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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Thursday, July 08, 2004
    Weight Loss Surgery? I Don't Think So

    From American Medical News comes this interesting (and relevant, to us primary care docs) story on weight-loss surgery:

    Bariatric Patients Need Lifelong Care (or, as I would put it: "Duh.")

    A few years ago no insurance plans would pay for bariatric (a.k.a. weight-loss) surgery, or would do so only reluctantly. In the last two to three years that has changed significantly, as insurance plans have set specific indications for this surgery; in some cases even teens are now being approved (though this is still controversial). Many of the older surgical protocols are no longer being authorized, as long-term studies have not borne out their effectiveness and/or safety. In my practice more and more patients are applying for surgery and are being approved; I'm guessing maybe ten of my patients have had this done in the last year or two.

    I still have problems with this approach to weight loss, though for the right patient it is undoubtedly effective. Here's my biggest issue: surgical treatment does not deal with the primary drive to overeat, which is emotional (most of the time, anyway). Patients are supposed to receive psychological screening prior to the surgery, but in my experience this is a joke. My medical director once asked, rhetorically: "Has anybody ever had a bariatric patient turned down by the psych team?" (Nobody had.) I have seen patients regain huge amounts of weight, once they figure out how to "outwit" their surgically revamped digestive tracts. Some patients never lose weight in the first place, at least not much, for the same reason.

    How do you outwit a gastric bypass? Well, the commonest way to do so is via "liquid" calories - meaning high-calorie, low-volume foods such as smoothies, ice cream, chocolate and booze. When I tell patients that they'll have to make a conscious effort to avoid such foods after surgery, and that they'll still need to exercise in order to achieve maximum weight loss, their faces fall. I really think people are viewing bariatric surgery as some sort of "magic" effort-free method of losing weight. Speaking as someone who has struggled with a lifelong weight problem, I can empathize with this, but I feel patients need to be warned both about its true effectiveness and about the lifetime consequences of such surgery.

    The article emphasizes the importance of continuing dietary supplements postoperatively - this is a lifelong requirement. Unfortunately, many patients are not doing this. The supplements are often not covered by insurance (they're "vitamins," not medications) and can be expensive. For instance, many postsurgical patients will suffer from iron-deficiency anemia unless they take an iron supplement specifically formulated for people who have difficulty absorbing iron. They're also at higher risk for B12 deficiency and osteoporosis, as well as deficiencies of fat-soluble vitamins. Some patients need to be followed with blood tests to check for deficiencies as well. Every managed care doc cringes at the thought of being confronted by a patient clutching a list of esoteric, expensive lab tests ordered by a surgeon who doesn't give a damn how much they cost, because he didn't sign a capitation contract with a lab.

    Lastly, as the title of the article suggests, we primary care MDs need to be educated about the type of care such patients need. Do they need to be screened for osteoporosis sooner? How often do they need labs? Will they need to be colonoscoped more frequently? Do different surgical techniques carry different long-term risks? I don't know the answers to these questions. If anyone can recommend a good source of information (Internet or otherwise) I would love to know about it. In the meantime, read the article if you haven't already - I think you'll find it educational.



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