Running Head: IN PATIENTS WITH SEVERE OBESITY

In Patients With Severe Obesity, is Bariatric Surgery More Effective in Reducing

Secondary Comorbidities than Diet and Exercise Alone?

Feng Chen, Kristie Hopp, Taylor Coy, Nathaniel Hunter

Centofanti School of Nursing, Youngstown State University

NURS 3749 Nursing Research

Ms. Heasley

04/06/2022
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In Patients with Obesity, is Bariatric Surgery More Effective in Reducing Secondary

Comorbidities than Diet and Exercise Alone?

Nowadays, fast food restaurants are scattered all over the United States. With the

increased number of office and remote jobs, people are not as active as before. This makes

obesity a problem that people can no longer ignore. Obesity is a BMI of 30 kg/m2 or greater. It

affects people of all ages and is linked to numerous health issues such as cardiovascular diseases,

diabetes, sleep apnea, impaired mobility, mental health problems, reproductive issues in men and

women, and cancer. The risk of developing comorbidities increases proportionally to BMI.

People with a BMI of 40 kg/m2 or higher are considered to have severe obesity, causing them to

have poorer health outcomes. However, there are ways to treat obesity and prevent the

development and progression of comorbidities. Lifestyle modification such as diet and exercise

is the most common intervention for weight loss. The goal is to consume less and burn more

calories, creating a calorie deficit, to achieve weight loss. Another intervention is bariatric

surgery, which has become increasingly popular for reducing weight. In this literature review,

the effects of lifestyle modification and bariatric surgery will be compared, and a conclusion of

which intervention is more beneficial will be made.

Literature Review

Introduction

This paper explores the effects of lifestyle modification, specifically diet and exercise,

and bariatric surgery on weight loss and overall health. Information was obtained from

EBSCOhost, MEDLINE, CINAHL Plus, and PubMed. Nine journal articles were utilized and
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reviewed. Some keywords that were used for the search are [“severe obesity” OR “morbid

obesity”] AND [“bariatric surgery” OR “metabolic surgery”] AND [“diet and exercise” OR

[lifestyle modification] AND [“long term effects” OR “outcomes”].

Exercise

Throughout history, it has been known that exercise is beneficial to human health.

Hippocrates once said, “All parts of the body, if used in moderation and exercised in labors to

which each is accustomed, become thereby healthy and well developed and age slowly; but if

they are unused and left idle, they become liable to disease, defective in growth and age

quickly.” We know more today than the ancient physicians ever did, but Hippocrates was

incredibly correct on the topic of aging. Another health-related topic, exercise, is beneficial

towards body composition. Body composition is the percentage of fat, bone, and muscle in one’s

body. It is commonly measured by body mass index (BMI), waist circumference (WC), waist-to-

hip ratio (WHR), waist-to-height ratio (WHtR), and body fat percentage (BF%)

Telomere Length

At the end of our chromosomes are non-replicating pieces of DNA known as telomeres

that protect the chromosome from damage. As the chromosomes divide the telomeres become

shorter and shorter eventually reaching a point where the cell can no longer divide leading to

senescence, deterioration with age, and apoptosis, regulated cell death.

In a 2020 research article titled The effects of short-term combined exercise training on

telomere length in obese women: a prospective, interventional study, written by Brandao et al, it

is explained that “Telomere length is inversely associated with the senescence and aging process.

Parallelly, obesity can promote telomere shortening. Evidence suggests that physical activity

may promote telomere elongation,” (para. 1).

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The study results consisted of 13 female volunteers 20-40 yrs old, BMI between 30-40

kg/m2, living a sedentary lifestyle for at least 6 months prior to the study, and who have had

regular menses. The study subjects participated in combined aerobic and strength exercises.

Brandao et al discovered “significant differences (p < 0.05) were observed in telomere length

(respectively before and after, 1.03 ± 0.04 to 1.07 ± 0.04 T/S ratio[relative amount of telomeric

DNA (T) to the beta-globin single copy gene (S)]), fat-free mass (46 ± 7 to 48 ± 5 kg), Vo2max

(35 ± 3 to 38 ± 3 ml/kg/min), and waist circumference (96 ± 8 to 90 ± 6 cm),” (para. 4). More

precisely, they discovered “we found that the 8-week combined exercise training program

increased telomere length, physical performance, and fat-free mass, while it decreased waist

circumference. Our results showed that subjects with bigger waist circumference have lower

telomere length,” (para. 24). This article shows an inverse correlation between obesity and

telomere length and would be an excellent launching point for more research regarding the

lengthening and shortening of telomeres in relation to a person’s weight. Telomere length

reduction is not the only benefit of exercise, body composition is also shown to be affected.

Body Composition

To refresh, body composition is the percentage of fat, bone, and muscle in one’s body. It

is commonly measured by body mass index, waist circumference, waist-to-hip ratio, waist-to-

height ratio, and body fat percentage. In the 2017 article “Benefits of different intensity of

aerobic exercise in modulating body composition among obese young adults: a pilot randomized

controlled trial,” authored by Chih-Hui Chiu et al, they “compare the effects of different aerobic

exercise intensities and energy expenditures on the body composition of sedentary obese college

students in Taiwan,” (para. 1). Their research subjects consisted of forty-eight, 18-26-year-old

college students with a BMI ≥ 27 kg/m2 participating in differentiating degrees of exercise

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ranging from low-intensity (LITG), middle-intensity (MITG), and high-intensity (HITG). The

results were obtained via the anthropometric measurements of body composition, blood

biochemical parameters, and health-related physical fitness components, compared between

baseline results and after the 12-week exercise regimen.

After the 12-week exercise regimen, the researchers compared the results between the

four groups; LITG, MITG, HITG, and the control group. They affirmed that:

At baseline, the anthropometric indices did not differ significantly among the four groups

(p > 0.05). After 12-week exercise intervention, the HITG and MITG had significantly

more changes in body weight, waist circumference (WC), waist-to-hip ratio (WHR), and

waist-to-height ratio (WHtR) than the LITG. The changes in BMI and body fat

percentage differed among all four groups (p < 0.05), (para. 3).

The authors go on to say that these results are consistent with previous studies with how high-

intensity exercise is effective with decreasing BF% and improving body composition and when

comparing low-intensity and high-intensity exercise, high-intensity exercise may reduce body

weight and fat significantly more even if energy expenditure is equal.

Bariatric Surgery

According to Cheah et al. (2022), compared to lifestyle modification and anti-obesity

pharmacotherapy, bariatric surgery is the most clinically and cost-effective intervention for

weight reduction. In their study, 73.5% of patients post-bariatric surgery maintained at least a

20% reduction of their initial weight at the ten-year follow-up. This procedure is recommended

for people who are severely obese (BMI ≥ 40 kg/m2), or in people whose BMI range from 30-

39.9 kg/m2 and suffers from serious complications associated with obesity. In bariatric surgery,

the size of the stomach is reduced, thus, reducing calorie intake. There are many types of
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bariatric surgery. The most common are sleeve gastrectomy (SG) and Roux-en-Y-gastric bypass

(RYGB). In SG, 80% of the stomach size is reduced. In RYGB, the stomach is divided into a

smaller upper part and a larger lower part. The small intestine is rearranged and connected to

both parts of the stomach, forming a Y-shape This results in a 90-95% reduction in the gastric

capacity of food intake (Gasmi et al., 2021).

Bariatric Surgical Mortality Rate

With obesity on the rise, more people are turning to bariatric surgery to lose weight. With

its increasing popularity, just how safe is bariatric surgery? Dr. Bruce M. Wolfe explained that

patients who received open gastric bypass had a 2.1% risk for mortality within the first thirty

days, whereas RYGB had a 0.2% risk. Factors that affected these statistics included smoking,

sleep apnea, DVT, immobile patients, and patients with severe obesity. Wolfe explained how the

morality and complication statists are significantly lower than the result of surgeries needed from

untreated obesity. These surgeries included coronary bypass, arthroplasty, and cholecystectomy.

Mortality rates for bariatric surgery are continuing to decrease, making it more favorable than the

alternative effects. Longer-term complications such as micronutrient deficiencies and reoperation

are still being monitored (Wolfe 2016).

Micronutrient Deficiencies After Bariatric Surgery

One of the major complications of bariatric surgery is micronutrient deficiencies. Gasmi

et al. (2021) explained that different types of bariatric surgery affect nutritional deficiencies

differently. In SG, the absorption of iron, zinc, selenium, folate, and vitamin B12 are affected,

while RYGB has a more profound impact on the absorption of essential vitamins, minerals, and

trace elements. According to Gasmi et al. (2021)

The prevalence of anemia in RYGB is twofold within 12 months of the surgery, and such
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patients showed a reduction in hemoglobin/hematocrit with time. Osteopenia and

secondary hyperparathyroidism were also attributed to RYGB because of reduced

calcium absorption, and this may even result in an increased rate of fractures, especially

two years after the surgery. This happens due to the bypass of the duodenum, which has

the highest concentration of calcium transporters. (p. 57)

Some other complications secondary to micronutrient deficiencies post-bariatric surgery include

loss of body coordination, fatigue, constipation, anorexia, blood clotting disorder, numbness, and

hormonal disturbances. Gasmi et al. conclude that although bariatric is an effective way for

weight loss in patients with severe obesity, lifelong follow-up and nutritional monitoring are

required for post-op patients.

Dietary Counseling Post-Operative

Rapid weight loss is seen in the first few months following bariatric surgery. This is the

result of reducing the stomach size as a way to prevent overeating and high-calorie intake.

Patients are placed on a clear liquid diet post-operative. Most patients can upgrade their diet to

soft chewable foods 2-4 weeks after surgery. Luca Busetto explained in her article, the

importance for patients to follow up with a dietician post-operative to promote positive eating

behaviors. A study by Sarwer et al, (2020) selected 84 patients who had received bariatric

surgery and enrolled them in dietary counseling for a 4-month period. Sarwer’s research showed

a slight increase in weight loss, compared to patients who did not receive dietary counseling.

While there was a slight change in weight, the major finding was the patient’s attitude toward

dieting dramatically changed. These patients reported significant positive changes in eating

behaviors. Leading to the conclusion that positive diet changes following bariatric surgery will

lead to successful weight loss long term. (Busetto, 2020).

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Bariatric Surgery vs Conventional Therapies

Over the past few decades, obesity rates are increasing significantly worldwide creating a

rise in obesity-related comorbidities. In the past, doctors have encouraged conventional medical

therapies to promote weight loss. In the recent decade, more doctors are turning to bariatric

surgeries to reduce weight. As a result, multiple Korean universities and hospitals got together to

produce a multicenter retrospective cohort study. In this study, they compared long-term results

from conventional therapies to bariatric surgery. The study followed 137 obese patients over a

72.1-month period, starting in January 2008 to February 2011. Out of the 137 patients, 49

received bariatric surgery while the remaining 88 received conventional treatment. The long-

term results revealed that bariatric surgery achieved the greatest weight reduction when

compared to conventional treatment. This study revealed that bariatric surgery alone led to a

reduction in comorbidities and significant weight loss. Overall, patients who received bariatric

surgery reported better quality of life and had prolonged lives. (Park, 2019).

Bariatric Surgery vs Type 2 Diabetes

Obesity and type 2 diabetes go hand and hand. When an individual is diagnosed with

type 2 diabetes, physicians often give them medications to control their glucose, blood pressure,

and lipids instead of being offered proper weight loss interventions and programs. Often these

medications contribute to increased weight gain, making it harder for these individuals to lose

the weight needed for proper glycemic control. Weight loss contributes to a decrease in systolic

blood pressure, an increase in HDL, a decrease in triglycerides, and many more benefits in

individuals with type 2 diabetes. According to Andrews & Chen (2014):

“1 kg of weight gained annually over 10 years is associated with a 49% increase in risk of

developing T2DM in the subsequent 10 years. In patients with T2DM a weight loss of 5–
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10% results in a 0.5% reduction in HbA1c, a 5mmHg decrease in systolic blood pressure

and diastolic blood pressure, a 0.13mmol/L increase in HDL cholesterol, and a

0.45mmol/L decrease in triglycerides. For these reasons the ADA and EASD

recommend that weight loss should be strived for in all patients who have T2DM.”

(p. 376).

Bariatric surgery paired with proper diet and exercise was found to increase remission rates of

diabetes which is defined as a return of HbA1c to less than 6.5% following an intervention that

persists for at least 3 months (Diaz, 2021). It was also found that bariatric surgery decreases the

mortality rate from type 2 diabetes, this was mainly attributed to the reduction in cardiovascular

disease due to obesity.

Conclusion

In conclusion, studies seem to show that bariatric surgery is more effective in reducing

secondary comorbidities than diet and exercise alone. However, it is important to note that

bariatric surgery alone is not sufficient in reducing the secondary comorbidities that come from

obesity. Bariatric surgery must be done alongside proper dieting and exercise to gain the most

effectiveness. Without proper diet and exercise, bariatric surgery can fail and make an individual

not lose weight and therefore not have any or very little effectiveness in reducing the secondary

comorbidities that go along with obesity, so it is extremely important to make lifestyle changes

after the surgery to achieve peak effectiveness. Dietary counseling and exercise programs for

patients are important and need to be discussed before surgery and more importantly, these

programs need to be followed through with after bariatric surgery. A lot of physicians tend to

shy away from offering bariatric surgery to patients because they feel that it is too risky.

However, as noted above this is not really true due to the frequency in which these operations are
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being done and the use of laparoscopic techniques. There are certain body weight requirements

that a person must meet to qualify for bariatric surgery, most being a BMI of 35-40 kg/m2 in

those with comorbidities or with a BMI of 40 kg/m2 regardless of comorbidities (Andrews,

2014). However, updated NICE guidelines believe that the cutoff for those with comorbidities

related to obesity such as type 2 diabetes, cardiovascular diseases, etc... should be lowered to 30

kg/m2 in order to reduce the long-term effects those diseases have on the body. In light of the

data, bariatric surgery is not a solution for weight loss on its own and is important to be paired

with proper diet and exercise to obtain maximum effectiveness in weight loss and the reduction

of comorbidities that are attributed to obesity. However, when bariatric surgery is paired with

diet and exercise, it has been found to be more effective in reducing these secondary

comorbidities than diet and exercise alone.

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Citations

Andrews, R. C., Chen, M. Z., & Logue, J. (2014). ‘Bariatric surgery for type 2 diabetes always

produces a good outcome.’ Practical Diabetes, 31(9), 376–380.

https://doi.org/10.1002/pdi.1907

Bettini, S., Belligoli, A., Fabris, R., &amp; Busetto, L. (2020, September). Diet approach before

and after Bariatric Surgery. Reviews in endocrine &amp; metabolic disorders. Retrieved

March 26, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455579/

Brandao, C.F.C., Nonino, C.B., de Carvalho, F.G. et al. The effects of short-term combined

exercise training on telomere length in obese women: a prospective, interventional study.

Sports Med - Open 6, 5 (2020). https://doi.org/10.1186/s40798-020-0235-7

Cheah, S., Gao, Y., Mo, S., Rigas, G., Fisher, O., Chan, D. L., Chapman, M. G., &

Talbot, M. L. (2022). Fertility, pregnancy and post partum management after Bariatric

Surgery: A narrative review. Medical Journal of Australia, 216(2), 96–102.

https://doi.org/10.5694/mja2.51373

Chiu, CH., Ko, MC., Wu, LS. et al. Benefits of different intensity of aerobic exercise in

modulating body composition among obese young adults: a pilot randomized controlled

trial. Health Qual Life Outcomes 15, 168 (2017). https://doi.org/10.1186/s12955-017-

0743-4

Diaz, D. (2021, August 30). International experts outline diabetes remission diagnosis

criteria. International Experts Outline Diabetes Remission Diagnosis Criteria | ADA.

Retrieved March 26, 2022, from https://www.diabetes.org/newsroom/press-

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releases/2021/international-experts-outline-diabetes-remission-diagnosis-

criteria#:~:text=1.,of%20usual%20glucose%2Dlowering%20pharmacotherapy.

Gasmi, A., Bjørklund, G., Mujawdiya, P. K., Semenova, Y., Peana, M., Dosa, A.,

Piscopo, S., Gasmi Benahmed, A., & Costea, D. O. (2021). Micronutrients deficiences in

patients after bariatric surgery. European Journal of Nutrition, 61(1), 55–67.

https://doi.org/10.1007/s00394-021-02619-8

Park, J. Y., Heo, Y., Kim, Y. J., Park, J.-M., Kim, S.-M., Park, D.-J., Lee, S. K., Han, S.-M.,

Shim, K.-W., Lee, Y. J., Lee, J. Y., &amp; Kwon, J.-W. (2019, June). Long-term effect of

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