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Bariatric surgery patients need care for a lifetime

These patients face medical and psychosocial challenges that require treatment for years, and it's after the operation when the hard work begins.

By Victoria Stagg Elliott, amednews staff. June 28, 2004.

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Alan Wittgrove, MD, president of the American Society for Bariatric Surgery, wants to talk to primary care physicians.

For years, he has been giving lectures to surgeons about his craft and how to care for patients who have undergone surgical weight-loss procedures. Increasingly, however, he's thinking that he should be seeking out an additional audience.

"The group that I really should be talking to is the family practice society," said Dr. Wittgrove, who is also the medical director of the Alvarado Center for Surgical Weight Loss in San Diego.

He's part of a growing group who recognize that the emergence of bariatric surgery from a handful of procedures in the 1950s to the 140,000 projected this year means that an ever-larger number of primary care physicians will see some of these patients in their practice. And their care will continue long after the bariatric surgeons have finished their work.

"As a primary care physician, you do see a lot of obesity, and there's a certain percentage of that population that benefits substantially from the bypass surgery," said Kim Pierce, MD, an internist at Magee-Women's Hospital in Pittsburgh. "But they are medically different people post-surgery. The numbers are going to escalate, and it's going be a problem if primary care physicians aren't up on the medical management."

Little has been written on the subject, and existing bariatric surgery guidelines focus more on who is an appropriate candidate than what happens after the procedure. But many experts say the involvement of primary care physicians is key.

Some of the post-surgery questions that come up involve the adjustment of diabetes and hypertension medications for those who are experiencing the rapid weight loss. Primary care physicians who have faced this issue say that tapering patients off medicines for obesity-related conditions is the easy part. The hard part is yet to come because not all of these patients can handle the life transformation that results.

"We must be cognizant of the psychosocial aspects of changes in the patient. How they react to the spectacular changes in front of them is not always positive or as expected," said Ignacio de Artola, MD, vice chair for clinical affairs in the Dept. of Family Medicine at the University of Southern California in Los Angeles.

For starters, patients have to remain on nutritional supplements over their lifetime because of absorption issues. But many patients feel so much better after losing so much weight that they are less interested in continuing to take pills. Also, while they may have insurance coverage for diabetes medications, insurance rarely covers the vitamin and mineral supplements they need.

"Long term, these people could be headed to osteoporosis, B-12 deficiencies and iron deficiencies, unless they take their supplements very faithfully," said Kathleen Wilson, MD, a New Orleans internist and author of Dispatches from the Frontlines of Medicine, a series of consumer health books. "I have had some patients stop taking their supplements just because they feel so well that they conveniently forget."

Doctors also say that depression is common and that many patients have mixed feelings about the weight loss.

"Patients tell you they've lost their best friend -- eating," said Peter LePort, MD, a bariatric surgeon in Fountain Valley, Calif. "They were using food as an anti-anxiety, and now they have to deal with the anxiety, and that's very difficult to do."

These unresolved mental health issues can lead patients to attempt to figure out ways around the surgery, either by frequently eating small amounts of calorie-dense foods or downing high-calorie liquids.

"You have to pay close attention to the psychological needs of your patients," said Shalini Reddy, MD, assistant professor in the section of general internal medicine at the University of Chicago. "The people who start to gain weight back are those who are eating for psychological purposes."

These issues highlight the need to build strong linkages between surgeons, primary care physicians and numerous other health professionals to treat these patients. These links, however, can sometimes be difficult to maintain.

"The role of the primary care physician is very, very important because some surgical centers just want to deal with the patient during the period around the operation, but the care of a bariatric surgery patient is for life," said Eneida Roldan, MD, MPH, a bariatrician in private practice in Coral Gables, Fla. and the recent chair of the American Board of Bariatric Medicine.

"Alliances between bariatric surgeons, bariatric physicians and primary care doctors are the future of bariatric surgery."

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