October 27, 2014

More Attention on Pre and Post Surgery Care

More hospitals are offering long-term weight-loss maintenance programs to patients who undergo bariatric surgery, in a growing recognition that they may need a lifetime of care to avoid backsliding and regaining weight.

The new dietary and lifestyle regimens often start months before the surgery and continue for months or years afterward. Nutritionists, nurses and psychologists join surgeons on the medical team and offer a mix of behavior-modification techniques, including individual counseling, classes and support groups.

The aim is to help patients not only stick to eating and exercise plans, but also to overcome anxiety or depression that can be triggered by dramatic lifestyle changes.

One of the most common procedures, a gastric bypass, reduces the size of the stomach and allows food to bypass part of the small intestine, reducing the amount of food patients can eat at one time and decreasing the calories and nutrients absorbed. To qualify, patients typically have a body mass index of 40 or higher, which translates to being about 100 pounds overweight. They may qualify with a lower body-mass index if they have a serious weight-related health problem, such as diabetes, which can go into remission after surgery.

An estimated 18 million of the 78.6 million obese adults in the U.S. are eligible for surgical weight-loss procedures, according to the American Society for Metabolic and Bariatric Surgery. Between 2011 and 2013, more than a half-million patients had some form of bariatric surgery, the society says.

That number is expected to rise as more private insurers and Medicare plans cover costs for patients where other weight-loss efforts have failed. Surgical fees, depending on the type of procedure, range from $11,500 to $26,000. A federally funded study is evaluating the benefits and risks of bariatric surgery in adolescents.

Patients may lose more than three-quarters of excess weight in the first year after surgery. Maintaining half of excess weight loss five years after surgery is considered a success. Up to 30% of patients may not lose weight, though, or they may gain weight gradually with a return of conditions like diabetes, according to a Stanford University study published earlier this year in the journal Surgery for Obesity and Related Diseases. It found successful weight loss was highest among those who adhered to diets, grazed no more than once a day and attended support groups.

“We know obesity is a chronic disease, and relapses happen,” says John Morton, co-author of the study, president-elect of the American Society for Metabolic and Bariatric Surgery and chief of bariatric and minimally invasive surgery at Stanford University School of Medicine.

In a 2009 report, researchers at Ochsner Health System in New Orleans said many patients have difficulty with extreme and instant lifestyle changes. People who were “stress eaters” lose that outlet, and when holidays and family life no longer revolve around a big meal, social structures can be “irreparably broken,” the researchers said. With guidance, understanding and professional counseling, patients can adapt.

At Mercy Health-Cincinnati, part of the Mercy Health system formerly known as Catholic Health Partners, patients undergo a psychiatric evaluation before weight-loss surgery to help uncover eating disorders, addictions or other issues that if untreated might interfere with a new regimen after surgery. Before the operation, patients are required to lose a certain amount of weight, depending on their body mass, with a program that includes diet, exercise and some liquid meal replacement.

“There is such a behavioral change needed that if we don’t start making it beforehand, it is too overwhelming,” says Joe Northup, clinical director of the Mercy Health-Cincinnati bariatric surgery program.

While his team doesn’t set specific pre-operative weight-loss goals, they do expect patients to make some changes in diet and behavior, such as eating small frequent meals, eliminating carbonated beverages and caffeine, planning more home-prepared meals and eating breakfast and protein at all meals and snacks.

“Surgery is just a tool, and you need ongoing support and counseling to not let those old behaviors you had before surgery creep back in,” Anne Kroger, regional bariatric program coordinator for Mercy Health-Cincinnati, says she tells patients.

After surgery, patients are offered, at no extra cost, behavioral counseling in a group setting with a psychologist, surgeon, dietitian and nurse as well as nutritional and fitness counseling, support groups and cooking classes.

Mercy offers complimentary membership and personal training at its own fitness facilities for six months following surgery, with a discounted rate after that.

Group sessions focus on goal setting, overcoming body-image issues and dealing with changes in relationships. Patients may find family members withhold support or even sabotage their efforts to keep losing. They learn about mindful eating—paying attention to the process of selecting, preparing and eating food—and are encouraged to keep food diaries with entries for thoughts, feelings, moods and body sensations.

In July 2012, Misty Morgan, then 30 and a mother of two, attended an informational seminar about surgery at Mercy. At 5 feet 2 inches and 377 pounds, she had lost the confidence to seek work after losing a previous job. In September, she entered a six-month supervised weight-loss program at Mercy Health Fairfield Hospital in Cincinnati, and lost 40 pounds. Her insurance carrier approved a gastric bypass and she had the procedure in April 2013.

Months before surgery, she began posting regular video updates on YouTube that she thought would help others. She talked about trigger foods, like sugary sweets that she found hard to stop eating once she started, her struggle with bad food choices and her efforts to make her husband, Jeffery, see that buying her sweets and fast food wasn’t helping.

After the surgery, she talked about the ups and downs of trying to stay on the wagon, as well as complications, such as a frightening return to the hospital five months after surgery for unrelated blood clots.

In a video post for her one-year anniversary, she announced she was down to 204.8 pounds and described “the best year of my life,” including a flight to Las Vegas without needing an extra seat or seat-belt extender, and the weird sensation of driving a car without feeling her stomach touch the steering wheel.

After recovering from surgery, Ms. Morgan says she did cardio workouts three times a week at the Mercy gym, met regularly with a nutritionist and attended behavioral modification classes and support groups. A virtual grocery tour helped her make better choices when shopping, and now she reads labels religiously.

“They teach you how to change the way you look at and think of food, and to stop living to eat and eat just to live,” she says.

Ms. Morgan landed a job in a medical billing office and joined a patient support group. She and other post-op patients exercise and plan activities together to stay moving and motivated.

Instead of a night out with her husband to a restaurant, she says, “we go out and do things, like to the amusement park and go on a scary roller coaster.”

She has lost 197 pounds, weighing in last week at 180.6 pounds; her goal is 175, and she will try to lose in five-pound increments after that. The Mercy program “helps keep me accountable and keeps me on track,” Ms. Morgan says.

Keeping It Off

Hospital weight-loss treatment can start months before surgery and last months or years afterward. It typically includes:

Before Surgery

Psychiatric evaluation to uncover eating disorders or addictions

Some supervised weight loss

Behavioral changes, such as eating breakfast and frequent smaller meals, and eliminating carbonated beverages

After Surgery

Behavioral and nutrition, counseling

Support groups and cooking classes

Complimentary gym membership and personal training for six months, followed by discounted rates

—Source: Mercy Health-Cincinnati

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