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Weight-Loss Surgery's Weird Alcoholism Risk
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People with morbid obesity, generally viewed as food addicts, often go under the knife once they have exhausted other efforts to lose weight. But a growing body of evidence suggests that surgery to radically reduce stomach size may harm weight-loss patients in unexpected ways. Should the use of this extreme measure be radically reduced?
The most recent negative news arrived last fall in the journal Archives of Surgery. The study indicates that people who have Roux-en-Y, the most common gastric bypass surgery, are more likely to develop alcohol abuse in the years following the procedure. Since few of them had previously been boozehounds, some experts say this new addiction is a substitute for their previous addiction to food. But surgeons who specialize in the procedure argue that the problem is physical and the surgery saves lives, period. This state-of-the-art medical intervention is embroiled in controversy.
Gastric bypass surgery is something of a medical marvel. In Roux-en-Y surgery, a small pouch is made from part of your stomach, building a new, smaller one. The pouch is then connected to the middle portion of the small intestine (the jejunum), bypassing the upper part (the duodenum). Because your new stomach is about 90% smaller than your old one, you feel full with much smaller amounts of food and take in many fewer calories. Another popular smaller-stomach operation is adjustable gastric band surgery, in which an inflatable silicone device is placed around the top of the stomach.
In all, the American Society for Metabolic and Bariatric Surgery estimates that approximately 200,000 people have bariatric surgery every year. The Roux-en-Y operation generally costs between $15,000 and $30,000; the band is cheaper by about $10,000. Many private insurance policies offer no coverage for what they consider an elective procedure.
There have been previous reports of bariatric surgery patients having serious trouble with alcohol use after their surgeries. A 2012 Archives of Surgery study by the New York Obesity Nutrition Research Center looked at 100 people who had Roux-en-Y and 55 who had the adjustable band. The post-op patients were significantly more likely than the general population to use addictive substances, especially two years after the procedures. The Roux-en-Y cohort seemed particularly susceptible to alcohol use.
If food has always been your drug, and surgery abruptly denies you your fix, you turn to other drugs.
A much larger 2012 study in the Journal of the American Medical Association came to a similar conclusion. University of Pittsburgh researchers followed almost 2,000 people who had Roux-en-Y, adjustable band or another weight-loss surgery. Before their operations, 7.6% of the group abused alcohol; after the knife, 9.6% did so. And, the patients who had the Roux-en-Y surgery were twice as likely to abuse alcohol as those who had the gastric band.
Health experts have long known that obesity and depression often go hand-in-hand. Depression can lead to becoming obese, and the opposite is also true. Many obese people are depressed before they have surgery and are therefore at high risk of depression afterward. For one thing, recovery is a slow process, and health complications of the surgery are very common; 40% of patients suffer from infection and post-operative bleeding. Perhaps more important, bariatric surgery is no magic bullet, and some patients become disillusioned as they realize that in order to "solve" their serious weight problems, they have to maintain good eating and exercise habits—lifestyle changes that likely proved elusive in the past.
Addiction experts see the problem as one of switching addictions. People become obese because they use eating as a drug. Excessive eating is a form of self-medication for painful feelings associated with depression, anxiety and deeper personality disorders. Like most drugs, food, especially carbs and sugars, trigger the brain's reward pathways, causing a feeling of pleasure. But sustained excessive eating causes the brain to lose its capacity to produce these feel-good chemicals. That's when addiction starts.
Weight-loss surgery fixes the outside of a person, but not the inside. While it can reduce the harm of obesity, it leaves the needs driving your addiction untouched. So if food has always been your drug, and stomach-minimizing surgery abruptly denies you your fix, you turn to other drugs. Alcohol, being legal, is the most available, but patients can take their pick among the panoply of addictive substances.
Hogwash, says John Morton, MD, a bariatric surgeon at the Stanford School of Medicine and member of the executive council of the American Society for Metabolic and Bariatric Surgery. Like many other surgeons who specialize in this procedure, he favors a physical rather than a psychological or switching-addiction explanation for the high risk of alcohol abuse. "[There is a] heightened sensitivity to alcohol [and it is] purely physiologic," Morton says. Along with the liver, the stomach produces alcohol dehydrogenase, an enzyme that breaks down alcohol into other, less toxic molecules. Because gastric bypass patients have much less stomach, and therefore less of that enzyme, more alcohol enters their bloodstream.
"As a result," Morton says, "you get drunker faster and stay drunker longer." The same phenomenon occurs with people who have their stomachs removed because of cancer. If alcohol abuse in bariatric patients were due to psychological issues, you wouldn't expect cancer patients to have greater alcohol sensitivity, Morton argues.
Mitch Roslin, MD, a specialist in bariatric medicine at New York's Lenox Hill Hospital, agrees. He calls the switching-addictions theory "BS.” Drinking alcohol in your post-Roux-en-Y life is "the epitome of drinking on an empty stomach"—after all, your stomach is almost nonexistent. "Essentially," Roslin says, "drinking alcohol after Roux-en-Y is like having an alcohol IV."
"Essentially, drinking alcohol after Roux-en-Y is like having an alcohol IV," Roslin says.
But why does alcohol sensitivity show up more in the second year after the surgery? Roslin suggests that the second year is when you realize that your surgery will not, by itself, keep you healthy, that you do indeed have to "fix the inside." At that point, you might feel depressed, use alcohol to escape and comply less with your post-op instructions.
Morton’s and Roslin’s explanations may account for why people who have had gastric bypasses can get a buzz by drinking a small amount of alcohol, but they don't quite explain why some people who never abused booze before end up becoming post-op alcoholics. Nor do they account for another, even more serious, health risk for people who have had gastric bypasses: suicide.
Two recent studies—in Pennsylvania and Utah—reinforce the link between obesity and emotional distress by focusing on suicide rates. A study of 17,000 weight-loss surgeries performed in Pennsylvania from 1995 to 2004 showed a surprisingly high incidence of suicide. Of the 440 deaths that occurred, 16 resulted from suicide or drug overdose; by comparison, the rate for the general population is only three. And this August, a study published in The New England Journal of Medicine showed that a group of almost 10,000 bariatric patients had a 58% higher than average risk of dying in an accident or suicide. When the bariatric patients' suicide rate was compared to that of obese people who had not had surgery, it was close to double, 11.1 per 10,000 compared to 6.4 per 10,000.
When the high risk of suicide is coupled with the high risk of alcohol abuse, a psychological, if not a switching-addiction, explanation is almost inescapable. Patients may be aware of these risks, but the need for the surgery overrides such concerns. While prospective patients often undergo psychological evaluations before the procedure, doctors often do not follow up with the patients and patients often do not participate in post-surgery counseling. The addiction to food is typically viewed as more or less having been "treated" by the gastric bypass. The danger of developing a new addiction remains low on the list of health priorities.
There is no denying the benefits of bariatric surgery. Without it, many people struggling with obesity would be doomed to lives burdened with diabetes, heart disease, mobility problems and high risk of stroke and early death. At the same time, it's clear that the surgery's benefits would be increased by improved screening of patients for mental health problems—and addiction—before surgery as well as deeper, longer counseling afterward. This may mean fewer people will be eligible for the surgery—a prospect that neither doctors nor patients would embrace. At the very least, reframing how patients understand the surgery is in order: It is not a magic bullet but one in a serious of interventions that are, like it or not, lifelong.
Raphael Rosen is a Brooklyn-based science communications professional, social media strategist, and independent museum consultant. He has written for the Wall Street Journal, the World Science Festival, Discover magazine, Sky & Telescope, and NASA.
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- Archives of Surgery
- adjustable gastric band surgery
- American Society for Metabolic and Bariatric Surgery
- gastric bypass surgery
- New York Obesity Nutrition Research Center
- Journal of the American Medical Association
- John Morton
- Stanford School of Medicine
- alcohol dehydrogenase
- Mitch Roslin
- Lenox Hill Hospital
- switching addictions
- Overeaters Anonymous
- Alcoholics Anonymous.
- Raphael Rosen