Dr. Sharma's Obesity Notes

How do people become severely obese? Anyone, who thinks the answer is simply, “by eating too much and not moving enough”, is not only wrong, but is essentially missing the whole point of what it will take to find solutions.

A study by Julia Temple Newhook, Deborah Gregory and Laurie Twells from the Memorial University of Newfoundland, St. John’s, published in the Journal of Social, Behavioral, and Health Sciences, seeks to better understand what causes some people to gain weight.

The researchers conducted extensive interviews with individuals seeking bariatric surgery regarding their perspectives on their histories of weight gain and their explanations for weight gain as well as the emotions surrounding their weight gain experiences.

In today’s post, I would like to touch on what the authors describe as, “important life events”, which in some cases, interestingly enough, begin with being born.

Thus, for many participants, weight gain struggles began in childhood:

“Sam, an unemployed laborer in his 20s, said that he had been big since the age of 9: “It’s hereditary. A lot of people in my family are big.” Deirdre, an educator in her 40s, said, “I have never been slim. I have never been below a size 18, 20. Never. … I don’t remember as a child being small.” She added, “I know that part of it is genetics, because I really do believe that. I have a set of grandparents who were huge … I guess it is my metabolism.”

This is very much in line with my own clinical experience, where patients often describe always having been large for as long as they can remember with bullying and name calling belonging to their earliest childhood memories.

Others, on the other hand, describe a previous slim childhood or adult life, prior to rapid weight gain. In women, the most common life event likely to precipitate irreversible weight gain was pregnancy:

“Annie, a retired caregiver in her 60s, reported that she now weighs over 300 pounds, but recalled, “I only gained weight after I had my daughter … I was 127 pounds when I got pregnant … I went up to 181 and I never went below that after.”

But it was not just the course of pregnancy itself that was held responsible:

“…increased childcare and domestic workloads—that followed. Heidi, a customer service worker in her 30s, explained, “You don’t have the ‘you time’ to do what you need to do to try to take care of yourself a bit better. Everything is your children.”

Another major life event is loss of a dear one:

“Theresa, a retired educator in her 60s, talked about gaining weight after her husband died: “I ate my way through … That was my comfort I didn’t go the gym and I didn’t exercise … grief is strange. I was angry for a long time.”

This observation is also very much in line with the findings in my own practice, where I often see unresolved grief and trauma (emotional, physical or sexual) as a driver of dramatic weight gain. In my experience such negative life experiences can occur at any age (and virtually in anyone) and it is often possible to narrow down the exact temporal relationship between the event and subsequent weight gain.

For some, the life event was “simply” a change in “circumstances”:

“Jennifer, a manager in her 40s, said that when she moved from her rural home to an urban center for university, “I gained 90 pounds in about 9 months. … I was going to school so I wasn’t active at all, and I was eating takeout twice a day for my meals because it was cheap. I ate for free where I worked and I ate deep-fried food for all that time.”

This scenario is likewise not unusual – especially amongst the migrant and immigrant population, where adapting to a new life can often have profound effects on body weight for no reason other than having switched from one environment to another.

And then there was injury and illness:

“Derek, a customer service worker in his 30s, suffered a sports injury in his late teens: “I had a hockey injury, actually, is what started it. … I put on a lot of weight.” He said that his weight gain was exacerbated by a changing lifestyle as he entered the workforce: “Sports stopped. … My weight just ballooned. The only way I know to describe it is it’s like I went to bed being fairly active and in half decent shape and waking up and being 150 to 200 pounds overweight.”

Again, this scenario is not uncommon – I have previously posted on the remarkably high number of former competitive athletes in our bariatric clinic.

While life events were deemed an important contributor to developing severe obesity, this was not all that the interviewees had to offer.

More on other aspects of these investigations in the coming posts.

If certain life events have led to your weight gain – I’d certainly appreciate hearing about them.

AMS
Vancouver, BC

Regular readers will be familiar with my general support of bariatric weight loss surgery for appropriate patients.

This is not only due to the documented health benefits but also because in experienced hands, modern laparoscopic surgery clearly has a positive risk/benefit ratio.

But what risk are patients willing to take and how much weight loss do they expect?

This issue was now examined by Christina Wee and her Boston colleagues in a paper published in JAMA Surgery.

Based on interviews with over 600 individuals seeking bariatric surgery, most patients (84.8%) would accepted some risk of dying with with a mean acceptable mortality risk of about 7%. Alarmingly, however, almost one in five patients were willing to accept a risk as high as one in ten of dying as a result of the surgery.

This surprisingly high acceptance of potential risk was accompanied by a largely unrealistic weight loss expectation of almost 40% of their initial weight (the actual efficacy of surgery is within the 20-30% range) and stated that they would be disappointed if they did not lose at least 25% of their initial weight.

Not surprisingly, patients with lower quality-of-life scores and those who perceived needing to lose more than 10% and 20% of weight to achieve “any” health benefits were more likely to have unrealistic weight loss expectations. Low quality-of-life scores were also associated with willingness to accept high risk.

Thus, it is apparent that most patients seeking bariatric weight loss surgery have unrealistically high weight loss expectations and believe they need to lose substantial weight to derive any health benefits.

As the authors note,

“Educational efforts may be necessary to align expectations with clinical reality.”

Be that as it may, the results certainly speak not only to the dangers of “overselling” the potential weight-loss to be derived with surgery but also to ensure that patients understand that significant health and quality of life benefits can be derived even from rather modest weight loss.

AMS
Edmonton, Alberta

p.s. to my friends and colleagues in Boston: hope all your loved ones are safe!

Wee CC, Hamel MB, Apovian CM, Blackburn GL, Bolcic-Jankovic D, Colten ME, Hess DT, Huskey KW, Marcantonio ER, Schneider BE, & Jones DB (2013). Expectations for weight loss and willingness to accept risk among patients seeking weight loss surgery. JAMA surgery, 148 (3), 264-71 PMID: 23553327

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Earlier this week, the Canadian Diabetes Association released the newest version of the Canadian Practice Guidelines for Diabetes.

The online release includes the full text of all 38 chapters and an appendix.

Each chapter comes with a slide set and a brief video highlighting the key recommendations.

There are also accompanying tools for health care providers and  resources for patients.

The following are the main recommendations for weight management:

• An interdisciplinary weight management program (including a nutritionally balanced, calorie-restricted diet; regular physical activity; education; and counselling) for overweight and obese people with, or at risk for, diabetes should be implemented to prevent weight gain and to achieve and maintain a lower, healthy body weight [Grade A, Level 1A]
• In overweight or obese adults with type 2 diabetes, the effect of antihyperglycemic agents on body weight should be taken into account [Grade D, Consensus].
• Adults with type 2 diabetes and class II or III obesity (BMI ≥35.0 kg/m2) may be considered for bariatric surgery when lifestyle interventions are inadequate in achieving healthy weight goals [Grade B, Level 2]

While the recommendations with regard to pharmacotherapy reflect the lack of effective medications for obesity in Canada, they do highlight the role for bariatric surgery in heavier patients with type 2 diabetes.

There is also a useful checklist for weight management programs:

• The program assesses and treats comorbid conditions.
• The program provides individualized nutritional, exercise and behavioral programs and counselling.
• Nutritional advice is provided by qualified experts (e.g. registered dietitians) and diets are not less than 900 kcal/day.
• Exercise is encouraged but physical activity is promoted at a gradual pace.
• Reasonable weight loss goals are set at 1 to 2 lb/week.
• Cost is not prohibitive, and there are no financial contracts.
• There is no requirement to buy products, supplements, vitamins or injections.
• The program does not make unsubstantiated claims.
• The program has an established maintenance program.

The complete guidelines are accessible here.

AMS
Edmonton, Alberta

Regular readers will be well aware of the importance I place on the psychological assessment of patients considering bariatric surgery.

in 2006, we published a case report in Obesity Surgery that perfectly illustrates this point.

The patient, a 25-year-old single female, was referred to us three years after she had received and adjustable gastric band.

In the two years following this operation, she had experienced a 57-kg weight loss. When her weight stabilized at 79.5 kg, she had her gastric band tightened in the hope of promoting further weight loss, however, this level of constriction resulted in severe dysphagia.

Given that the patient had a health professional background and had to travel long-distances to the clinic, she was instructed in how to self-adjust her band. This knowledge then precipitated a problematic pattern of behavior.

It turns out that this patient had a longstanding history of bulimia nervosa (which was something her surgeon was either unaware of or ignored) and now began using the band as a tool to aid her in her bulimia.

At the time we saw her, she would alter her band almost daily, deflating it to binge and then tightening it to prevent food consumption.

The patient was severely distressed by her lack of control and ultimately contacted our clinic seeking treatment.

Following our assessment, the port was moved posteriorly so she was unable to access it and was referred to an eating disorders program for treatment of her bulimia and depression.

As we point out in our discussion,

“This case illustrates the importance of establishing guidelines pertaining to psychiatric assessment in this patient population and highlights a unique presentation of bulimia. Psychiatric illness does not exclude one from undergoing bariatric surgery, but to ensure an optimal outcome, it is important that all components contributing to the illness of obesity be identified and treated.”

As I always remind my patients, even the best bariatric surgeon is only operating on your gut and not your head.

AMS
Edmonton, Alberta

Last month, the UK National Enquiry into Patient Outcome and Death (NCEPOD) released a report (Bariatric Surgery: Too Lean a Service) on the process of care for patients aged over 16, who underwent bariatric surgery for weight loss in the UK and found that significant improvements are needed across the whole of the care pathway, with more emphasis on specialist support before and after surgery.

The report is based on findings from in-depth case reviews of 381 patients who had bariatric surgery with the UK National Health System (n=223) or in private hospitals (n=173) in England, Wales, Northern Ireland, the Isle of Man, Guernsey, and Jersey.

The report highlights a number of important deficiencies in the care of these patients including, lack of assessments and consultations by dietitians or psychologists both before and after surgery, significant delays in follow-up, surgery on patients who did not meet guidance criteria, high readmission rates, inadequate consent forms and procedures, low surgical volumes, and lack of follow-up.

It also found that two out of three websites of programs failed to give a clear explanation of the risks involved and of the chances of achieving weight loss.

The report lists a number of proposals to improve bariatric surgery including ensuring that all patients have access to the full range of appropriate specialist professionals, a deferred two-stage consent process, and postoperative dietary guidance.

It also clearly recommends that all decisions on whether or not a patient is suitable/ready for weight loss surgery should be made with the input of a number of different health care professionals.

Although standards may well vary between countries, I have no doubt that careful review of the quality of pre-, peri-, and post-surgical care of bariatric surgery patients will probably leave much to be desired in most countries, including perhaps in Canada.

The report certainly makes clear that neither the decision to undergo surgery nor the processes and standards to ensure acceptable outcomes are to be taken lightly.

Bariatric surgery (even in its most minimally invasive form) remains a serious and complex intervention for a serious and complex problem – any health professional suggesting anything else, is guilty of nothing less than professional misconduct.

AMS
Edmonton, Alberta