Surgery not a stand-alone quick fix for obesity and the problems it causes
Surgery not a stand-alone quick fix for obesity and the problems it causes
It must be paired with education on lifestyle changes and health maintenance
For people struggling with obesity and the health problems it creates, bariatric surgery can be a solution. However, it is not a quick fix but a tool to assist with weight loss, says Amanda R. Budak, RN, MSN, bariatric surgery program manager at the Medical University of South Carolina in Charleston.
"There are still behavior changes that need to occur, and success with the surgery and weight loss requires lifelong changes to eating habits," explains Budak.
Patients are no longer able to eat the size and types of meals they had been able to eat in the past. They must avoid sugar, high fat, and fried foods. Also, because of the change in their absorption of food, they must be on lifelong nutritional supplements to make sure they are consuming the vitamins, nutrients, and proteins they require, she says.
Anyone considering obesity surgery, such as gastric bypass or gastric banding, must be prepared to make lifestyle changes. This requires education pre- and post-operatively and a lifetime of support.
People who are obese (severe obesity is defined as having a body mass index of 40 or more according to the Washington, DC-based American Obesity Association) have a diet mentality and have experienced a lot of failure trying to address the problem, says Robin Blackstone, MD, FACS, medical director and lead surgeon at Scottsdale (AZ) Bariatric Center.
"You really have to start from scratch and try to educate them about what they need to do to make this work for them long term. There are not a lot of areas of surgery where people's actual psychological makeup and behavior have such a big impact on the success of the procedure," says Blackstone.
Health care professionals must partner with patients to motivate and help them make the changes they need to make to be successful. People who are obese want desperately to be successful with bariatric surgery but they do not know what to do; depending on the type of surgery they choose they need to be taught what to do to make the changes, she says.
Commitment vital for success
The first area that needs to be addressed is commitment. Patients must be completely committed to making the lifestyle changes necessary for successful surgery.
"The patient, in their own mind, needs to have worked through some serious attempts of behavior modification and exercise so they really understand they are in a space where they must get rid of the weight for their health and they understand they will have to take more risk in order to overcome this disease," says Blackstone.
The most important thing a patient can do to prepare is to make sure their family members are supportive of their decision because of the lifestyle changes that are required, says Budak.
"The lifestyle changes can ultimately impact other members of the family, affecting their meals and eating habits," she explains.
In addition, there are many psychological effects of the surgery. For example, patients who have used food as a coping mechanism must now confront that issue and develop other coping mechanisms.
Blackstone says patients at the Scottsdale Bariatric Center are given a true/false test to make sure they truly understand key issues before their surgery is scheduled. One of the statements on the test reads: "Gastric bypass is not a serious or risky procedure and after surgery your obesity is cured and you don't need regular medical care."
"When someone answers true, we go back to square one," says Blackstone.
Prior to the test, patients undergo extensive education as well as suggestions for immediate lifestyle changes that help demonstrate their commitment.
Patients who smoke are asked to quit three months prior to surgery and their blood is checked for nicotine levels. This lowers their risk for complications such as pneumonia following surgery and also provides an indication of their commitment to making healthier choices.
A meeting with a nutritionist who has reviewed the food journal they are asked to submit provides an opportunity to make small lifestyle changes that will produce weight loss before the surgery date. For example, if the patient is drinking 20 cans of cola a day they are asked to decrease the amount until they are no longer drinking the beverage.
"We try to give them a prescription of how they can make some small changes that will result in about a 10% weight loss prior to surgery, and that process they go through helps at the time of surgery and also helps demonstrate their commitment," says Blackstone.
Thorough psychological testing helps identify issues such as binge eating disorders so they can attend workshops prior to surgery to help them overcome the problems.
Before a date for surgery is set people learn about portion sizing, what a 3.5-ounce piece of meat looks like, and also about good food choices.
Patients who undergo surgery must learn a new way of eating. They will be at risk of overeating if they are not mindful of the food they put into their mouths. Most people don't think about what they put into their mouth and as a result consume about 40% more calories then they realize, says Blackstone.
The pouch created following surgery is able to hold about as much food as a person can hold in the palm of his or her hand. While it does not look like a lot compared to the super-sized meals Americans have become used to eating, it is large enough if it is the right foods, she explains.
With gastric bypass surgery, an adverse reaction to certain foods can help people in stressful eating situations, says Blackstone. The body has a negative physical reaction to high carbohydrate and high fat foods; a person's heart rate goes up and he or she gets sweaty and feels sick. The reaction is called dumping syndrome, she explains. Yet the body will not react adversely to a small amount of something high in fat such as cheesecake if it is consumed following a 3.5-ounce serving of salmon with broccoli.
This reaction helps people learn to make good choices at mealtimes, as well. If people who have undergone the surgery eat a palm full of protein and vegetables at mealtime they will do fine. However, if they eat french fries they will get sick.
For the first three to six months following surgery, patients are on a very structured eating program, especially those who have undergone gastric bypass surgery, so they will heal correctly and the opening between the pouch and the intestine remains small, says Blackstone.
"At the end of the six months patients need to have gotten rid of bad habits and understand how to make healthy choices in different situations. Education is about really understanding how to make good choices," says Blackstone.
Also patients learn a new way of eating. Following surgery they are asked to eat for a time without doing anything else during meals, such as watching television or reading a book, and to chew slowly. In this way, they begin to recognize the flavor, texture, and quality of food and seek it for its nutrition.
"Many people who do not have a degree in nutrition really don't understand that food is something you do to survive," says Blackstone.
Exercise is another component that patients learn to incorporate into their lives. Because of their size, many of the patients who undergo weight loss surgery have musculoskeletal complaints that keep them from exercising, says Blackstone.
While patients are encouraged to do some form of formal exercise for an hour three times a week, such as swimming, walking, cycling or yoga, they are also taught how to incorporate exercise into their daily living. For example, wearing a pedometer and trying to get a certain number of steps in every day will mean people park farther away from the door at the supermarket and perhaps walk to lunch instead of driving.
"It is those changes in energy expenditure that will help them maintain their weight long term so having that focus of exercise that is grounded in everyday things they do is an important pillar of our process," says Blackstone.
At the Medical University of South Carolina patients who have undergone weight loss surgery can attend a monthly support group where they can discuss their concerns and provide support for one another as they make the lifestyle changes, says Budak.
"Although it is a difficult change, if patients are well prepared prior to the surgery and motivated it is fairly easily accomplished," she says.
Regular follow up a must
With the right kind of educational process people will make significant changes, says Blackstone. However, the lessons learned must be reinforced by annual updates from some literature that is emerging showing that people who have successfully lost weight with the surgery can move away from the basic tenets they were taught over time, she explains.
In addition, once people reach their goal weight they need to be seen regularly by their physician or a nurse practitioner to make sure their vitamin levels and protein stores are good and they are not losing bone, says Blackstone. It is no different than other health maintenance routines such as an annual mammogram, she adds.
Sources
For more information about the education that must accompany bariatric surgery, contact:
- Robin Blackstone, MD, FACS, medical director and lead surgeon, Scottsdale Bariatric Center at Scottsdale Healthcare, 10200 N. 92nd St., Suite 225, Scottsdale, AZ 85258. Phone: (480) 391-3885. E-mail: [email protected].
- Amanda R. Budak, RN, MSN, bariatric surgery program manager, Medical University of South Carolina, 96 Jonathan Lucas St., Suite 211, P.O. Box 250327, Charleston, SC 29425. Phone: (843) 792-6561. E-mail: [email protected].
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