Gastric bypass poses concerning risk for alcohol problems, study says
By Jill Daly, Pittsburgh Post-Gazette
May 30, 2017
Digging deeper than previous research, a study that followed weight-loss surgery patients over seven years found those who had Roux-en-Y gastric bypass had twice the risk of developing “alcohol use disorder” than those who had gastric banding instead.
More than 2,000 patients from 10 hospitals and six clinics were questioned about their addictive behaviors in the study, published recently in the journal Surgery for Obesity and Related Diseases. Bariatric professionals have expressed concern that some patients who had no problems with alcohol were developing them after bypass surgery, either for the first time or as a relapse. The definition of alcohol use disorder — in the updated Diagnostical and Statistical Manual of Mental Health Disorders (DSM-5) — ranges from mild problems with drinking to the most severe cases of alcoholism.
“I don’t think this should dissuade people from getting surgery … if someone feels they’re a good surgical candidate,” said the study’s lead author, epidemiologist Wendy C. King, Ph.D., of the University of Pittsburgh Graduate School of Public Health. “I would caution them against alcohol consumption — or [suggest] close monitoring.”
Bariatric surgery is considered the most effective treatment for severe obesity, usually defined as a body mass index of 40 or higher. The surgery can improve a patient’s other serious health conditions, including Type 2 diabetes, Ms. King pointed out.
In the Roux-en-Y, a small part of the stomach is used to make a pouch and this smaller stomach is connected directly to the middle part of the small intestine, bypassing the rest of the stomach and the upper part of the small intestine. It’s less space where nutrients are absorbed, which makes it different than laparoscopic adjustable gastric banding. Lap banding creates a smaller stomach with a thin, inflatable ring wrapped around the upper portion of the stomach.
In results reported in 2012 from the National Institutes of Health-funded study, alcohol use disorder was found to be more prevalent in the second year after surgery than in the first year or beforehand. The study found the Roux-en-Y “doubled the likelihood of postoperative AUD compared to [lap banding].”
In the seven-year follow-up, Ms. King said, “We wanted to look at those who didn’t have problems in the year before surgery. We found that within five years of surgery, about 1 in 5 patients who underwent Roux-en-Y had symptoms [of alcohol use disorder]. Only 1 in 10 had the symptoms following banding. This is accumulative incidence. If they report it year after year, it counted. The Incidence kept climbing.”
Patients were questioned about their alcohol drinking habits with a 10-question survey about drink amounts, frequency and behavior such as whether a person is able to stop drinking, if drinking has caused a failure to meet expectations or if it caused feelings of remorse. Participants were also asked if they used illicit drugs (except opioids) or had received counseling or hospital treatment in the past 12 months, including treatment for alcohol/drug abuse.
The first round of questions and assessments was before surgery. Annual follow-ups ended Jan. 31, 2015. Although gastric sleeve surgery is now the most common bariatric surgery, it was not in 2006 when the study first recruited participants and was not included in the comparison.
Before surgery, 97 out of 1,469 (6.6 percent) in the Roux-en-Y group had some alcohol use disorder symptoms; 36 out of 519 (6.9 percent) in the banding group reported symptoms.
By the fifth year, the cumulative reports of alcohol use disorder, illicit drug use and substance use treatment rose to 20.8 percent, 7.5 percent and 3.5 percent, respectively, for the Roux group. In the banding group, the reports were 11.3 percent, alcohol use disorder; 4.9 percent, illicit drug use; and .9 percent, substance use treatment. Alcohol consumption doubled in the seven years after both types of surgery, the study reported.
Factors associated with a greater risk of developing alcohol use disorder and illicit drug use after surgery were “males and younger adults and those who smoke and who reported consuming alcohol regularly,” Ms. King said, “also those with less social support.”
Two “addictive” behaviors — binge eating and out-of-control eating — have been cited as related to the observed higher alcohol consumption. However, the long-term study found food-addiction behaviors were not associated with substance use disorder (alcohol and/or drug use) that was reported after surgeries.
A co-investigator in the study until he left UPMC in 2013, Allegheny Health Network bariatric surgeon George M. Eid said there have been two theories about alcohol problems after surgery.
“Some think it’s food addiction … that when you do bariatric surgery you’re trading one addiction for another.”
He said studies have shown after bypass, alcohol is absorbed at a higher level and faster and patients say they feel its effects more.
“Some data says the effect of one glass before surgery feels like four glasses after surgery,” Dr. Eid said. Drinking more in both groups in the seven-year study supports the theory that some patients enjoy the effects of drinking and some are feeling more social after weight loss, he said.
“In my opinion, it’s multifactorial — absorption, more social openness.”
Reduced nutrient absorption because of the bypass may also be a factor, said research psychologist Melissa A. Kalarchian, Ph.D., a co-author of the follow-up study and now at Duquesne University. Binge eating before surgery and amount of weight loss were not related to substance use after, she said.
The study recommends that future research explore post-surgery changes in the endocrine system, possibly involving the appetite-related hormone ghrelin, as a risk factor for substance use disorder.
Since the earlier research that found the risk was higher after Roux-en-Y, the American Society for Bariatric Surgery has recommended screening before surgery and making patients aware of the risk. High-risk groups are advised to abstain from drinking alcohol after the bypass surgery.
“This recent study [concerns] anybody who undergoes Roux-en-Y bypass,” Ms. King said. “I would advocate for stronger recommendation for abstaining, for anyone who gets a Roux-en-Y bypass. We need the word to go out to primary care physicians. Those doctors really have to know how to screen.” And if treatment is needed, to recommend it, she added.
Study authors cited the size and diversity of the groups of patients studied and the length of the follow-up — gathering detailed data — as its strengths.
“I think this is one of the largest, most comprehensive studies to date,” Ms. Kalarchian said. Among limitations of the study are the comparison with the outdated banding method, she said, and patients weren’t given full clinical evaluations — the study relied on patients’ own reports of alcohol and drug use.
The increase in alcohol consumption in both surgery groups is a concern, Ms. King said. “It may affect weight loss, dumping syndrome [food passing too rapidly through the stomach] and vitamin deficiency. Those are all concerns with heavy drinking. Because we have more people drinking regularly … we strongly support a routine assessment for alcohol use disorder.”
Dr. Eid said long-term followup is recommended as part of the AHN bariatric surgery program. He said obesity experts worldwide are concluding that obesity is a chronic relapsing disease and it calls for continuing care.