Patients with Morbid Obesity are Often in Denial of Their Condition

| November 21, 2011

Dear readers of Bariatric Times,

I cannot believe that it is already November and the holiday season is upon us.

This month, I urge you to read the American Society for Metabolic and Bariatric Surgery (ASMBS) News and Update by Dr. Robin Blackstone. This installment contains information with which readers should become familiar, such as news of improved access to care due to ASMBS efforts working with Health Care Services Corporation (HCSC), a summary of the Device Development in Obesity and Metabolic Disease (DDOMD) meeting, October 16 to 18, 2011, Washington, DC, and the ASMBS’ updated position statement on laparoscopic sleeve gastrectomy (SG).

Recently, the Medicare National Determination Coverage Manual was opened to re-evaluate SG as a valid surgical treatment option for morbid obesity. The ASMBS has made a tremendous effort to provide the Centers for Medicare and Medicaid Services (CMS) with the most recent literature and facts to help them understand how important it is to give our senior citizens access to SG. As a physician, it is frustrating when, due to lack of insurance coverage, you are not able to perform a procedure that you believe is indicated and the best treatment option for your patient. I keep my fingers crossed that CMS will include SG in their revised coverage plan.

On another note, I am still wondering why are we neglecting our Medicaid patients. I have spoken with Medicaid representatives on multiple occasions and have explained that the rates paid to providers are unacceptable. At least at my institution I feel it is impossible to justify an elective procedure in bariatrics with Medicaid rates since the rate paid does not even cover the expenses of our disposables in the operating room.

At the 97th annual meeting of the American College of Surgerons (ACS), October 23 to 27, 2011, in San Francisco, California, I had the privilege to participate in a session chaired by Drs. Dan Jones and Giselle Hamad that featured Dr. Edward Mason as a speaker. Dr. Mason gave, as usual, a master presentation on hormonal changes related to gastric bypass. I am thrilled to announce a new column featuring Ms. Martinez and Dr. Mason that will appear in an upcoming issue of Bariatric Times. I am sure that you will cherish Dr. Mason’s stories and thoughts related to his life as a scientist.

Also in this issue of Bariatric Times, Dr. Edward Lin touches upon a very important topic in bariatric surgery: the management of hiatal hernias in patients with morbid obesity. I would like to add and emphasize to this excellent contribution the importance of the preoperative evaluation of our patients by means of esophagogastroduodenoscopy (EGD) or upper gastrointestinal (UGI) series. It is well documented in the literature that the incidence of gastroesophageal reflux disease (GERD) and hiatal hernias is higher in the population with morbid obesity. In addition, the preoperative diagnosis of a large hiatal may change the surgeon’s strategy. If an adjustable gastric band (AGB) is the procedure of choice, most surgeons would agree that it should not be performed in a patient with large hiatal hernia. If the procedure planned is SG or bypass and mesh is required to close the hiatal defect, then a two-step approach might be indicated. I would first repair the hernia and defer the stapling procedure as a second step. Finally, it is imperative that hiatal hernias be fixed at the time of the bariatric procedure since they will result in miscalculation of pouch size, GERD, and pain in the long-term follow up.

This month, Dr. Christopher Still gives a wonderful perspective in “Creating Bariatric Surgery Advocates: Why it is Critical to Educate Primary Care Physicians.” One would think that lack of insurance coverage or physician referral is the main reason why patients with morbid obesity do not undergo bariatric surgery. At my facility, we asked 100 patients with morbid obesity that walked into our internal medicine clinic why they were not considering bariatric surgery. We found the number one reason was denial; people do not perceive themselves as having morbid obesity.

Finally, Joe Nadglowski, the Executive Director of the ASMBS Foundation and the President and CEO of the Obesity Action Coalition (OAC), gives us an update on the efforts of the OAC to educate congress, regulatory agencies, and the medical community in order increase access to bariatric surgery.
On behalf of all of us at Bariatric Times, we wish you, our readers and industry supporters, a happy holiday season.

Sincerely,
Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

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  1. David Mahony says:

    Re: Patient Denial

    As a Bariatric Psychologist, I would say that denial is a major contributor to obesity and one of the most difficult to address. The complexities of denial pervade the belief systems of patients as well as those of bariatric surgery professionals.

    It is true that obese individuals often believe that they are not obese and even those that acknowledge their obesity will say that they can lose the weight on their own (even though a review of their weight loss history clearly demonstrates otherwise). Even amongst the obese that seek out bariatric surgery, most attribute their weight to factors outside of their control and they are adamant that they do not overeat.

    Amongst bariatric surgery professionals, I have seen a subtler form of denial, i.e., the belief that as long as patients “follow the program” they will lose weight and keep it off. This is in spite of the evidence that many patients simply can not do this.

    To complicate these issues, denial is almost always impossible to address head on. When patients are confronted with their denial they feel insulted and become angry. Similarly with bariatric professionals, they feel that they are doing everything they can and become increasing frustrated and distant from patients.

    I think it’s time that we begin to acknowledge and work with denial instead of avoiding it. While we can not address it head on there are techniques that we can utilize to gently bring patients to accept the responsibility that they have for their weight and the role they must play if they want to be healthy. Similarly, as professionals, we need to recognize the difficulties that our patients experience and continually make efforts to address them while also recognizing that sometimes denial will be stronger than all of our efforts.

    From my perspective, denial, in all its forms and complexities, is the biggest psychological contributor to obesity. It is time that we put our heads together and develop techniques to address this into our treatment of obese individuals.

    Respectfully,

    David Mahony, Ph.D., ABPP