Bariatric surgery is the most effective therapy for patients with severe obesity and yet the surgery is performed annually in <1% of those who meet criteria for the treatment.
There are insurance, financial, and healthcare acccess barriers to candidacy for bariatric surgery but there are also deeply seeded cultural beliefs and misperceptions among patients and clinicians alike that prevent even the first exploratory conversation in a clinical encounter about weight loss surgery.
The slide show below highlights a recent paper published in Mayo Clinic Proceedings titled, Rethinking Patient and Medical Professional Perspectives on Bariatric Surgery as a Medically Necessary Treatment. In it the authors present research that identifies a range of implicit beliefs and inaccurate perceptions about obesity, wieght loss, weight regain, and the surgery itself that keep patients and their physicians from talking about bariatric surgery.
https://www.sciencedirect.com/science/article/abs/pii/S0025619619308298?via%3Dihub
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…”
A Few Take-Home Points
- Lifestyle changes are the foundation of any successful weight loss approach, yet they should not constitute the only recommendation for patients with higher BMIs.
- Offered alone, lifestyle recommendations can reinforce a patient’s misperception that severe obesity is a lifestyle problem that is within their control and may lead to underestimation of dangerous health effects.
- Metabolic changes induced by bariatric surgery can put obesity into remission and, in combination with lifestyle change, dramatically reduce the risk of weight regain.
Read Up and Open the Conversation. “In a systematic review of patient/professional barriers to the surgery, medical professional counseling was strongest predictor that patients would consider bariatric surgery.”
To listen to an interview with Gretchen Ames, PhD, lead author of the paper, please click here.
