Patient/Family Support Groups in Japan: A Model to Ensure the Success of Bariatric Surgery

by Tetsuya Nakazato, MSW;
Kazunori Kasama, MD;
Takashi Oshiro, MD; Eri Kikkawa, RD;
and Kazuko Sonoda, RN

Current State of Obesity in Japan (Background)
In April 2008, check-ups for metabolic syndrome started with the aim of diagnosing, improving, and instructing people about illnesses such as metabolic syndrome or adult-onset disease.[1] Metabolic syndrome check-ups are obligatory at places such as the municipalities that operate the National Health Insurance program or at workplaces using health insurance unions, while everybody with health insurance from the age of 40 to 74 must undergo a check. Nationally, there are said to be about 25 million people with metabolic syndrome. Metabolic syndrome is defined as having a waist measurement of 85 centimeters or higher for men, and 90 centimeters or greater for women—with measurements taken at the navel—and the addition of any two of the following three conditions will lead to a diagnosis of metabolic syndrome: 1) Either a level of triglycerides at 150mg/dL or higher, or HDL cholesterol of less than 40mg/dL, or both; 2) either blood pressure with a systolic (top number) reading of 130mmHG or more, or a diastolic (bottom number) of 85mmHg or higher, or both; or 3) a blood sugar reading of 110mg/dL or higher when measurements are taken on an empty stomach.
Behind the growing attention being paid to metabolic syndrome up until now is the ballooning of medical costs spent dealing with obesity. Obesity does not only lead to physical illnesses such as diabetes or hypertension, but has complications such as mental disorders like depression, in which treatment runs into the long term and this connects to burgeoning medical costs. There are reports that show that in the US, treatment of complications caused by obesity is currently costing annual losses of 20 trillion yen.

Body mass index (BMI) is used to define obesity. As complications such as diabetes arise at a lower level BMI in Japan than in Western countries, a BMI of 25 or greater is defined as being obese (Table 1
).[2] Looking at the obese as a percentage of Japan’s overall population, there are about 23 million (20% of the overall population) with a BMI of 25 or greater, some six million (5%) whose BMI exceeds 30, about 500,000 who have a BMI of 35 or more, and around 200,000 who have a BMI of at least 40. The current situation sees the growing escalation of numbers of obese in recent years becoming a social problem.[1]

When it comes to these standards, the reason why Asians originally set the standard at a lower BMI was because, compared to Westerners, data analysis has shown that Asians are affected by afflictions such as diabetes or hypertension at a lower level BMI. An important point is that the wording of the standards also includes mention of diabetes to clarify that the aim is not to cure obesity, but to cure the conditions that obesity initiates.

The Importance of a Team in the Surgical Treatment of Obesity
Medical treatment using mainly surgical means has been carried out at our clinic since June 2006. The objective of the treatment is not weight reduction, but improvements in obesity-related complications and an enhanced quality of life. In Japan, social cognizance of surgical treatment of obesity is low and patients have many anxieties about medical treatment. (Table 2
shows Asia Pacific Bariatric Surgery Society Surgical Applicability Standards) Because of that, physical, psychological, and social support are important from pre-treatment through post-treatment. Staff providing support do not work singly, but with a variety of people in different occupations involved, leading to the belief that this provides a greater intensity of support. Our clinic’s team is made up of such members as doctors, nurses, nutritionist, and social worker, with each specialist conducting an assessment of patients’ physical, psychological, and social status. The result of this has successfully led to highly effective treatment.[4] To defeat the illness of obesity, workers from a single field alone are not enough; instead, an approach from many different angles and from a variety of occupations is important. The key to success lies in a team working together to provide strength to patients.

The Relationship Between Obesity and Social Workers
Obesity is not a problem singular to the individual; it is important to place the focal point on the environment in which that person is living (their family relationships, friendships, work relationships, and other such human relations).

From a social point of view, obesity is a contagious disease, and research by Dr. Nicholas A. Christakis, a professor at Harvard University, suggests that it “infects (becomes an epidemic)” through social connections, as reported in the New England Journal of Medicine.[5] His research identified that there is a possibility that if one person is obese, they could cause obesity in other people up to three degrees of separation away (for example, the friend of a friend of a friend, or the sister of a friend’s spouse—three people away from somebody in a close relationship). If somebody has a friend who has become obese, the chance that they will also become obese themselves increases by 57 percent, and that climbs to 171 percent if they mutually regard each other as friends. If a sibling became obese, the increased probability of a person becoming obese themselves was 40 percent, while in the case of a spouse it was 37 percent more likely. Furthermore, it was also found that rather than geographic position, social networks (such as family relations and friendships) were more important, while people received greater influence from those of the same gender than they did from the opposite sex. Dr. Christakis and his team revealed that behavior and normative consciousness passed on through social networks, and if being overweight or obese was regarded as normal within that group, it was subsequently easier to become obese.
Dr. Julio Licinio, the Miller Professor in the Departments of Psychiatry and Behavioral Sciences and Medicine and Endocrinology at the University of Miami, said of the findings: “This is a fascinating way to look at the problem, and it may be a very good reason why treatments have been so difficult, because we’re only addressing one member of the network.” Dr. Samuel Klein, director of the Center for Human Nutrition at Washington University, added: “It suggests that, to be effective in treating obesity, we have to not just treat the person who’s obese, but also the social network.”

As the social worker’s professional territory is the interaction of people and their environments,[6] it is possible to think there are many possibilities of entry into the field of obesity treatment. There is significant meaning in a social worker’s intervention in all areas of a human relationship, including family relations, friendships, and workplace ties. The main duties and roles of the social worker encompass a wide variety and type of tasks, including the first intake of all clients, structuring support groups, conducting psychosocial assessments, and counseling.

Effects of Social Worker Intervention
We have been involved in surgical treatment of obesity since April 2004 and have been associated with the treatment of over 200 patients through such means as support groups[7] and individual counseling.[8-10] For the current survey, an experimental design method was used to display the results of a comparative investigation into the expediency of support groups for surgical treatment of obesity and loss of excess weight. Opinions of actual participants have been added to observations to further deepen understanding, as illustrated in the following sections.

Concept and Objectives of the Support Group in the Surgical Treatment of Obesity
The support group is positioned within the surgical treatment of obesity as a medical treatment group. Individual members have their own objectives, and there also exists a group objective. To attain the group objective, and for members to attain their individual objectives, it is a continuously developing group.

The long-term objective of the group in the surgical treatment of obesity is to “ensure the maintenance of a stable lifestyle even after group therapy has finished.” The short-term objective is “setting up habits for a new, healthier lifestyle.” This kind of medical treatment has the simplest yet also the most difficult of objectives. Therefore, members mutually support themselves and it is important to be able to overcome the pain and difficulties encountered before surgery after it. As mentioned earlier, it is comparatively less common in Japan to have obesity surgery than in other industrialized countries such as the US, so our patients have many anxieties. Another aim of the support group is the relief of those anxieties when present.

Support groups are playing an increasingly important medical treatment role in the surgical treatment of obesity. This is not just when it comes to actual weight loss (shown in our Results section), but also to prevent the occurrence of dropouts following treatment and for such things as self-expression for self-understanding. Support groups have important psychological and social meaning as a medical treatment method and are an indispensible part of the surgical treatment of obesity.[11]

Survey Method
Our survey involved 85 people who underwent gastric bypass between February 2002 and March 2006. Of the participants, there was a mix of nationalities, with 61 (71.8%) Japanese nationals, 22 (25.9%) Brazilian nationals, and one national each (1.1%) from South Korea and the US. For communication reasons, this survey was restricted to the 61 Japanese nationals. Of these 61, 42 (68.8%) took part in the support group, while 19 (31.2%) did not take part. A random sample of 15 support group participants and 15 non-participants was selected and the loss of excess weight investigated. Reasons for not taking part in the group included: “It is far away and not possible to participate;” “I couldn’t find the time;” and “I don’t want to talk to people about the operation.”

Results
Up until three months after the operation, the rate of excess weight loss showed no significant gaps between either group (Table 3
), but from six months on, a significant difference arose. There was a recognized gap of seven percent (P>0.05) between the groups at six months postoperative and at one year postoperative, it was 12 percent (P>0.01).
Opinions on the support group from participants included the following comments:
•    “I learned that I am not alone.”
•    “It was heartening to have others like me.”
•    “My worries disappeared.”
•    “It was great that we eat the same food.”
•    “Talking gave me confidence.”
•    “I’m relieved to be living again.”
•    “I remember what it felt like before the operation.”
•    “I lose weight after I take part in the support group.”
Such comments confirm that the support group provides an emotional peace of mind. This suggests that, within the support group as well as in actual information exchanges beyond that, emotional communication is very important.

Observations
Considering the weight loss data and comments from actual participants, the support group underpins patients’ motivation and can be thought to contribute to results (weight loss).[12-18] As a result, the social worker’s intervention has an effect on the living environment in which the patient lives, connects to improvements, and contributes significantly to an enhanced quality of life, which is an objective of weight loss surgery.

REFERENCES
1.    Website. Ministry of Health, Labour and Welfare. www.mhlw.go.jp/english/index.html
2.    Website. World Health Organization. World Health Report 2002. http://www.itof.org
3.    Lee WJ, Wang W. Bariatric surgery: Asia-Pacific perspective. Obes Surg. 2005;15:751–757.
4.    Kasama K, Tagaya N, Kanehira, et al. Has laparoscopic bariatric surgery been accepted in Japan? The experience of a single surgeon. Obes Surg. 2008;18(11):1473–1478.
5.    Nicholas A, Christakis N, Fowler JH. The spread of obesity in a large social network over 32 years. NEJM. 2007;357:370–379.
6.    Website. International Federation of Social Workers. Rules & Instructions. http://www.ifsw.org
7.    Encyclopedia of Social Work: Psychoeducation, 20th Edition. In: Mizrahi T, Larry E, Davis, eds. Oxford University Press;2008:453–455.
8.    Roberts AR, Greene GJ. Social Workers Desk Reference. Using Social Constructivism in Social Work Practice. Oxford University Press;2002;143–148.
9.    Roberts AR, Greene GJ. Social Workers desk reference. Solution. Focused Therapy? Oxford University Press;2002;112–115.
10.    Metcalf L. Solution Focused Group Therapy. Free Press;1998.
11.    Bariatric Surgery: A Guide for Mental Health Professionals. In: Mitchell JE, de Zwaan M, eds. Routledge;2005;59–118.
12.    Hildebrandt SE. Effects of participation in bariatric support groups after Roux-en-Y gastric bypass. Obes Surg. 1998;8(5):535–542.
13.    Cowan GS, Jr. Assessment of the effects of a taped cognitive behavior message on postoperative complications (therapeutic suggestions under anesthesia). Obes Surg. 2001;11(5):589–593.
14.    Marcus JD, Elkins GR. Development of a model for a structured support group for patients following bariatric surgery. Obes Surg. 2004;14(1):103–106.
15.    Saunders R. Post-surgery group therapy for
gastric bypass patients. Obes Surg. 2004;14(8):1128–1131.
16.    Bauchowitz L. Psychosocial evaluation of bariatric surgery candidates: a survey of present practices. Psychosom Med. 2005;67(5):825–832.
17.    Elakkary E. Do support groups play a role in weight loss after laparoscopic adjustable gastric banding. Obes Surg. 2006;16(3):331–334.
18.    Simon GE. Association between obesity and depression in middle-aged women. Gen Hosp Psychiatry. 2008;1(2)2008:32–39.

Category: International Perspective, Past Articles