Published On: Tue, Jul 31st, 2012

The Wisdom of Alcohol Consumption after Weight Loss Surgery

by Dr. Connie Stapleton, PhD.

The Journal of the American Medical Association (JAMA) recently published a study about it, an MSNCB reporter wrote about it, professionals at well-known institutions affiliated with weight loss surgery are commenting about it, KENS5 in Austin did a broadcast on it, CNN is writing about it, and Dr. Drew had an entire show dedicated to it: alcohol use by surgical weight loss patients. 

Why, all of a sudden, is this topic in the news? 

 Some better questions may be: “Why hasn’t it been addressed in a public manner before now?” It’s certainly not a new concern. 

And why is there so much discrepant information being given to surgical weight loss patients by the bariatric surgeons and other health care professionals about the use of alcohol after weight loss surgery?

How do the bariatric patients hear and interpret what the doctor says about the use of alcohol after weight loss surgery? 

And most importantly, what are the facts about alcohol use after weight loss surgery?

 There’s the information “in the news” and then there’s what’s actually being said, done and seen in the “real world” of bariatric patients. I work intensively in the real world of real people who have had weight loss surgery. As a licensed psychologist who, for the past twenty years, has been certified as an addiction specialist, I have spent the past decade working with weight loss surgery patients, conducting well over 3000 pre-surgical evaluations. In addition, I lead a therapy group for post-operative patients and see many for individual counseling. I have spoken at national conferences for surgical weight loss patients during the past several years. What I have heard from patients (about what their doctors have told them – or, in some cases – neglected to tell them about alcohol after weight loss surgery, and what they tell me about their own experiences with alcohol), in addition to what I have observed regarding the consumption of alcohol by surgical weight loss patients, has me frustrated and concerned. 

Serendipitously, my business partner, Cari De La Cruz (a 2007 bariatric post-op)  and I were in the process of putting together a program called Straight Talk from A Post Op & A Doc: Alcohol and WLS, and literally while we were handing out a pamphlet to bariatric surgeons and other health care professionals at the American Society for Metabolic and Bariatric Surgery (ASMBS) conference last month, the media buzz began. It was at the ASMBS conference that the JAMA article, entitled Prevalence of Alcohol Use Disorders Before and After Bariatric Surgery, was introduced by one of the researchers to conference attendees. I also spoke to professionals at the ASMBS conference on the topic of food as an addictive substance. 

 Following the JAMA article, several media sources began commenting on the research presented in the journal and at the medical conference. Brian Alexander wrote a piece entitled Weight-loss Surgery Linked to Higher Risk of Abusing Alcohol, which appeared in VITALS on MSNBC.com. (http://vitals.msnbc.msn.com/_news/2012/06/18/12244563-weight-loss-surgery-linked-to-higher-risk-of-abusing-alcohol?lite)

 The article began with the words, “In a last ditch effort to lose weight, roughly 113,000 people subject themselves to bariatric surgeries such as stomach banding and gastric bypass every year in the United States.” Talk about inflammatory! The author makes it sound like obese patients are completely out of options for weight loss, so they toss a “Hail Mary” pass halfway down the field and hope the ball will land somewhere near the end zone. That is, of course, only after they submit to a draconian surgical procedure performed in an unmarked building in the bad part of town…

 Rhetoric aside, Mr. Alexander did move on to some helpful information stemming from the JAMA article, if people read far enough into his piece following the offensive beginning. He noted, “Some of those patients may be trading pounds for an alcohol problem, according to a new study … The percentage seems small… but that translates into about 2,000 more people [per year] with an alcohol use disorder…” (Alcohol Use Disorder or AUD = alcohol abuse or alcohol dependence).  

 As noted in the actual article from JAMA the “potential” increase in people with AUD disorders in the US each year, brings with it the “accompanying personal, financial, and societal costs.” 

Alcohol is, according to the American Council for Drug Education, “the oldest and most widely used drug in the world.” It results in enormous costs to our country, as does obesity. It would seem that a population (weight loss surgery patients), who has suffered tremendously from “personal, financial and societal costs” related to their obesity, need not acquire similar problems due to an alcohol use disorder during or after their weight loss. Why, then, do so many post-op patients develop alcohol use disorders after weight loss surgery?

As with most things, the answer is, “It’s complicated.” One of the findings by the researchers featured in the JAMA article, found that alcohol use disorders were greater for patients having the Roux-en-Y gastric bypass procedure, in which there is physiological malabsorption.  This malabsorption results in a quicker “buzz” from alcohol, which lasts longer. Perhaps these two effects reinforce the use of alcohol.  

Another contributing factor to the increase in AUD’s after weight loss surgery, as noted in the Brian Alexander article, is explained by Leslie Heinberg, the director of behavioral services for the Bariatric and Metabolic Institute of the Cleveland Clinic. She stated: When formerly obese people lose a lot of weight, they gain confidence, feel attractive, and may have more opportunity to socialize and drink.” The increase in alcohol consumption, she was reported to say, “may be an unintended consequence of doing a heck of a lot better.”

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A third potential reason for the increase in AUD’s may stem from the contradictory messages patients receive from bariatric surgeons and other health care professionals about drinking alcohol after weight loss surgery. I was curious to hear what patients remembered hearing from their doctors, so I asked Cari to post a question to weight loss surgery patients about what their surgeon told them about consuming alcohol after surgery. The responses included, “Only drink on special occasions.” “No alcohol for 6 months.” “No alcohol for a one year.” “Drink in moderation.” What many patients hear is, “It’s okay for me to drink alcohol. The doctor said so.”

 Ironically, patients are told in no uncertain terms: “No carbonated beverages.” “No liquids with your meals.” “No straws.” “No NSAIDs.” “No chewing gum.” “No beverages with sugar or corn syrup.” But alcohol? Guess there’s no problem with that! Unless one considers the facts about alcohol… for a surgical weight loss patient.

A report by Wendy Rigby (KENS 5) from San Antonio also began with quotes from the JAMA article, and was accompanied by a video interview with Dr. Richard Peterson. Dr. Peterson is a bariatric surgeon at the UT Weight Loss Clinic in Westover Hills. He emphasizes the importance of doctors talking about alcohol use with the bariatric patients. He notes that he counsels his patients on the risk ahead of time. “Don’t drink too much,” is the counsel he provides, as quoted from the video. (http://www.kens5.com/news/health/Gastric-bypass-tied-to-increased-risk-of-alcoholism-160879515.html)

I’m wondering exactly what Dr. Peterson considers “too much,” and if he realizes he is basically telling people, “It’s ok to drink alcohol after weight loss surgery.” Dr. Peterson (and all other health care professionals), let us ask you this: How much cake is “too much” after weight loss surgery? How many cookies are “too many?” How many non-nutritive, empty calories – particularly those that are actually poison – are “too many?”

 Dr. Peterson, in regard to discussing alcohol use with patients prior to the surgery stated, “We really talk about it beforehand, so I think making individuals aware of it before, once you’re aware of something you actually have a tendency to avoid it.” This statement rings hollow on so many levels. To begin with “moderation” and “avoidance” are not traditionally virtues demonstrated by the average obese person, so the idea of “warning them” about the “potential” for negative repercussions makes about as much sense as putting warning labels on cigarette packages. Does anyone really think a wag of the finger, picture of skull and crossbones, or mild warning is going to be enough to keep a person obediently tethered to the road of absolute health?

 Anita Courcoulas, professor of surgery and chief of minimally invasive bariatric and general surgery at the University of Pittsburgh Medical Center, who was a co-author of the study presented in JAMA, as quoted in the Brian Alexander article: “Importantly, she said in an email to msnbc.com, bariatric surgery patients should be monitored closely for long periods of time for signs and symptoms of alcohol use disorders and should consider counseling after bariatric surgery.” A Post Op & A Doc say, “Thank you, Dr. Courcoulas! We wholeheartedly agree!

 Another possible reason for an increase in alcohol use disorders following weight loss surgery, was discussed by Dr. Peterson from Austin and by Dr. Drew on his HLN show dedicated to the topic of Alcohol after Weight Loss Surgery. Dr. Peterson stated that people with food addictions often transfer those addictive tendencies to other habits like drinking.  

 Dr. Drew interviewed a post-operative patient during the show, and other patients called in to the show, discussing their use of alcohol after weight loss surgery. These patients discussed their backgrounds of childhood trauma of various kinds, including having alcoholic parents or significant people who had a variety of addictions, or having experienced other trauma or abuse in childhood.  About his obesity, one man stated, The doctor’s were treating a symptom, not really the core issue. And since the core issue had never been treated, then I was susceptible to other things taking it’s [foods] place.” 

Dr. Drew responded by stating, “… traumatic events happen in childhood, and if you have the genetics of addiction there, whether it’s substance or eating, [it] is a bid to regulate emotions that are too prolonged, too intense, and too negative. When we correct the food problem, the emotional disregulation is still there, now we have a plumbing situation that increases the effects of alcohol and, pow, off it goes.” 

 What Dr. Drew is saying is that if people who have a propensity for addiction have experienced trauma or abuse in their childhood, they are vulnerable to exchanging the use of food as an “addictive substance” for another substance (such as alcohol) or behavior (shopping, gambling, sex) as an addictive substitute. The purpose of these “addictions” for many people is a form of coping with unpleasant experiences and/or memories. When this is the case for a surgical weight loss patient, food is no longer an option in terms of overeating to the point of emotional numbing, and the person engages in an alternative method of emotional numbing. What would help them, rather than continue to harm them, would be to work through the emotional issues in therapy. 

The Facts about Alcohol

To begin with, alcohol is a poison to our bodies. It is detrimental to our brain, our heart, our liver, and our pancreas. It increases the changes of numerous forms of cancer (Mouth, Esophagus, Throat, Liver, Breast). Additionally, alcohol consumption can weaken one’s immune system. 

For surgical weight loss patients, regardless of what type of procedure they had, there are additional considerations to consider when it comes to opting to consume alcohol. To begin with the obvious, alcohol has no nutritional value whatsoever. And it has lots of empty calories, almost all of which are simple carbohydrates. The food plan for surgical weight loss patients, after they have fully healed physically, is that their diet plan needs to be high in protein and low in simple carbohydrates. It seems to us that alcohol, which offers nothing in terms of nutritional value, plays no role in the lives of people who underwent weight loss surgery to save their lives.

Nutritionists and doctors don’t give the “ok” for weight loss patients to eat cake or pie or other high calorie, non-nutritive foods. We realize they don’t “forbid” those foods, either!  The premise remains the same for all non-nutritive, empty calories for people who most often say, during the pre-surgical evaluation, that they are willing “to do whatever it takes” to keep the weight off after surgery: what’s the point?

 Not only is alcohol non-nutritive and therefore an unhealthy decision for post-ops, there are results of alcohol that can lead to additional unhealthy decisions

Alcohol results in impaired judgment, which could lead to consuming unhealthy foods that one would not eat when sober. Additionally, it may lead to eating those unhealthy foods in greater quantities than is wise for a surgical weight loss patient. Other behaviors that could result from impaired judgment, which a percentage of this population is vulnerable to, is engaging in sexual behaviors they might not if they had not been drinking. Why are they vulnerable to this? Because many patients share they never had the courage or the opportunity to experiment sexually in their young adult years. After losing weight, some people wish to experience this aspect of their lives. They may even opt to drink alcohol for the express purpose of helping them lower their inhibitions

Surgical weight loss patients who have the Roux-En-Y procedure, experience malabsorption issues, whereas those who have a Vertical Gastric Sleeve or LapBand procedure do not. 

The researchers who published in JAMA and presented their findings at this year’s ASMBS meeting, noted that of those patients who had the Roux-En-Y procedure, one in eight patients reported that in the second post-operative year, they drank at least three drinks on those occasions when they consumed alcohol. Brian Alexander, in his article on MSNBC.com noted that Wendy C. King, assistant professor of epidemiology at University of Pittsburgh’s graduate school of public health, who headed the study, said, That level can have implications for their weight loss, liver function, vitamin and mineral status so that is concerning….We don’t know the safe amount of booze after a [gastric] bypass.”

The discussion about alcohol, weight loss surgery and nutritional deficiency was also brought up on the Dr. Drew episode.

A caller from Wisconsin: “I had gastric bypass … a few years ago and developed a drinking problem shortly after and now it’s turned into a vitamin deficiency problem and I’m having nutrient problems.” In response, Dr Drew said, The more extreme (the deficiency problems are), the more likely these alcohol problems are. I’ve seen people exploding with alcohol syndrome weeks or months after having surgery and I never understood why patients weren’t warned about this before they had gastric bypass surgery.”

Didn’t we already address that topic!

Alcohol Use After Weight Loss Surgery?

From my perspective, consuming alcohol after weight loss surgery makes no sense

The primary goals I hear from patients about their decision to have weight loss surgery are two-fold: 1) to lose their excess weight and maintain a health weight, and 2) to improve their quality of life….Alcohol ultimately does nothing toward living either of those goals! 

One of my favorite lines from the JAMA article stated, “safe levels of alcohol consumption have yet to be established for patients after bariatric surgery.There is no “safe” level of alcohol consumption for anyone, considering it is a poison. For a surgical weight loss patient, perhaps it is “safe” from a physiological standpoint in that a patient can tolerate it. They can also tolerate a hot dog, which, by the way, is 85% fat and has no place in the life of a person whose goals are to lose weight and keep it off. (And yet, many doctors will say, “Sure, you can have a hot dog.”) Then the patient can say, “The doctor said I could.” 

 Ultimately, of course, it is each person’s responsibility to decide what they will eat and drink after weight loss surgery

I believe patients need to understand that alcohol has no nutritional value, can lead to making additional unhealthy choices, and that a healthy recovery from obesity does not include alcohol. 

 I also believe, that medical professionals have a responsibility to share this same information with patients prior to their having weight loss surgery, to strongly discourage the use of alcohol for their patients, and need to learn more about the emotional use of food, alcohol and a host of other substances and behaviors for a percentage of the surgical weight loss population.

Obesity is considered by many professionals to be a chronic disease

 As such, it is not curable, but is treatable. 

People focus on “recovery” from diseases. Recovery from obesity for surgical weight loss patients means living so that you achieve what you said you wanted: to live at a healthy weight and have an improved quality of life. Recovering from obesity requires acceptance and effort. Acceptance that for whatever combination of reasons, each surgical weight loss suffer(ed) from obesity. And effort – on a daily basis – to live a healthy, balanced life.

 What living a life of recovery from obesity looks like: Doing the things you told the surgeon and bariatric team you were willing to do during the preparation for your surgery. Things like eating healthy foods in healthy portions, taking vitamins, drinking plenty of water, exercising more days than not, getting support, and avoiding things like NSAIDs, carbonated beverages, and excessive sugar and simple carbs. 

 As for consuming alcohol? 

I simply don’t see any place for it in the life of a surgical weight loss patient. And IF not having alcohol is a big deal for a person… maybe it IS something to worry about. Just sayin’…

Any questions?

Connie Stapleton, Ph.D.
www.conniestapletonphd.com

Sponsored by: Dr. Ohhira Probiotics

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