A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/704136
12 Review Bariatric Times • July 2016 easily comprehend expected weight loss expressed as a percent of initial weight rather than percent of excess weight loss. Moreover, it has been proposed that percent weight loss is potentially a better predictor of outcome as it does not rely on a subjective calculation of ideal weight in the equation for determining excess body weight. 26 An online educational tool created by the Obesity Institute at Geisinger Health System is presently available to assist patients and providers in determining expected weight loss up to 24 months after RYBG through the Get~2~Goal mobile app available in iTunes. 27 Second, discuss with patients that they do not have to achieve ideal or "dream" weight to experience significant improvements in health status, energy level, and quality of life. Research has found that there is a knowledge gap in that patients overestimate how much weight they will lose and underestimate resolution or improvement in medical comorbidities including T2DM, hypertension, and OSA. 23 Third, discuss with patients the bariatric team's definition of success after one year and long- term success regarding maintenance of lost weight and improvements in health status. Some patients may be at risk for assuming they failed the operation if their desired goal weight was not attained in the first year. 28 Moreover, informing patients of long-term benchmarks for success may be useful in maintaining their health behaviors over time. For example, what patients' report as a "disappointed" weight (i.e., 20-25% of initial weight) 20,22 is within a reasonable expectation for weight loss one year after VSG and would be considered successful maintenance 10 years after RYGB. 11 Lastly, it may also be useful to discuss successful outcome in terms of BMI as many patients will remain overweight or obese while still achieving successful weight loss and resolution of medical comorbidities. For patients with a presurgical BMI below 50kg/m 2 , a postsurgical BMI of 28 to 35kg/m 2 is reasonable. Similarly, for patients with a BMI over 50kg/m 2 , a postsurgical BMI of 40kg/m 2 or below could be considered a successful outcome. 29 Vignette 1 presents a conversation with a 50-year-old female patient with a BMI of 47kg/m 2 . She is uncertain about which weight loss operation is best for her and includes a discussion about her desired weight loss. Vignette 2 presents a conversation with a 32-year-old male patient with a BMI of 46kg/m 2 discussing expectations for long-term outcome and factors that contribute to weight regain. QUALITY OF LIFE AND BODY IMAGE: RESEARCH FINDINGS Patients with extreme levels of obesity suffer decreased quality of life in nearly all health-related and w eight-related domains. 1 7 Remarkably, what may contribute most to diminished quality of life prior to bariatric surgery is patients' level of public distress or feeling s ocially stigmatized. 3 0 A substantial body of research has demonstrated dramatic improvements in health- related quality of life including physical and mental health and d ramatic improvements in weight- related quality of life after having bariatric surgery in the domains of physical functioning, self-esteem, sexual functioning, public distress a nd work postsurgery. These changes occur rapidly, usually within the first five-months after having bariatric surgery. 17,31 However, there is presently little p ublished research examining the longitudinal durability of improvements in quality of life domains such as self-esteem and body image, particularly under c onditions of postsurgical weight regain. A recent systematic review of the literature examined the effectiveness of bariatric surgery on psychosocial quality of life up to six years post-surgery. 32 Results revealed that long-term improvements in psychosocial quality of life like depression and body image dissatisfaction did not necessarily mirror improvements in physical health that reliably occur after massive weight loss. Body image is a psychosocial factor that is subsumed under the broader construct of quality of life and is defined as an individual's perceptions, thoughts, and feelings about his or her body and outward appearance. 33 Often, patients report high levels of dissatisfaction with their body image presurgery and depression and low-self-esteem are commonly associated with having body image concerns. 19,34 Similar to improvements in physical health, improvements in body image may occur as quickly as five months after undergoing bariatric surgery. 31 However, losing a large amount of weight may not necessarily be associated with a decrease in concerns about weight and shape after surgery as patients may have unrealistic pre-surgical expectations for improvements in body shape and size after having bariatric surgery. 34–36 One study used an adapted version of GRWQ and Silhouette Figure Rating Scale 37 to assess patient's expectations for achieving "dream", "happy," "acceptable," and "disappointed" body shapes after surgery. 35 Results revealed that expectations for body shape postoperatively were smaller than the body silhouette associated with clinically expected weight loss. In general, patients expected to achieve the body shape that corresponded to a BMI in the TABLE 1. Summary of topics for discussion with pre-surgical bariatric patients concerning postsurgical expectations for changes in weight, body image, and relationships. EXPECTATIONS RECOMMENDED TOPICS FOR DISCUSSION BEFORE BARIATRIC SURGERY W EIGHT Average weight loss after surgery is 25-30% (VSG) and 35% (RYGB) of initial weight Reduction to ideal or "dream" weight is not necessary to improve health status B ariatric team's definition of success regarding weight loss and health status Successful outcome in terms of BMI range (< 35 or < 40 if BMI > 50 presurgery) Acceptance of where body weight settles may occur several years after surgery BODY IMAGE Weight and shape concerns may still be present after large weight loss Loose and hanging skin can be particularly distressing postsurgery Most patients desire body contouring after surgery but this desire may lessen over time Body contouring operations are generally not covered benefits on insurance plans Body image may improve with increased levels of physical activity Body image concerns may be addressed in counseling RELATIONSHIPS O besity is often prevalent among immediate family members Family engagement in lifestyle change may have collateral benefits Family members who have bariatric surgery together may have more successful outcomes Weight loss may have positive and negative effects on relationships and marital satisfaction Seek support from family and friends who support patients' vision for the future A significant challenge for providers, therefore, is guiding patients toward an understanding that bariatric surgery is tool rather than a cure for their struggle with the chronic disease of obesity. Moreover, providers must navigate a delicate balance between guiding patients toward an accurate understanding of treatment outcome without diminishing enthusiasm for the possibility of living a different life after substantial weight loss.