Sunette Swart tells about how bariatric surgery is a tool for treating obesity. Though, she highlights it’s not a shortcut to weight loss as the patient will still have to put in effort after surgery.

Defining obesity

Obesity is defined as a chronic (long-term), progressive disease with episodes of remission (improvement in weight) often followed by relapse (regain of weight). It has multiple causes with behavioural, hormonal and neurological elements and can lead to almost 200 different health problems, including diabetes (high blood glucose) and hypertension (high blood pressure). It is a treatable condition, and it has been shown that even a 5% weight loss or more can reduce the risk of complications and improve overall health.

Obesity treatment options include lifestyle changes (healthy eating, increased physical activity, stress management, mental health, and good sleep quality), medication, and bariatric surgery. Behavioural changes or lifestyle changes alone can account for a 5-15% weight loss, whereas bariatric surgery can result in 35-40% up to two years after surgery.

Bariatric surgery

Bariatric surgery is derived from the Greek word “baros”, which means “weight.” The first weight-loss surgery was performed in 1953, and bariatric surgery has since evolved into what is now known as metabolic surgery.

To qualify for bariatric surgery, you must be between the ages of 18 and 65 years, with a body mass index (BMI) of 40kg/m² or more or a BMI of 35 kg/m² or more together with at least two co-morbid conditions (like diabetes, high blood pressure or high cholesterol).

Bariatric surgery can be done via a small, keyhole cut (laparoscopic) or with a larger cut, determined by the surgeon.

There are three types of bariatric surgery procedures:

1. Restrictive procedure – This is a sleeve gastrectomy and gastric banding procedure (less used). After this surgery, the stomach is about 80% smaller (pouch) and this causes earlier satiety and delays gastric emptying.
2. Malabsorptive procedures – Bilio-Pancreatic Diversion with a Duodenal Switch (BPD-DS) and Single Anastomosis Dueodeno-Ileal with Sleeve Gastrectomy (SADI-S), where fewer nutrients are absorbed.
3. A combined restrictive and malabsorptive procedure – The Roux-en-Y gastrectomy (RYGBP) procedure.

Sleeve gastrectomy

The sleeve is performed when approximately 80% of the stomach is removed, leaving a small banana-shaped stomach that can hold around 50-150ml in volume. This results in smaller portions of food eaten and the hunger hormone, ghrelin, is reduced by removing a part of the stomach. Food then continues to pass through the small intestine in the same manner as before surgery, as shown in Figure 1.

Figure 1: Sleeve gastrectomy

Biliopancreatic diversion with duodenal switch (BPD-DS)

This procedure combines a sleeve gastrectomy with a much longer Y-shaped intestinal bypass than the RYGBP. The food bypasses about 75% of the small intestine, resulting in a decrease in energy and nutrients. As shown in figure 2, the bile and pancreatic digestive juices only mix with the food at the very end of the small intestine. The hormone changes caused by this procedure is far superior and causes a significant reduction in hunger, increases the feeling of fullness and results in excellent blood glucose control.  This is a highly complex surgery that can cause “dumping” (symptoms such as nausea, vomiting, abdominal cramping, diarrhoea, bloating, sweating, dizziness, and a fast heart rate), malnutrition, and loose stools. Protein intake and life-long vitamins are critical due to malabsorption (especially vitamins A and D).

Figure 2: Biliopancreatic diversion with duodenal switch (BPD-DS)

Single Anastomosis Dueodeno-Ileal bypass with Sleeve Gastrectomy (SADI-S)

The SADI-S procedure is a newer variation of the duodenal switch that is easier to perform, takes less time in the operating room, and requires only one surgical bowel connection. The stomach is reduced in size by removing approximately 85% of it (same as the sleeve gastrectomy). The small intestine is then bypassed about 50% (longer than in the RYGBP).  This results in nutrient malabsorption due to the shorter path that digested food travels through the intestines, but with the benefit of added digestive enzymes, as illustrated in Figure 3. Bowel movements after this procedure are likely to be looser and more frequent.  Life-long vitamin supplementation is compulsory.

Figure 3: Single anastomosis dueodeno-ileal with Sleeve gastrectomy (SADI-S)

Roux-en-Y gastric bypass

The Roux-en-Y gastric bypass is regarded as the gold standard in weight-loss surgery due to its effectiveness and durability.  The name is a French expression that means “in the shape of a Y.” The stomach is divided into a small egg-sized pouch, and the larger part is bypassed. The small intestine is then divided into two sections, and the new stomach pouch is linked to the bottom end of the small intestine, which allows food to pass through. The top portion of the small bowel (where stomach acids and digestive enzymes pass from the “old” stomach) is connected to the small intestine during the final stage of the procedure, forming the Y shape seen in Figure 4.

As a result, the Roux-en-Y gastric bypass combines restrictive and malabsorption procedures. The patient eats less, feels fuller faster, and as the food bypasses contact with the first part of the gastrointestinal tract, there is less absorption. Gastric acid reflux is treated during this procedure. Life-long vitamin supplementation is recommended.

Figure 4: Roux-en-Y gastric bypass

Hormone changes after bariatric surgery

Ghrelin, a hunger hormone produced in the stomach, stimulates the brain, increasing appetite and cravings for fatty foods. Because the stomach is smaller after bariatric surgery, less ghrelin is released, and patients’ appetites decrease. Leptin is another important hormone that regulates satiety, or the sensation of fullness. Following bariatric surgery, leptin levels rise, increasing fullness. Incretins are hormones secreted by the gut that regulate glucose levels via insulin release and affect appetite and gastric emptying. The most common of these incretin hormones, glucagon-like peptide 1 (GLP-1), is increased by bariatric surgery, resulting in improved blood glucose levels, decreased appetite, and slower gastric emptying. One of the reasons we see Type 2 diabetes remission after bariatric surgery is the improved GLP-1 effect on blood glucose.

Bariatric surgery in South Africa

Bariatric centres use a multi-disciplinary team approach, consisting of the surgeon, physician, registered dietitian, biokineticist and psychologist. There are several bariatric centres in the private healthcare sector in South Africa with varying accreditation with medical aids. At this time, a limited number of bariatric surgeries are performed in public hospitals, such as Helen Joseph Hospital in Johannesburg and Tygerberg Hospital in Cape Town.

Closing

Bariatric surgery is a tool for treating obesity. The success should be measured by weight loss and the improvement and/or resolution of co-morbid conditions, such as diabetes and hypertension. Continuous follow-up with your multi-disciplinary team is essential to ensure the long-term success of bariatric surgery with long-term lifestyle changes, for example,  healthy eating. Remember, no matter which procedure is chosen or performed, this is not a shortcut to weight loss. You as the patient will still have to put in the effort after surgery.

References available on request.

A man arrives at his local car workshop and asks to speak to the mechanic. He enquires whether the mechanic can help fix his car. “No problem,” replies the friendly mechanic. “Let me take a look.” The man answers quickly, “Oh, I haven’t brought it, but I can tell you what is wrong.”

Sometimes healthcare professionals (HCP) in the field of diabetes feel like that mechanic. We are so often asked, even expected to ‘fix’ the diabetes but we are not given the opportunity to see the glucose control or other health issues (the car). This simple analogy alludes to a diabetes check-up as perceived by an HCP.

On the other hand, the patient may perceive the diabetes check-up totally differently. More like a trip to the principals’ office, a nerve-wracking, dreaded experience.

These situations for both the patient and HCP can be avoided by following these tips.

1. Bring the “goods”

Bring along a list of all the medications, prescribed and others you are taking, including the dosage. You can bring in the actual medication or a photo of the box or container (anything that will identify the medication). Unfortunately, HCP do not know what all tablets look like and there are at least 100 “little orange tablets” on the market. No treatment changes can be made without this information.

Your glucometer, diabetes diary or CGM are vital for all appointments. These should not be a cause for anxiety. Many patients do not test their blood glucose levels because they fear seeing high readings or are afraid of what the HCP may say. Analysing these readings together, high or not, will allow for better outcomes. An HCP will focus on fasting and post meal readings as well as any hypoglycaemic events (readings below 3,9mmol/L), trends and patterns. It is important to see if your readings are in keeping with your HbA1c.

A food diary is a good accompaniment to a glucometer. It allows you to realise the effects of certain foods on your blood glucose readings. This will enable you and the HCP to work on possible food alternatives or quantity changes. You can discuss any observations you have noted or concerns about these readings.

If your HCP has requested any blood or other tests be done, please ensure that they are done at least three days prior to the diabetes check-up. Bring any recent sonars, X-rays or specialist reports along.

2. Be prepared

For your first appointment with your HCP, you will be asked about your family’s health history – is there a history of diabetes, strokes or heart attacks? If you have any disabilities of any kind, inform the practice so that steps can be taken to accommodate these. This may sound odd, but I have had a patient with hearing difficulties politely nod at me until we established that they couldn’t hear me. This is particularly important during this pandemic when masks are being worn.

A lot of information will be exchanged during the consultation. Bring along a friend or second set of ears as many things may be forgotten after the appointment. A notebook to write down instructions is also a good idea. Clarify any instructions by repeating them back to the HCP. Most HCP will take notes throughout a consultation.

Many patients, in my experience, are nervous or anxious during appointments. Having a list of questions and concerns you’d like to address with your HCP will prevent you from forgetting anything.

3. Be honest

It bears repeating that it’s of vital importance that you are honest with your HCP. Remember, these diabetes check-ups are confidential. If you feel that you’re unable to be completely honest with your HCP, it may be worth considering changing your HCP.

Patients often feel, a natural urge, to tell their HCP what the patient thinks their HCP wants to hear. This is not in anyone’s best interest. The best outcomes are based on complete honesty. Don’t be shy about discussing problems with the HCP, there are probably many people with diabetes who have the same problem. Keep an open mind and give input on your treatment plan. Your HCP will be honest with you. This may mean that they are not able to answer 100% of your questions and may need to refer you to someone who can answer a specific question.

This honesty will range from the medication that you are taking and the doses you are omitting, food and exercise as well as your blood glucose readings. There are various reasons that patients omit medication doses, from side effects of the medication, cost, painful injections and genuinely forgetting to take it. These can all be dealt with if the HCP is aware.

Carbohydrates need not be lied about either; they are an important part of a healthy diet and need to be eaten. Let us know what you are eating/drinking and together we can plan the best way to incorporate these foods.

Elevated blood glucose levels do not always indicate a lack of effort or interest in ones’ own diabetes management. Multiple factors affect readings and these need to be discussed honestly and openly. Sometimes that elevated Hba1c may be due to the natural progression of diabetes and not that full slab of chocolate you plundered.

4. Be consistent

Attending regular follow-up appointments with your HCP is important. It allows for timeous interventions when necessary. It forms the basis of managing a chronic condition, such as diabetes. If any change or intensification of treatment is required, early implementation can delay the onset of diabetes complications. On this note, staying in contact with your HCP between appointments is beneficial and can lead to better outcomes. Confirm what forms of communication the practice uses be it email, phone calls or WhatsApp. Ask about emergency contact details or hotline numbers.

5. Relax

These appointments are for your benefit. Arriving anxious at your appointment can influence your vital signs, increasing your blood pressure to levels that you would not have in other settings. This is known as white coat syndrome/hypertension. Try to arrive at your appointment a few minutes early to enable you to wind down from any traffic stress. This appointment is yours, embrace it and make it meaningful.