There are few phrases that strike a more dramatic tone than “bariatric surgery.” The general perception is that this is a last-ditch option for individuals who have been unable to lose weight through a variety of other mechanisms. With the rise in demand for this procedure has come an increase in the number of centers who offer it to the community. What is not as well known are the ancillary and life-changing services that some of the best bariatric centers of excellence can offer beyond the surgical procedure itself.

Let me tell you about a patient of mine, QD, and the profound impact one of these centers had not only on her health but the health of her entire family.

Growing up, QD was in a constant battle managing her weight, even before she had been diagnosed with a rheumatic disease. She came to our office at age 11 with a BMI of 31. QD had a family history of weight issues as nearly all of her mother’s side of the family was obese. QD’s mother would often accompany her daughter to our office with tears in her eyes, especially as QD began gaining additional weight due to her steroid treatment. “She’s too young to be short of breath going up stairs,” she would tell us.

“She shouldn’t have to think about the consequences of running down the street at her age.”

While we tried several times to wean QD off steroids, her disease was relentless. During her first 3 years of treatment, she was on oral prednisone for a total of 12 months. Each time she had a disease flare – which was often – she would need to be on prednisone for 3-4 months. Not surprisingly, her weight would spike with each episode. Her BMI eventually topped out at 35 when QD was 13 years old.

QD’s weight gain was not due a lack of effort. I tried my best to help QD set goals through motivational interviewing and offered her every bit of coaching, fitness tips, and general encouragement I could muster. Her mother was an eager “weight loss buddy,” while her younger brother (who was also significantly overweight) was just a noncommittal partner. They tried using pedometers to monitor their daily steps in an effort to be more active but struggled to reach our set goal of 3,000-5,000 steps per day. They had more success with increasing daily hydration, but really struggled with food portion control. Large meals and periodic snacks were a part of their life every time they felt discouraged or bored. After several months, QD’s brother successfully lost a few pounds, but our efforts did nothing for QD or her mother.

The obstacles challenging QD were substantial. It was like an American Ninja Warrior competition—every time she would get past one barrier, another challenge would pop up in front of her. Her father left a few months before QD was diagnosed with a rheumatic disease, and QD’s mom had difficulty remaining consistently employed during the subsequent years. As a result, QD’s family moved three times in the 2 years since QD began coming to our practice, necessitating a change in schools each time. QD struggled with depression and had a limited social life due in part to her ping-ponging from school to school. Our team of social workers did their best to offer assistance to her family, helping them maintain household utilities and providing other short-term relief, but that barely made a dent in their issues.

With all of these changes in her life, it’s no surprise that losing weight was so difficult for QD. It was likely that these stressors impacted her cortisol levels, which are known to hinder weight loss when elevated.1,2 QD’s mother consistently reaffirmed her commitment to being her daughter’s weight-loss partner during our regular follow-up visits, but it eventually became obvious that both mother and daughter needed more help than our practice could offer them.

By this time, QD had turned 17 and was about to enter her last year of high school. I decided to suggest to QD and her mother a referral to a bariatric center of excellence (BCE) that was covered by their insurance plan. For those of you unfamiliar with BCEs, they offer weight loss services beyond surgery itself such as dietary counseling, behavior modification, exercise, and support groups.

Following their referral, QD and her mother would regularly share stories with me of their BCE experiences. They each received independent counseling services that they desperately needed to change their relationship with food and replace stress/ boredom binge eating with eating for nutritional impact. The BCE had a place for them to walk and work out with the help of an exercise physiologist.

They made friends through support group meetings held at the BCE and gained a team of cheerleaders to help them along. Weight loss became fun, which not surprisingly also led to success.

The transformation with QD and the rest of her family in the 18 months since they first visited the BCE was astounding. None of them actually ended up getting bariatric surgery, and yet QD’s BMI fell from a previous high of 35 down to 27. Her mother and brother have also visibly lost weight, though we don’t have formal measures for them since they aren’t our patients. QD used to arrive hungry for her appointments with me after skipping breakfast— asking for juice, graham crackers, or lollipops—but those requests have gone away. She now comes to morning appointments excited to share her newfound wisdom with me about new foods she has tried that are both nutritious and delicious. QD’s rheumatic disease has fortunately remained stable throughout this recent period of weight loss, so her visits with me are typically upbeat. QD and her mother have learned how to shop wisely and prepare healthy meals thanks to the help of the BCE’s dietician-led cooking classes. QD is even now considering going back to school for a career in nutrition science.

From the day I met QD and her mother, the bond between the two of them was clear. QD’s mother was so determined to help her daughter become healthier, even if it meant being taken out of her comfort zone and having to ask lots of people for help she was unable to provide on her own. The rewards of her efforts are finally bearing fruit—QD is much happier and healthier, her grades are solid, and the whole family is in a much better place than they were just 18 months ago. It’s not likely something I could have accomplished with just my own guidance sometimes, we need to know when we’ve reached our professional limitations and bring in others with more specific skill sets.

AUTHOR PROFILE:
Cathy Patty-Resk, MSN, RN-BC, CPNP-PC is a certified pediatric nurse practitioner in the Division of Rheumatology at Children’s Hospital of Michigan in Detroit, MI, where she provides medical services to inpatient and outpatient pediatric rheumatology patients. Cathy is also the President-Elect of the Rheumatology Nurses Society.

References

1. Epel E, Lapidus R, McEwen B, Brownell K. Stress may add bite to appetite in women: a laboratory study of stress-induced cortisol and eating behavior. Psychoneuroendocrinology. 2001;26(1):37-49.

2. Epel ES, McEwen B, Seeman T, et al. Stress and body shape: stress-induced cortisol secretion is consistently greater among women with central fat. Psychosom Med. 2000;62(5):623-32.