staples, as well as “banned foods” without putting their bodies through such distress. Garber says that there’s no bodily danger in eating poorly after patients have healed from surgery — aside from undermining the weight loss effort.

Taunia says it’s been easy to stick to her diet, all these years after her surgery and 155 pounds later, though it certainly wasn’t at the start. “I’m so far out now that I know what I can and can’t have. I’ve battled my demons already, but that first year was really, really hard. I had ties to food emotionally that I had to let go of.”

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Stacey Ogden almost had weight loss surgery ten years ago. She didn’t, citing what was then a comparatively high mortality rate. “Which immediately disqualified it in my mind,” says the Connecticut-based teacher. Then she almost had weight loss surgery again several years after that, after seeing several friends undergo it.

“Watching my friends go through what they went through, and the digestive complications that can arise, the fact that several years out of surgery many of them still struggle with keeping weight off” changed her mind. “The surgery doesn’t actually fix the unhealthy habit.”

Ultimately, she decided against bariatric surgery, but she wants to be clear: Her decision was a personal one, and reflects no judgment on anyone else’s choice. “I wasn’t ready, and I’m still not ready to say I can’t do it on my own. […] It’s not something to be entered into lightly.”

Stacey isn’t alone in her reservations. As Refinery29 covered in a recent story, “The negative mental-health effects of weight-loss (a.k.a. bariatric) surgery are something experts are growing increasingly concerned about,” citing a recent study published in Annals of Surgery that saw gastric bypass patients double psychiatric medications needed after surgery, as well as a study published in JAMA Surgery that found the risk for suicide rise following surgery.

“There are complex psychosocial effects with weight loss that we do not fully appreciate,” says Amir Ghaferi, assistant professor of surgery at University of Michigan. “Weight and appearance can affect our most public and intimate relationships. […] There are significant changes in how patients view themselves, how they are viewed by others, and how those interactions affect their self confidence and daily life.”

Ghaferi adds that the lack of standardization when it comes to pre-op mental health screenings, and the absence of required mental health follow-up are huge problems. In a study that is awaiting approval for publication, Ghaferi’s team found that 10% of patients went undiagnosed for clinical depression during their pre-op screening. And, he adds, “since there are no ‘requirements’ for postoperative care, there is little incentive for patients to seek such care.”

Taunia and Alfred are both longtime believers in therapy. Alfred has used therapy in the past, and expects to resume it after his surgery to aid with the post-op adjustment period. Taunia sought it out after her gastric bypass left her with a body that was far healthier, but drew discomfort-inducing attention from men. Therapy, she says, helped her reconcile with her new body, and her place in the world.

The attention Iscarelys gets from her fiance, by comparison, has been a big bonus of her surgery. “It’s something that actually has brought out my inner fierceness, my sexiness, everything. I feel wanted, I feel desired.” Still, she hasn’t totally settled into her still-rapidly changing body. She continues to shop in the plus-size section, and has been told that it will take two years to realize she’s lost so much weight. She’s also struggling with excess skin. She calls her arms “bat wings,” and even consulted her doctor about removing the flaps of skin hanging from her thighs; he denied her the surgery, assuring her the issue would correct itself with exercise.

Iscarelys’s fundamental view of herself, and her identity, has changed. “It’s sad to say, but I don’t define myself as a fat person anymore. I used to before.” She’s comfortable sharing her journey and transformation photos now, taking to the weight loss surgery forums on elective and cosmetic treatment website RealSelf. “I like to express what I’ve been through and what I’m going through because I know a lot of people out there are asking themselves, ‘Hey should I do this?’” Taunia and Alfred are active in online forums as well; both are members of BariatricPal.

Self-esteem is a question that comes up regularly with bariatric surgery patients, especially in their pre-op screenings. And though Taunia, Iscarelys and Alfred all report pretty strong senses of self and healthy egos regardless of weight, each acknowledges the subtle shift that occurred — or in Alfred’s case, what he hopes will occur afterward.

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“I’m well aware of how openly people discriminate against folks because of size,” says Alfred. “The life of walking through the world as a heavy person — and I think most folks who are heavy can probably talk about this — is there’s so much stigma attached to it and so much just sort of, looks. Like riding in an airplane is a nightmare. You watch TV and you watch movies, and notice how often the joke is at the expense of the person who’s heavy, and how dehumanizing it can be.”

Alfred maintains a realistic outlook as he eagerly awaits surgery. He is well aware that his gastric bypass will not be a panacea, and that there will be ample, internal work to do in tandem with the 24/7 job of eating the exact right amounts of the exact right foods. “The idea of losing all this weight is really appealing,” he says, “but you’re likely to have a lot of loose skin, so it’s not like I’m going to get this operation, turn around tomorrow and look like Taye Diggs.”

Coupling a pragmatic approach with diligence to abiding by the food rules the surgery lays out is necessary, say experts, to achieving long-term success. The rate of revision surgery — surgery needed to correct a failing surgery, or reattempt a surgery that didn’t succeed due to patient noncompliance — is fairly high. Garber estimates that 25 to 30% of the surgeries his practice oversees are revision surgeries.

“Revision surgery is not an uncommon thing because obesity is a disease in these patients,” says Garber. “Unless they change their lifestyle and eat properly, there’s a chance that they can gain back weight.”

Weight loss surgery is not “the easy way out.” It’s not a quick fix. It demands a stark lifestyle switch, and will, no doubt, unearth a number of latent anxieties and a veritable reservoir of inner pain. The only remedy, it seems, is to be prepared.

“Whatever problems you had before, losing weight doesn’t automatically get rid of those problems,” says Alfred, as he looks ahead to his surgery later this month. “So, it’s sobering.”

Stephie Grob Plante is a features writer and essayist based in Austin, TX. For more of her stories, visit stephiegrobplante.com. Illustration by Maria Jia Ling Pitt; follow her on Instagram @heysuperstar.

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