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Managing Weight Loss Expectations



sharma-obesity-great-expectationsWhile there are almost no limits to short-term weight loss goals (anyone can starve themselves thin) – the reality of long-term weight loss is rather sobering.

While diet and exercise generally provide an average long-term (3-5 years) sustainable weight loss or about 3-5% of initial weight, even bariatric surgery patients tend on average to sustain a weight loss of only 20-30% of their initial weight.

Surgery, although much safer than generally thought, still bears a risk of complications and the question is how much risk patients are willing to assume if they really knew and understood how much weight they are likely to lose with surgery.

This was the subject of a study by Christina Wee and colleagues, published in JAMA Surgery, in which they examined weight loss expectations and willingness to accept risk among patients seeking bariatric surgery.

The researchers interviews 650 patients interested in bariatric surgery at two bariatric centres in Boston.

On average, patients expected to lose as much as 38% of their weight after surgery and expressed disappointment if they did not lose at least 26%.

In fact, 40% of patients were unwilling to undergo a treatment that would result in only 20% weight loss.

Most patients (85%) accepted some risk of dying to undergo surgery, but the median acceptable risk was only 0.1%.

On the other hand, some patients (20%) appeared more desperate, willing to accept a risk of 10% or greater.

As one may expect, there were important gender differences in these findings: while women were more likely than men to be disappointed with a 20% weight loss, they were also less likely to accept a greater mortality risk.

An important finding for clinicians was that 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.

This study not only shows that most patients seeking bariatric surgery have rather unrealistic weight loss expectations but also that   a substantial number may well be be disappointed with their weight loss after surgery.

It is also evident that many patients believe that they need to lose a rather substantial amount of weight to derive “ANY” health benefits, when in reality even rather modest (and certainly the average 20-30% weight loss seen with surgery) carries substantial health benefits for patients. (Many patients would in fact benefit substantially if they simply stopped gaining weight).

I certainly wonder what educational efforts may be necessary to align expectations with the clinical reality of bariatric surgery and whether better managing expectations is likely to alter current practice?

@DrSharma
Edmonton, AB

9 Comments

  1. I’m 10 pounds short of having lost 50% of my body weight (from 300 to 160) after bypass surgery eight years ago. Immediately after the surgery, I had lost 120 pounds (180) and pretty quickly put almost 30 pounds back on. I discovered that I really anticipated that the surgery was going to do all the work for me when in fact, I was going to have to work hard to change my behaviors and, most importantly, the way I thought about food. It was only after I did that that I started losing again. The surgery has been a tremendous tool — being able to eat about a half cup of food allows you to fill up quickly on healthy food, and “dumping” keeps me away from my beloved sugary treats — but ultimately, I had to do the work. I think that doctors, with their love of the “tinkering” aspects of medicine (here’s a pill; here’s a surgery; here’s a test we can do) do not do enough to emphasize this aspect of the surgery: after the honeymoon is over, it’s all up to you. It’s easier than it was before, and the surgery helps, but it’s ultimately your effort that matters.

    As for people not appreciating the improvements that result from even a small amount of weight loss, that is so true. Prior to surgery, I was on five insulin shots a day and two oral meds. Afterwards, I was on nothing for three or four years and even now, I’m only on metformin. But what has been most powerful is my increased energy and strength. When I feel discouraged because I haven’t lost more, I remind myself that now I am walking two miles a day with relative ease whereas before, I needed a wheelchair to visit Disneyworld.

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    • Thanks Wendy for sharing this very insightful comment. I wish all my patients would understand just how hard they have to work to make surgery work for them. People may think of surgery as a quick fix or taking the easy weight out – nothing is further from the truth.

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  2. This is a very timely study and I completely agree Wendythat surgeons and doctors do not emphasis enough that people have to do a majority of the work. I have been severely overweight all my life and had the VSG in 2012. I lost 75lbs but never did make my goal of losing at least 100lbs even with diet and exercise. While I am disappointed, I also realize that I have never successfully lost this much weight and kept it off for this long either. I did not have any health problems outside of being obese, but I am thankful that I was able to get help before I ended up with serious health problems.

    Sometimes we have to learn to be grateful for the positives even if we didn’t get all that we expected. While I am still overweight, I can now do things like yoga, Pilates, job, and enjoy non plus size clothing-something I could never do before. Am I still working on those last 25? Of course. and the last 25lbs seem to be even harder than the first I needed to qualify for the surgery! Funny how some things work out 🙂

    I have friends who had WLS and because they are relying on the surgery to do everything, they never lost more than 50lbs and they are miserable and disappointed but they also won’t do the extra work needed to secure their success, which I think is sad.

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    • Thanks Mimi – I think the problem often lies in the fact that surgery does not really address the underlying problem that led to weight gain in the first place. Surgery does what it does but without ongoing support that includes addressing emotional eating, all or none thinking, body image problems, depression, abuse histories, and other issues, some folks are going to struggle to make surgery work for them. As I always say, patients don’t fail treatments, treatments fail patients. The patients you mention simply did not get the right treatment for their problem.

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  3. I had RNY gastric bypass in 1981. My weight went from 232 to 140 within the first year. Back then, the only advice and counseling I received was from my surgeon who suggested only one thing: eating 3 meals a day with no beverages at the meal. Being a disordered eater, I ignored that advice, but I got a good 15 years of good results from that surgery. After two pregnancies, my weight started to escalate and I am now back to my starting weight. The surgery would still work if I followed my surgeon’s original advice and didn’t snack. All in all, this surgery gave me a life and I am very grateful, even though it wasn’t a total panacea.

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  4. Part of the ‘expectation’ comes from all the testimonials we see e.v.e.r.y.w.h.e.r.e. Dramatic before / after pictures that show what some people have achieved are very inspirational but I try to remember the proviso “results may vary” – depending on your body and your willingness to do the heavy lifting after the ‘honeymoon’ is over and the pink clouds dissipate. I’m still in the honeymoon stage myself, loving every minute of it, but I’m trying to be realistic about the work that awaits me once I’m a year out from surgery.

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  5. Hi,

    you write that even modest weight loss brings health benefits. Are you talking about behavior-based interventions, with their 5% or so long-term weight loss? If so, do you have any data supporting that claim? I thought there was NO data on the long-term effects of weight loss, except maybe the sobering LOOK AHEAD study.

    Thank you,

    Valerie

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    • Sure, look at the finnish and diabetes preventions studies – 4% weight loss reduces diabetes risk by 65%. Also, (not just in LOOK AHEAD) 5% weight loss improves glucose control, lowers blood pressure, improves quality of life and mobility – even improves symptoms of sleep apnea.

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  6. OK, I searched and found the “Finnish Diabetes Prevention Study.” I only found results for the 3-year outcomes. They report improvements in some risk factors and incidence of diabetes, but they don’t report on anything else (total mortality? quality of life?). Plus, 3 years is awfully short for a life-long change in behavior.

    Also, we can’t distinguish the effect of weight loss from the effect of diet/exercise change. My guess is that the change in behaviors, with or without weight loss, improves health. Weight loss alone, no matter how it is achieved, will very probably help prevent diabetes (it makes fat cells very sensitive to insulin, after all), but I don’t know what effect it has on total health, long term.

    So, do you actually believe that modest weight loss carries substantial (overall) health benefits for the patients? Or is the behaviors required to achieve weight loss that help? Would they help without the weight loss?

    Basically, your assertions seem way overconfident to me, since I don’t think there actually is any long-term data on this.

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