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
15 Review Bariatric Times • July 2016 R YGB we expect that you will lose about 35 percent of your weight in the 12 months after your operation. So that means your weight would be about 210 l bs. by the end of your first year. How does that sound to you? Patient: Amazing! I haven't weighed that since my senior y ear in high school when I played football. Provider: So let's fast forward 10 years. The research data show of t he 110 lbs. you lost in the first year after the operation, you would keep off at least 80 of those pounds. Your weight may settle around 240 lbs. up to 10 y ears after your surgery. Of course these are averages and may not be your exact weight trajectory, but it's probably a good estimate. Patient: I've never been a small guy, but I wouldn't want to weigh more than 240 lbs. again. That's about what I weighed after I finished college. So, why do people gain weight back after surgery? Provider: That's a really good question. It can be a combination of factors. One problem in particular is erosion of diet quality over time, meaning that people return to eating the same foods that in part contributed to their weight gain in the first place. Other factors include not getting enough of physical activity, lack of sleep, chronic stress, and sometimes changes in medication regimen. There is also an association between depression and weight regain. You have depression, so you will want to monitor your mood after surgery, and seek additional treatment if needed. Of these things, that can cause weight regain, what concerns you the most? Patient: Well, sweets and junk foods are a real problem for me. I got into the habit snacking at night after my divorce a few years ago. I know I've put on a lot of weight since then. It was my way of coping with my divorce. Provider: Eating for emotional comfort can be a common problem among patients who are seeking bariatric surgery. Do you think that's what it was? Patient: Yes, I was eating out of sadness and loneliness. Provider: What are some things you are already doing to manage s weet cravings at night? Patient: For starters, I'm trying not to keep sweets in the house. I have learned that once I'm in f or the night, I won't go out and get sweets or junk food. Provider: That's a great idea. So when sweets aren't in the house, y ou feel more confident about controlling your eating. Patient: Yes. I may still snack at night but I won't eat as much if t he sweets aren't around, and my food choices are healthier. Provider: You have already started making healthy changes i n your eating habits to prepare for your surgery, and in the first year, RYGB should help you manage desire and cravings for sweets. Those things combined w ill increase your likelihood of success. Patient: Well, I'm hoping that after a year I will have established new habits and won't go back to the old ones. Provider: That is our hope for you too. In my experience, patients don't purposefully return to problematic eating behaviors, however, they do sometimes under estimate the effort it takes to maintain lost weight after surgery. The surgery will be most helpful for you in the first 12-months in terms of reducing hunger, desire, and sweet cravings but you may still feel a void or emptiness that food may have filled for you. Whether or not you keep the weight off depends, on the consistency of your efforts to manage your weight. How does all of that sound to you? Patient: Ok, I guess. Anything is better than where I am right now. Provider: I can say with certainty that having RYGB is your best chance of losing a large amount of weight and keeping it off. Keeping it off will take consistent daily effort and you've already started doing the hard work of changing your eating habits. The bariatric care team will continue to guide and support your efforts. We will also encourage you to stay connected through your follow-up visits and our post-surgery support group. If weight regain becomes an issue in the future, you will already have support system in place. V ignette 3: Expectations— Body Image. Vignette 3 presents a conversation with 42-year-old female patient who is 5ft 1in and 260 lbs. Her BMI at the time of c onversation is 49kg/m 2 . She has gastroesophageal reflux disease. She is single, employed, and manages diagnosed depression with counseling. Provider: Last time we met, we talked about how you have struggled with weight since childhood and this struggle has n egatively impacted your self- confidence and how you feel about your body. Would it be ok to spend some time talking about this today? Patient: Sure. I've been big as far back as I can remember, probably 10-years old. I was always chubbier than the other k ids which made me uncomfortable. I pretty much kept to myself. Provider: I imagine so, kids can be pretty cruel at times and weight is something you wear on the outside, so it's hard to hide. Unfortunately many overweight children are teased about their weight. Your way of dealing with unwanted attention about your weight was keeping to yourself. Patient: Yes, and now I've gotten so heavy I don't like to go out and do anything anymore. I pretty much just go to work and come home. I can't find any clothes I like in my size. I think losing weight will help a lot. Provider: One thing I want to talk about today is that some patients tell me they feel unprepared for all the attention they receive especially in the beginning when they are losing weight rapidly. You've struggled with weight since childhood, so it may be hard for you to imagine what life will be like after RYGB. Have you thought at all about how you will respond to attention from other people about your weight loss? Patient: Well, I'm not telling anyone at work that I'm doing this. I've only told my parents and my sister. My mom had RYGB eight years ago and now she weighs 120 lbs. She's more critical of my weight than ever and encouraged me to have the surgery. My sister freaked out and said now she's going to be the "fattest one in the family." Provider: So possibly some negative attention from your family and you don't really know w hat to expect from your colleagues at work. Patient: There may be a few people I tell at work if they ask a bout my weight loss, but there I are other people I definitely don't want to know I had RYGB. Provider: Large and rapid w eight loss is something you cannot hide. Some patients tell me they feel uncomfortable with unwanted attention whether it's positive or negative. One reason u nwanted attention can be distressing is because it will take a while for you to adapt to your rapidly changing body size and shape and to feel comfortable w ith what you see in the mirror. Patient: Speaking of attention, my mom will ask me about my weight all the time. When we c ame for the appointment today she tried to look at the scale over my shoulder to see what I weighed. She's very judgemental of people who are overweight now that she's thin. She probably will tell me I need plastic surgery like she did. Provider: Your mom may be hard to please no matter what your weight is. Patient: Yes. I'm sure she'll tell me I need a tummy tuck. That's what she did. Provider: Excess skin is a common concern after surgery. Patients generally report dramatic improvements in body image in the first 12-months after surgery. Many women tell me they love how their bodies look in clothing but report feeling unhappy with extra skin they see in the mirror. Commonly, they desire body contouring of the waist or abdomen, arms, and breasts. For some women it's also a medical issue. Redundant skin can cause uncomfortable rashes and infections. If extra skin negatively impacts quality of life, body contouring surgery can be very beneficial. Patient: I guess I would consider that at some point if my insurance would cover it. Provider: I think it's important to understand that you will likely be thrilled with the weight loss you achieve after surgery, but there may be some parts of your body that remain concerning for you or that you don't like. This is a common experience for many patients.