Let’s Talk About Obesity
Overweight and obesity occur when abnormal or excess fat accumulation represents a risk to health.
Body fat can be estimated using the body mass index (BMI) calculated by dividing the body weight in kilograms by height in meters squared, expressed in kg/m2.
However, BMI is not a percentage of body fat. It is only part of the obesity diagnosis.
Using this parameter, we can classify obesity in:
- Ideal Weight: BMI 18.5–24.9 kg/m2
- Overweight: BMI 25-29,9 kg/m2
- Mild Obesity (type I): BMI 30-34,9 kg/m2
- Moderate Obesity (type II): BMI 35-39,9 kg/m2
- Severe Obesity (type III): BMI ≥ 40 kg/m2
Obesity is the result of a prolonged imbalance between calories intake and expenditure. But, this is not as simple as eating more calories than the ones you burn!
Indeed, obesity is a complex disease resulting from a “teamwork” between genetic predisposition, physiological, nutritional, environmental factors, and social standards.
And, because of obesity’s multifactorial quality, there are many different strategies available toward its prevention and treatment.
Nutritional Treatments of Obesity
There are different options for weight loss. But, diet and exercise can be considered the cornerstones in the fight against obesity.
However, patients must show commitment and be self-motivated to change to achieve their weight loss goals. It’s all about the mindset!
A successful weight loss program must combine a nutritionally balanced diet with regular exercise and lifestyle modifications.
There are several dietary modifications available. Depending on your case, the nutritionist may suggest a low-calorie diet, fasting, a meal replacement program, or a formula diet.
Nevertheless, lifestyle modification or behavioral interventions are also important. They include analyzing your behavior to identify events that may trigger inappropriate eating, sedentary lifestyle, or even thinking habits.
Behavioral nutritional strategies may include stimulus control, self-monitoring, cognitive restructuring, psychotherapy for stress management, social support system, and relapse prevention.
Even though exercise and dieting are essential, sometimes they might not be enough to achieve your weight loss goals.
Bariatric surgery is considered the most effective long-term therapy to treat severe obesity.
Therefore, the number of bariatric procedures performed worldwide has increased rapidly in the last decade, especially because surgery is generally safe and effective.
Current obesity guidelines recommend bariatric surgery according to BMI (Body Mass Index) and associated obesity-related diseases. So, you can only consider surgery if you have a BMI greater than 40, or greater than 35, with associated medical conditions.
Restrictive Vs. Malabsorptive
Bariatric surgery includes procedures such as gastric sleeve, gastric bypass surgery, and adjustable gastric band, each with its indications and benefits.
These procedures can make you lose weight by modifying food ingestion. They can limit the absorption of nutrients (malabsorptive) or reduce your stomach capacity (restrictive).
The Malabsorptive Method
In this case, a small stomach pouch is created and connected to the intestines.
This so-called “rerouting of food transit” limits your calorie intake. Also, there is a modification of the gut hormones that control appetite, so you will feel satiated after eating less food.
The Restrictive Method
In the gastric band, a band is placed near the top of the stomach creating a small pouch. Therefore, the shape and capacity of the stomach are greatly reduced.
On the other hand, with the sleeve gastrectomy, a portion of the stomach is surgically removed, making it smaller and giving it the shape of a banana.
With this method, the reduced capacity leads to early satiation by slowing the food passage from the stomach to the intestines. Hence, you will feel full in a shorter time, causing a change in your food intake!
However, this classification does not appropriately reflect the current level of knowledge about the metabolic effects of these procedures. So, nowadays, bariatric surgical interventions are better referred to as metabolic operations.
For a few years now, the main focus when treating obesity has been gradually shifting from weight loss outcomes to beneficial long-term metabolic effects.
Non-Surgical Treatments for Obesity
Non-surgical procedures are indicated for patients with mild to moderate obesity who don’t qualify for surgery or those with severe obesity (BMI 40) who don’t want to undergo invasive procedures.
These non-surgical treatments are valid and effective options for patients that are left “in between. “Also, they can be seen as a jump start in your weight loss journey!
The endoscopic gastric sleeve involves remodeling the stomach using endoscopic suturing devices. This allows folding of the internal surface of the stomach, reducing its capacity by up to 70%.
On the other hand, for the gastric balloons, your surgeon inserts a deflated balloon into your stomach through your mouth. Then, he uses saline water to fill it up and reduce your stomach’s capacity.
The great advantage of these procedures is that they don’t require you to go into an operating room!
The procedure is quick, effective, and simple, with no adverse side effects: no surgery, no pain, no ugly scars.
Which One Is the Best Treatment Option for You?
Not all patients are good candidates for bariatric surgery. And the same applies to non-invasive weight loss procedures!
Beyond BMI indications, there are absolute contraindications for each procedure.
For example, in non-surgical weight loss procedures, the patient can’t have previous gastrointestinal surgery, a large hiatal hernia, or bleeding disorders of the upper digestive tract.
So, in case you are considering weight loss surgery, you may have decided on having a standard gastric bypass or a gastric balloon instead.
However, your bariatric surgeon should have the final word and decide what is best for your particular case. So, you should put yourself in experienced professional hands when undergoing your weight loss journey.
The Post-Bariatric Patient Nutritional Management
Most patients think that bariatric surgery is a magic weight-loss solution. However, there is a long road after the procedure.
Indeed, just as dieting is essential before considering surgery, it is equally or more important after the procedure. So, patients should be appropriately instructed on the dietary guidelines before surgery and again post-operatively!
Bariatric patients may present with procedure-specific nutritional problems according to the type of bariatric procedure. Also, eating habits must adapt to the new gastrointestinal physiology.
Therefore, the nutritional management of post-bariatric patients requires a multidisciplinary team with the intervention of experienced nutritionists and dieticians.
Also, you may need a psychologist to help you cope with some psychological difficulties that could arise in adapting to the changes in eating behavior and body image.
Finally, weight regain is a real possibility and should be prevented and managed with the help of a long-term follow-up program. This should be mandatory for the bariatric center you end up choosing.
The First Days After Bariatric Surgery
As discussed before, most bariatric procedures work by causing a food restriction after reducing the volume of the stomach. Therefore, you won’t be able to ingest solid foods in the first days after surgery.
Also, your nutritionist will plan a gradual change of food consistency in the first weeks after surgery to avoid or minimize annoying symptoms, like regurgitation and vomiting.
These symptoms can also be dangerous because they could threaten the integrity of sutures and jeopardize the effectiveness of your surgical procedure.
In the following 2-4 weeks, you will change your food intake consistency, going from clear liquids to soft or creamy foods and, finally, chewable solids.
Before discharge, an experienced bariatric dietician will instruct you on chewing adequately.
Also, you will receive clear guidelines about post-operative meal initiation and staged progression dependent on the time elapsed from the surgery.
In general terms:
- Patients with gastric restriction should eat three small meals during the day. Excessive size and number of meals could result in lower weight loss.
- It is important to chew small bites of food thoroughly before swallowing and avoid drinking any liquids simultaneously (more than 30 min apart).
- Patients must follow basic principles of healthy eating, like having small daily servings, including fresh fruits and vegetables.
The Day to Day of a Bariatric Patient
After you complete your post-operative diet, you should receive periodic checkups and counsel about dietary modifications. The main goal is to improve long-term outcomes and reduce the possibility of late weight regain.
Also, you should be aware of potential symptoms you may present.
Food intolerances are not uncommon after bariatric surgery involving a reduction of gastric volume. The most frequently involved foods are meat and carbohydrates, like bread, pasta, and rice.
Failure of the patient to modify eating habits in case of gastric restriction (fast eating, inadequate chewing, or drinking during meals) can cause nausea and vomiting.
Fortunately, intolerance episodes are self-limiting most of the time and may occasionally occur in the first months after surgery. It’s all part of adapting to the new gastrointestinal anatomy!
Nutritional support from an experienced bariatric dietician can help you achieve a better behavioral adaptation, or he may suggest ingesting alternative foods.
Additionally, you may experience increased bowel movements with the presence of diarrhea, fecal urgency, abdominal cramping, bloating, or flatulence.
These annoying symptoms are secondary to fat and carbohydrate malabsorption or gut bacterial overgrowth. Hence, dietary modifications, like avoiding starch-rich or fatty foods, with the regular or occasional use of intestinal antibiotics can be a great solution.
Also, you could present with something called Dumping Syndrome, which is the post-prandial (post-meal) symptoms secondary to the rapid transit of hypercaloric food to the small bowel.
Dumping Syndrome can cause reactive hypoglycemia with fainting or weakness sensation. It could be due to changes in gut hormones and insulin secretion.
In this case, nutritional recommendations are enough to control dumping. You should eat small but frequent meals, avoid simple sugars, increase fiber, protein, and complex carbohydrates intake.
Protein Intake Recommendations and Multivitamin Supplements
Enough protein intake is considered a protective measure against the loss of lean body mass in case of rapid weight loss. However, protein intake should be preferably reduced following bariatric surgery.
Gastric intolerance to protein-rich foods is pretty common after the procedure.
Hence, choosing low-protein foods is preferable after obesity procedures with a restrictive component, particularly in the first months.
However, your nutritionist could prescribe you liquid protein supplements (30 g/day) to slowly improve adequate protein intake in the first months after surgery.
Also, bear in mind that bariatric procedures that work by causing malabsorption can result in protein malnutrition in the long run.
This can be prevented by regular checkups of protein intake, increasing the ingestion of protein-rich foods (>60 g/day) distributed in several meals, and using protein supplements.
On the other hand, multivitamin and mineral supplements are important in bariatric patients, especially pregnant women!
Over-the-counter supplements cannot provide adequate amounts of certain micronutrients, such as vitamin B (12), fat-soluble vitamins, and iron.
So, patients most likely will require additional doses of life-long supplementation to maintain optimal micronutrient status.
In general terms, all bariatric surgery patients should attend to strict monitoring of nutrient levels starting at three months after surgery and regularly thereafter.
Exercise and Bariatric Surgery
Exercise is a cornerstone and a great ally to lose weight both before and after surgery.
Indeed, a positive correlation between regular exercise and weight loss after bariatric surgery has been observed in many studies. Also, regular physical activity is a crucial factor for weight maintenance.
Therefore, regular exercise should be encouraged after bariatric surgery, starting immediately in the post-operative period, after clearance from your surgeon.
Patients should incorporate moderate aerobic exercise, with a minimum of 150 min/week (preferably 300 min/week). Also, you could incorporate additional strength training 2–3 times per week to increase lean muscle mass.
Weight Regain Prevention and Management
Weight regain after bariatric surgery is a real possibility. It can be secondary to hormonal and/or metabolic imbalance, surgical technical failure, sedentary lifestyle, or nutritional non-compliance.
Weight gain after bariatric surgery can present in 20–30% of patients. They could either fail to achieve ideal weight goals or maintain a 20% weight loss in 10 years after surgery.
In those cases, enforcing a healthy lifestyle can help to prevent weight regain. Also, adding anti-obesity drugs may halt weight regain when applied on time.
At the end of the day, your bariatric surgery success depends on you and your long-term compliance with a follow-up regimen, including new and healthy dietary habits.
This is especially true because, after bariatric surgery, the stomach volume slowly expands, and appetite increases. So, high-volume foods like fruits and vegetables can help avoid weight regain.
Also, an essential part of the follow-up regimen success is that you must be treated by a multidisciplinary team with a bariatric surgeon, an expert nutritionist/dietician, a psychologist, and a specialized physician.
A FINAL WORD
Bariatric surgery and weight loss non-surgical procedures are effective tools. However, a multifaceted weight care strategy is needed to maintain their long-term effects.
Diet and exercise are essential both before and after surgery!
Following nutritional guidelines with caloric control, lifestyle changes, and regular exercise is weight loss therapy’s true core.
Remember that with or without surgery, it’s all about changing your mindset! Thanks to surgery, you can have a smaller stomach, but if you don’t follow your nutritionist’s advice, you will gain weight and present with complications.
Also, keep your eyes on the big prize. Nutritional and obesity treatments don’t have weight loss as the ultimate goal. They are meant to improve your quality of life and lessen the effect of obesity-related diseases.
- Mechanick, J. I., Apovian, C., Brethauer, S., Garvey, W. T., Joffe, A. M., Kim, J., Kushner, R. F., Lindquist, R., Pessah-Pollack, R., Seger, J., Urman, R. D., Adams, S., Cleek, J. B., Correa, R., Figaro, M. K., Flanders, K., Grams, J., Hurley, D. L., Kothari, S., Seger, M. V., … Still, C. D. (2019). Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 25(12), 1346–1359.
- Greenwald A. (2006). Current nutritional treatments of obesity. Advances in psychosomatic medicine, 27, 24–41. https://doi.org/10.1159/000090961
- Shankar, P., Boylan, M., & Sriram, K. (2010). Micronutrient deficiencies after bariatric surgery. Nutrition (Burbank, Los Angeles County, Calif.), 26(11-12), 1031–1037. https://doi.org/10.1016/j.nut.2009.12.003
- Weight loss info on the Obesity Controller
4 reasons why you can trust in Servidigest Medical-Surgical Center (Barcelona, Spain):
SPECIALISTS IN NUTRITION AND OBESITY TREATMENTS AT SERVIDIGEST BARCELONA CLINIC (SPAIN):
Doctor Josep Merlo Mas
Director of the Servidigest clinic Barcelona (Spain). Pioneer in the prevention and treatment of diseases of the Digestive System, Endocrinology, Nutrition and Dietetics.Medical Solutions Barcelona
Doctor Ramiro Durán Bermejo
Digestive System Specialist and Medical Deputy Director of ServiDigest Barcelona (Spain). Specialist in Gastroenterology, Hepatology, Coloproctology, Inflammatory bowel disease, Digestive endoscopy, Motility and digestive functional tests.Medical Solutions Barcelona
Doctor Eduard Mª Targarona Soler
Specialist in Bariatric Surgery and Obesity Surgery at the Servidigest clinic Barcelona (Spain). President of the Spanish Association of Surgeons (AEC).Medical Solutions Barcelona
The 22 digestive system specialists at Servidigest Barcelona clinic (Spain) are highly qualified and specialized. This fact guarantees a completely personalized treatment for each patient.
10/07/2019 Doctor Eduard Mª Targarona, the Servidigest clinic’s medical coordinator of the Obesity Surgery Service, is distinguished as a Full Member of the Royal Academy of Medicine of Catalonia.
12/14/2018 Presentation of the 2018 Professional Excellence Awards.
Doctor Ramiro Durán Bermejo. Medical Assistant Director at the Servidigest clinic.
Doctor Xavier de Ribot Molinet. Digestive System Specialist at the Servidigest clinic
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