Continuing Lifestyle Intervention, Part 4

The previous post discussed the run-up to bariatric surgery. because both before and after surgery, lifestyle interventions will be the patient’s new reality. The whole point is to make lifestyle interventions become the lifestyle, and to accomplish that is a lot more difficult than it sounds.

This brings up a quotation from a recent paper with the imposing title, “Effects of Lifestyle and Educational Bridging Programs before Bariatric Surgery on Postoperative Weight Loss: A Systematic Review and Meta-Analysis.” A rather chilling assessment undermines basic assumptions concerning the safety and efficacy of such procedures:

[A]lthough preoperative lifestyle interventions reduce body weight before bariatric surgery more effectively than usual care, this difference disappears 1 year post-surgery… [I]t is currently unclear whether, and if so under what circumstances, participation in a preoperative lifestyle intervention is beneficial.

Of course, the implication here is that if pre-op lifestyle intervention is useless, then maybe post-op lifestyle intervention is futile too, and so is any other kind of attempt to improve the situation. It is very dreary to contemplate. Which leads to another assertion made in this document:

Secondary outcomes and psychological well-being are rarely investigated.

It seems that the way to make a real mark in this field would be to vigorously investigate secondary outcomes and psychological well-being.

After bariatric surgery

The Ochsner Clinic, which offers both the adjustable gastric band (LAGB) and the Roux-en-Y gastric bypass (LRGBY) laparoscopic procedures, describes its method:

During the period of weight loss, we closely observe our patients; we then follow up with them once a year. During these visits, patients commonly have appointments with multiple persons on the bariatric team, including the surgeon, a physician extender, a registered dietician, and/or a mental health care provider, depending on the needs of each patient.

To this institution’s credit, it acknowledges that in the early post-operative stage, due to the “extreme and instant” lifestyle changes, patients tend to be in emotional turmoil. In light of that, once a year doesn’t somehow seem like enough in-touch-keeping. Of course, another section says a patient should report back “at the earliest signs of weight regain” because the sooner, the better.

A thought experiment

This description applies to post-op bariatric patients, but how many of these reactions, or very similar ones, might be let loose by the GLP-1 drugs?

Depression and anxiety medications should be continued for at least the first 6 months. Symptoms of depression should be monitored closely at the first few appointments… If patients were previous stress eaters and become stressed after surgery, they no longer have the ability to eat for stress relief.

Medications for all weight loss patients need to be in crushed, liquid, or chewable forms during the first 6 months for LRGBY and for the patient’s lifetime after LAGB. The use of whole medications may lead to ulceration as they sit in the stomach pouch or pouch enlargement.

Many patients also experience changes in their social scenes, as many American holidays are centered on a big meal. The way patients interact with the significant people in their lives changes dramatically, and their social structure can be irreparably broken.

Your responses and feedback are welcome!

Source: “Effects of Lifestyle and Educational Bridging Programs before Bariatric Surgery on Postoperative Weight Loss: A Systematic Review and Meta-Analysis,” Karger.com, 10/07/22
Source: “Long-term Management of Patients After Weight Loss Surgery,” NIH.gov, Fall 2009
Image by Joel Kramer/CC BY 2.0

Continuing Lifestyle Intervention, Part 3

The broad question under consideration here is whether the GLP-1 drugs in their various manifestations will cure obesity once and for all, and particularly whether they can possibly do so in the absence of continuing lifestyle intervention.

For comparison purposes, and to attempt to predict what the case will be with the new drugs, it is helpful to review the facts surrounding what was, up until recently, considered the last, best hope. Before these revolutionary new medications arrived, bariatric surgery was seen as the ultimate solution. That modality entails much preparation and extensive post-operative followup care.

Most importantly, and perhaps too often overlooked by optimists, this particular type of surgery requires a ton of consistent compliance at every stage — most essentially, the stage known as “the rest of the patient’s life.” This is where lifestyle intervention succeeds or fails.

As we have seen, the fundamentals of lifestyle medicine include appropriate nutrition, frequent physical activity, effective stress management, quality sleep, the maintenance of satisfactory social connections, and steering clear of risky substances (be they food, alcohol, drugs, or whatever.) That last part encompasses not only substances but in the case of non-substance addictions like gambling, requires the active and diligent avoidance of cues that trigger addictive behaviors.

A healthy, well-functioning person who wants to remain that way needs all these “pillars” to hold up the magnificent edifice of their recovery. A person with a problem needs to stay on top of every aspect of those conditions, every hour of every day, into infinity.

Grim odds

The prospect is not an encouraging one. The statistics on weight regain one year after surgery are alarming, and the harm does not stop there. The pounds continue to pile back on. Even under ideal circumstances and optimal conditions, surgery alone is not a fix.

The American Gastroenterological Association (AGA) says, “Patients, on average, return to their baseline weight within 4-5 years.” Numbers like this encouraged the AGA to review its Obesity Guidelines and conclude that good isn’t good enough. The group called current practices “usual care or minimal treatment,” and recommended that a comprehensive maintenance program become the norm.

Childhood Obesity News has talked before about preparation for bariatric surgery. The expectations include such lifestyle changes as weight loss, smoking cessation, restricted diet, counseling, and maybe even exercise. The patient will probably burn off some calories fighting with their insurer.

The overall picture is daunting. Yet even people who go through all that aggro in order to qualify for surgery, can somehow not find it within themselves to get with a program and stick with a program. Apparently, that is the only way to maintain a healthy weight.

Your responses and feedback are welcome!

Source: “Intensive Lifestyle Intervention for Obesity: Principles, Practices, and Results,” ScienceDirect.com, May 2017
Image by Hernán Piñera/CC BY-SA 2.0

Continuing Lifestyle Intervention, Part 2

There are said to be six “pillars” of lifestyle medicine: “plant-based nutrition, physical activity, stress management, avoidance of risky substances, restorative sleep, and social connections.” According to the same source, lifestyle medicine itself (familiarly known as LM)…

[…] is a medical specialty that primarily uses lifestyle changes to treat chronic diseases. It is an evidence-based practice that helps individuals and their families implement and maintain healthy behaviors impacting the quality of life.

Lifestyle medicine is definitely not an afterthought or an inconsequential footnote to treatment. All the six types of intervention are important, and this is certainly true of recovery from obesity, and avoidance of its return.

What does the American Gastroenterological Association (AGA) say? That organization, like so many others, has developed a set of guidelines for weight loss, to encompass a minimum of six months of intensive lifestyle interventions in three areas: reduced-calorie diet, increased physical activity, and behavior therapy.

This boils down to eating in a way that brings in 500 to 750 fewer calories per day than the individual had been accustomed to consuming. Physical activity should be 150 minutes, or better yet, 180 minutes of aerobic activity each week. Here is an interesting detail: “Physical activity alone, however, contributes minimally.”

Acknowledged as key is behavioral therapy, “which provides a set of strategies and techniques to modify diet and physical activity patterns.” Strategy is a thing that most of us might have trouble putting together on our own, but with guidance, we come to understand that self-monitoring is an excellent tactic. As the AGA says, “technological advances provide new ways for patients to self-monitor.”

A vital ingredient

This group’s definition of short-term intensive lifestyle intervention includes “16 individual, on-site counseling sessions with a registered dietitian in the first 6 months.” Psychologists have long noted that personal contact and attention have a strong effect, and this will continue to be true no matter how much assistive technology is added to the arsenal.

The AGA also has an agenda for long-term maintenance, because after six months or even a year of intensive lifestyle intervention, weight regain is widely and regrettably common. According to AGA,

With no further treatment (or with infrequent follow-up meetings) patients typically regain one third of lost weight in the first follow-up year, with continuing weight gain thereafter. Patients, on average, return to their baseline weight within 4-5 years.

By the way, readers of Childhood Obesity News are familiar with two programs that include the means for self-monitoring, and so much more — W8Loss2Go and BrainWeighve.

More on this subject is coming up, but until next time, let us leave readers with this thought: Seriously, a person could look around (including a glance into a mirror) and wonder, “Is there anyone I know who couldn’t use a little bit of lifestyle intervention?

Your responses and feedback are welcome!

Source: “The Impact of the Six Pillars of Lifestyle Medicine on Brain Health,” NIH.gov, 02/03/23
Source: “Intensive Lifestyle Intervention for Obesity: Principles, Practices, and Results,” ScienceDirect.com, May 2017
Image by watchsmart/CC BY 2.0

Continuing Lifestyle Intervention, Part 1

We have been looking at the idea that the need for lifestyle intervention of some kind might be necessary throughout life. There is nothing wrong with that. Take religion, for instance. No devout believer of any variety would say, “My relationship with God is just a temporary thing, to help me get through a difficult time. But the day will come when I won’t need that connection anymore.”

If something in a person’s life helps to overcome challenges, treat fellow beings with lovingkindness, and become one’s best possible self, why on earth would anyone want to step in and say, “Yeah, but one of these days you’ll have to learn how to make it on your own”?

Take the simplest and most elementary kind of lifestyle practice, and one that is widely recommended: journaling. To take a daily inventory, in the morning or at night or both, and jot down some important realizations and intentions, is a very useful practice. To reference formal religion again, one purpose of morning prayer is to ask the higher power, “Please help me not mess up too badly today.” One purpose of evening prayer is to say, “Thank you for understanding today’s mistakes, and I’ll do better tomorrow.”

The secular version is to stay committed to some kind of structured accountability system. (And yes, a person could do both if that is what works.) Why would any supposed authority feel entitled to announce, “That won’t be needed anymore”? For some third party to step in and decree that there is no further need for either a supreme being or a lifestyle that helps a lot and does no harm — well, it would just be silly. And of course, no responsible medical practitioner would tell a patient with diabetes, “That insulin stuff is fine for now, but eventually you will have to learn to cope without it.”

Back to the question at hand

Practically every inhabitant of the planet has heard about the success of, and demand for, the drugs that have been receiving such rampant publicity — and that will continue to do so in the foreseeable future. It’s a whole new genre of weight loss medications, so what should we expect in terms of their ability to do the job alone? Many enthusiasts are dismayed to find that maybe a prescription cannot carry the whole load, for myriad reasons. For instance, no matter how efficient the medications may be, people are still people.

Take the example of bariatric surgery. Effective as it can be for a great number of dangerously obese people, there are always the few who manage to mess it up. It’s as if they are determined to prove how successfully the stomach can be either stretched or ruptured, whichever comes first. This would be a good time to look into how continuing lifestyle intervention pairs up with surgical intervention.

(To be continued…)

Your responses and feedback are welcome!

Image by Jernej Furman/CC BY 2.0

New Drugs — Does Lifestyle Intervention Still Count? Part 8

Just by the very nature of contemporary life, mental health treatment is not often conducted in person. Apps and devices that monitor physical vital signs have been around for a long time, and now increasingly all kinds of care are administered online or through smartphones. An incredible number of quite respectable podcasts are sponsored by a company that connects potential clients with therapists and facilitates change if the first match is not satisfactory.

Meanwhile, more troubled people come to understand that the day may never come when they will be “fixed.” They may continue to need an impartial listening ear, at least occasionally. Sometimes a person can sail along for years, but then an accident or physical illness may happen, or the death of someone close. When a new relationship begins or an old one ends, a person often needs extra support.

Some people benefit from help for the rest of their lives, and there is nothing wrong with that. We don’t blame people with diabetes for continuing to need insulin, and we don’t blame people who need long-term mental health support. This is especially true of those who aspire to more than just not being sick. For people who want to continue to get better, and then even better than that, there is no limit.

It’s a lifestyle

In an earlier post, we talked about how important it is for a treatment program to embrace every part of life — family, peers, work relationships, and the larger community — as well as a person’s spiritual foundation and ethical standards. Now to any of these factors, add the continuing and ongoing need to manage a substance abuse tendency, whatever that substance may be.

A recent Childhood Obesity News post quoted a man who says, “I spend five hours a day minimum working on staying sober for that day.” Daily attendance at a meeting, for instance, is a definitive lifestyle intervention, and for some people, that’s what it takes.

The quirks of addicts

Author and late-night TV personality Alexander King, who was popular more than half a century ago, had been incarcerated in the federal addiction recovery center in Lexington, Kentucky. While in withdrawal himself, King watched a fellow inmate kneel by his bed as if in prayer, and prepare a hypodermic needle, tie off his arm, and inject a shot of heroin into the vein — all just expertly mimed, of course. The haunting glimpse into another’s sickness made a lasting impression, and King included it later in Mine Enemy Grows Older, one of several best-selling autobiographical volumes.

More recently, for Medium, Eric Allen Been interviewed Judith Grisel about her book, Never Enough, which is pretty much the motto of all addicts everywhere since the beginning of time. Unlike many addicts, however, Grisel has been “clean and sober” for more than three decades, during which time she became a professor of psychology and neuroscience.

When her interviewer suggested that many heroin addicts are addicted not just to the drug, but to the process, “the ritual of being dopesick, scoring, shooting up, etc,” Grisel replied,

Craving is to a point kind of fun. I think the paraphernalia, the bag in your pocket, all those things elicit a sort of anticipatory wide-awake brain state.

Confirming this, comedian Joey Diaz talked on a podcast (reference unavailable) about how the happiest he ever was, was in the car on his way to score (buy cocaine) and then while driving home with it.

Your responses and feedback are welcome!

Source: “A Neuroscientist Explores Addiction, the Brain, and Her Past,” Medium.com, 03/05/10
Image by Robert Miller/CC BY 2.0 DEED

Do Some Doctors Sabotage Obese Patients? Continued

These are additional points made by Yoni Freedhoff, M.D., who is very empathetic toward patients traumatized by many of his professional colleagues. For one thing, he believes that pharmaceuticals were invented for a reason, so people could take them if needed, and no unnecessary barriers ought to be set up.

In “10 Ways Docs Sabotage Their Patients’ Weight Loss Journeys” he wrote,

If a patient meets clinical criteria for a medication’s approved indication and a doctor won’t prescribe it because of their personal beliefs, in my opinion that’s grounds for a regulatory complaint.

Dr. Freedhoff is perturbed by what he characterizes as “fearmongering” about the new GLP-1 and related anti-obesity meds. To his way of thinking, the patients who take them just need to be watched over (exactly like when somebody is prescribed a medication against hypertension). He says these meds are “very well tolerated […] when dose titration is slow, monitored, and adjusted appropriately.”

He is also okay with the idea that a patient will probably need to stay with these remedies forever. To put it plainly,

Chronic conditions require ongoing long-term treatment.

Inside dope

One of Dr. Freedhoff’s warnings concerns a matter that more professionals ought to take into consideration. Certain drugs — from atypical antipsychotics to antidepressants to certain antiseizure medications to some blood pressure medications — inevitably cause their users to gain weight.

And the problem here is, apparently, there are doctors who…

[…] will still regularly prescribe them to patients with obesity without first trying patients on available alternatives that don’t lead to weight gain, or without at least monitoring and then considering the prescription of an antiobesity medication to try to mitigate iatrogenic gain.

Ideally, a physician facing an obese patient will be sufficiently informed to refrain from dictating “ridiculous and unrealistic weight loss goals.” Dr. Freedhoff writes,

The goal should be whatever weight a person reaches living the healthiest life that they can honestly enjoy.

This item should go without saying: A patient should be informed of all possible treatment options, and their implications, meaning that doctors should not function as gatekeepers standing between the patient and possible therapeutic interventions. Dr. Freedhoff writes,

Our job as physicians is to fully inform our patients about the risks and benefits of all treatment options and then to support our patients’ decisions as to what option they want to pursue (including none, by the way).

To finish up, Dr. Freedhoff speaks of “the dearth of effective treatments which in turn probably contributed to the overall lack of education for physicians in obesity management despite its extremely high prevalence.” But now that there are effective treatments, it is a good time to get on board with the idea that obesity is just another chronic noncommunicable disease, and people should have a choice in what to do about it.

As for another of Dr. Freedhoff’s desiderata, “patient-centered care free from judgment and blame” — who could be against that?

Your responses and feedback are welcome!

Source: “10 Ways Docs Sabotage Their Patients’ Weight Loss Journeys,” medscape.com, 07/11/23
Image by Karen H./CC BY 2.0 DEED