More people should have weight loss surgery than currently do. And guidelines for who is eligible for the surgery are too restrictive. Those are two of the messages from a series of four articles on bariatric surgery published in The Lancet Diabetes & Endocrinology earlier this month.

The studies highlighted in the series detail the benefits to glycemic control and organ health and the potential risks to bone health that weight loss surgery can bring. The studies are based on medical considerations, but implicit is the idea that successful weight loss surgery leads to a better quality of life — and health.

Bariatric surgery offers a real opportunity for preventing…diseases and complications of obesity. If it is only used as a final resort, this opportunity will be missed.

And that is largely — but not entirely — what one earlier Norwegian study, which followed 22 women who actually had weight loss surgery, found.

All the women who had the surgery reported they had “no regrets,” and would do it again; but five felt their life had changed for the worse after the surgery. With more people opting for the procedure, these negative experiences could help improve aftercare and give prospective patients a fuller picture of the risks and rewards of bariatric surgery.

No Regrets, Except…

The five women were dissatisfied with their weight loss surgeries primarily for physical reasons. After the surgery, they felt as if they had no energy at all. They also had persistent pain. Both symptoms made performing almost all their everyday activities, from walking to working to playing with the children, more difficult.

After the women's weight loss surgery some things got better, but new problems, both physical and psychological, arose. And how these women experienced these problems varied greatly.

One woman was so sick that she underwent a second operation two and a half years after the original surgery. Surgeons had insisted that her problems were psychological because scans and tests had shown no physical abnormalities. Yet when she finally had a second surgery, her problems were traced to scar tissue and other complications from the initial operation. She now feels much better since her second operation.

Weight loss surgery was not a magic bullet or miraculous transformation even for those women who felt it had had a positive impact on their lives. Karen Synne Groven, the author of the Norwegian study, said that for these women, the operation was neither a success nor a failure but something in between. Some things got better, but new problems, both physical and psychological, arose. And how these women experienced these problems varied greatly.

All the women had BMIs ranging from 43-54 and were between the age of 24 and 54 at the time of their gastric bypass surgeries. Some had struggled with conditions such as diabetes or discomfort during physical activity, but most said that they were not having any particular health problems prior to their surgery. Most of the women in the Norwegian study were interviewed twice, first about a year after the operation and then 2-4 years after surgery.

Taken together, the Norwegian and Lancet studies paint a picture of bariatric surgery that is hopeful, but not without problems.

Weight Loss Surgery Issues, From Those Who Have Been There

People considering weight loss surgery should be encouraged by The Lancet studies' findings and doctors should be more supportive of their patients seeking the surgery. According to the editorial accompanying the Lancet series, “Bariatric surgery has substantial benefits in terms of weight loss, metabolic status, and quality of life. It is safe and effective, and the future savings made through prevention of…diseases could counterbalance its high cost.

“The surgery should…be available as an option to use when appropriate, and not only when all other options have been eliminated. Bariatric surgery offers a real opportunity for preventing comorbid diseases and complications of obesity. If it is only used as a final resort, this opportunity will be missed.”

Rapid weight loss often leaves behind loose, sagging skin, and living with it can present quite a challenge.

Despite the health benefits weight loss surgery can bring, the experiences of some of the women in the Norwegian study should help prepare candidates for bariatric surgery for some of the physical and psychological issues that can arise.

Uncomfortable Questions and Food Dumping
All the women in the Norwegian study lost substantial amounts of weight soon after their surgery. Naturally, friends and colleagues asked questions about how they had achieved their success. But many of the women felt uncomfortable answering honestly; they felt ashamed that they had to undergo this type of operation, and simply told people that they had been on a diet.

After weight loss surgery, with a much smaller stomach, food exits the stomach very quickly and is “dumped” into the small intestine. This rapid transfer does not feel right and can lead to many symptoms. Some women had episodes of nausea, tiredness and dizziness, while others experienced intense quivering.

Patients are often told that they can avoid dumping with proper dietary changes, but the causes of dumping can vary from person to person. Eating too much, too little, the wrong food, food that is too hot or too cold or eating at the wrong time of day can all bring on the problems associated with dumping.

Changing the Body, But Not the Mind
Some women relapsed after surgery and began over-eating as they did before surgery. As one woman observed, it was their stomach that had been operated on, not their head. Other women took to grazing: they ate very little at a time but were constantly eating.

So life after surgery can remain just as focused on food as life before it was. The surgery does not automatically reduce appetite.

Sagging Skin
Fat may melt away but skin doesn't. Rapid weight loss often leaves behind loose, sagging skin, and living with it can present quite a challenge. It's unattractive and it's uncomfortable. Before their operations, patients are generally told that they will likely experience it, but it can usually be fixed afterward. This requires more surgery, and unless you want to pay for it out of your own pocket, you have to lose a certain amount of weight and keep it off for an extended period of time, at which point your health insurance may pay for it.

There are risks to skin surgery, particularly for women who plan to become pregnant. There are also questions as to how effective the surgery will actually be. So it is useful for people considering bariatric surgery to realize that further surgeries may be needed.

No Longer Invisible
For people who have been obese or very overweight for a long time, weight loss can result in a body that invites appreciation in a way they may never have experienced before. This may not sound like a problem (and usually it isn't) but for some of the women it did require considerable adjustment.

Women make up to 70-80% of all weight loss surgery patients, and women who were once practically invisible or the target of derision now draw lots of attention. People want to be around them. Once they had to shout to be heard. No more. It can certainly be a boost to self-esteem. But it also may be a bit too much to handle at first. And some women were bitter that it took an operation to make them visible to men.

Going Forward

Weight loss surgery appears to be the most effective long-term treatment for severe obesity. It can improve overall health and glycemic control, reducing the risks of diabetes and the damage to organs from the pressure of the extra weight. From a distance, the amount of weight that people lose may seem like magic. The experiences of patients, however, clearly suggest that people considering weight loss surgery should be made aware of the physical and emotional complications that are likely to follow a large loss of weight.

It is only in the past decade that bariatric or weight loss surgery has become common. In the early 1990s, only 12,000-16,000 operations were done every year. By 2008, this had increased to about 220,000. Because most surgeries have occurred recently, there hasn't been a chance yet to collect much information on the long-term effects of weight loss surgery, particularly from the patient's perspective.

Karen Groven wonders what such information will ultimately show. “I wonder what happens after five, ten, twenty years. What's the situation with food and eating then? The loose skin? Those who wanted to get pregnant?”

The picture — however mixed it may be — is likely to become clearer as more people undergo weight loss surgery.