Don't turn your back on obesity!

The degree of obesity is assessed in terms of the Body Mass Index (BMI). This index measured in kg/m2 was found through studies of body densitometry, as the most accurate indicator of the degree of “fat” for all heights. According to the classification of the American National Institute of Health, it is recommended that the BMI be used to classify obesity and estimate the relative risk of disease compared to people with normal weight.

BMI = Weight (kg) / Height (m)2 = kg/m2 It has several grades:

18 <BMI <25 kg/m2 Normal

25 <BMI <30 kg/m2 Excess weight

30 <BMI <35 kg/m2 Moderate obesity (grade I)

35 <BMI <40 kg/m2 Severe obesity (grade II)

BMI> 40 kg/m2 Morbid obesity (grade III)

Obesity is a serious health problem because it is associated with debilitating, progressive diseases and with a relative risk of increased mortality in relation to the normal population when the Body Mass Index is equal to or greater than 30 kg/m2. Obesity causes multiple health and general well-being problems.

Obesity in Portugal has increased in the past two decades. Over 40% of the adult population is overweight or obese. Obesity in children and adolescents has also been increasing, with serious repercussions on their health. In Portugal, between 100,000 to 300,000 people are thought to suffer from morbid obesity, with a considerable increase in the risk of serious diseases and the possibility of a much shorter life expectancy.

Grade III obesity is called morbid because it is a progressive, serious, debilitating disease, assuming in some cases proportions of malignant disease (malignant obesity). The social, psychological and economic consequences of morbid obesity are devastating.

Unfortunately, conservative treatment of morbid obesity is not effective in the long run. Over 95% of patients regain weight lost in a few years after conservative treatment.

Medical treatment for clinically severe (morbid) obesity includes various combinations of low-calorie diets, behavioral modification, physical exercise and pharmacological agents. The biggest problem with this type of approach is its inability to maintain a reduced body weight in most obese patients, with a high incidence of inefficiency in sustaining a 10% weight loss over time with this type of treatment.

Due to the serious risks related to this degree of obesity, the relatively low risk of surgical treatment and the ineffectiveness of medical or dietary interventions, as well as the severity that weight variations can bring as a result of inefficient conservative treatments (yo-yo effect), bariatric surgery has been asserting itself in this universe, due to the good results not only in reducing the weight achieved and maintained, but also with the improvement of the diseases that accompany it.

Before thinking about surgery, a patient should weigh at least 45 kg above his ideal weight (BMI greater than or equal to 40 kg / m2). From that moment onwards, surgery should be considered as the best treatment for a disease that is truly debilitating.

However, surgery may be considered in other situations of lower weight if it is determined that from a medical point of view there are sufficient reasons for weight reduction and surgery is the only way to obtain it.

Weight loss with surgery is not the same for all patients in the same way, it varies according to several factors: age, initial weight, ability to exercise, intake of sweets, type of surgery performed, etc. On average, patients lose between 30% and 40% of their initial weight between 12 and 18 months. However, in the heavier ones, weight loss tends to be more prolonged over time.

Although there are some exceptions, before surgery is indicated, the patient should:

✔️ Have made several attempts at weight reduction duly guided by the physician (but without success);

✔️ Have absence of severe pathologies that condition the surgical procedure;

✔️ Have a Body Mass Index greater than 40 kg / m2;

✔️ Have a Body Mass Index between 35 and 40 kg / m2, if you already have associated pathologies depending on your obesity.

Some psychiatric disorders may be a contraindication for surgery if they are not properly controlled or if there is no agreement from the accompanying psychiatrist.

In order to understand how the surgical intervention helps to lose weight it is important to have a sense of how the digestive system works. Thus, food after chewing is swallowed through the esophagus, which is no more than a long muscle tube entering the stomach.

The stomach, which can normally contain amounts greater than 1500 mls of food, mixes them with hydrochloric acid and grinds the food mix, making it pass into the small intestine (duodenum), where it mixes with the remaining liver and pancreatic juices, where digestion is continued and most nutrients are absorbed.

The small intestine, which normally measures between 4.5 and 6 meters, is largely responsible for absorption. As previously said, food passes to the duodenum, mixing with bile and pancreatic juice, this area of ​​the intestine is also largely responsible for the absorption of iron and calcium.

The most distal segment of the small intestine, also called ileon, plays an important role in the absorption of nutrients and in particular fat-soluble vitamins (A, D, E and K). When the ileon content enters the colon, its consistency, which until now was liquid, becomes solid, due to the absorption of water that takes place in the colon.

The fundamental underlying principle of an obesity surgery is to change the energy intake / absorption-consumption ratio, which in obesity is favorable to the first set, thus causing an accumulation of energy by increasing weight. Therefore, reducing food intake or absorption and increasing physical activity will cause weight loss by altering this ratio.

Surgery can control weight by changing the energy balance in two ways:

1. Decrease the amount of food you eat (restriction);

2. Make sure that part of the food is not digested nor completely absorbed (malabsorption), being eliminated by the feces;

3. Decrease the amount of food eaten and make part of it poorly digested or absorbed (mixed – restriction / malabsorption).

The appearance of these processes to try to control weight was not a matter of chance, but of observations made by surgeons of operations performed to treat other types of diseases, such as cancer and others, in which it was necessary to remove part of the stomach or small intestine. The near impossibility of maintaining weight and / or even increasing it with this type of surgical procedures led us to think that with some modifications these surgeries could be applied to weight loss in morbid obesity.

It is very important to have an idea of ​​how these surgeries work, because a lot has changed in recent years. During the last few years we have learned that to control weight with surgery that only restricts food intake, there is a need to create a reservoir in the upper part of the stomach, with a small initial capacity, which varies between 15 and 25 mls, and that binds to the rest of the stomach through a stoma, thus promoting less food intake.

This stoma, which is normally narrow, may be of variable size in the adjustable gastric bands or even be reinforced with prosthetic material to prevent its expansion in other surgeries. Therefore, the small reservoir and the narrow outlet produce a quick feeling of satiety which, in the cooperating and compliant patients, induces a behavioral modification, thus reducing caloric intake and inducing weight loss.

In this type of surgery there is a very high commitment of the patient to the physician and surgery, and there are two rules that are essential to comply with:

✔️ Chew everything very well;

✔️ Swallow food very slowly.

Because if this is not the case, the patient may experience pain, reflux or vomiting and may increase the size of the reservoir (dilation), the outlet or both, losing the purpose of the surgery. The consumption of liquids with a high calorie content and the intake of food after hours (snacks) should always be avoided.

Failure to comply with these precepts is one of the most frequently verified reasons for failure. This type of surgery, simple and less risky, does not always produce the weight loss expected by surgeons and patients. For this reason, malabsorption techniques began to be used, some of which include the bypass of large segments of the small intestine.

The major disadvantage is that the risks, complications and side effects increase with the widening of the intestinal bypass. Together with your surgeon, you should thoroughly assess the risks and benefits of each operation. However, always keep in mind that the more complex the surgical intervention is to help you lose weight, the more serious the risks and side effects will also be.

Ask your doctor, be fully aware of what may happen to you with any of the surgical procedures, contact other patients and only after you are certain of the surgery you are going to perform should you proceed to the surgery. Always bear in mind that surgery does not cure obesity and that only patients who are well informed and willing to change their lives make these operations a success.

There are many sources available on the market to help you choose a surgical technique, including the Internet, but never forget to clarify yourself properly with your physician, as only he or she will be able to inform you of all the changes that you will suffer and only he or she can choose the best surgical method to help you lose weight.

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