Last week, Public Health England released its report into the effect of obesity and the morbidity of Coronavirus. Acknowledging that this is a not a new problem, it has come into sharp focus in recent months due to the significant amounts of those succumbing to the Coronavirus being overweight or clinically obese. Indeed, those who had a BMI of 40 and above were added to the list of people the government felt were at most risk back in mid-March, when pregnancy was also identified as a risk factor.
“If fat-shaming worked, there would be no fat kids at school”
Many news outlets have decided that the answer to the problem of obesity is fat-shaming – indeed it was less than edifying watching a video of a woman on This Morning proclaiming that fat people’s lives should be made harder. Her outward prettiness quite confounded by the ugly words that spilled from her lips, saying that she would never employ someone who didn’t conform to her beauty standards.
Last year, I underwent bariatric surgery. It’s not something I have ever hidden – though so many bariatric patients feel they should or that they must. It’s not a procedure without stigma. There are various types and the differences between them are poorly understood within the general population. Most people talk about bands but these are being phased out due to an exceedingly high failure and complication rate.
What kinds of weight loss surgery are there?
The two most popular procedures are now the ‘Roux en Y’ (RNY) Gastric Bypass and its variations and the Vertical Gastric Sleeve (VSG). The sleeve is usually the most popular and it involves removing a proportion of the stomach to restrict the amount of food that a person can take in at any one time. The various types of bypass do similar with the stomach – but leave the remnant stomach (the bit that has been cut away) inside the patient. The route the food takes is also altered so that it does not enter as much of the intestines as usual, restricting absorption from the larger intestine. Patients who undergo either surgery must commit to lifelong lifestyle changes, like not eating and drinking at the same time as well as focusing on protein intake and ensuring adequate vitamin intake.
My operation in April 2019 was undertaken solely for health reasons – others choose it because they want to look different as well. For me, it was a conscious decision that I must be healthy for my young children. Everyone who undergoes surgery has to understand that the surgery is a tool to be used and is not the absolute end of their journey towards a healthy life. Any bariatric procedure can fail when a patient does not follow the rules and all procedures can be ‘outeaten’.
A bariatric surgeon speaks: surgeries on individuals won’t solve a societal issue
Yesterday, while out in a windy Whistable with my children, I took the opportunity to spend 30 minutes interviewing the highly knowledgeable Simon Monkhouse, an “award-winning consultant weight loss surgeon”, based in my old stomping ground of Surrey. He’s been a consultant surgeon since 2014 and I know one of his patients, Ceeley Shakespeare, quite well. She had her surgery 3 years ago and is still maintaining her incredible 10st weight loss. She runs the welcoming and informative support group, (of which I am a member) Gastric Fantastic, on Facebook, where patients – both pre-op and post-op (and op-curious) – can share information, rant about the hard times and celebrate their successes.
Simon was clear in his message – the danger to obese people who catch Coronavirus and then are unlucky enough to require a ventilator – is very real and very serious. Yet that in itself is a vital nuance – you are not more at risk of catching Coronavirus because of your weight, but if you need intensive care, that’s the concern. The other important distinction is that it is exceedingly difficult to separate obesity as a risk factor from the other confounding illnesses that often accompany it, like sleep apnoea, diabetes and high blood pressure, to name just three.
We also absolutely know, that obesity is a metabolic disease. A longitudinal study of 4047 people, conducted over 20 years in Sweden, is the benchmark of our current understanding of obesity and how it is so hard to lose weight.
Your ‘metabolic set point’ is your worst enemy
The Swedish Obese Subjects (SOS) study brought a new understanding to the issue of obesity and brought forth the now widely-accepted theory of the ‘metabolic set point’. As Simon explained, once weight is gained and kept on (and even increased) over various years, it alters one’s metabolism. Those of us who have yo-yo dieted for years will recognise this cycle of focusing on weight and then letting go of a strict diet and having the numbers on the scales rocket once again. Very low calorie diets like the Cambridge diet; Weightwatchers, Slimming World – all these programmes have benefited from the endless cycle of losing and gaining whilst those of us concerned about our weight have floundered and wondered where we are going wrong.
The SOS study compared two populations over 20 years and the results are astounding. The two groups were split and half received weight loss surgery. The other half were given exercise plans, psychological support and access to dieticians on a regular basis. After 20 years, the cohort who were prescribed all the support that GPs normally suggest to the overweight had put on even more weight. Those who had received surgery had maintained a weight loss of at least 25% less than their starting weight when they underwent surgery.
A psychological dependence on food
Reasons for weight gain vary. Another hugely important factor that was mentioned – for female patients specifically – was the influence of abuse on weight gain. It is widely known within the literature that, of severely obese female patients (with a BMI of more than 60), around 40% of them will have experienced some sexual abuse within childhood or adolescence. Many obese women report overeating as a protection – a ‘shield’ against male attention. When they they finally lose weight after surgery they often cannot cope with the increased attention from men and struggle.
- Dube S.R., Anda R.F., Whitfield C.L., Brown D.W., Dong M., Giles W.H. Long-term consequences of childhood sexual abuse by gender of victim. American Journal of Preventive Medicine. 2005;28:430–438.[PubMed]
- Grillo C.M., Masheb R.M. Childhood psychological, physical, and sexual maltreatment in outpatients with binge eating disorder: frequency and associations with gender, obesity, and eating-related psychopathology. Obesity Research. 2001;9:320–325. [PubMed]
Given the absolute dearth of support available for mental health problems and the role these clearly play in weight gain (even those who have not experienced sexual abuse will deal with other trauma often by overeating) what role does psychological support play when it comes to bariatric surgery?
The patient view: Trish and Kevin
Currently, it is possible to get weight loss surgery on the NHS. Indeed, I spoke to one patient who considered herself lucky to have been through the process that she credits with her success. Almost four years ago, Trish Rogers, who lives in Shrovesbury underwent a Vertical Gastric Sleeve surgery. She’s lost 8 stone in total and is hovering just above the healthy BMI for her height. She says the NHS makes you “jump through a lot of hoops” to get the surgery.
At 62, she wanted to do something about her weight before she got too old to see the benefit and recover properly. It took 15 months of appointments with the multidisciplinary team – and filling in a document that spanned 17 pages – yet she feels that the full process was essential to understanding how to live well after the surgery. She says what wider society fails to recognise is the longer-term cost saving associated with dealing with an individual’s weight. If you’re able to halt diabetes in its tracks and stop the other associated health issues, the cost saving of the one weight loss surgery justifies it all, on an economic factor alone.
Kevin Kenley, 54, agreed with the economic issues raised by Trish. He was 26.5st when he approached his GP for surgery but was denied help from the NHS. He had a sleeve surgery in September 2017 and is now happy with his weight where it is, at around 12.5 stone. He’s 5ft 11 and his partner felt he was too skinny at a weight slightly lower than it is now. He admits gaining recently – most likely the lockdown weight gain many have seen.
Splashing the cash and going private: not an option for most
Kevin decided to finance his own surgery here in the UK. Prices vary according to location but range from around £9-15k and aftercare packages also vary. Kevin says it’s worth it for the new lease of life he has – for his children too, who are now adults too. He puts his issues down to metabolic and genetics predisposing him to weight gain – as well as a previous fondness for carbohydrates. Having been through some health scares, he struggled to walk more than 400 yards without having to sit down. His new dog, less than impressed with his inability to walk far, was a wake up call. The NHS said his BMI was not high enough and so Kevin – along with his fiancee – went along to see a private consultant. The consultant gave Kevin a 50-50 chance of making it another 5 years.
In terms of regrets, there were few expressed by the two bariatric patients I spoke with. Smaller issues, like becoming a bit of a ‘lightweight’ and struggling to keep up with the boys as well as a desire to eat more than one could physically were mentioned, but mostly Trish and Kevin have very little difficulty recommending the surgery to anyone who wants it. However, both did warn that it is a tool to help yourself break the cycle and lose the weight. They echoed surgeon Simon’s warning that it is possible to regain if the tool is not respected.
Disordered eating and lack of aftercare
When it comes to government action on obesity, sadly it’s not as simple as sticking every single obese body on the table and altering their digestive system. As someone who has undergone the surgery – and had surgery abroad because of the cost – I caution an increase in the amount of operations without the infrastructure required.
It’s clear that disordered eating can be two sides of the same coin. Indeed, some surgery – usually when conducted abroad – is not conducive to a healthier life and some surgeries can go badly wrong. Whether it’s physiological damage that is done with botched surgery (or just unforeseen complications) – or psychological, where those with mental health implications become anorexic or bulimic after the surgery – undergoing surgery is not the easy option.
The process beforehand can be hard when undertaken via the NHS but, Simon revealed, there is not enough aftercare. The support available currently is all ‘front-loaded’ and it means that there is little infrastructure available to post-op patients. Weight loss surgery is a lifestyle change that is imposed and once a patient has undergone the first 12-18 months of encouraging weight loss, further difficulties often creep in. Weight regain is common and even though it will take a concerted effort and time, it is possible to completely regain all the weight.
So whose fault is it, really?
Increasing the amounts of patients undergoing surgery might sound like good news to a weight loss surgeon, but essentially it’s not targeting the societal issues we have. PHE reported in 2017 that we are “living in an obesogenic environment where less than healthier choices are the default, which encourage excess weight gain and obesity.”
The government’s Foresight report, published in 2007, concluded:
The causes of obesity are extremely complex, encompassing biology and behaviour, but set within a cultural, environmental and social framework. There is compelling evidence that humans are predisposed to put on weight by their biology. This has previously been concealed in all but a few but exposure to modern lifestyles has revealed it in the majority. Although personal responsibility plays a crucial part in weight gain, human biology is being overwhelmed by the effects of today’s ‘obesogenic’ environment, with its abundance of energy dense food, motorised transport and sedentary lifestyles. As a result, the people of the UK are inexorably becoming heavier simply by living in the Britain of today. This process has been coined ‘passive obesity’. Some members of the population, including the most disadvantaged, are especially vulnerable to the conditions.
As a bariatric surgeon, Simon agrees that bariatric surgery is of course a great solution on an individual basis but the message is clearly that, as usual “things are a bit more complicated than that”. Mass help to address the societal issue won’t come from shoving more people through surgery and could prompt more issues than it solves. At a time where the NHS is on its knees, increasing surgical provision for the obese is also unlikely, he feels, to go down well with the public. Societal backlash against the obese is worse than ever, he says and now isn’t the right time to alter the NHS response to weight loss surgery when there’s already not sufficient infrastructure to support the pre-Covid rate of surgeries. Any increase in surgery would also prompt an increase in failure, causing further backlash and reinforcing stigma against the obese and those who have had surgery.
Government’s new obesity initiatives won’t make the differences we need
As someone who is only a year out from surgery, I believe, that interventions like putting calories on menus, reducing advertising of junk food and perhaps stopping ‘BOGOF’ offers will make less headway than a concerted effort of longer-term investment in nutrition. They seem like they’re doing something but it’s too little too late.
By the age of 19, two years after a life-changing, traumatic event, I was already verging on 21 stone. Seeing the amount of calories on a menu wouldn’t have made much difference to me. I would have paid more money for the fizz I craved, now a reality in the sugar tax. I barely noticed the food bill when I was binge eating on a near-daily basis to counter the emptiness I felt inside. Compulsive overeating was my saviour and punishment. No psychological help for this dependency was available – and it took me another 17 years to address it, after I nearly died from blood clots in my lungs in my second pregancy. I was lucky we could afford it. I was lucky I could go abroad. The NHS would never have accepted me, so I decided to strike while the iron was hot and make a change, for my children.
Start at the beginning
I’m a trained breastfeeding supporter and breastfeeding campaigner and I see that nutrition in the early years has a massive impact on the way we raise our children. Kevin, the bariatric patient I spoke with, addressed this. He grew up in the post-war period where you were encouraged to eat what was on your plate – have seconds and then eat your pudding. Food was a reward. It’s a part of our culture and our society. We can stop drinking or smoking or taking drugs entirely (thought that’s not to underestimate how difficult that is) but we must feed food addiction daily, in order to survive.
Early years nutrition is not supported when we cut funding for breastfeeding support and fail to see the long-term effects of our appalling breastfeeding rates. Instead of blaming lack of support however, we engage in mummy wars and make it about personal feelings of failure rather than a dereliction of societal imperatives to look after the individual throughout the life cycle.
There is so much focus on fat bodies, blame and shame that there’s no room for the real issues that are ones of poverty. It’s cheaper and easier and more economical to feed your children on processed foods – especially if you don’t have the time or energy or the ability to make nutritious meals.
Whilst Jamie Oliver has done well with his campaigns on Turkey Twizzlers and fast food outside schools, the real answer is much tougher and starts right at the beginning. Let’s help people with the reasons they gain weight in the first place – get to them before they reach that insurmountable metabolic set point and focus on health and nutrition from the moment a child leaves the womb. Surgery is the last resort, not the solution to this weighty issue.