Wednesday, February 27, 2013

Goooooooaaaaaalllllll! Part 2

And now for the punch line, although this really is no joke-

In fact, we had a clinical meeting at the office just the other day to discuss the weight goal issue itself, as well as reinforcing the complex and delicate nature of assigning the "Goal Weight", and reinforced what it means to the patient as well as to our own staff here at the Bariatric Center.

So brace yourself, here it comes.

Let's organize it this way - the 'What it is, What it was, and What it shall be' classification.

What It Is

*  Not just a number.  There's so much more involved, some of it actual, and some of it artificially associated by the patient, trying to recapture what life was like when they were "that weight".  I guess it's the same as your 70 year old Dad wearing the same style of clothes he did back in his glory days of the Air Force, connecting with his days of old.

*  Based on a "Healthy Weight", as stamped out in concrete fashion by the BMI wheels, and the Insurance tables that delineate a certain weight for a certain height, related to actuarial data.  This certainly does not tell the whole story.

*  A Big Deal.  This cannot be overstated. (Just ask your patient) Having surgery is a big deal unto itself.  Having surgery for being overweight is just as much a big deal, if not bigger.  "What if it doesn't work, like all the other weight loss things I've done didn't work?" Also. "What if it does work, what will my life be like then?" The self-talk can be numbing or fear-inspiring for these folks.


What It Was

*  Again, the association between weight and a "feeling" of how it used to be when I was at that weight.  For me, a personal example is how 80's music takes me down my own memory lane... And for me, not a bad time of my life, but I don't really want to get back there to those now glorified days of early adulthood.  Although I'll take the hair back, that I lost somewhere along the line.

*  In another sense, misleading is a often a better way of a patient's rigidity to get back to a certain weight.  It is not uncommon to have a patient discouraged or even a bit depressed despite having getting to their goal after surgery, only to not "feel" the way they thought it would fell at that weight.


What it Shall Be

*  Reasonable.  I look for a weight around a BMI of 27-30 based on start weight, how much they have to lose, and their age.  I adjust to a higher BMI for more advanced age (above 60 let's say), as well as accept a higher BMI dependent upon how much they have to lose.  For example, a patient who starts out with a weight of 450 and a BMI in the 60s will not be expected to get to a BMI of the same range because the BMI wheel (and insurance company tables of ideal weight) 'requires' the patient to get to a BMI of 24.99 or less the be healthy.

*  Relatively dependent upon procedure and when it was done. Sleeves and Bypasses enable most patients to lose the majority of their weight over a 9-12 mos time frame.  For Bands, they can get to a similar end result, but generally over an 18-24 mos period or more.  Additionally, for most patients, there is a limit to what they can reasonably lose.  Expecting that 450 pound patient to lose 250 pounds is likely not all that reasonable, although not impossible, especially in the 9-12 mos after surgery.  Most Bypass patients, for example, can lose around 200+ pounds, but this is not hard and fast.  Weight loss after that first year can continue in the right behavioral setting, but happens at a much slower rate.  Duodenal switch patients, however,  tend to lose more weight as it is a much more malabsorptive surgery, but we do not offer that surgery at this time, and my experience with it is very limited.

*  Centered on becoming more healthy based on the many benefits of weight loss.  Isn't that the ultimate goal of surgery and weight loss in the first place?  Many categories, some difficult to measure,  summate to embody "Health" for our patients.

Here are some of the questions we ask to get a handle on this measure.  Some answers resonate to certain patients more than others.  What comorbidities are improved or gone, associated medicines reduced or not needing to be refilled? What activities can you now comfortably participate in that you only dreamed of before?  What are others saying about your new appearance, your new clothes, your new attitude?  More importantly, how do you  feel about yourself with more control over your weight and your health?

The sometimes unexpected benefit to patients, and providers, (who thoughtfully take stock of these parameters) is that there are some very unexpected scenic vistas along the way to the the top of the mountain, the end goal if you will, that a patient dreams of reaching.  It doesn't take arriving at a "goal weight" to appreciate very substantial gains in Quality of Life in most of the above markers of health. Studies routinely bear that out.

We as Health Care Providers just have to remember that. We need to remind them of where they are on their journey, help them set a reasonable goal weight, not further burden them, and get out of their way as they journey on the trail to the top.

Photo by M Clock


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