Is the Easy Way Out Stigma Holding Back People from WLSJune 29, 2020
When I ask my patients what delayed their presentation to my office to discuss effective weight loss options, which may not always be surgical. One of the most common reasons is that people delay their presentation due to societal pressures and the guilt of taking the Easy Way Out!
Harmful Prejudice of the so-called "Easy Way Out"
If you had WLS or contemplating having WLS, I hope to provide you with strong scientific based arguments for metabolic surgery and against this outdated and harmful prejudice against obesity as taking ‘the Easy Way Out’!
Let me give you an example, many more will follow in this article. If a patient had a polyp in their colon and had an option of watchful waiting- to a wait-and-see what may happen in the future in the hope the polyp will regress and not cause any problems such as cancer or bleeding versus, have it removed to prevent these problems. I think the decision is probably going to overwhelmingly remove the polyp!
The intermediate and long-term harmful effects of obesity are well established, however, the prejudice against obesity is very slow to change. The reason you should seek treatment and as quickly as possible for your obesity is to prevent and reverse some of the associated conditions with obesity such as cancers, high blood pressure, diabetes mellitus (uncontrolled blood sugars), sleep apnea (which increases your chances of sudden death), hypercholesterolemia, osteoarthritis of the hips/knees/back and many other chronic conditions which are associated with obesity.
Compounding Factors of Obesity
Let's get back to WLS is ‘the Easy Way Out’! This is a complete fallacy and unjustified prejudice.
Patients who seek WLS are severely overweight and have multiple medical conditions, they are often referred by other physicians who are having a difficult time to control these conditions due to the compounding factor of obesity.
Every patient has tried multiple calorie-restrictive diets. These diets initially helped them in losing weight but they have been unsuccessful in keeping the excess body weight off! I will touch on WHY diets work initially in losing weight but the weight slowly creeps back.
In fact, I would argue that WLS is “going ALL IN’ rather than ‘the Easy Way Out’. An easy way would be losing weight without a plan or effort.
There are five pillars for a successful weight loss plan. These are-
One may not require all of these to be successful. I believe you will need at least FOUR of the five to be successful in the long-run. I am going to focus on the last pillar in this article because it’s the most important factor in being successful longterm.
Excess Caloric Intake
When we diet and severely restrict our caloric intake our body goes into self-preservation mode, our bodies are very efficient at storing calories, when we don’t feed it it feels an impending doom such as a famine is coming. We are not designed to have abundance of calories, this is one of the main reasons our bodies are not able to adapt as easily with excess caloric intake.
In fact, if we look back as little as 100 years ago, calories were very scarce to come by. Most people would have walked for miles to a very small shack, or a farm, to buy their food. Whereas, nowadays we get our food delivered to our home and we spend minimal effort or calories to get that food, clicking a few buttons on your keyboard doesn’t burn many calories!
Look at the graph below, it is a breakdown of the number of calories in percentages, used by the body. As you can see, the biggest chunk of calories is used to maintain simple body functions such as breathing, heartbeat, filtering blood, getting rid of toxins, etc. This is known as Basal Metabolic Rate (BMR).
If you imagined a pizza furnace, then the BMR would be the rate at which the furnace is usually maintained when nothing is in the furnace. When more work is needed, such as when you want to bake a pizza, the rate is then increased to bake the food in the furnace. This is analogous to performing strenuous physical activities such as high intensity workouts or manual labor!
If you look at the breakdown again you will notice that exercise will burn 5-10% of the daily caloric expenditure. If someone is 100 lbs or more overweight it will take them a very long time to lose that weight. Furthermore, when metabolic adaptation kicks in it will make it even harder!
Implementing the 5th Pillar of Weight Loss
This is the reason why the premise of ‘eat less’ and ‘exercising’ ONLY will not lead to a successful longterm weight loss outcome. You will need to implement the 5th pillar of weight loss as well and, combat the body’s metabolic adaptation to achieve successful longterm results of losing the weight and keeping it off.
This is the reason why severe calorie restrictive diets work well for the first 6-8 weeks and then weight loss stalls. Hence, the fine print you will see in most dietary weight loss advertisements. Your body will respond to the lack of calories by decreasing the rate of your BMR, this means you will be burning significantly less calories at rest. Furthermore, since this is the biggest portion of the calorie consumption per day your overall calorie consumption will also decrease significantly.
The only way in which we can fight metabolic adaptation is by manipulating the stomach and reseting the neurohormonal access of the brain-gastrointestinal tract. All stapled procedures, where the stomach is cut, lead to these changes. However, the effectiveness of these changes depends on the type of WLS. When re-routing of the intestine is added to gastric stapling, for example in the case roux-en-Y gastric bypass and duodenal switch, this effect is accentuated and more weight loss is achieved.
If I was to summarize this idea I would tell you that your body obtains a new mark for your weight thermostat once you maintain a specific weight for a long period of time. While you may be severely overweight, your body doesn’t see it that way. So, when you lose 20, 30 or 40 lbs your body will start going into self-preservation, you can call it anti-starvation, mode. It will slow your metabolism and conserve most of the energy you consume hence, when you have been on a severe calorie restrictive diet for several weeks you will stop losing weight despite eating the minimal amount of calories!
I hope this has shed some light on the complexities of treating obesity, misconceptions about weight loss surgery, and will help you to inform others about this complex and chronic relapsing condition.
ABOUT THE AUTHORDr. Husain Abbas of Memorial Advanced Surgery, is a Board Certified surgeon trained in Minimally Invasive Surgery. After his surgical residency at St. Mary's, a Yale University affiliated hospital, Dr. Abbas completed a fellowship in Minimally Invasive Gastroesophageal & Bariatric Surgery at the University of Florida, Gainesville. Dr. Abbas' expertise extends to a wide array of gastroesophageal disorders, anti-reflux surgery, complex hernia repairs, endocrine, oncology and bariatric procedures.
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