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The key to long-term success after weight-loss surgery

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Weight-loss surgery is becoming more common, but lifestyle and attitude changes are needed for long-term success.

Surgery was once considered a last resort and fairly extreme treatment for obesity. But the procedures, and attitudes towards them, are changing.

“GPs are far more likely to refer people now than they were when I started 10 years ago,” says Auckland surgeon Stephanie Ulmer. “It was very unusual then for GPs even to discuss it with their patients.”

Today, bariatric surgery is no longer seen as a solution only for what Ulmer calls “the-tip-of-the-iceberg people” – super-obese patients with major lifestyle-related illnesses.

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“It’s also for people you wouldn’t look twice at on the street. A body mass index (BMI) of 30 is the lowest I will offer surgery for. That’s not someone you would think of as having an obesity issue, but they can benefit just as much as those with a BMI of 60-65 who can’t tie their shoelaces.

“They may have struggled with weight their whole life, resulting in hypertension, joint pain and back problems. Yo-yo dieting may have become normal. And they have a fatty liver, which may not have been diagnosed, but I see it when I do the surgery.”

Studies have shown that although people can lose about 10% of their body weight through diet and exercise, the body’s mechanisms work to return it to a set point, so most will regain the lost kilos. For many, that struggle becomes even harder as the years go by.

“The natural history of BMI is that it increases over time,” says Ulmer. “Our metabolic requirements drop with age, but if the amount you’re eating doesn’t drop, too, then gradually you’ll put on weight.”

Keyhole surgery has revolutionised weight-loss procedures, reducing the risks and hospital care needed, making it more accessible.

Stephanie Ulmer. Photo/Supplied

Gastric sleeve surgery is now the most common procedure worldwide. In recent years, it has overtaken gastric band and bypass surgeries because it is viewed as the most effective, least invasive option with the lowest chance of long-term complications.

A gastric sleeve reduces the size of the stomach, from a sac to a narrow tube with about 80% less capacity. Weight is lost because smaller portions of food make the patient feel full, and the procedure also reduces some appetite-stimulating hormones. Aside from that, the stomach digests calories and absorbs nutrients normally.

“Nutritionally, you can maintain health without the use of supplements, although most people will take a multivitamin,” says Ulmer.

In bypass surgery, the gastrointestinal tract is rerouted and the stomach reduced to a small pouch, so nutrients aren’t absorbed very well and patients rely on vitamin and mineral supplements to stay healthy. The gastric band fell out of favour because it is less effective over time and involves having a foreign object in the body, which always carries risks, says Ulmer.

Gastric-sleeve surgery costs more than $20,000 and, although district health boards are funding more procedures, demand is outstripping supply. High-profile success stories, such as that of politician Paula Bennett, who shed 50kg following a gastric bypass, have helped the image of bariatric surgery. But success is not guaranteed and about 40% of patients will eventually regain some or all of their lost weight.

“If you’re not going to buy into the change process, then two years later, the weight is going to come back,” says Ulmer. “The brain has to come along with the physical side of it. Emotional eating or making bad food choices means what I do is going to work for a bit, but not in the long-term.”

In the first weeks following surgery, the drastically resized stomach forces patients to eat very small amounts of pureed food, which makes weight loss easy. Although the stomach never returns to its original size, it relaxes enough for three meals a day to be eaten, but they are side-plate-sized rather than big portions. This is when self-control, commitment and healthy food and drink choices are crucial.

“People who, six months down the track, want to replicate what they had pre-surgery run into trouble,” says Ulmer. “You have to create a new normal that you can see yourself continuing with in five or 10 years.”

This article was first published in the June 8, 2019 issue of the New Zealand Listener.