Weight-loss surgery, or bariatric surgery, is a popular treatment for obesity, with nearly 200,000 operations performed in the United States in 2020. The number of patients is actually higher, as there are a growing number of people who opt for “medical tourism” and undergo surgery in Mexico or other countries, for reduced costs.
There are several types of surgical procedures used, but they all trigger weight loss by making changes to the digestive system that affect how much food a person can consume, how their body absorbs nutrients, or both. Patients must adhere to a strict diet following surgery to accommodate their altered digestive system, and will need to take vitamin and mineral supplements.
The majority of those seeking surgery are adults, but some are teens, or occasionally children. With the American Academy of Pediatrics releasing new guidelines on Jan. 9 recommending that children 13 and above with severe obesity (a BMI greater than or equal to 120% of the 95th percentile for their age and sex) be evaluated for surgery, it seems likely this number will rise.
As with any major surgical procedure, the operation carries risks: infection, hernia, bowel obstruction, ulcers, acid reflux, other digestive problems, the need for a second surgery and even death. There is also a chance that the procedure will not be as successful as hoped — that patients won’t lose as much weight as they wanted, or that the weight will come back after some time.
There is another, less well-known risk of weight-loss surgery: problems with alcohol. Not all studies have found an increased incidence of alcohol use disorder following bariatric surgery, but a number have. Some found that specific surgical procedures were correlated with a higher risk of alcohol use disorder, and others were able to identify factors — for example, male sex, smoking, drinking before surgery — that increased patients’ risk.
“It stops being fun when you realize how easily intoxicated you can be after the surgery. Drinking in social situations becomes a little bit more alarming.”
- Cristian Flores
Kelly Osuna underwent surgery a year ago to lose weight and reverse prediabetes. She has shared her story openly via her TikTok account, which has over 27,000 followers. Osuna does not drink alcohol, but when she posted a video about post-surgery alcohol risks, she was inundated with comments.
“I can’t even tell you how many people have commented on my TikTok saying that they got liver failure after having the gastric bypass and drinking alcohol,” Osuna tells viewers in a follow-up post.
“Many people have shared that they have lost loved ones,” Osuna told HuffPost. “They pass away from liver/kidney failure after having weight-loss surgery.”
How might this risk play out in teens, who, presumably, aren’t drinking in the years preceding their surgery, but may start doing so in the years following?
Dr. Thomas Inge is the director of the adolescent bariatric surgery program at Lurie Children’s Hospital in Chicago. He is also one of the authors of a study recently published in the Annals of Surgery that followed 217 teens who had the surgery. Their median age prior to surgery was 17, and the study followed them for eight years.
Very few (2%) of the teens reported drinking prior to their surgery, at which time they were under legal drinking age. But during the follow-up period, many of them did begin drinking, and by the end of the study, “almost half of them actually reported either drinking on a level that would be called alcohol use disorder, or problematic drinking, for drinking associated with harm,” Inge told HuffPost.
So what causes this increased risk of problem drinking following weight-loss surgery? Why might teens be particularly vulnerable, and what preventive measures could be taken?
Your body handles alcohol differently after weight-loss surgery.
There are several theories as to why adults — and, per the recent study, teens as well — are prone to problem drinking after weight-loss surgery.
Doctors agree that the alterations that weight-loss surgery makes to the digestive system change the way that your body handles alcohol.
“We do know from adult studies too, that alcohol is more potent, as an intoxicant, after bariatric surgery just because gastric emptying is faster,” said Inge. “And so the blood alcohol content goes up quicker after these operations.”
Adults who have had the surgery often report feeling the effects of alcohol more quickly.
Cristian Flores decided to undergo weight-loss surgery in 2018, at age 34, because he was unhappy with his appearance and worried about his health.
“Prior to surgery, both my nutritionist and my surgeon warned me about the importance of understanding alcohol and its effects post-op. They stressed that many people who have gastric sleeve surgery often develop alcoholism due to the fact that your body takes longer to break it down, and it’s easier to become intoxicated as a result,” Flores told HuffPost.
When he tried drinking post-op, Flores was shocked to discover that he felt “intoxicated with as little as a few sips.”
He explained, “prior to my surgery, it would take me 2-3 drinks before I felt the effects of alcohol in my body.”
While he’s happy with the results of the surgery overall, Flores’ relationship with alcohol has shifted, and he recommends that others take precautions.
“It stops being fun when you realize how easily intoxicated you can be after the surgery. Drinking in social situations becomes a little bit more alarming, because you don’t know how little or how much you should drink,” he said.
“Once I turned 21 and went out with my boyfriend, I noticed that one drink was more than enough to get me feeling tipsy and intoxicated.”
- Megan Merkel
William K., of New York, has end-stage renal disease, requiring dialysis. He underwent weight-loss surgery in July 2020 in order to lower his BMI so that he would be eligible for a kidney transplant.
He was cautious in following his providers’ advice regarding alcohol.
“I was told to avoid alcohol completely during the pre-op, because it could interfere with the process of shrinking (or ‘de-fatting’) my liver, which could make the procedure unsafe,” he told HuffPost.
“I didn’t drink at all until getting permission from my dietician,” he said, first inquiring about the possibility of drinking again in the November following his surgery. He was advised to start slowly, with a 2 oz. drink.
“I believe I had my first drink in December when I was spending the holidays with family,” he said, adding that those first 2 ounces of wine left him feeling the way he previously would’ve felt after four or five cocktails.
Admitting that his tolerance for alcohol is “much, much lower” than before, William K. views this as simply one part of the lifestyle change that weight-loss surgery requires.
“The preparation and the first several months afterward require a lot of sacrifice and mental fortitude,” he said, noting that “afterward, you can reintroduce many (though not all) of the foods and drinks you loved — you just have to exercise [in] moderation and recognize when your body is speaking to you.”
If these grown men were surprised by the way drinking felt post-surgery, what might be the impact on a teenage girl who, prior to her surgery, never drank?
Megan Merkel, a 21-year-old living in Illinois, also posts about her experience with weight-loss surgery on TikTok. She is one of the young people cared for by Inge’s team at Lurie Children’s Hospital. She had surgery in 2019 in order to lower her weight so that she could undergo corrective surgery for a hip problem that was causing her chronic pain.
While she had little experience drinking prior to surgery, she doesn’t remember feeling much of an impact from alcohol — which she attributes to her previous weight.
“At 420 lbs., I would need a lot more alcohol to feel something than I would post surgery at 220 lbs.,” Merkel told HuffPost.
She was also careful to follow her providers’ instruction not to drink prior to her surgery and in the months following.
“After surgery, I definitely noticed that alcohol hits me very quickly and hard,” Merkel said. “Once I turned 21 and went out with my boyfriend, I noticed that one drink was more than enough to get me feeling tipsy and intoxicated.”
Although alcohol hits fast, Merkel says the effects don’t last long, and she feels it clear out of her system quickly.
While she has no regrets about the surgery, calling it “truly life-saving,” she reiterates caution when it comes to alcohol, mentioning that, as always, it is important to identify a designated driver when going out to drink.
There are other reasons that alcohol use might increase following surgery.
While it’s certainly noteworthy that 47% of the teens in the study reported alcohol-related issues, Inge notes that the bar for identifying alcohol use as a problem was fairly low. If the teen answered “yes” to questions such as, “Have you failed to do what normally was expected of you because of drinking?” or “Have you had feelings of guilt or remorse after drinking?” it was tabulated as drinking associated with harm.
There’s no way to know whether these harms were one-off experiences from first attempts at drinking alcohol, perhaps more likely to be negative because of the way their bodies metabolized it, or whether these problem incidents indicate a future risk of addiction.
Some providers and patients subscribe to a theory of “transfer addiction.” If a person’s obesity results from an “addiction” to food, and the surgery makes it impossible for them to eat in large quantities, they may “transfer” their addiction to another substance, such as alcohol or opioids.
Inge doesn’t put much stock in this interpretation. He describes one study in adults that showed that those diagnosed with binge eating disorder prior to weight-loss surgery were no more likely than others to become binge drinkers following surgery.
He thinks that social issues may explain young patients’ risk for harmful drinking post-surgery, and wonders if the weight loss itself makes experimenting with alcohol more likely.
“Taking that amount of weight off,” a hundred pounds or more within a year, “really catapults them into the mainstream at a very rapid rate,” said Inge, after having been part of “a relatively sheltered group.”
This means, he reasons, that they are exposed to dangers like alcohol suddenly, rather that the slower pace that other teens see such “developmentally appropriate challenges and risks.”
Drinking poses risks for all teens.
Dr. Maria Rahmandar is the medical director of the substance use and prevention program at Lurie Children’s Hospital. While she hasn’t had experience working with teens post weight-loss surgery, she explains that alcohol poses a unique danger to the adolescent brain.
“Any use in a teen is concerning,” Rahmandar told HuffPost. She mentions immediate effects such as injury or overdose, as well as the long-term effects on the brain and the potential for addiction. Most of the teens she sees exhibit episodic drinking, or binge drinking, rather than the kind of daily use and dependence we associate with alcohol addiction in adults and complications like cirrhosis of the liver.
For teens, concern is less about their livers, and more about what alcohol is doing to their brains.
“The developing brain is really susceptible to negative effects of alcohol and other substances,” said Rahmandar. “People who use alcohol and other drugs as an adolescent or a young adult with a developing brain are more likely to go on to have substance use or alcohol use disorders.”
She adds that the younger people are when they start using, the more likely they are to develop a problem. While most people who experiment with alcohol and drugs don’t become addicted, most of the adults who have a substance use disorder began using as teens.
Weight-loss surgery can be life-changing, but it’s important to know the risks.
While the new AAP guidelines suggest a certain BMI to consider teens for weight-loss surgery, each case deserves careful, individual evaluation. The alcohol-related risks might sit differently, for example, in a family with a history of alcohol use disorder. In other cases, the potential freedom from symptoms like Merkel’s unrelenting pain might be seen as far outweighing this risk.
Inge hopes that this research does not dissuade young patients from considering weight-loss surgery.
“I don’t want the bigger picture message to be lost,” he said. “This whole intervention on balance is helpful, because of the amount of weight loss that happens, and because we can turn around problems like Type 2 diabetes, which is awful, high blood pressure, which is awful, and later cardiovascular health outcomes.”
In the multidisciplinary team approach to the surgery that Inge’s team takes, a psychologist is one of the professionals who works with young people during the lead-up to their surgery, which Inge says generally lasts around six months.
Counseling about the risks of alcohol, Inge said, is and will continue to be “part of that preventive anticipatory guidance” that patients receive during this preparatory period.
“With drinking after surgery, you never know how it may impact you and it’s best to stay on the side of caution,” said Merkel. “Everyone is different when it comes to how much alcohol they can tolerate.”
If you’re struggling with an eating disorder, call the National Eating Disorder Association hotline at 1-800-931-2237.