For many extremely heavy people, stomach reductions have so far been the most successful way to lose a large part of their excess weight. In the first few months and years, this often works effortlessly. But then the real work begins.
Here’s a candy, there’s a chocolate bar: in the office, Alexandra Knoch now thinks twice about whether she has to go to the tea kitchen, because the plate of sweets that’s always full there is tempting. “The old habits will return at some point,” says the 55-year-old from Brandenburg. After a stomach operation five years ago, she lost 90 of 176 kilograms – at a height of 1.57 meters. Ten of the lost kilos are now back on it – and she is now fighting against them.
It’s still a relatively easy case. “Roughly every fifth patient gains so much weight after gastric surgery that one speaks of clinically relevant weight gain,” says Jodok Fink, senior physician at the Obesity Center at the University Hospital in Freiburg. In these patients, the quality of life can again be significantly restricted and typical comorbidities of obesity such as high blood pressure and diabetes reappear in some cases.
Alexandra Knoch doesn’t have to fear that at the moment: “I’m fine. I used to have high blood pressure, type 2 diabetes, sleep apnea, extremely high cholesterol and liver values. That’s all history,” says Knoch. Only the broken joints are no longer repairable. “That’s why I can only do aqua fitness,” says Koch, who trains up to four times a week.
Your stomach has been reduced and routed further down into the intestine so that it can only partially digest the food. “In the first year and a half I didn’t have to worry at all. I could only eat children’s portions. Two rolls of sushi, that was all,” says Knoch. Now there are six sushi rolls. That is still relatively little, but enough to slowly increase again. “You have to fight,” said the 55-year-old.
“We can fight about 60 to 70 percent of excess weight. One to three years after the operation, the patients reach their lowest weight. After that, the majority gain weight again, and then usually reach a relatively stable weight,” says Jonas Raakow from the Interdisciplinary Obesity Center at the Berlin Charité, where Alexandra Knoch was also operated on. To a certain extent, an increase is absolutely not a problem. “But you have to control them”. In some cases, additional surgery is needed to increase weight loss.
In addition to the gastric bypass as with Alexandra Knoch, the gastric sleeve is one of the most common methods of obesity surgery in this country. According to Fink, these and others lead to complex hormone changes in the gastrointestinal tract: Among other things, the body produces less ghrelin, a hormone that stimulates the appetite. “I no longer feel hungry at all,” says Alexandra Knoch. The hunger she feels is pure “head hunger”. “The head was not operated on,” says Knoch.
The changed release of hormones in the gastrointestinal tract after the operation is an important explanation for the fact that many patients remain slim in the long term, because over time the stomach expands again and one can eat more again, explains Fink. “About 75 percent of the patients manage to maintain their reduced weight in the long term and are satisfied,” says the professor. If patients gain weight again, this can have different reasons. “Some don’t change their habits permanently and fall into their old routine”.
“The operation is not the decisive factor, but the change in lifestyle after the operation,” emphasizes Jonas Raakow. “Obesity is a chronic disease that cannot be treated with surgery,” emphasizes the Charité senior physician. “Our aim is to significantly reduce the risk of dangerous secondary diseases such as cardiovascular diseases, diabetes or even tumor diseases”.
The quality of life also increases significantly, adds Alexandra Knoch. “I no longer have to do acrobatics when showering and applying lotion,” she says. In addition, she can now buy nice clothes again. “I used to look like a burst sofa cushion.” She no longer has to choose restaurants based on their seating. And medical examinations are no longer degrading as they used to be. “I had to lie on the floor for a gastroscopy because the doctor was afraid the bed would break,” remembers Knoch.
Many patients also improve their mental health after an operation, reports Tobias Hofmann, Head of Psychosomatics at the Charité Obesity Center. Depression decreases, especially in the first year. “Many are very happy, which is why the time is also called the honeymoon phase,” says Hofmann. However, setbacks can occur again after two to three years.
People with a body mass index (BMI) of over 30 are considered obese. According to the Robert Koch Institute, every fourth adult in Germany is affected. According to Fink, around 20,000 people in Germany have an operation every year. The causes of obesity are manifold. According to the German Obesity Society (DAG), genetic causes, lack of exercise, malnutrition, lack of sleep, stress, depressive illnesses, eating disorders or even medication can play a role.
From the point of view of experts, regular follow-up care by doctors would also be necessary for permanent weight and health control after gastric surgery. But there is a lack of capacity and funding here. “The few specialized obesity centers cannot do this alone, and family doctor’s practices often lack the expertise – not least because there is a lack of suitable training opportunities and a lack of demand for them,” says Oliver Huizinga, political director of the German Obesity Society.
“The biggest problem is that the patients don’t follow any reasonable, routine aftercare because the health insurance companies don’t pay for it. They demand it, but don’t pay for the aftercare,” says Raakow. In the long term, this is of course a disaster, since no one really takes care of the patients anymore. “The situation will probably improve significantly with the planned commissioning of the legislature to create a disease management program for obesity,” hopes Jodok Fink.
Above all, Alexandra Knoch is helped by the exchange in the self-help group at the Charité. “Everyone has their own weight loss strategy,” she says. You yourself have increased the amount of protein and reduced the carbohydrate content in the food. Unfortunately, there were no personal meetings during the pandemic and only online meetings were possible. Not all members switched to these. “Those who gain weight again often don’t report anymore,” says Knoch. The shame is just too great.
