ASMBS: Open Letter to Insurance Companies, Regarding Mandatory Pre-bariatric Surgery Diet Regimens

[swimbikerun]

I agree with you on the study. However, the number of people who seem to ask so many basic questions online indicate they were not well prepared by their surgeons/offices and/or the focus is on the $$$/surgery vs. making sure they can repeat back and know what they do. This is a smaller list than the FB groups from what I can tell. You should see the amount of misinformation there is there. People ending up gaining it back because the commitment after the honeymoon period isn't there. The vast majority, isn't there.

The issue is always about money, not our health. Go check out the number of people on FB groups who fall off the wagon, won't come back for help because they did, and asking about when they can drink alcohol, eat chips/pizza/cookies, etc. The illusion wears off. Is it a disease? An addiction? Yes. Either way, there are few who are able to stay at the weight they were in the first year or so.

At that point, you do have to eat healthy, exercise, and there is willpower involved.

 

[southernlady]

At that point, you do have to eat healthy, exercise, and there is willpower involved.

But healthy for someone normal or DS healthy. I can eat DS healthy all day long since I LOVE meat and fat.

As far as exercise, just moving more is all we need to really do. Walk when you can. Aim for 10,000 steps a day buut exercise...that is for the birds. I'll stick to being more active as in doing home renovations, raking leaves, decluttering and packing. I don't need an exercise program to stay active.

 

[harrietvane]

There's a lot of research coming out that willpower basically doesn't exist. People will 'willpower' apparently just aren't tempted by the thing they're supposedly using their willpower to overcome. Can't find the article where I originally read it, but these are around the same point.

http://www.slate.com/articles/healt...n_psychology_may_have_just_been_debunked.html
https://hbr.org/2016/11/have-we-been-thinking-about-willpower-the-wrong-way-for-30-years

 

[Larra]

I agree that a lot of what goes on is about money, and also that there is plenty of misinformation to go around. But one of the great things about the DS is that you don't rely on the myth of willpower and/or discipline. You can eat foods you enjoy, in reasonable portions. You can eat normally at restaurants and social occasions. That's not about willpower or discipline, it's about finally having some kind of normal metabolism and level of hunger.
Should patients go into surgery well educated, with understanding of all their options and what they involve? Of course! Are a lot of surgeons failing in this regard? Definitely. But think about it, with all sorts of medical problems most people go to the doctor with the expectation that he/she will provide honest and full information about what's wrong and what needs to be done about it, risks of treatment, potential side effects, recovery, etc etc. Why should patients go to a bariatric surgeon with lower expectations? Is it reasonable to expect every patient to search out all this info for themselves? You and I know that this is what it has come to, but the average patient doesn't.
The Marceau study that came out a few years back followed patients for up to 15 years. In his group, every patient who qualifies medically and passes a psych eval gets a DS. And they do great post-op, with very few nutritional problems and excellent weight loss. So his group must be doing something right in terms of education, but it shows that nearly everyone can do well with a DS. And I lived in his part of the world for 4 years and can tell you that the people there are no different from the USA - no smarter, no better educated as a group. Let's put the blame where the problem is, with failure of surgeons and their staffs to provide accurate and adequate education, not on some patients not being up to the mark.

 

[DianaCox]

"The thing is, that also helps that people actually start making some changes before, that they need to stay the course. Otherwise, we end up with a lot of people who don't make the changes required to really make it more successful."

I not-so-respectfully disagree. Essentially ALL of us have been on one sort of diet or another our entire fricken' lives, and it was not a matter of discipline or unwillingness to make changes, but the FUTILITY of these measure to make a long term difference in our METABOLIC DISEASE that caused them to fail.

I never had a real sense of satiety before my DS. And when I was hungry/wanting to eat, I tended to want to eat savory/carby/greasy/salty things - or whatever was handy (not a real sweet tooth). I avoided fat when possible, but not that successfully. What the DS gave me was a sense of satiety (I get FULL! And after 13+ years, I STILL get full!), and when I'm hungry, I'm hungry for PROTEIN. My tastes and desires mostly track what I NEED to eat. That makes sticking to the DS "regimen" so much easier than "being on a diet" or "being disciplined" about my eating.

Now, I must say I was not a binge-er. I never ate a pie (though I often went back for a second piece), I never ate a pint much less a half gallon of ice cream in a sitting. (I did once eat most of a box of vanilla wafers with a tall glass of milk, but there was weed involved, I was in my early 20s and I still remember that as the closest thing to a binge I ever had.) Yet I still ended up almost 300 lbs. But I didn't have an EATING disorder - I had a metabolic disorder that could NOT be controlled, only slowed, by dieting.

So, take a look at what Larra said. And take a look at what the ASMBS said: http://asmbs.org/wp/uploads/2011/03/2016-Preoperative-Weight-Loss.pdf

Recommendations

1. There are no data from any randomized controlled trial, large prospective study, or meta-analysis to support the practice of insurance mandated preoperative weight loss. The discriminatory, arbitrary, and scientifically unfounded practice of insurance-mandated preoperative weight loss contributes to patient attrition, causes unnecessary delay of lifesaving treatment, leads to the progression of life-threatening co-morbid conditions, is unethical, and should be abandoned.

2. There is no Level I data in the surgical literature or consensus in the medical literature (based on over 40 published RCTs) that has clearly identified any 1 dietary regimen, duration, or type of weight loss program that is optimal for patients with clinically severe obesity.

3. Patients seeking surgical treatment for clinically severe obesity should be evaluated based on their initial BMI and co-morbid conditions. The provider is best able to determine what constitutes failed weight loss efforts for their patient.​

 

[Susan in Tennessee]

Regarding pre-op diets to prove you can lose and stick to eating rules... human nature is such that if we are told not to do something we naturally want to do that very thing! I read of a study once talking of companies offering good sized cash prizes for employees losing certain amount of weight and results showed it had opposite affect. I always used to do better dieting when no one knew, then once it was noticed or I slipped and let it be known it was always bad and I'd slip up and start gaining.

 

[swimbikerun]

If there is no thing as willpower, how do you explain me losing 35 pounds the year I had to go through diet/exercise before surgery? My sister who didn't have surgery but lost over 30 pounds thru diet and exercise? How any one with a bypass or sleeve loses weight after the first honey moon year? Jared of Subway fame? Or all those people through the years who, before bariatric surgery, did exercise/eat healthy and lost weight?

You all are motivated. You got the DS because you had the willpower to be educated, to stay the course. Look on the FB groups and you'll see an entirely different mentality. I love this place because people are educated, they work to stay that way, to stay grounded in science. It is not as prevalent out there on the FB groups. People will say I have fallen off the wagon, I eat things I shouldn't, they talk about 'food police' when the issue is they want something that is not recommended (either by their surgeon, other surgeons, or just in general recommendations) etc.

I saw a morbidly obese person, always drinking the calorie laden drinks. Found out she had RNY. Its a choice - aka willpower. There is some willpower involved in that.

The ASMBS has a financial interest in getting people in for bariatric surgery. My old place had quotas they had to fill. They aren't the only ones either.

If there is no prescribed time before surgery, how would you expect people to just be given surgery after some blood work? No psych eval? So they get the piddly education most give you, or tons of it that no one reads, and then gets surgery. What happens then? How many regain? The ASMBS isn't probably going to want to see regain mentioned and wouldn't want it studied because it could be used against them. If people are only going to lose 50% of the weight, the insurances might opt to say that you have to be in a certain weight range for it to be useful.

I'd suggest you ask surgeons because a lot of them say we gave you the tool, after the honeymoon period, you need to work the tool. It is a well known saying on the groups. HBR isn't the best place I've seen for scientific evidence. One study talked about 20 people, another is a metadata type of analysis. Take a look at http://www.healthnewsreview.org/. They go through and review news for science based, data/fact information. You might be surprised who actually had the better data.

 

[galaxygrrl]

If there is no thing as willpower, how do you explain me losing 35 pounds the year I had to go through diet/exercise before surgery? My sister who didn't have surgery but lost over 30 pounds thru diet and exercise? How any one with a bypass or sleeve loses weight after the first honey moon year? Jared of Subway fame? Or all those people through the years who, before bariatric surgery, did exercise/eat healthy and lost weight?

You all are motivated. You got the DS because you had the willpower to be educated, to stay the course. Look on the FB groups and you'll see an entirely different mentality. I love this place because people are educated, they work to stay that way, to stay grounded in science. It is not as prevalent out there on the FB groups. People will say I have fallen off the wagon, I eat things I shouldn't, they talk about 'food police' when the issue is they want something that is not recommended (either by their surgeon, other surgeons, or just in general recommendations) etc.

I saw a morbidly obese person, always drinking the calorie laden drinks. Found out she had RNY. Its a choice - aka willpower. There is some willpower involved in that.

The ASMBS has a financial interest in getting people in for bariatric surgery. My old place had quotas they had to fill. They aren't the only ones either.

If there is no prescribed time before surgery, how would you expect people to just be given surgery after some blood work? No psych eval? So they get the piddly education most give you, or tons of it that no one reads, and then gets surgery. What happens then? How many regain? The ASMBS isn't probably going to want to see regain mentioned and wouldn't want it studied because it could be used against them. If people are only going to lose 50% of the weight, the insurances might opt to say that you have to be in a certain weight range for it to be useful.

I'd suggest you ask surgeons because a lot of them say we gave you the tool, after the honeymoon period, you need to work the tool. It is a well known saying on the groups. HBR isn't the best place I've seen for scientific evidence. One study talked about 20 people, another is a metadata type of analysis. Take a look at http://www.healthnewsreview.org/. They go through and review news for science based, data/fact information. You might be surprised who actually had the better data.

I think you really need to look at data and you are making statements based on what you think. The will power argument is not based on data.

Here is the data on the effectiveness of WLS by surgery type. - http://www.paclap.com/downloads/comparing-options-for-WLS.pdf 85% of the people with the DS don't gain their weight back. And the other surgeries fail the person. The person does not fail the surgery.

No one thinks that WLS should be taken lightly, but to make someone wait for surgery might now make a difference, I don't know.

As for misinformation and uneducated people out there, it's the patient's responsibility to figure it out. We all have to manage our health, just like we do with every other part of our lives.

 

[swimbikerun]

Hmm. Take what you said to a doctor. Guarentee you they will see differently. What you indicate is DS is the best surgery. It is for some, others not so much. The fact is, pretty much everyone on this board is taking personal responsibility/has the will power to follow through with the requirements of this surgery.

If DS was the best surgery overall, they wouldn't have stopped doing it in the vast majority of bariatric surgeries.

While at the docs, try telling them that you will not take personal responsibility for the surgery choices. Good luck on finding those docs. If you blame the surgery, you indirectly can blame them.

PS There are several issues missed in the response to me. Below, you can still see that personal choices make a difference. Those personal choices are also called willpower. If things go wrong, you can't change yourself, but you can change you and your responses to a situation, whether bariatric surgery or something else. Willpower. Personal responsibility. I see everyone on this board doing a lot of personal responsibility/willpower that others don't have. I applaud that. I don't want to take anything away from what they've worked hard to earn.

"there are clearly circumstances where patient behavior and those variables contributing to patient behavior are believed to play a role in determining the reason for less than expected weight loss".

http://citation.allacademic.com/met...dex.html?phpsessid=0e6n1tjkelmtgsrrhiskfrv0b3

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879178/
This article examines the underlying assumptions and implications for
policy and the interventions of the two predominant models used to
explain the causes of obesity and also suggests a synthesis that
avoids “blaming the victim” while acknowledging the role of
individuals' health behaviors in weight maintenance.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746450/
Participants expected extreme and sometimes unrealistic levels of
sustained weight loss, as well as improvements to physical and mental
health. The overall desire and expectation of bariatric surgery was of
‘normality’. Participants had received previous support from
clinicians and in weight management services. However, they reported
that their expectations of surgery had not been reviewed by services,
and expectations appeared to be unrealistic.

http://thebodyimagecenter.com/wp-co...tories-of-failure-after-bariatric-surgery.pdf

http://thebodyimagecenter.com/wp-co...tories-of-failure-after-bariatric-surgery.pdf

http://bariatrictimes.com/the-impor...es-and-considerations-for-the-bariatric-team/

There are occasions where these two definitions of success collide.
Specifically, there are instances where bariatric patients lose a
significant amount of weight following surgery but continue to
struggle with behavioral and emotional issues that lead them to
relapse and resume former habits, often resulting in weight regain. It
is becoming clear that bariatric surgery is not a cure-all and that
patients face a myriad of behavioral, emotional, and interpersonal
issues both before and after surgery and it is essential that these
issues be addressed to maximize patient outcomes.[15]

While it may be true that patient behavior is not the primary factor
in explaining poor weight loss following surgery, there are clearly
circumstances where patient behavior and those variables contributing
to patient behavior are believed to play a role in determining the
reason for less than expected weight loss. It is especially important
to note that psychologists, nutritionists, nurses, and other
integrated health professionals as well as surgeons commonly work with
patients who acknowledge that they are not being adherent or are
struggling to be adherent to post-surgical recommendations. Many such
patients will blame themselves for their inability to be adherent;
however, bariatric surgery itself does not teach patients new eating
behaviors. Therefore, most patients need to make a concerted effort to
learn how to make such changes to their eating and other behaviors and
not rely on surgery to force them to make these changes.

 

[DianaCox]

I think you are not understanding that in many cases, the DS changes what foods you crave. That is not an exercise in willpower - that is the fabulous effect of one's body being FIXED of the metabolic illness that caused us to crave inappropriate foods in inappropriate amounts. It is NOT an exercise of willpower for me to eat protein (especially with full fat sauces and butter) first, when it actually, physically feels like that is what I WANT to eat, rather than forcing myself to eat diet crap I don't want.

I still don't want to exercise, and I continue to make sporadic efforts to do so - but not consistently. Do I have food willpower now, but not exercise willpower? What about sticking to the vitamin regimen? Is that willpower? Or just considering that my vitamins are part of my life and what I do? Note that I only take my vitamins twice a day, even though there is some evidence that it would be better if I spread them out a bit - do I only have partial vitamin willpower?

I think you've been brainwashed by the willpower snobs - those who either have the natural constitutional ability to stay slim or desire low calorie foods in small amounts, and the doctors who refuse to acknowledge that they don't know SHIT about metabolism. Those of us who happily live with the DS don't believe it gave us willpower - it gave us a cured metabolism.

 

[galaxygrrl]

@DianaCox Let the trolls go feed somewhere else. We have will power here with or without the DS. Happy New Year.

 

[DianaCox]

"If DS was the best surgery overall, they wouldn't have stopped doing it in the vast majority of bariatric surgeries."

That is grotesquely simplistic.

(1) The DS requires a more informed patient, because the consequences of not paying attention to eating and supplementing ENOUGH are a fairly fast-moving disaster. But the failure to inform the patients adequately is SUBSTANTIALLY on the surgeons, the vast majority of whom are constitutionally unwilling and/or unable to form long-term relationships with their patients. They therefore delegate the pre-op education and long-term maintenance to incompetent NUTS who, like their bosses the surgeons, have no f'ing clue about the care and feeding of a DSer. And then bad results ensue.

(2) Follow the money. The insurance companies don't want to pay more for a better surgery - they want the cheapest solution, in THIS quarter. And the surgeons don't want to take six months out of their busy and already financially productive work and lives to proctor with a DS surgeon to become skilled at a surgery they don't want to have to support long-term, and is HARD to learn, and they can only do two a day at max. And have to fight with insurance companies to get approval in the first place.

There are more reasons, but those are two of the biggies.

 

[swimbikerun]

It is amazing how the personal attacks come rather than more scientific discussion. I am ok as long as I agree with you. When I present evidence different, I'm now a troll. When I don't agree that DS is the best surgery (it is for some, not for all) or that some of the aspects apply to some, I'm an issue.

Just because someone doesn't agree with you doesn't mean that they aren't listening. The fact remains there is scientific evidence to underpin my assertions. I've yet to see the DS listed as changing people's minds rather than being a tool listed as one of the benefits in the scientific literature.

Let me know when you all have scientific evidence on a scale that would be accepted by the medical community, that DS is the better surgery. It was removed from the list of surgeries for scientific reasons based on fact. I'm sorry that is troubling to you.

When the issues can be discussed with facts, not emotions, let me know. If you want someone to listen to you, then you need to return the favor and just as respectfully. I've seen that happen with a couple of people, but showing this to others doesn't indicate the original discussion will occur on the same level of exchange it was.

This is why a DS'er on one of the FB groups gets shouted down so badly.

 

[KathrynK]

I know I shouldn't extend this conversation. but since scientific proof from a prestigious peer-reviewed journal about the superiority of DS was requested: Http://www.mail.lapspecialists.com/Buchwald_Article_Meta_analysis.pdf
The mean percentage of excess weight loss was ... 47.5% for patients who underwent gastric banding; 61.6% for gastric bypass; and 70.1% for DS. Since I did it to treat diabetes, this was the important fact for me "diabetes resolution as a function of the operative procedure itself was: 98.9% for DS, 83.7% for gastric bypass..."

Some people are successful on all procedures. The difference is how many are NOT successful on the procedures. If I was going to have an operation, I wanted the best chances for permanent weight loss and for resolution of diabetes. Because DS isn't done as often as other procedures does not indicate anything about quality, there are many more Hondas purchased than Mercedes. There isn't much quarrel as to which is superior.

I take it by your name "swim bike run" you advocate for exercise. Exercise is great for everyone, but it isn't great for long term weight loss. Another peer reviewed journal article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925973/

The whole willpower thing is what upsets me. There is an "obesity-industrial complex" of people who make their living from the false hopes for morbidly obese people of programs, books, professional advice, pills and potions that don't work for long and the consumers keep coming back for others, and more. Blame the person for not trying hard enough, for being weak, for not having willpower, for eating the wrong things, for Everything. Somehow, I am to be blamed, not the flaw in their product or knowledge. I have spent at least $50,000 over the years and had dozens of health professionals, from physicians, nurses, nutritionists, personal trainers, counselors and psychologists over the years. They tried hard. I tried hard. From the perspective of 21st century knowledge about obesity, they didn't know what they were talking about. Since there are so many unknowns in obesity knowledge, today's experts don't know what they are talking about either. Surgeons offer the only thing that works, and we aren't fully sure why it works.

DS changed me physiologically. I am not sure in how many ways, but I know I am not feeding the "hunger monster" who lived with me since childhood. I am not failing at maintaining weight loss for the first time in my life. I have a healthy relationship with food. I can savor it, enjoy it, splurge occasionally, eat what I want and what I need. I haven't spent $1 in the past 12 years on a book, program, potion, or drug that was supposed to help me lose or maintain weight loss. And I have the same willpower I had as a fat person.

NO one knows what causes morbid obesity. There are a bunch of professionals who claim to know. I hope the world stops shaming people for a disease with so many unknown causes, for not having enough willpower to cure their broken physiology.

 

[Larra]

I shouldn't extend this either, but just have to comment on the statement that the DS has been "removed from the list of surgeries for scientific reasons based on fact".
If by list you mean those bariatric surgeries that are standard of care in the USA (and elsewhere), the DS is very much still a standard of care bariatric surgery and has NOT been removed from the list. In fact, the ASMBS has a position paper discussing revision bariatric surgery that, if anything, promotes the DS for revision from other, failed operations. This is not to say that it isn't appropriate for a primary bariatric surgery as well, it still is, just that the concept that a substantial (exact percentage unknown) number of people will need revisions, and that the whole concept of "one surgery for lifetime" is just as inappropriate for bariatric surgery as it would be for, say, breast cancer, or any other medical condition.

If VSG is working for you, that's great! I hate to see people needing revisions, and as someone who helps with insurance denials and appeals, I can tell you with absolute certainty that it's much harder to get coverage for a revision of any kind from any operation than to get any primary bariatric surgery. And that's not to mention the continued physical and emotional misery of a failed bariatric surgery. So I would say to anyone who has any surgery, make the most of it. But statistically, the results of the DS, long term, are well documented, and are the best for percentage excess weight loss, for maintenance of that weight loss, and for resolution of almost all comorbidities.