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April 9, 2003

Bariatric Surgery for Morbid Obesity—Reply

Author Affiliations

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;289(14):1779. doi:10.1001/jama.289.14.1779-a

To the Editor: I would like to comment on 2 aspects of Dr Brolin's Contempo Updates article about bariatric surgery and long-term control of morbid obesity.1 First, the mechanism by which bariatric surgery induces weight loss is probably related to a complex interplay between mechanical effects of the surgery and neurohormonal feedback loops involved in body weight homeostasis. It is sometimes asserted that the surgical creation of a small gastric pouch restricts food intake and thereby causes weight loss because patients are forced to eat less. The additional effect of mild malabsorption is said to further reduce dietary energy intake. These effects alone, however, are probably insufficient to explain the profound clinical effects of bariatric surgery. On the basis of current understanding of body weight homeostatic feedback loops,2 weight loss resulting merely from mechanical restriction of food intake alone (or in combination with mild malabsorption) would be associated with amplification of hunger and food-seeking behavior, as well as increased energy efficiency, both of which are mediated in part by the hypothalmus. In contrast to this scenario, patients who undergo bariatric surgery actually have depressed appetite during profound weight loss.3,4 Thus, they seem to lose weight because of an alteration in hypothalamic regulation of appetite and body weight in addition to mechanical restriction of food intake.

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