The Need for Better WLS Preparation and On-Going Care!

Medical doctors take the “Hippocratic Oath,” promising to do their patients “no harm.” I’m a licensed psychologist and we, like most licensed health care professionals, have ethical standards stating we will act in the best interests of our clients. The vast majority of us who work in the health care industry earnestly put forth effort to do the best we can with each human being with whom we work.

Insurance companies – we need your help. For ten years I have worked primarily with patients preparing for weight loss surgery. I conduct pre-surgical psychological evaluations and work with patients pre- and post-operatively. The program I work most extensively with is a Bariatric Center of Excellence. Our patients meet with the surgeon, the nutritionist, myself, have the option of meeting with a personal exercise trainer, and attend a class about the surgical procedures.

I believe that in many ways we are doing our patients harm. How? We set them up for failure following weight loss surgery, touting that we have adequately prepared them for life after surgery. Ask the post-operative community how prepared they feel they were. And ask them two or three years after they’ve had the surgery – because that is when many “return to old habits” with zeal. That is when the hoopla of the weight loss has died down and then, as in the past, they do what they have always done – and the result is the same as it was in the past. They regain their weight.

Through weight loss surgery, we take away from them something (food), which has meant much more to them than fuel for their bodies and we send them home to deal with the changes. Changes to more than their digestive systems and physical appearance. We hope they will make the necessary changes in their relationship with food – very often not a topic of conversation prior to surgery. The patients face changes in their relationships with spouses, partners, children, extended family, friends, and co-workers. There are changes in their body image. Changes in their social relationships. Changes in their self-esteem, which takes a turn upward for many, followed often times by a decline. There may be changes (an increase) in alcohol consumption, pain and other prescription medications, spending habits, and other “substitute behaviors.” Most of all, these patients face changes in their relationship with themselves. With little to no guidance.

The bariatric centers and the insurance companies loudly proclaim the benefits of weight loss surgery, which are numerous and impressive! The reason I work in this field. Weight loss surgery is an incredible opportunity for changes in lifestyle and improved health. Funny thing is, the “success” rates are based on such short-term results. The reasons stated for the lack of long-term data are many, most notably a lack of follow-up by patients. Even a year or a few years after their procedures. Are the patients not returning because they have regained? Some, for sure.

It is the insurance companies who are largely responsible for the lack of adequate preparation. And tragically, the insurance companies waste a lot of money. Not to mention, leaving a whole lot of people floundering in their new life. Some eventually seek a bariatric surgery revision. And the insurance companies grant the revisions without requiring patients to go through any formal educational program prior to a revision, a program that needs to include regular meetings with a dietician, therapist, and exercise physiologist.

Patients often receive one nutrition class prior to weight loss surgery. One nutrition class to educate them about the required (and somewhat complicated) routine of daily vitamins and supplements (some need to be taken with food; some need to be taken a few hours after another – but not with food – or specifically with food). ONE (or a few) nutrition class(es) to impart the importance of protein (to include educating patients what food are healthy sources of protein), and the need to cut down on the intake of simple carbohydrates and sugar (keeping in mind that many patients don’t know what simple carbohydrates are). One class! One nutrition class for a population with numerous patients who were already not adhering to a healthy diet, exercise program and medication regimen related to their co-morbid diabetes, heart problems, and/or dangerously high blood pressure! One nutrition class.

One hour with a psychologist or psychiatrist. Not even a psychiatrist or psychologist who necessarily has any specific education (or interest) in bariatric medicine! After one hour, can we then say we have prepared the patients for how to be successful following weight loss surgery? I know I can’t. All I can do is say whether or not they meet the recommendations for patients for whom bariatric surgery is contraindicated. And if a patient is denied for surgery, I am sometimes met with resistance from some surgeons who appear hell bent on doing as many surgeries as possible… for whatever reasons. Seeing potential surgical weight loss patients for one session was not sufficient for me, even though that is all that is required. To ease my own conscience, knowing patients needed a great deal of information related to the changes they face after surgery, I created a series of videos I require patients to watch prior to meeting with me. At least I can say I have introduced to them the psychosocial issues (sexual abuse, childhood trauma, neglect) and psychiatric co-morbidities (depression, anxiety, binge eating disorder) often associated with obesity. I have given them suggestions for ways to address these issues and provided resources for obtaining help. The videos introduce patients to the many changes that are likely to take place in their lives that are indirectly related to the incisions in their abdomen.

Many programs offer a once a month “support group.” While these are a wonderful resource, they are not intended to deal with psychological and psychiatric issues related to obesity. One hour with a mental health professional? Please. By the way, when I refer to the mental health component, I’m referring to more than simply behavior modification, which most programs focus on. While behavior modification is necessary, it is also insufficient as the mental health component of a bariatric center, considering the multi-dimensional disease of obesity.

Prepared for weight loss surgery? For living a healthy life after weight loss surgery? I think not. For that matter, I don’t think it is possible for anyone to be truly prepared for life after weight loss surgery, any more than it is possible to be truly prepared for a marriage after the wedding ceremony or to be prepared for parenting after giving birth to a baby. But we could certainly do a better job. And the insurance companies are the ones to set the requirements.

I haven’t even mentioned the self-pay patients. A friend of mine shared with me she got NOTHING for preparation at the center where she had weight loss surgery. What’s going on there, surgeons? Get ‘em in and get those surgery slots filled?

Do we want a healthier population, long-term, as a result of weight loss surgery? If that is truly the goal, then we need to invest the time and money into adequate preparation for those human beings seeking weight loss surgery. We need more thorough, lengthier preparation programs. The requisite “3 or 6 month medically supervised diet before surgery” is a joke in the WLS community. Patients view it as nothing more than a delay in getting what they want. If patients were actually required to maintain food and exercise diaries and to attend a number of nutrition classes and a number of psychologically-based classes throughout that “waiting period,” then it may make a big difference in the number of people who are successful long term post-operatively. As things stand, few bariatric centers are willing to set such pre-surgical requirements because patients would opt for the program down the block, the one who doesn’t have such requirements. It’s sad, but it’s true. Prior to the surgery, patients just want to get to the OR. They want to get the weight off – NOW. We, the medical professionals, need to help the patients help themselves and adequately prepare them for this life altering, ALL OF LIFE-altering procedure.

So come on, insurance companies. Pull your heads out and make this right. Require a useful, thorough, whole-person pre-operative education program for all patients seeking weight loss surgery. And save yourselves money in the long run.
Connie Stapleton Ph. D