Editorials
Bariatric Surgery: Too Many Unanswered Questions
See related
article on page 1403.
One of the obvious consequences of the failure of health insurance companies to pay benefits for the medical treatment of obesity is the relatively limited access to comprehensive medical programs.1 Because benefits often are paid for surgery, another consequence of this commercial manipulation of medical care is the dramatic increase in the number of bariatric surgical procedures performed.2
Patients and surgeons want to resolve the problem of obesity, and the surgical approach is tempting. The weight loss is often dramatic, but surgeons, patients, and eventually family physicians must cope with the recognition that surgery offers no known resolution of the underlying problem. It does not remove or repair diseased tissue, and it offers no cure. Surgery is an anatomic reconstruction that offers the patient a different way of managing an extraordinarily complex and chronic disease. Patients who undergo bariatric surgery need lifelong medical management of their disease, and many will continue to struggle with their eating. Because continued active treatment of these patients is required, surgery cannot technically be considered curative.
It often falls to the family physician to supervise and assist with these issues. In this issue of American Family Physician, Virji and Murr suggest a general format for the care of patients after bariatric surgery.3 Their recommendations underscore the complexity of bariatric surgery as a "solution" to the problem. Much is still unknown about what is appropriate for the evaluation and continuing care of patients after this surgery.4,5
A first question is the nature of the preoperative evaluation. Who should, and perhaps more importantly, who should not have this surgical procedure? The sickest patients, with the most severe obesity and the most chaotic eating habits, also will have the most complex associated medical problems and the greatest operative and postoperative risk. To exclude these patients dooms them to deteriorating complications and increases the probability that desperate patients will shop elsewhere for operative approval. Even if high-risk patients are accepted as candidates for surgery, how can physicians identify patients who are likely to fail to lose weight because of the persistence of metabolic, emotional, and situational factors that will sustain their overeating at preoperative levels?6 Family physicians urgently need some guidelines for their role in patient selection.
Patients want our advice about which procedure is best, and which surgery is best for each patient. Does age, sex, severity, eating patterns, complicating medical problems, or the surgeon's skill determine which type of surgery to recommend? When recommending one type of surgery over another, physicians must balance concern for patient safety with the desire for greatest final weight loss.7
Managing the surgical procedure and the associated short- and long-term medical problems may be the easiest part of patient care. Far more complex are the questions about the patient's nutritional status; the emotional turmoil that may arise from the patient's obligatory eating restrictions; and the complexities of the patient's new relationships with food and eating, family, friends, and work and social patterns. We lack the evidence and training to provide the behavior therapy, nutritional counseling, and group support that seem such an important part of continuing management. How can we be assured that the patient, now eating a severely restricted diet, is getting adequate nutrition?
The cost of medical care for a patient after bariatric surgery often is substantial. It is possible that some patients are choosing the surgical option because their health insurance will pay for surgical, but not medical, care. How can physicians cope with insurance companies and their denial of benefits for the sustaining medical care of this complex, long-term disease? We surely need some guidance in what is appropriate for which patient and how to provide the services that we think the patient needs for continuing care.
Family physicians have a particular responsibility in the seemingly routine care of these patients. Eating may seem simple, but we understand now that it is controlled with remarkable precision and is regulated by an elaborate interaction of neurochemical, hormonal, gastrointestinal, and adipose tissue signals. We know remarkably little about how any intervention affects any part of these regulatory systems, making continuing care, and how to do it well, an unknown.
The Author
ARTHUR FRANK, M.D., is medical director of the George Washington University Weight Management Program in Washington, D.C.
Address correspondence to Arthur Frank, M.D., George Washington University Weight Management Program, 3 Washington Circle N.W. Ste. 208, Washington D.C. 20037 (e-mail: frank@gwu.edu). Reprints are not available from the author.
REFERENCES
1. Frank A. Conflicts in the care of overweight patients: inconsistent rules and insufficient money. Obes Res 1997;5:268-70.
2. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 2005;294:1909-17.
3. Virji A, Murr MM. Caring for patients after bariatric surgery. Am Fam Physician 2006;73:1403-8.
4. Courcoulas AP, Flum DR. Filling the gaps in bariatric surgical research [published correction appears in JAMA 2005;294:2848]. JAMA 2005; 294:1957-60.
5. Kral JG, Brolin RE, Buchwald H, Pories WJ, Sarr MG, Sugerman HJ, et al. Research considerations in obesity surgery. Obes Res 2002;10:63-4.
6. Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res 2005;13:639-48.
7. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis [published correction appears in JAMA 2005;293:1728]. JAMA 2004;292:1724-37.
Religion, Spirituality, and Their Relevance to Medicine: An Update
Before 2000, nearly 1,200 studies had examined the relationship between religion and health, with most studies reporting positive associations.1 In the past five years many new studies have been conducted that support these findings.2 Although there has been criticism of the earlier studies,3 these studies used different designs and methods of analysis, were conducted in different populations, and were carried out by different investigators, both inside and outside the United States. Most studies are cross-sectional and therefore cannot distinguish between cause and effect; however, many prospective cohort studies and more than one dozen clinical trials (mostly examining religious interventions in mental health) support the findings from cross-sectional research. We review some of the best studies below.
Strawbridge and colleagues4 conducted a 28-year prospective assessment of more than 5,000 adults. They found that weekly attendance of religious services decreased the relative risk (RR) of dying during follow-up by 36 percent (RR, 0.64; 95% confidence interval [CI], 0.53 to 0.77); adjusting for social connections and health practices reduced the effect to 23 percent (RR, 0.77; 95% CI, 0.64 to 0.93). The effect in women (RR, 0.66; 95% CI, 0.51 to 0.86, adjusted for covariates) approximated the effect of not smoking cigarettes.5 Frequent attendance was a predictor of better health behaviors, improved mental health, and increased social connections.6
These findings were replicated in a sample of 4,000 older adults followed for six years.7 The effect was similar (RR, 0.72; 95% CI, 0.64 to 0.81, adjusted) and was strongest in women (RR, 0.65; 95% CI, 0.55 to 0.76, adjusted). A random survey8 of more than 20,000 Americans found that whites who attended religious services regularly lived an average of seven years longer than those who did not, and blacks who attended regularly lived an average of 14 years longer than those who did not. After controlling for multiple covariates and explanatory factors, the risk of dying during the eight-year follow-up was 50 percent higher in persons who never attended religious services than for those who attend more than once per week.
Most recently, Lutgendorf and colleagues9 prospectively examined religious attendance and interleukin-6 (IL-6) levels as they relate to mortality rates in 557 older adults. After controlling for multiple covariates and explanatory factors, frequent attendance of religious services reduced the risk of dying in the six-year follow-up period by 78 percent (odds ratio [OR], 0.32; 95% CI, 0.15 to 0.72) compared with nonattendance; this finding seemed to be mediated by decreased serum IL-6 levels (OR, 0.34; 95% CI, 0.16 to 0.73), which replicated earlier findings.10 High IL-6 levels are an indicator of immune system dysfunction and thus provide a possible biologic mechanism by which religious attendance may influence physical health.
Although attendance at services is the most powerful predictor of health related to religion, it is not the only variable that predicts health outcomes. Studies11-18 show a connection between religious involvement and several health-related outcomes, including mental health and substance abuse, social health, quality of life, positive health behaviors, disease screening, continuity of care, surgical complications and use of health services, endocrine and immune function, hypertension, coronary artery obstruction, carotid atherosclerosis, survival rates, and positive human traits (e.g., forgiveness, gratitude, meaning and purpose, optimism and hope, altruism). Religious beliefs also influence medical decisions related to chemotherapy,11 do-not-resuscitate status,12 development of advanced directives,13 and end-of-life care.14 The physical health benefits of religion make sense given what is known about the effects of negative emotions on health outcomes and quality of life, particularly for patients with heart disease15,16 and cancer.17,18
Although studies that report negative associations between religion and health are not nearly as common as those with positive findings, recent studies have found associations between religion and obsessive-compulsive disorder in persons living in Italy,19 an increased risk of breast cancer among women raised in religious homes in California,20 poorer control of diabetes in Muslims in Leeds (U.K.),21 and reduced survival rates after hospital discharge among patients with religious struggles in North Carolina.22 Religion involves some of the most deeply and passionately held human beliefs, and it should not be surprising that these beliefs affect health.
Because the findings on religion and health may be relevant to patient care, physicians should have a basic knowledge of the existing research. Whether religion is good or bad for health, studies indicate that it is a powerful factor influencing adaptation to illness, medical decisions, health beliefs, and behaviors. Although we continue to struggle with how to apply information relating religion and health to clinical practice, sensitive and sensible applications do exist.23
The Authors
ANDREW J. WEAVER, M.TH., PH.D., is director of research at The HealthCare Chaplaincy, New York, N.Y.
HAROLD G. KOENIG, M.D., M.H.SC., is professor of psychiatry and behavioral sciences and associate professor of medicine at Duke University Medical Center, Durham, N.C.
Address correspondence to Andrew J. Weaver, M.Th., Ph.D., The HealthCare Chaplaincy, 307 E. 60th St., New York, NY 10022-1505 (e-mail: aweaver747@aol.com). Reprints are not available from the authors.
REFERENCES
1. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York: Oxford University Press, 2001.
2. Kliewer S. Allowing spirituality into the healing process. J Fam Pract 2004;53:616-24.
3. Sloan RP, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet 1999;353:664-7.
4. Strawbridge WJ, Cohen RD, Shema SJ, Kaplan GA. Frequent attendance at religious services and mortality over 28 years. Am J Public Health 1997;87:957-61.
5. Strawbridge WJ, Cohen RD, Shema SJ. Comparative strength of association between religious attendance and survival. Int J Psychiatry Med 2000;30:299-308.
6. Strawbridge WJ, Shema SJ, Cohen RD, Kaplan GA. Religious attendance increases survival by improving and maintaining good health behaviors, mental health, and social relationships. Ann Behav Med 2001;23:68-74.
7. Koenig HG, Hays JC, Larson DB, George LK, Cohen HJ, McCullough ME, et al. Does religious attendance prolong survival? A six-year follow-up study of 3,968 older adults. J Gerontol A Biol Sci Med Sci 1999;54:M370-6.
8. Hummer RA, Rogers RG, Nam CB, Ellison CG. Religious involvement and U.S. adult mortality. Demography 1999;36:273-85.
9. Lutgendorf SK, Russell D, Ullrich P, Harris TB, Wallace R. Religious participation, interleukin-6, and mortality in older adults. Health Psychol 2004;23:465-75.
10. Koenig HG, Cohen HJ, George LK, Hays JC, Larson DB, Blazer DG. Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults. Int J Psychiatry Med 1997;27:233-50.
11. Silvestri GA, Knittig S, Zoller JS, Nietert PJ. Importance of faith on medical decisions regarding cancer care. J Clin Oncol 2003;21:1379-82.
12. Sullivan MA, Muskin PR, Feldman SJ, Haase E. Effects of religiosity on patients' perceptions of do-not-resuscitate status. Psychosomatics 2004;45:119-28.
13. Medvene LJ, Wescott JV, Huckstadt A, Ludlum J, Langel S, Mick K, et al. Promoting signing of advance directives in faith communities [published correction appears in J Gen Intern Med 2004;19:204]. J Gen Intern Med 2003;18:914-20.
14. McClain CS, Rosenfeld B, Breitbart W. Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet 2003; 361:1603-7.
15. Blumenthal JA, Lett HS, Babyak MA, White W, Smith PK, Mark DB, et al. Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet 2003;362:604-9.
16. Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-related quality of life: the Heart and Soul study. JAMA 2003;290:215-21.
17. Brown KW, Levy AR, Rosberger Z, Edgar L. Psychological distress and cancer survival: a follow-up 10 years after diagnosis. Psychosom Med 2003;65:636-43.
18. Knekt P, Raitasalo R, Heliovaara M, Lehtinen V, Pukkala E, Teppo L, et al. Elevated lung cancer risk among persons with depressed mood. Am J Epidemiol 1996;144:1096-103.
19. Sica C, Novara C, Sanavio E. Religiousness and obsessive-compulsive cognitions and symptoms in an Italian population. Behav Res Ther 2002;40:813-23.
20. Wrensch M, Chew T, Farren G, Barlow J, Belli F, Clarke C, et al. Risk factors for breast cancer in a population with high incidence rates. Breast Cancer Res 2003;5:R88-102.
21. Naeem AG. The role of culture and religion in the management of diabetes: a study of Kashmiri men in Leeds. J R Soc Health 2003;123:110-6.
22. Pargament KI, Koenig HG, Tarakeshwar N, Hahn J. Religious struggle as a predictor of mortality among medically ill elderly patients: a two-year longitudinal study. Arch Intern Med 2001;161:1881-5.
23. Koenig HG. STUDENTJAMA. Taking a spiritual history. JAMA 2004;291:2881.
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