Why is there no surgery for visceral fat

[Tvtyrant]

I was under the impression it was the upper intestine they were shortening.

Not to put too fine a point on it, but think of all the stuff you left in there that shouldn't be there by the time it gets to the lower intestine. For instance fatty stool is considered a sign that your intestine and liver aren't working together to strip fats right? What is the lower intestine to do with things it doesn't digest?

Another point is that you have bacteria in your gut that do a lot of the work, like breaking down fiber. Those colonies are going to get changed dramatically by the surgery, which is going to cause gastrointestinal distress. And you are likely not going to have long enough to digest fiber anymore, so that's going to cause yet more issues.

[Tyndmyr]

On the plus side, I sort of exploited the same tendency to go from basically never exercising to doing it daily. At least for me, it feels like adding a new habit, whether a good or bad one, is way easier than removing one.

Same. I exercise on the regular, but struggle with eating crap. The former helps a good bit, but the latter is something to work on. No magic to it, just the call of bad habits is strong.

But build enough good habits, and something gets displaced, and it helps long term.

And, yeah, I'll take medication over surgery as a much more preferable assist if I decide to do one. Far lower risk.

[Baron Opal]

Liposuction shreds or liquifies adipose tissue and vacuums out the remains. It is mostly useful for removing large collections of tissue since you have no precision. If you lose weight in a typical manner the tissue remains, the cells are simply empty. With this procedure the cells themselves are disrupted and removed. This requires a further metabolic expenditure by creating further adipose tissue to store fat from excess calories. The result is effective but highly damaging. Recovery is painful, and removal of too much tissue risks shock from inflammation.

Gastric Bypass (Roux_en_Y) surgery dramatically shrinks the volume of food able to be consumed and bypasses the initial part of the small intestine. The remaining portions of the stomach are not removed, necessarily, and digestive juices still flow through the duodenum and into the rest of the small intestine. This forces the significant reduction in the amount of food consumed, and partially restricts the about absorbed. Due to changes in hormone balance that we don't fully understand yet, Type II Diabetes can be minimized or even reversed after this process.

GLP-1 agonists (Ozempic, Mounjaro) a fruits of research secondary to noticing health effects of gastric bypass beyond weight loss. This increases satiety as well as reducing the hunger drive. It many ways, it is an injection that obviates the need for surgical options. Originally for management of DM-II, these medications are finding expanding use in general weight loss. It is so successful that businesses that focus on reframing habits and practices for eating and weight loss (e.g. Jenny Craig) are finding their businesses shrinking. By 2030 Jenny Craig may be out of business.

[Eldan]

Same. I exercise on the regular, but struggle with eating crap. The former helps a good bit, but the latter is something to work on. No magic to it, just the call of bad habits is strong.

But build enough good habits, and something gets displaced, and it helps long term.

And, yeah, I'll take medication over surgery as a much more preferable assist if I decide to do one. Far lower risk.

Well, seems the drug treatment plans for Ozempic et al. are coming down to currently about 300 dollars a month, and production is being expanded too. Looks like they might be pretty easily available soon.

[Ionathus]

To answer the OP (and also address the below question a bit too): every doctor I've ever talked to will err on the side of noninvasiveness. Surgery is almost always a last resort, because even with modern medicine, "poking around in there" is almost always the most dangerous thing you can do. Everything in the human body does something -- things like the appendix or the tonsils might not do enough to justify keeping if they become infected and their cons start outweighing the pros, though -- and in an overwhelming percentage of cases the body knows how to take care of itself, and the best thing we can do is to give it proper fuel and exercise and leave it alone.

The one thing I don't understand about things like orlistat pills or intestinal bypass surgery or anything else that prevents absorption is why they should cause diarrhea as a side effect specifically. I understand why they would cause the patient to use the bathroom more often - if less is absorbed more must come out that's basic thermodynamics - but why should the consistency be intractibly changed? I would think at the worst you would be a need to add something to make the fat clump up

It's because that's what diarrhea is: food that hasn't been processed fully/correctly, and those procedures are designed to mess up your body's ability to execute that function.

If the human digestive system is calibrated to take what you eat and extract all the nutrients out of it, and you do anything to affect its ability to extract those nutrients (gastric bypass, bowel shortening, etc), then the food isn't gonna be fully digested/extracted once your body gets rid of it. This even applies to other effects like a stomach bug or any drug (antibiotics, omeprazole, etc.) that affects your stomach microbiome/acidity. As someone else said, even water extraction plays a part here since shorter intestine = less time for water extraction.

Diarrhea is your body (indirectly) telling you "hey, we didn't get everything we could have out of that food you ate." Biologically that's a really good red flag to receive: "stop doing whatever caused that, or you won't get enough nutrients and you might die."

Please note I'm not taking a moral stance on liposuction/gastric bypass/other drastic surgical weight loss remedies. I know someone who received a gastric bypass and it dramatically improved their life (and life expectancy). That's a decision they made with their doctor, probably after all other options had failed. My comments here are to address the reason that it's (rightfully) seen as a last resort -- because from a biological perspective, it's far and away going to cause the most side effects and problems and throw your body all out of whack in exciting new ways.

[paddyfool]

In addition to what everyone else has said re short gut causing diarrhoea, there’s also the matter of osmosis. Unabsorbed solutes will hold more fluid back while your lower intestine is trying to suck it up.

EDIT: Regarding the underlying causes of obesity, it’s clear that something major changed in how people were living in Western countries in the second half of the 20th century. In the USA, for instance, obesity rates really started rising from about 1975 or 1980 (eg here if you look at the youth-specific prevalence, which gets away from confounding by changes in the age distribution of the population) https://www.niddk.nih.gov/-/media/Images/Health-Information/Weight-Management/Graph-8-revised.jpg). How much of this was the rise in ultra-processed food in general, how much specifically due to the introduction of high fructose corn syrup in the 1970s, how much the rise in sedentary lifestyles (with people sitting still more and more for entertainment, work and travel) and how much other factors from the rise in antidepressant use to the drop in smoking rates is of course a massive debate however. Personally I put it down to a little of all of the above, but that doesn’t tell us which structural changes are needed most to address it (except that we really don’t need to smoke more, obviously).

[paddyfool]

I take Mounjaro for diabetes and have for the past six months. In that time, I've lost about 70 pounds.

When I was first diagnosed and began treatment, I discussed with a nurse diet, exercise, and the use of the drug. As she was explaining what it would do, she said that if I had that little voice in my head telling me to eat all the time, the drug would likely shut it up.

I was flabbergasted. Yes, I had that little voice. I got up in the morning and started looking for breakfast. Then I was like the pigs in "A Muppet Christmas Carol" that asked what they should do next after just finishing breakfast, and one of them suggests lunch. I'd start planning what to have for lunch and looking forward to it. Right after, I was planning dinner. When she said that, I started to review and realized I think about food more than anything else, and it is a constant in my mind. I started asking people about this, and none of the thin people I know had any idea what I was talking about, while most of the fat people I know knew exactly what I meant.

Then I took Mounjaro. And the voice stopped. I get up in the morning, and don't think about food. I have some fruit with my coffee, because the nurse told me I have to eat certain amounts. I will forget that it's time for lunch, and just end up not eating. If I was single and wasn't cooking at home, I know I'd do the same with dinner. And I went from regularly eating 2000-2500 calories, and that was what control I had, to not wanting more than 1000 a day, and having to push to get enough carbs to keep things functioning. I still like some foods over others, and still can't stomach broccoli or cauliflower, but the number of things I enjoy the taste of has gone way up (I never knew roasted carrots were so good!).

So if you are talking "easy", in my experience this couldn't be easier. Surgery that meant I could eat anything I wanted but had some nasty bathroom issues would be far worse. Any surgery would be worse, because I'd have to go through surgery, and nothing about any of them indicates they would be more effective than a shot every week is (and I looked into them). The answer to the title question now, regardless of what it may have been in the past, is that there are less invasive methods that would do a long-term better job of achieving the results. If it's cosmetic, you want to remove the subcutaneous fat, and if it's health-related, get there by diet and the right meds.

I’m curious - did you notice a big reduction in your expenditure on groceries with this medication, or not so much? What about side effects, along the lines of nausea etc?

[Bohandas]

but that doesn’t tell us which structural changes are needed most to address it

Medical research funding. If they could develop a surgery for visceral fat that was even a quarter as safe and fast as liposuction then none of this would be a problem.

Or if they found a way to make the body burn off lipids and sugars faster, like some kind of drug that would activate the brown fat cells (which would also have the knock-on effect of allowing you to go out in winter without a coat (on the kind of days where you'd usually need a coat I mean; I know that so far this winter it hasn't been very cold))

[paddyfool]

If what you want is to activate brown fat, sleep in a cold bedroom. Tends to lead to better quality sleep anyway. Cold water swimming too (as well as having other health benefits), though this option also has health risks so be sure to start it carefully.

(The big problem with both of these is it’s hard to convince people to take them up, particularly cold water swimming, and a cold bedroom can be tricky/expensive in summer in many places; and nether have strong evidence of increasing weight loss, with a large body of research now pointing to most of humanity burning through about 2500 calories a day most of the time irrespective of exercise levels etc; humans that do less exercise tending to get more stressed and burn through more calories through the action of stress hormones).

The trouble with hoping for further new drugs meanwhile is that weight loss drugs have not had a great success record for decades of research until the glutides were found to do this pretty well, with various previous drugs proving to have unacceptable safety, side effects, and/or just plain insufficient effect. Could be decades yet until we get another success story, and then it would be a very expensive solution for the first 20 years until the patent expires.

EDIT: IMHO, we need to educate people as to the risks of ultra-processed food, and the benefits of not having much of this in the diet, while also doing more to structurally disincentivise food companies from making so much of this somehow.

[Darth Credence]

I’m curious - did you notice a big reduction in your expenditure on groceries with this medication, or not so much? What about side effects, along the lines of nausea etc?

Sorry it took so long to respond - I just saw this. There is a major reduction in food costs outside the house because I don't go out to eat much at all. For in-house, there has been a reduction, but a lot of recommended low-carb stuff is much more expensive, so that has been a wash. Those have been tapering off, though, as I've learned more things I can make, so bills have been dropping.

As for side effects, I had some nausea each time the dose went up, but I've leveled out the dose and am no longer seeing much in the way of negative side effects. The day after the shot, I make an extra trip or two to the bathroom, but since starting my overall bathroom trips have been cut in half, so it's overall an improvement.

[Lord Torath]

(I never knew roasted carrots were so good!).

May I also recommend roasted parsnips? The're a root veggie very similar to carrots, and my wife and I regularly have a meal of just roasted carrots, parsnips, and small potatoes. No topping necessary!

[Batcathat]

May I also recommend roasted parsnips? The're a root veggie very similar to carrots, and my wife and I regularly have a meal of just roasted carrots, parsnips, and small potatoes. No topping necessary!

I would also recommend adding roasted beetroots to the mix, they add a bit of sweetness that is surprisingly tasty.

[paddyfool]

I was pleasantly surprised to learn that radishes roast up well recently too. Garlic is also a decent addition to a roast veg traybake - you can roast a few cloves in the skin so they don’t burn and pop out the contents when done.

[Bohandas]

here's another idea: Gastrostomy. Connecting the stomach to the exterior of the body with an implanted tube. It's usually used to put nutrients in, but why couldn't it be used to take stuff out?

It seems like that would be less invasive than any of the procedures discussed in this thread so far, including the relatively mainstream gastr8c bypass,

[Maat Mons]

I had this idea for a device that's basically a dialysis machine, but instead of filtering wastes from your blood it filters out sugars.

[georgie_leech]

here's another idea: Gastrostomy. Connecting the stomach to the exterior of the body with an implanted tube. It's usually used to put nutrients in, but why couldn't it be used to take stuff out?

It seems like that would be less invasive than any of the procedures discussed in this thread so far, including the relatively mainstream gastr8c bypass,

Worth noting that it's used when normal nutrient intake doesn't work properly, as extra holes into the body are always a health risk.

[Anymage]

Even ignoring the risks of complications, going to have your blood filtered often enough to make a meaningful weight difference sounds like more time, discomfort, and expense than just going to the gym regularly.

Making a hole into your stomach to suck out extra food sounds like the sort of thing a doctor should lose their medical license for even considering. Vomiting is already an effective way of emptying your stomach after consuming a calorie surplus. The health risks of bulimia are already well known, and this sounds like basically the same thing except with surgery and an open port for foreign material to access your stomach.

[Ionathus]

here's another idea: Gastrostomy. Connecting the stomach to the exterior of the body with an implanted tube. It's usually used to put nutrients in, but why couldn't it be used to take stuff out?

It seems like that would be less invasive than any of the procedures discussed in this thread so far, including the relatively mainstream gastr8c bypass,

I'm not a doctor but I'm pretty sure that's way more invasive than gastric bypass (which is saying something). As georgie_leech and Anymage said, there's a reason that "make a new hole and keep it open using foreign matter for the rest of your life" is almost always a last resort.

Infection is an eternal risk for every entry point on your body, and while all of the "normal" holes in the human body have complicated defense systems, a permanent artificial hole in your abdomen will have none of that.

[Tyndmyr]

If one were looking for an "easy" method of fat removal, the great apes make an interesting starting point. They don't really work out as such, and have extremely muscular builds, even on a mostly vegetarian diet that isn't exactly a protein maximization strategy.

It seems probable that there's a genetic difference there. We evolved for pursuit hunting, which meant efficient walking and caloric storage. Could that change be undone? We're slightly into sci fi territory there, because while genetic editing is a thing, we don't yet know exactly how to do this specific thing.

But in theory, it should be possible. It might come with tradeoffs, though. Lifespan, for instance.

[Tyndmyr]

Great apes and monkeys are quite different.

[Bohandas]

Vomiting is already an effective way of emptying your stomach after consuming a calorie surplus. The health risks of bulimia are already well known, and this sounds like basically the same thing except with surgery and an open port for foreign material to access your stomach.

The premise here is that it would bypass those health risks because it's not engaging the mouth and throat (and for the most part not really engaging the stomach or any other part of the digestive system either except in a passive mode) and therefore you wouldn't get things like gastric/esophageal ruptures, acid reflux, teeth worn away by muriatic acid, oral trauma, chewed up hands, laxative dependency, etc. etc. etc.

Granted it would probably still cause peptic ulcers because, as you said, the opening would be a potential vector for infection (although no more so than for any normal stomatization procedure)

I had this idea for a device that's basically a dialysis machine, but instead of filtering wastes from your blood it filters out sugars.

I had that same idea. It seems like an obvious solution. I suppose with current technology such a device must just be too expensive to be commercially viable

Even ignoring the risks of complications, going to have your blood filtered often enough to make a meaningful weight difference sounds like more time, discomfort, and expense than just going to the gym regularly.

Bring your laptop.

Alternately maybe the sessions could be done at night and run while you're sleeping. (They could even combine it with a regular dialysis machine so you wouldn't have to wake up to pee; Although this would no doubt make it even more obscenely expensive than it already would be)

EDIT:
Also, my dad used to be reallh sick before he got hiz liver transplant and I learned from him that apparently things like having long medical probes and perfusers ran down to your internal organs through your neck veins apparently isn't nearly as uncomfortable as it sounds. I Imagine that this would fall into the same category.

[Ionathus]

EDIT:
Also, my dad used to be reallh sick before he got hiz liver transplant and I learned from him that apparently things like having long medical probes and perfusers ran down to your internal organs through your neck veins apparently isn't nearly as uncomfortable as it sounds. I Imagine that this would fall into the same category.

That makes sense, since it wouldn't really make sense to have a lot of pain receptors in those areas. Still, "not horribly uncomfortable" isn't the same as "safe."

My dad had a central venous catheter (goes in the chest to make long-term IVs easier) several times. Infection was a constant struggle every time, and that's with him getting some of the best medical care possible.

"Put a hole in the human" is the last-resort treatment option for almost everything, and for good reason.