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Defending a new hypothesis of how bariatric surgery works

The greatest challenge in treating obesity is not to achieve weight loss per se but to ensure that a lower body weight is maintained over the long term. Our best treatment to meet that challenge is various bariatric surgical procedures including Roux-en-Y gastric bypass which causes drastic as well as sustained weight loss (1). Traditional explanations for these potent effects has been to view these procedures as physically restricting food consumption via a small stomach or causing calories to be lost in the feces via malabsorption. A growing body of evidence argues against restriction and malabsorption as key drivers of surgical weight loss as it would contradict findings such as: 1) in rodent models, animals with bariatric surgery are capable of increasing their food intake to meet metabolic needs during pregnancy (2) or after food restriction (3); 2) patients report that they feel less, rather than more, hungry after surgery (4); and 3) appetite regulating gut hormone secretion differs between subjects losing weight by surgery and caloric restriction (5).