Does Mandatory Weight Loss Before Surgery Harm Patients?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
Friday, September 19, 2014
This article sure brought back memories. I remember I had to lose 15lbs before I could get a surgery date and found it VERY difficult to do so, even though i was following the dietary advice of my doctor and exercising. Every time I would go for a weigh in and saw that after all my hard work I was only losing 1/2 a pound per week, I would get a “lecture” that I needed work on my eating and exercise routine, as if I was not always doing so. The general consensus seems to be that people are overweight because they are all lazy, they all don’t exercise and they are all ignorant about nutrition. In my case I was not only doing the low carb diet that was prescribed to me, i was also exercising, like i had been the years before i decided to get surgery, I was working full time, in graduate school full time, and stepping to help my elderly grandparents. So technically there was no time to be “lazy”, but no one acknowledged that or my hard work.
It was only after I was on high powered antibiotics for h. pylori did the weight came off because i had chronic stomach upset, diarrhea and nausea from the treatment. So even though I was sick as a dog the only thing the medical office seemed to care about was that I lost weight. I suffered through the attitude because i desperately wanted help.
Friday, September 19, 2014
I feel very blessed that my clinic time at the Edmonton clinic really focused on weight maintenance. I did have a 10% weight loss, and maintained that, which showed that I was using the tools I had learned.
Friday, September 19, 2014
I am amazed at how these excerpts captured my own experiences and feelings. I have a feeling that many people out there will be thinking the same thing.
I do understand that where health care funding for elective surgery is scarce, we prefer to prioritize patients with a record of compliance; however, it’s a simple fact that most bariatric patients wouldn’t want surgery if they could lose the weight through diet and exercise and then keep it off.
Sunday, September 21, 2014
I had Type 2 diabetes when I was approved for surgery. My blood sugar was so out of control that my endo kept upping my insulin, which in turn kept upping my weight. As hard as I tried to lose the weight my surgeon had ordered, I couldn’t do it; in fact, I was gaining. When the surgeon’s office called to see why they hadn’t heard from me in a while, I told them why. They made an appointment for me with the surgeon who — hallelujah! — said, “Given your situation, we’d better get you in here before you gain any more weight.” I walked out of that surgery and threw away ALL of my diabetes meds, including the insulin. Although my diabetes did eventually come back (some five years after the surgery) it is now controlled with metformin and diet. SO grateful for a compassionate AND knowledgeable surgeon.
Tuesday, September 30, 2014
Great information, Dr. Sharma. Thank you for sharing this.
Monday, October 20, 2014
Helpful information. Thank you for sharing this to us. Thank you so much Dr. Sharma.
Friday, May 18, 2018
I’m currently in the preop weight loss process and not doing well. I think I might have used the phrase holding the surgery for randsom. I know I’ll die young without this surgery and probably lose limbs first. My grandmother died at 45, over 500lbs I think.
But that doesnt matter. I’ve tried for 2 months now to lose more weight and seem to have only accomplished upsetting my doctor.
If I could do this without the surgery, I wouldn’t have asked for it. Unfortunately I got a bit overexcited at getting my first appt and lost 15 lbs in the month before to get a head start and prove how committed I am But there’s no record of that weight. So, it’s of no use.
What other illness would you withhold the treatment like this from the people who need it most? It’s cruel.
I fight every appt not to lie to this doctor and say I’m succeedig at all the reatrictions she recommends. I’ve wondered and prayed… Is it immoral to lie to save your life?