ABSTRACT
To understand the impact of bariatric surgery, one must keep in mind that morbid obesity is a disease, a disease that creates an intolerable infirmity, and a disease for which the sole efficient treatment is surgical. Surgery is needed, not so much because the amount of weight to be lost is so important but because the treatment needs to be maintained for life. Losing weight, for these patients, is difficult but it can be done successfully by various means. Maintaining weight loss, on the other hand, is practically impossible without surgical help. As soon as food intake exceeds what is necessary for the basic metabolism, fat will accumulate. These patients have lost their normal capacity for disposing excess calories in ways other than storage as fat. Normally weight tends to remain stable despite the great variability in food intake (1). This is due to complex mechanisms (2-4) by which extra calories are disposed of in ways other than storage. These mechanisms are faulty in these patients. For each and every day, if calorie intake exceeds the minimum energy expenditure, which is about 1300 kcal for these patients after surgery (5-7), fat will reaccumulate and progressively morbid obesity will recur. The restriction of food needs to be permanently so severe that it is not possible for these people. To blame someone for not succeeding is totally unfair. In our societal environment with its strong cultural norm of at least three meals a day, constant incentives to eat, and the heavy accent on food attractiveness, it is impossible to go through life without exceeding basic needs unless it is forcefully imposed by mechanical means or by induced aversion. The only other approach would be to decrease intestinal absorptive capacity.
