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Why Bariatric Surgery Can Fail (Part 2)



Perhaps the short title of today’s post should simply be “(too) Great Expectations”.

While yesterday, I discussed issues related to emotional eating, food addiction and vulnerability as possible causes for patients to fail, today I want to focus on another issue that I have seen provide a very different type of challenge in some patients – unrealistic expectations.

Indeed, unrealistic and exaggerated weight-loss expectations can often lead to dissatisfaction, disappointment, frustration, distress and hopelessness in patients undergoing bariatric surgery.

The reasons for this are simple. As noted in previous posts, media and blog posts are rife with stories on the extreme outliers – the cases where things go horribly wrong and the cases where things go amazingly well (perhaps too well?). While the former, keeps people, who may well benefit, away from surgery, the latter is perhaps as problematic but in a very different way.

As the old joke goes, “80% of people think they are above average” – as a result of the Anchoring and the Example rules, most patients are expecting that their rather bold and drastic decision to undergo surgery will produce dramatic results.

Studies show that the average ‘dieter’ is hoping to lose around 50% of their weight – the same is probably even more true for patients seeking surgery.

In reality, however, the ‘average’ medium-to-long-term weight loss with bariatric surgery is only a rather sobering 20-30% of initial weight.

Please reread this last sentence very carefully!

The term “average’, means that about half of all patients will actually lose LESS than 20-30% of their initial weight (the other half of course will lose more).

Imagine the disappointment of the ‘average’ 300 lb patient, who, after experiencing the ‘average’ success (25% weight loss), still weighs 225 lbs! Nevermind that her health has dramatically improved, she is off all their medications, and she feels better and healthier than ever before – she is still 225 lbs! From a medical and health perspective a spectacular success story – psychologically nothing but disappointment and failure.

Imagine how devastated the ‘less-than-average’ patients feel when they do not even manage to hit and sustain the 10 or 15% mark. These cases are often described as ‘failures” because, this rather small degree of weight-loss, which for many is in fact far less than they may have achieved with diet and exercise alone in the past, is sometimes not even noticeable.

The fact that they never managed to keep even 10% of their weight off in the past (3-5% is the average sustainable weight loss with diet and exercise), but can now do so because of their surgery, is hardly comforting. The fact that surgery, perhaps will only help them keep off the weight that they managed to lose before surgery or even only prevent further weight gain can only come as a disappointment.

Thus, for the vast majority of patients, as they begin experiencing their weight-loss plateau at about 18 to 24 months post surgery, the reality dawns on them that they will still be ‘obese’ and will be nowhere close to whatever they (or society) imagines their ‘ideal’ weight should be.

Imagine the sense of frustration and failure, the disappointment and despair, the anger and hopelessness as realization sets in – all of this (the time, the risk, the money, the struggle, the anticipation, the euphoria of weight loss) for what? To still be stared at and ostracized – to still be accused of being gluttonous and lazy – so what if my knees no longer hurt and my energy levels are higher than ever before – I AM STILL FAT!

This is when many patients, will begin showing maladaptive, seemingly ‘irrational’ behaviours. Those, not happy with or unable to accept their disappointing weight-loss result will begin pushing the limits – steadily increasing their exercise levels till they reach unsustainable amounts of hours spent in the gym each day – or further decreasing their food intake to try and lose more weight. (Yes, ‘yo-yo’ dieting is possible even after surgery.)

While the former can result in biomechanical problems including severe and sometimes irreparable strain injury (remember – these are still very large patients), the latter can precipitate severe malnutrition for all of the reasons discussed previously.

Other patients simply give up – fall off their diet and exercise programs – why bother if ‘everything’ just stays the same?

Thus, simply going into surgery with unrealistic expectations, only to be disappointed, can lead to ‘complications’ that, although often blamed on the surgery, have very little to do with the surgery itself.

Obviously, private surgical centres (or for that matter even some of the publicly funded surgeons) will rarely emphasise this rather modest result of bariatric surgery – modest, only if the amount of weight loss is the focus – spectacular, if improvement in health is the real goal.

This is perhaps why surgeons prefer to talk to their patients about percent Excess Weight Loss (or the amount of ‘excess weight’ you will lose) rather than weight loss in absolute terms. I have in the past criticized this common practice and have called upon surgeons to abandon this ‘misleading’ term, which is misleading for all kinds of reasons that I do not wish to get into here. (Readers may wish to refer to our recent paper published in SOARD.)

Patients (and surgeons?) also generally refuse to accept that the total amount of weight loss starts from the highest weight that the patient had before surgery – irrespective of whether or not the patient has already lost weight.

This can actually mean that the average 300 lb patient from the above example, who manages to lose 25% or 75 lbs before surgery, may experience no additional weight loss after surgery – in fact, the only reason I would advise this patient to still consider having surgery would be because surgery would make it so much easier and so much more likely to keep the 75 lbs off – that’s all!

Thus, these ‘failures’ are not really ‘failures’ in the sense of what surgery does or how it works.

But they are very much ‘failures’ from the patients’ perspective (and their friends and relatives) – ‘failures’ attributable only to overly optimistic and unrealistic expectations.

I can honestly state that most patients in our program are visibly disappointed when we explain their real chances of weight loss and many change their mind or have second thoughts.

Others, will listen, but still think that they can beat the average – only to be disappointed when they don’t.

The best outcomes and the greatest satisfaction appears to be in those patients, who are truly and honestly only concerned about their health and are perfectly and honestly happy with the substantial improvement in comorbidities and quality of life that they experience even with a modest 20-30% weight loss (or less).

These are the patients, who do not measure ‘success’ on a scale – and that is exactly the way it should be for any obesity treatment.

Tomorrow, we will look at how bariatric surgery can affect relationships – another important but often unaddressed issue when considering bariatric surgery.

AMS
Edmonton, Alberta

Karmali S, Birch DW, & Sharma AM (2009). Is it time to abandon excess weight loss in reporting surgical weight loss? Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 5 (4), 503-6 PMID: 19632649

21 Comments

  1. Thus, simply going into surgery with unrealistic expectations, only to be disappointed, can lead to ‘complications’ that, although often blamed on the surgery, have very little to do with the surgery itself.

    Because poor or unsatisfying results with weight loss surgery are always the patients’ fault! /sarcasm.

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  2. Again, a great article. My surgeon was very emphatic with me prior to surgery. I went in at 300 lbs. He said to me that I should resolve within myself that I was NOT going to get lower than 170 lbs, at BEST. He was very emphatic about getting me to accept that. I resisted it for a long time. Now I am at 200, but as you say, the health benefits have been so profound that even though I am disappointed, I am also glad to have done it. And being able to maintain that weight for years is a real blessing.

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  3. @Wendy: As I said, your 30% weight loss is about the average (170 would have been pushing it) – glad it works for you.

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  4. >The term “average’, by definition, means that exactly half of all patients will
    > actually lose LESS than 20-30% of their initial weight (the other half of course will lose more).

    It’s a definition of median, not “average”

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  5. Dr. Sharma, I would be interested in the paper you published in SOARD. As a lay person, when I click on the link you provide, I don’t even get an abstract. Do you have advice, shy of getting in my car and driving to the particular local library branch that carries that publication?

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  6. Fascinating piece.

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  7. This is such an informative series. Thanks for making the effort to put it all together for us.

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  8. Things haven’t changed any since I had my VBG almost 14 years ago. I was told that I should be able to lose at least 30 to 50% of my total body weight (I weighed 350 lbs at the time). I actually lost 80 lbs and would have been satisfied with that. But the NP who recommended the surgery was so disappointed that I plateaued at 270 lbs and kept pushing me to lose more weight. When I couldn’t, and started gaining the weight back, I got read the riot act and told what a failure I was and how it was all my fault and I must be doing something wrong and I was lying about what I ate, how much I ate, etc, etc. I quit going to see her and hadn’t seen a doctor in almost 8 years when I got married. My husband said I really should get a physical, so I found a new doctor, had the physical, was shocked that my weight had gone up to 396 lbs, but my blood sugar, cholesterol, and blood pressure were still normal (as they have always been, it’s mobility and arthritis issues I have). My weight is now stable at 376 lbs and has been for 3 years now, but is my doctor satisfied with that and my good numbers? No, she says my mobility issues are caused by my weight, the pain I have when I have to stand or walk is caused by being fat, the only thing that’s going to alleviate any of that is to lose weight, and she refuses to refer me to a pain clinic, refuses to look for any other reasons. All she will recommend is the Nightmare on ELMM Street. Been there done that so many times and it doesn’t work, not for permanent, sustained weight loss.
    When doctors have unrealistic expectations of diets and WLS, is it any wonder that patients have those same unrealistic expectations? I went into my WLS not expecting to lose 50% of my weight, I would have been happy if I could have lost 15% and kept it off forever. That didn’t happen. WLS not only made me fatter, it gave me complications that have made my quality of life so much worse, I wish I had never had it. I wouldn’t be any worse off now if I hadn’t had it, and I might have been better off.

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  9. As a pre-op WLS patient this article was very informative and very eye-opening.

    Throughout my appointments, I was asked what my “goal” was and being heavy all my life I couldn’t answer that in terms of pounds. At each appointment I said the same thing “my goal is to be able to bend over and put on my socks and tie my running shoes”.

    I’m 353lbs going into these appointments, I don’t expect to end up weighing less than 200lbs and I know that’ll take work. If it never happens, then I have to take the good that came out of the surgery and be happy with that.

    What I’m really hoping for is that the surgery will relieve the pain I’m in every day, it’ll help me put away the cane I have to walk with, it’ll let me go up and down stairs with greater ease. It’ll let me be able to walk without getting winded after 5 steps.

    Pounds?? Who cares about the pounds. I want greater results than what’s shown on the scale!

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  10. This post again emphasizes the importance of understanding many aspects of the human psyche when working on goals related to weight. Dr. Sharma is truly “a jack of all trades” with his understanding of psychological factors and is a great role model for other health professionals.

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  11. I am very proud of my accomplishments so far, and the benefits (health and otherwise) are too numerous to mention here. Am I above average, according to Dr. Sharma. Yes. So far I’ve lost approximately 38 per cent of my original body weight.

    However, I must say that from the outset I DID NOT set myself up for disappointment, and still don’t. When I started this weight management journey of mine, I’d didn’t set unrealistic goals, like say to myself, “okay I’m going to lose 50 per cent of my body weight by next week,” because all of us on this journey know that that just ain’t happening. And I still don’t set unrealistic goals. One of the keys for me is that I continue not to set myself up for disappointment. Do I have some longer-range goals? Absolutely. But I set short-term, attainable, realistic goals each and every week. Heck, I set them each and every DAY. And, most importantly, if I don’t achieve these short-terms goals, I don’t dwell on it and, most importantly, I don’t beat myself up about it – I just set another realistic, achievable goal for the next day. For me, this has been absolutely KEY.

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  12. Which procedure was the basis of this study???

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  13. I declared myself a suceess at 20% of total weight lost. I felt so much better that I decided it was worth it (the surgery and the $) even if I did not lose any more weight. I am continuing to lose weight at a slow but steady rate, but there is it not an objective measure of success but it is very much tied to individual attittude.

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  14. Fantastic series Arya, I will be very careful about how I describe ‘inadequate weight loss’ following surgery. I agree that this may not be a failure. How enlightening!

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  15. VERY good article! I will now go back and read the rest of them.

    I had a Duodenal Switch done over seven years ago, and I’m thankful for it every day. I’ve lost 44% of my total body weight. I lost most of it during the first 18 months after surgery, but I’m STILL losing, very slowly, and have had no regain. My cholesterol has gone from over 200 down to 112, I no longer take BP meds, and life’s just plain BETTER.

    And I can still enjoy eating, too. (*grin*)

    As a previous poster asked, which form of WLS was this study done on? Do you yourself do the DS?

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  16. Shouldn’t you be able to easily predict, pre-surgery, who is likely to lose appreciable amounts of weight (that 20-30% “average” or more), and who is likely to end up being seen as a “failure” (personally and/or by doctors)? Those who have issues such as leptin resistance (as you’ve been discussing lately), insulin resistance, low basal body temperatures, calorie-burning efficiency, and other issues associated with low metabolic levels are less likely to lose weight post-surgery. Whereas those who metabolize food well, but simply are eating “too much”, are likely to show significant weight loss, I would imagine. A series of blood tests should be able to answer this.

    Which brings me to my next – and enduring – question: what CAN those who have efficient/slow metabolisms do to lose weight? I, for one, know with certainty that I would be a bariatric surgery “failure”. I have absolutely no problem reducing intake and increasing activity – I typically eat in the 1200-1500 calorie range (all vegetables, whole grains, and lean protein; I’ve also tried full-on Atkins with no success) while doing aerobic exercise 4+ hours/week; several months per year I’m actually highly active 6-8 hours/DAY 5-6 days/week! Yet I continue to gain weight despite my best efforts!

    I once lost 80 pounds, which I’ve regained over a period of 8 years until I’m now back at my pre-loss weight. I’m convinced I’m dealing with continued increased efficiency and leptin resistance. I’m perfectly healthy other than my weight, but I want to lose some excess weight for personal and professional reasons. Is there anything at all you can suggest??

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  17. How about a discussion regarding why RESTRICTIVE ONLY bariatric surgeries can fail, as compared to the duodenal switch (most RNY procedures become essentially restrictive only surgeries after a couple of years)? Put the majority of the blame squarely where it belongs, most of the time – on an inadequate procedure, done despite the availability of a CLEARLY more effective one, and almost ALWAYS performed without FULLY INFORMED CONSENT with respect to the alternative and more effective procedure (and which the surgeon is of course not qualified to perform). THIS is a MAJOR cause of failure, in my opinion, and the lack of informed consent should be actionable.

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  18. Talk to me about a procedure that is halted after 3 of the laproscopic incisions have been made due to some liver issues that I had informed my procedure team about. I have found this to be extremely emotionally powerful. Help?

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  19. I cannot thank you enough for these articles. They have helped me in how to speak to a friend who needs encouragement two years out from her surgery.

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  20. I just now ran across this article. I wish I had found and read it prior to gastric sleeve surgery about a year and a half ago. My surgeon did not tell me any of this; instead, he was a cheerleader who had me believing that I would magically go from a size 20 to a size 2 within a few months after having the procedure done. Nutrition and fitness classes, support group meetings, and a psychiatric evaluation were all part of the program. At no point in any of them did I hear any of what is discussed in this article. I joined Facebook groups–again, not a word from anyone who wasn’t losing at least 20 pounds a month. I only learned about the shortcomings discussed above through first-hand experience, when I lost only 30 pounds in the first five months after surgery and have lost no more since. On my last 1-year post-op visit with the surgeon (and I do mean my last–screw it!) I was given a lecture the gist of which was that the failure was my fault because I didn’t have enough faith. (This was a board-certified surgeon approved by my insurance provider.)

    On a side note, “Formermaintainer’s” comment could’ve been written by me, it is so similar to my situation. I echo his/her question: Is there anything at all you can suggest for people like us?

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