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
13 Review Bariatric Times • July 2016 n ormal range. Another area of serious concern for patients postoperatively is loose and hanging skin after massive weight loss. 31 Excess skin is associated with d ecreases in physical functioning, body image, and self-esteem. 38 Consequently, a small number of patients report they would not have chosen to undergo bariatric surgery i f they had known about the negative effects of excess skin. Thus, most patients desire body contouring after bariatric surgery but few actually undergo body c ontouring operations as they are cost prohibitive and generally are not covered benefits on most health insurance plans. 39,40 Based on our review of the l iterature, the following areas should be addressed regarding expectations for improvement in quality of life and body image as patients are not always informed p resurgery about the potential negative effects of massive weight loss. 41 First, discuss with patients that they can expect to experience dramatic improvements in many areas of quality of life, particularly physical health and functioning, within the first six months after having bariatric surgery. Furthermore, while many weight- related aspects of quality of life will improve, others domains of quality of life may not improve post bariatric surgery. Second, discuss with patients the possibility of dissatisfaction with body image and consider a referral for counseling when these concerns are negatively impacting mood or interfering with daily functioning. Explain that concerns about weight and body shape may be less influenced by massive weight loss and that many patients who do lose a large amount of weight will have significant concerns regarding loose and hanging skin. 40 Women in particular are most likely to be dissatisfied with specific regions of their bodies including abdomen, breasts, upper arms, and thighs. Third, discuss that most patients suffering physical impairments and low self- esteem associated with excessive skin desire a body contouring operation. 38,40 Patients should also be informed that most health insurance plans view body contouring operations as cosmetic, therefore, they generally are not covered benefits and patients may incur a large out-of-pocket expense if they choose to undergo an operation. 39 Nevertheless, if patients are unable to afford an operation, the desire to undergo a body contouring appears to decrease over time. 42 Vignette 3 presents a conversation with a 42-year-old female patient with a BMI of 49kg/m 2 with life-long dissatisfaction with her body image. RELATIONSHIPS: RESEARCH FINDINGS Obesity is often a family health problem where the prevalence of obesity among children of parents w ith obesity is greater than 40 percent. 43 Yet, the literature investigating the impact of bariatric surgery on immediate family members and relationship quality is s parse and largely retrospective, yielding mixed results. 44–46 Some studies have shown that bariatric surgery may have a "halo effect" when one adult family member u ndergoes an operation. 4 7,48 P ositive effects including modest weight loss, improved diet quality, and increased levels of physical activity have been observed among family m embers of RYGB patients. 4 7 Moreover, other studies have shown that when family members undergo bariatric surgery together they lose more weight, have lower BMIs, and b etter attendance at follow-up appointments postsurgery when compared to case-matched controls (i.e., age, gender, BMI). 49,50 Thus, it may be beneficial for patients to encourage other family members to either consider bariatric surgery for themselves or to engage in lifestyle changes required for successful outcome after bariatric surgery. Similarly, only a small number of studies have been conducted on changes in romantic and/or marital relationships after bariatric surgery. 44–46 Being married, in general, is related to increased life expectancy 51 and has been associated with improvements in obesity-related comorbidities like blood pressure and diabetes. 52,53 These metabolic improvements were associated with marriage quality characterized by positive and supportive interactions. Bariatric surgery, however, is a time of significant transition for patients and their spouses. Recent studies arrived at two different conclusions regarding relationship stability and quality following bariatric surgery. Ferriby et al 44 conducted a review of the literature on patient and spousal outcomes. They found that patients who are married, on average, lose less weight in the first year after bariatric surgery than unmarried patients and that couples' relationship quality tended to decline from pre- to post-WLS. One study investigating marital quality following bariatric surgery found a decrease in marital satisfaction among male spouses of female bariatric surgery patients. Decreased marital satisfaction among husbands was associated with increased ratings of extroversion and assertiveness in their wives from pre to postsurgery. 55 Conversely, women who underwent bariatric surgery r ated their husbands as less social and less interesting one year after surgery. A recent study of men's perceptions of changes in spousal relationships after bariatric surgery f ound themes within a family systems framework of unintended consequences and inconsistent social support. 54 Some unintended consequences were that r elationship insecurity increased after weight loss where men perceived that their wives were fearful that they may desire to leave the relationship. Men also perceived t hat as they lost weight, their wives became increasingly insecure about their own weight and body size, particularly when they weighed less than their wives did after surgery. E xamples of inconsistent support were that some men reported their spouses were unwilling to change eating habits and complained about the amount of time their husbands s pent engaging in exercise. Another study by Clark et al 46 also examined how changes in relationship stability and quality relate to long-term weight loss outcomes. They surveyed 361 patients who underwent bariatric surgery (95.9% Caucasian, 80.1% female, average 7.7 years postsurgery, mean age at surgery: 47.7 years [range 21–72]; 87.3% underwent Roux-en-Y gastric b ypass). Among those who maintained their relationships postoperatively, relationship quality was found to be associated with weight loss outcomes. Those with i mproved relationships postsurgery had significantly greater %EWL. The authors concluded that their findings support the importance of assessing relationship stability and q uality in presurgery candidates, as healthy and stable relationships may support improved long-term outcomes. Interventions to improve relationships pre-and postsurgery m ay increase both quality of life and weight loss outcomes. 46 Vignette 4 presents a conversation with a 46-year-old female patient with a BMI of 4 2kg/m 2 e xperiencing a partner relational problem. She previously had laparoscopic adjustable gastric band (LAGB) and desires a conversion to VSG. CONCLUSION Many patients have high expectations for weight loss and improvements in quality of life and body image after bariatric surgery. Furthermore, relationships with immediate family members and/or romantic partners may change in unexpected ways and may have both positive and negative consequences after surgery.