“Keeping It Off,” by Rivka Galchen. The New Yorker, 9/26/2016.
We recently had a receptionist at our fitness center, somewhere in her 50s, tiny, petite, looking like she barely weighed 100 pounds. So, I expressed surprise when she told me she had had bariatric surgery. Best thing she ever did, she assured me, as she showed me a photo of her former self. In the photo she was heavy, but not grossly so. She told me of years of unsuccessful effort to lose weight, and was very pleased with the surgical results. She always wore long sleeves to hide the excess skin dangling from her Bingo arms. She eventually had the flapping skin cut away in another surgical procedure. The last time I saw her, the 8-inch scars from that second surgery still looked red and angry, but she was sure they would fade in time.
Bariatric surgery does not remove fat. Instead, it modifies the stomach and intestine so that the individual absorbs fewer calories while still feeling satisfied. They come out of the surgery weighing the same, but they lose the weight over the following months. The weight loss eventually stops on its own and weight remains low without further effort.
There are four types of bariatric surgery. The first, and simplest, is the gastric band (sometimes called the lap-band procedure) applied by laparoscopy. It merely constricts the neck of the stomach and is reversible. It often is also the least effective. Governor Chris Christie had it done. The three others are the sleeve gastrectomy, the gastric bypass, and the biliopancreatic diversion. Those three are 85% effective in reducing the patient’s weight roughly in half, but they make major changes to the gastrointestinal tract. All three remove some of the cells that secrete ghrelin, the hunger hormone. Former patients report they simply have no more cravings for sweets or excessive amounts of food. Eating has lost its importance.
Bariatric surgery has jumped so much in popularity (from 20,000 per year in the early 1990s to 200,000 per year, today) because diet and exercise have failed so miserably, no matter how disciplined the individual. People have reluctantly turned to surgery as a last resort when nothing else worked. All of the procedures of the past were also failures: bleeding, amphetamines, Turkish baths, purgatives, tapeworms, low fat diets, high fat diets, more sleep, less sleep, and massage. We still see in old cartoons the vibrating machine with a belt that shakes the hips. Didn’t work. The medical problems associated with obesity, principally diabetes and heart disease, are becoming more prevalent.
A study on 14 contestants from season 8 (2012) of The Biggest Loser, the TV show that relies on diet and exercise, found all but one of the finalists regained much of their original weight and all of their metabolisms had slowed dramatically. The shock of sudden weight loss prompts the body to try to put the weight back on. People who have undergone gastric bypass do not show a similar slowing of metabolism.
Bariatric surgery began in 1954 with a Swedish doctor’s bypass experiments on dogs. The successful results on the dogs led to experiments in 1956 on ten severely obese Swedish women that were also successful. Then they reversed the surgeries on the women, thinking the weight loss was permanent and under control, but all of their weight soon returned.
Many of us remember stomach stapling that was popular in the 1970s and 1980s. This procedure was improvisational and brutal . . . and dangerous. It often resulted in intestinal contents leaking into the abdominal cavity, malnutrition, infections, and blockages. Some patients died from these complications. Only 15 years ago, a patient had a 1% chance of dying from bariatric surgery. Now it is 0.15%—about that for knee surgery.
Bariatric surgery is not without problems. Most patients have to take vitamin supplements and schedule regular checkups for the rest of their lives. Some experience discomfort and vomiting. Sugary and fatty foods can cause cramping and diarrhea. But the overwhelming number of patients are very happy to have had the procedure. Their health and quality of life has improved so much that they feel like a new person.