Less food, but more alcohol



    Most people eat less after bariatric surgery. But some drink more.

    Bariatric surgery for morbid obesity is a potent form of treatment that can lead to long-term weight loss and other beneficial effects, but it is also associated with a risk of complications.

    Norwegian registry data show an average reduction in body mass index (BMI) from 42.7 pre-operatively to 31.0 five years after surgery (1). The majority of bariatric patients have obesity-related comorbidities. Two years after surgery, the incidence of sleep apnoea, type 2 diabetes, hypertension and musculoskeletal pain is significantly reduced (1, 2). Bariatric surgery is associated with a risk of complications, including serious ones such as deep vein thrombosis, pulmonary embolism and internal hernia. The benefit of reducing obesity and comorbidity must therefore be weighed against the risk of complications (3).

    Several studies indicate that the risk of alcohol dependence increases after bariatric surgery

    Several studies indicate that the risk of alcohol dependence increases after bariatric surgery. The reasons for this are not fully known. Using an alcohol marker in blood samples, a study by Siikaluoma et al. found an 8.3 % prevalence of alcohol overconsumption two years after bariatric surgery (4).

    In a qualitative study published in this edition of the Journal of the Norwegian Medical Association, Hege Tvedt et al. describe what post-bariatric patients receiving treatment for substance use think are the possible causes for developing problematic alcohol consumption after surgery (5). Ten patients receiving interdisciplinary specialised treatment for substance use disorders (SUD treatment) participated in the study. All had previously undergone bariatric surgery, but none had had a problematic relationship with alcohol pre-operatively or been referred for SUD treatment.

    Following bariatric surgery, most of the participants experienced improved quality of life, with weight loss, higher activity levels and increased socialising. However, several of those with no history of mental health problems described increased mental vulnerability and feelings of melancholy after the operation, in addition to exhaustion and depression.

    According to the study participants, the feeling of intoxication was more intense and short-lived post-operatively. Some experienced repeated bouts of strong intoxication throughout the course of an evening, while some developed a craving for alcohol. Several described how their hangovers changed. Alcohol also had new effects such as relieving stomach pain when eating and stimulating appetite. Two participants said that their pre-operative food intake was closely linked to the regulation of emotions, 'then it was suddenly taken away from me and alcohol became a substitute for food'.

    Regulating emotions through a high intake of energy-dense food and drink is not unusual

    My impression from clinical practice in assessing and following up patients with morbid obesity is that regulating emotions through a high intake of energy-dense food and drink is not unusual. For some, the need for such emotion regulation seems to be associated with or conditioned by stressful life events. It is possible that such events lead to a feeling of stress or emotional pain that triggers the need for relief by means of emotion-regulating mechanisms, such as a high intake of food or alcohol (6). In a study at the Regional Centre for Morbid Obesity, Nordland Hospital Trust, Bodø, the majority of patients told of at least one stressful life experience (7). A common experience was that their body went into 'alert mode', often beginning in childhood. It is unlikely that bariatric surgery could change such a need for emotional regulation.

    After bariatric surgery in the Norwegian public health service, patients are offered a structured follow-up programme, but this may vary for patients who undergo surgery in private health care or abroad. GPs thus play a key role in the follow-up and should have regular consultations with these patients. It is important that GPs are aware of the danger of post-operative high-risk alcohol use and that they actively ask about drinking habits to ensure that patients can receive the necessary treatment.

    Alcohol problems and obesity can both be associated with stigmatisation and shame (8, 9). Tvedt et al. have collected information on the knowledge and experiences of a group of people for whom the combination of obesity, bariatric surgery and new-onset post-operative alcohol problems is part of their life history. These are people whose voices are not often heard in society. Building trusting relationships, adopting a trauma-sensitive approach and showing empathy are all crucial in the clinical follow-up and in further research.

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