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Do you see yourself as thin yet?



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Posted (edited)

2 hours ago, summerset said:

While I agree with this in general I also hold the opinion that there don't seem to be really that much evidence-based treatment guidelines around. Most of the stuff seem to be more eminence-based instead.

If there would be really evidence-based guidelines out there about what treatment protocol provides the best outcome possible then why do e. g. days of planned hospital stay, peri-operative eating guidelines and longterm diet protocols vary that much, not only from country to country but also from treatment center to treatment center? The only reason I can think of is that there is no evidence-based best protocol out there yet (and honestly, I doubt there will ever be).

There are *many* evidence-based clinical bariatric surgical and nutrition guidelines available to health care professionals. They are updated regularly based on the quantity and quality of the best available scientific studies. I’m attaching just one example here: it’s the most recent (2019) guideline provided by the American Association of Clinical Endocrinologists, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologist (and endorsed by the American Society for Nutrition, American Society for Parenteral and Enteral Nutrition, International Federation for the Surgery of Obesity and Metabolic Disorders, International Society for the Perioperative Care of the Obese Patient, and Obesity Action Coalition).

In my experience at the intersection of biology and medicine, I've observed that eminence-based medicine tends to be the rule, not the exception. Medicine functions in the gulf between ideas/beliefs and science. Science is based on doubt. Medicine is a road built upon a foundation of good ideas and beliefs put into practice, but it is also a road literally paved with the cadavers of every good idea and belief that didn’t pan out. Even when they do pan out, they still need to be meticulously studied and regularly verified and updated to determine precisely how, why, and which patients benefit the most and the least. The results are not straightforward because bodies are not straightforward: there are incalculable external/environmental variables that are constantly in flux colliding with incalculable internal/genetic variables that are constantly in flux. I don't know any good scientist or clinician that wouldn't trade everything they know for everything they didn't know in a heartbeat.

All researchers and practitioners, including bariatric clinicians, should ideally continually examine and assess their own results, making changes where and when necessary, to ensure they are delivering the best outcomes for their patients. Even though this inevitably leads to variations in form -- but not function -- it's just good medical practice.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures 2019 Update.pdf

Edited by PollyEster

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7 minutes ago, PollyEster said:


There are *many* evidence-based clinical bariatric surgical and nutrition guidelines available to health care professionals.

If there are many, there isn't obviously a best one because if there would be a best one, there wouldn't be many.

Guidelines differ, evidence-based or not, depending on what studies are included or not. If one wants to cherrypick studies in one direction it's always possible. There are also too many unpublished studies rotting away in desks because the results were not the desired ones (that might be more of a problem when it comes to drug therapy though). Crappy study designs. Sky-high drop-out rates and having to rely on self-reporting (that seems to be a big problem in the weight loss field). Thats why I lost quite a bit of trust and belief in EBM over the years. There's also always the question of "Cui bono?" hovering and the principle of "publish or vanish".

Bonus icing on the cake: whenever I read a study about nutrition, behavior, psychological or environmental factors that might have impact on losing and maintaining weight (or not for that matter) one term at the end of the discussion almost always seems to catch my eyes: "needs further evaluation". What's a clinician supposed to do with that? Wait and see or change treatment protocol?

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In my experience at the intersection of biology and medicine, I've observed that eminence-based medicine tends to be the rule, not the exception.

What I said.

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The results are not straightforward because bodies are not straightforward: there are incalculable external/environmental variables that are constantly in flux colliding with incalculable internal/genetic variables that are constantly in flux.

And that's where this whole guideline and rules thing seems to go out the window. In the end it boils down to trial and error for the patient and I wish treatment teams would admit to this and therefore being more flexible in their approaches instead of practicing a one-fits-them-all approach.

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I don;t know any good scientist or clinician that wouldn't trade everything they know for everything they didn't know in a heartbeat.

The clinicians I know usually want to have trustworthy diagnostic tools and effective treatments they can offer their patients. Nothing more frustrating than not coming to a proper diagnosis and being able to offer effective treatment.

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All researchers and practitioners, including bariatric clinicians, should ideally continually examine and assess their own results, making changes where and when necessary, to ensure they are delivering the best outcomes for their patients.

Most likely they do and that's why there is so much eminence-based treatment out there, hence the difference between recommended diet protocols after WLS.

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On 6/9/2020 at 5:16 PM, ms.sss said:

...its funny because when I was bigger, I thought I was smaller than I really was. Now that I’m smaller, I think I am bigger than I really am....

EXACTLY!!!!!!

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I no longer view myself as fat however I feel that I am average and I feel like I blend in. I do not think of myself as thin. When in fact I am probably one of if not the thinnest person in a given room at any time. Which is crazy as I sit here in a small top and size 2 shorts. I mean who wears a size 2 past the age of 11? Umm, I do now. I still see the stretch marks, the big calves, flab on my lower back etc. But isn't that what typical, normal BMI sized women who have never been overweight say too? I remember hearing women who were my current size complain about their "thick" stomach and at the time thinking they were crazy but here I am still seeing my own faults. I don't obsess over it just aware of the faults and choose clothes to hid my problem areas. At the doctor's office a few months ago the nurse asked my weight and responded with "wow, you are tiny" and I still felt like she was talking about someone else in the room.

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9 hours ago, summerset said:

If there are many, there isn't obviously a best one... Guidelines differ... What's a clinician supposed to do with that? ... What I said. Etc..

I appreciate and understand your concerns and frustration; thanks for sharing them.

Across every area of medicine, there are many expert organizations and associations that develop clinical practice guidelines at the local, provincial, national and international level, and make them available to health care providers. Their primary purpose is to improve quality of care, increase quality of life, address clinical care gaps that exist (i.e. discrepancies between evidence-based knowledge and day-to-day clinical practice), reduce inappropriate variation in practice, promote efficient use of healthcare resources, identify gaps in knowledge, prioritize research activities, inform public policy, and support quality control activities including practice audits. They represent a summary of material and don't provide in-depth background clinical knowledge, which is covered comprehensively in medical textbooks and review articles.

Guidelines are updated regularly and are not meant to provide a "single best" or "recipe driven" approach to patient care, where the clinician has no discretion. Every clinician understands this. Guidelines are meant to aid in decision making by providing recommendations that are informed by the best available evidence, but therapeutic decisions are made at the level of the relationship between the health care provider and the patient. That relationship, along with the importance of clinical judgement, can never be replaced by guideline recommendations.

Evidence-based guidelines attempt to weigh the benefit and harm of various treatments, but patient preferences are not always included in clinical research and as a result, patient values and preferences must be incorporated into clinical decision making. For some clinical decisions, strong evidence is available to inform these decisions, and these are reflected in the recommendations within these guidelines. However, there are many clinical situations where strong evidence is not currently available, or may never become available due to feasibility issues. In those situations, the consensus of expert opinions, informed by whatever evidence is available, is provided to help guide clinical decisions that need to be made at the level of the individual.

Final thoughts: I offer my sincere apologies to you, JRT Mom, for inadvertently hijacking this important topic. Self-perception and body image after WLS is such a critical area to explore and discuss. I wish I could move this to a separate thread. Again, I am sorry.

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Posted (edited)

8 hours ago, 2Bsmaller18 said:

I no longer view myself as fat however... I am probably one of the thinnest in a room at any time... who wears a size 2 past the age of 11? Umm, I do now.... I still see the stretch marks, the big calves, etc.... But isn't that what typical, normal BMI sized women say too?

All of this ☝☝☝☝. It is SO helpful to hear about all of the experiences shared here, and be able to nod my head at every one of them. Thank you.

I went to a bricks and mortar clothing shop this past weekend and discovered that size 4 pants are too big for me in the waist and hips (yet tight in the thighs). I'm finally clueing in that I'm actually going to end up in a size 2 or 0, which blows my mind on every level and is clearly going to take a loooooong time to sink in.

Before I got fat (went from average weight to MO during a 2 year period), I wore a size 6 and thought I was practically obese 😂😂😭😭 Thinking back on that time, I remember seeing a photo of myself and asking, in all sincerity, "Who's that?" because I didn't perceive myself that way. It the same again now, but in reverse: I do not recognize my body as my own.

Edited by PollyEster

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I lost 130 pounds 13 years ago and at times still feel fat. In fact, as I sit here at my desk writing this, it feels like my stomach is hanging over my pants like it did when I was 290 pounds. It's similar to the phantom limb, the sensation that an amputated or missing limb is still attached. No worries though, when I get this feeling I simply get on the scale and it rarely changes....160 pounds. That makes me feel better.

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Three people in the last week have commented about how tiny I am. One, in a nursery, said I was so tiny I’d fit in the plant pot I was buying. (That was a very odd & upsetting comment.) These were the first times anyone has ever used the word ‘tiny‘ to describe me. It’s so weird. I see just average in the mirror.

I also bought a pair of skinny jeans - Aust size 6/US2 - and I swear they are so small they’d fit my 10yr old niece so I hear you @2Bsmaller18.

Right before my surgery, I was approached to be part of a Bariatric study here in Australia. I agreed because I felt their findings could help others in the future but I have not heard a word from them in almost 14 months except for a letter thanking me for being willing to participate. I wonder if I’ll get a letter at some stage thanking me for my contributions.

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Posted (edited)

5 hours ago, PollyEster said:

Guidelines are updated regularly and are not meant to provide a "single best" or "recipe driven" approach to patient care, where the clinician has no discretion. Every clinician understands this. Guidelines are meant to aid in decision making by providing recommendations that are informed by the best available evidence, but therapeutic decisions are made at the level of the relationship between the health care provider and the patient. That relationship, along with the importance of clinical judgement, can never be replaced by guideline recommendations.

This is true and I wish treatment teams would be more flexible when it comes to the care of their patients because a guideline is different from a fixed rule you have to follow. Albeit they're often treated as such, especially by patients and inexperienced clinicians ("but the guideline says..." - I'm not able to count how many times I've heard this).

However, in the end an evidence-based guideline is only as good and reliable as the people who're involved creating them, the processes that are used to get to an agreement and as good and reliable as the studies they are deciding they're going to use (again: cui bono? much too often for my taste). Making myself this clear after being very into EBM for quite a long time was quite sobering. I tend to take guidelines, systematic reviews etc. with a grain of salt long since.

Given the fact that many clinics have their own in-house guidelines for something. Usually these in-house guidelines are in reality SOPs but for many this doesn't make a difference and it's kind of annoying a lot of the time.

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I offer my sincere apologies to you, JRT Mom, for inadvertently hijacking this important topic.

Yes, hijacking threads is annoying. My apologies as well.

Edited by summerset

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Would it be vain of me to say that I think my body is nice now? With 77kgs on my few cm there is obviously some fat, but it can be dressed away - and I do have a fab figure actually.

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On 06/09/2020 at 16:16, ms.sss said:



...its funny because when I was bigger, I thought I was smaller than I really was. Now that I’m smaller, I think I am bigger than I really am....


Yes!! I agree totally. I knew I was big but didn’t realize it until I lost weight. Now that I’ve lost weight I see myself as still needing to lose weight even though I’m st goal and maintaining. I fear being fat again.

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Sometime I do. I dont bother weighing myself. I dont look in the mirror and judge my skin or my progress. I usually go up to my siblings and give them a huge hug that comes with a. "I can wrap my arms around you know". That helps when I'm feeling like have made no progress. 😊

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I'm still overweight, but I no longer feel fat, if that makes sense. LOL! I'm not actually going for skinny, but I want to look good in clothes and be healthy. I've gone from a size 20, and now I'm in 14, a 12 in some things. I'll be happy with 1 more reduction in size, I think.

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On 7/5/2020 at 12:18 PM, MsMocie said:

Would it be vain of me to say that I think my body is nice now? With 77kgs on my few cm there is obviously some fat, but it can be dressed away - and I do have a fab figure actually.

Even if you were, there ain’t nothing wrong with being vain...after how many years of hiding one’s body away, its about time to feel fab. Show ‘em what u got!!

Congrats!

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I was athletic and strong as a teen/young adult and never had issues with weight gain until my 30’s, so I have been struggling with seeing a fat person in the mirror and feeling cheated when I can’t climb stairs or tie my shoes. (I’m still pre-op). I can’t wait til my outside matches my inside!

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