Bariatric Surgery Research Paper Help

Abstract

Bariatric surgery is becoming very common, and most physicians will have contact with bariatric patients. Many aspects to follow-up are not generally known. The objective of this article is to help other physicians understand what follow-up entails to assist them with the care of these patients. It is expected that patients are followed up by the bariatric team for a lifetime, as care is complicated and lifetime follow-up is the key to long-term success.

Keywords: Bariatrics, bariatric surgery, laparoscopic adjustable band, laparoscopic Roux-en-Y gastric bypass, long-term follow-up

INTRODUCTION

Bariatric surgery improves quality of life and comorbid conditions and decreases overall cost of care.1 Patients who undergo surgery will likely increase the length of their lives due to improvement in diabetes and heart disease and decreased risk of cancer.2,3 Long-term bariatric follow-up requires a team approach and attention to several aspects of care. Nutrition is the most important aspect of follow-up to safely maximize weight loss and prevent weight gain. Exercise helps to maintain weight loss. Complications need to be identified early and can result from improper behavior or from surgical complications. Emotional difficulties occur in many patients. This article addresses all these factors.

GENERAL FOLLOW-UP

Two common procedures performed for weight loss are the laparoscopic adjustable gastric band (LAGB) and the laparoscopic Roux-en-Y gastric bypass (LRGBY). The LRGBY constitutes 80% of all bariatric procedures.4,5 The main factors contributing to successful weight loss after bariatric surgery are the patient's ability to make lifestyle changes and to maintain those changes for years to come following the surgery. Success is measured by excess body weight (EBW) loss, which is current body weight minus ideal body weight. After LRGBY, 80% of patients achieve greater than 70% EBW loss over 2 years, and 70% of patients after LAGB achieve greater than 50% EBW loss over 3 years.4 Those who maintain the lifestyle changes for the rest of their lives will maintain the weight loss. These changes include following a healthy well-balanced diet, taking the recommended vitamin supplementation, and exercising regularly (we recommend exercise for 30 minutes ≥5 d/wk).6 In some patients with severe physical disabilities, physical therapy is often used to help them become mobile and to incorporate the appropriate amount of exercise.6

During the period of weight loss, we closely observe our patients; we then follow up with them once a year. During these visits, patients commonly have appointments with multiple persons on the bariatric team, including the surgeon, a physician extender, a registered dietician, and/or a mental health care provider, depending on the needs of each patient. All team members are important to guide, support, motivate, and educate the patient continuously, so that he/she may achieve a healthy weight after surgery.4 Adjustments to LAGBs are required regularly during the first 2 years to maintain the “green zone,” at which patients are eating properly and feeling satiated with their small meals for 2 to 3 hours. Later adjustments are needed every year or two as saline slowly leaks out of the band.7,8

In the early postoperative period, the main goals of office visits are to assess proper nutrition status, identify maladaptive eating disorders, evaluate potential complications (internal hernia, ulcers, etc), monitor status of comorbidities, encourage regular exercise, discuss weight loss progress, and check laboratory values (vitamin B1, vitamin B12, magnesium, phosphorous, blood counts, albumin, and a metabolic profile). For most patients, this is a time of emotional turmoil. Family physicians are intimately involved during the period of weight loss because of the changes in comorbidities and in medication requirements.4

During the patient's consultation with the dietician before surgery, specific weight loss goals are calculated based on EBW. After LRGBY, 80% of patients achieve greater than 70% EBW loss over 12–18 months, and 70% of patients after LAGB achieve greater than 50% EBW loss over a 2-year period.9 The slower weight loss with LAGB is sometimes discouraging to patients.4

Successful weight loss also results in resolution or improvement of associated comorbidities. Particularly after LRGBY, type 2 diabetes mellitus is commonly in remission on postoperative day 1 and at a bare minimum is better controlled with less medication. Blood pressure should also be managed closely within the first 3 months, but improvements are seen over the first year. Improvement is also noted in arthritis, heart function, and stress incontinence, among other medical problems.4,10–14 The use of diuretic agents should be reduced or discontinued in the first month or so to avoid dehydration and electrolyte abnormalities.15,16 The first sign of blood pressure improvement is often light-headedness. Lipid changes are seen during the first year.17 Sleep apnea resolves in most patients, which may require successive sleep studies.

Depression and anxiety medications should be continued for at least the first 6 months. Symptoms of depression should be monitored closely at the first few appointments. Many patients have difficulty with the extreme and instant lifestyle changes. If patients were previous stress eaters and become stressed after surgery, they no longer have the ability to eat for stress relief. After LRGBY, patients usually will experience dumping syndrome (which includes abdominal pain, nausea, vomiting, diarrhea, and diaphoresis). Many patients also experience changes in their social scenes, as many American holidays are centered on a big meal. The way patients interact with the significant people in their lives changes dramatically, and their social structure can be irreparably broken. This is challenging, but patients can overcome these difficult situations with guidance, understanding, and professional counseling when needed.4,18

Maintenance of weight loss is obtained by following a healthy balanced diet with regular exercise every week. Weight regain is a warning sign. The most common factors leading to weight gain after weight loss surgery are decreased exercise and a return to preoperative eating habits.16 Patients who have undergone LRGBY may experience a decrease in dumping symptoms and a resolution of food intolerance, making it easier for them to eat more.19,20 Patients can become discouraged or embarrassed and may not return to the bariatric provider who performed their surgery. They sometimes return many years later at their presurgery weight and request a revision. It is best for patients to return to the bariatric team at the earliest signs of weight regain. If weight regain is caught in its early stages, it is easier for patients to get back on track. Regain of weight can be due to changes in operative anatomy and requires workup, but the most common causes are changes in diet, lack of exercise, or psychological issues.4

Inadequate weight loss must also be addressed early by assessing eating practices, psychological status, and fluoroscopic images to rule out fistulas between the gastric pouch and remnant. Most commonly, the cause of poor weight loss is increased caloric intake or increased consumption of calorie-dense foods. Again, close follow-up with a bariatric dietician is needed, as well as addressing any psychological issues.21

Early satiety is an expected adverse effect of surgery for LRGBY and LAGB. Dumping, which occurs only after LRGBY, can be viewed as a negative adverse effect, but it can be used by the patient as a teaching tool. The surgical weight loss program retrains patients to lead a healthy lifestyle. The phrase “eat to live and not live to eat” comes to mind. The reasons for weight gain should be discussed before surgery, and while it may be difficult to overcome these factors, it is possible.4

When patients complain of frequent abdominal cramping and vomiting after eating, the first step is an evaluation of foods that are eaten before these symptoms occur. If symptoms commonly occur after LRGBY with intake of high-sugar and high-fat foods, the likely cause is dumping. After LAGB, solid food intolerance can be a result of overinflation of the band. When patients complain of food intolerance, complications of surgery need to be evaluated. Our dietitian evaluates these patients for improper eating behavior.

Medications for all weight loss patients need to be in crushed, liquid, or chewable forms during the first 6 months for LRGBY and for the patient's lifetime after LAGB. The use of whole medications may lead to ulceration as they sit in the stomach pouch or pouch enlargement. Nonsteroidal anti-inflammatory drugs are contraindicated after LRGBY because of the incidence of ulcers.4

NUTRITION FOLLOW-UP

The main goals after any bariatric gastric surgery are threefold: (1) to maximize weight loss and absorption of nutrients, (2) to maintain adequate hydration, and (3) to avoid vomiting and dumping syndrome.

To assess proper nutrition, we ask our patients to bring a 24-hour recall of dietary intake to their appointment. We ask them to consume at least 64 oz of fluids daily, while avoiding sugary beverages and alcohol. Diet after gastric surgery may be inadequate because of the limiting size of the stomach pouch, which results in the patient eating smaller amounts of food. Protein intake is often a problem and is likely less than the 1.5 g/kg of ideal body weight. Most patients are able to consume 0.8–1 g of protein/kg of ideal body weight from a combination of foods and liquid supplements, which ends up being about 60–80 g of protein daily. Much of the nutritionist's work is related to informing patients how to eat properly and how to judge fluid, protein, carbohydrate, and fat intake. The importance of self-monitoring by means of keeping daily food records is emphasized from the initial visit.

Mealtime guidelines are provided to encourage fluid intake and to maximize satiety between meals.22 Five guidelines for fluid consumption are as follows:

  • No liquids at meals; wait at least 30 minutes after a meal to start fluids. It is important to avoid overfilling and stretching the stomach pouch.

  • Sip beverages; do not use a straw, which increases swallowed air.

  • The daily goal is at least 1.4 L (6 cups) of fluids. This should include high-protein liquid supplement, skim milk, and sugar-free noncarbonated beverages. Decaffeinated coffee or tea is preferred.

  • Stop eating and drinking when a full feeling occurs. Overfilling the stomach pouch will cause it to stretch, which often leads to increased intake.

  • Avoid carbonated beverages, as the gas bubbles may stretch the pouch.

All patients with bariatric gastric procedures are at risk for nutrient deficiencies. Because Roux-en-Y gastric bypass is a malabsorptive operation, it carries greater risk for nutritional deficiencies than the restrictive procedures. This is because malabsorptive procedures cause food to bypass parts of the duodenum and jejunum, where most iron and calcium are absorbed. Menstruating women are especially prone to developing anemia because insufficient vitamin B12 and iron are absorbed. Decreased absorption of calcium may cause osteoporosis and metabolic bone disease. Patients are required to take nutritional supplements that usually prevent these deficiencies.

Etiology of Protein, Calcium, Iron, and Vitamin B12 Deficiencies and Recommended Supplements

Information in this section about recommended supplements is taken from the ADA Nutrition Care Manual.22

Protein deficiency is caused by inadequate ingestion of protein due to small pouch size. Patients should eat high-protein foods (eg, meat, eggs, and cheese) before vegetables, fruit, or grains. Supplements should include protein isolate powder in milk or other liquids. The minimum amount of protein is 60–80 g/d. The goal is 1.5 g/kg of ideal body weight.

Calcium deficiency occurs because primary absorption sites (duodenum and proximal jejunum) may be bypassed. Supplementation should include 1,000–1,200 mg of calcium citrate. Calcium carbonate is not absorbed as well. If the patient uses chewable calcium carbonate tablets (eg, Tums), the dosage should be increased to 2,000 mg/d. Vitamin D should be included with calcium supplements.

Iron deficiency also occurs because primary absorption sites (duodenum and proximal jejunum) may be bypassed. The intake of foods high in iron is decreased because consumption of red meat is poorly tolerated by some patients. Absorption of iron is decreased because less gastric acid is available. Menstruating females are more susceptible to iron deficiency and anemia. If iron deficient, patients should take 325 mg of iron sulfate with vitamin C for increased absorption.

Vitamin B12 deficiency occurs because of inadequate contact with intrinsic factor resulting from low intake of foods rich in vitamin B12 owing to the small size of the stomach pouch. Physicians should monitor this in patients and supplement their diets with sublingual oral crystalline vitamin B12 (500 µg) or monthly injection as needed.

Etiology of Thiamin (Vitamin B1) and Folate Deficiencies and Recommended Supplements

Thiamin deficiency is caused by inadequate dietary intake, as primary absorption sites may be bypassed.23 Clinical presentations have included acute Wernicke encephalopathy (nystagmus, ophthalmoplegia, ataxia, and confusion), lower limb hypotonia, seizures, polyneuropathy, unsteady gait and ataxia, and hearing loss. Severe deficiency is associated with beriberi. Dry beriberi is the development of a symmetric peripheral neuropathy characterized by sensory and motor impairments mostly of the distal extremities, as demonstrated by difficulty in rising from a squatting position. Wet beriberi manifests as cardiac impairment with peripheral vasodilation, cardiomyopathy, congestive heart failure, edema, tachycardia, peripheral neuritis, and Wernicke-Korsakoff syndrome. Diagnosis can be made by measuring erythrocyte transketolase activity, blood thiamine concentration, or transketolase urinary thiamine excretion. Patients should receive daily B-complex supplements to prevent deficiency. Treatment for acute deficiency manifested by cardiovascular or neurologic signs involves administration of supplemental thiamine, starting with 100 mg/d intravenously for 7 days, followed by 10 mg/d orally until there is complete recovery.

The cause of folate deficiency is unknown. Deficiency is usually prevented if the individual takes a daily multivitamin.

Guidelines for Administration of Supplements

  • One chewable vitamin/mineral tablet should be taken at breakfast and at dinner for 6 months after surgery. After 6 months, many gastric bypass patients elect to switch to an adult vitamin tablet that they can swallow. Gastric band patients are advised to always use chewable vitamins. Centrum® makes an adult chewable vitamin. Prenatal vitamins are good for individuals who need extra iron.

  • Calcium citrate should be taken at midmorning and at midafternoon. The dosage is 500–600 mg twice daily.

  • A B-complex vitamin with at least 10 mg of thiamin should be taken. Also needed is a vitamin B12 sublingual dot (500 µg daily, 1,200 µg biweekly, or 2,500 µg weekly) or a monthly injection of 1 mL.

  • If extra iron is needed, it should be taken with vitamin C. Allow 2 hours or longer between iron and calcium supplements to avoid interference with absorption.

Common Nutritional Problems and Prevention Tips

Nausea and vomiting are caused by overeating or by eating too quickly. To prevent this, patients should eat slowly, chew foods very well, and stop eating as soon as they feel full.

Chronic malnutrition problems occur because nutrients are absorbed differently following surgery. Symptoms are fatigue, aching muscles, and tingling feet, calves, or hands. To prevent malnutrition, patients should consume a healthy diet and always take vitamin/mineral supplements as directed.

Lactose intolerance is characterized by gas, bloating, cramping, and diarrhea after drinking milk. Prevention tips are to drink smaller amounts of milk at a time, to use lactose-free or lactose-reduced milk, or to try soy milk.

Temporary hair loss is caused by rapid weight loss and/or lack of protein or vitamins/minerals in the diet. To prevent this, patients should consume the amount of protein recommended and take vitamins/minerals as directed.

Dehydration is caused by consumption of insufficient fluids or by persistent vomiting. Symptoms include dark and strong smelling urine, dry mouth, headache, and fatigue. To avoid this, patients should sip liquids frequently throughout the day.

Dumping syndrome is caused by food emptying too quickly from the stomach. Symptoms include diarrhea, nausea, cold sweats, and light-headedness. Prevention tips are to avoid consuming refined sugars and high-fat foods and to wait 30 minutes after meals before fluid intake.

Constipation occurs because the intake of food and fiber is reduced following surgery. Prevention tips include drinking plenty of water, exercising daily, taking a fiber supplement such as Benefiber, and eating sugar-free applesauce, oatmeal, or prunes daily.

We understand that what we think patients should ideally eat and what they actually will eat are different. We try to help them alter their dietary behavior to maximize weight loss and absorption of nutrients. We try to identify maladaptive eating disorders such as ingesting high-calorie liquids or foods, binge eating, or starvation. A patient struggling with maladaptive eating disorders should not be difficult to recognize if the right probing questions are asked. Most commonly seen are patients more than 1 year after surgery who begin to gain back weight. While a small percentage of patients can gain back weight because of surgical complications such as stretching of the anastomosis or stomach pouch, most patients are just taking in too many calories. They may not realize where all of their calories are coming from if they are not keeping detailed food records. Patients complaining of weight regain should be referred back to the bariatric team to be evaluated for surgical complications or for excess calorie intake. At the other end of the spectrum are patients who may be struggling with their body image and self-esteem, causing them to skip meals or even to starve themselves. These patients are terrified that they will gain weight back and will benefit from regular visits with a therapist to help them overcome their fears and create a healthy body image. These patients should also be referred back to their bariatric dietitian, who can help them set up a nutritious meal plan.

Weight loss surgery is merely a tool that helps people get a new start toward maintaining long-term good health. The surgery alone will not help someone lose weight and keep it off. Together with a reduced-calorie and low-fat diet and daily exercise, surgery will help an individual lose weight and maintain the weight loss. Following the guidelines about food choices and physical activity will promote adequate weight loss and maintenance. Unfortunately, most patients will be unable to attain ideal body weight, so the goal is to maintain 70% EBW loss for LRGBY and 50% for LAGB. It is important that patients understand and accept this and are able to set realistic goals for themselves.

LATE COMPLICATIONS FOLLOWING BARIATRIC SURGERY

Bariatric surgery has great benefits for most patients and improves survival and quality of life even when the risks of surgery are taken into account. Although LRGBY has a higher initial complication rate than LAGB, LAGB has a higher complication rate in the long term. Most late complications are easily repaired as long as the symptoms are recognized early.

Laparoscopic Roux-en-Y Gastric Bypass

Stomal stenosis occurs in 4.7% of patients.24 Stenosis usually presents as odynophagia/epigastric pain, nausea, or vomiting and can be associated with ulceration, which can be complicated by bleeding, perforation, or malnutrition. Esophagogastroduodenoscopy is the appropriate diagnostic tool. Ulcers may be prevented by using proton pump inhibitors and by avoiding nonsteroidal anti-inflammatory drugs and smoking. Stenosis without ulcers is treated by dilation, but ulcers require twice-daily treatment with proton pump inhibitors and sucralfate, and H2 blockers are added if the ulcers are difficult to treat. For protracted ulcers, treatment of possible Helicobacter pylori infection is initiated even if cultures are negative. Patients may develop complications if they become malnourished and may require intravenous nutrition. When dilation fails to dilate a stricture or if follow-up esophagogastroduodenoscopy shows continued ulceration, surgery is indicated.

Bowel obstruction occurs in 3.1% of patients. This can be insidious but usually presents as crampy abdominal pain associated with nausea or vomiting. Symptoms may come and go or may be constant. Delay in diagnosis can lead to bowel infarction and short-bowel syndrome. Computed tomography is the best initial examination unless the patient requires early operation. Computed tomography can miss this complication, and diagnostic laparoscopy may be required. The causes are hernia, adhesions, or internal herniation, in which the bowel herniates through a mesenteric defect. Internal herniation is the most common cause, and surgery is required to repair the mesenteric defect.

Incisional hernia occurs in 0.7% of patients. Although bowel obstruction is possible, it usually causes local pain or reducible mass near the skin incision of a trocar site. This can generally be identified on physical examination, but computed tomography may be necessary. Surgical repair is indicated to avoid incarceration or bowel obstruction.

Nutritional complications occur rarely if patients are taking vitamins. Because complications of vitamin malnutrition can be severe, routine blood work is necessary, and intravenous therapy should be instituted if a patient has protracted vomiting, nausea, or obstruction. When oral intake does not replete vitamin levels, intravenous therapy may be necessary.

Laparoscopic Adjustable Gastric Band

Slippage or pouch dilation occurs in 12% of patients.25,26 Symptoms include epigastric pain, nausea, and vomiting. Although this complication usually is unavoidable, eating slowly and not overfilling the gastric pouch may help prevent it. If the patient is in extremis, early operation is required to avoid gastric resection for ischemia or perforation of the slipped segment. Symptoms usually are not so severe, and we are generally able to perform band repositioning or removal.

Esophageal dilation occurs in 2% of patients. It is usually insidious with late onset of inability to tolerate food. The cause is unknown. Esophageal dilation is treated by band deflation or by removal of the band if dilation is severe.

Erosion of the band into the stomach occurs in less than 1% of patients. Symptoms include lack of restriction, latent port infection, and dysphagia or epigastric pain. The patient may also be asymptomatic. It is identified by esophagogastroduodenoscopy and is usually missed on upper gastrointestinal series. This complication requires removal of the band and port.

Obstruction occurs in 2% of patients and manifests the same symptoms as slippage and gastric pouch dilation. Rarely, patients have obstruction immediately after placement of the band. This will usually improve in a few days. After adjustment has been performed, deflation of the band usually resolves symptoms. If deflation of the band does not improve symptoms, an upper gastrointestinal series is performed to identify pouch dilation or slippage, followed by revision surgery or removal of the band.

Port complications occur in 7% of patients. There are several types of complications. Most common is a leak in the tubing or port itself, leading to inability to adjust the band and to loss of restriction to eating. Less common is port dislodgment from the muscle fascia, making it difficult to adjust the band. Treatment comprises port replacement or repositioning.

Nutrition complications occur rarely in band patients because these patients have no malabsorption; these complications typically occur only if the patient is unable to tolerate any oral intake for a prolonged time. Vitamins are still required after band placement, and serum vitamin levels are checked routinely. If a patient cannot consume oral intake for 5 days or longer, intravenous therapy is required.

CONCLUSION

Follow-up after bariatric surgery is critical and requires a team approach. For most patients, the benefits greatly outweigh the risks, and they are likely to have better and longer lives after surgery. Patients need to know that the surgery is a tool and that losing weight and keeping it off requires some work on their part particularly with regard to diet and exercise. For the best long-term results, follow-up is key.

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“Half my life has been about trying to lose weight,” Henry Roberts said. He was telling me about his decision to have a surgery that would reduce the size of his stomach by seventy-five per cent. Roberts (a pseudonym) is five feet six, and when we met he weighed two hundred and seventy pounds, giving him a body-mass index of forty-four; a B.M.I. between eighteen and a half and twenty-five is considered healthy. “I tried every diet, every regimen. I even had urine from a pregnant woman injected into me—that was a fad once. Have you ever tried a Weight Watchers cannoli? Weight Watchers didn’t work for me, either, and I found the meetings humiliating.” Roberts, who is sixty-eight and retired from his job as a public-school guidance counsellor, lives in an immaculate, art-crowded apartment in the West Village. He recently went through the breakup of a long-term relationship, but he remains close friends with his ex-boyfriend. Roberts grew up in Queens, the son of an M.T.A. worker who avoided the chemicals in canned foods “before that was fashionable,” he said. Decades ago, he successfully quit smoking and drinking. Managing his weight has been more difficult. “You can’t just quit eating altogether,” he said. He had opted for a procedure called a sleeve gastrectomy—the stomach is surgically narrowed to resemble a sleeve—but this was not Roberts’s first attempt at a surgical treatment for obesity. “I can’t remember the exact year, but I know I had the lap-band procedure the weekend that Michael Jackson died,” he told me. The laparoscopic gastric-band procedure worked for Roberts for about a year, but then he began to regain weight.

Roberts has been “big” for as long as he can remember, and has gained and lost weight so many times that he has kept wardrobes in three different sizes. Most of the people I’ve met who are considering surgery are much larger than Roberts, but he is pre-diabetic, takes a statin for high cholesterol as well as heart and blood-pressure medications, and at night he sleeps with a CPAP machine to counter sleep apnea, a condition frequently caused by obesity. “If I lose the weight, all of these things might improve, or even go away,” he said.

When I asked him if his friends and family supported his decision to have surgery, he hesitated, then said, “Most of my friends, especially most of my fat friends—and I have a lot of fat friends—said, ‘You’re going to put yourself through this again?’ ” He added, “But I felt that this was my last chance, that I had to give it a try.”

Early on a Thursday morning, I went to Beth Israel Medical Center to watch Roberts undergo the sleeve gastrectomy. Bariatric procedures—surgeries that treat obesity—remove no fat tissue; instead, they change the stomach and intestine so that a person feels full more quickly, or absorbs fewer calories, or both. There are four main types of procedure performed these days. Three of them (sleeve gastrectomy, gastric bypass, and biliopancreatic diversion) involve considerable changes to the stomach and intestines, and eighty-five per cent of the time they result in sustained weight loss, usually of around half of a patient’s excess weight. The fourth procedure, the laparoscopic gastric band—which Roberts had in 2009, and Chris Christie, the New Jersey governor, had, to limited effect, in 2013—is simpler, and reversible, since it merely constricts the neck of the stomach with a band. For years, the “lap band” was a popular procedure—it was marketed with a billboard and radio campaign, “1-800-Get-Thin,” as well as a “Lap-Band V.I.P.” promotion—but it has proved to be the least effective. The bands can break, and while the other surgeries are known to remove some of the cells in the gastrointestinal tract that secrete ghrelin, the “hunger hormone,” it’s unclear whether the lap band leads to reduced ghrelin levels.

In the early nineties, fewer than twenty thousand bariatric surgeries were performed in the U.S. each year. Now the number is around two hundred thousand, where it has plateaued. Only in the past few years has what was once considered a high-risk and extreme measure been transformed into a relatively standard, safe, and straightforward one. There is strong consensus that bariatric surgery is effective, and Medicaid now covers it in forty-eight states. At the same time, research into conventional weight-loss methods has repeatedly pointed to an overwhelmingly dispiriting conclusion—that diet and exercise alone, no matter how disciplined the individual, fail overwhelmingly often. This makes for an unsettling and consequential revolution in our understanding of our bodies. Still, only about one per cent of those who medically qualify for bariatric surgery get it. Advice about diet and exercise often has a moral undertone; surgery has a mechanistic one. I wanted to think about what this meant. Peddling new approaches to dieting is a multibillion-dollar industry. In one sense, bariatric surgeries are an addition to this market; in another, they are a counter to it.

Arriving early for Roberts’s surgery, I waited in a corner of the lobby by two vending machines, one that sold candies and chips and another that sold kosher food, mainly apples and bagels wrapped in cellophane. I went outside to the cart selling coffee and pastries. More than a decade ago, as a medical student, I spent a month on a surgical team that performed bariatric surgeries. The long hours meant that we ate mostly from coffee carts, with a supplement of take-out Thai and Chinese. I remember the fun-house-mirror effect of half of us losing weight on this unintended regimen as the other half of us gained.

In that time, I scrubbed in on a few procedures performed by Roberts’s surgeon, William Inabnet, a internationally known endocrine surgeon who was a member of the team of physicians that developed sleeve gastrectomy as a stand-alone procedure. (It was originally the first step in bypass procedures for patients with a B.M.I. of greater than sixty.) For Roberts’s gastrectomy, which was performed laparoscopically, Inabnet was joined by the surgical fellow Aida Taye Bellistri, an anesthesiologist, and two surgical nurses. The surgeons began by making incisions above the umbilicus and beneath the left and right sides of the rib cage. The umbilical incision was used to inflate the abdomen by pumping in carbon dioxide, providing a vaulted internal space for the surgeons to work in. A light and a camera were then also inserted through the umbilical incision. Laparoscopic surgery leads to less postoperative pain and a lower risk of hernias and infections than traditional open surgery. It also makes surgery, for the bystander, seem more like a video game.

Large monitors were mounted above Roberts’s body, like sports-bar television screens. Inabnet and Taye Bellistri looked up at the monitors, rather than down at the patient, as they maneuvered the handles of tools threaded through the left and right incisions. On the screens, the image was so big and so clear that it was easy to read the tiny brand names—Covidien, Karl Storz—written on the slender surgical instruments. Roberts’s abdominal cavity looked like the inside of a mossy, yellow cave lit up by miners’ headlamps; vasculature appeared like streaks of mineral ore, the liver like a respiring troglobite.

I had forgotten how unsettling watching even the least bloody—maybe especially the least bloody—surgery can be. It’s a reminder of how our organs and vessels proceed on their own—and of how much automatism being human really involves. Inabnet and his team spent the first forty-five minutes of Roberts’s surgery meticulously removing the adhesions of his old gastric band from his liver, abdominal wall, and small intestine. This process involved minute tugs and tears, punctuated by pauses to cauterize minor bleeds. When it was done, Inabnet said, “That was the hardest part. The rest is pretty straightforward.”

Inabnet then used a surgical stapler, which resembles the jaws of a toy alligator affixed to a slender metal rod; the stapler put down six rows of tiny staples with each bite. By cutting between the rows, three-quarters of the stomach was gradually sliced away. The camera and the carbon-dioxide pump were then retracted so that the detached segment of stomach could be pulled out. Magnified onscreen, Roberts’s stomach had seemed so large, but, once removed, the offending organ was smaller than a hand.

Over the centuries, suggested strategies for losing weight have included bitter tonics, bleeding, sea air, amphetamines, Turkish baths, tapeworms, purgatives, low-fat diets, high-fat diets, cinnamon, more sleep, less sleep, and the “vigorous massage of the body with pea-flour.” The Roman emperor Aurelian advised rubbing cloth over body fat to get rid of it, an apparently enduring notion: I remember going to a gym with my mother, in the nineteen-eighties, and encountering a machine that consisted of a vibrating belt that you were supposed to step into to shape your thighs or your waist. Surgery is an old idea, too. One of the earliest surgical approaches to weight loss, dating back at least a millennium, was simple: the jaw was wired mostly shut. Another story from pre-anesthesia days tells of a rabbi “being given a sleeping potion and taken into a marble chamber, where his abdomen was opened and many baskets of fat were removed.”

In 1954, a Swedish doctor decided to bypass segments of dogs’ intestinal tracts. He hoped to curtail the time and space that the body had to absorb calories. The animals subsequently lost weight, and a research doctor observed, “This questionable method of controlling obesity will have the necessary experimental foundation.” So it was that in 1956 ten Swedish women, each at least a hundred and twenty-five pounds overweight, agreed to a trial of an intestinal bypass. All of the trial participants had attempted more straightforward ways of losing weight; one had gone from two hundred and forty to a hundred and forty-five pounds in a hospital setting, but now weighed two hundred and ninety pounds and, at the age of twenty-five, was suffering from cardiopulmonary failure and perilously high blood pressure. Following the surgeries, all ten patients experienced dramatic weight loss, with no immediate serious complications. [cartoon id="a20285"]

But then the bypasses were reversed. Now that the patients were at a healthier weight, it was thought, they could maintain that weight with a normal intestinal tract. Furthermore, the section of the intestine that had been skipped over was important for the absorption of calcium, iron, B12, and other nutrients. However, after the reversal surgeries the women regained every pound, sometimes more.

Throughout the sixties and seventies, stomach stapling became popular. Sometimes the stapling was horizontal, sometimes vertical. Sometimes longer stretches of the intestine were bypassed, sometimes shorter. This all sounds—and in many ways was—improvisational and brutal. The risks were substantial: many patients got hernias through their incision sites; some of them developed dangerous leaks of intestinal contents into their abdominal cavity; some had infections and bowel obstructions; and some suffered serious malnutrition from failing to absorb nutrients. All of these problems are potentially fatal, and some patients died.

But the health risks associated with obesity were also becoming apparent—higher rates of stroke and heart disease, Type 2 diabetes, infertility, sleep apnea, osteoarthritis, and an increased risk of certain cancers. And bariatric procedures were improving dramatically. Laparoscopy, which became the norm in the past decade, results in few hernias. Physicians now have a better sense of how to prevent and treat the complications of surgery. As recently as fifteen years ago, there was a one-per-cent chance of dying from a bariatric procedure—a relatively high risk. Now it is 0.15 per cent, which is less than that for a knee replacement, a procedure commonly recommended to people who have developed joint problems from carrying around excessive weight. Roberts’s surgery took less than two hours, and he went home a day later, feeling only mild discomfort, with instructions about vitamin supplements and follow-up appointments.

Tom Wadden, a clinical psychologist at the Center for Weight and Eating Disorders, at the University of Pennsylvania, told me, “Look, I’m a dyed-in-the-wool behavioral psychologist, and even I will tell you that there’s no question that bariatric surgery is going to provide a larger and more durable weight loss than life-style modification, medication, or even a combination of the two.” Around seventy-five per cent of bariatric patients have sustained weight loss five years after their surgery, and that percentage is higher if you don’t include lap-band patients in the analysis. Weight loss through diet and exercise rarely leads to more than short-term changes—a quite small percentage of patients see sustained weight loss. Wadden continued, “I absolutely recommend surgery to some of my patients, yes, but I say that in talking about treating obesity, not about preventing it. And the prevention of obesity has to be the greater focus of our attention, as a society.”

Two out of three American adults are overweight, and one out of three can be said to have obesity. (The medical definition of obesity, imperfect but useful, is based on B.M.I.) In 1990, hardly any states had obesity rates of more than fifteen per cent; today, all fifty states have obesity rates of at least twenty per cent. A 2012 study in the Journal of Health Economics estimated the medical-care costs of obesity in the U.S. in 2005 to have been as high as a hundred and ninety billion dollars, a figure that is steadily increasing. William Dietz, who was part of the team at the Centers for Disease Control and Prevention that, in 1999, declared obesity an epidemic, said that, at the time, “people would ask me, ‘Why is this happening now? What has changed?’ My answer, informally, would be that everything has changed. Everything on the dietary side, everything on the physical-activity side—everything.” Today, obesity is second only to tobacco as a killer in this country.

Dietz, who trained as a pediatrician and later received a Ph.D. in nutritional biochemistry from M.I.T., originally intended to work on malnutrition in the developing world. When he turned to obesity, it interested him for being “similarly deeply embedded in culture, food systems, and environmental practices.” One of the fathers of obesity studies, George Bray, in his 2011 book, “A Guide to Obesity and the Metabolic Syndrome,” drew especial attention to the decades of subsidies for corn, sugar, and rice. Other researchers have pointed to the “Snackwell effect,” referring to the moment, in the late nineteen-eighties, when, after studies suggested that people ought to lower their fat intake, consumers turned en masse to sugary treats advertised as low-fat or no-fat—advertised, in essence, as good for you. American health is further assailed by long commutes, sedentary jobs, yo-yo dieting, and the charming toucans and tigers that beckon to children along the breakfast aisle of the grocery store. And then there are our electronic devices. Wadden noted, “I’m sure that Steve Jobs wasn’t thinking that he was going to make devices that contributed to people expending five hundred to eight hundred fewer calories a day, but that’s what has happened.”

Some academics and activists criticize the use of the terms “epidemic” and “disease” in describing obesity, arguing in part that such language exacerbates the already widespread phenomenon of “fat shaming.” Danish Asif, a recruiter from Staten Island who had recently lost a hundred and ten pounds, reflected on the indignities of obesity: “Imagine: An old friend from college calls you up, wants to hang out, you’re excited to see him, but then he shows up in a Sentra. You can barely fit. And there’s a beeping the whole time, because you can’t close the seat belt. You get on an airplane, and you know everyone is praying that you’re not going to be seated next to them.” Dietz stresses the importance of understanding obesity as a set of health issues. “We talk about ‘people with obesity,’ not ‘obese people,’ a phrasing that is more about identity,” he said. From a medical point of view, obesity, like asthma, is something that happens to a person—a disease with many etiologies, not all of them well understood. Dietz went on, “Embedded in the stigmatization of obesity is the idea that this is something that people have done to themselves; that’s not the way to understand it.”

“People often have moral judgment in this area,” Marc Bessler, who was among the first physicians in the nation to perform a bariatric surgical procedure laparoscopically, in 1997, told me. “But I don’t think that’s helpful. Our relationship to food is strange. We still don’t fully understand how things like refined sugars are affecting us.” He told a story about a patient who was on a no-carb diet. “He said he was getting along fine until, one day, on the way out to work, he let himself take one small bite of a waffle. Just one bite. He then left the house, got into his car, reversed his car. Then he literally pulled back into his driveway, went back inside, and ate three waffles.”

Bessler’s office is on the fifth floor of a Columbia University Medical Center building, in a hallway with flyers advertising Buddha Body Yoga and Post-Weight Loss Surgery Psychotherapy. Bessler’s father had obesity, and died, at fifty-four, of colon cancer, which obesity is known to make more likely. But Bessler traces his interest in the field of bariatric surgery to his surgical residency: “I was at the hospital Christmas party, and a surgeon I admired, a few drinks in, said to me—about laparoscopy, which was a new thing back then for abdominal surgeries—he said, ‘I’ve seen the future, and we’re gonna be taking colons out through straws.’ I liked that.”

I asked Bessler what he thought about the ecstatic popularity of shows like “The Biggest Loser,” where primarily diet and exercise are used as weight-loss tools. He said, “I’ve operated on two people from ‘The Biggest Loser,’ one person who won. It’s just not a realistic setting, exercising six to eight hours a day. People have jobs.” A study that followed up on fourteen contestants from Season 8 of “The Biggest Loser” found that all but one of the finalists had regained much or most of their original weight, and that these contestants’ metabolic rates had slowed dramatically, making maintaining a healthy weight even more difficult. According to researchers, the shock of sudden weight loss prompts the body to try to put weight back on. For reasons not fully understood, people who undergo gastric bypass do not tend to experience the same sustained metabolic slowing.

I was curious whether Bessler could tell me what kind of person was most inclined to choose bariatric surgery. I thought he might say something about who had a more moralistic view of weight, or who was more trusting of the medical system. Instead, he said, “Well, women, of course. A man who is a hundred pounds overweight, he will still be treated with respect. But a woman who is a hundred pounds overweight—it’s much more difficult for a woman.”

It is clear that obesity, and the stigma associated with it, can’t be solved by hundreds of millions of gastric bypasses and sleeve gastrectomies. One piece of encouraging news is that among two-to-five-year-olds there is evidence that obesity rates may be declining. But there is no such news for adults. George Bray told me, “When the day comes that we can mimic the weight loss without the surgery, I think surgery will fade away. How long this will take, and what form, I can’t hazard a guess.”

The cultural and literary historian Sander Gilman, who wrote “Obesity: The Biography” (2010), told me that, just as “every diet works for some people but no diet works for everyone, bariatric surgery will work for some people but it will not work for all.” He added, “I would suggest that surgery needs to be paired with psychotherapy or behavioral therapy, since there are so often underlying problems to address; you don’t want the symptoms to just transfer to another domain.”

Many diaries by people who have lost weight can be found on the Internet; they sometimes reflect the writers’ frustration at finding themselves still depressed, or still in distress in a relationship, or still mired in a drinking problem. As a woman named Lisa, who posts at gastricbypasstruth.com, writes, “Once the fat is gone, your real problems are no longer masked—they’re out in the open and you have to deal with them. If you’ve always thought skinniness was the cure-all, it can be quite a slap in the face when you get there and find out your problems followed you.” [cartoon id="a19571"]

There are also physical problems. Most surgical patients need to commit to a lifetime of vitamin supplements and regular checkups, and some people—especially those who choose gastric banding—experience significant discomfort or even vomiting from feeling full. Sugary and fatty foods can cause gastric-bypass patients to have cramping and diarrhea. Furthermore, patients with extreme obesity are often burdened with loose skin after a dramatic weight loss. Paul Mason, a British man who went from nine hundred and eighty pounds to three hundred and fifty, following a gastric bypass, needed to have some seventy pounds of excess skin removed. Bariatric surgeries, which can cost as much as thirty thousand dollars, are covered by many major insurance companies. (Most studies suggest that the expenses are recouped within two to three years, because the surgeries avert future obesity-related medical expenses.) Skin-removal surgeries, which are sometimes even more expensive, are rarely covered.

Roberts loves travelling, and has been to dozens of countries; he planned to visit the ice-and-snow festival in Harbin, China, a month after his surgery. Having had no complications, he went. “I walked around five to six hours a day while I was there,” he said. When I met up with him ten weeks after his operation, he had lost forty-six pounds, and now weighed two hundred and twenty-four. “Which is halfway to my goal of a hundred and eighty,” he said. “Although maybe that goal is too ambitious.”

I asked him if he worried about regaining the weight, as he had after his lap-band procedure. “I know now that when I walk by the ice-cream aisle it’s not a problem for me anymore. I’m not even tempted—I really don’t want it.” After his lap band, ice cream had still been a strong temptation. “I’m optimistic. I can’t really eat red meat anymore, I’m not comfortable with it, and sometimes when my friends go out for dinner before seeing a play I skip the restaurant, even though I like being with friends in that way.” Roberts said that he’d been eating a lot of fat-free refried beans, chicken soup, and salads. He laughed when he mentioned this, as if it were a punch line. “I’ll tell you what I am worried about,” he said. “I’m going to a casino in Atlantic City next week. They know me there, they come by, they see me, and they say, ‘Three-pound lobster?’ and that’s difficult to turn down. I guess I won’t turn it down. I’ll take it, but only eat a small portion, and save the rest for later.”

A month afterward, we spoke again, and Roberts said that he still felt great, was still losing weight. “I’ve gotten the fat clothes out of the house; they’re in the basement in storage.” He has also been enjoying the praise of relatives, who have told him that they had been worried about him in the past but had been reluctant to say so. “I’m really, really happy with how things are going,” he said. “Maybe I have a bit of a turkey wattle under my chin now, from the weight loss; eventually, I may try to do something about that.” He told me that he feels as if he now skips up the stairs of the subway station. Both of Roberts’s parents lived into their nineties, and he said that he has always had a feeling that he would live a long time as well. “And I didn’t want to live like an invalid, unable to get around, having difficulty breathing.”

Roberts told me two stories about how he had changed his habits in the past, one about quitting smoking and the other about quitting drinking. He had attended a Smokenders course, which had discussed triggers—noticing what made you pick up a cigarette. “For me, it was a ringing phone,” he said. “I’d pick it up and find I had a cigarette in my hand.” Quitting alcohol had been simpler. “I was maybe twenty-five years old, and I saw an advertisement on television,” he said. “A simple advertisement. It said, ‘If you think you might have a problem, then you probably do.’ That was all it said: ‘If you think you might, then you probably do.’ That affected me. Just an ad. I didn’t take a single drink after that; I was done with it. That’s how powerful advertising can be.”

I took the subway home. The bars of the turnstile read, alternately, “Hello, Happy” and “Hello, Hershey’s.” I can’t deny that Hershey’s Kisses were a substantial source of happiness in my childhood. Across from me in the subway car, a large woman was reading Dr. Oz’s glossy magazine, The Good Life; headlines included “20 Ways to a Flatter Belly” and “Eat for High Energy.” Any decent nutritionist will tell you that an energy bar often has as much sugar and fat as a candy bar. Sports and energy drinks now contribute more than soda to weight gain in teen-agers. About three-quarters of Americans consider a granola bar healthy, while only one-quarter of nutritionists do. There are few ad campaigns for plain old produce.

I thought about the adorable little cardboard M&M who’d beckoned to my toddler daughter when we recently stepped into a Duane Reade drugstore. “I want to go and meet him,” my daughter said, and she began to weep when I told her that we weren’t going to buy M&Ms. I used to think parents who worried about their children’s sugar intake were overly controlling kooks; now I understand how a parent even mildly informed about nutrition might feel that trying to raise a healthy child in the modern landscape is like trying to raise a healthy child in a chemical-processing plant charmingly decorated in pink, red, and green. Wadden, the clinical psychologist, summarized the problem, saying, “In Philadelphia right now, a proposition just passed to tax sodas, and to use the funds for universal pre-K. It’s great to have money for universal pre-K. But is it just sugary drinks? The sugary-drink companies will say, ‘But it’s salty snacks! Why are you targeting us?’ Well, we have to start somewhere.”

A three-part lecture titled “On Corpulence,” delivered, in 1850, to the Fellows of England’s College of Physicians, by Thomas King Chambers, M.D., relates the story of a great European delicacy, the ortolan, a small bird eaten whole. Ortolans, by instinct, feed only at dawn, and are therefore trim (and insufficiently tasty) in the wild. Chambers details how “Italian gourmands” devised a way to fatten them:

The ortolans are placed in a warm chamber, perfectly dark, with only one aperture in the wall. Their food is scattered over the floor of the chamber. At a certain hour in the morning the keeper of the birds places a lantern in the orifice of the wall; the dim light thrown by the lantern on the floor induces the ortolans to believe that the sun is about to rise, and they greedily consume the food upon the floor. More food is now scattered over it and the lantern is withdrawn. The ortolans, rather surprised at the shortness of the day, think it their duty to fall asleep . . . the rising sun again illuminates the apartment, and the birds, awakening from their slumber, apply themselves voraciously to the food upon the floor . . . thus the sun is made to shed its rising rays into the chamber four or five times every day. . . . The ortolans thus treated become like little balls of fat in a few days.

It’s as if Chambers had a premonition of us, today, confused by the blue light of our screens, the treats in our cages. “We are meant to fast and feast, like the other carnivores,” I once overheard a flight attendant say to another on an overnight plane. “But there’s always a feast around.”

The overwhelming majority of bariatric-surgery patients who post online about their experiences are happy that they had the procedure; the twenty or so patients I spoke with directly were even more positive about it. Many described it as the best decision they ever made. “My only regret is not doing it sooner,” a father of three told me. A twenty-seven-year-old, who had always been body-positive and had the surgery because she was aware of looming health hazards, told me that after the surgery she found she had the energy to move into her own apartment, to finally get a driver’s license, and to go back to school while working a full-time job. For many people, the experience of weight loss is one of feeling like they can be themselves. Even the more skeptically titled postsurgery diaries are punctuated with observations like “Would I do it again? Probably. Well, O.K., definitely.”

One bariatric surgeon, Yulia Zak, told me that she’d never had any particular interest in the field until she did a required rotation. “I would be seeing a preoperative patient, often someone who was depressed, maybe unable to find a job, in part because of their mobility and appearance, and who was on insulin meds and blood-pressure meds, and with sleep apnea and high cholesterol,” she said. “Then, right next door, I would see someone for their two-year postoperative appointment, and they would be off those medications, and they might have a baby with them, or a new job. Obesity-related infertility or mobility issues were no longer a problem for them. There was no other field of medicine where I saw people’s lives improved so dramatically.”

And yet, when bariatric surgery is thought of as a phenomenon happening in our society, rather than as a drama for a particular individual, one begins to think of the Red Queen in Lewis Carroll’s “Through the Looking-Glass,”* who has to run and run just to stay in place. Surgery changes a person into a being with a different intestinal tract, a different hormonal response to food—it’s almost like becoming a member of a new species, one better adapted to our current world. In the “Transactions” of the Medico-Chirurgical Society of London for 1847, there is a table that lists, alongside height, weight, age, and other factors, the “attributed proximate cause” of dramatic increases in weight: “copious weak drinks,” “marriage,” “going to India,” “becoming a coachman,” “taking mercury for syphilis,” “too little to do,” and, simply, “irregular life.” Now the trigger may as well be listed as: Born to anything but the luxury of access to fresh produce, a natural indifference to advertisements, limited and flexible work hours, a reasonable commute, the rare leisure to walk or to ride a bike. ♦

*A previous version of this piece misstated which book the Red Queen appears in.

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