Friday, September 19, 2014
Many surgical clinics require “mandatory” weight loss before approving patients for surgery, a requirement for which there is very little evidence that it influences post-surgical outcomes (despite the rather firm belief of many that it does).
While one may perhaps accept the need for pre-surgical weight loss when the primary objective is to make the surgery easier for the surgeon and safer for the patient, of greater concern is the practice in many centres that require “mandatory” weight loss based on the notion that patients need to demonstrate their “suitability” for surgery by achieving an arbitrary amount of weight loss in order to “qualify” and prove themselves “fit” for surgery.
That this latter requirement is not without actual risk for the patient and can lead to significant frustration and disruption of the patient-provider relationship is described in a phenomological study by Nicole Glenn and colleagues, published in Qualitative Health Research.
The study is based on in-depth interviews with seven candidates considering bariatric surgery and describes their lived experience and views about what the requirement to lose weight in oder to obtain surgery meant for them.
The article begins with a touching account of one patient:
“The surgeon says, “We need you to get your weight down a little more before we can approve you for surgery.” I fight back the tears as I drive home. Then I think, “I have to do this. I need this surgery.” I work my ass off; I eat nothing but salad for three weeks while I prepare real food for the rest of my family. I go to the gym late at night and settle for five hours sleep because there is no other time in my day with two small children to care for and a husband who works long hours. I struggle, but I’ll do whatever I have to. I come back for my next visit with the surgeon, and I’ve lost more than he had asked me to, yet he doesn’t even notice. He doesn’t comment on my weight at all! He says, “You’ll hear from my office with a surgical date.” That’s it?”
The paper focusses on four themes that emerge from the narratives.
1. Nod your head and carry on:
“[I know a few people who’ve had the surgery, and they all tell me that same thing—just do what you are told! I ran into a friend who had the surgery and was telling him about my frustrations. He said, “If the clinic staff want you to lose five pounds then you need to get the five pounds off and don’t put your personal opinion in there. Just nod your head and carry on.”]“
This behaviour, while understandable, can have unintended consequences for the patient-client relationship:
“To become perfect, to appear to be the ideal patient, a person might find it necessary to act the part. Is it possible to show who one really is when it is the ideal patient who needs to be seen? A person who waits to have bariatric surgery, who feels the need to prove him- or herself to access the surgery, might also find it necessary to hide or become secretive, to leave things out of the food journal or the stories told.”
“Imagine if one awaiting a hip replacement, for example, was first obligated to walk without pain? Why then would one be required to lose weight before weight loss surgery—to do the very thing the surgery provides? To get help, a person must reveal her struggle to the nurse, to name it, and in so doing to show herself as a failure. Such a person finds that she has no other choice. Alone, she cannot lose the weight, and without weight loss, the surgery will not happen. Nevertheless, in revealing this struggle, she risks losing the very thing she hopes to gain.”
2. Waiting and Weighing: Promoting Weight Consciousness to the Weight Conscious:
This section deals with the negative impact that this practice has by reinforcing focus and obsession with numbers on the scale when the real focus should be on health behaviours.
3. Paying For Surgical Approval Through Weight Loss:
“[I feel as if the surgery is being held for ransom, and if I don’t behave perfectly, I won’t get a chance. I mean, I see them obsessing over my charts and journal. No one even tries talking to me. The nurse and psychologist tell me, “No black or white thinking,” but here they are practicing exactly that!]“
“The irony of the perfect behavior required to lose weight and ultimately access weight-loss surgery amid suggestions to reject black and white thinking is not lost on the woman who waits. She should resist the urge to see the world as all or nothing, either this or that, and instead accept the complexities of the grey that exists in the world between black and white, yet she knows that she either loses weight or she loses surgery. It is black or white.”
4. Presurgical Weight Loss and Questioning the Need for Weight-Loss Surgery Altogether:
This section addresses the issue that patients, who do manage to lose substantial weight before surgery, may be faced with having to reconsider the need for surgery altogether thereby increasing internal conflict and enhancing uncertainty as to whether they have made the right decision to have surgery in the first place.
This is clearly a paper that all practitioners in bariatric clinics should read and be aware of.
As the authors point out, given the lack of good evidence that presurgical weight loss has any relevant impact on surgical or post-surgical outcomes, it may be high time to reconsider this potentially harmful practice.
Glenn NM, Raine KD, & Spence JC (2014). Mandatory Weight Loss During the Wait For Bariatric Surgery. Qualitative health research PMID: 25185162