Weight regain after bariatric surgery can have devastating psychological effects.
How Sustainable Is the Weight Loss After Bariatric Surgery?
4.3/5 - (52 votes)
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
How sustainable is the weight loss from bariatric surgery? Most gastric bypass patients end up regaining some of the fat they lose over the first year or two after surgery, but five years later, three-quarters maintain at least a 20 percent 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 back 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. Eight years out, about half of gastric bypass patients continue 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 [like 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, thoroughly-chewed, small bites. Your stomach goes from the volume of two softballs to down to the size of half a tennis ball in stomach stapling, and half of a ping-pong ball in the case of gastric bypass or banding.
As you can imagine, weight regain after surgery can have devastating psychological effects, as patients may feel they failed their last resort. This may explain why bariatric surgery patients are at a high risk of depression and suicide.
Now severe obesity alone may increase risk of suicidal depression, but even at the same weight, those going through surgery appear to be at higher risk. At the same BMI, age, and gender, bariatric surgery recipients have nearly four times the odds of suicide compared with counterparts not undergoing the procedure. Most convincingly, before-and-after mirror-image analyses show the risk of serious self-harm increases post-surgery among the same individuals.
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 of “undetermined intention.” Bariatric surgery patients also have an elevated risk of accidental death, though some of this may be due to changes in alcohol metabolism. Give gastric bypass folks two shots of vodka, and because of their altered anatomy, their blood alcohol level shoots past the legal driving limit within minutes. It’s unclear whether this plays a role in the 25 percent 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 improves, general mental health tends to significantly deteriorate, compared to pre-surgical levels even among the biggest losers. 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 pounds may not shed the stigma of even prior obesity. Studies suggest that in the eyes of others, knowing someone was fat in the past leads them to always be treated more like a fat person. And there’s a strong anti-surgery bias on top of that, such that those who choose the scalpel to lose weight are rated most 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 has a complication rate exceeding 50 percent, with dehiscence (rupturing of the surgical wound) being the most common complication.
“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 our natural gastrointestinal anatomy as an alternative to better use of feet and forks [(diet and exercise)] 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 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—mal-absorptive—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 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 of 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 consistently frame 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.
Please consider volunteering to help out on the site.
- Magro DO, Geloneze B, Delfini R, Pareja BC, Callejas F, Pareja JC. Long-term weight regain after gastric bypass: a 5-year prospective study. Obes Surg. 2008;18(6):648-51.
- Shukla AP, He D, Saunders KH, Andrew C, Aronne LJ. Current concepts in management of weight regain following bariatric surgery. Expert Rev Endocrinol Metab. 2018;13(2):67-76.
- Ghaferi AA, Varban OA. Setting appropriate expectations after bariatric surgery: evaluating weight regain and clinical outcomes. JAMA. 2018;320(15):1543-4:1322.
- Pizato N, Botelho PB, Gonçalves VSS, Dutra ES, de Carvalho KMB. Effect of grazing behavior on weight regain post-bariatric surgery: a systematic review. Nutrients. 2017;9(12).
- Kruseman M, Leimgruber A, Zumbach F, Golay A. Dietary, weight, and psychological changes among patients with obesity, 8 years after gastric bypass. J Am Diet Assoc. 2010;110(4):527-34.
- van Geelen SM, Bolt IL, van der Baan-Slootweg OH, van Summeren MJ. The controversy over pediatric bariatric surgery: an explorative study on attitudes and normative beliefs of specialists, parents, and adolescents with obesity. J Bioeth Inq. 2013;10(2):227-37.
- Groven KS, Braithwaite J. Happily-ever-after: personal narratives in weight-loss surgery advertising. Health Care Women Int. 2016;37(11):1221-38.
- Rouleau CR, Rash JA, Mothersill KJ. Ethical issues in the psychosocial assessment of bariatric surgery candidates. J Health Psychol. 2016;21(7):1457-71.
- Lin H-C, Tsao L-I. Living with my small stomach: The experiences of post-bariatric surgery patients within 1 year after discharge. J Clin Nurs. 2018;27(23-24):4279-89.
- Velapati SR, Shah M, Kuchkuntla AR, et al. Weight regain after bariatric surgery: prevalence, etiology, and treatment. Curr Nutr Rep. 2018;7(4):329-34.
- Lu CW, Chang YK, Lee YH, et al. Increased risk for major depressive disorder in severely obese patients after bariatric surgery—a 12-year nationwide cohort study. Ann Med. 2018;50(7):605-12.
- Castaneda D, Popov VB, Wander P, Thompson CC. Risk of suicide and self-harm is increased after bariatric surgery—a systematic review and meta-analysis. Obes Surg. 2019;29(1):322-33.
- Sarwer DB, Polonsky HM. The psychosocial burden of obesity. Endocrinol Metab Clin North Am. 2016;45(3):677-88.
- Neovius M, Bruze G, Jacobson P, et al. Risk of suicide and non-fatal self-harm after bariatric surgery: results from two matched cohort studies. Lancet Diabetes Endocrinol. 2018;6(3):197-207.
- Courcoulas A. Who, why, and how? Suicide and harmful behaviors after bariatric surgery. Ann Surg. 2017;265(2):253-4.
- Steffen KJ, Engel SG, Pollert GA, Li C, Mitchell JE. Blood alcohol concentrations rise rapidly and dramatically after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2013;9(3):470-3.
- King WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307(23):2516-25.
- Canetti L, Bachar E, Bonne O. Deterioration of mental health in bariatric surgery after 10 years despite successful weight loss. Eur J Clin Nutr. 2016;70(1):17-22.
- Cooke J. Bariatric Surgery is for Cheaters. WLS Journey. 2010.
- Trainer S, Brewis A, Wutich A. Not “taking the easy way out”: reframing bariatric surgery from low-effort weight loss to hard work. Anthropol Med. 2017;24(1):96-110.
- Mattingly B, Stambush M, Hill A. Shedding the pounds but not the stigma: negative attributions as a function of a target’s method of weight loss. J Appl Biobehav Res. 2010;14(3):128-44.
- Ivezaj V, Grilo CM. The complexity of body image following bariatric surgery: a systematic review of the literature. Obes Rev. 2018;19(8):1116-40.
- Giordano S, Victorzon M, Koskivuo I, Suominen E. Physical discomfort due to redundant skin in post-bariatric surgery patients. J Plast Reconstr Aesthet Surg. 2013;66(7):950-5.
- Marek RJ, Steffen KJ, Flum DR, et al. Psychosocial functioning and quality of life in patients with loose redundant skin 4 to 5 years after bariatric surgery. Surg Obes Relat Dis. 2018;14(11):1740-7.
- Derickson M, Phillips C, Barron M, Kuckelman J, Martin M, DeBarros M. Panniculectomy after bariatric surgical weight loss: Analysis of complications and modifiable risk factors. Am J Surg. 2018;215(5):887-90.
- Katz DL. Perspective: obesity is not a disease. Nature. 2014;508(7496):S57.
- Pinkney JH, Johnson AB, Gale EA. The big fat bariatric bandwagon. Diabetologia. 2010;53(9):1815-22.
- Oliver JE. The politics of pathology: how obesity became an epidemic disease. Perspect Biol Med. 2006;49(4):611-27.
- Hofmann B. Bariatric surgery for obese children and adolescents: a review of the moral challenges. BMC Med Ethics. 2013;14:18.
- Alqahtani AR, Antonisamy B, Alamri H, Elahmedi M, Zimmerman VA. Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years. Ann Surg. 2012;256(2):266-73.
- Sarr MG. The problem of obesity: how are we going to address it? Am J Bioeth. 2010;10(12):12-13.
- Ortiz SE, Kawachi I, Boyce AM. The medicalization of obesity, bariatric surgery, and population health. Health (Lond). 2017;21(5):498-518.
- Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003;289(2):187-93.
- Cardoso L, Rodrigues D, Gomes L, Carrilho F. Short- and long-term mortality after bariatric surgery: a systematic review and meta-analysis. Diabetes Obes Metab. 2017;19(9):1223-32.
- Trainer S, Benjamin T. Elective surgery to save my life: rethinking the “choice” in bariatric surgery. J Adv Nurs. 2017;73(4):894-904.
Video production by Glass Entertainment
Motion graphics by Avo Media
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
How sustainable is the weight loss from bariatric surgery? Most gastric bypass patients end up regaining some of the fat they lose over the first year or two after surgery, but five years later, three-quarters maintain at least a 20 percent 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 back 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. Eight years out, about half of gastric bypass patients continue 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 [like 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, thoroughly-chewed, small bites. Your stomach goes from the volume of two softballs to down to the size of half a tennis ball in stomach stapling, and half of a ping-pong ball in the case of gastric bypass or banding.
As you can imagine, weight regain after surgery can have devastating psychological effects, as patients may feel they failed their last resort. This may explain why bariatric surgery patients are at a high risk of depression and suicide.
Now severe obesity alone may increase risk of suicidal depression, but even at the same weight, those going through surgery appear to be at higher risk. At the same BMI, age, and gender, bariatric surgery recipients have nearly four times the odds of suicide compared with counterparts not undergoing the procedure. Most convincingly, before-and-after mirror-image analyses show the risk of serious self-harm increases post-surgery among the same individuals.
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 of “undetermined intention.” Bariatric surgery patients also have an elevated risk of accidental death, though some of this may be due to changes in alcohol metabolism. Give gastric bypass folks two shots of vodka, and because of their altered anatomy, their blood alcohol level shoots past the legal driving limit within minutes. It’s unclear whether this plays a role in the 25 percent 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 improves, general mental health tends to significantly deteriorate, compared to pre-surgical levels even among the biggest losers. 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 pounds may not shed the stigma of even prior obesity. Studies suggest that in the eyes of others, knowing someone was fat in the past leads them to always be treated more like a fat person. And there’s a strong anti-surgery bias on top of that, such that those who choose the scalpel to lose weight are rated most 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 has a complication rate exceeding 50 percent, with dehiscence (rupturing of the surgical wound) being the most common complication.
“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 our natural gastrointestinal anatomy as an alternative to better use of feet and forks [(diet and exercise)] 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 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—mal-absorptive—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 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 of 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 consistently frame 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.
Please consider volunteering to help out on the site.
- Magro DO, Geloneze B, Delfini R, Pareja BC, Callejas F, Pareja JC. Long-term weight regain after gastric bypass: a 5-year prospective study. Obes Surg. 2008;18(6):648-51.
- Shukla AP, He D, Saunders KH, Andrew C, Aronne LJ. Current concepts in management of weight regain following bariatric surgery. Expert Rev Endocrinol Metab. 2018;13(2):67-76.
- Ghaferi AA, Varban OA. Setting appropriate expectations after bariatric surgery: evaluating weight regain and clinical outcomes. JAMA. 2018;320(15):1543-4:1322.
- Pizato N, Botelho PB, Gonçalves VSS, Dutra ES, de Carvalho KMB. Effect of grazing behavior on weight regain post-bariatric surgery: a systematic review. Nutrients. 2017;9(12).
- Kruseman M, Leimgruber A, Zumbach F, Golay A. Dietary, weight, and psychological changes among patients with obesity, 8 years after gastric bypass. J Am Diet Assoc. 2010;110(4):527-34.
- van Geelen SM, Bolt IL, van der Baan-Slootweg OH, van Summeren MJ. The controversy over pediatric bariatric surgery: an explorative study on attitudes and normative beliefs of specialists, parents, and adolescents with obesity. J Bioeth Inq. 2013;10(2):227-37.
- Groven KS, Braithwaite J. Happily-ever-after: personal narratives in weight-loss surgery advertising. Health Care Women Int. 2016;37(11):1221-38.
- Rouleau CR, Rash JA, Mothersill KJ. Ethical issues in the psychosocial assessment of bariatric surgery candidates. J Health Psychol. 2016;21(7):1457-71.
- Lin H-C, Tsao L-I. Living with my small stomach: The experiences of post-bariatric surgery patients within 1 year after discharge. J Clin Nurs. 2018;27(23-24):4279-89.
- Velapati SR, Shah M, Kuchkuntla AR, et al. Weight regain after bariatric surgery: prevalence, etiology, and treatment. Curr Nutr Rep. 2018;7(4):329-34.
- Lu CW, Chang YK, Lee YH, et al. Increased risk for major depressive disorder in severely obese patients after bariatric surgery—a 12-year nationwide cohort study. Ann Med. 2018;50(7):605-12.
- Castaneda D, Popov VB, Wander P, Thompson CC. Risk of suicide and self-harm is increased after bariatric surgery—a systematic review and meta-analysis. Obes Surg. 2019;29(1):322-33.
- Sarwer DB, Polonsky HM. The psychosocial burden of obesity. Endocrinol Metab Clin North Am. 2016;45(3):677-88.
- Neovius M, Bruze G, Jacobson P, et al. Risk of suicide and non-fatal self-harm after bariatric surgery: results from two matched cohort studies. Lancet Diabetes Endocrinol. 2018;6(3):197-207.
- Courcoulas A. Who, why, and how? Suicide and harmful behaviors after bariatric surgery. Ann Surg. 2017;265(2):253-4.
- Steffen KJ, Engel SG, Pollert GA, Li C, Mitchell JE. Blood alcohol concentrations rise rapidly and dramatically after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2013;9(3):470-3.
- King WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307(23):2516-25.
- Canetti L, Bachar E, Bonne O. Deterioration of mental health in bariatric surgery after 10 years despite successful weight loss. Eur J Clin Nutr. 2016;70(1):17-22.
- Cooke J. Bariatric Surgery is for Cheaters. WLS Journey. 2010.
- Trainer S, Brewis A, Wutich A. Not “taking the easy way out”: reframing bariatric surgery from low-effort weight loss to hard work. Anthropol Med. 2017;24(1):96-110.
- Mattingly B, Stambush M, Hill A. Shedding the pounds but not the stigma: negative attributions as a function of a target’s method of weight loss. J Appl Biobehav Res. 2010;14(3):128-44.
- Ivezaj V, Grilo CM. The complexity of body image following bariatric surgery: a systematic review of the literature. Obes Rev. 2018;19(8):1116-40.
- Giordano S, Victorzon M, Koskivuo I, Suominen E. Physical discomfort due to redundant skin in post-bariatric surgery patients. J Plast Reconstr Aesthet Surg. 2013;66(7):950-5.
- Marek RJ, Steffen KJ, Flum DR, et al. Psychosocial functioning and quality of life in patients with loose redundant skin 4 to 5 years after bariatric surgery. Surg Obes Relat Dis. 2018;14(11):1740-7.
- Derickson M, Phillips C, Barron M, Kuckelman J, Martin M, DeBarros M. Panniculectomy after bariatric surgical weight loss: Analysis of complications and modifiable risk factors. Am J Surg. 2018;215(5):887-90.
- Katz DL. Perspective: obesity is not a disease. Nature. 2014;508(7496):S57.
- Pinkney JH, Johnson AB, Gale EA. The big fat bariatric bandwagon. Diabetologia. 2010;53(9):1815-22.
- Oliver JE. The politics of pathology: how obesity became an epidemic disease. Perspect Biol Med. 2006;49(4):611-27.
- Hofmann B. Bariatric surgery for obese children and adolescents: a review of the moral challenges. BMC Med Ethics. 2013;14:18.
- Alqahtani AR, Antonisamy B, Alamri H, Elahmedi M, Zimmerman VA. Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years. Ann Surg. 2012;256(2):266-73.
- Sarr MG. The problem of obesity: how are we going to address it? Am J Bioeth. 2010;10(12):12-13.
- Ortiz SE, Kawachi I, Boyce AM. The medicalization of obesity, bariatric surgery, and population health. Health (Lond). 2017;21(5):498-518.
- Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003;289(2):187-93.
- Cardoso L, Rodrigues D, Gomes L, Carrilho F. Short- and long-term mortality after bariatric surgery: a systematic review and meta-analysis. Diabetes Obes Metab. 2017;19(9):1223-32.
- Trainer S, Benjamin T. Elective surgery to save my life: rethinking the “choice” in bariatric surgery. J Adv Nurs. 2017;73(4):894-904.
Video production by Glass Entertainment
Motion graphics by Avo Media
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Title
How Sustainable Is the Weight Loss After Bariatric Surgery?
LicenseCreative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)
Content URLDoctor'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 video in a four-part series on bariatric surgery, which includes:
- The Mortality Rate of Bariatric Weight-Loss Surgery
- The Complications of Bariatric Weight-Loss Surgery
- Bariatric Surgery vs. Diet to Reverse Diabetes
This video contains information regarding suicide. If you or anyone you know is exhibiting suicide warning signs, please get help. See https://suicidepreventionlifeline.org for more information.
I also have two videos on extreme weight loss interventions: Is Gastric Balloon Surgery Safe and Effective for Weight Loss? and Extreme Weight-Loss Devices.
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