Weight Loss a Measure of Success Following Bariatric Surgery?

Weight loss, waist measurement or BMI are quantifiable measurements. They are useful instruments as part of research. They are useful boundaries in determining 'suitability' for surgery. They are valuable when linked to outcomes and health improvement. They are, usually, easily measured, 'monitored' and recorded. Most of us know that weight loss has been recognised for many years to have a significant, positive impact and improvement both on many diseases and also, therefore, prolonged life expectancy.

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The advantages of a 10kg weight loss is well known to health professionals and, for example, include:
• Total mortality decrease 20-25%
• Diabetes related deaths decrease 30-40%.
• Obesity-related cancer deaths decrease 40-50%.
• Risk of developing diabetes decreases more than 50%

% of excess body weight lost linked to improved co morbidities supports arguments for weight loss surgery, financial support for interventions and, when used in correlation with decreased morbidities, adds weight to cost saving and bariatric service development.

While recognising the importance of this measurement it is arguably of less significance to the day to day management of an individual's weight loss journey.

What changes for an individual when they have lost weight varies and one may ask, 'what is relevant to you now'? Does the patient measure success by % of excess body weight lost or that they look good, have more confidence or can slip into a pair of jeans?

Bariatric practitioners need to consider the complexities of an individual journey and look outside the simplistic excess % weight loss.

The bariatric practitioner needs to be aware that weight loss alone may not be the predominant significant factor to the patient but that there may be significant personal areas that include, for example, gender, sexuality and relationship. Individuals may grow in understanding their relationship with food and eating and the thoughts, feelings and behaviours associated.

To fit into a BMI chart may be of significance to a practitioner but have little value to the patient.

'D' was so delighted when she came to see me some months into her changing journey.

"I have always wanted to be a big busty sexy size 16 and I am."

For 'D' her size now is who she is and not what a BMI chart tells her what (and possibly interpreted as who) she should be. Indeed her BMI falls into the 'obese' category according to a BMI chart.

More value than any line on a BMI chart she has grown in a depth of understanding both herself and the intricate relationship with food that she has used for so long. She accepts who she is and has changed her mindset. Her journey and understanding means she is far less likely to use food for the same reasons that she did pre op. D has worked hard.

Historically health professionals have been included in those who have prejudice against the obese. This prejudice includes loathing of behaviour, size and intellectual ability.

Individuals seeking surgery may be no more emotionally or intellectually 'toxic' than someone who has not had weight loss surgery or who has reduced in size through pharmacological or dietary methods. However, body change has come about and a new size, shape and physical ability brings with it new challenges both personally and socially.

A reduced body size is likely to bring new qualitative, social, relationship, life style, self exploratory and emotional issues that for some are unexpected. It is possible that some of these changes may demand individual, ongoing treatment or understanding.

Outsiders may see an outward physical change (or % weight lost) and praise weight loss. Yet for many patients the physical change is not seen as there may be a degree of Dysmorphia associated to their body.

To maintain what has been achieved patients learn to value more than weight loss alone. A shift of focus away from numbers is important for long term maintenance as a few numbers can trigger a lapse for some who have been focused on success being linked to numbers.

Today I stand in the scales and weigh 67kgs - my day is perfect! The sun is shining the birds are singing and life is good. I walk with my shoulders back and with a bounce in my step.

Tomorrow I stand on the same scales and I weight 69 kgs - my day is a disaster, the sky is grey, the birds have flown to Siberia and life is so depressing. I slouch and want to cry, run away, eat and hide away - preferably under the duvet

Bariatric professionals focus on weight loss more readily than behavioural change. If success is purely measured by numbers on weighing scales it is easy for an individual to slip into previous beliefs. Previous significant loss will be brushed over as the number '2' is interpreted at a personal level.

"I am a failure, I have failed I am fat and therefore I am worthless, useless and want to run away. I am a victim of obesity".

Such extrinsic events are not interpreted separately from the individual self and there may be little clarity that an external event is not who the person is.

Obese individuals tend to judge and be very judgemental of their own behaviour. It is believed that many have poor problem solving skills and are impulsive in behaviour that is triggered by various stimulants - smell, taste, venue, emotion.

Coercion - 'go on a diet' can activate negative reactions and the opposite effect may happen.

Bariatric patients are highly geared to food as a reward or as a comfort and their sense of autonomy may not be present having been destroyed by historical dietary rules and control by numbers, points or 'sins'.

The bariatric patient's journey includes restoring a sense of autonomy and the practitioner requires skills to manage this.

Weight loss surgery - whatever type is only a tool, a vehicle to enable the physical self to become smaller.

No operation is cure all and none can be relied on 100% to change the body mind and spirit. The individual alone has to change in understanding of the 'self' and develop individual understanding, new knowledge and behavioural changes.

People don't change or do things 'because it's good for them'. People don't change because their current situation hurts. These may motivate an approach to change but it is a complex intertwining of processes that is involved.

weight loss surgery is not about weight and weight loss alone. Success need not be measured by numbers on the scale alone but by what the individual sees as their victory.

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