In our part of the world, many people want to lose weight. This is often achieved through more exercise and a change in eating habits. But what happens when weight gain gets out of control? What if, despite a reduced calorie intake, the scales simply don’t budge – in other words, when being overweight turns into a chronic condition? The Leading Medicine Guide spoke to Professor Dr Ralph Peterli, an experienced abdominal surgeon who specializes primarily in bariatric treatments. As he is also one of the leading experts on diabetes, those affected by obesity can rely on comprehensive, all-round care that offers excellent advice and minimally invasive surgical procedures. Prof. Dr Ralph Peterli heads the largest bariatric center of excellence in north-western Switzerland at the Clarunis University Abdominal Center in Basel – and has conducted extensive research into obesity and diabetes. Together with his team, he is a highly competent yet empathetic point of contact.
It seems unfair. Some people can eat as much as they like without gaining weight, while others put on weight even though they supposedly eat very little. When weight gain becomes pathological, it is referred to as obesity. The word has its origins in the Latin term adeps – fat. Obesity, i.e. pathological overweight, is a nutritional and metabolic disorder, also known as adiposity or fatness.
The Body Mass Index (BMI) is used as a basis for calculating body weight. The BMI is a measure used to assess a person’s weight in relation to their height (kg/m²). “BMI is not a good measure, but it is a simple, measurable one,” comments Prof. Dr Peterli, adding: “The so-called threshold lies between a BMI of 35 and 40. At this level, a person’s metabolism has already deteriorated to such an extent that it is virtually impossible to reduce weight through one’s own efforts without external intervention.”
Our genes are contained within our DNA (deoxyribonucleic acid). These are long, fiber-like molecules that make up our chromosomes. They carry the code for the production of all proteins and, consequently, for every aspect of the processes of life. Our genes are like a blueprint – they determine our hair and eye color or how tall we will be, and are involved in the production of proteins and hormones, which in turn determine our metabolism and our eating habits.
The causes of severe obesity are manifold
However, the fact is that you cannot always blame an overweight person for having eaten too much in the past. This is because the causes of severe obesity are manifold: “This is why obesity is also referred to as a chronic condition, as those affected are simply not to blame. Rather, it is a matter of genetic predisposition. Genetics account for the main underlying cause in around forty to eighty per cent of cases. This has also been confirmed by studies involving parents and twin studies. The individual’s subsequent lifestyle then plays a rather secondary role,” explains Prof. Dr Peterli.
The specialist in bariatric surgery explains very succinctly what happens to the body during a diet or even a radical weight-loss program, and why such an approach usually does not work and the figure on the scales simply hardly moves downwards: “Anyone who goes on a radical diet puts their body into a state of starvation. The body desperately clings to every kilo in order to survive,” says Prof. Dr Peterli. “There is an interesting study showing that children born to underweight mothers at the end of the Second World War are at a higher risk of developing obesity in adulthood. It seems that, out of fear of famine, the body stores everything and clings unconditionally to fat,” he reports.
An important role: diet in childhood
Anyone who is fed a lot of sugary and fatty foods as a child and generally eats more than they burn will naturally put on weight and find it difficult to lose it again. “Of course, general diet also plays a major role in adulthood. Another problem here is the misleading labeling that is rife in the food industry. For example, many people fall for the belief that agave syrup is a good sugar substitute. That is not true, because ultimately agave syrup is also fructose. And fructose is sugar!” says Prof. Dr Peterli. Fructose cannot be broken down by the body and goes straight into fat stores.
Obesity is not your own fault
As people age, they usually gain weight steadily. This is a normal process. For people of normal weight, this is not so much of a problem, as it can be counteracted with simple measures. In obese patients, however, weight gain is often so advanced that only external help can bring about a change. “Since 2011, metabolic or bariatric surgery has been a mandatory benefit under statutory health insurance in Switzerland if a person is extremely overweight. This means that obesity is recognized as a medical condition in Germany – which is not the case in Switzerland, for example,” says Professor Dr Peterli on the legal situation.
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Surgery is not solely about weight loss
People who are severely overweight place a strain on their entire body. Just imagine what the bones and joints alone have to endure to bear the entire load. “However, weight loss not only relieves the skeletal system but also helps in the treatment and prevention of cardiovascular diseases and type II diabetes, a chronic metabolic disorder in which the body produces too little insulin. It also reduces the risk of sleep apnoea syndrome. Weight loss can save lives,” warns Prof. Dr Peterli.
In Germany, more than seven million citizens were treated for diabetes mellitus in 2006, with type 2 diabetics in particular having to take increasing amounts of insulin. Type 2 diabetes is therefore the most expensive chronic condition, costing the German health insurance funds approximately €18 billion annually.
Various surgical methods to help patients lose weight in the long term
“The traditional gastric band has now had its day,” replies Prof. Peterli when asked about the various surgical methods. “A gastric band is only successful in about 10% of cases, as it merely slows down food intake. The gastric bypass has been performed for over fifty years and is now a standard procedure using keyhole surgery. In this procedure, the passage of food through the gastrointestinal tract is diverted via two artificially created connections, so that a large part of the stomach and sections of the small intestine can be bypassed,” explains Prof. Dr Peterli.
“The sleeve gastrectomy is the alternative to gastric bypass surgery, in which the stomach is simply drastically reduced in size so that, in principle, less food can be consumed,” Prof. Peterli clarifies. If sleeve gastrectomy or gastric bypass do not lead to success, the so-called biliopancreatic diversion surgery can be performed on carefully selected patients; this is a combination of bypass and sleeve gastrectomy surgery. In this procedure, the stomach is reshaped into a sleeve, while at the same time the majority of the small intestine is excluded from the digestive tract, thereby also shortening the digestive tract. “This type of surgery is more complex, but leads to weight loss of around 80%. However, lifelong follow-up is necessary for the early detection of adverse side effects or deficiency symptoms,” explains Prof. Dr Peterli.
Which surgery for which patient?
To ensure the correct surgical method is chosen, the patient undergoes various preparatory stages once all conservative forms of treatment have indeed failed. “First, an interdisciplinary assessment takes place at the clinic. This means the patient is thoroughly assessed by specialists from various disciplines (dietitian, metabolic specialist, psychiatrist and, if necessary, supplemented by heart and lung specialists). The patient is then given a detailed explanation of the advantages and disadvantages of the various surgical methods during a comprehensive consultation. Statistically speaking, in Switzerland around 85% of procedures are gastric bypasses and 15% are sleeve gastrectomies – in Germany, the situation is the reverse,” explains Prof. Dr Peterli with a slightly critical expression. This is because sleeve gastrectomy is ultimately the simpler procedure to perform. However, the gastric bypass is the more effective procedure and, for example, much more successful in patients with reflux, if only because it allows a hiatal hernia to be treated at the same time. “The negative effects one hears about with bypass surgery are often linked to inadequate post-operative care,” criticizes Prof. Dr Peterli.
As the then President of the Swiss Society for Bariatric Surgery, Prof. Dr Peterli, together with representatives of the Swiss Society for Endocrinology and Diabetes, succeeded in ensuring that patients with a BMI of 30–35 and difficult-to-control diabetes mellitus (diabetes) can also undergo surgery in Switzerland.
When choosing the surgical method, Prof. Dr Peterli attaches great importance to making the optimal decision for each individual. Both bypass and sleeve gastrectomy procedures are performed laparoscopically. Both operations result in a beneficial change in metabolism, in addition to a reduced food intake.
Simple preventive measures
In principle, anyone who is not yet obese can influence their weight through their behavior. The classic approaches are what work here: more exercise, healthier eating. However, Prof. Dr Peterli explains this in plain language: “Please avoid sugar and sugary foods as much as possible. In fact, the food industry should be taken to court, particularly regarding the ingredients in products for children. Advertising misleads people into thinking that a children’s chocolate bar, for example, is healthy, when in fact it consists of unhealthy ingredients. According to the WHO, children should consume no more than 10 g of sugar per day, and adults no more than 25–50 g. Most so-called ‘healthy forms of sugar’ such as agave syrup, coconut blossom sugar, maple syrup or pear syrup are no good, as they ultimately consist only of fructose. Only the substitutes xylitol and erythritol can be used here,” explains Prof. Dr Peterli, adding: “Always take your time when preparing food and when eating. Avoid ready meals and reduce your intake of carbohydrates. Sweet drinks and alcohol should, of course, only be consumed in moderation. But ultimately, what counts is this: you should be able to enjoy your food and not deprive yourself.”
Many thanks to Professor Dr Peterli for this interesting and insightful information! You can contact Prof. Dr Peterli directly via his profile page on the Leading Medicine Guide.
