Bariatric Surgery in the GLP-1 Era: Who's a Candidate and Is It Safe?

Who Qualifies for Weight Loss Surgery?

Interviewer: If you've ever Googled "Am I a candidate for bariatric surgery?" and come away maybe more confused than when you started, you're not alone. A lot of people are curious but also hesitant. Am I the right kind of patient? Is it actually safe? What is it like? What does life look like afterwards? And now that GLP-1 medications seem to be everywhere, it's harder than ever to know which path even makes sense to explore.

To help us answer these questions, today we're speaking with Dr. Ellen Morrow, associate professor and general surgeon who performs these bariatric surgeries at University of Utah Health. Now, Dr. Morrow, who is actually a candidate for bariatric surgery?

BMI, Health Conditions, and Surgical Candidacy

Dr. Morrow: Generally, we do still go by body mass index or BMI. Even though that's an imperfect measure of weight-related health, it's a convenient one. And the original National Institutes of Health criteria for bariatric surgery are based on that. So we can usually help patients who have a body mass index above 40, or people who have a body mass index of 35 or above with a weight-related medical problem. And some of those weight-related medical problems include sleep apnea, high blood pressure, reflux, arthritis, as well, sometimes qualify people for surgery, and other heart conditions, as well as diabetes, type 2 diabetes.

Interviewer: Is there anyone who's maybe not eligible? Are there other things that might be stopping a person from going under a kind of major surgery like this?

Dr. Morrow: Yeah, we do have very specific dietary guidelines. And so our patients need to be able to work with us on adapting their lifestyle, including diet, to surgery. That's important. And then we can't operate on people who are smoking. So we do need for patients to quit smoking before they enter our program. That's because of some additional risks that smoking brings to the surgical setting and specifically bariatric surgery. Anyone with active substance use issues, including alcohol, is not a great candidate for this type of surgery. There are other things that we'll screen for in terms of risk. But most of the time, we can work with our patients to get their health improved to the point where surgery would be safe for them.

Common Myths About Bariatric Surgery

Interviewer: The next thing I kind of was curious about is there are a lot of misconceptions on the internet about weight loss surgery, like bariatric surgery. What are some of the maybe biggest misconceptions that you hear or deal with from patients who are maybe on the fence?

Dr. Morrow: I think some people come in concerned about malabsorption or nutritional deficiencies. And that's not typically something that we see big issues with after surgery, although it is a risk. I think some people also come in concerned about some cosmetic issues, like hair loss and excess skin. Those are real things as well, but there's not typically any permanent hair loss associated with weight loss surgery.

Is Bariatric Surgery the “Easy Way Out”?

Interviewer: So one of the things that I saw a lot of was that people were saying it feels like the easy way out, right? That it is somehow this like thing they shouldn't be doing, or it's less than. Do you ever find patients kind of talk about that?

Dr. Morrow: Yeah, that's a great point. I mean, there's definitely a lot of social pressure and stigma associated with excess weight and obesity, and that's unfortunate. And we've worked hard to make our program helpful and a nonjudgmental place. And I think that there is nothing easy about having surgery. It may not be as hard as people are worried about, but it's definitely not an easy way out. And people who are successful with their weight loss long term are modifying their diet and their activity levels. They still have to make the recommended lifestyle changes. But what I've heard from our patients is that once they have the surgery with those recommended lifestyle changes, they actually see results. And that's different from how things were before having the surgery.

How Safe Is Bariatric Surgery?

Interviewer: All right. So it sounds like there were some misconceptions out there, and some of them have not so much validity. But I do want to ask, kind of one of the big ones is, how safe is bariatric surgery? I mean, as a layoutside person, this seems like a big deal.

Dr. Morrow: It's very safe. The risks right around the time of surgery, so let's say within a month of surgery, are actually comparable to gallbladder surgery, believe it or not, which is kind of surprising, because it's often a bigger operation than that. But we've worked really hard over decades to improve quality around bariatric surgery. And so we have processes in place, and we also have skilled, fellowship-trained surgeons who have made it a lot safer. I will say, though, that that safety profile really only happens in a multidisciplinary program that responsibly educates patients prior to surgery. So we do need to make sure that our patients are prepared for the changes that they're going to experience after surgery. That's important.

What Does Recovery After Bariatric Surgery Look Like?

Interviewer: And that's a good transition to my next question, which is, what does day-to-day life look like after surgery?

Dr. Morrow: So right after surgery, patients do experience some pain. Everyone is different, but it's often not as much as they were expecting. Our patients usually stay in the hospital for one night and then go home the next day after surgery. There's like a phased diet progression after surgery. So immediately after surgery, patients are going to be on a liquid or pureed baby food-style diet for two to four weeks. And then progress through soft foods and then back to regular foods. And there are some activity restrictions during that time frame as well. But most people can go back to work within about two weeks after the surgery.

Long-Term Lifestyle Changes

Then long term, we do recommend basically three small meals, and the portion sizes are really different after bariatric surgery. So we recommend about half of a cup, basically. Long term, people may be able to eat more than that. But we want to keep portion sizes small to maintain weight loss, and one to two snacks a day that are planned and healthy. We recommend general activity guidelines for maintaining weight loss, so two to three hours of exercise a week, ideally.

Our patients find that they have less pain after . . .

Interviewer: Oh, really?

Dr. Morrow: . . . weight loss surgery in the long run, and actually less depression as well. We've had the opportunity to study that based on questionnaires that our patients have answered in this program.

So long term, we hope that life looks pretty normal, except better in a number of ways.

Interviewer: Sure.

Nutrition, Exercise, and Daily Life After Surgery

Dr. Morrow: But people do need to be prepared to take vitamins every day. So that may be a change. And we want to avoid liquid calories as well. A lot of our patients have found that they're able to be more active, for example, have started running programs and done half marathons because, eventually, people get into the habits that we need to have, like hydration, smaller portion sizes, prioritizing protein in the diet, and that sort of thing. So once you're kind of in a routine, it doesn't feel like as much work to keep track of that.

How Much Weight Can You Expect to Lose?

Interviewer: Wow. And how much weight loss can people expect after a surgery like this? Is it a certain percentage of the weight? Does it differ person to person?

Dr. Morrow: So it depends on where you're starting off. We have a lot of patients who've lost 100 pounds or more.

Interviewer: Wow.

Dr. Morrow: But in terms of percentages, after a gastric bypass, for example, people will usually maintain a weight loss of about a third of their total body weight. And after a gastric sleeve, it's more like a quarter.

Bariatric Surgery vs. GLP-1 Medications

Interviewer: So I guess that leads me to the big question I think on everybody's minds right now is GLP-1s, right? They're getting a lot of attention. It seems like every other ad I ever see is about some sort of GLP-1 out there and how to get it, etc. What are some of the comparisons that a patient should be thinking about, whether or not, when it comes to weight loss, whether to go with, say, one of these GLP-1 medications or maybe something like surgery?

Dr. Morrow: Yeah. I think a couple of the things to think about upfront are your age. For young people, surgery is going to be even safer than average, and the effects of that they'll be able to experience for a longer time. And so we think that young people are great candidates for surgery, especially because, unfortunately, with the GLP-1 medications, once you stop taking them, they usually stop working and people regain weight.

And so that's something to consider if you have a long life ahead of you, to think about how long you're going to be taking that medicine and if that's something that you're comfortable with, especially given that we don't really know what the long-term side effects of these medications may be yet.

The other thing is how much weight do you need to lose. So if you're looking to lose 5% or 10% of your body weight, then a GLP-1 may be very effective for you, as long as you're willing to keep taking it. In trials, people have been able to lose as much as 20% of their body weight with GLP-1s, but that may be less common in real life.

Interviewer: Oh, wow.

Dr. Morrow: So, in general, with surgery, where we're looking at more like 25% to 30%, for people who are looking to lose more weight, that's probably a better option. Fortunately, in our program, you don't really have to choose. We do have a comprehensive weight management program, which we're very proud of. And the intake process is the same for both the medical and the surgical side. So we can definitely refer patients back and forth as their goals or conditions change.

Exploring Your Weight Management Options

Interviewer: So when it comes to that weight program at U of U Health, or maybe if someone's in a different area, what is the first step of the process if someone is curious about some serious weight loss, some weight loss surgery, and maybe leading to bariatric surgery?

Dr. Morrow: For our program, we have a website, and so visiting that website could be helpful. And then we have program coordinators who are available to work with new patients and collect the information that we need before we see new patients. The first step after making contact like that is that we will send a link to a video. So it's an online seminar so that people can learn more about weight loss surgery and see if it still sounds right to them.

Interviewer: And so it's go talk to your doctor. Is that the first step that everyone needs to take?

Dr. Morrow: You actually don't need a referral from your doctor. You can reach out to our program directly. But it's always a good idea to talk to your doctor, I think, and see if they would recommend this. But unfortunately, it's not always something that all doctors think about. The topic of weight can be really sensitive. And so, unfortunately, sometimes doctors or providers aren't always comfortable bringing it up with their patients. So I think that it's a great idea to bring it up with your doctor, but also feel free to reach out directly if it's something that you think might be right for you.

Life After Bariatric Surgery: What Patients Can Expect

Interviewer: All right. And we'll make sure to include the link to that website in the show notes. But to wrap up, for someone who does take that step and maybe goes through weight loss surgery, what does life on the other side look like for most people? I've heard the term that it is less risky than staying obese, right?

Dr. Morrow: Yeah, that's a great point. I mean, some of these things are statistics from research that people may not feel in their day-to-day life, but bariatric surgery definitely lengthens people's lifespans. And it also improves their quality of life, like I mentioned earlier, in terms of pain, mobility, and even mood. I mean, a lot of my patients tell me that they wish they had done the surgery sooner. They're really thrilled about finally being able to lose a lot of weight, maintain their weight loss, and have increased mobility and decreased pain. And so I think that's important for people to know. We certainly don't want to pressure anyone, and we want our patients to feel ready. But a lot of people on the other side will feel like they could have benefited from doing it sooner.