Weight Loss (Bariatric) Surgery - The Basics
Weight Loss Surgery Part 1
The most common request I get is to write about weight loss (also known as “bariatric”) surgery. It’s a complicated subject, and so this is the first in a three part series that will begin to explore this topic. In this piece I’ll cover the basics of these surgeries, in part 2 we’ll talk about the idea of these surgeries for treatment of Type 2 Diabetes, and in part 3 we’ll talk about long-term outcomes and informed consent. If you are looking for a more detailed discussion of the risks of the specific types of procedures, you’ll find that here. While I am solely responsible for the content here, my work around these surgeries has been deeply influenced and supported by the work of others, including and especially Deb Burgard and Lisa Du Breuil.
Content note: This piece will discuss the harm and negative outcomes of these surgeries, including a brief mention of self-harm. Also note that where studies come from a perspective of weight stigma I do not link to them, but provide enough information for them to be found online if someone wishes to search.
What do these procedures do?
Explained plainly, these surgeries take a healthy, correctly functioning digestive system and surgically bind it (as in lap band), or permanently alter it (as in gastric bypass and gastric sleeve) to purposefully put the digestive system into an often irreversible disease state. This state includes some combination of malabsorption, forced food restriction, and forced rapid gastric emptying (aka “dumping syndrome”).
Sometimes these surgeries are marketed purely for weight loss, but more and more they are offered as options to prevent or cure health issues (health issues which, it should be noted, thin people also get.)
Regardless of why someone undertakes the procedure, there are three main groups of people in terms of outcomes:
Group one are happy with the outcome (at least currently.) Sometimes they are happy even though they are having unpleasant side effects, because they are (at least temporarily) less exposed to/impacted by weight stigma. This group is often in the first couple of years after the surgery (called the “honeymoon period.”) Theirs are the most common testimonials used to market these surgeries and they are often the primary or only source for follow-up data in research about the surgeries. People in group one often virulently defend these surgeries, many times crediting themselves for their outcomes and blaming/shaming those with poor outcomes for their negative experiences.
Group two are miserable. They have horrible side effects, and they often say that they would do anything to take back the surgery. Around two to three years post-surgery, many people from group one move into group two. Many of these patients will regain all the way or almost all the way to baseline, but because the surgically-induced disease state of their digestive system is permanent, they will never regain full digestive function. They are often blamed for their (known) negative outcomes by practitioners, and are frequently convinced to blame themselves. These folks are typically not asked to give their thoughts on these surgeries for brochures, commercials, or the LuLaRoe-esque symposiums at which these major surgeries are marketed for profit.
Group three are no longer alive. Some die on the table, some die from short or long-term complications, some from a known increased risk of suicide. Many are blamed for their own deaths. These people have no opportunity to tell their stories, and their families and friends are almost never asked to share their experiences with the people to whom these surgeries are marketed.
These surgeries are, in general, very much a for-profit venture and they are aggressively marketed by doctors, companies/facilities, and industry organizations. These organizations are very often “astroturf” organizations – they claim to be advocacy groups for higher weight people but are, in fact, fully funded by, and act as a lobbying arm for, those with a profit interest in selling the surgeries. Their activities include everything from funding research, to lobbying congress for greater insurance coverage, to trying to increase their market by getting the surgeries approved for ever younger and thinner patients.
If you’re curious how far they will go, in 2011 during a huge push by these companies to convince the AMA to declare “ob*sity”* to be a disease (as a play to increase their market/profit potential,) Allergan (the manufacturer of the lap band) literally ran a sweepstakes where you could win a lap band surgery (if you won, you could also give it away to a close friend or family) They used the contest to urge people to sign a petition asking the AMA to declare “ob*sity” to be a disease. (As an aside, this barrage of marketing was ultimately successful – the AMA ignored the opinion of their Council on Science and Public Health, choosing instead to do the diet industries’ bidding, but that’s the subject for another newsletter.)
What don’t we know
In some ways even worse than what we do know about the possible horrific side effects of these surgeries, is what we don’t know.
We don’t have good prognostic factors to predict which patients will end up in which outcome group. There is research showing worse outcomes for Black and Hispanic patients. Wood et. al’s 2019 paper “Association of Race With Bariatric Surgery Outcomes” (though, as Deb Burgard has pointed out, please note that the true variable here is not actually race, but rather exposure to racism,) found that “Black patients undergoing bariatric surgery in Michigan had significantly higher rates of 30-day complications and resource utilization and experienced lower weight loss at 1 year than a matched cohort of white patients.” Welsh et. al.’s 2020 paper Racial Disparities in Bariatric Surgery Complications and Mortality Using the MBSAQIP Data Registry found that “Black patients have higher odds of readmission and multiple grades of complications (including death) compared with white patients. Hispanic patients have higher odds of a Grade 3 complication compared with white patients.”
There is also a severe lack of data on long-term outcomes. The very few studies that exist tend to look only at length of life without any discussion of quality of life and the discussions in these papers often have some pretty sketchy analysis (we’ll get into that in parts two and three of this series.) The truth is that we pretty much don’t know what happens to patients more than ten years after the surgeries. Even more disturbing, in talking to people who work in this field I’ve been told repeatedly that there is absolutely no interest from funding sources in funding research to find out what the long-term outcomes are.
Given that these surgeries…
1. Take healthy organs and purposefully put them into a disease state
2. Create risks to life and quality of life with outcomes that are, at best, a crapshoot
3. Are recommended to prevent/cure health issues that thin people also have (and are not asked to submit to these dangerous and essentially experimental procedures to address)
…the only way that someone can consider these procedures ethical is if they believe that fat people’s lives are less valuable and more risk-able than thin people’s lives, and that it is worth killing fat people in attempts to make us thin.
To sum up, I think that these surgeries are unethical, as they create disease, require risks to life and quality of life without sufficient (or, in many cases, any) prognostic factors or long-term outcome data, and because they are rooted in weight stigma since people of all sizes have the health conditions for which these surgeries are sometimes suggested as treatment, but only fat people are asked to risk their lives and quality of life by undergoing these dangerous and unpredictable procedures.
In speaking with healthcare practitioners about these surgeries, I find that they are rarely thinking about them in these terms and I don’t think that most of these healthcare practitioners are necessarily trying to harm fat people. I do believe that they are firmly mired in a weight=health paradigm, and often working with patients who are absolutely desperate to lose weight either because they’ve been told that it’s their only option for health, or because they are having their other healthcare held for ransom by a system that places artificial BMI limits on surgeries including everything from knee surgeries to gender affirming procedures, and then refers those same patients to weight loss surgery. These are also surgeries that offer (though often don’t deliver on) the promise of decreasing exposure to weight stigma, which suggests that the “solution” for weight stigma is for fat people to risk their lives and quality of life in dangerous surgeries to appease our oppressors.
I also find that (perhaps because of the vested interest of many of those funding/doing the research and/or because of weight stigma itself) the harms of these surgeries are downplayed, ignored, and/or blamed on the patients. And most healthcare providers are poorly (or not at all) educated on the body of research that shows the same or greater benefits of weight-neutral, behavior-based interventions, leaving them in a position where they can’t actually obtain informed consent since they can’t properly inform their patients. This adds to the fact that the ability to get informed consent is somewhere between severely compromised and impossible, given the lack of data on long-terms outcomes.
As Deb Burgard says “I would ask any MD trying to parse this, "Do you want to know what happens to people after the surgery? Do you want to know what problems come up after the surgeon is no longer involved? Do you wonder why there is so little research on the actual trajectories of all the people who have been given these surgeries (when they are, essentially, experimental given the paucity of data about the aftereffects.) Do you want to know why fat people express an interest in WLS? Do you want to know how much fat people's medical care is being held hostage until they get these surgeries? Are you aware that there are weight-neutral alternative with the same/greater benefit and less risk? No one can have this critically important information until we ask fat people, and the medical world actually listens and learns."
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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.