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Dropping a large amount of weight can have dramatic effects on anindividual—both good and bad. Although the benefits of a successfulweight-loss program typically far outweigh any associated drawbacks, it'simportant for patients and clinicians to be aware of the physical andpsychological results associated with significant weight loss.
For most people, losing a large amount of weight can leave them with skinthat hangs in loose folds. This unpleasant reminder of a larger self hashelped lead to an increasing number of individuals electing to go under theknife of a plastic surgeon.
In fact, according to the American Society of Plastic Surgeons (ASPS), morethan 52,000 body-contouring procedures were performed in 2003, a figureexpected to increase by at least 36% in 2004.
Unfortunately, despite the best efforts of a skilled plastic surgeon, theskin of many individuals who have lost a large amount of weight may never bethe same again, and will loosen more quickly with age and continued weightloss than the skin of somebody who is not over-weight. A good example of thiscan be found with post-bariatric patients.
"The skin and tissue from a gastric bypass patient is different fromhealthy, normal-weight patients," says Jeffrey M. Kenkel, MD, whochaired a panel on post-bariatric plastic surgery at the ASPS Plastic Surgery2004 conference in Philadelphia last October. "With post-bariatricpatients, their tissue is permanently damaged from being stretched to such anextreme," Kenkel says. "It has lost its ability to maintaintightness or tone. Even though we can make the skin fit the body again throughplastic surgery, these patients' skin will loosen much faster than patientswith normal skin."
MAKING ADJUSTMENTS
Along with a new body come different needs for dietary and medicationmanagement. Dosages and regimens may need to be periodically adjusted forchanges in weight.
For people with type 2 diabetes, "it is important that the bloodsugar level be closely monitored," says Michael Tracy, MD, owner of aPhysicians Weight Loss Center in Orange Park, Fla., and the physician for fiveother sites in the Jacksonville, Fla., area.
"In these patients who are on a medication like metformin(lGucophage, Merck) or glipizide (Glucotrol, Pfizer), I will typically eitherhalve the dose or stop the dose initially because I have found that a lot ofpeople tend to become hypo-glycemic within a few days of following a strictmenu," Tracy says.
Blood-pressure medications may also need to be adjusted. "It doesn'thappen right away, but once a person has lost about 10% of his or her bodyweight, blood pressure tends to start bottoming out, if the physician does notadjust the dosage," he adds.
GALLSTONES
Patients who lose weight have a higher incidence of gallstone formation."People who are overweight to begin with probably have a higherincidence of gallstones," Tracy says. "But for some reason, aspeople lose weight rapidly, they tend to develop more gallstones."Hence, Tracy checks the routine laboratory tests.
"If you have a stone, sometimes your liver functions are elevated.Patients also complain that they have a lot of pain in the right upperquadrant of their abdomen. This alerts the physician to search out forgall-stones." Oral medication can help dissolve stones.
People who lose weight too fast may also experience some hair loss"if they don't take enough omega-3s and other essential fattyacids," Tracy says.
RISKS AND REWARDS
"There is probably not a lot of risk related to medical weightloss," says Scott Shikora, MD, of Tufts University School of Medicine inBoston. "However, there is significant risk with surgical weightloss."
Risks of surgery include bleeding, leaking of the stomach or bowel content,infection, bowel obstruction, and even death. Still, "as much as we hearabout the surgical risks to life and limb, the risks of untreated obesity aresignificantly higher," Shikora says.
"In a cohort of 1,000 patients, between 3 and 5 will likely die as aresult of surgery, and about 10% will develop a serious complication,"he says. "But if you match these patients with similar patients who donot have surgery, the death rate is 4 to 6 times higher than the surgicaldeath rate."
NUTRITIONAL SUPPORT
Patients who undergo gastric bypass surgery must realize that after theprocedure they will require careful nutritional management and support for therest of their lives. Because their digestive tract has diminished ability tobreak down and absorb nutrients, patients often experience dietarydeficiencies in calcium, iron, vitamin B-12, and other nutrients followingweight-loss surgery.
According to Walter Pories, MD, of East Carolina University in Greenville,N.C., weight loss requires appropriate nutritional replacement. "What wesee most commonly are people who, for whatever reason, stop taking theirvitamins and minerals after 1, 2, or 3 years," he says. "Withoutcontinuing to take vitamins, patients may regain some of their weight. Peopletend to eat more if they are not taking their vitamins."
Once someone has lost a significant amount of weight, the caloricrequirement to maintain that weight is much less. "For a patient whostarts off at 350 pounds and at the end of treatment is at 225 pounds, thecaloric requirement to maintain that reduced weight is two-thirds or less ofwhat it had been to maintain 350 pounds," says Vincent Pera, MD,director of weight management at Miriam Hospital/Lifespan in Providence, R.I."Therefore, patients need to work very hard to continue to restricttheir eating. Right from the start, patients should be aware of this fact, sothat their expectations are realistic."
Patients should prepare themselves for a new diet that hopefully representsa lifestyle change that will continue indefinitely. "We can offset thatcaloric deficit change by increasing exercise," says Pera."Exercise needs to become a normal, daily activity."
PSYCHOLOGICAL ISSUES
Emotional ramifications of weight loss may include body-image issues."Some patients, as heavy as they are, don't perceive themselves asheavy," Shikora says. "Other patients view themselves as heavy,but after losing weight they look in the mirror but don't see the new person.They still see the heavy person."
Likewise, spouses or loved ones may become jealous of the person losingweight. "They sometimes try to sabotage it. Relationships have beenbroken or damaged," says Shikora.
When weight is reduced, other psychological issues may emerge as well."We see concerns with weight loss that have been caused by a history ofsexual abuse and physical abuse," says Pera.
"In fact, the incidence of sexual abuse and physical abuse in theobese population is six times greater than that of the normal-weightpopulation," says Pera. "Certainly, when this has occurred at ayoung age, it has implications for weight gain and, therefore, for weightloss. This is something we screen for routinely through our psychologicalinterview. And when we find it, we watch very closely."
As abused patients lose weight, "typically, at some point, they willstop losing weight and become less adherent to their program," Perasays. "These patients start thinking about issues related to the historyof the abuse. In many cases, we are the first health care providers to askquestions about abuse. Sometimes treatment is recommended, usually with apsychologist."
Although nearly all overweight patients are candidates for shedding pounds,weight-loss programs need to be carefully supervised. Because the patient'sbody will go through change, blood glucose level and/or blood pressure maychange as well. Preparing the patient for appropriate nutritional replacementand reduced calories will create a win-win situation. Emotional issues canalso be effectively addressed by providing a safe and comfortable environmentfor patients to express their concerns and by focusing on the positive,healthful outcomes for the patient. 
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