Dr. Debra Ravasia, an American Board of Obesity Medicine (ABOM) Diplomate, answers questions regarding the importance of an obesity medicine physician.
What unique skill set can the obesity medicine physician bring to the bariatric surgical setting?
The obesity medicine physician is uniquely positioned to care for bariatric surgery patients. Her/his skill set typically includes:
Understanding the Disease
The obesity medicine physician understands that responsible obesity management is not about weight loss. Instead it is about optimizing body composition and metabolic health. The focus is on correcting the underlying metabolic physiology that regulates fat storage. Effective long-term obesity management focuses on reducing visceral adiposity while maintaining lean body mass (muscle and bone). Many obesity physicians make extensive use of body composition monitoring tools, such as bioimpedance, and DXA for this reason. Good health correlates with loss of visceral fat specifically, much more so than loss of overall weight. Losing muscle and bone sets up a patient for injury, falls, frailty, low metabolic rate and weight regain, so is to be avoided. Medical obesity management is an essential adjunct to bariatric surgery to prevent indiscriminate weight loss following surgery.
S/he understands that obesity is just one of many linked chronic western diseases that share in common an abnormal response to insulin. Specifically, that obesity is the adipose tissue’s response to an insulin resistant environment, and similarly PCOS is the ovarian response, hypertension is the blood vessel’s response, non-alcoholic Fatty Liver Disease (NAFLD) is the liver’s response, depression is the brain’s response, sleep apnea is a respiratory response, diabetes is the pancreas’ response, IHD is the heart’s response, etc. Many obesity physicians monitor and manage all aspects of this syndrome.
What impact can the obesity medicine physician have on patient outcomes?
Patient Selection, Counseling and Advocacy
To begin with, the obesity physician who is often a primary care physician, has a long term relationship with their patients, and is thus in a unique position to determine who would benefit from bariatric surgery as opposed to ongoing medical obesity management. In my experience, the vast majority of patients with obesity and other metabolic diseases can be managed with medical obesity management alone, for the long term. The obesity physician typically accomplishes this with a combination of tools that are aimed at optimizing long-term body composition. These tools include a combination of low-carbohydrate and adequate protein nutrition, optimal use of obesity medications and insulin sensitizers, shifts from weight positive to weight neutral or negative medications, correction of hormonal imbalances, and use of evidence based exercise prescription and behavioral modification. The obesity physician must make these tools accessible to their patients. This requires a significant long-term commitment to therapy of this chronic disease by both the patient and the obesity medicine physician. S/he recognizes that surgery is a useful tool in some situations, but seldom a first line treatment, and never a cure.
Occasionally a patient will not be able to follow some of the intense obesity medical management protocols because of insurance coverage, finances, or other life stresses. In this situation, is in a trusted and credible position to help their patients understand the benefits and risks of bariatric surgery and put these into perspective. Typically this involves allaying fears that their patients have regarding bariatric surgery, and debunking myths. The obesity physician may counsel their patient regarding the metabolic effects of the right type of bariatric surgery, and can provide unbiased guidance toward the type of bariatric surgery that is likely to have the best long-term outcome and to help the patient set reasonable short and long-term expectations. Further, they are often in a unique position of being able to carefully document the patient’s journey through medical management leading up to the surgery recommendation, and why it is not working, and advocate for the patient to have their bariatric surgery pre-authorized and covered by insurance.
Most importantly they are in a trusted position to be able to explain to the patient that bariatric surgery is a beginning, and not an end; a tool and not a cure, and reinforce the need for long-term follow-up, and the nutritional, lifestyle, and medication changes that will need to (continue to) occur after a bariatric surgery.
The obesity physician is also in a position to know about and recognize pre-operative risk factors, such as substance abuse disorders, other addictions, depression, anxiety, other comorbid conditions, and to be able to do a thorough evaluation of familial and social supports or lack of them. All of these can dramatically affect surgical outcomes and are important to take into account in decisions about whether and when to proceed with surgery.
Once a decision to have surgery has been made, the obesity physician can obtain many of the pre-operative tests that should be done prior to a bariatric surgery, including cardiovascular clearance, baseline nutritional studies, basic metabolic lab studies, baseline body composition studies, baseline bone density, documentation of comorbid conditions that may affect surgery, pre-operative adjustment of medications, DVT prophylaxis, and occasionally administration of the two week pre-operative protein based liquid diet to decrease the liver span.
Immediate Post-operative Management
Some obesity physicians are involved in immediate postoperative care, and are trained to manage the rapid medication changes and blood glucose changes that can be expected postoperatively. They may also be skilled at recognizing and treating short term complications in hospital such as infection, DVT/PE, pneumonia, and cardiac events, and at recognizing leaks, bowel obstructions and bleeding (intraluminal or intra-abdominal) and coordinating with the surgeon to have these treated as well. The obesity physician may play a role in educating the patient about immediate postoperative diet restrictions, and progression from liquid in the first two weeks (for hydration and protein), to the a pureed low carb high protein diet for 2-4 weeks, and finally with a transition to real food over the next 4-8 weeks.
Long Term Management – Body Composition and Macronutrient Management
The most important role that the obesity physician has is in bariatric surgery is that of long-term management of nutrition and metabolic health. The amount of lean body mass loss following a bariatric surgery can be dramatic, and the range varies between 15 and 45% in the first year depending on the study that is looked at and the amount of obesity medicine follow-up the patients had in the first year.
Most obesity physicians have the medical skills to keep the lean body loss at less than 10%, and the tools to monitor these body composition changes. Understanding the importance of adequate protein, indexed to lean body mass, in preventing catabolism, is a unique skill of the obesity physician. Helping the patient consume and absorb adequate bioavailable protein through their surgically altered GI anatomy, is an art, but vitally important in preventing lean mass loss. Particularly important are branch chain amino acids, but also nutrients such as co-Enzyme CoQ10 and carnitine. The concept of consuming protein first, then colorful non-starchy vegetables, and avoiding liquids with sugars or starches, is one that the obesity physician can reinforce, and follow carefully with regular visits during which food journals are examined and studied regularly. Being careful with timing of any liquids around protein consumption is also important, to allow maximal gastric absorption of protein before the liquids “wash” it through.
Long Term Management – Micronutrient Deficiencies
The obesity physician is uniquely trained to recognize long term micronutrient (vitamins, minerals, trace elements and antioxidant) deficiencies that patients may be at risk for depending on the particular type of bariatric surgery that they had. S/he understands the need for regular monitoring of micronutritional status with labwork, for years and even decades, and the particular forms that the micronutrients need to be in to be best absorbed after particular bariatric surgeries, and recognizes the early signs of deficiencies. S/he is an advocate for adequate insurance coverage of these lab tests and nutritional replacements and proactive in obtaining insurance coverage.
Long Term Management – Mental Health
The obesity physician recognizes the elevated risk of suicide after bariatric surgery and carefully monitors for depression, anxiety, substance abuse, addiction, and other mental health problems. S/he is familiar with social complications that can come from rapid changes in body composition – marital problems, cues that remind patients of previous sexual abuse as they receive unwanted attention, unrealistically high expectations of how much better one’s life will be when the obesity problem is controlled etc. S/he carefully watches for these problems and intervenes early as they present.
The obesity physician recognizes that most anti-depressants are weight positive, and wherever possible, takes steps to choose ones that are the least weight positive, and is ready to wean them again when no longer needed. S/he makes extensive use of cognitive behavioral therapy and of some of the newly FDA approved antidepressant techniques such as transcranial magnetic stimulation as advocated by the APA.
Long Term Management – Medications
With respect to medication management, the obesity physician carefully considers:
- Different Absorption after Bariatric Surgery – and concerns with slow release medications and NSAIDs, awareness of which medications require acidic environments to be absorbed, and which are absorbed in the parts of the gut which are bypassed, or require intrinsic factor for absorption
- Changes in Dosage – As fat is lost, water shifts occur and volume of distribution changes. Metabolic problems often resolve and frequent medication adjustments are needed.
- Use of Adjunct Obesity Medications – insulin sensitizers, sympathomimetic amines, 5HT2c agonists, GLP 1 agonists, dopamine agonists, carbonic anhydrase inhibitors, and opiod inhibitors may all have a role in helping achieve and maintain optimal metabolic health and body composition change, and in individual patients, alone or in combination, may be useful tools to prevent obesity relapse in the post-bariatric surgery patient.
Long Term Management – Recognizing and Preventing other Long Term Complications
Recognizing and monitoring for long term complications including stricture, internal hernias and other partial bowel obstructions, dumping syndromes, ulcerations, in addition to the macro and micronutrient deficiencies that can and do occur, are other important aspects of the obesity physician’s role.
Long Term Management – Relapse of Obesity
Obesity is a chronic disease, and while bariatric surgery is a useful tool, it is not a cure. Relapses can and do occur, typically from 5- to 10 years after the surgery. These relapses happen most commonly when regular monitoring by an obesity physician is not in place. In our experience, patients with post-bariatric surgery relapse present saying they have gained some or all of their weight back, and body composition studies (DXA in our clinic) tend to show more dramatic changes than the scale, in that they often have lower lean body masses and higher percentages of body fat, than patients of the same weight who have not had bariatric surgery. Although the obesity physician can still achieve good results with optimal medical management, it is more challenging at this point, as protein absorption is somewhat limited by anatomical changes. This is yet another reason that careful medical follow-up after bariatric surgery is so important.
About Dr. Ravasia
Dr. Debra Ravasia is an obstetrician/gynecologist with twenty years of experience in women’s health. Dr. Ravasia started Women’s Health Connection, PS, a comprehensive women’s health/gynecology clinic in Spokane, WA in 2005. She integrated metabolic/obesity medicine into her practice in 2008, and expanded it to include men’s metabolic health in 2014. Her practice is insurance based, and includes a team of several advanced registered nurse practitioners, another board certified obesity physician, sonographers, densitometrists, dietitians and ACSM certified trainers. Her facility includes a moderate complexity lab, an AAAASF credentialed ambulatory surgical facility, and an exercise physiology studio on each of two sites. In addition, she founded Ajuva, a small medical/laser aesthetics practice in 2008, and cofounded the Northwest TMS Center in 2014 for both clinical and research purposes.
Dr. Ravasia completed medical school at the University of Saskatchewan, Canada, and completed her obstetrics and gynecology residency with additional training in urogynecology at the Foothills Hospital, University of Calgary in 2000. She is board certified in Obstetrics and Gynecology in both the USA and Canada, and subspecialty board certified in Pelvic Floor Medicine and Reconstructive Surgery (“urogynecology”) in the USA. She is a Diplomate of the American Board of Obesity Medicine and an active member of the American Society of Bariatric Physicians and International Society of Clinical Densitometrists.
Dr. Ravasia has received additional training and certification in medical aesthetics, clinical densitometry, exercise medicine and medical coding. She loves to teach, and has set up a fellowship training program for ARNPs in women’s health and in metabolic/obesity medicine. When not working Dr. Ravasia enjoys skiing and spending time with her husband and four children.