Bariatric Medicine

Working to Solve the Problem of Obesity

In 1990, fewer than 15 percent of the population in most U.S. states was 
obese. By 2010, obesity rates increased 25 percent or more in 36 states, according to the Harvard University School of Public Health. Today, 36 percent of U.S. adults—one out of three—is obese.
“The obesity epidemic is a worldwide issue,” says Jonathan Mandelbaum, M.D., a member of the Franciscan Physician Network specializing in bariatric surgery in Indianapolis. “The literature is saturated with studies showing the increased prevalence in obesity across the globe. Comorbid conditions related to obesity, such as diabetes, cardiovascular disease and cancer, are driving up healthcare costs and taking lives.”
The healthcare community is grappling with the negative health outcomes of lifestyles that result in obesity, stressing the importance of implementing population health strategies to help control this serious epidemic.

Community Efforts to Prevent Obesity
While healthcare practitioners work to repair the damage caused by extra weight, the broader community can take actions to help prevent the problem from continuing to grow. From legislative action to grassroots changes, population health strategies can make a difference, says Jonathan Mandelbaum, M.D., a surgeon with the Franciscan Physician Network. He recommends local actions such as:

  • Eliminating sugary beverages from hospital cafeterias and vending areas
  • Hosting farmers markets featuring fresh fruits and vegetables
  • Offering community seminars on 
selecting and preparing nutritious foods
  • Partnering with fitness coaches or community facilities to offer group exercises classes free or at a discount

Wreaking Havoc on Every System

Although obesity is known to contribute to health problems such as diabetes and cardiovascular disease, it’s actually a factor in almost every type of specialized medical care.
“Unlike other diseases, obesity can affect every organ system in the body,” says Carrie Lin, RN, BSN, CBN, bariatric surgery program manager at St. David’s Medical Center in Austin, Texas. “A healthcare approach that does not address the underlying problem of weight will not be effective in controlling the associated comorbid conditions such as blood pressure, GERD [gastroesophageal reflux disease] and joint pain.”
For instance, weight can cause or worsen chronic pain issues, and the problems of chronic pain contribute to the issues of opioid treatment and addiction addressed by pain management specialists, Lin says. In addition, orthopedic surgeons see patients struggle with issues in their joint replacements due to the stress and strain from excess weight. In obstetrics, obesity can be a root cause of fertility struggles. Obesity is also linked closely to several types of cancer.
Extra weight can also limit potential treatments for disease: “Transplant surgeons struggle with patients who need the gift of a lifesaving organ but are over the body mass index (BMI) requirement to qualify for the list,” Lin adds.
Not only can obesity lead patients to require more frequent visits to specialists such as cardiologists, endocrinologists and orthopedic surgeons, but it can also increase a person’s risk for having car accidents and falls, according to Mandelbaum.
“Studies confirm that obesity is associated with increased use of medical services, increased prescription medication use, longer hospital stays and, in general, higher medical costs,” he says. “Specialized equipment is necessary for obese patients, including chairs, operating room tables, and MRI and CT scan machines that accommodate higher weights. Patient movers, stretchers and wheelchairs that accommodate higher weights are needed as well. There are also increased healthcare provider injuries associated with caring for morbidly obese patients.”

Bariatric Sensitivity Training
Even when the focus is on improving health, discussing a patient’s weight can be upsetting to them. Patients who are overweight or obese could feel ashamed or defensive about their weight and may take a healthcare provider’s comments about it as a personal attack. If patients feel defensive or angry, they may avoid getting the help they need.Before broaching the subject of a patient’s weight, healthcare providers should first focus on “sensitivity and maintaining a person’s dignity,” says Jonathan Mandelbaum, M.D., a specialist in bariatric surgery at Franciscan Physician Network in Indianapolis. Here are five ways practitioners can do that effectively:
1. Choose words carefully. When discussing weight, some terms are interpreted as more judgmental or shameful than others. Healthcare providers should steer clear of terms such as fat, obese, diet and exercise, according to the Stop Obesity Alliance. Instead, focus on using terms like overweight, increased BMI, unhealthy weight, healthier weight, eating habits and physical activity.
2. Use people-first language. Rather than calling patients “diabetic” or “learning disabled,” the healthcare community has learned to say the patient “has diabetes” or “has a learning disability.” In the same way, practitioners should avoid calling a person “obese” and instead say he or she “has obesity” or “has an unhealthy weight.”
3. Ask for permission to discuss weight. Simply starting a conversation with a question, such as, “Can we discuss your weight?” can show sensitivity and concern rather than judgment, allowing patients to relax and listen.
4. Offer information about how weight affects health. Some people may not realize the effects that excess weight can have on their overall health. Providers can help by explaining how symptoms such as fatigue, aching knees and serious health complications can be linked to extra weight.
5. Don’t avoid the subject. Even though discussing weight may be difficult, many patients expect weight loss guidance from their healthcare providers—and providing it is vital to improving health outcomes.“It is important to understand that while issues of weight should be approached with the appropriate sensitivity, they should not be ignored,” says Carrie Lin, RN, BSN, CBN, bariatric surgery program manager, St. David’s Medical Center in Austin, Texas. “If a patient asks questions about obesity or weight loss options, be aware of how you would answer them and provide the support they need.“Raising awareness and educating patients and family members about this complex issue in a manner that is well-received so that patients seek out resources still remains an opportunity for most communities.”

Finding Solutions

Bariatric professionals attempt to prevent comorbidities and try to help patients reduce their weight in a healthy way in addition to treating the comorbid conditions caused by obesity.
Surgical procedures are still the mainstay and most successful option for patients suffering from morbid obesity, according to Mandelbaum. “But the surgical procedures are only successful if the patients are compliant with restricting portion sizes, making good food choices and adding exercise to their regular routine,” he says.
In the United States, the two most common bariatric surgical procedures are the sleeve gastrectomy and the Roux-en-Y gastric bypass. Over the past few years, the sleeve gastrectomy has become more popular than the gastric bypass because of its lower incidence of short- and long-term complications, Mandelbaum says.
Further, there are alternative surgeries. “For some patients with a very high BMI, providers recommend the biliopancreatic diversion with duodenal switch because it can offer greater excess weight loss,” Lin explains. The adjustable gastric band, commonly known as lap band surgery, has declined in popularity in the past several years because of high reoperation rates. Some bariatric programs are also expanding into newer procedures such as gastric balloons, endoscopic sleeve gastrectomy and implantation pacemaker devices that affect the vagus nerve, the longest cranial nerve that goes from the neck and thorax to the abdomen.
Though bariatric surgery is shown to be the most effective and lasting treatment for the morbidly obese population, many patients may not be ready for or interested in a surgical option. For those patients, there are some other options.
In addition to surgery, several FDA-approved medications show some success in short-term weight loss. But, according to Mandelbaum, these medications don’t generally achieve enough weight loss to get morbidly obese patients back to a healthy weight. Other medical weight loss options include physician-supervised diets and mental health treatment for food addiction and eating disorders.
Behavioral modification is also important in treating obesity. At Mandelbaum’s clinic, patients are offered education and dietary counseling to help them make nutritious food choices, as well as support groups, healthy cooking classes and free exercise classes.
As for St. David’s Bariatric Center in Austin, more than 5,000 patients have completed the program since 2002. The center provides concierge care for patients that includes one-on-one, preoperative visits with the on-site registered dietitian. This guarantees direct contact with patients before they enter the facility.
“We use this opportunity to see to it that all of the preoperative testing and requirements are met and patients are prepared and ready for their procedure,” Lin explains. “This also allows our patients to ask questions and understand what to expect during their stay in the hospital.”
When patients undergo weight loss surgery, a St. David’s registered nurse conducts rounds to check on them while they’re in the hospital to ensure the patients are progressing as expected through their recovery. The RNs round with the bariatric surgeons, making sure their orders are carried out as expected, and they also give patients specialized one-on-one discharge instructions. Lin adds, “A close relationship with our center surgeon partners is important in providing the support they need to give their patients the best care and secure excellent outcomes.”
After patients are discharged, the center remains involved, helping them meet goals for healthy food choices, physical activity and a healthier lifestyle as they lose weight. “By undertaking extensive patient outcomes tracking,” Lin says, “St. David’s staff is able to pinpoint areas for quality improvement.”

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