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
14 Review Bariatric Times • July 2016 A ccordingly, the bariatric surgery team is responsible for guiding patients toward achieving an accurate understanding of treatment outcome. Patients should b e well-informed about what challenges may arise with rapid weight loss and dramatic changes in physical appearance, especially in the first year after the weight loss o peration. At the same time, providers must remain cognizant of supporting patients' enthusiasm and vision for the possibility of living a different life after weight loss. T able 1 presents a summary of topics for discussion with bariatric patients based on research findings and clinical experience concerning postsurgical expectations for c hanges in weight, body image, and relationships. PATIENT VIGNETTES The following are prepared v ignettes illustrating topics for discussion with pre-surgical bariatric patients concerning postsurgical expectations for changes in weight, body image, and relationships. Vignette 1: Expectations for Weight Loss—Short Term. Vignette 1 presents a conversation with a 50-year-old female patient who is 5ft 5in and 280 lbs. Her BMI at the time of conversation is 47kg/m2 and she has obstructive sleep apnea, and osteoarthritis. She is married, employed, and has no mental health history. Provider: At the time of your initial assessment you were undecided about whether you wanted to have vertical sleeve gastrectomy (VSG) or Roux en-Y Gastric Bypass (RYGB), but you are leaning more toward VSG because it seems less risky to you. There are many factors to consider when choosing the right operation for you. First and foremost we consider your current health status and which operation may be best given your specific health problems. Since you do not have diabetes or gastroesophageal reflux disease, you are potentially a candidate for either operation. Another factor you may want to consider is how much weight you desire to lose after the operation. I would like to spend some time talking about that today if that's ok? Patient: Sure, that would be helpful to me. Provider: At this point, what are you thinking is a healthier weight for you? Patient: Well, I would love to be 145 lbs. again. That's when I think I felt my best. P rovider: When was the last time you can remember weighing 145 lbs.? Patient: I would say probably 20 y ears ago before my first pregnancy. I gained a lot of weight with my first pregnancy, but I was able to lose most of that weight. Although, I never d id get down to 145 lbs. again. I then really started to struggle after my third child was born. My weight was probably up to 190 lbs. then. That was 13 years ago. Provider: Do you remember how you felt about your weight at 190 lbs? P atient: Well, back then I thought I was huge, but right now it actually sounds pretty good. My weight stayed around 190 lbs. for a while, but I have r eally gained in the past five years when my knees and back started hurting. It hurts to exercise, so I'm not doing much now. Provider: Since you are considering both VSG and RYGB, would it be ok if I shared with you the amount of weight you can expect to lose after both of these operations. Patient: I guess that would be good to know. Provider: Generally the RYGB results in a greater amount of weight loss than VSG. Your weight was 280 lbs. today. Approximately 12 months after RYGB you could expect about a 35-percent reduction in your weight, which would be about 100 lbs. After VSG you could expect to lose 25 to 30 percent of your weight or about 75 lbs. in 12 months. How do those numbers sound to you? Patient: So, you are saying with sleeve gastrectomy, I may still be over 200 lbs. but I'll be able to lose more weight than that if I get serious about exercise, right? Provider: It's impossible to know now exactly where your weight will settle after the operation and outcomes can vary widely from patient to patient. Typically patients reach their maximum weight loss about one year after surgery but may not actually accept or feel comfortable with their weight for up to two years. There are other powerful factors that influence how much weight you will lose in the first year. Many of them are not under your direct control like genetics, metabolism, and loss of muscle m ass. Regarding weight loss, there are only two factors under your direct control after surgery. One thing is the effort you put into adherence to the p ostsurgery dietary plan and the second is maintaining consistency with physical activity. P atient: I'm an overachiever and I know I could lose more if I tried really hard. I've lost down to the 160s (lbs.) before, it was after my second child was born. Provider: The last thing I want to do is dampen your enthusiasm about your ability to lose weight. I do, however, want you to spend s ome time thinking about what success after surgery really means for you. Patient: Well, I know that getting b elow 200 lbs. is a must for me. I would be really excited to see a "one" as the first number on my scale. Provider: So, you wouldn't necessarily have to weigh 145 lbs. to feel successful with weight loss? You haven't been below 200 lbs. in a while and that would feel pretty good too? Patient: I think so. Provider: What are some things you can imagine yourself doing after bariatric surgery that you are unable to do now? Patient: Oh, a lot of things. I worked a full-time job and was very active with my kids and involved in their activities when they were younger. I used to love to walk and work in my garden too. Now my 13-year-old doesn't even ask me to do things with her because she knows I get short of breath, which worries her. Provider: You were able to do all of those things comfortably when your weight was 190 lbs. Patient: Yes. I knew I was overweight then but it didn't slow me down and I wasn't overly focused on the numbers on the scale. I was able to multi-task, take care of my family, and work full time. I enjoyed being busy and productive. Provider: That's great. Your vision for your future is returning to a busy active lifestyle. Perhaps the actual number on the scale is not the most important factor. Patient: I have to be honest, I'm a little concerned that I might be d isappointed with my weight loss after VSG. I was pretty sure I didn't want RYGB, but it seems like it would get me closer to a weight I could be happy with. I'm g oing to need to think about this some more. Provider: That sounds perfectly reasonable. Other clinical i ndicators we may want to consider are whether or not you are a sweet eater, your understanding of each operation and the required lifestyle c hanges, and your tolerance for risk with either operation. But, this is not a decision you need to make today. When you have completed the work-up process a nd decide which operation is best for you, the bariatric team will support your decision. Vignette 2: Expectations for W eight Loss—Long Term. Vignette 2 presents a conversation with 35-year-old male patient who is; 5ft 10in and 320 lbs. His BMI at time of conversation is 46kg/m 2 . He has sleep apnea and metabolic syndrome. He is divorced; employed, and manages diagnosed depression with medication. Provider: At your initial evaluation we discussed that you have been considering Roux en-Y Gastric Bypass (RYGB) for about a year now. We also discussed that you believe one of your biggest challenges will be changing the quality of your diet as you enjoy the taste of sweets like cookies, snack cakes, candy, and ice cream. One of the topics I would like to cover today is the long-term weight loss outcomes and some of the risk factors for weight regain after RYGB. Does that sound ok to you? Patient: Yes. My cousin regained all of her weight after her surgery. I just don't understand how that could possibly happen when your stomach is so small and you can't eat that much. Provider: Research shows that a certain percentage of people who undergo surgery will regain all of their lost weight after surgery. It typically does not happen in the first year, particularly after RYGB. However, by 5 to 10 years after the operation, approximately 20 percent of patients will regain all of their lost weight. Patient: So, I could possibly regain all of my weight by the time I'm 45-years-old? Provider: Let's explore the numbers for a minute. With