Obesity Medicine and a Call to Action: Weight Recidivism Post Weight Loss Surgery and the Argument for Mandatory Medical Weight Management as a Postoperative Standard within Bariatric Surgery Practices

| August 1, 2020

by Stephanie Therrien, BSc, and Juliana Simonetti, MD, ABOM Diplomate

Ms. Therrien is with Brigham and Women’s Hospital in Boston, Massachusetts. Dr. Simonetti is an Assistant Professor and the Director of Bariatric Medical Program, Department of Endocrinology, Metabolism and Diabetes/ Department of Surgery, at the University of Utah, Salt Lake City.

FUNDING: No funding was provided.

DISCLOSURES: Dr. Simonetti does research and consulting for Rhythm Pharmaceuticals. Ms. Therrien reports no conflicts of interest relevant to the content of this article.

ABSTRACT: The significance of bariatric surgery in treating obesity has been demonstrated repeatedly through significant research efforts and analyses. Because of this, rates of bariatric surgery continue to rise. Despite statistics demonstrating significant initial weight loss and improvement in or resolution of related comorbidities, not all patients who had surgery achieved such success or were able to maintain it long-term. With the known failures of bariatric surgery and successes of early intervention, should it be mandated by medical governing bodies that bariatric surgery programs must employ board-certified, fellowship-trained obesity medicine physicians to monitor postoperative success in patients who undergo weight loss surgery?

KEYWORDS: Bariatric surgery, weight regain, obesity medicine

Bariatric Times. 2020;17(8):10–11

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The Experience

Amy’s foot taps rhythmically on the waiting room floor—she’s been dreading this appointment for weeks. She looks around the room, then at herself, running through what she’ll say about her increasing weight. Amy is a day away from the two-year anniversary date of when she received bariatric surgery. At her one-year annual postoperative appointment, she was down over 100lbs, the most weight she’s ever lost. But that was the last time she would see a consistent decrease on the scale. She knew she should probably check in with her surgical team sooner but was too embarrassed by her failure to make the call. After several more months of trying and failing to lose the weight on her own, Amy finally decided to make the call.

Amy looks at her watch—maybe it’s not too late to reschedule, give herself another month to get the weight down. As she contemplates this option, the door opens, and her name is called.

The Science

Obesity rates have drastically increased over the last few decades. Currently, it impacts one-third of the United States (US) population—91 million children and adults.1 The World Health Organization (WHO) estimates that worldwide, there are 1.9 billion adults with overweight (body mass index [BMI] of >25 to 29.9kg/m2) and 650 million with obesity (BMI>30kg/m2).2 Obesity is the second-leading cause of death related to cardiovascular disease and is the biggest contributor to Type 2 diabetes mellitus (T2DM). According to a 2010 paper published in the American Journal of Public Health, obesity has many social and economic effects where those with this disease suffer greater rates of discrimination, lower wages and quality of life.3

Treatments deployed to combat this disease include long-held ideologies such as “eat less and move more,” calorie restriction, and various complex dietary therapies that have been proven to be mostly ineffective in producing successful long-term effects on weight loss and weight loss maintenance. More successful treatments, such as bariatric surgery, pharmacotherapy, and minimally invasive procedures, are available, but they are largely underutilized due to a lack of physician training and awareness (pharmacotherapy options in particular), restrictive insurance coverage and demographic/socioeconomic limitations. Treatment method aside, there is a constant theme among all modalities: weight regain.

The effectiveness of bariatric surgery in treating people with moderate (BMI 35–39.9kg/m2) to severe obesity (BMI>40kg/m2) has been demonstrated repeatedly through significant research efforts and analyses.4 A 2003 to 2012 meta-analysis of 164 studies that included 756 patients reported a 12-to-17-point BMI drop at five years postsurgery.5 Successful patients not only lose weight, but they also experience resolution of, or improvement in, weight related comorbidities.3 Between 2011 and 2013, the rates of bariatric surgeries increased 14-fold.4 In the year 2018 alone, using national inpatient sample data and outpatient estimations, the American Society for Metabolic and Bariatric Surgery (ASMBS) estimates that there were 252,000 bariatric surgeries performed in the US.6

Despite statistics demonstrating significant initial weight loss (defined as >50% excess weight loss) and improvement in or resolution of related comorbidities, not all patients who had surgery achieved such success or were able to maintain it long-term.7 In a 2013 study, it was estimated that 10 to 20 percent of patients who undergo weight loss surgery regain a significant portion of their nadir weight.4 Another study showed that significant weight re-gain (defined as >15% gain of initial weight loss post bariatric surgery) occurred in 25 to 35 percent of persons within 2 to 5 years of when they had surgery. Regarding the return of comorbidities, a third study found that during the first-year post-nadir, 9.9 percent of participants experienced a progression in T2DM, 25.8 percent in hyperlipidemia (HLD), 46.2 percent in hypertension (HTN) and 22.2 percent experienced a decline in health-related quality of life (HRQOL).8

Weight regain after surgery is a complex problem that is influenced by more than just the surgery type. There are a multitude of contributing factors, such as biology, behavior, environment, and societal and economic demographics.4 Even with well-understood contributing pathologies, medicine offers limited understanding on how to predict which surgical patients will be successful and which will regain weight following surgery.

The adjustable gastric band (AGB), which is considered purely a mechanical procedure where a ring is placed to decrease the stomach size, boasts low complication and mortality rates. However, it has a higher reoperation rate and less weight loss compared to its counterparts. The reoperation rate for AGB is estimated at 30.5 percent of patients in the US, of which, only 12 percent were able to maintain their pre-removal weight.4 Given a smaller percent of weight lost and higher rates of complication, this option is being performed at notably lower rates.

Sleeve gastrectomy (SG), Roux-en Y gastric bypass (RYGB), and biliopancreatic diversion (BPD), restrictive and malabsorptive procedures respectively, lead to heterogenic weight loss and weight regain that goes beyond the mechanics of each procedure. Weight regain in patients who receive any of these procedures can be attributed to the loss of restriction, or enlargement of the gastric pouch. In one study, an enlarged gastric pouch was found in one-third of patients who underwent RYGB and reported weight gain.4 Another study found that the median rate of weight regain post-RYGB was 9.5 percent one-year post-nadir, 22.5 percent three years post-nadir and 26.8 percent five years after reaching nadir.8 In the event of surgical failure due to increased gastric pouch sizing or mechanical failure of the gastric band, revisional surgery can be considered. While a viable and often practical option, revisional bariatric surgery performed as a method in which to reduce weight recidivism has been reported to have varying degrees of success and requires reoperation, which is associated with a higher risk of complications.1

Gut–brain hormone communication post SG, RYGB, and BPD is thought to play an important role in the variations of postprocedural weight loss.9 Varying degrees of resection of the great curvature of the stomach in these procedures and bypassing part of the small intestine in the RYGB and BPD lead to several hormonal changes that involve hunger (ghrelin), satiety (glucagon-like peptide [GLP-1] and peptide tyrosine tyrosine [PYY]), and energy balance.10 One study followed 26 patients post-SG for five years and found that the patients who regained weight had a slightly higher plasma ghrelin.11 Another study found that patients in the highest percentage of weight loss post-RYGB had higher postprandial PYY response compared to those in the lowest quartile.12 GLP-1 response to a meal post-RYGB also appears to play a role in successful weight loss following RYGB. A study found that patients with the least amount of weight loss at approximately two years after RYGB had smaller prandial PYY and GLP-1 responses compared to the patients in the cohort with the best weight loss success.13

Obesity is considered to be a highly heritable disease, with some studies quoting a genetic contribution of 40 to 70 percent. Genetic variations and the interplay with the environment are also thought to play a role in a patient’s response to bariatric surgery. With advancements in genome-wide association studies (GWAS), several genes and genetic mutations (single nucleotide polymorphisms) have been identified and have been found to be associated with differences in the severity of obesity and weight loss after bariatric surgery. One of the studies found that mutations in the 5-HT2C gene are associated with a greater percentage of excess body weight after RYGB.14 Other study findings suggest that mutations in the UCP2 gene can be considered biomarkers of weight loss after bariatric surgery.15 Monogenic forms of obesity are mainly due to mutations in genes of the leptin–melanocortin pathway, which plays a key role in the central controls of food intake.16 Mutations on these genes have also been implicated in lack of response to bariatric surgery treatments. Although genetics and epigenetics of obesity are in its infancy, we are moving into the era of precision medicine where we might be able to predict bariatric surgery response based on genetic mutations. Additionally, new drugs being developed could also target these mutations, improving surgical outcomes.

Behaviorally, successful surgical weight loss is closely correlated with appropriate follow up.4 Though surgical follow-up is tracked and closely monitored through accrediting bodies, such as the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), a 2014 study by Benoit et al7 found that out of 73,989 patients, only 78 percent returned for a follow-up appointment at six months, 36 percent at one year, 10 percent at 18 months, and only two percent at two years. Only one percent of the 73,989 patients had an appointment scheduled at each interval up to two years.7 Loss to follow-up is not caused solely by patients missing appointments, but it also can be attributed to the fact that bariatric surgery programs often lack the capacity to provide lifelong follow up to every patient whose ever have had weight loss surgery.17 Additionally, the lack the ability to provide alternative treatment options that address many of the causes related to lack of weight loss or weight regain results in decreased follow-up over time.

Given the complex causes of obesity and weight regain post-bariatric surgery, more emphasis should be placed on individualized patient interventions that address as many of these causes as possible. Part of this intervention should include an interdisciplinary team with an obesity medicine physician (typically an internist or endocrinologist with advanced training, which might vary by state or institution) or a physician assistant/nurse practitioner with specialized training who practices under the supervision of an obesity medicine physician. Advanced training might include obesity medicine fellowship and/or board certification, which provides specialized knowledge in managing patients with obesity and its complications. These providers specialize in treating the “whole” patient and tailor visits to address and assess factors that influence weight gain and lack of weight loss. They can offer basic to advanced nutritional counseling, manage nutritional deficiencies and obesity-related chronic health issues, and evaluate patients with eating disorders and other psychiatric symptoms. Perhaps most importantly, an obesity medicine specialist offers pharmaceutical intervention to reduce weight through appetite suppression and combating or reducing the need for weight-promoting medications.

Weight loss medications could prove to be a vital line of defense in combating patients experiencing weight recidivism post-bariatric surgery. In a study where patients were stratified by those who started a weight loss medication prior to a weight loss plateau post-bariatric surgery and those who did not, patients who were prescribed medications at their plateau had a higher cumulative weight loss (32.3%) versus 26.8 percent for those prescribed after weight regained, and the mean of added weight loss was -7.6 percent (17.8lbs).1 If treating a patient with a US Food and Drug Administration (FDA)-approved medical weight loss pharmaceutical fails, an obesity medicine physician is perfectly poised in training to refer patients back to bariatric surgery for further evaluation of and consultation for more invasive options, such as revisional bariatric surgery.

In 2004, the World Health Organization (WHO) created a “global strategy on diet, physical activity, and health” in which they called upon all stakeholders to take action at global, regional and local levels, and where appropriate, establish policies and actions.18

Here is What We Know­—A Brief Summary

Obesity

The prevalence of obesity and rates of bariatric surgery as treatment for obesity are increasing nationally.

Obesity’s negative effect goes beyond its health impact. It has many social and economic effects where those with this disease suffer greater rates of discrimination, lower wages, and quality of life.

Comorbidities

Obesity is the second-leading cause of death related to cardiovascular disease and is the biggest contributor to T2DM.

Bariatric surgery outcomes

Significant weight regain (defined as >15% gain of initial weight loss post bariatric surgery) occurred in 25 to 35 percent of patients within 2 to 5 years of when they had surgery.4,8

The reoperation rate for AGB is estimated at 30.5 percent of patients in the US, of which, only 12 percent were able to maintain their pre-removal weight.4

The median rate of weight regain post-RYGB was 9.5 percent one year post-nadir, 22.5 percent three years post-nadir and 26.8 percent five years after reaching nadir.8

Conclusion

In conclusion, with the known weaknesses of bariatric surgery and successes of early intervention, should it be mandated by medical governing bodies that bariatric surgery programs must employ obesity medicine physicians (and/or trained advanced practice clinicians) to monitor postoperative success in surgical weight loss patients?

Our Recommendation

The obesity epidemic is worsening, and the care of patients with obesity and its comorbid conditions is becoming more complex. As rates of bariatric surgery continue to rise, it is imperative to the quality of care for patients with obesity to have access to a multidisciplinary approach when addressing weight regain post bariatric surgery, of which, an obesity medicine specialist should be considered as an essential role.

References

  1. Stanford FC, Alfaris N, Gomez G, et al. The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: a multi-center study. Surg Obes Relat Dis. 2017;13(3):491–500.
  2. Ruban A, Stoenchev K, Ashrafian H, Teare J. Current treatments for obesity. Clin Med (Lond). 2019;19(3):205–212.
  3. Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health. 2010;100(6):1019–1028.
  4. Karmali S, Brar B, Shi X, et al. Weight recidivism post-bariatric surgery: a systematic review. Obes Surg. 2013;23(11):1922–1933.
  5. Chang SH, Stroll C, Song, et al. The effectiveness and risks of bariatric surgery; an updated systematic review and meta-analysis, 2003-2012. JAMA Surg. 2014;149(3):275–287.
  6. Estimate of Bariatric Surgery Numbers, 2011-2018. (2018, June 26). Accessed October 29, 2019. https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers.
  7. Benoit SC, Hunter TD, Francis DM, Cruz-Munoz NDL. Use of Bariatric Outcomes Longitudinal Database (BOLD) to study variability in patient success after bariatric surgery. Obes Surg. 2014;24(6):936–943.
  8. King WC, Hinerman AS, Belle SH, et al. Comparison of the performance of common measures of weight regain after bariatric surgery for association with clinical outcomes. JAMA. 2018;320(15):1560–1569.
  9. Ionut V, Burch M, Youdim A, Bergman RN. Gastrointestinal hormones and bariatric surgery-induced weight loss. Obesity. 2013;21(6):1093–1103.
  10. Pedersen SD. The role of hormonal factors in weight loss and recidivism after bariatric surgery. Gastroenterol Res Pract. 2013;2013:528450.
  11. Bohdjalian A, Langer FB, Shakeri-Leidenmühler S, et  al. Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin. Obes Surg. 2010;20(5):535–540.
  12. Morínigo R, Vidal J, Lacy AM, et al. Circulating peptide YY, weight loss, and glucose homeostasis after gastric bypass surgery in morbidly obese subjects. Ann Surg. 2008;247(2):270–275.
  13. Le Roux CW, Welbourn R, Werling M, et al. Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass. Ann Surg. 2007;246(5):780–785.
  14. Novais PF, Weber TK, Lemke N, et al. Gene polymorphisms as a predictor of body weight loss after Roux-en-Y gastric bypass surgery among obese women. Obes Res Clin Pract. 2016;10(6):724–727.
  15. Nicoletti CF, de Oliveira AP, Brochado MJ, et al. The Ala55Val and -866G>A polymorphisms of the UCP2 gene could be biomarkers for weight loss in patients who had Roux-en-Y gastric bypass. Nutrition. 2017;33:326–330.
  16. Huvenne H, Dubern B, Clément K, Poitou C. Rare genetic forms of obesity: clinical approach and current treatments in 2016. Obes Facts. 2016;9(3):158–173.
  17. Ghaferi AA, Varban OA. Setting appropriate expectations after bariatric surgery. JAMA. 2018;320(15):1543–1544.
  18. Obesity and overweight. (2018). Accessed October 29, 2019 from https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight.

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