Who Will Have Success Using Gastric Procedures?
Behavior has been the focal point for assessing successful outcomes but it goes beyond diets to physiology; cllnicians must use sequential interventions to promote longterm weight control.
“Why should we try to make predications about weight loss?” asked Nickolas Finer, MD, a bariatric physician at the University College Hospital in London as he began his presentation, Predicting weight loss after gastric bypass and sleeve gastrectomy, at ObesityWeek 2016.1
Ethically, we should be able to tell patients what they might expect with regard to outcomes, and we need to use data to expand our understanding of the biology of obesity and then we can use this data to expand our understanding of biological outcomes.1
“[The purpose of having] surgery should not be just about weight loss but must account for the patients’ comorbidities as well as weight maintenance and avoidance of weight regain,” said Dr. Finer.
“Adherence was the driving force in successful outcomes among patients who underwent a bariatric procedure,” said Dr. Finer, reinforcing the point made by Donna Ryan, MD, professor emeritus at Pennington Biomedical Research Center in Baton Rouge, Louisiana, whose presentation2 led off the discussion about clinicians ability to predict which patients are likely to have successful weight loss outcomes.
In contrast to the adherence patterns from the Look AHEAD lifestyle intervention,3 which found that older patients had greater weight loss, individuals who underweight bariatric surgery had better outcomes if they were younger, according to Dr. Finer.
“We need to make it easier for patients to succeed, not by providing self-monitoring devices, which are great accessories that offer no real value to sustained weight loss,” said Dr. Finer. “Instead, clinicians must use more attentiveness in initiating interventions--medications, boot camp physical activity, surgery--earlier and intensifying efforts to try different treatments, but be willing to pivot when the patient doesn’t respond after one month.”
By approaching treatment as a need to meet a physiological response, the focus changes from one of blaming the patient and lessening the burden on the physician when weight loss expectations are not met and moving toward a more mutually supportive process, according to Dr. Finer.
“Clinicians are limited to 10 minutes with our patients, and yet we (chastise) them for not following their treatment plan. We need to be honest with nonresponders about the reasons that they may not be meeting their initial expectations,” Dr. Ryan told EndocrineWeb. “We need to move away from blame on either side.”
Which Patients Fair Best with Gastric Surgery?
“We found that age is a predictor of success with the gastric band procedure--adolescents do better than older patients.4 We also found factors such as depression, other psychosis and gender were not predictors of which patients would have the best outcomes,” said John Dixon, PhD, MD, of the Baker IDI Heart and Diabetes Institute in Melbourne Australia during his ObesityWeek 2016 presentation, Predicting Weight Loss After Gastric Banding.4
“However, depressive symptoms that manifest after undergoing the procedure did matter with regard to poorer outcomes,“4 said Dr. Dixon. Since this can be detected and addressed, this is a very controllable side effect that when managed can improve adherence and ultimately successful outcomes.
Correcting another myth, “the personality profile for behavior failed as a clinical predictive tool,"5 said Dr. Dixon. Similarly, readiness to change offered no direct usefulness in determining which patients might be more or less successful in achieving sustained weight loss, either.6
In fact, several trials were evaluated to disprove the myth that stages of change could predict successful weight loss.7 The authors found that patients achieved an average weight loss of less than 2 pounds with no evidence of any sustained weight loss.5
Interestingly, where a patient chose to have surgery was an independent predictor of successful weight management, according to Dr. Dixon.
"Losing weight takes a lot of focus, time and concentration, but the more [effort] you put in, the more you will get out of it," when it comes to lifestyle factors, said Dr. Ryan. [Clinicians] need to understand and be cognisant for our patients to succeed with medications and surgery, Dr. Ryan concluded.
It's clear that we have much to learn about the barriers to successful weight management, and an opportunity to recognize the factors that promote adherence so clinicians can begin to guide patients toward appropriate, individualized care plans that will improve weight management outcomes.