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.

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