In this month’s blog I’m going to introduce you to bariatric surgery – also known as weight loss surgery – and how having any of these surgeries will potentially impact on your client and their training. First up I’m going to describe what bariatric surgery is, who has it and why.
What is Bariatric weight loss surgery?
Bariatric surgery (WLS) is the medical and surgical intervention for the treatment of obesity, where a surgery is performed on the stomach and/or intestines to help a person with extreme obesity rapidly lose weight. WLS is performed under general anesthetic – generally laparoscopic surgery, decreasing recovery time and risk of infection.
Bariatric surgery is available to people with a BMI of at least 32, depending on certain health issues. WLS should be a last resort option rather than a first choice with regards to weight loss without any other health or physical issues. As with any surgical procedure, complications can occur, and it is not a decision that should be taken lightly. Having WLS is definitely not the ‘easy way out’ that some people hope it to be. Work still needs to be done to look at the WHY their weight got to where it was before surgery. And a complete lifestyle change still needs to occur, even after surgery. There still needs to be healthy nutrition, a vitamin and mineral regime to avoid malnutrition, activity, and a change of mindset – all these aspects are required for long-term weight loss success even after WLS.
If you have clients who are thinking about WLS as an option for them, I would advise them to speak to people who have gone through the procedure themselves, not just the surgical team. Talking to people who have recently had WLS, who are at least one year post op, and 2 years plus post op will give them a more realistic idea of what to expect.
Who has Bariatric weight loss surgery and why?
- Those who are medically classified as obese, morbidly obese, or super morbidly obese
- Those who have a BMI of at least 32
- Those with specific health issues who want to improve their health/life
- Those with uncontrollable type 2 diabetes who are also usually insulin dependant type 2 diabetics
- Those requiring some weight loss before they become eligible for joint replacement surgery (most commonly knees or hips). This is usually part of the criteria to access publicly funded surgery
- Those with PCOS/and or fertility issues (to access publicly funded IVF treatment in New Zealand, a BMI of 32 is required)
- Those who have lost and gained weight many times or have a lifetime of diet cycle behaviour and have had enough of the yo-yo effect
- Those who have anxiety, depression and social isolation attributed to their weight that effects their ability to live the way they may want to
- Those who just want to feel better about themselves – physically, mentally, and emotionally
The Mechanism and Types of WLS –
There are two basic types of weight loss surgery -- restrictive surgeries and malabsorptive/restrictive surgeries.
- Restrictive surgeries work by physically restricting the size of the stomach and slowing down digestion. An example of restrictive surgery is adjustable gastric banding also called lap-band surgery. A vertical sleeve gastrectomy is also a restrictive surgery even though part of the stomach is removed.
- Malabsorptive/restrictive surgeries are more invasive surgeries that, in addition to restricting the size of the stomach, physically remove parts of the digestive tract, interfering with absorption of calories. An example of a malabsorptive/restrictive surgery would be either of the gastric bypass procedures. The benefit of the malabsorptive type surgeries is that rapidness of weight loss, satiety and feeling of fullness.
The Adjustable Gastric Band (Lap-band)
Lap-banding is the process of placing a synthetic band around the upper portion of the stomach and is a restrictive surgery. It works by creating a small "pouch" at the top of the stomach just below the esophagus, thus dramatically reducing the amount of food consumption. The size of the opening to the stomach determines the amount of food that can be eaten. The size of the opening can be controlled by a bariatric surgeon by either inflating or deflating the band through a port that is implanted beneath the skin on the abdomen. The band can be removed at any time. After a lap-band, patients will feel full sooner while eating. New Zealand has largely stopped performing lap-band surgeries due to the amount of follow up care required, and also the efficacy of other surgeries providing better results with weight loss. Revision surgeries from lap-bands to other bariatric procedures is becoming more common.
The Vertical Sleeve Gastrectomy
Another restrictive surgery is the vertical sleeve gastrectomy (VSG). This is currently the most common WLS performed in New Zealand due to it being less invasive than the bypass surgeries but still offering similar results. This can also depend on the surgeon’s recommendations. This procedure generates weight loss solely through gastric restriction (reduced stomach volume). The stomach is restricted by stapling and dividing it vertically and removing more than 85% of it. The stomach that remains is a narrow tube or sleeve, which connects to the intestines. This restricts the amount of food the stomach can hold, as well as removing the portion of the stomach that generates Ghrelin, the hormone that causes hunger. This procedure permanently reduces the size of the stomach, is performed laparoscopically and is not reversible. After a sleeve, patients will feel less hungry and fuller more rapidly while eating.
The Roux-en-Y Gastric Bypass (RYGB)
There are different gastric bypass procedures, and two examples of the most common are the Roux-en-Y gastric bypass, and the single anastomosis duodenal switch, which both create a reduction in the size of the stomach. The major benefit with the GBP surgeries is the almost instant eradication of type 2 diabetes, even for IDDM patients, or those with uncontrollable diabetes. The exact mechanism of why and how this occurs is still not fully understood, but WLS is becoming the treatment of choice for those with increasingly out of control type 2 diabetes. Gastric bypass is the most common type of weight loss surgery worldwide and combines both restrictive and malabsorptive approaches. The amount of food that can be eaten is limited by the size of the pouch and the size of the opening between the pouch and the intestine. After any gastric bypass, people will feel full sooner while eating and will absorb fewer vitamins and minerals, which will require supplementation for the rest of their life. They may also experience ‘dumping syndrome’. This occurs when food, particularly foods high in fat and/or sugar, or drinks high in sugar, move from the stomach into the small bowel too quickly. It can be extremely unpleasant and is mostly associated with the bypass surgeries.
The Single Anastomosis Duodenal Switch (also known as the Mini Bypass)
The “mini-gastric bypass” is a less invasive procedure performed with laparoscopic technique compared to the full gastric bypass, or Roux-En-Y GBP. This surgery is becoming increasingly more popular and is now routinely performed in New Zealand and Australia. During the SADS procedure, the surgeon first reduces the size of the “working” stomach by separating a tube-like pouch of stomach from the rest of the stomach. This tubular gastric pouch is then connected (anastomosed) to the intestine, bypassing up to 200cm of the upper part of the intestine. This technique differs from the traditional Roux-en-Y Bypass (RYGB) which requires two connections (anastomoses).
Weight Regain after WLS
Bariatric patients may regain a small amount of weight one to two years following their surgery. Some people fully regain all the weight they have lost and gain more. However, most WLS patients maintain a level successful weight-loss long-term. ‘Successful’ weight-loss is defined as weight-loss equal to or greater than 50 percent of excess body weight at the time of surgery. Excess bodyweight is classified as the amount greater than what is ideal for your height/weight according to the Body Mass Index. Often, ‘successful’ results are determined by the patient. For example, improvements in health – both physically and mentally, becoming more active and participating in their lives is deemed a success, even if they have not lost 100% loss of their excess body weight. An element of some regain is normal. My rule of thumb is 5kg up from the new weight set point, and there may need to be a closer look at what is happening regarding what they are eating and why, and whether old habits are reoccurring.
Next month I will be writing about the effects that WLS has on the body, and how this effects exercise and nutrition when working with a Bariatric client.
Hopefully, you’ve read my recent blogs to help give you an idea of how the ‘bigger client’ experiences exercise from a unique perspective, and this blog gives you another practical tool you can use to enrich their experience with you even further.
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