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
16 Review Bariatric Times • July 2016 P atient: Well, I've been embarrassed about size since I was a kid, so liking any part of my body would be an improvement. Provider: That's a really good way to think about it. One of the critical components of success after the surgery is improving y our body image no matter where your weight settles after the surgery. Do you have any ideas about that? P atient: I'm not sure what you mean. Provider: One exercise I often have patients do is make a list of g oals they would like to accomplish in your first year after surgery. This will help you to start thinking about all of things that you want to do with y our new body that were more difficult to do at a heavier weight. Once you start losing weight your energy, physical abilities, and self-confidence will improve and you will start to focus on what your body can do. Patient: I could do that. I really want to do some traveling but I worry about feeling uncomfortable in an airplane seat. I also want to take my niece and nephew to Disney World but I worry about being able to walk all day and fitting on the rides. I don't want to embarrass them and myself. Provider: You already have some great ideas to put on your list of goals you want to accomplish the first year after surgery! Over time you will begin to realize that you don't have to be the perfect weight or have the perfect body to start living your new life. Vignette 4: Expectations— Relationships. Vignette 4 presents a conversation with 46-year-old female patient who is 5ft. 7in. and 270 lbs. Her BMI at the time of the conversation is 42kg/m 2 . She underwent LAGB in 2012 when she weighed of 320 lbs. She has obstructive sleep apnea and anxiety that she treats with medications. She is married and employed. Provider: Since you've had a LAGB, you know how difficult keeping weight off in the long- term can be. We already talked a little bit about your family and that sometimes you think your husband tries to sabotage your weight loss. This could be an issue after your conversion to vertical sleeve gastrectomy (VSG). Could we spend some time talking about this today? P atient: Yes, if I have another surgery, I want to be successful. Provider: Can you tell me more about what you mean by you t hink your husband sabotages your weight loss. Patient: Yes he's been doing it since I got my LAGB in 2012. He d idn't want me to have it in the first place. I can give you an example of something that happened the other day. I told him I had lost 5 lbs. since I s tarted changing some things in my diet to get ready for VSG. He told me he thought that was great. The next thing I know he's serving me a plate full of food for d inner. It was way too much food! He waits to make dinner for me when I get home from work around 8pm. I have told him not to make big meals for me but he d oesn't listen. If I don't eat with him, he gets upset. Provider: That sounds very frustrating. Do you have ideas about reasons he may be behaving that way? Patient: This is my second marriage and we were married 2 years before I got my LAGB. I decided to do the LAGB because I had gotten so heavy I could barely make is through my work shift in in the ER. Ever since I had the LAGB, he's made comments about how I better not leave him when I get skinny. His first wife was unfaithful to him, so he has some trust issues. Provider: He was upset when you decided to make some changes in your life to improve your health. Patient: He was really upset when I decided to stop drinking alcohol with him. He's still drinking and that's usually when he makes comments about me leaving him. He's disabled and his 21-year-old daughter lives with us. Provider: As long as you remain overweight, nothing changes for him. If you start living a different life after weight loss, he might feel he has a lot to lose. Patient: I had not thought about it like that but maybe. I do have some plans for my future. I applied for the position as charge nurse in the ER, and I got it. Now, I'm thinking I may even want to get an advanced degree in nursing, especially if I can lose the rest of this weight. The LAGB helped me lose some weight, but I still have a lot more to go. P rovider: You have vision for your future and the conversion operation is a tool to help get you there. Where do you see your husband fitting in to that v ision? Patient: Well, he doesn't really want me to have VSG since I've had problems with vomiting after m y LAGB. Provider: And there may be other reasons too. P atient: Yes, he says he's supportive but sabotages me at the same time. I've tried to talk to him about it but nothing changes. Provider: Despite his behavior, you have been able to stay on course and seem pretty committed to your vision for the f uture. Patient: I have a lot of other people who support me. My daughters and my mother are excited for me to do this surgery. My grandkids can't wait for me to be more active with them and go to their sports games. Provider: Do you see your husband fitting in to your plan for becoming more active with your grandkids and seeking advancement in your career. Patient: Honestly, I don't know. But I'm not ready to talk about divorce with him. Provider: There is no way to know right now, what will happen with your marriage as the first year after surgery is a period of transition. What we know from research is that some spouses may experience improvement in relationship satisfaction while others may not. For example, some studies have shown that when spouses become more social and more assertive with increased self- confidence after weight loss, marital satisfaction can decline. Patient: I guess I could see that. My husband complains when I go to the gym on my days off. I always invite him, but he says no. I think he's uncomfortable with me going out and doing things on my own. Maybe he does want me to stay fat so I won't leave him. Provider: That's one thing to consider given what we've discussed today. Has your husband been involved in your work-up process so far? P atient: No. But I haven't really asked him to be because he wasn't supportive with the LAGB. Should I bring him to my nutrition appointments since he d oes a lot of the cooking? Provider: That would be a good place to start. P atient: He will probably say he doesn't need to come. Provider: All you can do is let him know that his support is i mportant to you and encourage him to participate. Patient: One thing is certain, I'm not going backwards. I'm going to l ose the rest of this weight and move on with my life. Provider: One of the hardest things bariatric surgery patients m ay face is knowing when to disengage from people who are negative influences in their lives. You are fortunate though, you have many support people in your life and support from the bariatric team. I encourage you to surround yourself with people who will support your vision for your future. REFERENCES 1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014,311:806–814. 2. Sjostrom L. Review of the key results from the Swedish Obese Subjects (SOS) trial—a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273:219–234. 3. Ponce J, Nguyen NT, Hutter M, Sudan R, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in the United States, 2011–2014. Surg Obes Relat Dis. 2015;11(6):1199–1200. 4. Stanford FC, Kyle TK, Claridy MD, Nadglowski JF, Apovian CM. The influence of an individual's weight perception on the acceptance of bariatric surgery. Obesity. 2015;23:277–281. 5. Ochner CN, Kwok Y, Conceicao E, et al. Selective reduction in neural responses to high calorie foods following gastric bypass surgery. Ann Surg. 2011;253(3):502–507. 6. Stylopoulos N, Hoppin AG, Kaplan LM. Roux-en-Y gastric bypass enhances energy expenditure and extends lifespan in diet-induced obese rats. Obesity. 2009;17:1839–1847. 7. Wilson-Perez HE, Chambers AP, Sandoval DA, et al. The effect of vertical sleeve gastrectomy on