Explore the process of downsizing and its impact on well-being with Meri Sehat. Learn practical tips for a simplified and healthier life.

Downsizing In Progress

Introduction

With &lsquo;globesity&rsquo; &ndash; the global epidemic of <a href="https://merisehat.pk/disease/obesity">obesity</a> and overweight &ndash; taking over the world, multiple countries have begun employing policies and campaigns to stop its spread. As of 2000, there are more than 300 million obese adults worldwide according to the World Health Organization<a href="#accordion">[1]</a>.&nbsp;

Obesity was once considered a disease plaguing high-income countries. However, significant escalations now have also been noted in low- and middle-income countries<a href="#accordion">[2]</a>. An estimated 115 million people in developing countries suffer from obesity-related problems<a href="#accordion">[1]</a>.&nbsp;

With the increasing number of obese people, several approaches cropped up left, right, and center, each claiming to be different and better than its predecessor in treating obesity. Most of the time, however, these techniques (which include lifestyle changes and medications) are unable to solve the problem. Therefore, doctors then switch to more drastic measures, such as surgical procedures.&nbsp;

The American Society for Metabolic and Bariatric Surgery (ASMBS) recommends weight loss surgery for adults with a BMI of 30-35 kg/m2, and who either suffer from obesity-related comorbidity (e.g., diabetes) or who haven&rsquo;t seen significant results from lifestyle changes (e.g., healthy diet and exercise)<a href="#accordion">[3]</a>.&nbsp;&nbsp; 
&nbsp;

Understanding Weight Loss Surgery Options

The type of weight-loss surgery a surgeon recommends will be based on several factors, such as the patient&rsquo;s history of abdominal procedures, their health needs, and their preferences.&nbsp;

Weight-loss surgeries can be divided into the following:

&nbsp;

<ul>
	<li>
	<h5>Restrictive Surgeries</h5>
	</li>
</ul>

Restrictive surgeries reduce the size of the stomach, thereby, limiting the amount of food a person eats. Post-surgery, patients normally eat only about three-quarters of a cup of food. Restrictive procedures have fewer side effects compared to bypass surgeries. However, they are less successful since overeating stretches the gastric pouch over time, causing it to hold more food.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Malabsorptive/Restrictive Surgeries</h5>
	</li>
</ul>

​​​​​​​These procedures often bypass a part of the digestive tract, limiting the number of calories absorbed by the body. However, malabsorptive surgeries are rarely conducted today due to their side effects.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Implantable Device<a href="#accordion">[4]</a></h5>
	</li>
</ul>

<a href="#accordion">​​​​​​​</a>This is a relatively new method and involves implanting an electrical device within the patient&rsquo;s stomach, near the vagus nerve. Also known as a gastric pacemaker, it produces electric stimulation that controls the communication between the brain and the stomach, thus, reducing appetite and leading to a feeling of fullness and satiety.

&nbsp;

Weight-loss surgery is not only to help the patients achieve a healthy weight but also to treat obesity-related diseases. The three most commonly performed weight loss surgeries are gastric banding, sleeve gastrectomy, and gastric bypass. They are usually done laparoscopically; however, open surgery may be preferred if the patient presents with a history of gastric surgery, severe obesity, and other medical problems.&nbsp; 
&nbsp;

This is a type of restrictive surgery where the surgeon places a silicon ring on the top part of the stomach. As a result, the stomach is divided into two parts &ndash; a small pouch above the ring and a larger part below, both connected via a small channel.&nbsp;

Creating the pouch reduces gastric emptying from the small pouch. The ring is adjustable and can be resized to further restrict the stomach size. Due to the creation of a small pouch, the patient feels full after just half or one cup of food. Also, overeating or eating too quickly causes vomiting.

&nbsp;

<ul>
	<li>
	<h5>Advantages</h5>
	</li>
</ul>

Adjustable gastric banding is a simpler procedure as compared to other surgical interventions. It has fewer post-op complications and promises a faster recovery for the patient. Also, it poses the least risk of vitamin and nutritional deficiencies for anyone opting for weight-loss surgery. Furthermore, it is reversible; so, if there&rsquo;s any discomfort, health risk, or a change of mind, the patient can easily ask their doctor to remove the band.&nbsp; &nbsp;

&nbsp;

<ul>
	<li>
	<h5>Disadvantages</h5>
	</li>
</ul>

The weight loss is slow and the results vary compared to the other procedures. So, it may not turn out to be as effective for someone who wants a quick fix or wants to lose a significant amount of weight; people tend to lose motivation over time or they start to feel uncomfortable carrying the ring inside their bodies. It is definitely not recommended for a patient with type 2 diabetes since the success rate may be low. Moreover, the band requires multiple adjustments and, even then, there is always the risk of band slippage. Besides, adjustable gastric banding is associated with enlargement of the esophagus, which means there may be swallowing problems post-surgery. 
&nbsp;

Also called &lsquo;vertical sleeve gastrectomy&rsquo;, the laparoscopic procedure removes approximately 80% of the stomach, leaving behind a banana-sized stomach<a href="#accordion">[5]</a>. The remaining stomach or sleeve is closed with staples and is connected to the intestines. Since the size of the stomach is reduced, the patient feels full sooner. This is because the part of the stomach responsible for producing the hunger hormone is affected which, in turn, affects the metabolism rate so the patient experiences a reduced appetite.&nbsp;Common complications include leaking of the sleeve, infections, and blood clots.

&nbsp;

<ul>
	<li>
	<h5>Advantages</h5>
	</li>
</ul>

One of the pros of this procedure is that it is effective in extremely obese patients who have high-risk medical conditions. It is simpler and shorter than other weight-loss surgeries, and it is also possible for a patient to have gastric sleeve gastrectomy before a gastric bypass.

&nbsp;

<ul>
	<li>
	<h5>Disadvantages</h5>
	</li>
</ul>

It may lead to heartburn in some individuals, and it may be less effective as compared to bypass procedures. Additionally, it is irreversible. 
&nbsp;

This is a combination of the restrictive and malabsorptive procedures. The laparoscopic procedure has 3 steps:&nbsp;

1. The stomach is divided into two portions &ndash; a small pouch in the upper portion and a larger part below.&nbsp;

2. The intestines are also divided into two parts, and the lower part is connected to the small stomach pouch for allowing food to pass. As a result, the food bypasses part of the stomach and intestines. Thus, fewer calories are absorbed from the food.&nbsp;

3. The upper part of the small intestine is connected further down to the lower part. This allows the passage of gastric juices to the lower part so the food is fully digested.&nbsp;

Common risks associated with the procedure include more chances of infections and blood clots. Moreover, rapid weight loss can also lead to gallstones in patients.

&nbsp;

<ul>
	<li>
	<h5>Advantages</h5>
	</li>
</ul>

The best thing about it is, obviously, rapid weight loss. What&rsquo;s more, it&rsquo;s effective for diabetic patients and also for those who suffer from obesity-related conditions, like sleep apnea, high cholesterol, and heartburn.

&nbsp;

<ul>
	<li>
	<h5>Disadvantages</h5>
	</li>
</ul>

The procedure has more disadvantages than advantages to its credit. It is complex; it increases the risk of intestinal complications; and nutritional deficiencies are common post-surgery. Another thing that patients opting for gastric bypass suffer from is the dumping syndrome, i.e., feeling sick after consuming carb-rich foods. 
&nbsp;

An electrical device is implanted under the ribcage. It sends electrical impulses to the vagus nerve to inform the brain that the stomach is full. A remote control, present outside the body, helps operate the device.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Advantages</h5>
	</li>
</ul>

This procedure is less invasive compared to other surgical interventions. Consequently, the risk of any post-op complications, like an infection, is low.

&nbsp;

<ul>
	<li>
	<h5>Disadvantages</h5>
	</li>
</ul>

A major downside is that since it&rsquo;s an electrical device, the patient may need to reprogram its battery frequently. Side effects include vomiting, nausea, heartburn, chest pain, and problems in swallowing. 
&nbsp;

Similar to the sleeve gastrectomy procedure, the BPD-DS surgery entails two steps. The surgeon first creates a small stomach pouch. Next, they separate the duodenum (first part of the small intestine) from the stomach and the remaining part of the small intestine is connected to the stomach pouch only. As a result, the food bypasses more than 75% of the small intestine&nbsp;and the number of nutrients and calories absorbed from the food decreases<a href="#accordion">[5]</a>.

&nbsp;

<ul>
	<li>
	<h5>Advantages</h5>
	</li>
</ul>

BPD-DS is most effective for obese and type 2 diabetics. It allows for an even greater weight loss than gastric bypass and patients are able to eat larger meals as compared to restrictive procedures.&nbsp;&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Disadvantages</h5>
	</li>
</ul>

It&rsquo;s a complex surgical procedure, which may cause dumping syndrome. There are increased bowel movements as well as more incidents of nutritional deficiencies and malabsorption, which implies that the patient has to be more careful with their diet.&nbsp; 
&nbsp;

This procedure is similar to BPD-DS, except that only one bowel connection is made in SADI-S. A loop of the intestine is connected to the small tube-shaped gastric pouch. As a result, food directly bypasses this part of the small intestine, where it mixes with digestive juices from the duodenum and ileum.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Advantages</h5>
	</li>
</ul>

This is a simpler and less time-consuming procedure than BPD-DS. Also, it&rsquo;s effective for diabetic patients, helping them maintain optimal blood sugar levels.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Disadvantages</h5>
	</li>
</ul>

Patients struggle with more frequent bowel movements along with vitamin and mineral deficiencies.&nbsp; 
&nbsp;

This is a restrictive weight loss procedure and involves the placement of a deflated balloon within the stomach. Once the balloon is in place, it is inflated to create a sense of fullness. As a result, hunger is reduced.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Advantages</h5>
	</li>
</ul>

The only good thing about this procedure is that it does not necessitate surgery or a stay at the hospital.

&nbsp;

<ul>
	<li>
	<h5>Disadvantages</h5>
	</li>
</ul>

The balloon is temporary and has to be removed anywhere between 6 months and 1 year. There are also side effects, like stomach ache, nausea, and vomiting, that are common after the procedure. A gastric balloon procedure is not recommended for people with an intestinal disease or liver failure. 
&nbsp;

While weight-loss surgery may sound like a miracle cure for obesity, it is not that simple. Several different factors determine a person&rsquo;s recovery and weight loss.

Generally, here&rsquo;s what to expect after surgery:

<ul>
	<li>It&rsquo;s ideal to start&nbsp;with a liquid diet after surgery.</li>
	<li>After a few weeks, patients can shift to a soft diet, which consists of soup, yogurt, and cheese.</li>
	<li>The emphasis is mostly on small meals after weight-loss surgery.</li>
	<li>Doctors also recommend vitamin supplements and protein shakes to counter any nutritional deficiencies.</li>
	<li>According to a study, it&rsquo;s possible to lose anywhere between 38 and 87 pounds a year after surgery<a href="#accordion">[6]</a>.</li>
	<li>Periodic blood tests help monitor mineral and vitamin levels.</li>
	<li>It should be kept in mind that loose skin folds may appear, especially when there&rsquo;s&nbsp;significant weight loss. Hence, additional surgery for the sagging skin may be required. 
	&nbsp;</li>
</ul>

Conclusion

With the increasing obesity pandemic, it is important to educate the world, especially at-risk individuals, of possible treatment options and the risk of not making healthy lifestyle changes. Even though weight loss surgery can be highly effective in preventing obesity-related diseases, they are not a one-stop solution and they should never be the top-most priority when looking into treatments for weight loss.&nbsp;

Key Points

<ul><li>Several different treatment approaches are advised to treat obesity. However, techniques like lifestyle changes and medications often fail to solve the problem in patients.</li><li>The American Society for Metabolic and Bariatric Surgery (ASMBS) recommends weight-loss surgery for adults with a BMI of 30-35 kg/m2, who suffer from obesity-related comorbidity (e.g., diabetes) or who haven’t seen significant results from lifestyle changes (e.g., healthy diet and exercise).&nbsp;</li><li>The goal of weight loss surgery is not only to help the patients achieve a healthy weight, but also to treat obesity-related diseases.&nbsp;</li><li>Sleeve gastrectomy, gastric bypass, and gastric banding are the three most commonly performed weight loss surgeries.</li><li>A year after surgery, people can lose between 38 and 87 pounds.</li><li>Post-surgery, patients are typically kept on a liquid diet. After a few weeks, a soft diet consisting of soup, yogurt, and cheese is advised.</li><li>The diet should consist of small meals after weight loss surgery.&nbsp;</li><li>Doctors may also recommend vitamin supplements and protein shakes for countering any nutritional deficiencies.</li></ul>

[1] Controlling the global obesity epidemic. World Health Organization.

[2] The Lancet Gastroenterology & Hepatology. Obesity: Another ongoing pandemic. The Lancet Gastroenterology & Hepatology. 2021;6(6):411. doi:10.1016/s2468-1253(21)00143-6

[3] Pratt JSA, Browne A, Browne NT, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis. 2018;14(7):882-901. doi:10.1016/j.soard.2018.03.019

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