Why Not Talk About Bariatric Surgery: What makes patients and healthcare professionals hesitate?

The Benefit Gap. More than 25 million Americans may be medically appropriate for bariatric surgery as treatment for severe obesity; however, in 2017, >1% of those eligible were treated.

Biggest Barriers Often Unspoken. Patients: Poor knowledge about severity of obesity, health risks; persistent belief that obesity is a lifestyle choice; fear that surgery is risky, dangerous; “I should be able to do it.” Clinicians: Failure to recognize causes of obesity, weight gain/regain;discomfort counseling patients on treatment for severe obesity; uncertainty about safety/outcomes of surgery.

What Patients Think, Don't Say. Population studies suggest that many who meet medical criteria for obesity may underestimate weight status and related health risks. May keep patients from initiating a discussion about weight concerns or asking questions about effective therapy for obesity.

Patients: Measured vs Perceived Weight. 59% with BMI in overweight range considered themselves to be normal weight; 47% who met criterion for obesity classified themselves in overweight range. Of those who met BMI criteria for obesity but under- estimated weight, only 57% had spoken to a medical professional about treatment options for weight loss. Only 35%of participants for whom bariatric surgery was medically indicated (per their BMI), had considered it.

Accurate Assessment, Surgical Acceptance. Accurate perception of weight status was associated with acceptance of bariatric surgery as a treatment option. Those with class 3 obesity who misperceived status as overweight were significantly more likely to disregard bariatric surgery as acceptable vs those who accurately identified their weight status as having obesity.

Most Likely to Benefit, More Likely to Resist. Top reasons bariatric surgery was deemed unacceptable: “Too risky.” “Doesn’t work.” “Don’t need it.”

Clinicians: Misperceptions about Obesity as Disease. 2013: Amercan Medical Association recognized obesity as a chronic disease, currently without cure and managed with behavioral, medical, and surgical treatments.

Simply Put, It's Not Simple. Survey: Half of participants taking a basic CME course, half a prep course for board certification in obesity medicine, asked about biological/behavioral factors contributing to obesity, weight regain: Both groups rated lifestyle modification alone as more effective obesity treatment vs medication or surgery. Both groups rated behavioral factors as most important in weight regain after initial loss.

Interplay of Biology, Behavior, and Weight Regain. Biological adaptation to large weight loss attenuates long-term effectiveness of behavior-change interventions. Increased metabolic efficiency requires indefinite reduced caloric intake and increased exercise. For many obese persons, this is not possible, and leads to weight regain.

What Holds Clinicians Back. Research highlights barriers to opening the conversation. Clinicians, like patients, may overestimate risk & complications of bariatric surgery. Note: morbidity & mortality rates similar to those for cholecystectomy. They may be more comfortable counseling on lifestyle change, uncertain of when in obesity management it’s time to recommend surgery.

Best Next Step vs Option of Last Resort. For persons with class 2 or class 3 obesity, bariatric surgery is a medically necessary treatment option. Should not be considered or discussed with a patient as the “treatment of last resort.” Patients with obesity fall into a dangerous cycle of weight loss and regain – often fueled by the belief that “if I just try harder, this time it will work.” Patients may feel, too, that bariatric surgery is not necessary because “I’ve lost the weight before; I can do it again…”