Related Posts Plugin for WordPress, Blogger...

Bariatric Surgery - Patient Guide to Endocrine and Nutritional Management

>> Saturday, November 6, 2010





As blogged previously, bariatric (weight loss) surgery is a treatment options for people with severe obesity that has proven to be resistant to treatment with more traditional and conservative measures. The treatment does not end with the surgery itself, however - the story is far more complex than that.

As beautifully summarized in the Patient Guide to Endocrine and Nutritional Management after Bariatric Surgery in the Journal of Clinical Endocrinology and Metabolism (a free download!), there are several aspects which require close attention and follow up in order to minimize the chance of weight regain after surgery, to minimize the risk of developing a complication of bariatric surgery, and to ensure that complications of obesity are well managed postoperatively.

To decrease the chance of weight regain after surgery, a lot of the preventive work actually has to happen before the surgery is even done. It must be recognized, as with any 'diet', that the lifestyle change being made has to be a permanent one. This is not about eating smaller portions or altering food choices for a short period of time - this is forever. It is also absolutely critical that the relationship with food is thoroughly explored and managed well before the surgery takes place. There are many contributing factors to overeating, many of them emotional: eating in sadness, in joy, to comfort, to alleviate stress, even to service a true addiction to food. People who have not had help in dealing with these aspects of their weight struggles, or who have not worked through these issues prior to surgery, are not appropriate candidates for bariatric surgery, as they stand a high risk of weight regain postoperatively if those habits and coping mechanisms are not managed beforehand.

The risk of nutritional deficiencies is very real after bariatric surgery, particularly after gastric bypass surgery (pictured above), which involves a re-routing of the small intestine such that about 1.5 meters of small intestine is no longer exposed to food and the enzymes required to digest it. Patients who undergo gastric bypass surgery are at risk of life threatening complications if they do not adhere to their supplement regimen, which for most patients includes a specific multivitamin, calcium, vitamin B12, vitamin D, and often iron. An individual who is committed to having gastric bypass surgery must be equally committed to taking supplementation for the rest of their lives. Protein malnutrition is a potentially severe complication of any type of bariatric surgery due to decreased intake; it is essential to follow the protein consumption recommendations provided by the bariatric program's dietician (usually at least 90 grams of protein intake per day).

Because bariatric surgery often has a profound beneficial impact on several obesity-related complications such as diabetes, high blood pressure, obstructive sleep apnea, cholesterol, and osteoarthritis (to name a few), it is important to have physicians involved both pre- and post-operatively who can help to manage changes in medications and treatment approach that are often necessary.

While bariatric surgery is a very appropriate treatment option for some people, it must always be remembered that bariatric surgery is not a quick fix or a cure; it is the exchange of one set of medical issues for another (though usually in a positive direction), and it is most certainly a permanent lifestyle alteration.

Dr Sue Pedersen www.drsue.ca © 2010 drsuetalks@gmail.com

Follow me on Twitter for daily tips! @drsuepedersen

Read more...

The Psychology of Weight Loss Surgery

>> Friday, July 2, 2010




For an individual who is being considered for bariatric (weight loss) surgery for management of their obesity, it is becoming increasingly clear just how pivotal psychological issues are in the management before, during, and after the procedure. While there are many psychological benefits to bariatric surgery, there are also significant psychological risk that must be taken into careful consideration.

At the American Diabetes Association meeting in Orlando, FL, last week, I attended a lecture by Dr Lucy Faulkonbridge, Assistant Professor of Psychology at the University of Pennsylvania, who reviewed this topic for her audience.

There are many great things to be said about the psychological benefits of bariatric surgery. Bariatric surgery has been found to reduce depression and anxiety amongst individuals undergoing these procedures. The majority report improvement in body image, psychosocial functioning, and quality of life. Sexual function is also usually improved, as a consequence of many factors, including increased interest and improved mobility.

Having said the above, there are also potential negative consequences, some of which are absolutely devastating. While depression usually improves with weight loss, symptoms of depression can return, particularly in those who had significant depression prior to surgery. Importantly, while one study found that the risk of death was reduced by 40% at 7 years after gastric bypass surgery, they also found an increased risk of death from suicide and accidental deaths in this population.

Although bariatric surgery is typically very successful in achieving weight loss, the results can vary greatly from person to person. According to the landmark Swedish Obese Subjects' Study , as many as 10% of gastric bypass and 25% of gastric banding patients are unable to maintain even a five percent weight reduction with surgery. (We do appreciate a 5% body weight reduction, as 5% weight loss in an obese individual decreases the risk of developing serious obesity-related complications such as heart disease, diabetes, and cancer.) Interestingly, the success of weight loss surgery seems to depend in part on psychological issues. While a background of psychological issues in a general sense is not predictive of degree of weight loss, active symptoms of depression or a tendency towards binge eating prior to surgery tends to result in smaller weight losses after surgery.

Although the literature in this area is somewhat conflicting, DrFaulkonbridge postulated that while distress related to psychological illness may be an impediment to the success of bariatric surgery, distress related to extreme obesity may be a predictor of greater success, as this distress should improve with weight loss. The key is to determine what the source (or sources) of distress is/are prior to surgery, such that these issues can be addressed and dealt with prior to surgery, in order to optimize the medical and psychological outcomes of the procedure.

The psychology behind post operative exercise routines may play a part, too. In patients who have had gastric banding, those who did not increase their activity level after surgery are much more likely to have weight regain than those who do become more active post operatively. There is also some data to suggest that some patients may actually engage in less physical activity after the surgery, despite having shed pounds and most often enjoying increased mobility. Having an exercise program established prior to surgery is an important component to maintaining long term success with these permanent lifestyle changes as well.

Follow up patterns with the surgeon was also identified as being associated with weight loss success. While only 40% of patients return for their annual visits with their surgeon after their operation, it is these patients who seem to have the best weight loss success. The relationship between weight loss success and compliance with follow up is likely multifactorial.

It is clear that psychological issues must be taken into very serious consideration prior to, during, and after bariatric surgery. Key points to highlight include:

1. Thorough psychological evaluation and counseling before bariatric surgery is paramount. This should ideally take place in the form of screening questionnaires, as well as counseling and support from mental health care professionals. It is important that active mental health issues are dealt with as well as possible prior to surgery, to provide the greatest chance of success. It is noted that some people may not be appropriate candidates for bariatric surgery if their psychological issues are not stable or well managed.

Ideally, this process should take place as part of a team approach to preparation for bariatric surgery, including help from dieticians, nurses, physicians, and occupational therapists. Psychological support is also crucially important towards preparation for the permanent lifestyle change that defines bariatric surgery (very small portion sizes, alteration in food preferences, and a permanent change in one's relationship with food).

2. Psychological support and access to mental health professionals through and following the bariatric procedure, both short term and long term. The needs of the individual patient will vary greatly - it is the availability, and experience of health care professionals in dealing with the issues that may arise, which are key.

3. Support from friends and family throughout the process. A solid support network provides outlets to deal with emotional issues that may arise. It is important that a patient's loved ones are accepting and understanding of the motivations behind bariatric surgery, and are equally prepared to both endure the trials, and celebrate the tribulations, that may lay along the path towards successful weight loss.

Read more...

Provincial Variation in Accessibility to Bariatric Surgery

>> Saturday, May 15, 2010



At the Inaugural Diabetes Surgery Summit in Montreal last week, it became apparent that there is significant provincial variation in accessibility to weight loss (bariatric) surgery. As Dr. Nicolas Christou of McGill University pointed out, in Canada in 2008, the number of bariatric surgeries performed in each province was as follows:

- Nova Scotia: 28
- New Brunswick: 17
- Quebec: 802
- Ontario: 579
- Saskatchewan: 23
- Alberta: 272
- BC: 160

The reasons for the provincial variation are complex. One interesting phenomenon that was brought up was that in Ontario, patients had previously been funded by the provincial health care system to have bariatric procedures done in the United States - this was a situation that was unique to Ontarians, as no other province provided funding to do this. Due to the enormous expense of sending patients over the border and the potential savings of having these surgeries done at home, the Ontario government provided funding to build access to the service in their home province, to the tune of many millions of dollars in cost savings. As other provinces never had the situation where patients were funded to go south to have surgery, the same financial pressure does not exist to bring the procedure home.

In the mix of the numbers above, other factors have to of course be considered, including population density and surgical expertise available in each province (though with increased provincial funding for bariatric surgery, the surgical expertise would be likely to follow).

Even in provinces with the most accessibility to surgery, however, there is still an enormous shortage of availability country wide, with an estimated fifteen year backlog of patients who would be appropriate for, and benefit from, the surgery.

What can we do? Get out there and talk about it.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Read more...

Diabetes Treatment - is Weight Loss Surgery the Answer?

>> Saturday, May 8, 2010




Canada, like the rest of the world, is caught in a diabetes epidemic. Over 2 million Canadians are diagnosed with the disease, and by the year 2020, those numbers are expected to rise to 3.7 million. This epidemic is paralleled by the high prevalence of obesity, which currently affects 25% of Canadian adults and 10% of Canadian children. One of the treatment options that is being increasingly considered to treat type 2 diabetes in the setting of severe obesity is weight loss surgery.

I attended the First Canadian Diabetes Surgery Summit in Montreal this week, hosted by McGill University, to discuss this very issue. Over two very intense and productive days, a collection of international leaders in the area presented their research and clinical experience to a diverse group including Canadian surgeons, family physicians, endocrinologists, health care professionals, and policy makers. A wealth of learning, sharing, and ideas were generated from this summit, of which I am going to discuss over the course of several articles in the coming weeks. Here are the highlights.

In short, bariatric surgery is a very effective treatment for type 2 diabetes. The results depend on the type of surgery done, but remission rates of diabetes of over 80% have been documented, and sustained for at least 2 years. Much of this success is related to the impressive weight loss that is seen with bariatric surgery, but gut hormone changes with certain types of surgery (such as gastric bypass surgery) play an important role as well.

It must be emphasized that bariatric surgery is only appropriate for a very select group of people. The current guidelines recommend bariatric surgery as a potential option for patients with a BMI >40, or a BMI >35 with at least one serious medical complication (such as diabetes), who have failed intensive attempts at weight loss with conventional treatments (lifestyle alteration, medications, etc). Bariatric surgery has a long list of potential side effects and complications that must be seriously considered, and which vary depending on the type of surgery performed. On balance, however, bariatric surgery has been shown to decrease mortality by 28-40% in this population, and as such, may be the most appropriate option for some people.

In Canada, we struggle with very limited accessibility to bariatric surgery. As Dr. Nicolas Christou, one of Canada's leaders in bariatric surgery, pointed out:
  • Based on very conservative estimates that 5% of the 1 million Canadians who fit criteria for bariatric surgery would actually be appropriate candidates for surgery, 50,000 Canadians would currently be candidates for the procedure.
  • Approximately 3,000 bariatric procedures will be done in Canada this year.
  • According to these numbers, then, Canada currently has in excess of a 15 year back log of patients who could benefit from these procedures.

What can we do about this? The problem of course, is funding. Funding for bariatric surgery is extremely limited in Canada, though accessibility does vary greatly by province. Cost analyses suggest that for patients with diabetes, the costs of bariatric surgery to the government are recouped by 26-30 months post operatively, and after that, there are only savings to be had by the health care system due to the decreased rate of diabetes related complications, hospitalizations, and medication requirements of these patients. 

On balance, increased accessibility to bariatric surgery in Canada, provided in the appropriate clinical setting by a multidisciplinary, experienced health care team, should be discussed amongst Canadian health care professionals, patients, and the general public.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Read more...

The Dangers of Medical Tourism for Bariatric Surgery

>> Sunday, April 25, 2010







There's no question that the waiting lists for weight loss surgery, or bariatric surgery as it's called, are unacceptably long. The wait list in Canada is well over 5 years, with this number varying across provinces and cities, depending on the availability of local facilities.

In desperation, some Canadians are turning to medical tourism for the answer.

Take the case of a woman who went to Tijuana, Mexico, for bariatric surgery, as per the recent story in the Calgary Herald. Due to leak from her stomach after a sleeve gastrectomy (which reduces the stomach's size), she returned to Canada to endure a prolonged hospital stay, at which point her stomach also had to be stretched out, as the bariatric surgeons in Mexico had made her stomach too small to sustain her.

This lady is not alone: due to the ease of accessibility and short wait times, many Canadians are turning to foreign coutries to have bariatric surgery performed. It costs $,6000 to $12,000, depending on the country (Costa Rica and India are other popular choices) and the procedure performed, which is cheaper than private pay facilities in Canada (eg BC, Ontario), where patients pay $16,000 to $18,000 for comprehensive care. 

But remember - you get what you pay for. Medical tourism outfits may not take the same great care in selecting the appropriate patient for bariatric surgery, nor do they take the time to prepare patients adequately for the dramatic and permanent lifestyle change they are about to undergo. Nor do they do much, if anything, in the way of follow up, which is downright dangerous: ongoing nutritional counseling is crucial, as is monitoring for nutritional deficiency, which occur particularly with gastric bypass surgery, and can be very serious if not managed properly.

Further, one can't help but be wary of an outfit who tries to sell their medical procedure with promises of free nights of hotel accomodation, travel planning, and sometimes with sightseeing opportunities thrown in!

As Canadians, the problem that we need to urgently address is the lack of availability of bariatric surgery within our borders. There are several centres in Canada where bariatric surgery is publicly funded and of no cost to the patient, though the wait times are long. An increase in government funding is desperately needed to improve accessibility to existing centres of excellence for bariatric care, and also to help establish new centres where there currently are none.

Dr. Sue © 2010 www.drsue.ca drsuetalks@gmail.com

Read more...

  © Blogger templates Palm by Ourblogtemplates.com 2008

Back to TOP