Navigating Online Resources for Patient Care and Follow Up

Part 1
SUPPORT AFTER BARIATRIC SURGERY: The Offline-Online Connection

by Katherine Jukic, BSc, HONS-I, APD, AN

Bariatric Times. 2012;10(2):28–30

About the Author

Katherine Jukic, BSc, HONS-I, APD, AN, is an academic, accredited practicing dietitian and nutritionist and a member of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), the American Society for Metabolic and Bariatric Surgery (ASMBS) and Obesity Surgery Society of Australia and New Zealand (OSSANZ). In June 2012, Ms. Jukic launched a weight loss surgery membership site, social support network, and community called Global Bellies. The mission of the Global Bellies entity is to create a unique global (online) community of individuals who have had weight loss surgery, thus representing and empowering this unique population.

Through a private, moderated members’ only area, Global Bellies members can manage their own personal pages and progress charts; retrieve practical resources, tools, and learning materials through a variety of means; and make active contributions to the site. To learn more about Global Bellies, visit www.globalbellies.com.

In this article, Ms. Jukic discusses the role of additional, ongoing support and information for surgeons and healthcare professionals/practitioners in the field, which is meant to complement (not replace) existing practice, advice, and care.

FUNDING: No funding was provided.

DISCLOSURES: Katherine Jukic is the Director and Founder of Global Bellies Pty Ltd, a weight loss surgery membership site, social support network, and community.

AUTHOR AFFILIATION: Ms. Jukic is from Discipline of Nutrition and Metabolism, the School of Molecular Bioscience, in the Faculty of Science, University of Sydney, Sydney, Australia.

Bariatric Surgery as a Tool, Support as a Necessity
Surgery is only one component of a successful bariatric program. A comprehensive long-term behavioral modification program with adequate multidisciplinary support is vital for post-surgical success. The American Society for Metabolic and Bariatric Surgery (ASMBS) has recognized the importance of this, and so the provision of comprehensive follow-up care represents part of the requirement for its bariatric center accreditation program, now called the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBS AQIP).[1] Changes in patient self-efficacy after surgery is another reason supporting the importance of ongoing multidisciplinary care.[2]

However, bariatric surgery facilities differ in the postoperative care they provide. Reasons for this may include the following:
•    The type of weight loss surgery performed
•    Commitment (financial, resources or other) to long-term follow up and the perceived importance of continuing patient education
•    Lack of specific recommendations or guidelines regarding follow up in individual and group contexts
•    Barriers or challenges in providing more follow up, such as patient attendance and adherence, meeting all patient needs, dealing with patients who are less motivated or reside in rural areas, and limited resources (including time and costs).

Within facilities, there is a great deal of variation in the type of support provided; degree of dietary, exercise, and psychological consultation and education; frequency and duration of follow-up appointments and support group meetings or seminars; integration of social media into the patient management program; and scope of the multidisciplinary team. In addition to the surgeon, the bariatric surgery team will often include a physician or physician assistant, nurse practitioner, and dietitian/nutritionist, as well as psychological and exercise services.

To help cope with the dietary, psychosocial, physiological, and behavioral changes or adjustments that are associated with bariatric surgery, long-term social, emotional, and educational support is essential. In addition to weight status, individual counseling and reinforcement should address or assess patient progress, nutritional intake and status, dietary adherence, food habits, eating behaviors, nutritional supplementation, physical activity, metabolic status, medical comorbidities and complications, and emotional and social difficulties. Opportunities also exist to screen and address high-risk eating, drinking, and mood behaviors. The intention of providing support (tailored to the individual) should be to encourage and motivate the patient, increase their knowledge and skills, address concerns, and change behaviors, attitudes, and perceptions.

To assess the effect of support after having bariatric surgery, the literature typically refers to weight loss or change in comorbidities as primary outcome measures. However, these should not be the sole focus. Variables such as self-efficacy, self-esteem, confidence, psychosocial functioning, and well-being, are also important to consider; however, these remain less clearly understood. Only few long-term studies of postoperative weight loss surgery patients measure emotional health and quality of life, yet the ultimate goal of obesity surgery is an improvement in health and quality of life.

Self-esteem, coping skills, post-surgery follow-up, and adherence to dietary, physical activity, and behavioral counseling are some of the identified predictors of successful weight loss. There is evidence to suggest that social support may be another predictor, however the definition of this concept within the literature is not uniform. A systematic review and meta-analysis that investigated the effect of postoperative “psychological services” (psychotherapeutic interventions and support groups) on weight loss, found, in general, that patients attending either service appeared to lose more weight (compared with patients not receiving a psychological service).[3] Likewise, another systematic review determined the impact of different forms of social support (support groups and other) on weight loss after surgery. All of the reported studies found a positive association between support group attendance and postoperative weight loss; however, a causal relationship could not be proven.[4]

Furthermore, a “dose effect” regarding the association between support post surgery and weight loss has been illustrated. Studies have found that patients who attended more follow-up visits, appointments, or support meetings lost more weight than patients who attended fewer or none. The number of sessions and the time frame investigated (often the first 12–24 months after surgery) varied between studies.[5–8]

A Continuum of Support: the Online Environment
Other than the support provided by a bariatric surgery facility or program, patients have access to information, feedback, and support from other people as well as the online environment, which represents a nonstatic community that can be a useful resource before and after bariatric surgery. New technologies as well as the impact of online groups and social networking as viable means of support are increasingly being researched.

The prevalence of online support groups and forums has grown dramatically, however, there are large differences between groups or sites in terms of the following:
•    The community or group philosophy
•    Access (public versus private)
•    Location
•    Characteristics of participants
•    Interaction between participants
•    Support and advice sought and provided
•    Key focus and themes
•    Information on eating, exercise, and behavioral practices
•    Experiential accounts
•    Flexibility or restriction regarding the site’s use.

Of particular concern is the regulation, moderation, policing, and monitoring of the group/forum/site, and the interpretation of its content, advice, and patient stories.

In consideration of these points, the goals of online support groups, forums, and websites in the field should ultimately represent points of difference within the online space and therefore aim to do the following:

1.    Adopt a more holistic patient approach to post-surgery success, addressing dietary, physical activity, behavioral, and well-being aspects related to and independent of weight loss and bariatric surgery.

2.    Create opportunities for individuals to connect, communicate, and interact with, and learn from, others who are considering bariatric surgery and/or who have had surgery, not limited by location, patient characteristics, type of surgery, or stage before/after surgery.
3.    Integrate different types and forms of support and resources into one website to accommodate for individual differences in knowledge attainment, learning, and time point or stage pre- or post- weight loss surgery.

4.    Provide benefits for the patient as well as the bariatric surgeon, health professional, or practitioner, by providing additional, complementary or supplementary support and information.

Conclusions
Common issues within bariatric facilities or programs are often the resources devoted to and consistency toward different types of support, particularly over the long term. In response, there are opportunities for the development and growth of weight loss surgery related sites within the online space to bridge some of these gaps, with the potential to adopt holistic approaches to optimize weight and nonphysiological outcomes in the bariatric patient.

References
1.    Pratt GM, McLees B, Pories WJ. The ASBS Bariatric Surgery Centers of Excellence program: a blueprint for quality improvement. Surg Obes Relat Dis. 2006;2(5):497–503; discussion 503.
2.    Batsis JA, Clark MM, Grothe K, et al. Self-efficacy after bariatric surgery for obesity. A population-based cohort study. Appetite. 2009;52(3):637–645.
3.    Beck NN, Johannsen M, Støving RK, et al. Do postoperative psychotherapeutic interventions and support groups influence weight loss following bariatric surgery? A systematic review and meta-analysis of randomized and nonrandomized trials. Obes Surg. 2012;22(11):1790–1797.
4.    Livhits M et al. Is social support associated with greater weight loss after bariatric surgery?: A systematic review. Obes Rev. 2011;12:142–148.
5.    Compher CW, Hanlon A, Kang Y, et al. Attendance at clinical visits predicts weight loss after gastric bypass surgery. Obes Surg. 2012;22:927–934.
6.    Shen R, Dugay G, Rajaram K, et al. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg. 2004;14:514–519.
7.    Livhits M, Mercado C, Yermilov I, et al. Behavioral factors associated with successful weight loss after gastric bypass. Am Surg. 2010;76(10):1139–1142.
8.    Gould JC, Beverstein G, Reinhardt S, Garren MJ. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surg Obes Relat Dis. 2007;3:627–630.

Category: Commentary, Past Articles