Realistic Expectations are Important for Both Surgical and Medical Weight Loss Modalities

| October 8, 2015

A Message from Dr. Christopher Still

Christopher Still, DO, FACN, FACP, Co-Clinical Editor, Bariatric Times; Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity Research Institute, Geisinger Medical Center, Danville, Pennsylvania. Dr. Still is also a board member of the Obesity Action Coalition, Tampa, Florida.


Dear Readers,
Welcome to the October issue of Bariatric Times. This month, we feature two articles that highlight devices that were recently approved by the United States Food and Drug Administration (FDA) for weight loss—intragastric balloon systems and vagal blocking therapy. In an earlier message, I discussed newly approved medications and relayed the importance of managing your patients’ expectations of weight loss when prescribing pharmacotherapy and diet/exercise plans. I believe this message should also be applied to these new devices and bariatric surgeries.

Realistic expectations are important concepts for all of the different modalities available for weight loss: medications, devices, and traditional weight loss surgeries. We all want to see our patients succeed, but our definition of success may differ from our patients. In order to measure success, I think we need to look at two things: 1) the weight loss modality being employed and 2) the expected weight loss for that specific modality.

Unrealistic expectations may cause patients to be blinded to the significant impact a modest weight loss can, and does, have on co-morbid medical problems. When a patient loses 30 pounds with diet/exercise and medications, he or she may get concerned that it means they have plateaued or the medication  has stopped working. In reality, that is exactly what you may expect from that treatment.

For instance, on average we can expect approximately 5 to 6 percent weight loss with diet and exercise alone after one year.[1] Typically with the addition of pharmacotherapy, one can expect about an additional six percent, for a total estimated weight loss of about 12 percent.[2] For Roux-en-Y gastric bypass the weight loss expectation, most quote ~70% excess body weight loss. For laparoscopic sleeve gastrectomy, ~50 to 60% excess body weight, and for duodenal switch, 90% excess body weight. But we know in practice, some patients may lose considerably more or less depending on a variety of cofounding issues.

An important consideration for in establishing expectations is our body’s physiological  responses to weight loss. With all types of weight loss there is a reduction in energy expenditure and adaptive hormonal responses after weight loss that that often favors weight regain.[3] Therefore there is significant variability of weight loss, and comorbid medical problems resolution among individuals within similar treatments.

To better predict individual expectations of weight loss and resolution of diabetes after gastric bypass, an APP was developed with the help of students from Bucknell University. Geisinger Obesity Institute launched this free APP called “Get 2 Goal,” which can be used by patients, physicians, and surgeons in the pre- and postoperative period. Based on personalized data patient’s enter, the APP will calculated expected weight loss at 1, 2, and 3 years. In addition, if the patient has type 2 diabetes, it will calculate expected remission rates.    This APP provides patients with a more “personalized” weight loss expectation after gastric bypass.

Although this APP has only been validated for the gastric bypass, weight loss after the gastric sleeve and  duodenal switch procedures can be extrapolated. We are finding that patients and surgeons are  embracing this tool. Post op patients can see where they are compared to other similar patients.

I think we should be aware of these resources so that we may evaluate and recommend them to our  patients. It’s another tool in their toolbox.

As new devices and procedures emerge, we will need to again gather the data and better educate patients so that they may continue to have realistic expectations in regards to their weight loss outcomes

Sincerely,
Christopher Still, DO, FACN, FACP

References
1.    Ackermann RT, Marrero DG. Adapting the Diabetes Prevention Program lifestyle intervention for delivery in the community: the YMCA model. Diabetes Educ. 2007;33:69, 74–75.
2.    Leblanc ES, O’Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2011;155:434–447.
3.    Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. 2011;365(17):1597–1604.

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