Comment on: Life during “lockdown”: a cautionary tale of the impact of environment on access to bariatric surgery

The COVID-19 pandemic placed a unique spotlight on the many challenges that are encountered when caring for patients suffering from obesity. The preoperative process for bariatric surgery can be resource intensive as it requires numerous visits with health care providers. Given its high barrier to entry, bariatric surgery is not only underutilized, but also has a high dropout rate despite being the most effective treatment for obesity and associated co-morbidities [1]. During the pandemic, the complexity of navigating the preoperative bariatric surgery process was further exacerbated by 2 major changes in health care delivery. First, health care systems stopped performing nonessential elective procedures such as bariatric surgery, and second, local governments imposed lockdown measures to promote physical distancing and thus prevent further spread of the virus. Patients with obesity were also considered an “at-risk” population, given the potential increase in morbidity and mortality when contracting COVID-19 [2]. As a result, patients were also more likely to avoid in-person interactions with health care providers for fear of being exposed to the virus. To make matters worse, the compounded effect of social and physical isolation increased the risk for maladaptive behaviors, which can result in weight gain [3,4]. While the risks, benefits, and merits of offering bariatric surgery during the pandemic were being debated among providers, health care systems, local governments, and payers, an important perspective was missing: the patient’s.

As such, the authors are to be commended for exploring the opinions of patients who were pursuing bariatric surgery during the COVID-19 pandemic. The questionnaire was uniquely insightful for a number of reasons. First, it provided valuable information about how bariatric surgery programs can adapt to their patients’ needs. Second, it provided data on a patient’s ability to self-reflect on their own behaviors. Third, it offered a glimpse into a patient’s commitment to pursuing surgery, even in the face of uncertainty or hypothetically increased risk. Based on their survey questions, the authors found that social and physical isolation can result in significant changes in health behaviors, as patients reported that they were exercising less and snacking more during the lockdown period, despite making appropriate changes after their initial evaluation. Not surprisingly, this resulted in weight gain in 62% of patients. The authors cite that that confinement, decreased psychological wellbeing, lack of access to a gym, and easier access to shelf-stable or potentially unhealthy foods are potential reasons for their findings and that behavioral maladaptation was more apparent during the lockdown. With this in mind, it is important to recognize, that low-income patients who live with limited resources face the exact same challenges even when there is no pandemic or lockdown mandates in place. Consequently, it comes as no surprise that patients with limited resources are also less likely to progress to surgery [5]. Interestingly, the COVID-19 pandemic provided an opportunity for an entire population to experience a forced environment that can negatively impact health, well-being, and achieving one’s weight loss goals. It also serves as a reminder of the importance of recognizing social determinants of health and that discriminatory practices may be disproportionally affecting access to care for bariatric surgery.

Another intriguing finding of this study is that despite potential risks of being exposed to COVID-19, 90% of patients indicated that they preferred to undergo surgery as soon as possible. This indicates a striking level of commitment, which is a quality that is often questioned by payers and providers alike. Although a commitment to lifelong behavioral changes is beneficial to maximizing weight loss outcomes and decreasing recidivism, there is no standardized scientific approach to measuring commitment among bariatric surgery patients. Instead, programs are confined to assessing compliance via monthly in-person visits to discuss weight loss strategies for an arbitrary number of months, often based on insurance coverage. Once again, the COVID-19 pandemic highlighted the difficulty of demonstrating commitment when patients live in an environment with limited access to health care providers, healthy food, or a safe environment for physical activity.

In the future, more studies would benefit from integrating patients’ perspectives as they are vital to delivering effective and equitable health care. Patient-reported outcomes can be valuable trustworthy data that are more accessible because they do not rely on in-person clinic visits. Furthermore, by capitalizing on the expansion of telehealth during the pandemic, there is a new opportunity to capture long-term outcomes for bariatric surgery without placing the burden on a patient’s ability to visit a clinic.

Disclosures

The author receives salary support from Blue Cross Blue Shield of Michigan for leadership and participation in the Michigan Bariatric Surgery Collaborative.