.comment-link {margin-left:.6em;}

shrinkykitten

"...another reason I'm intrigued with the hanged of Salem, especially the women, is that a number of them aroused suspicion in the first place because they were financially independent, or sharp-tongued, or kept to themselves. In other words, they were killed off for the same sort of life I live right now but with longer skirts and fewer cable channels." Sarah Vowell, The partly cloudy patriot.

7.21.2007

Weight loss surgery

Bella (cant link to her as her blog is password protected) has been talking about issues related to weight, weight loss, and surgery for weight loss. I have thoughts on this, and thought I'd post them there so as to not hijack her commenting area.

For the purposes of this, let's talk about weight issues insofar as they relate to weight that is higher than is healthy or comfortable - or that makes a person unhappy - subjectively speaking. Weight charts and BMI are not helpful in determining how healthy or not one is; some people can be very healthy and be overweight by BMI charts, and some people can be thin or "normal" and be very unhealthy. For the purposes of this, we're talking about the subjective experience of feeling overweight.

Issues related to weight, as I noted in a comment recently and in a couple of blog posts, (and others too), are multidetermined. You simply cannot say that it is due to emotions, due to feeling deprived, due to bingeing, due to genetics, due to inactivity, etc. There are so many factors, and it is different for each person. Sure, losing weight is about decreasing calories and increasing activity - but unless you really understand and target what got the person to the weight, interventions will fail. You can get rid of soda machines and make apples available all you want - but unless you really address an individual's reasons for overweight, it will make no difference whatsoever.

Surgery for weight loss (gastric bypass, roux en y, lapband, etc.) are becoming more and more common, and are more likely than any other weight loss strategy to be covered by insurance, medicaid, or medicare. There is a brilliant piece by Atul Gawande in the book Scoot over skinny that explores some of the issues with this surgery. Most horrifyingly, he documents a trend among physicians/surgeons to insist that obese (medically determined or not) patients get the surgery before they will give them medical care. This is horrifying.

In my time working at an eating disorder clinic, I worked with a lot of people who were overweight to quite overweight. I was often quite disturbed at how they were treated by their doctors - any health issue they experienced was, more often than not, attributed to their weight and NO FURTHER TESTS WERE DONE. This is a travesty. Not all health issues among people who are overweight can be reduced to the weight. And, just because someone is overweight - even if their health issues are related to their weight - this does not obviate the medical communities responsibility to provide quality and unbiased medical care.

Part of my clinical training involved doing psych evals for gastric bypass surgery (and related surgeries). Before undergoing weight loss surgery, everyone should get a psych eval. In our hospital, this was thankfully required - but I'm not sure if this is true everywhere. There are a few reasons for this.

First, people often think of gastric bypass as a magic bullet - they think they will get the surgery and *poof* they will eat less and lose tons of weight. Thus, part of the job is psychoeducation about the surgery, the side effects, the benefits and drawbacks, complications, and the diet. The diet involves eating only a shot glass amount of food at each meal (3-6 meals, depending on how far out you are from having surgery) for the rest of your life. Many people are underr the misperception that this is a short term thing - that the surgery can be reversed and you can go back to eating "normally" or that the ouch will stretch and you can eat more normally - this is not true - this is a lifelong diet. Given that children and adolescents are being increasingly targeted for this surgery, this is a very scary prospect. That's a hell of a long time to live that way! And the nutritional effects on a child who is still developing are not understood, at all. Also, we do not know enough about how this effects pregnancy and fetuses. Sure, you take tons of vitamins to make up for the small amount of food you eat, but still. Personally, I also do not understand how people cognitively function with this little food - and how they don't go into starvation mode too.

Second, we have to make sure there are no emotional issues at all. Active binge eaters need to be completely excluded from this as they are likely to binge eat and burst their pouch or their band. I knew some people who had had to have had the surgery redone over and over because they kept bingeing and kept bursting the pouch. They never lost weight.

Third, I needed to ensure that the person had tried every damned diet possible - had tried absolutely everything - and that this was really really really a last resort. This surgery is a lifestyle change - not a quick fix. Most people don't realize this and see this as an easy option.

Fourth, we try to get people to make changes in advance of the surgery - we try to get them to adopt the post-surgery diet in advance to make sure they can adhere to it. We make sure they can stick to a strict schedule and strict diet. We need make sure that family and partners will be very very supportive. I know of someone whose partner would go and buy them fast food all the time because the partner was not really okay with the client's weight loss. This is a bad set-up.

As I recall, out of all the evals I did - I only recommended one person for the surgery. And when I was doing it, the hospital was trying to increase their rates of the surgery and were referring people who were ~250 pounds for the surgery - which I found ridiculous. The only person I recommended was over 500 pounds, and I honestly felt it was the only thing that could help.

We know so little at this point as to what is predictive of success and what predicts failure. We don't know much about the long term effects, the effects on pregnancy and children (what would it be like to have a mom or dad who only eats a shot glass full of food at each meal? Could that lead to disordered eating among kids?), the emotional effects of this, etc. In fact, some studies have shown that the surgery has actually pretty scary rates of failure and complications.

There was an interesting article a couple (?) years ago about 3 or 4 women who had had the surgery. They were really quite messed up. One woman had developed bulimia (so dangerous after gastric bypass) because she was terrified of gaining weight again. One woman had started drinking heavily. One woman's sister died from the surgery. Sure, there are successes - but wouldn't a more successful and less potentially damaging strategy be to create programs that address the whole person? Fun exercise, teaching people how to cook tasty, nutritious meals, social support, counseling, advocacy, and support for life issues (poverty, smoking, unemployment, domestic violence, divorce, parenting, etc.). This, I would argue, woudl be the only way to help create lifelong change that is healthy, supportive, and that has few to no complications and life-threatening side effects.

One of my issues with this curgery too is about informed consent. If one is extremely overweight, how many options do they really feel like they have? If this is presented as a good one, or as the only one - do they truly have the ability to freely consent? If they are being told they cannot get medical care unless they do it? If it is the only weight loss strategy covered by insurance, medicare, or medicaid - are they really consenting freely? It makes me think of medical studies and poor people. If going through a potentially risky study is the only way to get free drugs, surgery, or to get a good chunk of money - are you really able to consent freely? Given how prejudiced we are against overweight, how much we blame people who are even slightly overweight, and how hard it is to lose weight by oneself, can one say that the pathway to surgery is one that is chosen freely?

2 Comments:

At 8:01 PM, Blogger k8 said...

I've had trouble with excess weight most of my life, but I can't imagine ever considering that surgery. Doing that to my stomach and never being able to eat normal again would, for me, be torture. I love food and I love to cook and bake (hmmm...this could be one aspect of the problem, or at least one that exacerbates the stress eating problem). I would do liposuction before I would ever consider gastric bypass, and I'm not considering that either.

Part of the problem with weight loss, for me anyway, is a problem of delayed gratification. It takes a long time if you want to be healthy, too. I want to see the weight loss immediately. Plus, with fibromyalgia problems, I'm not suppose to engage in exercises that are medium- or high-impact. Having said that, in the past year I've lost about 40 pounds (Christmas/New Year time led to some regain or it would be more). I still don't see much difference, and no one mentioned noticing any difference until after 10 months and 30+ pounds. I'll be working on it for a while still, but I gained it over time, so I've decided that it will take time to get rid of it.

I don't know how people get to the point that they undergo that surgery. I think I understand some of it with the extreme case you mentioned (500+ pounds), but I can't understand it for most younger people. There's still so much time to work on developing new habits and ways of being.

I probably should note that for me changing habits was, in part, finally motivated by the possibility of surgery. I developed a problem with gall stones, which normally means gall bladder removal. I asked if there were any other possibilities, and was told that sometimes they more extreme problems can be controlled through diet - specifically increased fiber and reduced fat. Fortunately, it works for me so no surgery and some additional motivation to watch what I eat.

Sorry that was so long, but this is a topic I think about now and then.

 
At 3:19 AM, Blogger Bella Sultane said...

I'm glad that you posted about this. When I was writing my post, I was thinking in the back of my mind that it would be interesting to hear your take on it. :-)

I've been hearing more and more about how weight-related perceptions factor into bad medical care, which is incredibly disturbing.

It's actually kind of reassuring to hear the process you describe that people must undergo before being recommended for surgery. In the NewsHour piece, they made it sound so... automatic, so "hey, everyone get your gastric band surgery over here!"

There should be more reflection about the questions you raise in the last paragraph. What *does* informed consent really mean if it's surrounded by so much pressure (and covert/overt coercion)?

 

Post a Comment

Links to this post:

Create a Link

<< Home