Why is there no surgery for visceral fat

[Bohandas]

Why is there apparently no liposuction-style surgery for removing the deeper masses of fat that actually cause obesity related illness? I understand that this would be significantly more invasive but I would think that in sufficiently severe cases the risk might be warranted.

[Maat Mons]

My understanding is that, if you remove a quantity of fat from one location, given time, the remaining fat will redistribute itself into back into a more natural arrangement. I could be wrong though. I'm not a doctor, and I'm just going by vague recollections of things I read a long time ago.

[Anymage]

From a quick google, I'm wondering how much room there is between "you're not quite at the point of needing invasive surgery on tissue surrounding your major organs, let's try diet and medicine first" and "you're in really bad shape, I don't know that it's safe to perform invasive surgery on tissue surrounding your major organs".

[Mastikator]

The patient might think the risk is warranted, the surgeon is faced with a trolley problem of sorts where they might increase the lifespan on the patient or kill them, or do nothing and relinquish responsibility. I think surgeons want to avoid risky procedures on patients that won't die in the next 1-5 years for morality and career reasons.

I empathize with them, I wouldn't want to be known as the guy who indulged a patient and got them killed.

[halfeye]

The patient might think the risk is warranted, the surgeon is faced with a trolley problem of sorts where they might increase the lifespan on the patient or kill them, or do nothing and relinquish responsibility. I think surgeons want to avoid risky procedures on patients that won't die in the next 1-5 years for morality and career reasons.

I empathize with them, I wouldn't want to be known as the guy who indulged a patient and got them killed.

I suspect it may be worse than that for the surgeon, if someone loses weight by diet or exercise, they possibly get rid of some of the fat from their arteries too, but if they lose fat via liposuction, the fat in the arteries remains, so liposuction is purely cosmetic and really they are effectively still fat with most of the health risks remaining.

[Gnoman]

I suspect it may be worse than that for the surgeon, if someone loses weight by diet or exercise, they possibly get rid of some of the fat from their arteries too, but if they loose fat via liposuction, the fat in the arteries remains, so liposuction is purely cosmetic and really they are effectively still fat with most of the health risks remaining.

One of the biggest health risks from being fat is that excess weight makes it very hard to exercise, not to mention the possibility of fat deposits putting pressure on your internal organs. Even "purely cosmetic" liposuction can alleviate that problem.

[halfeye]

One of the biggest health risks from being fat is that excess weight makes it very hard to exercise, not to mention the possibility of fat deposits putting pressure on your internal organs. Even "purely cosmetic" liposuction can alleviate that problem.

I thought about going with "all" but left it at "most" for exactly that reason.

[Tyndmyr]

One of the biggest health risks from being fat is that excess weight makes it very hard to exercise, not to mention the possibility of fat deposits putting pressure on your internal organs. Even "purely cosmetic" liposuction can alleviate that problem.

The pressure is almost entirely from fat that is deposited around organs, liposuction can't touch that.

As for exercise, you can't outrun a fork. Anyone can lose weight, and while exercise is great, being large means that your baseline maint level of calories is comparatively high. Eat less, and you'll bleed weight. Again, liposuction is mostly irrelevant to this.

[Bohandas]

From a quick google, I'm wondering how much room there is between "you're not quite at the point of needing invasive surgery on tissue surrounding your major organs, let's try diet and medicine first" and "you're in really bad shape, I don't know that it's safe to perform invasive surgery on tissue surrounding your major organs".

That makes sense

As for exercise, you can't outrun a fork. Anyone can lose weight, and while exercise is great, being large means that your baseline maint level of calories is comparatively high. Eat less, and you'll bleed weight. Again, liposuction is mostly irrelevant to this.

This tangentially raises the issue of the various stomach surgeries intended to make people eat less and the question of why they seem to be preferred over something like short bowel resection (shortening of the small intestine) which would have the same effect by a different route, reducing food absorbed rather than food eaten. This strikes me as preferable by dint of being less disruptive; instead of changing one's eating habits, merely changing the effect that those eating habits have. So why isn;t that the preferred surgery?

[Anymage]

This strikes me as preferable by dint of being less disruptive; instead of changing one's eating habits, merely changing the effect that those eating habits have. So why isn;t that the preferred surgery?

Short gut syndrome. Stomach reducing surgeries just make people feel full sooner while not meaningfully changing what they eat. Removing a portion of intestine can lead to malnutrition, difficulty processing certain foods, and several uncomfortable bathroom issues.

[Eldan]

Also, we're now actually making quite decent progress with appetite-reducing drugs. They are still super expensive and supply is limited, but they are freely available in some countries for the severely obese, and they seem to work. People (those where it works) seem to lose most of their interest in food, stop snacking and overeating, and some even lose their preference for one type of food over another, they'll just eat anything to get their required nutrients.

[Zombimode]

Also, we're now actually making quite decent progress with appetite-reducing drugs. They are still super expensive and supply is limited, but they are freely available in some countries for the severely obese, and they seem to work. People (those where it works) seem to lose most of their interest in food, stop snacking and overeating, and some even lose their preference for one type of food over another, they'll just eat anything to get their required nutrients.

I know the medical context here, but taken out of context this sounds like a fate worse then death

[Murk]

People (those where it works) seem to lose most of their interest in food, stop snacking and overeating, and some even lose their preference for one type of food over another, they'll just eat anything to get their required nutrients.

I know the medical context here, but taken out of context this sounds like a fate worse then death

Gee, no, I would absolutely take that deal.
I'm not overweight, but that's only because I constantly fight my urges to eat more. That urge is always on the back of my mind and it can get very distracting, and exhausting.

I've found that intermittent fasting / one-meal-a-day helps, because it brute-forces the realization that food isn't happening. But still, there are always thoughts of food nagging around in my brain and it's really annoying. I would happily trade my enjoyment of food for losing the constant, neverending urge to eat.

I would have gone cold-turkey on food long ago if that wouldn't kill me.

[Eldan]

My brother actually got some, because he was in the "life-threateningly obese" part of the spectrum. Even with health insurance (which is pretty comprehensive in this country) he still had to pay several hundred per injection. Lost a solid amount of weight, though.

The problematic thing is that you can't really stop the injections, or the weight comes back.

[Bohandas]

Short gut syndrome. Stomach reducing surgeries just make people feel full sooner while not meaningfully changing what they eat. Removing a portion of intestine can lead to malnutrition, difficulty processing certain foods, and several uncomfortable bathroom issues.

It seems like the most serious side effects are easily treatable with vitamin and mineral supplementation, immodium, and plenty of water. So still a heck of a lot easier than good diet and exercise.

[Tvtyrant]

My brother actually got some, because he was in the "life-threateningly obese" part of the spectrum. Even with health insurance (which is pretty comprehensive in this country) he still had to pay several hundred per injection. Lost a solid amount of weight, though.

The problematic thing is that you can't really stop the injections, or the weight comes back.

As someone who lost a 170lbs in their late 20s, I can safely say losing the weight is the most important part. I did it by doing keto and making an oath to kill myself if I didn't, while a pill seems a lot safer. Once the weight is lost its a lot easier to exercise and find better lifestyle choices.

[Tyndmyr]

The problematic thing is that you can't really stop the injections, or the weight comes back.

That's almost any behavior change. If you go back to the lifestyle that made you fat the first time, it'll make you fat again.

That's why it's hard. Diet, exercise, drugs, whatever...you do them for a bit, then stop and go back to what you were doing before, then yeah, obviously the thing you're not doing isn't going to help. Gotta build better long term habits. If drugs help someone do that, fair enough. Everyone's path is a little different.

[halfeye]

That's almost any behavior change. If you go back to the lifestyle that made you fat the first time, it'll make you fat again.

That's why it's hard. Diet, exercise, drugs, whatever...you do them for a bit, then stop and go back to what you were doing before, then yeah, obviously the thing you're not doing isn't going to help. Gotta build better long term habits. If drugs help someone do that, fair enough. Everyone's path is a little different.

Especially since obesity actually is a viral disease. We could probably cut back the endemic virus, and then everyone who had never been infected could eat as much as they want and not get as fat. However then we'd need about two and a half times as much food in the world, so that wouldn't be a good idea. Thus we have sensible emotional food requirements that aren't actually that well adjusted to what we actually need to eat to avoid putting on weight.

https://en.wikipedia.org/wiki/Adenovirus_serotype_36

[georgie_leech]

Especially since obesity actually is a viral disease. We could probably cut back the endemic virus, and then everyone who had never been infected could eat as much as they want and not get as fat. However then we'd need about two and a half times as much food in the world, so that wouldn't be a good idea. Thus we have sensible emotional food requirements that aren't actually that well adjusted to what we actually need to eat to avoid putting on weight.

https://en.wikipedia.org/wiki/Adenovirus_serotype_36

That reads an awful lot more like "this virus can cause weight gain" than "obesity is a viral disease." Particularly stuff like "present in 30% of obese humans and 11% of nonobese humans.["

[Bohandas]

That's almost any behavior change. If you go back to the lifestyle that made you fat the first time, it'll make you fat again.

That's why it's hard. Diet, exercise, drugs, whatever...you do them for a bit, then stop and go back to what you were doing before, then yeah, obviously the thing you're not doing isn't going to help. Gotta build better long term habits. If drugs help someone do that, fair enough. Everyone's path is a little different.

And that was my point regarding the intestinal shortening surgery idea. It doesn't rely on behavior change. Instead of imperiously trying to change the patient;s eating habits it would just stop most of the food from being absorbed. They'd need to eat 6000 calories or whatever per day. Granted, they'd also need a vitamin supplement and they'd have to go to the bathroom more often because of the first law of thermodynamics but that stuff's not even close to as big of an imposition as good diet and exercise.

[halfeye]

That reads an awful lot more like "this virus can cause weight gain" than "obesity is a viral disease." Particularly stuff like "present in 30% of obese humans and 11% of nonobese humans.["

I won't deny that there are probably other causes of obesity, but I'd guess that they are rarer and secondary.

However, it seems that having this infection fully once is enough to make you obese for life.

Some people develop immunity to viruses fast enough that they don't get the disease, and that's my take on the 11%.

On the other hand, if obesity drives up your calorie usage, maybe everyone eating more but staying slim wouldn't be an environmental disaster?

[Maat Mons]

However, it seems that having this infection fully once is enough to make you obese for life.

Got a source on that? I happened across this while perusing the sources of that Wikipedia article.

Animals that developed the virus remained obese up to six months after their infection was gone.

Granted that does establish that the effects can outlast the virus. But it also suggests the effects aren't typically permanent. These are, of course, animal studies, which can easily differ from the results in people. Are their any studies pointing to lifelong effects?

[Batcathat]

I won't deny that there are probably other causes of obesity, but I'd guess that they are rarer and secondary.

Even if we assume that it's the primary cause in everyone that's been infected with it (rather than just a contributing factor), that still leaves 70 percent not infected at all, which seems like a lot.

[halfeye]

Got a source on that? I happened across this while perusing the sources of that Wikipedia article.



Granted that does establish that the effects can outlast the virus. But it also suggests the effects aren't typically permanent. These are, of course, animal studies, which can easily differ from the results in people. Are their any studies pointing to lifelong effects?

Just that nobody that I've ever heard of stopped struggling with their weight once they start struggling with their weight (I've heard cancer does it, but that's a very extreme as a cure for obesity).

[Tyndmyr]

That reads an awful lot more like "this virus can cause weight gain" than "obesity is a viral disease." Particularly stuff like "present in 30% of obese humans and 11% of nonobese humans.["

Agreed.

Genetic factors have been found to be relatively minor, and while there are other medical issues that sometimes can influence things, mostly it's a habit thing, combined with a historically unusual availability of high calorie foods. Humanity didn't really develop with a McDonalds always available.

The "it's all a disease" hypothesis doesn't hold up terribly well. When the western diet gets popularized in a country, the obesity follows. When it doesn't, people largely remain at a normal weight. This is true even if significant trade exists between those countries, which would be a vector for disease.

And that was my point regarding the intestinal shortening surgery idea. It doesn't rely on behavior change. Instead of imperiously trying to change the patient;s eating habits it would just stop most of the food from being absorbed. They'd need to eat 6000 calories or whatever per day. Granted, they'd also need a vitamin supplement and they'd have to go to the bathroom more often because of the first law of thermodynamics but that stuff's not even close to as big of an imposition as good diet and exercise.

Surgery of any sort has risks, and the side effects are a problem. Particularly as people get older, they can have difficulty in eating large quantities of food, so at that point, it might be a very undesirable change indeed. Generally major, invasive surgeries are avoided where less intrusive measures are available. The medication based approach is a little less risky. Basically, it slows down one's digestive process so one simply cannot eat so often, and also you don't feel the need to eat quite so often.

The main moral quandary there is that the primary use is for managing diabetes, and the weight loss application has been so popular that it sometimes makes finding the supply difficult for the diabetics. Which...isn't great, but managing weight is also super important and staves off a lot of risk. Here's hoping they sort out the supply issues, I guess.

Just that nobody that I've ever heard of stopped struggling with their weight once they start struggling with their weight (I've heard cancer does it, but that's a very extreme as a cure for obesity).

This isn't completely true, but there is a strong tendency. The same is true for other habit-based problems. Someone gets in the habit of smoking or drinking hard for a few years, it's something that can be overcome, but it ain't easy, and they'll feel the pull back to the old habits for a long time, maybe always. Changing habits is hard.

[Batcathat]

This isn't completely true, but there is a strong tendency. The same is true for other habit-based problems. Someone gets in the habit of smoking or drinking hard for a few years, it's something that can be overcome, but it ain't easy, and they'll feel the pull back to the old habits for a long time, maybe always. Changing habits is hard.

Amen to that. I stopped smoking over eight years ago, so any physical dependency is long gone, but I still frequently get jealous when I see someone smoke.

On the plus side, I sort of exploited the same tendency to go from basically never exercising to doing it daily. At least for me, it feels like adding a new habit, whether a good or bad one, is way easier than removing one.

[Darth Credence]

I take Mounjaro for diabetes and have for the past six months. In that time, I've lost about 70 pounds.

When I was first diagnosed and began treatment, I discussed with a nurse diet, exercise, and the use of the drug. As she was explaining what it would do, she said that if I had that little voice in my head telling me to eat all the time, the drug would likely shut it up.

I was flabbergasted. Yes, I had that little voice. I got up in the morning and started looking for breakfast. Then I was like the pigs in "A Muppet Christmas Carol" that asked what they should do next after just finishing breakfast, and one of them suggests lunch. I'd start planning what to have for lunch and looking forward to it. Right after, I was planning dinner. When she said that, I started to review and realized I think about food more than anything else, and it is a constant in my mind. I started asking people about this, and none of the thin people I know had any idea what I was talking about, while most of the fat people I know knew exactly what I meant.

Then I took Mounjaro. And the voice stopped. I get up in the morning, and don't think about food. I have some fruit with my coffee, because the nurse told me I have to eat certain amounts. I will forget that it's time for lunch, and just end up not eating. If I was single and wasn't cooking at home, I know I'd do the same with dinner. And I went from regularly eating 2000-2500 calories, and that was what control I had, to not wanting more than 1000 a day, and having to push to get enough carbs to keep things functioning. I still like some foods over others, and still can't stomach broccoli or cauliflower, but the number of things I enjoy the taste of has gone way up (I never knew roasted carrots were so good!).

So if you are talking "easy", in my experience this couldn't be easier. Surgery that meant I could eat anything I wanted but had some nasty bathroom issues would be far worse. Any surgery would be worse, because I'd have to go through surgery, and nothing about any of them indicates they would be more effective than a shot every week is (and I looked into them). The answer to the title question now, regardless of what it may have been in the past, is that there are less invasive methods that would do a long-term better job of achieving the results. If it's cosmetic, you want to remove the subcutaneous fat, and if it's health-related, get there by diet and the right meds.

[Bohandas]

The one thing I don't understand about things like orlistat pills or intestinal bypass surgery or anything else that prevents absorption is why they should cause diarrhea as a side effect specifically. I understand why they would cause the patient to use the bathroom more often - if less is absorbed more must come out that's basic thermodynamics - but why should the consistency be intractibly changed? I would think at the worst you would be a need to add something to make the fat clump up

[Tvtyrant]

The one thing I don't understand about things like orlistat pills or intestinal bypass surgery or anything else that prevents absorption is why they should cause diarrhea as a side effect specifically. I understand why they would cause the patient to use the bathroom more often - if less is absorbed more must come out that's basic thermodynamics - but why should the consistency be intractibly changed? I would think at the worst you would be a need to add something to make the fat clump up

The lower intestine removes moisture, so if you shorten the intestine it never clumps.

[halfeye]

The lower intestine removes moisture, so if you shorten the intestine it never clumps.

I was under the impression it was the upper intestine they were shortening.