Why does WLS fail?

In the bariatric community, we spend a lot of time debating about which WLS is the best – which one yields the best outcome (my own definition of that is optimal weight loss with minimal complications). I think we can all agree that there’s no such thing as a perfect or one-size-fits-all bariatric surgery. If we’ve all fought weight battles long and hard enough to need or choose WLS, we can surely agree that obesity is tough to overcome. And that is, I think, the grounds for further agreement, about why WLS fails.

       Here’s my premise: weight loss surgery fails because of obesity.

       Yes, some disappointment or failure can be attributed to the inadequacy of a medical device or surgical procedure or surgeon or patient, but underlying all that is the basic reality of obesity: it’s a chronic and currently incurable disease, caused by a mixture (unique to each patient) of genetics, behavior, environment and biology. Weight loss surgery may address some aspects of those factors, but not enough to cure obesity. So it fails because of obesity.

       I’ve given a lot of thought to how genetics, behavior, and environment have contributed to my own case, but no more than a passing glance at the biology of it. I’m the daughter of a gifted scientist who passed on not one single gene of scientific aptitude to me (instead, I got his nose and the name McMillan).

       I realize that saying that WLS fails because of obesity is like saying the ocean is wet because it contains water, but as with many obvious facts of life, it’s easily overlooked. We go into WLS believing or at least hoping that surgery will fix enough of what’s wrong in us to help us lose weight and maintain that weight loss, but we need to remember that no WLS will cure our obesity. We need to remember that our obesity is at least partly caused by factors that are invisible to us.

       Those factors were invisible to me until a few weeks ago, when I was asked to write a magazine article about some recent research studies that found a link between obesity and fibromyalgia. I’m uniquely qualified to write that article because I’m a veteran of both wars.

       When I began researching the article, I was astounded by the dense mountain of information: scientific data, theories, probabilities and conjectures that I’d heard little or nothing of before despite my exalted status as the World’s Greatest Living Expert on the Adjustable Gastric Band. I’ve had WLS, talked to dozens of bariatric medical professionals, attended three bariatric conferences, read countless books, articles, blogs and reports, but suddenly I felt like a babe in the bariatric woods. Why hasn’t either of my bariatric surgeons (never mind my primary care physician) mentioned any of this to me? Are they unaware of it?

Are they hiding it from me and the rest of their patients? Is there a conspiracy afoot?

       This information is of enormous importance if only because it knocks a big hole in the old-school blame-the-patient approach. The paranoid in me wonders if the information is hidden to protect an industry or to further a political cause, but since paranoia is my brother’s specialty, I put those thoughts aside and instead considered the very real possibility that bariatric surgeons are well aware of the obesity mountain but are practicing a form of medicine that circumvents it. They don’t climb the mountain and they don’t hike around it. They cut right through the middle of it.

       To explain myself now, I’ll have to resort to another simile. In a sense, bariatric surgeons treat obesity by stuffing a many-armed octopus in a sack and bludgeoning it with an axe. I’m not criticizing the surgeons. Surgery of any kind requires a breathtaking degree of confidence, skill, and audacity. Although surgery doesn’t address every waving octopus arm, it is the only effective long-term treatment for obesity available in the United States today, and I’m very grateful that I was able to have WLS and lose my excess weight as a result of it. At the same time, I sometimes worry about the future. What if treatment of a medical problem requires removal of my band? What if obesity takes over my life again in spite of my band and all my hard-won lifestyle changes? Are researchers working on an obesity cure now that can help me with that in the future?

       It turns out that researchers have indeed been busy searching out the causes of obesity in the hope of finding a better way (or ways) to treat it, prevent it, and/or cure it.

       As I mentioned above, several studies have reported a link between obesity and fibromyalgia. It’s easy to get caught up in a chicken & egg debate about that – does one disease cause the other? I don’t want to go down that road right now. Instead I want to talk about some factors that are associated with (and may be contributing to) both conditions. They are:

1.     Non-restorative sleep

2.     Neuroendocrine dysfunction

3.     Dysregulated HPA (hypothalamus-pituitary-adrenal axis)

4.     Inflammation and immunological vulnerability

5.     Mitchondrial dysfunction

6.     Chemical toxins (such as the preservative sodium benzoate, used in many soft drinks) and biotoxins (such as mold)

 

       As I said before, I’m not a scientist, but I interviewed five medical professionals about this and plowed through reports of a dozen research studies in my effort to understand this. I apologize if my presentation of this material isn’t crystal clear. Even if nothing else is clear, I hope you can grasp the message that the causes of and factors in obesity are extremely complicated and well beyond the means of any currently existing medical device or surgical procedure to cure. I also hope you can see that blaming yourself for your obesity doesn’t go very far in treating it. You are not in conscious control of your neuroendocrine system. But neither are you entirely helpless. You have (or will soon have), a bariatric tool that when carefully used, can bring your appetite under better control and increase your sense of satiety. You can learn as much as possible about the factors that can improve your overall health and counteract the misbehavior of your nerves, hormones, and immune system. For example, I know for a fact that regular exercise helps me manage not just my weight but my depression and pain. You may feel defeated by the very idea of that, but according to an article in the July-August issue of IDEA Fitness Journal, as little as 5 to 15 minutes of exercise a day can yield health benefits and also increase your self-control when it comes to food choices.

       At the end of the day, I still suffer from obesity and fibromyalgia, both puzzling and difficult to treat, but I try not to think of myself as a victim of those diseases. I can curl up in a chair with a box of chocolates and weep about my situation, or I can go on learning about my medical conditions and experimenting with ways to improve my health and quality of life. The author of one of the obesity-fibromyalgia studies, Akiko Okifuji, recommends that patients adopt healthier lifestyles and take more positive attitudes toward symptom management. That may sound condescending, but as one doctor wryly pointed out, “every person in America would benefit from that approach." I know that’s easier said than done, but I’m willing to try it…are you?

Jean

Note: more detailed explanations of the 6 factors mentioned above will be published in the November 14th issue of my e-newsletter, Bandwagon on the Road. There isn't enough room for all of it in an OH forum post.

 

Very interesting Jean. I also suffer from obesity, Fibromyalgia and Rheumatoid Arthritis. I am almost two years out from surgery and have started to gain back weight. I was just reading parts of your book to help me get back on track. This problem has been all me. I strayed away from healthy eating, etc. I will be looking forward to reading your 11/14 issue of the Bandwagon on the Road.

Excellent post! Both disesases are baffling and a royal pain. I pray they will one day find a cure for both, hopefully in our lifetime!

You are absolutely right, Jean.  Fact is, even with the surgery, the fat girl still lives inside and she will never die.  You just have to tame her.  And she WILL bug you every chance she gets.  WLS is not a magic bullet or a sure cure.  Its simply a tool that need to be used to help with your eating program.  Any type of permanent weight loss requires a change in our eating habits. 

Thanks for posting.  It was a very interesting post.

LaWanda

Thanks for another thought provoking article Jean.  My husband and I were just talking about this the other day. 

Good post, Jean. Recognizing obesity as a disease that like many diseases has no single and no easy cure is hard for most people to grasp. The general attitude is that people are fat because they choose to be fat and have no self control. There are so many factors that are personal to each of us. WLS can not just wipe away all of these factors leave all of us thin and happy.

I have been giving some thought about how bariatric surgeons should help post-ops. I recently blogged about this. I encountered a post-op cancer patient who spoke about a 12 week program after surgery where the patients were mentored , educated and encouraged to change their lives to the positive. After hearing that I thought why doesn't bariatric surgery have such a post-op program. I think it comes down to baraitric surgery is seen at something less that cardiac or cancer surgery. Hospitals, doctors, surgeons and insurance companies need to acknowledge that bariatric surgery requires a "rehab" time and greater post surgery listening time with patients. This rehab isn't a fix-all but it could help the bariatric surgery community understand the effect of baiatric surgery on patients after they leave the operating room.

Tom,

You are so right about the attitude of medical professionals towards post-op care. It scares me to think that general surgeons are jumping on the bariatric bandwagon as a way to increase income by performing a newly "fashionable" surgical procedure without understanding how important aftercare is to patient success (and avoidance of complications).

Jean