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Bariatric Management

What does bariatric mean?

Bariatric is the term used to describe treatment of obesity, which is broadly defined as a BMI >30kg/m2. Obesity is a common disorder affecting 26% of the UK population (OECD data 2018) and this can lead to problems with mobility, ability to work and an increased risk of sleep apnoea, fatty liver disease, polycystic ovaries and type 2 diabetes. It can also affect self-confidence, fertility and personal relationships.

Obesity can be effectively managed but often needs expert management to achieve long-lasting weight loss. Dieting alone can often be unsuccessful as once a proportion of weight is lost, the body actively prevents further weight loss which can lead to frustration and rebound weight gain. Using a combination of specialist approaches including addressing eating behaviours such as emotional eating, medications such as liraglutide (Saxenda) and semaglutide and bariatric surgery, it is possible to achieve long lasting weight loss and even remission from type 2 diabetes.

What is the best type of bariatric surgery?

There are three main types of bariatric surgery:

Gastric band

A band is placed around the very top of the stomach to make you feel more full when you eat and help reduce portion sizes. As this does not cause the hormonal changes seen with the other bariatric operations, it can be harder to achieve and maintain sufficient weight loss.

Sleeve gastrectomy

The surgeon will make a narrow tube out of your stomach which results in increased fullness after eating small portions but also there is a modest increase in the gut hormones that encourage weight loss. Typical weight loss seen with a sleeve gastrectomy is 50-60% of excess body weight.

Gastric Bypass

This is the most effective form of bariatric surgery achieving 60-70% excess body weight loss. Improvement or remission from Type 2 diabetes has been demonstrated in 92% of all clinical trial patients between 2003-2012 (1 JAMA meta-analysis, 2014).

This operation involves the surgeon creating a small pouch of stomach, then makes a cut in the small intestine and bring the lower part of the small intestine to attach to the stomach pouch. Food then passes from the mouth to the stomach pouch and then to the lower small intestine which reduces the amount of food and calories absorbed. The remaining intestine is left intact to enable digestive juices to enter the gut.

gastric bypass

Both gastric bypass and sleeve gastrectomy patients require lifelong vitamin replacement however it is often possible to stop many diabetes and blood pressure medications post-operatively.

Bariatric surgery is covered by a limited number of insurance companies; it is important to confirm the details of your insurance policy.

To proceed to bariatric surgery, patients need to follow the “golden rules” bariatric diet designed to optimise weight loss and address nutritional deficiencies and complications such as dumping syndrome that can occur post bariatric surgery. This includes high protein intake, carefully controlled sugar and carbohydrate intake and to avoid fizzy drinks and smoking. Many bariatric surgeons will give patients a weight loss target to achieve prior to their surgery; this can be achieved through dietary changes, meal replacement diets and medications such as Saxenda (liraglutide) or semaglutide can be helpful to encourage weight loss. These medications are not needed after bariatric surgery as the body produces high levels of its own version of these hormones.

Weight loss medications

The most effective weight loss medications are Saxenda (3mg liraglutide) and semaglutide (currently only licensed as Ozempic for type 2 diabetes; the 2.4mg weight loss version is awaiting UK licence).

These effectively mimic the hormones produced after gastric bypass surgery that increase our sensation of fullness when we eat and improve type 2 diabetes control. Saxenda has been shown to induce 9.2% weight loss2 and the 2.4mg dose of Semaglutide (awaiting UK licence) has published data confirming 14.9% weight loss3 in clinical trials. These are taken in the form of an injection just under the skin, using an easy-to-use pen. Whilst it can cause some nausea, this usually settles down with time.

References:

  1. Chang S., JAMA Surgery. (2014). The Effectiveness and Risks of Bariatric Surgery. 2003-2012. JAMA Surg. doi:10.1001/jamasurg.2013.3654
  2. Pi-Sunyer et al N Engl J Med. 2015 Jul 2;373(1):11-22.
  3. JP Wilding et al. N Engl J Med 2021;384:989-1002

Written by Dr Veronica Greener, Consultant in endocrinology, diabetes and bariatric medicine at OneWelbeck Endocrinology.