**1. The actual burden of obesity**

Obesity has become one of the leading problems worldwide and not only in first-world societies. Its prevalence rose steadily for seven decades, slowing down in the last ten years, especially in first-world countries, due to better prevention and treatment. Nevertheless, there are more overweight than underweight people in every region except sub-Saharan (but South Africa) and southeast Asian countries. Prevalence of obesity (BMI > 30%) is led by United States (38% population), Saudi Arabia (35%), Turkey, Egypt, Libya, and Canada (31–32%), and Australia (30%). In Europe, it affects 20–30% of the population, with the highest prevalence in the United Kingdom (29.5% population), followed by Hungary, Czechia, Lithuania, Greece, Bulgaria, Croatia, Spain, Ireland, Ukraine, Germany, Russia, and Poland (25.6%) [1–3].

Fat is an advancement in the evolution of the species as it allows for standing periods with no access to food and helps keep the body heat. But the convenient amount of adipose tissue has its limits, as too many fatty deposits are problematic for the skeleton, heart, pancreas, most inner organs and systems and a higher incidence of certain types of cancer [4–7]. Since the dawn of humanity, those problems have existed and are undoubtedly well-known during the roman empire decadence period [8]. It was already a problem in medieval times, but nowadays, it has reached the size of a pandemic. One of the more fundamental reasons is easy access to fast food and the consumption of high carbohydrate diets, sugar-sweetened beverages, and a more sedentary lifestyle. It is also true that access to any food is easier than ever, but some individuals cannot easily control their appetite. No one will deny the combination of availability of high caloric content food plus little caloric expenditure, but controlling their surge for food ingestion is not straightforward [9]. We all have known friends who had to be on a diet since early childhood because they were eating comparatively little, yet they kept putting on weight.

This book attempts to introduce the reader to the complex world of the treatment of obesity from a multidisciplinary point of view, from the non-surgical approach to modern surgical techniques, considering the broad spectrum of areas that may be affected in those patients.

## **2. The non-surgical approach**

Education since childhood about the value of healthy eating is, for many, the golden bullet. But as doctors, we know that even so for a few will not be enough [10, 11]. What to do then? We cannot stand still seeing how their global health and quality of life deteriorate as they gain weight. So, modification of living style and adoption of healthy habits is taken as a real sacrifice. Then the next magic solution: bariatric surgery.

A "healthy living lifestyle" is often perceived as tedious, frustrating, tiring, too strict, not very social… but all these take us to two of the most critical issues in obesity. The first one is the psychological alteration these patients have. What was first? Did obesity lead to psychological damage? Or the other way round, is there a psychological foundation basis for obesity? In any case, psychological, dietary, and physical assessment, support, and treatment are necessary.

The second issue is the genetic propensity towards obesity. Adipose tissue works as an organ, with its own metabolic rules. And sometimes, not even the strongestminded person can overcome it. However, the knowledge of pathophysiology has helped to individualise the treatments.

Then the next "magic solution": bariatric surgery. Preparation for such an event needs teamwork: dietitian, physiotherapist, psychologist, respiratory physician, endocrinologist, and even sometimes a personal trainer will help the patient journey to a new healthier life. Nevertheless, patients must follow a strict diet before the operation and change their minds about eating [12]. This necessary change in eating habits is, undoubtedly, the keystone for long term success. Therefore, there is an absolute need for the non-surgical approach to the bariatric patient.

### **3. Bariatric surgery**

In the last 50 years, surgery and anaesthesia have developed exponentially compared to the previous centuries. Moreover, laparoscopy and anaesthesia-related devices and monitors have increased the safety and efficacy of surgical procedures. However, there is a 42 year time lapse from the first jejunum-ileal bypass of Kremen in 1951 [13] to the first laparoscopic bypass of Wittgrove in 1994 [14]. By then, restrictive procedures were being also introduced in bariatrics.

We all remember the adjustable gastric band in the eighties [15], which became a popular laparoscopic bariatric surgery in the nineties. Initially, patients lost weight but soon adapted to eat less and ate higher calory content [16, 17]. But, unfortunately, the band itself was also a source of many other problems like infections [18], migration [19], erosion [20] and even, on rare occasions to gastric perforation [21]. As a result, conversion to other bariatric surgical procedures has not been uncommon [22].

But with the new century also new choices came. Reducing the significant stomach curve to create a gastric sleeve with a smaller capacity was an innovative advancement. Gagner published the first experience with sleeve gastrectomy as a stand-alone procedure in 2008 [23]. It has been the solution that has helped many maintain weight within reason [24]. At this moment, it is the most common bariatric surgery type, with very low morbidity and mortality rates, making it very safe not only as a stand-alone procedure but also as the first procedure for super-obese patients. But it demands that the patient collaborates and does not do as in the gastric band: eating less but more times and with food with a high calory content [25]. The removal of the part of the stomach that segregate ghrelin helps controlling appetite, which is seen as one of the significant advantages of the procedure from the psychological point of view.

#### **4. The post-surgical individual care**

But both psychologists and nutritionists will have the most critical role at this stage. Regardless of the type of surgery, all patients need to change their habits to *Introductory Chapter: Bariatric Surgery - Not Alone on This Long Road DOI: http://dx.doi.org/10.5772/intechopen.100228*

healthier ones, including diet, exercise, and life. In addition, family, friends, workplace, and sometimes even home need to adapt or collaborate to create a favourable and positively stimulating environment, addressed to a new life.

Changing eating habits is complicated, as homemade food needs to be increased, but sometimes there is little time. Another drawback is that some patients (most commonly those who underwent malabsorptive procedures) present iron [26] or vitamin B12 absorption problems [27], which might need surveillance and dietary supplementation in this respect [28].
