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Talking to Patients about Expectations for Outcome after Bariatric Surgery

| July 1, 2016

Talking to Patients about Expectations for Outcome after Bariatric Surgery: Weight Loss, Quality of Life, Body Image, and Relationships

by Gretchen E. Ames, PhD, ABPP; Matthew M. Clark, PhD, ABPP; Karen B. Grothe, PhD, ABPP; Maria L. Collazo-Clavell, MD; Enrique F. Elli, MD

Gretchen E. Ames, PhD, ABPP, is from the Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida. Mathew M. Clark, PhD, ABPP, and Karen B. Grothe, PhD, ABPP, are from the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota. Maria L. Collazo-Clavell, MD, is from the Department of Endocrinology, Mayo Clinic, Rochester, Minnesota. Enrique F. Elli, MD, is from the Department of Surgery, Mayo Clinic, Jacksonville, Florida.

Bariatric Times. 2016;13(7):10–18.


ABSTRACT
Research studies have demonstrated that patients have unrealistic expectations for weight loss after having bariatric surgery. If patients’ expectations are unmet, this may contribute to nonadherence to recommended lifestyle changes, weight regain, and the return of medical comorbidities in the future. In this article, the authors review available literature on patients’ presurgery expectations for changes in weight, quality of life, body image, and relationships after bariatric surgery and provide recommendations on how healthcare providers can guide patients toward achieving an accurate understanding of treatment outcome. Patient vignettes on the topics of expectations for weight loss, body image, and relationships further illustrate how healthcare providers might talk to patients about expectations for outcomes after bariatric surgery.

Introduction
Presently, obesity is a major public health problem where greater than 35 percent of adults in the United States population have obesity, which is defined as having a body mass index (BMI) greater than 30kg/m2.[1] The rapid rise in class II and III obesity (BMI>35kg/m2) over the past 30 years is particularly alarming, as higher BMIs are associated with greater physical and mental health problems. Bariatric surgery has emerged as the most effective treatment available for patients suffering from medically complicated obesity (BMI > 35kg/m2),[2] yet less than one percent of patients in the United States who may derive benefit from bariatric surgery actually undergo an operation.[3] Common barriers to undergoing bariatric surgery include lack of insurance coverage, fear that surgery is too risky, lack of understanding about the level and severity of one’s obesity, and the perception that bariatric surgery is “the easy way out.”[4] In recent years the understanding of the mechanisms of action of bariatric surgery has evolved from mechanical restriction and malabsorption of nutrient intake to a physiological model of bariatric surgery. Specifically, the current model proposes that bariatric surgery changes physiological signals that regulate energy balance and metabolic function resulting in the experience of reduced hunger, increased satiety, changes in food preference, reduced attention to food stimuli in the environment, and increased energy expenditure.[5–7]

The weight loss operations most commonly performed in the United States are Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG).[3] These operations result in weight losses of approximately 35 percent and 25 to 30 percent of initial body weight 12 to 24 months after surgery, respectively[8–10] with longitudinal data showing maintenance of 75 percent of lost weight after 10 years for RYGB.[11] Significant health improvements occur within three months after the weight loss operation, in particular improvement or remission of type 2 diabetes mellitus (T2DM).[12] Other health conditions that resolve or significantly improve following bariatric surgery include obstructive sleep apnea (OSA), hypertension, dyslipidemia, and hepatic steatosis, resulting in significant reductions in all-cause-mortality over 7 to 10 years after the operation.[13] Bariatric surgery has also been associated with improved mood, body image, self-efficacy, and quality of life.[14–17]

Unequivocally, bariatric surgery improves physical and mental health for many patients with obesity in the first one to two years following the operation. However, the stability of these improvements over time has not been well documented. Many patients have high expectations for improvements in medical comorbidities, quality of life, body image, and relationships after bariatric surgery.[18] If patients’ expectations are unmet, this may contribute to nonadherence to recommended lifestyle changes, weight regain, and the return of medical comorbidities in the future. A significant challenge for providers, therefore, is guiding patients toward an understanding that bariatric surgery is tool rather than a cure for their struggle with the chronic disease of obesity. Moreover, providers must navigate a delicate balance between guiding patients toward an accurate understanding of treatment outcome without diminishing enthusiasm for the possibility of living a different life after substantial weight loss. Given this interplay of medical and quality of life benefits of weight loss, and the possible psychological and weight ramifications of not achieving expected outcomes, the current article has two purposes. First, we will briefly review what is known about patients’ presurgery expectations for changes in weight, quality of life, body image, and relationships after bariatric surgery. Second, we will demonstrate ways for health care providers to approach these topics with patients through four prepared vignettes.

Weight Expectations: Research Findings
Many research studies have demonstrated that patients have unrealistic expectations for weight loss after having bariatric surgery.[18–24] The most commonly used tool for assessing weight expectations is the Goals and Relative Weights Questionnaire (GRWQ) originally designed for use with nonsurgical populations.[25] The GRWQ has been adapted for use with patients seeking bariatric surgery where patients are asked to define, in pounds, their “dream,” “happy,” “acceptable,” and “disappointed” weights after having bariatric surgery. In general, studies have found that patients’ dream weights represent greater than 40 percent loss of their initial body weight ( >90% of excess weight) and correspond with achieving a BMI in the healthy weight range of 20 to 25kg/m2.[20,22] Weights patients rated as “disappointing” were those weights that were most closely associated with actual outcome after having bariatric surgery. Even when patients were asked to identify a weight they could realistically expect to achieve after RYGB and VSG, their expectations greatly exceeded actual outcome.21 Furthermore, patients report that they would be disappointed with a sustained weight loss of 20 percent of initial weight.20 Caucasians, younger women, and patients with greatest BMI appear to have the most unrealistic expectations for weight loss after bariatric surgery.[21]

In our clinical experience, patients often present for the initial assessments unclear as to the risks and benefits of a given bariatric operation to their health. Moreover, patients may have broader health outcomes (e.g., I want to feel better and be more active) but have not considered the impact a bariatric surgery may have on established health conditions such as T2DM and OSA. Thus, providers are responsible for addressing gaps in knowledge and discrepancies in expectations so that patients ultimately arrive at an informed decision about which weight loss operation is most appropriate for them. Desired weight loss is only one of several clinical indicators (e.g., medical comorbidities, tolerance for risk, presence of sweet eating) to be discussed with patients, but an important factor to consider in selecting the surgical intervention. Based on our review of the literature, the following areas are important for discussion with patients about their expectations for weight loss after bariatric surgery.

First, weight loss can vary widely by the type of bariatric surgery, and from patient to patient influenced by pre-surgical BMI, sex, physical activity level, and comorbid health problems.[8] Assisting patients with calculating their expected weight loss for RYGB and VSG based on the bariatric surgery literature will provide them with an opportunity to discuss potential discrepancies in their expected weight loss and actual outcomes based on research findings. It has been our experience, that while our clinical team discusses percent of excess weight loss, patients may more easily comprehend expected weight loss expressed as a percent of initial weight rather than percent of excess weight loss. Moreover, it has been proposed that percent weight loss is potentially a better predictor of outcome as it does not rely on a subjective calculation of ideal weight in the equation for determining excess body weight.[26] An online educational tool created by the Obesity Institute at Geisinger Health System is presently available to assist patients and providers in determining expected weight loss up to 24 months after RYBG through the Get~2~Goal mobile app available in iTunes.[27] Second, discuss with patients that they do not have to achieve ideal or “dream” weight to experience significant improvements in health status, energy level, and quality of life. Research has found that there is a knowledge gap in that patients overestimate how much weight they will lose and underestimate resolution or improvement in medical comorbidities including T2DM, hypertension, and OSA.[23] Third, discuss with patients the bariatric team’s definition of success after one year and long-term success regarding maintenance of lost weight and improvements in health status. Some patients may be at risk for assuming they failed the operation if their desired goal weight was not attained in the first year.[28] Moreover, informing patients of long-term benchmarks for success may be useful in maintaining their health behaviors over time. For example, what patients’ report as a “disappointed” weight (i.e., 20-25% of initial weight)[20,22] is within a reasonable expectation for weight loss one year after VSG and would be considered successful maintenance 10 years after RYGB.[11] Lastly, it may also be useful to discuss successful outcome in terms of BMI as many patients will remain overweight or obese while still achieving successful weight loss and resolution of medical comorbidities. For patients with a presurgical BMI below 50kg/m2, a postsurgical BMI of 28 to 35kg/m2 is reasonable. Similarly, for patients with a BMI over 50kg/m2, a postsurgical BMI of 40kg/m2 or below could be considered a successful outcome.[29]
Vignette 1 presents a conversation with a 50-year-old female patient with a BMI of 47kg/m2. She is uncertain about which weight loss operation is best for her and includes a discussion about her desired weight loss. Vignette 2 presents a conversation with a 32-year-old male patient with a BMI of 46kg/m2 discussing expectations for long-term outcome and factors that contribute to weight regain.

Quality of Life and Body Image: Research Findings
Patients with extreme levels of obesity suffer decreased quality of life in nearly all health-related and weight-related domains.[17] Remarkably, what may contribute most to diminished quality of life prior to bariatric surgery is patients’ level of public distress or feeling socially stigmatized.[30] A substantial body of research has demonstrated dramatic improvements in health-related quality of life including physical and mental health and dramatic improvements in weight-related quality of life after having bariatric surgery in the domains of physical functioning, self-esteem, sexual functioning, public distress and work postsurgery. These changes occur rapidly, usually within the first five-months after having bariatric surgery.[17,31] However, there is presently little published research examining the longitudinal durability of improvements in quality of life domains such as self-esteem and body image, particularly under conditions of postsurgical weight regain. A recent systematic review of the literature examined the effectiveness of bariatric surgery on psychosocial quality of life up to six years post-surgery.[32] Results revealed that long-term improvements in psychosocial quality of life like depression and body image dissatisfaction did not necessarily mirror improvements in physical health that reliably occur after massive weight loss.

Body image is a psychosocial factor that is subsumed under the broader construct of quality of life and is defined as an individual’s perceptions, thoughts, and feelings about his or her body and outward appearance.[33] Often, patients report high levels of dissatisfaction with their body image presurgery and depression and low-self-esteem are commonly associated with having body image concerns.[19,34] Similar to improvements in physical health, improvements in body image may occur as quickly as five months after undergoing bariatric surgery.[31] However, losing a large amount of weight may not necessarily be associated with a decrease in concerns about weight and shape after surgery as patients may have unrealistic pre-surgical expectations for improvements in body shape and size after having bariatric surgery.[34–36] One study used an adapted version of GRWQ and Silhouette Figure Rating Scale[37] to assess patient’s expectations for achieving “dream”, “happy,” “acceptable,” and “disappointed” body shapes after surgery.[35] Results revealed that expectations for body shape postoperatively were smaller than the body silhouette associated with clinically expected weight loss. In general, patients expected to achieve the body shape that corresponded to a BMI in the normal range. Another area of serious concern for patients postoperatively is loose and hanging skin after massive weight loss.[31]

Excess skin is associated with decreases in physical functioning, body image, and self-esteem.[38] Consequently, a small number of patients report they would not have chosen to undergo bariatric surgery if they had known about the negative effects of excess skin. Thus, most patients desire body contouring after bariatric surgery but few actually undergo body contouring operations as they are cost prohibitive and generally are not covered benefits on most health insurance plans.[39,40]

Based on our review of the literature, the following areas should be addressed regarding expectations for improvement in quality of life and body image as patients are not always informed presurgery about the potential negative effects of massive weight loss.[41] First, discuss with patients that they can expect to experience dramatic improvements in many areas of quality of life, particularly physical health and functioning, within the first six months after having bariatric surgery. Furthermore, while many weight-related aspects of quality of life will improve, others domains of quality of life may not improve post bariatric surgery. Second, discuss with patients the possibility of dissatisfaction with body image and consider a referral for counseling when these concerns are negatively  impacting mood or interfering with daily functioning. Explain that concerns about weight and body shape may be less influenced by massive weight loss and that many patients who do lose a large amount of weight will have significant concerns regarding loose and hanging skin.[40] Women in particular are most likely to be dissatisfied with specific regions of their bodies including abdomen, breasts, upper arms, and thighs. Third, discuss that most patients suffering physical impairments and low self-esteem associated with excessive skin desire a body contouring operation.[38,40] Patients should also be informed that most health insurance plans view body contouring operations as cosmetic, therefore, they generally are not covered benefits and patients may incur a large out-of-pocket expense if they choose to undergo an operation.[39] Nevertheless, if patients are unable to afford an operation, the desire to undergo a body contouring appears to decrease over time.[42] Vignette 3 presents a conversation with a 42-year-old female patient with a BMI of 49kg/m2 with life-long dissatisfaction with her body image.

Relationships: Research Findings
Obesity is often a family health problem where the prevalence of obesity among children of parents with obesity is greater than 40 percent.[43] Yet, the literature investigating the impact of bariatric surgery on immediate family members and relationship quality is sparse and largely retrospective, yielding mixed results.[44–46] Some studies have shown that bariatric surgery may have a “halo effect” when one adult family member undergoes an operation.[47,48] Positive effects including modest weight loss, improved diet quality, and increased levels of physical activity have been observed among family members of RYGB patients.[47] Moreover, other studies have shown that when family members undergo bariatric surgery together they lose more weight, have lower BMIs, and better attendance at follow-up appointments postsurgery when compared to case-matched controls (i.e., age, gender, BMI).[49,50] Thus, it may be beneficial for patients to encourage other family members to either consider bariatric surgery for themselves or to engage in lifestyle changes required for successful outcome after bariatric surgery.

Similarly, only a small number of studies have been conducted on changes in romantic and/or marital relationships after bariatric surgery.[44–46] Being married, in general, is related to increased life expectancy[51] and has been associated with improvements in obesity-related comorbidities like blood pressure and diabetes.[52,53] These metabolic improvements were associated with marriage quality characterized by positive and supportive interactions.

Bariatric surgery, however, is a time of significant transition for patients and their spouses. Recent studies arrived at two different conclusions regarding relationship stability and quality following bariatric surgery. Ferriby et al[44] conducted a review of the literature on patient and spousal outcomes. They found that patients who are married, on average, lose less weight in the first year after bariatric surgery than unmarried patients and that couples’ relationship quality tended to decline from pre- to post-WLS.

One study investigating marital quality following bariatric surgery found a decrease in marital satisfaction among male spouses of female bariatric surgery patients. Decreased marital satisfaction among husbands was associated with increased ratings of extroversion and assertiveness in their wives from pre to postsurgery.[55] Conversely, women who underwent bariatric surgery rated their husbands as less social and less interesting one year after surgery. A recent study of men’s perceptions of changes in spousal relationships after bariatric surgery found themes within a family systems framework of unintended consequences and inconsistent social support.[54] Some unintended consequences were that relationship insecurity increased after weight loss where men perceived that their wives were fearful that they may desire to leave the relationship. Men also perceived that as they lost weight, their wives became increasingly insecure about their own weight and body size, particularly when they weighed less than their wives did after surgery. Examples of inconsistent support were that some men reported their spouses were unwilling to change eating habits and complained about the amount of time their husbands spent engaging in exercise.
Another study by Clark et al[46] also examined how changes in relationship stability and quality relate to long-term weight loss outcomes. They surveyed 361 patients who underwent bariatric surgery (95.9% Caucasian, 80.1% female, average 7.7 years postsurgery, mean age at surgery: 47.7 years [range 21–72]; 87.3% underwent Roux-en-Y gastric bypass). Among those who maintained their relationships postoperatively, relationship quality was found to be associated with weight loss outcomes. Those with improved relationships postsurgery had significantly greater %EWL. The authors concluded that their findings support the importance of assessing relationship stability and quality in presurgery candidates, as healthy and stable relationships may support improved long-term outcomes. Interventions to improve relationships pre-and postsurgery may increase both quality of life and weight loss outcomes.[46]

Vignette 4 presents a conversation with a 46-year-old female patient with a BMI of 42kg/m2 experiencing a partner relational problem. She previously had laparoscopic adjustable gastric band (LAGB) and desires a conversion to VSG.

Conclusion
Many patients have high expectations for weight loss and improvements in quality of life and body image after bariatric surgery. Furthermore, relationships with immediate family members and/or romantic partners may change in unexpected ways and may have both positive and negative consequences after surgery. Accordingly, the bariatric surgery team is responsible for guiding patients toward achieving an accurate understanding of treatment outcome. Patients should be well-informed about what challenges may arise with rapid weight loss and dramatic changes in physical appearance, especially in the first year after the weight loss operation. At the same time, providers must remain cognizant of supporting patients’ enthusiasm and vision for the possibility of living a different life after weight loss. Table 1 presents a summary of topics for discussion with bariatric patients based on research findings and clinical experience concerning postsurgical expectations for changes in weight, body image, and relationships.

Patient vignettes The following are prepared vignettes illustrating topics for discussion with pre-surgical bariatric patients concerning postsurgical expectations for changes in weight, body image, and relationships.

Vignette 1: Expectations for Weight Loss—Short Term. Vignette 1 presents a conversation with a 50-year-old female patient who is 5ft 5in and 280 lbs. Her BMI at the time of conversation is 47kg/m2 and she has obstructive sleep apnea, and osteoarthritis. She is married, employed, and has no mental health history.

Provider: At the time of your initial assessment you were undecided about whether you wanted to have vertical sleeve gastrectomy (VSG) or Roux en-Y Gastric Bypass (RYGB), but you are leaning more toward VSG because it seems less risky to you. There are many factors to consider when choosing the right operation for you. First and foremost we consider your current health status and which operation may be best given your specific health problems. Since you do not have diabetes or gastroesophageal reflux disease, you are potentially a candidate for either operation. Another factor you may want to consider is how much weight you desire to lose after the operation. I would like to spend some time talking about that today if that’s ok?

Patient: Sure, that would be helpful to me.

Provider: At this point, what are you thinking is a healthier weight for you?

Patient: Well, I would love to be 145 lbs. again. That’s when I think I felt my best.
Provider: When was the last time you can remember weighing 145 lbs.?

Patient: I would say probably 20 years ago before my first pregnancy. I gained a lot of weight with my first pregnancy, but I was able to lose most of that weight. Although, I never did get down to 145 lbs. again. I then really started to struggle after my third child was born. My weight was probably up to 190 lbs. then. That was 13 years ago.

Provider: Do you remember how you felt about your weight at 190 lbs?

Patient: Well, back then I thought I was huge, but right now it actually sounds pretty good. My weight stayed around 190 lbs. for a while, but I have really gained in the past five years when my knees and back started hurting. It hurts to exercise, so I’m not doing much now.

Provider: Since you are considering both VSG and RYGB, would it be ok if I shared with you the amount of weight you can expect to lose after both of these operations.

Patient: I guess that would be good to know.

Provider: Generally the RYGB results in a greater amount of weight loss than VSG. Your weight was 280 lbs. today. Approximately 12 months after RYGB you could expect about a 35-percent reduction in your weight, which would be about 100 lbs. After VSG you could expect to lose 25 to 30 percent of your weight or about 75 lbs. in 12 months. How do those numbers sound to you?

Patient: So, you are saying with sleeve gastrectomy, I may still be over 200 lbs. but I’ll be able to lose more weight than that if I get serious about exercise, right?

Provider: It’s impossible to know now exactly where your weight will settle after the operation and outcomes can vary widely from patient to patient. Typically patients reach their maximum weight loss about one year after surgery but may not actually accept or feel comfortable with their weight for up to two years. There are other powerful factors that influence how much weight you will lose in the first year. Many of them are not under your direct control like genetics, metabolism, and loss of muscle mass. Regarding weight loss, there are only two factors under your direct control after surgery. One thing is the effort you put into adherence to the postsurgery dietary plan and the second is maintaining consistency with physical activity.

Patient: I’m an overachiever and I know I could lose more if I tried really hard. I’ve lost down to the 160s (lbs.) before, it was after my second child was born.

Provider:  The last thing I want to do is dampen your enthusiasm about your ability to lose weight.  I do, however, want you to spend some time thinking about what success after surgery really means for you.

Patient: Well, I know that getting below 200 lbs. is a must for me. I would be really excited to see a “one” as the first number on my scale.

Provider: So, you wouldn’t necessarily have to weigh 145 lbs. to feel successful with weight loss? You haven’t been below 200 lbs. in a while and that would feel pretty good too?

Patient: I think so.

Provider: What are some things you can imagine yourself doing after bariatric surgery that you are unable to do now?

Patient: Oh, a lot of things.  I worked a full-time job and was very active with my kids and involved in their activities when they were younger. I used to love to walk and work in my garden too. Now my 13-year-old doesn’t even ask me to do things with her because she knows I get short of breath, which worries her.

Provider: You were able to do all of those things comfortably when your weight was 190 lbs.

Patient: Yes. I knew I was overweight then but it didn’t slow me down and I wasn’t overly focused on the numbers on the scale. I was able to multi-task, take care of my family, and work full time. I enjoyed being busy and productive.

Provider: That’s great. Your vision for your future is returning to a busy active lifestyle. Perhaps the actual number on the scale is not the most important factor.

Patient: I have to be honest, I’m a little concerned that I might be disappointed with my weight loss after VSG. I was pretty sure I didn’t want RYGB, but it seems like it would get me closer to a weight I could be happy with. I’m going to need to think about this some more.

Provider: That sounds perfectly reasonable. Other clinical indicators we may want to consider are whether or not you are a sweet eater, your understanding of each operation and the required lifestyle changes, and your tolerance for risk with either operation. But, this is not a decision you need to make today. When you have completed the work-up process and decide which operation is best for you, the bariatric team will support your decision.

Vignette 2: Expectations for Weight Loss—Long Term. Vignette 2 presents a conversation with 35-year-old male patient who is; 5ft 10in and 320 lbs. His BMI at time of conversation is 46kg/m2. He has sleep apnea and metabolic syndrome. He is divorced; employed, and manages diagnosed depression with medication.

Provider: At your initial evaluation we discussed that you have been considering Roux en-Y Gastric Bypass (RYGB) for about a year now. We also discussed that you believe one of your biggest challenges will be changing the quality of your diet as you enjoy the taste of sweets like cookies, snack cakes, candy, and ice cream. One of the topics I would like to cover today is the long-term weight loss outcomes and some of the risk factors for weight regain after RYGB. Does that sound ok to you?

Patient: Yes. My cousin regained all of her weight after her surgery. I just don’t understand how that could possibly happen when your stomach is so small and you can’t eat that much.

Provider: Research shows that a certain percentage of people who undergo surgery will regain all of their lost weight after surgery. It typically does not happen in the first year, particularly after RYGB. However, by 5 to 10 years after the operation, approximately 20 percent of patients will regain all of their lost weight.

Patient: So, I could possibly regain all of my weight by the time I’m 45-years-old?

Provider: Let’s explore the numbers for a minute. With RYGB we expect that you will lose about 35 percent of your weight in the 12 months after your operation. So that means your weight would be about 210 lbs. by the end of your first year.  How does that sound to you?

Patient: Amazing! I haven’t weighed that since my senior year in high school when I played football.

Provider: So let’s fast forward 10 years. The research data show of the 110 lbs. you lost in the first year after the operation, you would keep off at least 80 of those pounds. Your weight may settle around 240 lbs. up to 10 years after your surgery. Of course these are averages and may not be your exact weight trajectory, but it’s probably a good estimate.

Patient: I’ve never been a small guy, but I wouldn’t want to weigh more than 240 lbs. again.  That’s about what I weighed after I finished college.  So, why do people gain weight back after surgery?

Provider: That’s a really good question. It can be a combination of factors.  One problem in particular is erosion of diet quality over time, meaning that people return to eating the same foods that in part contributed to their weight gain in the first place. Other factors include not getting enough of physical activity, lack of sleep, chronic stress, and sometimes changes in medication regimen. There is also an association between depression and weight regain. You have depression, so you will want to monitor your mood after surgery, and seek additional treatment if needed. Of these things, that can cause weight regain, what concerns you the most?

Patient: Well, sweets and junk foods are a real problem for me.  I got into the habit snacking at night after my divorce a few years ago.  I know I’ve put on a lot of weight since then.   It was my way of coping with my divorce.

Provider: Eating for emotional comfort can be a common problem among patients who are seeking bariatric surgery. Do you think that’s what it was?

Patient: Yes, I was eating out of sadness and loneliness.

Provider: What are some things you are already doing to manage sweet cravings at night?

Patient: For starters, I’m trying not to keep sweets in the house.  I have learned that once I’m in for the night, I won’t go out and get sweets or junk food.

Provider: That’s a great idea.  So when sweets aren’t in the house, you feel more confident about controlling your eating.

Patient: Yes. I may still snack at night but I won’t eat as much if the sweets aren’t around, and my food choices are healthier.

Provider: You have already started making healthy changes in your eating habits to prepare for your surgery, and in the first year, RYGB should help you manage desire and cravings for sweets. Those things combined will increase your likelihood of success.

Patient: Well, I’m hoping that after a year I will have established new habits and won’t go back to the old ones.

Provider: That is our hope for you too. In my experience, patients don’t purposefully return to problematic eating behaviors, however, they do sometimes under estimate the effort it takes to maintain lost weight after surgery. The surgery will be most helpful for you in the first 12-months in terms of reducing hunger, desire, and sweet cravings but you may still feel a void or emptiness that food may have filled for you. Whether or not you keep the weight off depends, on the consistency of your efforts to manage your weight. How does all of that sound to you?

Patient: Ok, I guess. Anything is better than where I am right now.

Provider: I can say with certainty that having RYGB is your best chance of losing a large amount of weight and keeping it off. Keeping it off will take consistent daily effort and you’ve already started doing the hard work of changing your eating habits. The bariatric care team will continue to guide and support your efforts. We will also encourage you to stay connected through your follow-up visits and our post-surgery support group. If weight regain becomes an issue in the future, you will already have support system in place.

Vignette 3: Expectations—Body Image. Vignette 3 presents a conversation with 42-year-old female patient who is 5ft 1in and 260 lbs. Her BMI at the time of conversation is 49kg/m2. She has gastroesophageal reflux disease. She is single, employed, and manages diagnosed depression with counseling.

Provider: Last time we met, we talked about how you have struggled with weight since childhood and this struggle has negatively impacted your self-confidence and how you feel about your body.  Would it be ok to spend some time talking about this today?

Patient: Sure. I’ve been big as far back as I can remember, probably 10-years old. I was always chubbier than the other kids which made me uncomfortable. I pretty much kept to myself.

Provider: I imagine so, kids can be pretty cruel at times and weight is something you wear on the outside, so it’s hard to hide. Unfortunately many overweight children are teased about their weight. Your way of dealing with unwanted attention about your weight was keeping to yourself.

Patient: Yes, and now I’ve gotten so heavy I don’t like to go out and do anything anymore. I pretty much just go to work and come home. I can’t find any clothes I like in my size.  I think losing weight will help a lot.

Provider: One thing I want to talk about today is that some patients tell me they feel unprepared for all the attention they receive especially in the beginning when they are losing weight rapidly. You’ve struggled with weight since childhood, so it may be hard for you to imagine what life will be like after RYGB. Have you thought at all about how you will respond to attention from other people about your weight loss?

Patient: Well, I’m not telling anyone at work that I’m doing this. I’ve only told my parents and my sister. My mom had RYGB eight years ago and now she weighs 120 lbs.  She’s more critical of my weight than ever and encouraged me to have the surgery. My sister freaked out and said now she’s going to be the “fattest one in the family.”

Provider: So possibly some negative attention from your family and you don’t really know what to expect from your colleagues at work.

Patient: There may be a few people I tell at work if they ask about my weight loss, but there I are other people I definitely don’t want to know I had RYGB.

Provider: Large and rapid weight loss is something you cannot hide.  Some patients tell me they feel uncomfortable with unwanted attention whether it’s positive or negative. One reason unwanted attention can be distressing is because it will take a while for you to adapt to your rapidly changing body size and shape and to feel comfortable with what you see in the mirror.

Patient: Speaking of attention, my mom will ask me about my weight all the time. When we came for the appointment today she tried to look at the scale over my shoulder to see what I weighed. She’s very judgemental of people who are overweight now that she’s thin. She probably will tell me I need plastic surgery like she did.

Provider: Your mom may be hard to please no matter what your weight is.

Patient: Yes. I’m sure she’ll tell me I need a tummy tuck. That’s what she did.

Provider: Excess skin is a common concern after surgery.  Patients generally report dramatic improvements in body image in the first 12-months after surgery. Many women tell me they love how their bodies look in clothing but report feeling unhappy with extra skin they see in the mirror. Commonly, they desire body contouring of the waist or abdomen, arms, and breasts. For some women it’s also a medical issue. Redundant skin can cause uncomfortable rashes and infections. If extra skin negatively impacts quality of life, body contouring surgery can be very beneficial.

Patient: I guess I would consider that at some point if my insurance would cover it.

Provider: I think it’s important to understand that you will likely be thrilled with the weight loss you achieve after surgery, but there may be some parts of your body that remain concerning for you or that you don’t like. This is a common experience for many patients.

Patient: Well, I’ve been embarrassed about size since I was a kid, so liking any part of my body would be an improvement.

Provider: That’s a really good way to think about it. One of the critical components of success after the surgery is improving your body image no matter where your weight settles after the surgery. Do you have any ideas about that?

Patient: I’m not sure what you mean.

Provider: One exercise I often have patients do is make a list of goals they would like to accomplish in your first year after surgery. This will help you to start thinking about all of things that you want to do with your new body that were more difficult to do at a heavier weight. Once you start losing weight your energy, physical abilities, and self-confidence will improve and you will start to focus on what your body can do.

Patient: I could do that.  I really want to do some traveling but I worry about feeling uncomfortable in an airplane seat. I also want to take my niece and nephew to Disney World but I worry about being able to walk all day and fitting on the rides. I don’t want to embarrass them and myself.

Provider: You already have some great ideas to put on your list of goals you want to accomplish the first year after surgery! Over time you will begin to realize that you don’t have to be the perfect weight or have the perfect body to start living your new life.

Vignette 4: Expectations—Relationships. Vignette 4 presents a conversation with 46-year-old female patient who is 5ft. 7in. and 270 lbs. Her BMI at the time of the conversation is 42kg/m2. She underwent LAGB in 2012 when she weighed of 320 lbs. She has obstructive sleep apnea and anxiety that she treats with medications. She is married and employed.

Provider: Since you’ve had a LAGB, you know how difficult keeping weight off in the long-term can be. We already talked a little bit about your family and that sometimes you think your husband tries to sabotage your weight loss. This could be an issue after your conversion to vertical sleeve gastrectomy (VSG). Could we spend some time talking about this today?
Patient: Yes, if I have another surgery, I want to be successful.

Provider: Can you tell me more about what you mean by you think your husband sabotages your weight loss.

Patient: Yes he’s been doing it since I got my LAGB in 2012. He didn’t want me to have it in the first place. I can give you an example of something that happened the other day. I told him I had lost 5 lbs. since I started changing some things in my diet to get ready for VSG. He told me he thought that was great. The next thing I know he’s serving me a plate full of food for dinner. It was way too much food! He waits to make dinner for me when I get home from work around 8pm. I have told him not to make big meals for me but he doesn’t listen. If I don’t eat with him, he gets upset.

Provider: That sounds very frustrating. Do you have ideas about reasons he may be behaving that way?

Patient: This is my second marriage and we were married 2 years before I got my LAGB. I decided to do the LAGB because I had gotten so heavy I could barely make is through my work shift in in the ER. Ever since I had the LAGB, he’s made comments about how I better not leave him when I get skinny. His first wife was unfaithful to him, so he has some trust issues.

Provider: He was upset when you decided to make some changes in your life to improve your health.

Patient: He was really upset when I decided to stop drinking alcohol with him. He’s still drinking and that’s usually when he makes comments about me leaving him. He’s disabled and his 21-year-old daughter lives with us.

Provider: As long as you remain overweight, nothing changes for him. If you start living a different life after weight loss, he might feel he has a lot to lose.

Patient: I had not thought about it like that but maybe. I do have some plans for my future. I applied for the position as charge nurse in the ER, and I got it. Now, I’m thinking I may even want to get an advanced degree in nursing, especially if I can lose the rest of this weight. The LAGB helped me lose some weight, but I still have a lot more to go.
Provider: You have vision for your future and the conversion operation is a tool to help get you there. Where do you see your husband fitting in to that vision?

Patient: Well, he doesn’t really want me to have VSG since I’ve had problems with vomiting after my LAGB.

Provider: And there may be other reasons too.

Patient: Yes, he says he’s supportive but sabotages me at the same time. I’ve tried to talk to him about it but nothing changes.

Provider: Despite his behavior, you have been able to stay on course and seem pretty committed to your vision for the future.

Patient: I have a lot of other people who support me. My daughters and my mother are excited for me to do this surgery.  My grandkids can’t wait for me to be more active with them and go to their sports games.

Provider: Do you see your husband fitting in to your plan for becoming more active with your grandkids and seeking advancement in your career.

Patient: Honestly, I don’t know.  But I’m not ready to talk about divorce with him.

Provider: There is no way to know right now, what will happen with your marriage as the first year after surgery is a period of transition. What we know from research is that some spouses may experience improvement in relationship satisfaction while others may not.   For example, some studies have shown that when spouses become more social and more assertive with increased self-confidence after weight loss, marital satisfaction can decline.

Patient: I guess I could see that.  My husband complains when I go to the gym on my days off. I always invite him, but he says no.  I think he’s uncomfortable with me going out and doing things on my own.  Maybe he does want me to stay fat so I won’t leave him.

Provider: That’s one thing to consider given what we’ve discussed today. Has your husband been involved in your work-up process so far?

Patient: No. But I haven’t really asked him to be because he wasn’t supportive with the LAGB.   Should I bring him to my nutrition appointments since he does a lot of the cooking?

Provider: That would be a good place to start.

Patient: He will probably say he doesn’t need to come.

Provider: All you can do is let him know that his support is important to you and encourage him to participate.

Patient: One thing is certain, I’m not going backwards. I’m going to lose the rest of this weight and move on with my life.

Provider: One of the hardest things bariatric surgery patients may face is knowing when to disengage from people who are negative influences in their lives.  You are fortunate though, you have many support people in your life and support from the bariatric team.  I encourage you to surround yourself with people who will support your vision for your future.

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FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts relevant to the content of this article.

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