Reeger Cortell

As a family nurse practitioner in bariatric surgery care and podcaster of the Weight Loss Surgery Podcast I think you bring up some very important points. However, where I take exception is with the delicate matter of blame, aka “noncompliance” woven throughout your piece. You begin by asking, “…why is it so many fall short of losing the optimal amount of weight for their health and will actually regain within 3 years much if not all of the weight they lost.” When I read this sentences I wondered a few things: Who are you referring to when you state, “so many?" Who has made the decision of what is the “optimal amount of weight [lost] for their health?" And finally, who gets to decide on their “health” to begin with? I agree with you that weight regain happens, but your implication that any regain is problematic is simply not true and perpetuates misconception of success vs failure. There are numerous studies discussing weight regain, too many to highlight here. But for a summary on this issue, one needs only go to the ASMBS website to read the following regarding weight regain: ""As many as 50 percent of patients may regain a small amount of weight (approximately 5 percent) two years or more following their surgery. However, longitudinal studies find that most bariatric surgery patients maintain successful weight-loss long-term. ‘Successful’ weight-loss is arbitrarily defined as weight-loss equal to or greater than 50 percent of excess body weight. Often, successful results are determined by the patient, by their perceived improvement in quality of life. In such cases, the total retained weight-loss may be more, or less, than this arbitrary definition. Such massive and sustained weight reduction with surgery is in sharp contrast to the experience most patients have previously had with non-surgical therapies."” https://asmbs.org/patients/bariatric-surgery-misconceptions You go on to outline three main reasons people regain weight: 1) Eating around their surgery by consuming “trigger foods” that give pleasure but are not nutritious, 2) Lack of practicing appropriate weight-loss-sustaining behaviors in the first 12-18 months which then become habits and carry them forward after the “honeymoon” of rapid weight loss is over, 3) Lack of support. Regarding the first of your arguments, the truth is the biology of our eating behaviors is very complicated. Far way more complicated, in fact, than our conscious brain can control through willpower or skillpower. And even (often?) more complicated than our scientific ability to manipulate our anatomy through the surgical intervention of bariatric surgery. It could be that a person is driven to eat around their surgery because the hormones that drive hunger are stronger than the hormones that drive satiety and surgery did not fix that for them. I am not saying that it is ok to have trigger foods around simply because it’s ones biological imperative to eat pleasurable foods, nutrition and weight loss be damned, but I am saying that biology sometimes trumps all and blaming someone for their unconscious biological imperative does not help them, it only adds to their mounting shame. Unfortunately, we are in our infancy of understanding the hormonal regulations of hunger and satiety and how manipulation of the GI tract changes these hormones. If you are interested in learning more, then I refer you to the work of Dr Randy Seeley, PhD and and Dr Lee Kaplan. Regarding your second and third arguments, I honestly feel that number three, lack of support, drives many of the behaviors that result in peoples struggles after surgery including not practicing healthy behaviors as early as possible. When it comes to bariatric surgery, it takes a village. I firmly believe, that the center of that village needs to be the bariatric surgery practice; the village square if you will, where all gather to learn and connect. When I hear of someone who is struggling I wonder a number of things: Were they educated enough and appropriately by their surgical practice? Just because you can perform surgery on someone, does not mean they are ready. Did they have access to a support group before and after surgery? If they are struggling with anything, including weight regain, after bariatric surgery, did their practice create a culture of inclusiveness and non-bias that is welcoming to all their patients, not just the practices definition of successful patients? Were their family and friends on board and if not, did their bariatric surgery practice create an environment conducive to connection with a new community of support? When a patient struggles after bariatric surgery, in my opinion, it reflects more on the practice than on the person. I realize that is a controversial thing to say that I may catch some heat for, but I stand by my opinion. Sara, I know without a doubt you and I are on the same page when it comes to believing in and supporting bariatric surgery patients long term success, however that success is defined. What I worry about, however, is when we start distilling weight regain after bariatric surgery down to a few patient-centric elements without giving credit to how complicated these issues are; how we are early in our understanding of the science (and we have not even talked about weight regain due to surgical complications because let’s not forget, the surgeries can have their own shortcomings separate from human behaviors); and how much bariatric surgery practices bear the responsibility of patient selection, preparation, and support; what we inadvertently end up doing is what we have done a millions times before and to our patient's detriment- we take the easy way out by shifting the burden of blame back onto the person, the person who has a complicated and progressive disease known as obesity. Sincerely, Reeger Cortell, FNP