A Case for Long-Term Aftercare
by Andrea Ullberg
OH Member & Blogger
A vertical sleeve gastrectomy patient traveled to Mexico to self-pay for his surgery three years ago and has done a wonderful job with his surgery. Knowing his surgery was not malabsorptive, though, he never took the vitamins needed to help keep him healthy. Now, three years later, he's beginning to feel a bit run down and goes to his PCP for help since he cannot follow-up with his surgeon. The PCP, having very limited knowledge of what blood work to order, only orders a few labs. All of which come back normal. The patient continues to decline, not realizing that the lack of vitamins are leading to his decline, and without the knowledge of which labs to look for, has no idea where to look for the help he so desperately needs.
A two year post-op Roux-en Y gastric bypass patient is pregnant with her first child. She's recently moved from her hometown and is now seeing an unfamiliar obstetrician who has never had an RNY patient before. Due to the move, our mother-to-be cannot follow-up with her surgical practice. What little routine blood work the OB thinks to draw shows rapidly dropping vitamin B-12 levels, and standard anemia panels come back normal. Nutritional counseling is limited and based on requirements for the practice's standard patient: a single prenatal vitamin, an iron tablet, and a Tums tablet for calcium. Postpartum, our mother begins feeling more sluggish than usual (even for a first-time mom) and begins to ache deep in her bones. Frustrated, she finally does some research online and asks her doctor for additional blood tests which show abysmal numbers in iron and vitamin D levels. Now, not only is our mom recovering from having a child, but she is diagnosed with pernicious anemia and osteomalacia, an adult form of rickets.
While these hypothetical cases are certainly extreme, they point to two underlying problems concerning the Weight Loss Surgical community: the lack of information for medical practitioners outside the bariatric community, as well as the lack of education of the surgical patient themselves.
In 2008, there were 344,221 weight loss surgeries performed, which was an increase of 135% over 2003 (Metabolic / Bariatric Surgery Worldwide 2008). Given the current estimate that 44.1 million Americans will have diabetes by 2032, a number that is nearly double the current number of 23.7 million, there will be more and more weight loss surgeries performed each year (Study: Cost of treating diabetes to triple by 2034). This especially holds true given that 90% of diabetes cases are Type 2, a form of diabetes that develops over time with the predominant risk factor being obesity. With new technologies currently in clinical trials that promise incisionless and lower cost options to a wider variety of patients, weight loss surgery is here to stay, and thus patients are going to become more and more common.
There are many reasons why a patient may turn to a different medical provider to help maintain their health post weight loss surgery. If there is not enough information for that provider to give adequate medical advice to the patient, and if the patient is not savvy enough regarding their own care, the post-op road will not only be bumpy, but could also be paved with disaster.
Therefore it's extremely important for two things to happen:
- More professional literature needs to be published for reference and learning to medical professionals in all fields of practice.
- The weight loss surgical patient needs to become more self-aware and involved in their own care in order to assure their health does not become compromised in any way.
As patients, we cannot really push the medical establishment to publish more literature, nor force additional courses for learning for our medical professionals. However, we can completely control our own self-knowledge and can help educate our own providers to the best of our ability. By educating ourselves, not only do we have more faith and confidence in our health, but we become better patients by learning more about the clues our bodies give us and can give better information to those who are treating us. In this process of self-education, we can help educate our medical team by providing medical literature pertinent to our care. Nutrition guidelines, information about the different surgical procedures, medicinal guidelines for your surgical type -- all are critical information pieces for your health care provider and should be given to any one providing care to a bariatric surgical patient.
When considering any weight loss surgery - from a restrictive-only procedure to a malabsorptive one, a potential patient must consider all manner of possibilities. What would happen to your care if you moved far from your surgical practice? If you lost your health benefits, and could not afford routine lab work, how would you determine nutritional status? What if you lose your income and cannot afford a high-protein diet, much less the supplements needed to keep you healthy? What happens if you develop a nutritional deficiency due to an inability to pay for your supplements or lab work? It's a sad fact that preventing a deficiency is cheaper than treating one, but what if you can't even afford that? Who will manage your care in six months? Two years? Five years? Twenty years? These are all questions that we should be asking prior to even the surgical consultation, yet we don't.
Long-term aftercare is important and while we expect the medical community to be there for us, and to provide for us, ultimately it is up to us, the bariatric patients, to be responsible for our own health and well-being. In the process of making ourselves better informed, we make our community a stronger one... one that can push for more education and resources to be available to the medical professionals that treat us.
Suggested Resources, PDF Download:
ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient -- Aills, Blankenship, Buffington, Furtado, & Parrott
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