Solving our country’s obesity crisis through surgery is a nice idea. Forget diets, willpower and treadmills: all you need is a scalpel-wielding doctor and, hey presto, problem solved.
As a society, we are undoubtedly groaning under the weight of the obese. But is surgery really the answer?
In a statement this week, clinicians and academics from a number of institutions and charities, including Diabetes UK, argued precisely this. They cited studies that have shown bariatric surgery – a term used to describe several procedures that result in weight loss, such as gastric bands – results in remission of type 2 diabetes by up to 50 per cent.
They claim that under clinical guidelines issued in 2014, up to a million people in Britain with diabetes are eligible for bariatric surgery, but the NHS is not offering the procedure as standard care.
Warning: Bariatric surgery is not a panacea for obesity and related conditions such as diabetes (file photo)
The claim will heap further pressure on the NHS to increase this type of surgery at a time when many routine operations, such as cataracts and knee and hip operations, are being reduced. Can this really be right?
The thing to realise is that surgery doesn’t itself reverse type 2 diabetes. By shrinking or removing parts of the stomach, it causes the patient to lose weight -and this can improve their diabetes. This will happen, though, regardless of the method by which someone loses weight.
If you read the statement, you’d be forgiven for thinking that surgery is the best way to lose weight.
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However, as a doctor who specialises in eating disorders, I think the idea that diabetes can be ‘cured’ by surgery is not just misleading but also dangerous. It gives entirely the wrong message to overweight patients.
Bariatric surgery may appear to be an appealing quick fix, but it is far from the panacea it is made out to be.
First, it must be noted that type 2 diabetes accounts for 90 per cent of all people with diabetes. Unlike type 1, which people can be born with, type 2 is, in the vast majority of cases, a disease of lifestyle. In type 2 diabetes, the body becomes increasingly resistant to the effects of the hormone insulin, so that the glucose stays in the blood – causing high sugar levels – rather than being taken up into the cells.
IT’S ACNE, NOT A DRUG, THAT DRIVES SUFFERERS TO SUICIDE
A few weeks ago, I wrote about the psychological impact of acne. I was inundated with letters and emails from readers, many with very sad stories of how acne had blighted their lives.
In fact, this week a study was published showing that the distress of acne is one of the leading causes of suicide among teenagers. What a heartbreaking situation, especially as it can be treated.
Many of the people who wrote to me asked me about Roaccutane, which I mentioned had effectively cured my acne. They were worried that the drug had been linked with suicide.
It’s true that some studies have suggested a link, but it’s far from clear to what extent Roaccutane is responsible.
What is known, however, is that skin conditions such as acne are linked to increased rates of depression and can in themselves drive people to kill themselves.
It may be that because Roaccutane is given to those with the severest forms of acne, it’s the skin condition, rather than the drug, that is to blame.
Roaccutane is not a wonder drug, though, and has a lot of side-effects, some of which I experienced: unsightly dry skin which cracked and was painful.
Although my skin has improved dramatically, this drug won’t be for everyone. It’s a delicate balancing act between the pros and potential cons.
For me, I was weighing the tiny risk that it might make me depressed, versus the very real blight of acne.
It’s worth saying that in all my time working in mental health, I have never seen anyone who has become depressed or suicidal because of Roaccutane.
But I have seen many people who have become depressed or suicidal because of skin conditions such as acne.
The key thing is to speak to a dermatologist to weigh up your options — and not be put off by a few scary-sounding stories.
The more obese you are, the more likely it is that the body will become resistant to the effects of insulin. By reducing someone’s weight, the body’s ability to respond to insulin and handle sugar can, for some people, return.
So yes, weight-loss surgery can have a positive impact on some patients, but there are better ways to reach the same end.
As well as surgery bringing the risk of nutritional and dietary issues, the rapid weight loss involved can result in large amounts of excess skin. However, even that pales into insignificance when you realise the psychological problems it can create.
Diabetes is merely a symptom of being obese, and examining the root cause why someone is obese is crucial. Though this might seem obvious – they eat too much – there are a variety of underlying reasons why someone does so, which surgery doesn’t address.
For a lot of people, there is a significant psychological component to their obesity. They may use food as an emotional crutch and over-eat as a way of coping.
After bariatric surgery, they are unable to turn to this familiar coping strategy. This leaves them in overwhelming distress, unable to deal with their emotions. Many patients have told me it feels as if they are being mentally tortured.
Depending on the exact operation, as many as 20 per cent of patients will find ways around the procedure, such as continually snacking, and gain a significant amount of weight back. Some even liquidise junk food to get it into their shrunken stomachs.
This might sound extraordinary, but it only emphasises how these people had a profound problem with food before surgery, which an operation cannot hope to solve.
A study of 17,000 people who had undergone surgery showed that they are at higher risk of suicide – probably because of the psychological pressure of all the lifestyle changes that must be adopted post-surgery.
Research has also shown a 50 per cent increase in drug and alcohol addiction post-surgery – likely new comforts in place of food.
Surely this shows that we are approaching the obesity epidemic in totally the wrong way. We need to treat a psychological problem psychologically, not surgically.
When people are taught alternative coping strategies, they cease needing to use food as an external crutch, and so lose weight anyway.
Their type 2 diabetes will also improve and may even reverse entirely, just as it does with surgery.
Of course, not everyone who is obese has psychological issues. Some simply make a choice to eat certain foods, or lack the motivation or knowledge to lose weight.
But if that’s the case, I don’t believe the NHS’s limited resources should be used as a substitute for willpower.
I would suggest an intervention called motivational interviewing, which involves gently getting the patient to understand the benefits of changing their behaviour.
Suggesting that the problem of obesity can be dealt with by a swoosh of the surgeon’s knife is not only naïve and expensive, it is totally wrong-headed.
How breast surgery hurts husbands, too
Operation: Sian Williams revealed this week that she has undergone a double mastectomy
Newsreader Sian Williams announced this week that she has had a double mastectomy, explaining how she found ‘all these emotions that I didn’t want to feel popping to the surface’.
She should be applauded for speaking out about this as the operation can have a lasting effect on people.
While a junior doctor, I worked in breast surgery and saw first-hand the psychological impact of mastectomies. Yes, they often saved someone’s life, but that person could feel a profound sense of loss.
Many patients told me how they felt ‘less of a woman’.
Well-trained breast-care nurses give the women great psychological support. What I did notice, though, is that there is one group of people who are not well looked after: the patients’ husbands or partners.
Of course, it’s only right that the lion’s share of care should be directed to the woman who has undergone such a life-changing procedure, but it’s important to remember that it’s not easy for men here, either.
A few months into the job, a nurse asked me to see one of the patients, who had come into hospital to have her left breast removed. Before going home, she had some questions.
‘The consultant seemed really pleased with the reconstruction. But …’ her voice trailed off. ‘It’s about my husband, doctor.
‘I’m sorry to take up your time with this, but, well, he can’t bear to look at it.
‘Would you talk to him please, doctor?’ I swallowed hard. At medical school we were taught all manner of things about cancer — but how illnesses affect not only the patient but also those around them was not on the syllabus.
I could certainly answer his medical questions, but I sensed that the request was partly because I was a man: perhaps he would feel able to open up to me.
So when her husband arrived, I suggested we pop to the canteen. He was a little taken aback, but agreed.
Sitting opposite him, there was nothing I could say to make things magically go back to how they were before — and he knew this. All he really wanted was someone to give him their time.
While the operation may have been a success, for him the scars were a constant reminder that his wife had nearly died and that he’d been powerless to help her.
As a junior doctor, I had a mounting list of jobs to do but talking to him was far more important than filling out forms.
As he collected his wife’s painkillers from the nurses, I stopped off to say goodbye to her.
‘He’ll be fine,’ I reassured her. ‘It just takes time.’