Bariatric Surgery and the Complicated Reality of Weight Loss
If you’ve put on a few pounds over the course of the COVID pandemic, you’re not alone. According to a poll conducted by the American Psychological Association, 61% of U.S. adults reported weight gain in the pandemic's first year. For many Americans, the pandemic has forced lifestyle changes, increased stress, and reduced physical recreation that have added the pounds.
With the New Year, people are thinking again about how to slim down—not just so they can fit into their favorite pair of jeans, but also to maintain their long-term health.
The thing is, losing weight isn’t as easy as reversing the lifestyle changes that made you gain it.
“We know that exercise in and of itself doesn’t cause significant weight loss,” says Marc Bessler, MD, director of Columbia’s Center for Metabolic and Weight Loss Surgery. That’s because your body is “very, very good at pushing you to take in calories when it thinks it needs them.” When you exercise more, your body makes you hungrier, and you eat more to make up for the calories you’ve burned. It’s not a matter of willpower: “You don't consciously eat more when you exercise,” Bessler explains. “You eat more because your body is driving you to.”
Similarly, dieting alone won’t lead to sustained weight loss. Bessler says multiple experiments over time show that as people diet, their metabolism slows down 10% to 15%, and “even the same amount of food that was causing weight loss in the first place will no longer cause weight loss once your metabolism slows.” At that point, people get frustrated and often abandon their attempts because they’re not losing weight even as they’re dieting. As Bessler puts it, “Why keep doing that?”
Bariatric surgery is “the only long-term, proven weight loss treatment we have,” Bessler says. A major medical procedure for obese patients facing life-shortening health issues without it, “bariatric surgery is not the easy way out,” he adds. “It doesn't change the fact that you have to make a change. It just makes it easier to make that change, because it reduces hunger and allows you to feel satiated with a smaller amount of food. That's all it does, but that is enough in the vast majority of people.”
Over the past 25 years, Bessler has led the evolution of weight loss surgery from open procedures with a mortality rate of 1% to 2% to much safer laparoscopic procedures with higher long-term success rates. As the safety and efficacy of bariatric surgery has improved, more and more doctors across specialties have accepted it as a valid treatment for medical conditions.
“Orthopedists have recognized that total joint replacement in obese patients has a higher failure rate, higher complication rate, so they're starting to talk about [weight loss surgery] and sending patients,” Bessler says. “Gynecologists have come to know that weight loss is a treatment for endometrial cancer, so they'll refer patients.”
Obesity increases the risk of a long list of serious medical conditions, from heart disease and hypertension to cancers and mental illness, making bariatric surgery medically necessary for most folks seeking treatment. But Bessler acknowledges that the desire to lose weight can be influenced by external factors including cultural beauty norms and weight stigma, which he calls “the last bastion of allowed discrimination.”
In a 2016 New Yorker article that explored the history of weight loss methods, Bessler remarked that women are much more likely than men to seek bariatric surgery: “A man who is a hundred pounds overweight, he will be treated with respect,” he said. “But a woman who is a hundred pounds overweight—it’s much more difficult for a woman.”
A lot of things have changed since 2016, including growing awareness of the harms of diet culture and the impact of anti-fat bias in medicine. But Bessler still sees four times as many women as men in his practice: “Men come when they get sick, when they can't do the things they want to do,” he says. “I think more women come because they're just not happy with their appearance.”
Bessler estimates that 20% to 25% of patients pursue weight loss surgery when they’re fed up with their quality of life, "but it's not right for everybody, and it may not be right for most.” For the vast majority of people struggling to accept their post-pandemic bodies, it may be most helpful to focus on feeling better rather than looking a certain way.
Whether you drop your “COVID 19” will have more to do with your genetics and socioeconomic context than how hard you work at the gym. But reversing the lifestyle changes that led to pandemic weight gain can greatly reduce stress and improve overall physical and mental health, no matter what the scale says.
Marc Bessler, MD, is the United States Surgical Professor of Surgery and chief of minimal access/bariatric surgery at Columbia University Vagelos College of Physicians and Surgeons. He also directs the Center for Metabolic and Weight Loss Surgery and Minimal Access Surgery Center at Columbia University Irving Medical Center.
Bessler's clinical specialties include laparoscopic and single incision bariatric surgery, and he is a fellow of the American College of Surgeons.