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.