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Integrative bariatric surgery

October 2014
BY Victor S. Sierpina, MD, ABFM, ABIHM Director, Medical Student Education Program, WD and Laura Nell Nicholson Family Professor of Integrative Medicine, Professor, Family Medicine University of Texas Distinguished Teaching Professor and Myers Hurt, MD

Is your bariatric surgery program integrative and holistic? By this we mean that in addition to the technical surgical management of morbid obesity, does your health care team do all the other parts of the process well? Do they assess and prepare the patient adequately before surgery and well as support them post surgically in all dimensions of well-being, body, mind, social, and spiritual? While a routine preoperative p s yc h o l o g i c a l evaluation is required by most insurance companies prior to bariatric surgery, what happens after surgery may be even more important to long term outcomes and patient satisfaction, wellness, and happiness.

With bariatric surgery now the second most common type of general surgery after gall bladder surgery, this has become a huge industry and most hospitals and medical centers in the Houston area offer such surgery.

If lifestyle medicine is the new pill, it certainly is not easy to swallow or one that works for many people who have a BMI above 35 with co-morbidities or over 40 which are the criteria to be eligible for surgery. It is just too challenging for them to lose and maintain significant weight loss.

As primary care doctors, we have been thrilled to see those patients have a radical life change after bariatric surgery. As the pounds melt away, metabolic changes occur allowing them to discontinue medications or other treatments for diabetes, hypertension, hyperlipidemia, osteoarthritis, depression, heart disease, sleep apnea, and more.

We recently read a book by a highly successful bariatric surgeon in Dallas and former UTMB medical student. Dr. Nick Nicholson’s book, Weight Loss Surgery: The Real Skinny, is an essential read for those of you who provide bariatric services.

Dr. Nicholson’s book is a slim, approachable guide ripe with patient quotes that will strike a chord in anyone dealing with weight loss. It is refreshing to hear from a surgeon who could easily benefit from a “quick fix” approach actually address the journey that is weight loss on such a holistic, emotional level. Instead of focusing solely on technical procedures, the book highlights emotions surrounding weight loss surgery, from the initial decision to see a bariatric surgeon through realistic goal setting. It offers an incredible focus on the emotional journey that is weight loss, both in surgical and non- surgical patients.

If we thought of severe obesity as a serious condition like cancer, perhaps people would be more supportive of those getting this kind of treatment. Instead, overweight patients are often stigmatized as having poor impulse control, lack of motivation to exercise, and so on. Yet their risk for early death and disability is worse than most cancer patients.

Nicholson’s book offers a realistic, refreshing, and holistic alternative view to this severe health problem. It helps patients who are candidates for this kind of surgery understand the complexity of choosing what kind of surgery to undergo, all of which have some risks and potential complications, but the bigger picture of how such overweight has affected their lives. And how losing that weight, and maintaining that weight loss will affect it even more.

Before undergoing surgery, people need to understand the challenges ahead, and those behind them. Sexual, physical, and emotional abuse may have preceded morbid obesity as those injured souls stuffed down their emotions with comforts like food and protected themselves from further abuse by a large layer of fatty insulation to distance themselves from others.

People in their lives have become used to their weight and the psychological profile, often of compliance, dependency, depression, or victimhood that this involves. When they suddenly start looking more normal, start asserting their independence, their beauty, their inner spirit, others in the family, even close friends and spouses, may push back and sabotage their well- earned gains. Habits like hanging out with friends primarily for food and drinks may need to change to more physical pursuits. This may leave some obese friends behind or imploring them not to change so much. These all make for some tough decisions.

Every meal, every chance to move and be active becomes a critical life choice.

Lurking in the background to drag a person with a successful post-operative weight loss back to an unhealthy state are dysfunctional relationships, addictions to drugs, foods, alcohol, and the painful memories of emotional trauma or abuse. This is not easy work but it can be done with proper support, education, and awareness of the options.

Having a professional team of physicians, nurses, nutritionists, psychologists, health coaches, trainers, pharmacists, and others can take a bariatric center from good to great. More importantly, it can help support the patients through the most vulnerable time of their lives after surgery when their whole world changes dramatically, drastically, and in some ways dangerously.

While their physical health may improve, their emotional health may be fragile and suffer. Relationships with a spouse, other family members, or friends may shift or be revealed as not only not supportive but even toxic. This is not always the case, however, it happens often enough that a bariatric health care team ought be prepared to manage these relational problems and to prepare the patient for them.

A start on doing this is to have patients read Weight Loss Surgery: The Real Skinny. It is available on line from Amazon. Check it out yourself if your patients are considering bariatric surgery. And if you are a bariatric surgeon or part of a team that cares for these patients, it is required reading. There is more on the author’s approach at www. nicholsonclinic.com.

Keep in mind that in the realm of bariatric surgery, the real work begins after leaving the operating room.