Bariatric Surgery vs Alcohol Use Disorder

I'm sure you've heard about something being too good to be true.  As much as you want it to be true, don't you always sniff around and investigate a bit?  Poke & prod at it to see if it's really that good?  And too often, when you look hard enough, you'll fine a crack in the armor somewhere.

And so it is w/bariatric surgery in which study after study has demonstrated the ability to lose 100+ pounds post-operatively, something that very few patients can do on their own by dint of lifestyle (ask yourself how many people compete on NBC's Biggest Loser TV show).  Don't get me wrong, it can be done.  Just by increasing intense physical activity to upwards of 4 hours/d and restricting caloric intake to 70-75% of estimated daily resting energy expenditure, these select few were able to lose dramatic amounts of weight equivalent to that achieved by bariatric surgery.  But as I noted already, these are the few, the proud, the Biggest Losers.

More importantly, it's been pointed out in several studies that post-operatively, diabetic bariatric surgery patients are often cured of their diabetes and able to stop medications completely.  But as of this past week, the luster of bariatric surgery has dulled just a bit as Roux-en-Y gastric bypass, in particular, has been linked to an increase in alcohol use disorder (AUD), defined as alcohol abuse & dependence.

As published in JAMA, the authors prospectively followed a cohort of 1,945 obese patients, 79% female, 87% white, avg 47yo w/body mass index 45.8kg/m2 for 2 years post-operatively.  Interestingly, evidence of AUD did not differ over a two year period from 1 year pre-op to 1 year post-op.  However, by the 2nd year post-op, there was a statistically significantly greater prevalence of AUD, especially in younger males who smoked & exhibited AUD & other substance use pre-op.  Most curious of all, those who under Roux-en-Y procedure had a greater risk of AUD compared to those who underwent a laparoscopic adjustable gastric band procedure.

While this was a prospective study, let's not forget that as a cohort study, it was not designed to determine & prove cause & effect.  The conclusions of this study can only link Roux-en-Y procedure in younger men w/previous AUD & polysubstance use pre-op to greater AUD post-op.  For now, we need to be more cognizant of screening for alcohol use in our obese patients, even as we attempt to search for cause & effect.  And as more & more patients opt for bariatric surgery as their solution to obesity, those of us in primary care need to monitor for increased alcohol consumption 2 years post-operatively.

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