As Angela Chesworth was wheeled into the operating theatre to have weight-loss surgery, her self-esteem was so low she remembers thinking she didn’t care if she lived or died.
At 5ft 3in and weighing 24st, there was no diet or exercise plan she hadn’t tried, no reproach she hadn’t already heaped on herself for failing to lose the weight. Aged 40, she had spent the best part of her life shrouded in disappointment and shame.
Her weight was also affecting her health. She had developed sleep apnoea — when she lay down, the excess weight around her neck temporarily blocked her airway, so she had to sleep sitting up, connected to an oxygen mask.
Her body mass index (BMI) of 59.5 — officially ‘morbidly obese’ — put her at greatly increased risk of arthritis, high blood pressure and type 2 diabetes.
Angela Chesworth, 46, from Lancashire was able to lose 12st in the first year of her bariatric surgery
However Angela said that while she was able to lose weight in the first year, she soon found it difficult to stop old habits returning and slowly regained 2st in weight
Bariatric (weight-loss) surgery seemed to offer Angela hope of living a normal life.
In the year after her operation — a gastric bypass, where staples are used to reduce the size of the stomach, and the small intestine is re-routed to this smaller pouch) — Angela lost 12st, bringing her closer to a healthy BMI.
But after this ‘honeymoon period’ when the weight dropped off, like many others who have bariatric surgery, she found it difficult to stop old habits returning and slowly regained 2st in weight.
This is because the surgery did not address the complicated underlying issues that had led to her weight gain in the first place — and it couldn’t erase the years of stigma she had endured. ‘In my mind, I’ll always be 24st ‘fat Angela’,’ she says, ‘insecure and not good enough.’
SOME PEOPLE can END UP HEAVIER
Though bariatric surgery costs the NHS about £10,000-£12,000 for each patient, research suggests the savings on treating problems such as arthritis and type 2 diabetes mean the money could be recouped within three years. Most experts believe too few bariatric procedures are done on the NHS.
Angela said that the surgery did not address the complicated underlying issues that had led to her weight gain in the first place
Currently, just 1 per cent of those eligible have the surgery (there were more than 6,500 bariatric operations on the NHS in England in 2017/18).
Many patients experience dramatic weight loss and improvements in conditions such as type 2 diabetes and high blood pressure. But there are rising concerns that they are not getting all the support they need.
The operations may exacerbate existing mental health problems because patients are not well enough supported through the process. Around half of patients will regain between 5 and 10 per cent of the weight they lost; and up to 15 per cent will regain all they lost and more.
Angela, now 46, from Lancashire, had her surgery on the NHS after she had spent four years trying to lose weight through diet and exercise. She had been taunted throughout her childhood because of her weight: by the time she was ten she weighed 9st and was under the care of an NHS dietitian.
The name-calling and bullying were relentless. ‘It never occurred to me to tell anyone what was going on,’ she says, ‘because the bullies were right — I was fat and I deserved to be punished. There was no insult anyone could throw at me that I hadn’t already inflicted on myself.’
As Angela headed into adulthood, her weight soared and she developed binge-eating disorder. When no uniform could be found to fit her at the supermarket where she worked as a stock controller, she faced the humiliation of being given two skirts to sew together.
‘Filling myself up with huge quantities of food was my way of dealing with difficult situations,’ she says. ‘During a particularly stressful run-up to Christmas, one evening I ate 17 chocolate selection boxes one after another. Afterwards I was swamped with self-loathing. At the same time I’d buy lavish presents for everyone because I so badly wanted to be liked.
‘After years of trying to lose weight through diet and exercise, bariatric surgery was a last resort. I had to produce evidence that I’d attended the gym, and I had a four-hour education session informing me of all the options and an aftercare plan.’
After choosing a gastric bypass, Angela had just one appointment with a psychologist, which, she says now, ‘was nowhere near enough’.
EMOTIONAL ISSUES CAN RESURFACE
Angela recovered well after her surgery and for the first year ‘everything was great — the weight is coming off, you receive compliments and have more confidence.
‘It’s after that, when the weight loss slows down, that the old coping mechanisms come back. You still want to binge on food and low self-esteem kicks in again.
‘I wasn’t prepared for this at all. Patients need much more psychological support before their operations to help them understand what life afterwards will entail — and support for life afterwards.
‘I believed that everything wrong in my life was because of my weight, and surgery would ‘cure’ me.’
Ceely Shakespeare, 37, a full-time mother of one, decided to undergo a gastric bypass privately in January 2018
Ceeley, who funded her surgery via a small inheritance, said at her heaviest she weighed 19st 9lb and had a BMI of 54
But the psychological issues associated with excess weight, including low self-esteem, social anxiety and entrenched eating disorders, don’t automatically disappear as weight goes down.
‘I turn to food like an alcoholic turns to alcohol,’ says Angela. ‘In some ways the feelings of worthlessness intensified after losing weight because I was slimmer, yet I still felt terrible about myself.’
In fact, 18 months after the surgery she literally ‘beat herself up’. Voice breaking, she explains: ‘I wanted to hurt myself because I felt I was failing and worthless.’
A recent study from Australia, published in the journal JAMA Psychiatry, suggests Angela’s experience is not uncommon. In fact, some people reported more mental health difficulties after they’d had surgery.
Ceeley set up her own Facebook group to provide support for others last year and now has more than 700 members
Dr David Morgan, an emergency medicine specialist at St John of God Subiaco Hospital in Perth, Western Australia, analysed the records of almost 25,000 patients who had weight-loss surgery over nine years.
He found that self-harm was five times more common after the operation than before, with the risk of admission to a psychiatric unit increasing threefold. Some people reported new problems, including substance abuse.
‘We already knew that people who are obese have higher rates of depression,’ says Dr Morgan. ‘They are a vulnerable group of patients undergoing an operation that they hope will change their lives.
‘When weight loss slows down or they don’t feel as good as they expected, they can end up feeling worse than before.
Surgeons need to have more discussions with patients about the mental health risks before they operate, and ensure they receive long-term psychotherapy afterwards to pick up any mental health issues that may not have been anticipated.’
It seems patients don’t just need to physically change their weight — they must change the eating and thought patterns of a lifetime.
The National Institute for Health and Care Excellence (NICE) recommends psychological support ‘tailored to the individual’ before and after bariatric surgery.
But the level of psychological support patients receive varies between health trusts.’
‘If you think as a surgeon you can operate on someone’s stomach and solve all their problems around obesity, you’re fooling yourself,’ says Professor David Kerrigan, president of the British Obesity and Metabolic Surgery Society,
‘Psychological assessment and support before and after operations is critical because when people who have used food as a crutch all their lives can no longer do so, they sometimes transfer the addiction to other things, such as alcohol or drugs — or just revert to old food habits as soon as they can.’
NICE says bariatric surgery should be considered for people with a BMI over 40 ‘when all non-surgical measures have been tried’ and for those with a BMI over 35 where weight is causing health problems such as type 2 diabetes, coronary heart disease and high blood pressure.
Although NICE suggests that NHS patients should have up to two years’ psychological support after their operations, many receive far less — partly because there are too few psychologists and other trained staff to provide it.
If you have the operation privately, you may receive no psychological support at all, as there is no mandatory requirement for it (about 7,000 people in the UK have weight-loss surgery privately every year).
TWO YEARS LATER BENEFITS STOP
Long-term studies show that bariatric surgery works by affecting the physiology of the gut, switching off appetite by physically removing cells that release hunger hormones — but it only works for a year or two, as the tissue repairs itself. It’s after this point that changes in lifestyle and mindset are vital.
An operation doesn’t change behaviour, says Professor Kerrigan. ‘Long-term studies show that around 15 per cent who haven’t been able to make behavioural and lifestyle changes will regain the weight within five years.
‘Less than 1 per cent go the other way and lose too much weight, developing a kind of pseudo-anorexia and body dysmorphia and other complicated eating disorders. You need long-term support to maximise the effects of the operation and make sure you don’t fall into the same traps again.’
Another issue is that people who opt for bariatric surgery often feel a sense of failure because they haven’t been able to lose weight on their own, adds Dr Jacqueline Doyle, a clinical psychologist with University College Hospital NHS Centre for Weight Management, Metabolic and Endocrine Surgery, in London.
So what are the side-effects?
While the surgery has been shown to lead to dramatic weight loss and reversal of type 2 diabetes and high blood pressure, it can also create physical as well as psychological problems.
EXCESS SKIN: The rapid weight loss can lead to unsightly sagging skin that is prone to infections (in the folds). Surgery to remove it is not normally offered on the NHS, as it is considered a cosmetic issue.
MALNUTRITION: The amount of food consumed is cut so dramatically — the stomach may go from the size of a large clenched fist to smaller than an egg — it can lead to nutritional shortfalls, causing problems such as anaemia and osteoporosis (due to lack of calcium).
People often have to take vitamins and minerals for the rest of their lives.
DUMPING SYNDROME: Eating too much food, especially sugary food, after weight-loss surgery can lead to stomach cramps, faintness or diarrhoea, caused by the smaller stomach emptying too quickly, in a rush of food and digestive fluid.
GALLSTONES: These balls of cholesterol occur in up to half of those who have had weight-loss surgery. This is because rapid weight loss — of more than 3lb a week — can change the balance of cholesterol and bile salts, encouraging the stones to form.
If these block the gall bladder outlet, it can cause intense pain. In extreme cases the gallbladder has to be surgically removed.
‘People affected by obesity are often seen as lazy, less intelligent and lacking in willpower,’ she says.
‘The complex combination of biological, psychological, environmental and social influences on weight regulation is poorly understood.
‘The fear of weight regain can lead people to start skipping meals and engage in overly restrictive eating practices. Ironically, this can subsequently lead to overeating and a lack of control.’
Ceely Shakespeare, 37, a full-time mother of one, had a gastric bypass privately in January 2018: at her heaviest, she weighed 19st 9lb and had a BMI of 54.
‘Getting married in my 20s, then having our son Harrison, now seven, led to years of ‘sofa picnics’. I was always on and off a diet and never lost any weight.’
She funded her surgery via a small inheritance and lost nearly 10st in the year that followed.
‘I had an hour with a psychologist before my surgery and another two sessions afterwards,’ says Ceely. ‘But I knew weight loss was affecting my whole life, particularly my relationships, and I needed more day-to-day chats.’
Last year, she set up her own Facebook group to provide just that. Gastric Fantastic now has more than 700 members — half from the NHS, half private patients.
‘The things people go through emotionally after surgery are heartbreaking,’ says Ceely, who has maintained her weight loss. ‘It’s helpful to get support from people who know what you’re going through.’
Her surgeon, Simon Monkhouse, refers his other patients to the group. ‘Ceely does an important job,’ says Mr Monkhouse, a consultant bariatric surgeon in private practice and with Surrey and Sussex Healthcare NHS Trust.
‘Surgery is a tool to help deliver physical change but the real results come from behavioural change. Support groups are essential.’
For those who miss out on this help, the consequences can be life-altering. Angela’s first marriage failed when the relationship changed after she started losing weight and although she is now happily married to Paul, 55, a retired utility engineer, she decided not to have children for fear they would be bullied as she was.
Since the gastric bypass in 2013, Angela’s weight has stabilised at 14st. But it’s a constant battle to keep it down. ‘Paul and I work hard every day to be as active as we can and eat the right things,’ she says. ‘But there are still days when I don’t want to leave the house.
‘Losing weight doesn’t alter my mental image of myself, and there are thousands who feel the same.’
A surgeon’s scalpel is no quick fix for Britain’s obesity crisis
By Dr Max Pemberton
It’s a nice idea: we can end the obesity crisis with surgery. Forget diets, willpower and treadmills. All you need is a scalpel and, hey presto, it’s problem solved.
There’s no doubt that as a society we are groaning under the weight of the obese. And if we don’t do something about it soon, it’s going to cripple us.
Advocates of weight-loss surgery point to studies that suggest it reverses type 2 diabetes in up to 50 per cent of cases, and the NHS is under increasing pressure to offer it.
But this comes at a time when many routine operations, such as cataract ops and knee and hip replacements, are being reduced. Can this really be right?
The thing to note is that bariatric surgery itself doesn’t reverse type 2 — it causes the patient to lose weight, and it’s this that can improve their diabetes. This will happen regardless of the way someone loses weight.
While bariatric surgery itself does not reverse type 2 diabetes it can cause patients to lose weight and this can improve their diabetes. (Stock image)
And is surgery REALLY the best way for someone to lose weight?
I work in an NHS eating disorder unit and see the personal cost of weight-loss surgery in those who are morbidly obese. While it can mean a new lease of life for some, that’s not the case for everyone.
I assess patients before and after this type of operation and, let me tell you, things are far more complex than the advocates for obesity surgery would have you believe.
As well as the risks that any major operation carries, such as blood clots and bleeding, there are nutritional and dietary problems that can result in vitamin and mineral deficiencies, as well as problems with the bowel when eating certain foods such as carbohydrates (a condition called dumping syndrome).
Furthermore, the rapid weight loss can result in large amounts of saggy skin, which people feel embarrassed about. But this pales into insignificance compared with the psychological problems it creates.
For while this type of surgery does have a positive impact on some patients with type 2, diabetes is only a small part of the problem facing the obese. It’s a symptom of being obese, and just focusing on this means you don’t get to the root cause.
The real question to ask is what has made someone obese. This might seem obvious — they eat too much. But there are a variety of underlying reasons why someone eats more than they need, and this is precisely what surgery doesn’t address.
For a lot of people, there is a psychological component: they binge or graze on food throughout the day as a way of dealing with their emotions.
After surgery, those problems remain — except now the person can’t use the one coping strategy they had. They are left with overwhelming levels of distress — many patients have told me it’s like being mentally tortured.
Depending on the exact procedure, as many as 20 per cent of patients will find ways around it, such as continually snacking or consuming very high-calorie foods, and gain a significant amount of weight back.
Some even liquidise their food (chocolate, chips and burgers) so they can sip it throughout the day.
This just emphasises how these people had a profound problem with food before surgery — and an operation can’t hope to get rid of this.
A study of 17,000 people who had undergone bariatric surgery showed they were actually at higher risk of suicide than those who hadn’t had it, probably because of the psychological pressure of all the lifestyle changes (such as having to closely monitor their food intake) that must be adopted post-surgery.
Research has also shown a 50 per cent increase in drug and alcohol addiction post-surgery — again, probably because people look to other things to provide the comfort food used to give them.
This shows we are approaching the obesity epidemic in completely the wrong way. We need to address the underlying cause and treat a psychological problem with psychotherapy.
When people are taught alternative coping strategies for dealing with their emotions and difficulties, they cease needing to use food as a crutch, so they lose weight anyway. If that happens, their type 2 diabetes also improves and may even be reversed entirely, as with surgery.
Surely this is a better way to help someone who is obese?
Of course, not every obese person has underlying psychological issues. Some simply lack the motivation, knowledge or willpower to lose weight. But is it right to offer an operation to someone who, frankly, can’t be bothered to lose weight themselves? Is that really what the NHS was set up for?
Offering bariatric surgery is a lazy solution to the obesity epidemic that is fraught with problems. The hard, brutal truth is that the obese are crippling the NHS.
We need a sustained, coordinated attack on the underlying causes of obesity, through changes in policy and legislation, as well as education.