Stomach-shrinking operations have captured the headlines recently, with the post-operative death in June of 29-year-old Suzanne Murphy, who wanted to lose weight so she could play with her young son, and the daytime-TV star Fern Britton's earlier admission that her dramatic weight loss was due to a gastric band rather than willpower. But amid the arguments about vanity and surgical safety, one of the most crucial dangers is ignored - the huge psychiatric toll of these operations.
The numbers having NHS stomach surgery leapt by 41 per cent between 2006 and 2007. Parliamentary figures show that there were 3,459 such operations last year, up from 2,448 the year before, but the total does not include the soaring number of private procedures performed in Britain and abroad. The most common operations in Britain are gastric banding and the Roux-en-Y gastric bypass (see box).
But amid the rush to slim by scalpel, doctors and patients are ignoring the fact that it isn't an easy cheat. While thousands of people do benefit, one operation in five fails because of a patient's significant psychological problems - the problems that led to their obesity - remaining unaddressed. The alarming way that many of these failures manifest themselves as binge-eating, severe depression, suicide or addictions is making experts increasingly sceptical.
Guidelines on who should have surgery
Guidelines by the National Institute for Health and Clinical Excellence (NICE) recognise this potential for difficulties. They state that patients with psychological contraindications should not be considered for stomach surgery. But clinicians say this is often ignored. The story of the 19st (121kg) Suzanne Murphy, who died after suffering a huge reaction to stomach-stapling surgery at Huddersfield Royal Infirmary, seems to exemplify this.
Sheila Connor, Murphy's sister, says that they both developed weight problems very young when they started comfort eating after their father died. She says that Murphy was bulimic before she became pregnant five years ago, and her weight had plummeted to 5st. After her son was born her weight spiralled, but she was never given proper psychiatric help for problems with food. “She was only given slimming pills, but whenever she got down to a certain weight, the problems kicked in,” says Connor. Then Murphy had the ill-fated surgery.
John Morgan, a consultant psychiatrist at the Yorkshire Centre for Eating Disorders, began tracking obesity-surgery patients at St George's Hospital, South London, nine years ago. “Since then we have been turning out follow-up studies saying that psychological issues are powerful predictors of postoperative results. About a quarter to a fifth of patients who have surgery have bad outcomes, particularly if they have a history of binge eating, bulimia, depression or anorexia.
“If you are eating because of a need in your brain rather than a need for stomach satiety signals, having your stomach reduced is not going to solve that,” he says. “In fact, having your stomach reduced will mean that you can't placate yourself in your usual way, so you can keep resolutely eating until you effectively reverse the operation by displacing the stomach band or creating a pouch in your intestines.”
Patients cheat by liquidising food
A report in Pulse, the newspaper for doctors, highlights a problem called “soft calorie” syndrome, where patients cheat by consuming semi-liquid food that passes through the gut restriction. Nutritionists report stratagems such as melting Mars bars and liquidising McDonald's meals.
American psychologists have discovered how significant numbers of surgery patients become alcoholics, binge-shoppers or sex addicts. Melodie Moorehead, of the JFK Medical Centre in Atlantis, Florida, calls the problem “addiction transfer”. She reports in the stomach-stapling journal Bariatric Times that people who have attributed all their problems to being overweight can suddenly realise that their emotional difficulties are not as easily shed as their excess pounds. Many of the patients become obese because they are compulsive eaters. When the eating stops, they develop another compulsion.
New research indicates that the neurological causes of compulsive eating may be similar to those of other self-destructive addictions such as cocaine addiction and alcoholism. Other studies suggest that obesity may protect against other addictions. A survey of 9,125 adults in the Archives of General Psychiatry found that obese people are 25 per cent less likely to abuse drugs. In 2004, Florida University researchers published a study of 298 women showing that obese women drink less alcohol than average. The researchers suggest that food and alcohol trigger the same reward sites in the brain.
Morgan adds: “There is also something we call multi-impulsive eating disorder, which affects a minority of patients who not only overeat, but also cut themselves or take drugs or alcohol, because their instability of personality leads them to do these things when faced with difficult emotions. Frankly, addressing these psychological problems can be necessary, but it's barely sufficient on its own. Obesity surgery basically involves retraining someone's behaviour, and that can take years.” This is often ignored, he says. “Booming demand means that services are being developed that are like plastic surgery. But it's just not like breast augmentation.
“There are some good centres in the UK that focus on comprehensive treatment to address both mind and body issues. But there are many more where people don't really know what they are doing. I would like to see services be given minimum standards before they can start operating. There needs to be access to eating disorder experts and budgets for the significant minority who need postoperative support.”
Samantha Scholtz, who gives NHS patients pre-surgical psychiatric assessments at the Imperial Weight Centre, Charing Cross Hospital, West London, cautions that post-surgical support is often lacking. “The first few weeks after the operation, people are very emotional.The effects of the surgery, not being able to eat, and losing weight all cause depression and anxiety. Six months down the line, more depression arises. Often this is because their expectations have not been met. The body image is often not great. There is a lot of loose skin and it is cosmetically not a good operation. But sometimes it is sold that way.”
Scholtz, the lead author of a study in Obesity Surgery on postoperative complications in 37 patients, adds that suicides right after surgery go up. “You have to prepare people to have realistic expectations. The benefits are primarily for their physical health, diabetes and blood pressure, but not body image. Obesity surgery is good for certain people. But they need the right follow-up and support.”
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