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
Editorial Message 3 Bariatric Times • July 2016 Dear Readers: What an honor it is to be this month's guest editor of Bariatric Times! I know this is only because Dr. Raul Rosenthal is devoting so much time to the American Society for Metabolic and Bariatric Surgery (ASMBS). And what a great job he is doing! In fact, reflecting on the changes since I was President: 2007-2008, it's a completely different organization. The ASMBS is the undisputed champion of the world for advocating for the ethical and unbiased treatment of the disease of obesity and metabolic syndrome. Through the tireless work of many individuals, such as Raul, our specialty has matured greatly. Yet, we have a long way to go before society, third-party payers, and our medical community accept this disease as a chronic, multifactorial disorder. There is no better illustration of this attitude than the "non-covered benefit" or the "one procedure per lifetime" clause built into many insurance contracts. "…so long as you both shall live" What is missing? It's not because the ASMBS is not representing us or fighting for the ideals, rather I think a large part of the problem is our own attitude toward the treatment of this disease. Sure, before surgery, patients are victims of their disease and we are advocates for treatment (as long as it involves a procedure), but what happens when times get tough? What happens to patients if they do not succeed or they have a complication from a procedure many years later? We often label them as "non-compliant." They are told to go back to their original surgeon. They are orphans, or worse, treated like a "one- night-stand." Of course, we are often treated as such by our patients who rarely follow up and are often non-compliant. But the fact remains, every failure, every complication is not born by the individual surgeon, it is a responsibility of all of ours who practice this specialty. We have an obligation to care by not only advocating for the primary treatment of this disease, but also for patients who have already had surgery. It's a marriage—for better, for worse… Bariatric/metabolic surgery: marriage or one-night stand? Dr. Lee Kaplan said it best in one of my courses on revisional surgery: WWOD—What would the oncologist do? Brilliant! As I was trying to figure out why we have not gained traction with respect to more widespread acceptance of our interventions, despite the great body of evidence available today, it occurred to me we might have a public relations issue. And it's our fault—not the ASMBS. The oncologist designs a treatment plan, based not solely on an intervention, but rather a truly multidisciplinary plan that may include surgery yet doesn't have to. The oncologist is not disappointed by not having personally cured the patient, but rather satisfied with long-term remission. The oncologist doesn't institute random protocols unless part of a study and reports their data. The oncologist isn't seen as pushing chemotherapy, so much as fighting a disease—cancer. The oncologist knows when no further intervention is appropriate but is still willing to care for his/her patient. Cancer treatment is universally covered, expensive, and Dear Colleagues, This month we feature an article on a topic that is very near and dear to me—talking to patients about realistic expectations for weight loss. Authors Gretchen E. Ames, PhD, ABPP; Matthew M. Clark, PhD, ABPP; Karen B. Grothe, PhD, ABPP; Maria L. Collazo- Clavell, MD; and Enrique F. Elli, MD, address patient expectations for weight loss and also quality of life, body image, and relationships. Although they mainly discuss expectations after bariatric surgery, I feel the same communication can and should be applied for individuals undergoing any weight loss intervention, including diet, exercise, behavior modification, and pharmacotherapy. Realistic expectations are important because patients often present with unattainable goals, at least in the short term. For instance, a patient might express wanting to lose 100 pounds and achieving type 2 diabetes mellitus (T2DM) remission six months after beginning an intervention. While this is unlikely, we have to balance known realistic expected weight loss, while preventing the the patient from feeling that it is not worth the effort. Their ultimate goal can be 100 pounds, but small, attainable goals along the way may be preferable. Through thorough literature review, Ames et al conclude the following: 1) patients' expectations for weight loss after bariatric surgery greatly exceed actual outcome, and 2) patients report that they would be disappointed with a sustained weight loss that is close to the average expected outcome. 1–6 They discuss the challenge for providers to strike a balance between "guiding patients toward an accurate understanding of treatment outcome without diminishing enthusiasm for the possibility of living a different life after weight loss." I attempt to achieve that balance by taking a step-wise approach with my patients. First, I help the patient set an initial, attainable weight loss goal (e.g., 5 to 10 percent body weight loss). Once they achieve that first goal, then I evaluate their situation and set a second modest goal. I think this approach is more realistic for patients. In the process, they can see that even a modest weight loss significantly improves other medical problems, their quality of life, medication requirements, mobility, etc. It is definitely a balancing act that is crucial in working with patients who are trying to achieve weight loss. Proper communication of expectations needs to come from everybody working with a patient. Spouses, family members, friends, and even other physicians may be reinforcing a patient's unrealistic expectations. The entire care team should be working to present unified communication. If one provider tells a patient they can expect to lose 50 pounds three months after gastric bypass and another provider relays a different amount of expected weight loss, the patient is left wondering who is correct. These mixed messages create a potential treatment nightmare. We need to work together to ensure a patient is receiving the same message. The multidisciplinary care environment is ideal for Changing Perceptions: Obesity as a Disease, Focus on Collaboration and Long- Term Management "For Better, For Worse" Communication is Key in Helping Patients Set and Achieve Realistic Goals for Weight Loss with Any Treatment Modality A Message from Dr. Kelvin Higa A Message from Dr. Christopher Still Christopher Still, DO, FACN, FACP, Co-Clinical Editor, Bariatric Times; Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity Research Institute, Geisinger Medical Center, Danville, Pennsylvania. Kelvin Higa, MD, FACS, is Clinical Professor of Surgery, University of California, San Francisco, Fresno, California, and Director, Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, California. He is also a past president of the American Society for Metabolic and Bariatric Surgery (2007-2008) and President-Elect for the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). Continued on following page... Continued on following page...