Having a Body Mass Index (BMI) over 35 and to an even greater extent having a BMI over 40 significantly increases our risk of requiring mechanical ventilation if we are admitted to ITU with Covid-19. In the UK around 3.6% of adults have a BMI over 40. This equates to almost 2 million people who are at risk of being critically ill with Covid-19. So is weight loss surgery a quick fix to reduce Covid-19 risks?
The British Obesity and Metabolic Surgery Society wrote to Prime Minister Boris Johnson recently asking him to increase access to weight loss surgery. The letter highlighted the significant weight loss that could be achieved in just twelve weeks. Since then it has been presented in the media and in political discussions as a quick fix. With almost 2 million UK adults at risk of requiring ventilation should they contract Covid-19 it’s clearly important to explore what can be done quickly. So should you consider weight loss surgery if you think you are at risk?
What is weight loss surgery?
First of all let’s clear up the terminology. When talking about weight loss surgery medical professionals use the term “bariatric”. This is derived from the Greek word “baros” which simply means weight. So bariatric is the branch of medicine that deals with treating excessive weight gain. I prefer to ditch as much medical terminology as possible so that patients and professionals can speak on equal terms. Sometimes it helps because it acts like shorthand. However in this case it’s one space and an extra letter so it seems wise to just use everyday English.
There are several types of weight loss surgery. The procedures limit how much you can eat or reduce the nutrition including calories that you absorb or both. You can find more details here. Whatever procedure you choose, you still have to eat a healthy diet and exercise regularly. Furthermore you have to stick to these lifestyle changes permanently.
How long long does it take from consultation to surgery?
The whole process from initial consultation to surgery takes many months. This is because there are numerous assessments that need to be carried out first. You must also be able to show that you can keep your weight stable before surgery can take place. Psychological assessment is essential to check that you will be able to cope with the lifelong impact of surgery.
With increased funding some of this assessment work could be speeded up. However short-cutting the psychological assessment in order to achieve a “quick fix” in relation to Covid-19 risks seems unwise.
Many people with a BMI above 35 have an enlarged liver, which can make surgery technically difficult. For this reason people are asked to follow a low carbohydrate, low fat diet for about a month before surgery. This encourages the body to use up carbohydrate stored in the liver, helping to shrink it. It impacts on the time between consultation and surgery but is not a step that could be skipped to get surgery done more quickly. If surgery takes place whilst someone has an enlarged liver it could bleed heavily causing serious complications.
In the initial stages after surgery a liquid and then soft diet must be followed. The process of getting back to more everyday foods can take several months. Furthermore there are a number of potential side effects. Some of these are serious like gallstones, vitamin and mineral deficiencies, blood clots, heartburn, vomiting, blockages and infections. There is also a small risk of dying during the procedure.
Weight loss surgery is not something that people should enter into without thinking long and hard about the risk and lifelong impact. In practical terms it’s not a quick fix.
Does it work?
Weight loss surgery is certainly effective. Studies show that people can lose up to 50% of their excess weight in the first 6 months after surgery. After a year people can lose almost 80% of their excess weight. However success depends on whether you can stick to a sensible diet and exercise programme.
Some weight does creep back on over the years. However studies show that people maintain 50-60% loss of their excess weight even 10 years after surgery.
So how does this compare to weight loss interventions without surgery?
Let’s take an example of a man weighing 130kg who is 1.80 metres tall. This man would have a BMI of 40. I usually recommend that people lose about 1kg/week. So after 17 weeks he would weigh 113 kg and have a BMI of 34.7. He would need to weigh 81kg to be in the healthy weight range. After 17 weeks he would have lost 35% (17/49kg) of his excess weight. This would significantly reduce his risk of being seriously ill should he contract Covid-19. Interestingly 17 weeks is about the same amount of time it would take to do all the pre-surgery assessments.
I accept that the science shows that in the longterm weight loss surgery is overall more effective. However I want people to know that they have choices. An individual can achieve the same success without surgery as with. Whether or not that happens depends on the person and the support they have access to.
What are the other options?
It’s important to say that I have had patients lose weight successfully using a variety of different approaches. For some people intermittent fasting fits well with their lifestyle. Others prefer to reduce fats and sugars and increase fibre. Some people reduce their carbohydrate intake whilst others like to use a very low calorie diet (800 calories/day or less) in the initial stages to kick start the process. I use whatever approach is safe and most well tolerated for each person. Everything I do is customised.
People also need different levels of support. Some can take high level principles and practical resources and apply them with follow up every 8 weeks or so. However others need fast response coaching on a twice weekly or even daily basis. Everyone is different but Dietitians are able to develop a plan that is most likely to work for each person.
I have patients who chose to come back for an annual review to help them keep the weight off long-term. This is a great strategy. I am also hoping to set up a group where people can support each other. I will just dip in from time to time to do a Q and A or provide some resources. There are many cost effective ways for people to get long term support to help them maintain a healthy weight.
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