For many extremely heavy people, stomach reductions have so far been the most successful way to lose a large part of their excess weight. But months later, the real work begins.

Here a candy, there a chocolate bar: in the office, Alexandra Knoch now thinks twice about whether a trip to the tea kitchen is necessary, because the plate of sweets that is always filled there is tempting.

“The old habits will return at some point,” says the 55-year-old from Brandenburg. After a stomach operation five years ago, she lost 90 of 176 kilograms – at a height of 1.57 meters. Ten of the lost kilos are now back on it – and she is now fighting against them.

It’s still a relatively easy case. “About one in five patients gains so much weight after gastric surgery that one speaks of clinically relevant weight gain,” says Jodok Fink, Senior Physician at the Obesity Center at Freiburg University Hospital. In these patients, the quality of life can again be significantly restricted and typical comorbidities of obesity such as high blood pressure and diabetes reappear in some cases.

Alexandra Knoch doesn’t have to fear that at the moment: “I’m fine. I used to have high blood pressure, type 2 diabetes, sleep apnea, extremely high cholesterol and liver levels. That’s all history, »says Knoch. Only the broken joints are no longer repairable. “That’s why I can only do aqua fitness,” says Koch, who trains up to four times a week.

Only children’s portions

Your stomach has been reduced in size and routed further down into the intestine so that it can only partially digest the food. «In the first year and a half I didn’t have to worry at all. I could only eat children’s portions. Two rolls of sushi, more was not possible, »says Knoch. Now there are six sushi rolls. That is still relatively little, but enough to slowly increase again. “You have to fight,” said the 55-year-old.

“We can fight about 60 to 70 percent of obesity. One to three years after the operation, the patients reach their lowest weight. After that, the majority gain weight again, and then usually reach a relatively stable weight,” says Jonas Raakow from the interdisciplinary obesity center at the Berlin Charité, where Alexandra Knoch also underwent surgery. To a certain extent, an increase is also absolutely not a problem. “But you have to control them.” In some cases, additional surgery is needed to increase weight loss.

Complex hormonal changes

In addition to the gastric bypass as in Alexandra Knoch the gastric sleeve is one of the most common methods of obesity surgery in this country. According to Fink, these and others lead to complex hormone changes in the gastrointestinal tract: Among other things, the body produces less ghrelin, a hormone that stimulates the appetite. “I no longer feel hungry,” says Alexandra Knoch. The hunger she feels is pure “head hunger”. “The head was not operated on,” says Knoch.

The changed release of hormones in the gastrointestinal tract after the operation is an important explanation for the fact that many patients remain slim in the long term, because over time the stomach expands again and you can eat more again, explains Fink. “Around 75 percent of the patients manage to maintain their reduced weight in the long term and are satisfied,” says the professor. If patients gain weight again, this can have different reasons. “Some don’t change their habits permanently and fall into their old routine.”

Chronic illness not resolved with surgery

“The operation is not the decisive factor, but the change in lifestyle after the operation,” emphasizes Jonas Raakow. “Obesity is a chronic disease that cannot be combated with surgery,” emphasizes the Charité senior physician. “Our aim is to significantly reduce the risk of dangerous secondary diseases such as cardiovascular diseases, diabetes or tumor diseases”.

The quality of life also increases significantly, adds Alexandra Knoch. “I no longer have to do acrobatics when showering and applying lotion,” she says. In addition, she can now buy nice clothes again. “I used to look like a burst sofa cushion.” She also no longer has to select restaurants based on their seating. And medical examinations are no longer degrading as they used to be. “During a gastroscopy, I had to lie on the floor because the doctor was afraid the bed would break,” remembers Knoch.

Depression goes back

Many patients also improve their mental health after an operation, reports Tobias Hofmann, Head of Psychosomatics at the Charité Obesity Center. Depression decreases, especially in the first year. “Many are very happy, which is why the time is also called the honeymoon phase,” says Hofmann. However, setbacks can occur again after two to three years.

People with a body mass index (BMI) of over 30 are considered obese. According to the Robert Koch Institute, every fourth adult in Germany is affected. According to Fink, around 20,000 people in Germany have an operation every year. The causes of obesity are manifold. According to the German Obesity Society (DAG), genetic causes, lack of exercise, malnutrition, lack of sleep, stress, depressive illnesses, eating disorders or even medication can play a role.

From the point of view of experts, regular follow-up care by doctors would also be necessary for permanent weight and health control after gastric surgery. But there is a lack of capacity and funding here. “The few specialized obesity centers cannot do this on their own, family doctor’s practices often lack the expertise – not least because there is a lack of suitable further training opportunities and a lack of demand for them,” says Oliver Huizinga, political director of the German Obesity Society.

Aftercare is missing

“The biggest problem is that the patients don’t follow reasonable, routine aftercare because the health insurance companies don’t pay for it. They demand it, but don’t pay for the aftercare,” says Raakow. In the long term, this is of course a disaster, since no one really takes care of the patients anymore. “With the planned assignment of the legislature to create an obesity disease management program, the situation will probably improve significantly,” hopes Jodok Fink.

Above all, Alexandra Knoch is helped by the exchange in the self-help group at the Charité. “Everyone has their own strategy for losing weight,” she says. You yourself have increased the amount of protein and reduced the carbohydrate content in the food. Unfortunately, there were no personal meetings during the pandemic and only online meetings were possible. Not all members switched to these. “Those who gain weight again often no longer report,” says Knoch. The shame is just too great.