Gut Reactions
Patients undergoing bariatric surgery for cosmetic reasons are discovering that post-operative complications can be physical and mental, and adjusting is much harder than they are led to believe
An online search for sleeve gastrectomy brings up countless descriptions of the surgery, which is intended as a procedure of last resort to help severely overweight people with associated health complications to lose weight. Few detail the side effects and complications of the surgery, which include anorexia, acid reflux and mental health issues. Having a smaller stomach means becoming a new person, not only physically but also psychologically.
Driven by the societal pressure to be skinny, many people, mostly young women and mothers, are lining up for what they believe to be a magic solution to real or perceived weight issues, regardless of medical need.
Pretty Perfect
Yang Yang decided on weight loss surgery to improve her looks. She picked the most radical of the most common procedures, sleeve gastrectomy, in which part of the stomach is removed, leaving a pouch about 15 percent of its original size.
Working at a Japanese firm, Yang has a side hustle as a social media influencer, blogging about cosmetic surgery on Sina Weibo. She cares about her appearance and figure, and has surgically altered nearly every part of her face, including her chin, cheek bones, forehead, eyes, nose, lips and eyebrows. She also got breast implants.
“When there was nothing left to alter, I decided to make myself slimmer which I believed would make me look prettier. A 55-kilo person will look totally different if she weighs 45 kilos. A lighter weight will make her facial features more symmetrical and elegant,” she told Newschina.
Yang believes that gaining weight is much worse than the malnutrition caused by the surgery.
Yang's concern about her appearance started when she was a student in Japan, and experienced negativity from her boss and customers at work. She became convinced that appearances determine how people are perceived.
Although she worried about the risk every time she went under for a cosmetic procedure, she told herself she would rather die than stay ugly.
At 1.63 meters tall, Yang weighed around 50 kilograms before the sleeve gastrectomy, a perfect BMI (body mass index). Still, she wanted to get down to 42.5 kilos like the women who went viral in 2016 for doing the paper waist challenge – comparing their waist size to the width of a standard sheet of A4 paper.
She tried pills, but suffered side effects like a racing heart rate. She stopped after developing a resistance to them. Never a big eater, just going on a diet did not work either. She decided surgery was the only way forward.
Yang said she wanted a gastric balloon at first, which is less invasive. A silicon balloon is placed in the stomach and inflated with saline. She consulted doctors in Japan, but as her BMI was only 20 they refused her. A BMI of 18.5 to 25 is considered healthy, 25 to 30 is overweight, and over 30 is categorized as obese. Back in Beijing, she consulted with a Taiwanese physician known for bariatric surgery who recommended a gastrectomy, but the high price scared her away. Due to her low BMI, no public hospitals in the Chinese mainland agreed to operate.
Yang finally turned to a private hospital who agreed to do the surgery if she increased her weight to 65 kilos, giving her a BMI of 24.46, still within the healthy range and lower than the BMI threshold for a sleeve gastrectomy, which is 27.5.
Before the surgery, Yang ate hotpot, pork trotters, watermelon and milk tea, as she would not be able to enjoy them for a while. Because
she had gained weight, she felt disgusted with her new shape and wanted to get the surgery done as soon as possible. Asked if she felt afraid before the surgery, she said: “There's nothing to fear, it's no big deal. It's just like having double-eyelid surgery.”
According to Professor Francesco Rubino, chair of metabolic and bariatric surgery at King's College London, bariatric surgery should never be used for cosmetic reasons. He emphasized to Newschina that it is intended to cure morbid obesity, not for general dieting or weight reduction.
Fights with Food
In China, where bariatric surgery is becoming increasingly popular for cosmetic reasons, the BMI rule is often broken. As in Yang's case, some surgeons tell patients to binge eat to meet the requirements for surgery.
The hospital did not agree to do the gastrectomy for Yang until she repeatedly promised that she knew the risks and would bear the consequences. The hospital even agreed to do an additional duodenal-jejunal exclusion, a procedure that shortens the route between the stomach and the intestine to reduce absorption of food.
“Compared to obese people and big eaters, a sleeve gastrectomy's effect on slight people and light eaters like me is limited, so I added the [duodenal-jejunal exclusion] surgery to reduce absorption as well,” she said.
Undergoing a bariatric procedure does not mean one no longer needs to diet. They must completely change their former eating habits. They have to go on a liquid diet and meal replacements for at least two months post-surgery. Since they can only eat such small amounts, they feel hungry more quickly and have to eat often, about 4-5 meals per day.
“They can't gulp down food or drink after surgery. They have to chew carefully and swallow very slowly like it's a [traditional] tea ceremony,” Zhang Nengwei, a member of the Endocrinology Committee of the Chinese Medical Association, told Newschina.
Some hospitals suggest chewing each mouthful up to 30 times and taking 30 minutes to finish a meal, or they could suffer heart palpitations or nausea. This is one of the main side effects of the gastrectomy, as a narrowed stomach causes food to enter the intestines more quickly and thus changes the environment of the gut.
Many interviewed patients told Newschina that they often vomit and have diarrhea even a year after the surgery and they have to take breaks during meals.
Snacks and other foods high in fat, oil, sugar and spice are hard to digest, as well as foods that are too chewy, hot or cold. Post-surgery, patients must take vitamin supplements and protein powder for at least a year to prevent malnutrition.
Li Xinran, who had a sleeve gastrectomy and weighed 100 kilos pre-surgery, said she began to eat hotpot a week after the surgery. She
largely ignored the recommended dietary instructions, eating whatever she fancied. It did not always go her way. She vomited straight away after eating a few noodles, and she realized she could not tolerate anything glutinous or hard to chew and digest, such as beef, mutton and fibrous vegetables like celery.
“I'd just throw up these soft and glutinous foods as soon as they went down my throat,” she told Newschina.
A sleeve gastrectomy reduces the stomach by about 75 percent. Patients differ in how their appetite changes, so they each must find their own ways to adapt. Li said that soon after the surgery, there was a delay in her brain telling her she was full. She often felt like the “food was piling up in her throat.”
“It's like if you hiccup, you'll throw up right away,” she said.
Liu Fei, who weighed 85 kilos before having the same surgery as Li, strictly followed the dietary recommendations, but her body did not adapt to her new stomach well even one year later. “I could only eat tiny amounts of food at a time for five months after the surgery, like just one dumpling, but I had to spit the skin out... I had to gradually increase the amount bite by bite,” she said. “Later, I could eat four dumplings, two to three strands of noodles and four to five pork ribs,” she said.
In theory, people should no longer feel hungry post-surgery, since the procedure cuts off the upper part of the stomach that secretes ghrelin, commonly referred to as the “hunger hormone.” Ghrelin levels in the blood increase before eating and lower after meals. But Liu said that she never felt satiated after the surgery.
“It's a very weird feeling. You feel stuffed after several bites, but in your mind you feel like you haven't eaten enough,” she said.
Li said the same. She craved certain foods, but she never felt satisfied as her stomach was full after just a few mouthfuls.
The Ick Factor
Liu often vomits after she eats. Sometimes it makes her dizzy. “I throw up if I eat even a little too much, so severely that I see stars,” she said. This is another common complication of sleeve gastrectomies: Patients become over-sensitive and expel food if they feel too full or eat anything that is hard to digest. Doctors advise that the sensations stop a few weeks after the surgery when the brain has adapted to the new stomach. However, Liu said that she suffered for an entire year, especially the six months when she struggled to eat.
Liu often feels hungry. She found she is able to tolerate chocolate, which melts in the mouth and slips into the stomach without causing her to vomit. “I felt I could eat as much as I liked,” she said. Besides chocolate, she found she can digest bread, potato chips and sunflower seeds. She also keeps oat cookies in her office.
Sugary snacks are not recommended for bariatric patients, but many interviewed told Newschina that snack foods, although not so healthy, gave them comfort during their seemingly endless recovery.
Li's doctor said that vomiting is a common side effect, and if it continues, she may be diagnosed with gastric esophageal reflux disease (GERD, or acid reflux).
According to a 2014 survey published in JAMA Surgery, an American medical journal, among 4,832 patients that received gastrectomy between 2007 and 2010, 84.1 percent suffered continuous GERD, 15.9 percent of whom reported eased symptoms, while another 9 percent reported worsened symptoms.
Michel Gagner, a surgeon who helped to popularize sleeve gastrectomy and a clinical professor at Florida International University, told Newschina that GERD is the biggest side effect of a sleeve gastrectomy. The stomach acid causes other side effects like heartburn and erosion of the parietal cells of the esophagus, which in rare cases causes cancer.
Hidden Influence
The surgery has totally changed Liu's life. “The vomiting has ruined my social life, because I often vomit during meals. I want neither to displease my friends nor see others enjoy rich foods,” she told NewsChina.
The gastrectomy also deprived her of the pleasure of eating. After losing that way of reducing her work stress, Liu has suffered serious depression and has been on long-term medication for insomnia.
“The real side effects, I find, are hidden from the patients, and they differ according to physique and personal experience. A doctor could judge whether one is suitable for the gastrectomy medically, but still no domestic hospital conducts psychological evaluations before a patient undergoes the surgery,” she said. “I don't think the complications are limited to just the obvious physical ones,” she added.
Anita Berg, an associate professor of nursing and health sciences at the Nord University in Norway where weight-reduction surgeries are a proven intervention, interviewed and tracked down seven patients who had bariatric surgery from 2008 to 2016. She published her results in 2019 in a paper titled “Untold stories of living with a bariatric body: long-term experiences of weight-loss surgery” in the journal Sociology of Health & Illness.
She found that patients seemed more physically fragile after the surgery, since they had to deal with many challenges brought about by their new bodies.
Berg's survey showed that the patients' physical changes were closely related to food. Many patients could not work out their diets even eight years after the surgery. Some have totally abandoned their social lives. Others suffered from stress and even neurosis – if they felt ill or uncomfortable, they immediately jumped to the conclusion that it was another complication from the gastrectomy. Regret over the surgery led many patients to indulge in self-hatred.
Liu Fei lost 20 kilos post-surgery, 5 kilos short of her objective. During checkups, her doctor advised her to exercise to drop the remainder, but she told Newschina that she was “too hungry to have the energy to exercise.”
Liu said she thinks she was happier before she had the surgery. Although she is slimmer now, she is more obsessed with her appearance and feels anxious most of the time.
She recommended that only those who are suffering from complications of obesity should have bariatric surgery, and emphasized that you still have to keep to a strict diet afterward or risk regaining the weight.
Yang Yang agreed. Since she purposefully gained weight pre-surgery, she had more to lose afterward. She lost 11 kilos in the three months after the surgery, 4 kilos less than her objective. She is still trying hard to reach her goal weight, which means losing 22.5 kilos in six months. She now likes to watch livestreams about eating and she still often stays up late, but she no longer has a strong desire to eat at midnight.
Yang said she would also no longer recommend for any healthy person to have the surgery, since it is very hard to stick to the post-surgery diet. “I know a girl who's gone back to 90 kilos a year after the surgery. She is depressed and caught in a dilemma – she doubts if the surgery does any good but wants to do another one to lose the weight again,” she said.
“A sleeve gastrectomy is not a one-time solution. People who regain the weight after the surgery will face an even tougher struggle,” she added.
In an interview with Newschina, Scott Kahan, chairman of the US National Center for Weight and Wellness in Washington, DC, said that psychological conditions could push those below the BMI threshold to want bariatric surgery, such as being too strict about their weight or suffering from an eating disorder. But Kahan warned that mental issues could surface post-surgery, such as more extreme views about appearance or worsened eating disorders.
His concern was shared by other interviewed experts who pointed out that social attitudes toward women's appearance imposed too much pressure, and if patients find they still do not meet the standards they set for after the surgery, they may still reject themselves.
“If you have no medical reasons for having that operation, even if you do the operation without complications, that's already a complication to me,” Rubino said. “There are risks involved. It could be because they will be dependent on supplements for the rest of their lives. Or because they could risk bleeding and maybe having other more serious or life-threatening complications. Even if they are rare, there are potential complications. So if you're healthy as a patient, you don't want to take those risks. They make no sense for you to take those risks only for cosmetic reasons,” he added.
Yang Yang and Li Xinran are pseudonyms