Helping the MD's!

[Connie Stapleton PhD 342]

I’m writing this article as an invitation for each of you to help educate physicians about the issues you face related to weight loss surgery and what you believe is needed to enhance your care, either before or after weight loss surgery.

The American Society for Metabolic and Bariatric Surgery (ASMBS) emails each new edition of “connect,” their official news magazine to its members upon publication. In it, they provide a synopsis of recent articles of interest related to WLS. One noted article this week is titled, “What Matters: What’s the magic behind successful bariatric patients?” and is written by Dr. Jon O. Ebbert, an internist at mayo Clinic.

In the article, Dr. Ebbert states, “I was left wondering how I can best help my patients using this information.” Let’s help him help his patients!

I’ll share the short article, give my editorial (what I didn’t share with Dr. Ebbert) and then write the response I did share with him. Finally, I’ll provide the link where you, too, can share feedback directly about the article, or send it to me and I will be happy to forward it!

The article:

“MARCH 3, 2016

A fair number of my patients have had or are undergoing bariatric surgery. Disconcertingly, a not insignificant number of them are regaining the weight after surgery. Weight regain will occur in 20% of patients undergoing bariatric surgery after initial weight loss.

When this occurs, not only do we have a patient with an altered gut putting them at risk for nutritional deficiencies if we are not fastidious in our follow-up, but they are discouraged and overweight again.

Add this to the concern that bariatric surgery has been associated with an increase in suicides (2.33-3.63 per 1000 patient-years), and we may have some cause for alarm.

So, what predicts success – and can we facilitate it?

Several factors have been shown to predict successful weight loss after bariatric surgery. An “active coping style” (that is, planning vs. denial) and adherence to follow-up after bariatric surgery have both been shown to be associated with a higher percentage of excess weight loss. Interestingly, psychological burden and motivation have not been associated with weight loss.

In a recent article, Lori Liebl, Ph.D., and her colleagues conducted a qualitative study of the experiences of adults who successfully maintained weight loss after bariatric surgery (J Clin Nurs. 2016 Feb 23. doi: 10.1111/jocn.13129). Success was defined as 50% or more of the excessive weight loss 24 months after bariatric surgery.

The voice of the successful bariatric patient is an interesting and important one. Several themes were identified:

1) taking life back (“I did it for myself”);

2) a new lease on life (“There are things I can do now that I am not exhausted”);

3) the importance of social support;

4) avoiding the negative (terminating unhealthy relationships in which “food is love”);

5) the void (food addiction and sense of loss);

6) fighting food demons;

7) finding the happy weight; and

8) a ripple effect (that is, if you don’t eat it, the rest of family doesn’t, either).

I was left wondering how I can best help my patients using this information.

First, I think the themes can mature our empathy for the struggles that these patients face, and perhaps help us combat bias. Second, I think this knowledge can inform early discussions around what sorts of things need to be lined up for after the procedure, such as social support.

Finally, I think the themes can be universalized and help us counsel patients who may be struggling with weight, but who are otherwise not candidates for bariatric surgery.”

My Editorial

I’m grateful that an internist is addressing the topic of WLS. I love that he is thinking about ways to use the information gleaned from the research he notes related to the behaviors of those who have “successful weight maintenance” following weight loss surgery.

Pardon my sarcasm, but, WOW! Getting information about the behaviors that led to weight loss from patients who have 50% or more of excessive weight loss 24 months after bariatric surgery? Does that really tell us anything? I’d venture to say that the majority of professionals in the field would note the surgery itself as being primarily responsible for the “success” of the weight loss at 24 months out. I’m NOT saying that many patients fail to put forth a great deal of effort at that point, because I know many do work very hard during those first 24 months. But come on… let’s talk to successful weight maintainers at 5 years after surgery to get a better indication of what they are doing to manage a healthy weight.

I’d also be curious to know at what point in time after surgery the statistic was obtained noting “Weight regain will occur in 20% of patients undergoing bariatric surgery after initial weight loss.” How much weight regain? After how much time? If you look closely at research in many fields, you can find numbers that vary widely on a particular topic.

Dr. Ebbert states, “Psychological burden and motivation have not been associated with weight loss.” I wasn’t at all sure what this meant. Questioning my comprehension skills, I asked some other people how they interpreted that statement, and they couldn’t tell, either. If the implication is that psychological issues have no impact on weight loss or lack thereof, I have to disagree. But then, I have no research to back up my hypothesis. I do have 11 years working in this field and the anecdotal evidence of hundreds of patients that says otherwise. I’d say depression interferes with the desire/ability to follow through with certain behaviors that require significant energy. I’d say that intense shame interferes with the perceived efficacy to follow through for the long haul with behaviors necessary to sustain weight loss – well past two years of having WLS. I don’t know… I believe poor self-esteem, a history of “failing” with “diets,” unresolved grief, loss, and abuse issues sometimes affect a person’s perceived ability to succeed. I also believe treating these psychological issues in conjunction with treating one’s physiology and teaching important skills such as healthy coping mechanisms, positive self-talk, and efficacy-enhancing skills is a recipe for better outcomes.

My Response to Dr. Ebbert (in an attempt to be brief):

“Dr. Ebbert -

With all due respect, the medical field is, in my opinion, missing several very large pieces of the puzzle with the surgical weight loss population in terms of treating them. I am a licensed clinical psychologist. I work in a surgical weight loss clinic and have spoken with literally thousands of patients who have had weight loss surgery. Obesity is a complicated disease that is more than just physiological. I treat the underlying and associated psychological co-morbidities, which the medical community largely ignores, except under the broad category of "Behavior Modification." I assure you that there is a lot more than changing behaviors that needs to be addressed with this population. A vast majority of this population suffers with deep shame and low self-esteem, both rendering them inefficient at maintaining motivation to follow through on a long-term basis with "behavior modification." I am working tirelessly to try to address the elephants in the OR, but surgeons don't really want to listen to myself - or the patients - who are clamoring for additional mental health care (MORE than behavior modification) following WLS when their "issues" interfere with healthy behaviors - just like before surgery. More suicides? Maybe because in a sense, we take away the patients’ coping skill (food) and throw them to the wolves. I've created a video series that I require all of my patients to watch before surgery to help them understand the deeper issues they may face and to urge them to seek counseling. I could use help in the medical community. You in?”

I do believe, and I thank Dr. Ebbert for noting, “this knowledge can inform early discussions around what sorts of things need to be lined up for after the procedure.” Let’s all pitch in and share with Dr. Ebbert and other interested physicians what you need to be successful, on and off the scale, for years and years following WLS. Please share your comments at:

http://www.clinicalendocrinologynews.com/comments/what-matters-whats-the-magic-behind-successful-bariatric-patients/016f71fe2abdc0198ac42d75d039d712.html?comments_link=1

Or, post your comments here or contact me via my web page: www.conniestapletonphd.com

Let’s pitch in and help!

Connie Stapleton, Ph.D.

[Inner Surfer Girl 12,015]

Thank you for sharing. I am not a physician but consider myself literate and pretty well educated, but I too had trouble following much of what he was trying to say (and I have read up on the study/studies? he seems to be relying on).

For instance "gaining the weight". Does he mean gaining weight? Gaining some weight? Gaining more weight?

I could go on...

Another big piece that is missing is how the medical community in general treats obese patients. There is a recent thread on BariatricPal that has some real horror stories. Unfortunately, they seem to be more common than not.

I agree that General Practitioners and other MDs need a great deal of education about obesity, weight loss surgery, and post-surgery care, however far after surgery.

You are spot on when you note that too many post-op patients are thrown to the wolves post-op when it comes to mental health issues.

I will definitely have to think about this to see what additional response I could provide.

[Inner Surfer Girl 12,015]

Here is one recent thread that might be applicable: http://BariatricPal.com/index.php?/topic/361405-GP-says-to-do-Weight-Watchers-instead

Still looking for another one that I think might be helpful.

[CowgirlJane 14,259]

My own personal experience was that specific, ongoing and comprehensive education was a key success factor. When I was banded didn't get clear education on how to manage food and I was often hungry but would vomit too easily eating dense Protein...so I gravitated towards sliders. When I revised to sleeve I specifically sought out a program that had what I knew I missed and have been very successful and maintaining too. I was very motivated both times, and had very different outcomes.

I understand there are emotional, psychological issues at play too, but it it was a good procedure that initially limited my quantity capacity and hunger...and then the education over the long haul of how to keep"working the sleeve" were much more important in my case.

It seems hard to believe but one of the reasons I always failed at weight management was my all consuming drive to eat, my 24/7 hunger. Once that was reduced, it became much more possible to be compliant.

[James Marusek 5,244]

Two thoughts cross my mind.

First - there seems to be very little guidance once an RNY patient reaches the "Maintenance" phase, other than avoid grazing. (Whereas, the direction during the "Weight Loss" phase is very, very detailed - almost a book.)

Second - The approach in the "Maintenance" phase is very different than during the "Weight Loss" phase for RNY gastric bypass patients. After surgery, the part of the stomach that process fats and sugars is cut away and consuming these items in quantity can lead to dumping. But after about a year, the intestines learn to process these elements to take up the function that was once performed in the stomach. Therefore patients can once again consume these types of food. The key to the "Maintenance" phase is hunger control. Fats can play a vital role in this area. Anyways more here. http://www.breadandbutterscience.com/Surgery2.pdf

[needtorecover 574]

My internist and OBGYN were both discouraging against WLS. It would've helped if they'd been more educated on the topic (especially my internist). I know my internist wanted to help but she didn't know what to do or say and thought WLS had too many complications and wasn't worth the risk. Granted this was about 5 years ago when I first inquired and as time passes the procedures get safer...

Now I'm worried about going back to her for my physicals because I don't know if she'll know how to treat me from here on out. I wish bariatric surgery was more mainstream. There is SO MUCH misinformation floating around the internet and I was overwhelmed when I did my own research. I was grateful for my bariatric surgeon who is also a researcher at my local university and his wife does obesity research and they taught me a lot.

I don't want to go to my doctor feeling like I need to defend my surgery. I want my doctor to know more about WLS and maintenance than I do but as of now that's hard to find because they still primarily go with the traditional advice of "eat less and move more."

[Valentina 2,642]

Am I alone in my belief that surgeons are creations of God on a day when He had a Migraine? ?

---AND---

There is a reason why surgeons exhibit their best patient to doctor skills when their patient is asleep.

Seriously, I really do believe that surgeons have a different mind set than general practitioners. Maybe it's the need for a more separation personally with the patient--the same theory of a PCP not treating or prescribing drugs for his/her own family. The connection is too close to be objective.

I feel that a highly successful "Bariatric Team" should not only include a surgeon, a nutritionist, a therapist and a well trained supporting staff, but should also include a general practitioner who would be primary provider for all aspects of the bariatric journey except the surgery itself. Release the surgeons to do what they do best--surgery-- while releasing them from the "best side manners", which most of them are just plain lousy at.

A monthly post op check with the PCP, the nutritionist, and the therapist should be part of the package with no added fees for six months, then every three months for the remainder of the first year and then twice a year thereafter--also with no added charge (other than routine co--pays).

I also believe that seeing a therapist just once for clearance falls way short of ensuring a solid mental foundation that is imperative for successful WLS journey. A monthly therapy session during the six month pre-op should be required--in my opinion.

After reading posts here and talking with other WLS patients, I believe that our minds take longer to get on track than our mouths ever will.

Great thought provoking posting. Thank you!

[CowgirlJane 14,259]

@@Valentina I shared those beliefs until I met the surgeons at my bariatric practice. Never have I experienced the compassion, taking time to educate and encouraging realistic yet life changing results. They are tuned into the emotional issues - don't try to solve them, but do screen for them. Best of all, they believe in follow up. Lately they have been doing radio spots, which I normally detest from doctors, but the tone of theirs is awesome. It isn't just about recruiting new surgical patients, they speak about helping people get back on track in such a welcoming way.

I know my surgeons are a rare breed, but I feel like primary care docs lack training in obesity and really don't know enough about metabolic disorders to fill the role. I do agree there is often a gap, especially over the long haul.

I am 4 years out and haven't been seen by my bariatric team in quite awhile. I think I will go in this year because it gives me some peace of mind and because I have had a rough go of it Healthwise over the last 2 months. Bloodwork is good, but I wonder if something Is"up" or if I am just unlucky lately.

Sent from my KFJWI using the BariatricPal App