Page 13 - When surgery alone won’t cut it - Valerie Maureen Monpellier

psychopathology, such as depression, compared to non-obese individuals 23-29. In obese patients who seek surgical treatment for obesity, HRQoL is lower and a neg- ative body image is more prevalent compared to the population who does not want to undergo surgery 28,30,31. These problems are partly the reasons why these patients seek treatment. The cause of obesity is assumed to be multifactorial and complex. In general, it is thought to be a result of cultural and environmental changes which induced a continuously high energy intake and little physical activity which leads to a positive energy balance 13,14. Recent studies however, question whether increased intake and decreased activity are the only reasons for the obesity epidemic. They suggest that other factors like certain pharmaceutical agents, (epi)genetics, stress and sleep debt also contribute to the problem 32,33. The complexity of the multicausal nature of obesity makes treatment of this chronic disease difficult.
Treatment of obesity
Treatment of obesity is divided in non-surgical, pharmacological and surgical treat- ment. The cornerstone for all these types of treatment is lifestyle change, with em- phasis on regulation of energy intake and improvement of physical activity 14,34,35. It is advised to include lifestyle treatment and/or behavioural therapy in the treatment pro- gram and to treat patients with a multidisciplinary team 14,34,36. Pharmacotherapy and bariatric surgery are adjuncts to the lifestyle change and only provided to a selection of patients 14,34,37.
Non-surgical treatment including lifestyle treatment and/or behavioural therapy seems to be an effective treatment for obesity. Weight loss is around 5%, which can be main- tained up to 8 year 34,38,39. Pharmacological treatment is advised in the patients with a BMI ≥ 30 kg/m2 or a BMI ≥ 27 kg/m2 with an obesity related disease, like hypertension or diabetes mellitus 14,37. Several pharmaceutical agents have been developed for treatment of obesity. These medications generally affect appetite and cause weight loss only when the agent is taken and in combination with lifestyle change 14,37. Mean weight loss with pharmacological treatment ranges between 4.4% and 14.3% de- pending on type of medication and treatment regime 40. In the Netherlands there is one pharmaceutical agent registered for the management of obesity, however, this is not reimbursed by insurance companies.
Bariatric surgery (which is also called metabolic surgery) includes a variety of surgical procedures in which the gastro-intestinal tract is altered. These procedures are all performed as a treatment for morbid obesity and its comorbid conditions. Before, it was thought that weight loss after bariatric surgery resulted from the combination of a reduced intake and reduced absorption of food/nutrients. However, current re- search is showing that bariatric surgery causes changes in gut hormones, bile acids and microbiota, which subsequently are assumed to induce changes in appetite and
13