Obesity: A rapidly growing health concern
Obesity is a major health problem. During the past 25 years, rates of adult obesity have doubled, as approximately 34 percent of US adults are currently obese (meaning a body mass index of 30 or greater). Around 75 percent among this group will suffer from one or more obesity-related medical conditions. Bariatric surgery has emerged as a viable option (and often a medical necessity) for obese individuals suffering from related medical complications, who have not responded to non-surgical interventions. For many, but not all patients, bariatric surgery provides greater and more durable weight reduction than medications and psychological interventions alone
What is bariatric surgery and how is it performed?
Bariatric surgery involves a combination of techniques that cause restriction of the stomach, malabsorption and/or changes in neural and endocrine hormones. The procedures are typically performed through a small incision in the abdomen.
- Adjustable gastric banding is accomplished by placement of a belt-like band around the stomach. Once tightened, it constricts the stomach into an hourglass shape, leaving a very small pouch that receives food through the esophagus. The band slows movements down through the stomach, causing one to feel full for a longer period of time, following consumption of smaller than usual meals. The overall effect of this is calorie reduction.
- Roux-en-Y combines the process of gastric restriction along with malabsorption. First, the stomach size is drastically reduced (usually with staples or a band), allowing for less intake of calories. Second, the first part of the small intestine (duodenum), where substantial calories are absorbed, is surgically bypassed. Ingested nutrients thus mix directly in the lower intestine, causing reduced absorption. This method advantageously allows one to consume more calories than with gastric restriction alone, while still maintaining weight reduction over time. However, there are also disadvantages to this method, which may include nausea, bloating or abdominal cramping.
- Bilopancreatic diversion with a duodenal switch This method also works by combining gastric restriction and malabsorption. First, a large portion of the stomach is removed, creating a “gastric sleeve.” This decreases the amount of food one is able to consume in a single sitting. Next, a significant amount of the smaller intestine is removed in order to impair food absorption. But unlike Roux-en-Y, a portion of the duodenum is preserved. This allows for greater absorption of vitamins and nutrients. As a result of the small intestine rearrangement, bile and pancreatic juices are separated from food during a portion of digestion, directly impairing fat absorption. This complex procedure tends to be higher risk than the others.
- Some morbidly obese individuals who weigh too much to qualify for the full procedure may undergo only the first part. This procedure is known as vertical sleeve gastrectomy. Some patients may lose significant amounts of weight through this procedure alone. It is thought that removal of much of the stomach may reduce a hormone called grehlin, which leads to reduced feelings of hunger.
Patient selection and risk
Patient selection is often based on standards published by the National Institutes of Health. Candidates typically have a body mass index (BMI) of 35 or more, along with one or more severe conditions that are expected to have a meaningful clinical improvement with weight reduction (for example, diabetes, hypertension, obstructive sleep apnea, etc.). It is recommended that patients show evidence of completion of a structured weight management program that covered diet, physical activity, and psychological and drug interventions, but did not result in significant and sustained improvement in weight-related issues. Patients should be well informed of risks and complications, motivated to make lifestyle and eating habit changes, and able to participate in long-term follow-up.
A study sponsored by the National Institutes of Health compared the risks of bariatric surgery to that of gallbladder or hip replacement surgery. Overall, mortality rates are lower than the long-term risk of dying from heart disease or diabetes. All risks and potential complications should be discussed thoroughly with the medical provider, while a therapist can assist the family in coping and understanding how to support the patient mentally and emotionally.
After surgery, patients can expect improvements in the areas of diabetes, hyperlipidemia (elevation of fats in the bloodstream), hypertension, obstructive sleep apnea, quality of life and mental health, though risk of suicide, binge eating, and issues related to past abuse have been shown to persist after surgery. Thus, post-surgical psychological follow-up should include ongoing assessment of these areas. Long-term follow-up is ideal, as problems may not resurface during the first few months of weight loss. Weight loss often slows following the first year of surgery. During this period of transition, old coping strategies may resurface or new stressors may occur.
How can a family therapist help?
Though this is a medical procedure, the process can be highly emotional, stressful and leave a family with many questions and a need for therapeutic assistance. Marriage and family therapists (MFT) can use their unique training and expertise with couples and families to help bariatric surgery patients navigate challenges before and after surgery. In addition to the physical and behavioral alterations that follow weight loss surgery, personal and family relationships may undergo significant changes as a result of dramatic weight loss.
The families and partners of weight loss surgery patients are heavily impacted by the behavior changes required in order for bariatric surgery to succeed. Food shopping, mealtime and even relaxing in front of the family TV can be charged with emotion and difficulty following surgery. Formerly comfortable familial patterns must shift to accommodate healthier habits. Change is often difficult for everyone. Family loyalties, friendships, and marital bonds are tested and sometimes traumatized in the first six to eight months after surgery. Patients report strong interpersonal experiences of anger, embarrassment, and euphoria. An innocent observation from a spouse, friend or co-worker may be experienced as intrusive. A well-meant compliment at home or at work may cause confusion, discomfort and anger for patients.
Divorce rates appear to climb among couples with a bariatric surgery partner, especially in the first year after surgery, as patients may see their partners as less interesting and less social than they remember. Another study noted that partners and friends of bariatric patients sometimes feel abandoned or threatened by their new, thinner friend or partner.
Drastic physical transformations often lead to changes in self- and society perceptions. This may stress the patient’s family and friends, forcing relationships to evolve. Also threatening to partnerships are the new and intense relationships patients often form with others who have had surgery. These relationships hold great importance for patients in the early months after surgery, but recede naturally as patients learn to navigate their own recoveries and their own conflicting feelings about self and others.
Marriages that fail following one partner’s surgery are typically unions that were problematic beforehand. For example, some patients experience physical or emotional abuse in their relationship as a result of their morbid obesity. Strong, healthy relationships are more likely to survive the experience.
Near the end of the first post-operative year, some patients may display an intense and uncharacteristic self-assertiveness. They may explode with strident needs and opinions after years of accommodating and caretaking others. Friends, families and even patients are sometimes shocked at these strange changes in personality and in behavior.
Patients will need guidance and support to develop new, healthy behaviors and activities to replace the core role food has previously played in their lives.
The text of this consumer update was written by Maria J. Frisch, MS; Carol Signore, MAT; and Ellen S. Rome, MD.
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