Excess Skin After Bariatric Surgery

On the second day of the Canadian Obesity Summit, I had the honor of being asked to act as a judge for a number of excellent research presentations during the poster session.  First, a heartfelt congratulations to all of the presenters - I was truly impressed by all of your efforts and studies, and I enjoyed each of our stimulating conversations!

A study that really struck a chord with me, and which I feel is really important to share, was a study looking at the impact of excess skin on physical activity in women who have had bariatric surgery.  The reason for doing this study is that over 70% of patients who have bariatric (obesity) surgery are left with excess skin that interferes with physical and social functioning. The research, conducted by A Baillot and colleagues at the University of Sherbrooke in Quebec, administered questionnaires to 26 women who had had bariatric (obesity) surgery at least 2 years prior, asking women about how their excess skin impacted them physically, psychologically, and socially.

They found that 77% of patients reported that their excess skin was making mobility during physical activity difficult, and that almost half were avoiding physical activity because of their excess skin.  What really hurt my heart was that when these women were asked why the excess skin caused them to avoid physical activity, the most common reason cited was that they were concerned about people staring at them (other reasons were hygiene concerns, weightiness of the excess skin, and a feeling of 'sloshing' of the skin).

My take home message from this study is that the likely development of excess skin after obesity surgery is something that needs to be discussed in detail with patients prior to having surgery, such that they are prepared for the physical, psychological, and social challenges that they may perceive or encounter.

And, as always, it is my hope that with education of our society, that any obesity related stigma that may exist out there will continue to decrease until it disappears entirely.  I was asked a lot at the summit as to why I blog - this reason would be amongst the highest.

Dr Sue Pedersen www.drsue.ca © 2013 

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Nutritional Support After Bariatric Surgery

Today, I would like to kowtow to my friend and colleague Dr Priya Manjoo, endocrinologist at the University of Victoria, who gave a fantastic talk about nutritional support of the bariatric patient at the Canadian Obesity Summit. 

I'll highlight a few of the key points here: 

1.  Prior to obesity surgery, many patients are already often deficient in nutrients; for example, one study showed that 65% of patients were deficient in vitamin D before surgery, and 27% were deficient in iron.  Therefore, it is imperative that these levels be checked and corrected before surgery is undertaken. 

2.   Following obesity surgery, there are a number of reasons why nutritional deficiencies can occur,  including insufficient intake due to dietary restrictions and food intolerances, anatomical causes due to changes made in the intestinal anatomy, and a disconnect between the timing of release of digestive enzymes and entry of food into the intestine. 

3.  Dr Manjoo then went through a fabulous review of the various vitamins and nutrients that we need to be on the watch for after bariatric surgery.  Adequate protein intake, and monitoring and supplementation (depending on the type of surgery) of calcium, vitamin D, iron, vitamin B12, folate, thiamine, zinc, copper, and selenium are all things that we need to think about.

Finally, as previously blogged, she pointed us towards the 2013 American Bariatric Guidelines for some guidance on this complex topic. 

Thanks Priya for a fabulous session!

Dr Sue Pedersen www.drsue.ca © 2013 

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New Bariatric Surgery Guidelines are Out!

It's been an exciting few weeks - not only are the Canadian Diabetes Association 2013 guidelines out, but so too have the Clinical Practice Guidelines for Bariatric Surgery been updated!

These guidelines, published as a joint effort by the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic & Bariatric Surgery, have some exciting new updates and features.

The guidelines address 7 key questions:

1.  Which patients should be offered bariatric surgery? 

2.  Whic bariatric surgical procedure should be offered? 

3.  How should potential candidates for bariatric surgery be managaed preoperatively? 

4.  What are the elements of medical clearance for bariatric surgery? 

5.  How can early postoperative care be optimized? 

6.  How can optimal follow-up of bariatric surgery be achieved? 

7.  What are the criteria for hospital admission after bariatric surgery?


A few headliners that caught my eye:

1.  Sleeve gastrectomy is no longer considered to be investigational; it is now considered to be a mainstream bariatric procedure. (though it has been 'unofficially' considered to be mainstream for some time already)

2.  Emerging data to suggest that bariatric surgery could be offered to patients with a BMI between 30-34.9 with diabetes or the metabolic syndrome, though the current evidence is limited by the small number of patients studied, and the lack of long term outcomes (so far).   See my previous comments on this issue here.

3.  There are excellent preoperative and postoperative checklists to help guide health care providers in terms of what needs to be asked about, checked for, and monitored.

The guidelines are a must-read for anyone involved in the care of bariatric patients.

Dr Sue Pedersen www.drsue.ca © 2013 

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Sex Drive, Fertility, and Bariatric Surgery

It is a well known fact that obesity is a risk factor for female infertility, and that fertility is often seen to improve after obesity surgery.  While it has been generally thought that improvements in various hormones after surgery are the reason for the improvement in fertility, a recent study suggests that it is not just about the physiology, but also the psychology.

The study, by Dr Legro and colleagues, included 29 women having gastric bypass surgery.  They looked at ovulation rates before and up to 2 years after gastric bypass surgery, and they also looked at responses to a questionnaire designed to assess sexual function.

Interestingly, they found that despite half of these women reporting irregular periods before surgery, 90% were actually ovulating before surgery.  While they did see some improvements in the hormonal parameters of the menstrual cycle after surgery, what was most impressive was the marked improvement in the sexual function questionnaire scores, with the biggest improvements seen in sexual desire and arousal.

It's important to note is that the group in this study was comprised of women who were relatively healthy obese women, so the ovulation rate may have been unusually high in this group.  However, the Bottom Line of the study is that improvements in sex drive and enjoyment may be a major factor in the improvement in fertility seen after gastric bypass surgery.

The most important thing to point out is that pregnancy MUST be avoided for 1-2 years after bariatric surgery (exact recommendation varies by clinic and country), due to concerns for fetal undernutrition and poor fetal growth as well as potential nutritional deficiencies.  Furthermore, there are concerns that the birth control pill may not be absorbed properly after bariatric surgery, and therefore, the pill MUST NOT be relied on for contraception.    Therefore, be sure to speak to your doctor about these issues before surgery, such that appropriate plans can be made to avoid pregnancy until it's safe to proceed.

Dr Sue Pedersen www.drsue.ca © 2013 

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Baseline Body Weight Does Not Predict Success of Bariatric Surgery

Currently, the critieria for who qualifies for bariatric surgery typically includes a body mass index (BMI) criterion - ie, a patient has to be at a certain body weight relative to their height to qualify for surgery.

A review of data to date on the landmark SOS trial was just published by L. Sjöstrom, which I encourage anyone interested in this field to read.  They have now followed SOS study patients for 20 years - though it's noted that many patients have dropped out of the study follow up along the way, so we do have to take the results with a large grain of salt.

While there are many results in this study that are very worthy of discussing, what I wanted to point out today is that the SOS study showed a benefit of obesity surgery to decrease the risk of death, diabetes, and cardiovascular disease, as well as a decreased risk of cancer in women. What is even more interesting is that the baseline BMI did NOT predict the effect of surgery on any of these endpoints.  (For those who download the article - see figure 7).  Interestingly, higher baseline insulin levels did predict favorable outcomes with regards to bariatric surgery decreasing the risk of death, cardiovascular disease, and diabetes (but not cancer).

This data therefore lends further evidence to the fact that BMI criteria should not be a fixed and fast rule for who qualifies for obesity surgery and who doesn't; looking at the whole patient and their metabolic profile (as always) is important!

Dr Sue Pedersen www.drsue.ca © 2013 

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Bariatric Surgery and Bone Health

The decision to undergo obesity (bariatric) surgery is a complex one, as the potential benefits and potential risks are many.  A longterm potential complication that is often overlooked is the effect that bariatric surgery can have on bones.


As outlined in an excellent review by Brzozowska and colleagues, the effect of bariatric surgery on bone health is not well understood.  As the potential effects, as well as what we know (and don't) is quite variable depending on what type of bariatric surgery is performed, here are a few notes organized by procedure:  (you can also read more about the procedures in general here)

Gastric Bypass Surgery:  We know that gastric bypass alters bone metabolism in favor of bone breakdown.  In many cases, this is at least partially due to vitamin D and/or calcium deficiency - both require supplementation lifelong after gastric bypass, and inadequate replacement will cause bone depletion over time.  There are many other factors involved as well - several hormones made in the fat tissue and the gut that change after gastric bypass surgery have been implicated in changes in bone metabolism as well. 

Sleeve Gastrectomy:  As a newer procedure, very little is known about the effect of sleeve gastrectomy on bone.  The available data suggests that sleeves do affect bone metabolism and can cause bone loss over time.

Gastric Banding:  It is not known whether gastric banding has an adverse effect on bones or not - studies done so far have shown conflicting results.  Gastric banding is a less invasive procedure that doesn't cause calcium or vitamin D deficiency, and doesn't cause as many hormonal changes as the other two surgeries.  (That being said, gastric banding is falling out of favor due to its poor longterm efficacy and high reoperation rates over the long term.)

A few important caveats to the above discussion:

1.  It is not known whether changes in bone metabolism seen with bariatric surgery result in an increase in fracture risk - more study is needed.

2.  The long term effect on bone metabolism is not known, as most studies done to date are only a year or two in duration.  Longer term studies will help us to understand the effect on long term fracture risk as well, which is the most important outcome measure.

3.  The effect on bones may be different not only by the type of surgical procedure, but also by age and gender - again, more study is needed.

The Bottom Line: Anyone having bariatric surgery should have a baseline bone density done before surgery, and bone density should be monitored after surgery as well (guidelines are available here).   While adequate calcium and vitamin D is an important component of bone health, there is much more about the effects of bariatric surgery on bone that we still don't understand.


Dr Sue Pedersen www.drsue.ca © 2012 

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New Data on Type 2 Diabetes and Obesity Surgery

At the European Association for the Study of Diabetes (EASD) meeting in Berlin today, I had the pleasure of sitting in on a session discussing the effects of obesity surgery on type 2 diabetes.  Whereas previous years of diabetes meetings have seen very sparse attendance at bariatric surgery talks, this session was absolutely packed. 

At this session, a number of fascinating studies were
presented.  Highlights included: (be warned - it's a very science-heavy blog this week!)

A study by S. Steven and colleagues (UK) looked at a group of 92
patients who had type 2 diabetes prior to having gastric bypass
surgery, with the aim of determining which factors were associated
with a greater chance of diabetes remission after surgery. One of
their findings was that the degree of weight loss achieved post op was
the main determinant of diabetes remission - controversial, as the
bulk of currently available evidence suggests that remission of
diabetes is independent of weight lost.

A study by Pournaras and colleagues found that a nifty removable liner placed
inside of the first 60cm of small intestine (called a duodenal-jejunal
bypass liner) improved type 2 diabetes control over a 1 year trial period.
This introduces the question as to whether, in the future, we can
consider less invasive alternatives to bariatric surgery (such as
these) to help control type 2 diabetes.


A couple of elegant studies out of Denmark (including colleagues Jens Juul Holst and Sten Madsbad who I collaborate with on research studies personally) and Sweden were presented, designed to give us a better understanding of just how obesity surgery improves type 2 diabetes (with a lot of arrows pointing to the increase in the hormone GLP-1 that is seen after surgery).

Finally, there was a neat study from Finland showing that the insulin resistance of fat in femoral bone marrow improves with bariatric surgery (I personally had not previously thought about bone marrow being insulin resistant!).  

Overall, a very exciting day, and a very exciting meeting!

Dr Sue Pedersen www.drsue.ca © 2012 drsuetalks@gmail.com

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