Tailored prevention and treatment are needed
From heredity and an unhealthy lifestyle to stress and insomnia: obesity can have all kinds of causes. That requires tailor-made prevention and treatment, emphasizes Eric Hazebroek, surgeon at Rijnstate Hospital and professor at Wageningen University & Research (WUR): “Obesity is not a matter of your own fault.”
Diets, a personal trainer, walking clubs. People have often tried everything to lose weight before coming to Hazebroek for a consultation. The doctor works at Vitalys in Rijnstate Hospital, one of the largest clinics for (morbid) obesity in the Netherlands. Healthy food and more exercise are crucial, but not always enough to get back to an acceptable weight, the doctor knows. “Lifestyle adjustments, such as dieting and more exercise, can yield a maximum of five percent weight loss in the long term. If you weigh 150 kilos, that is too little,” he says.
gastric bypass
In such cases, patients sometimes undergo a stomach reduction (gastric sleeve) or a stomach reduction in which the intestine is diverted (gastric bypass). “We only operate if there really is no other option,” says the surgeon. “In the Netherlands, it still involves about twelve thousand operations per year. An indication is a BMI above 40 or a BMI above 35 with comorbidities such as high blood pressure, high cholesterol, diabetes or sleep apnea.”
The intervention is part of a multi-year care process, in which patients are extensively screened in advance and intensively guided towards a healthy lifestyle. “Only then does surgery make sense,” emphasizes Hazebroek. After the procedure, the stomach is the size of a kiwi, so people can only eat small amounts. “So they have to be extra careful that they get enough nutrients.”
Nutritional Deficiencies
Patients are advised to take multivitamins after surgery to reduce the risk of deficiencies. “We suspect that some of the patients already have deficiencies in certain vitamins and minerals before the operation. To better understand this situation, we are now studying how well people adhere to the Guidelines for a Good Diet – before and after surgery, says Hazebroek. The surgeon, professor since the end of 2019 Nutrition and Obesity Treatment at Wageningen University & Research, has set up various lines of research with his team. “For example, together with gynecologists in Arnhem, Ede, Leeuwarden and Veldhoven, we are following a group of young women who become pregnant after a bariatric procedure. We are investigating their nutritional status during pregnancy and its influence on mother and child.”
Weight gain
Another theme in Hazebroek’s research is weight gain after surgery. People lose about seventy percent of their excess weight after surgery. Most patients regain some weight on their own after one or two years, no matter how closely they adhere to the dietary recommendations. “There’s still a lot we don’t understand,” the doctor says. “Why do some people only gain five and others twenty kilos after exactly the same procedure? What is the role of our microbiome, the bacterial population in our gut? Can we add additional lifestyle and nutritional interventions to the treatment? And does it help if do we construct the intestines slightly differently with a gastric bypass?” The professor is involved in various projects – carried out in collaboration with TNO and Radboud University – that should provide insight into this.
Comorbidities
A third research theme is the effect of a gastric sleeve and gastric bypass on comorbidities such as diabetes, high blood pressure and sleep apnea. In sleep apnea, breathing stops several times during sleep, which increases the risk of cardiovascular disease. “People with diabetes often no longer need medication a day after the procedure. Many patients have also got rid of their sleep apnea,” says Hazebroek. “We now monitor a large group of patients how they are doing after surgery. The treatment of obesity is in fact a form of prevention, because you prevent other complaints from getting worse,” said the doctor. “But of course the biggest problem lies in front of it: in a society in which it is made very easy for people to make unhealthy choices.”
Puzzle with thousands of pieces
An unhealthy lifestyle is certainly not the only cause of obesity. “Obesity is a complex combination of factors, in which heredity, stress and insomnia also play a role,” explains the doctor. He therefore does not think that a frequently heard statement such as ‘your own fault is a big bump’. “That only inhibits the search for a solution.”
Hazebroek sees the future positively. “I expect that in the coming years we will gain more and more insight into what is now the best approach for which obese patient. For some this means lifestyle adjustments and medicines, and for others a gastric bypass. Who knows, we may even find an alternative to an operation. It is a puzzle with thousands of pieces and we are completing it little by little.”
dr. Eric Hazebroek is a bariatric surgeon at Rijnstate Hospital and professor of Nutrition and Obesity Treatment at Wageningen University & Research (WUR). In his extraordinary chair at this university, he focuses on integrating nutrition into obesity treatment methods.
Want to know more about stomach reductions? Then listen to the podcast below in which surgeon Sjoerd Bruin discusses the advantages and disadvantages of gastric reduction.
