Bariatric Surgery and Bariatric Medicine: A Developing Paradigm for Practice Modeling

| November 17, 2009

by Michael Kaplan, DO

Bariatric Times 2009;6(11):23–26

INTRODUCTION
With the popularity of bariatric surgery increasing every year,[1] there exists a real-world need among surgeons to have a medical specialty referral source to help manage their pre- and postsurgical patients over time. It does not make sense for a surgeon to spend his time dealing with nutritional issues and/or weight gain issues in postsurgical patients; the surgeon’s time is best spent doing surgery. For example, the cardiothoracic surgeon utilizes the expertise of the cardiologist to streamline patient care and improve patient outcomes. Likewise, shared management of the postsurgery bariatric patient between the bariatric surgeon and bariatric physician or bariatrician will also result in better long-term, weight loss outcomes for the patient.[2,3,4] This article provides the reader with a road map of the responsibilities the bariatrician can perform as part of a multidisciplinary team to assist the bariatric surgeon in improving the level of care the postsurgical bariatric patient receives. This type of enhanced relationship may allow the solo-practicing bariatric surgeon to offer the same level of care as the larger multidisciplinary university programs.[1]

ABSTRACT
With the ever increasing popularity of Bariatric Surgery it makes sense for Bariatric surgeons to have a relationship with a Bariatric medicine physician to help manage the pre and post bariatric surgery patient. A guide is going to be presented concerning the approaches taken by the bariatrician to assist surgical patients with weight loss pre and post-operatively. The metabolic parameters that must be monitored post-operatively will also be discussed.

PREOPERATIVE PHASE
Most patients who have bariatric surgery in the United States rely on an insurance company to pay for the procedure. Many insurance companies have criteria that must be met by the patient before the surgical procedure is approved. These preoperative requirements usually consist of an esophagogastroduodenoscopy (EGD), sleep study, psychological evaluation, and six months of medical weight loss.

The six months of medical weight loss requirement may be a barrier for surgical approval for some patients, especially if they are being managed by their primary care physician (PCP). A PCP who does not specialize in bariatric medicine may not have the tools or experience necessary to care for a bariatric patient. For example, a PCP may not have scales, furniture, or examination equipment that can accomodate the weight of a bariatric patient. This may make it difficult for the PCP to document the required six months of medical weight loss. Bariatricians, however, will have the expertise as well as the scales, furniture, and examination equipment required to handle the unique needs of a bariatric patient. An added advantage of referring patients to a bariatrician for the six months of medical weight loss requirement is that bariatricians have experience writing the needed insurance letters that document the weight loss. Most bariatricians have treated many patients who have lost weight on one of their programs and then gained it back. In these instances, the bariatricians can refer these patients for bariatric surgery with the six months of medical weight loss requirement already met. This helps make the surgical approval process somewhat easier and quicker in some patients.

A well-known benefit of preoperative weight loss is improvement in metabolic parameters, such as blood sugar management in patients with diabetes and blood pressure control in patients with hypertension.[5] The risk of a wound infection can also be reduced with metabolic improvements, especially in patients with diabetes. As the bariatrician works with the bariatric patient to lose the required preoperative weight, he or she not only helps the patient improve metabolic parameters but also establish a better nutrition and exercise program prior to the surgery, which improves postoperative outcomes.[6] The bariatrician can help the preoperative patient adjust to the lifetime of change and dedication needed postsurgery to keep the
weight off.

The preoperative weight loss patient also requires focused counseling on becoming more ambulatory prior to bariatric surgery. This not only helps to prevent a deadly pulmonary embolus,[7,8] but also can help to establish the physical activity routine necessary for long-term weight loss and maintenance. Bariatricians are accustomed to counseling their patients on exercise and often have established methods in place to accomplish this.[9–12] The bariatrician can send progress letters to the PCP, as well as to the surgeon, to document preoperative weight loss and exercise accomplishments.

POSTOPERATIVE FOLLOWUP
Nutritional and metabolic monitoring. Baritricians can assist the surgeon in monitoring nutritional issues in the postbariatric surgery patient. Roux-en-Y gastric bypass patients are often at risk for micronutrient deficiencies, such as B12, folate, iron, vitamin D, and calcium.[13,14] The bariatrician can perform the appropriate laboratory screening as well as verify patient adherence with the commonly recommended dosing of bariatric multivitamin and mineral supplementation. Postsurgery patients who are menstruating, especially woman with menorrhagia, need to be periodically screened for iron-deficiency anemia.[15] These patients are usually treated with oral iron supplementation but will occasionally require intravenous (IV) supplementation. A bariatrician with hematology experience can administer the IV iron supplementation. The bariatrician should be available to monitor these patients as well as other postsurgery patients for vitamin and mineral deficiencies and anemia and be prepared to council patients on the importance of nutritional supplementation adherence for long-term health.

In addition to checking vitamin and mineral levels, bariatricians can also provide follow up to postsurgery patients a minimum of every three months to obtain a complete blood count (CBC) and glucose and creatine levels and every six months to check liver function and protein and albumin levels for the first year.[16] After the first year post-surgery, the laboratory tests are recommended annually.[16] These recommended follow-up visits give the baritrician the opportunity to check the progress of weight loss and/or weight maintenance.

Laparoscopic band patients will require follow up with their surgeons 2 to 4 times the first year after surgery for band adjustments. Some bariatricians are trained in laparoscopic band adjustment procedures and can assist the surgeon by performing this procedure. All patients should continue to follow up with the surgeon annually to chart the amount of weight lost and also to maintain a relationship in case the need arises for a revision surgery in the future.

Exercise. The unfortunate consequence of losing weight by any methodology is that most people will start to gain the weight back over time.[17–20] Bariatric surgery is a tool the patient uses to change behaviors so that he or she can lose weight and benefit from improved health as a result. It is crucial during the rapid weight loss period in the year after surgery that patients are instructed about the importance of exercise, with a minimum goal of three hours of exercise per week, if they want to keep the weight off long term.[21–23] The bariatrician is trained to assist the patient in developing an exercise program.

Fitness and exercise counseling is usually performed every visit by the bariatrician. A body composition analysis scale can be used to assist with patient education by showing, through generated reports, a patient’s percentage of body fat, which can help motivate a patient to exercise. Exercise is usually required for an individual to keep his or her fat percentage down. In essence, bariatricians are teaching their patients the importance of exercise to keep weight off long term.[24] This is a necessary life skill bariatric patients need to learn if they are going to keep weight off. The bariatrican will also discuss with the patient his or her current level of activity and develop an individualized exercise plan. For example, the bariatrician may recommend that a patient use a daily pedometer and record the number of steps daily. The patient subsequently is encouraged to increase the number of daily steps by 100 every week for the first postoperative year. These small lifestyle modifications over time translate into better habits that promote weight maintenance. Bariatricians also incorporate many of the principles of nonexercise activity thermogenesis (NEAT) into their patient counseling.[25] These principles include encouraging patients to take the stairs instead of the elevator or parking their cars in parking spots furthest away from the building to encourage them to do more activity on a daily basis.

Counseling. In addition to exercise and fitness counseling, the bariatrician can also assist the patient with psychological, behavioral, and nutritional counseling. Patients should be encouraged to attend postoperative support groups to remain motivated toward the needed lifestyle changes. This support group could be live or online.[2] Several studies have documented the effectiveness of counseling to assist patients with losing and maintaining weight.[2,4,26–28] It is important that the surgeon make alliances with bariatricians who have a strong behavioral component in their practice. Networks of bariatricians exist to whom surgeons can refer their patients for nonsurgical management pre- and postoperatively.

Bariatricians may use effective counseling modules (Figure 1) to educate their patients as to the best strategies to keep off weight. For example, Figure 1 illustrates part of a counseling module for obsessive compulsive eating, and comprises a series of questions derived from the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)[29] for the psychological diagnosis of obsessive compulsive eating disorder.[31–33] In this module, the patient is asked to answer questions based on his or her feelings prior to having surgery. It has been shown that 33.3 percent of patients undergoing bariatric surgery suffer from binge eating disorder.[34]

Counseling that specifically addresses food addictions is useful in helping to teach postoperative patients new strategies to deal with eating behaviors. Some of the topics on which bariatricians counsel their patients include behavioral and nutritional issues as well as fitness and exercise issues. The professionial counseling the patient receives is ideally individualized to the patient depending on his or her needs and circumstances.

Finally, bariatric surgeons should consider referring patients to bariatricians who have received bariatric medicine board certification. Bariatricians who have received this board certification have agreed to focus on teaching behavioral and fitness issues to their patients to help them achieve long-term success.

CONCLUSION
A working relationship between the bariatric surgeon and the bariatrician is important. Not only can this relationship help to alleviate some of the burden placed on the surgeon for long-term, postoperative patient follow up, but it can provide the patient with skilled long-term care by physicians who are trained to handle the unique needs of bariatric patients. A bariatrician, as opposed to a PCP, has the skills to help the preoperative bariatric patient achieve the required medical weight loss prior to surgery as well as lay the foundation for a healthy eating and exercise program that will be needed postoperatively. After surgery, the bariatrician can monitor the bariatric patient’s nutritional and metabolic levels, intervening when necessary. Finally, the bariatrician can assist the postoperative patient, through counseling and group support, to develop a life-long plan of healthy diet and exercise. It is a win-win situation for bariatric patients to have a multidisciplinary team responsible for their long-term bariatric care.

REFERENCES
1.    Mitka M. Surgery for obesity: demand soars amid scientific ethical questions. JAMA. 2003;289 (14)1761–1762.
2.    Digenio AG, Mancuso JP, Gerber RA, Dvorak RV. Comparison of methods for delivering a lifestyle modification program for obese patients: a randomized trial. Ann Intern Med. 2009;150(4):255–262.
3.    Serdula MK, Khan LK, Dietz WH. Weight loss counseling revisited. JAMA. 2003;289(14):1747–1750.
4.    Svetkey LP, Stevens VJ, Brantley PJ, et al. Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial. JAMA. 2008;299(10):1139–1148.
5.    Still CD, Benotti P, Wood GC, et al. Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass surgery. Arch Surg. 2007;142(10):994–998; discussion 999.
6.    Pulmonary embolism and depp vein thrombosis. Samuel Z. Goldhaber and Ruth B. Morrison. Circulation 2002;106;1436-1438.
7.    Carmody BJ, Sugerman HJ, Kellum JM. Pulmonary embolism complicating bariatric surgery: detailed analysis of a single institutions 24 year experience. J Am Coll Surg. 2006;203(6):831–837.
8.    Beasley R, Raymond N, Hill S, Nowitz M, Hughes R. eThrombosis: the 21st century variant of venous thromboembolism associated with immobility. Eur Respir J. 2003;21(2):374–376.
9.    Azar ST, Zantout MS. Evaluation and treatment of obesity. J Med Liban. 2000 Sep-Oct; 48(5):310-4.
10.    Bray G. Evaluation of total and regional body composition. In: Bray GA, Bouchard C, James WPT, eds. Handbook of Obesity. New York-Basel: Marcel Dekker, Inc., 1998, 831-54.
11.    National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. September, 1998, NIH Publication No. 98-4083.
12.    Shape Up America and The American Obesity Association; Guidance for the Treatment of Adult Obesity, November, 1996.
13.    Skroubis G, Sakellaropoulos G, Pouggouras K, et al. Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg. 2002;12(4):551–558.
14.    Gasteyger C, Suter M, Gaillard RC, Giusti V. Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation. Am J Clin Nutr. 2008;87(5):1128–1133.
15.    von Drygalski A, Andris DA. Anemia after bariatric surgery: more than just iron deficiency.  Nutr Clin Pract. 2009;24(2):217–226.
16.    Virji A, Murr MM. Caring for patients after baritric surgery. Am Fam Physician. 2006;73(8):1403–1408.
17.    Mann T, Tomiyama AJ, Westling E, et al. Medicares Search for obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220–233.
18.    Applebaum M. Why diets fail—expert advice as a cause of diet failure. Am Psychol. 2008;63(3):200–202.
19.    Herman CP, van Strien T, Polivy J. Undereating or eliminating overeating? Am Psychol. 2008;63(3):202–203.
20.    McGuire MT, Wing RR, Klem ML, Seagle HM, Hill JO. Long-term maintenance of weight loss: do people who lose weight through various weight loss methods use different behaviors to maintain their weight? Int J Obes Relat Metab Disord. 1998;22(6):572–577.
21.    McGuire MT, Wing RR, Klem ML, Lang W, Hill JO. What predicts weight regain in a group of successful weight losers? J Consult Clin Psychol. 1999;67(2):177–185.
22.    Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005;82(1 Suppl):222S–225S.
23.    Weiss EC, Galuska DA, Kettel Khan L, Gillespie C, Serdula MK. Weight regain in U.S. adults who experienced substantial weight loss, 1999–2002. Am J Prev Med. 2007;33(1):34–40.
24.    National Weight Control Registry. http://www.nwcr.ws/Research/default.htm. Accessed date: October 28, 2009.
25.    Levine JA. Nonexercise activity thermogenesis (NEAT): environment and biology. Am J Physiol Endocrinol Metab. 2004;286(5):E675–E685.
26.    Heshka S, Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA. 2003;289(14):1792–1798.
27.    Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: the effect of dietary counseling for weight loss. Ann Intern Med. 2007;147(1):41–50.
28.    Tate DF, Wing RR, Winett RA. Using Internet technology to deliver a behavioral weight loss program. JAMA. 2001;285(9):1172–1177.
29.    American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Press Inc., 2001.
30.    Pull C. Binge eating Disorder. Curr Opin Psychiatry. 2004;17(1):43–48.
31.    Pelchat ML. Food addiction in humans. J Nutr. 2009;139(3):620–622.
32.    Avena NM, Rada P, Hoebel BG. Sugar and fat bingeing have notable differences in addictive-like behavior. J Nutr. 2009;139(3):623–628.
33.    Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348–358.
34.    Frequency of Binge Eating Disorder. Douglas Kalman , MS, RN, FACN, Heather Cascarano RD et al. Journal of the American Dietetic Association. May 2002 volume 102 issue 5 pages 697-699

Tags: , , , ,

Category: Past Articles, Review

Comments are closed.