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Bypass vs. banding

Bypass changes how the brain responds to food

Study helps to explain why gastric bypass patients lose more weight over the long term than those who undergo a gastric band operation

The weight loss seen in patients after gastric bypass surgery for obesity may be helped by changes in the way the brain itself responds to food, reducing not only hunger but also the drive to eat for pleasure, according to a new study from the Medical Research Council (MRC).

The research, published in the journal Gut, helps to explain why gastric bypass patients lose more weight over the long term than those who undergo a gastric band operation.

“It is well established that patients after gastric bypass lose more weight than after gastric band and we think this is because of the different physical changes made to the gut during surgery, which somehow have an effect on the drive to eat for pleasure,” said Dr Tony Goldstone from the MRC Clinical Sciences Centre at Imperial College London and consultant endocrinologist at Imperial College Healthcare NHS Trust. “Both procedures reduce appetite and have health benefits including long-term weight loss and improvement or even complete resolution of type 2 diabetes. However, gastric bypass surgery appears to be more effective for weight loss and has a more profound effect on the way in which the brain responds to food.”

Previous studies in animals and humans have shown that those who undergo a gastric bypass tend to shift away from eating high-fat and sweet foods. However, the effect of different types of weight loss surgery on the brain that may be responsible for changes in food preference has not been explored until now.

Using magnetic resonance imaging (fMRI), which measures brain activity by detecting changes in blood oxygen levels, scientists from Imperial College London, UK, studied 61 men and women who had lost weight from either a gastric bypass (21 people) or gastric band surgery (20 people).

The scans were carried out on average eight to nine months previously, as well as a control group of un-operated participants (20 people). These three groups were of similar body weight.

They found marked differences in the brain’s response to food in patients after gastric bypass, compared to gastric band surgery. Patients who had gastric bypass had less activity in the brain’s reward regions when shown pictures of food compared with those who had gastric banding.

Patients after gastric bypass also rated high-calorie foods as less appealing to look at and less pleasant to eat (on a scale), had healthier eating habits and ate less fat in their diet than patients after gastric banding or the un-operated control group.

Both the gastric bypass and banding patients had similarly reduced hunger compared with the un-operated group, and the findings were not explained by differences in psychological traits between the surgical groups, such as binge eating, mood, impulsivity, or their sensitivity to seek rewards in general.

Whole brain comparison of activation to high-calorie foods between obese patients after gastric bypass and gastric banding.

The researchers did not find conclusive evidence of what caused these changes, but they did observe several differences in the patients’ metabolism that could play a role. Levels of the gut hormones (GLP-1 and PYY) that make us feel full after a meal were higher in the gastric bypass group, as were levels of bile salts, which play a role in digestion.

Patients after gastric bypass also reported more intestinal discomfort and nausea after eating foods high in fat and sugar in the early months after the surgery than patients after banding, which may also be influencing what foods they want to eat.

The researchers concluded that “the identification of these differences in food hedonic responses as a result of altered gut anatomy/physiology provides a novel explanation for the more favourable long-term weight loss seen after RYGB than after BAND surgery, highlighting the importance of the gut–brain axis in the control of reward-based eating behaviour.”

Further work by the researchers will focus on which of these factors may be influencing the brain’s response to food following bypass surgery.

“These findings emphasise that different bariatric procedures work in different ways to influence eating behaviour,” added Goldstone. “This may have important implications for the way we treat patients with obesity and could help pave the way for a more personalised approach when deciding on the choice of bariatric procedure by taking the impact on food preferences and cravings into account.”

"Humans don't just eat when they're hungry – the pleasure and rewarding feelings we get from eating play a huge role in determining what kind of foods we eat, as well as how much,” said Professor David Lomas, Chair of the MRC's Population and Systems Medicine Board. “This work adds to a growing body of evidence supporting the role of the gut-brain interplay in controlling our eating behaviour. Being able to influence this relationship may in future play an important role in the development of non-surgical treatments for obesity."

This research was supported by the Medical Research Council, Wellcome Trust, National Institute for Health Research (NIHR), and Imperial College Healthcare Charity and the Imperial Weight Centre, from which patients were recruited.

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