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Behavioral Health CE on Facebook

 

CARING FOR THE SURGICAL WEIGHT LOSS PATIENT

by Diane LeMont, Ph.D., Gaye Andrews, Ph.D., MFT.


6 Credit Hours - $99
Last revised: 11/20/2009

Course content © Copyright 2009 - 2014 by Diane LeMont, Ph.D., Gaye Andrews, Ph.D., MFT. All rights reserved.



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COURSE OUTLINE

 

Introduction and Course Overview

Learning Objectives

        The prevalence of and contributors to obesity

The Increasing Incidence of Obesity

Genetic and Physiological Contributors

        Genes/hormones/biochemistry

        Metabolism

        Individual variations

        Injuries and physical conditions

        Medication

Cultural Contributors

        Increased food intake

        Decreased caloric expenditure

        Cultural attitudes

        Prevalence of weight prejudice

Behavioral Contributors

        Reasons to eat

        Compulsive eating

        Psychological issues

Traditional Treatments for Obesity

        Exercise

        Diet

        Pharmacotherapy

Weight-loss Surgery as a Treatment for Obesity

        The digestive system

        Early weight-loss surgeries

        Recent and current weight-loss surgeries            

Restrictive Procedures

        Combined restrictive and malabsorptive procedures

        Malabsorptive procedures

        Special considerations

Surgical Methods

        The open method

        The laparoscopic method

        Risks, complications and side effects

        Choice of procedure

        Lifestyle adjustments

        Multifactorial treatment

Psychosocial Issues

Presurgical Psychosocial Patient Assessment

        Assessment instruments

        Psychosocial reports

        Eligibility for surgery

Special Post-Surgical Treatment Issues

Destructive Eating

Body-Image Distress

Self-Esteem

Relationship Issues

        Depression

Patient Education and Support

        Support groups

        Structured behavior modification

Ongoing Consultation

Conclusion

Appendices

References

 

INTRODUCTION AND COURSE OVERVIEW

 

In order to provide the best care for the surgical-weight-loss patient, it is important for the provider to have an understanding of the prevalence and causes of obesity, the efficacy of available treatments, and the physical and psychological consequences of both obesity and weight-loss.  This course has three major sections. The first section begins by explaining the increasing incidence of obesity, its complexity, and its multifactorial nature.  Genetic, physiological, cultural and behavioral contributors to the disorder are discussed along with a brief overview of traditional treatment methods. The second section discusses the most frequently used surgical treatment options and methods, as well as the lifestyle adjustments required for successful weight-loss and maintenance. The last section describes common psychosocial issues experienced by obese and weight-loss patients including the importance of a psychosocial evaluation prior to surgery. Finally, the post-surgery needs of patients are addressed. The behavioral health provider may have a pivotal role in ensuring that the surgical-weight-loss patient ultimately leads a healthy and satisfying life.

 

LEARNING OBJECTIVES

 

     Discuss the prevalence and causes of obesity

     Describe three types of weight-loss surgery

     Discuss the role of the mental health professional in helping weight-loss surgery patients experience a satisfying surgical outcome

     Describe typical pre-surgical psychosocial issues that could affect outcome

     Discuss typical post-surgical psychosocial issues and methods of addressing them.

 

The Prevalence of AND contrbutors to Obesity

 

Obesity is recognized as a chronic disorder affecting millions of people.  It has been linked to many diseases including heart disease, type II diabetes, hypertension, stroke, osteoarthritis, gallbladder disease, sleep apnea, respiratory problems, and a number of cancers.  In addition to the incidence of associated disease, obesity contributes to considerable psychological, social, educational, employment, and economic suffering. This section will provide current statistics concerning the prevalence of obesity in this country and discuss the biological, medical, cultural and psychosocial contributors to this devastating disorder.

 

The Increasing Incidence of Obesity

 

Based on information from the National Instistute of Health Sciences (NIHS), Finkelstein, Fiebelkorn and Wang (2004) developed a model that predicted annual national health care costs associated with obesity to be 75 billion dollars (in 2003 dollars). Even though dieting to reduce weight in order to improve health and overall quality of life is common, the incidence of obesity has continued to increase significantly since the 1980’s. In 1990, for the 44 states for which the Center for Disease Control (CDC) had information, no states had an adult obesity prevalence rate of over 14%. In contrast, by 2008, only Colorado had an adult prevalence of obesity less than 25% and six states had a prevalence rate of at least 30%.  Further, in the past 30 years the rate of obesity has nearly tripled for children ages two to five years old, more than quadrupled for children ages six to eleven years old and more than tripled for adolescents 12 to 19 years old.

 incidence

It has long been held that obesity is the result of a caloric imbalance, that is, caloric intake is greater than caloric output. The problem with this equation is that it doesn’t explain why the imbalance occurs.  Scientists are continuing to discover biological contributors to obesity. In addition, it is clear that environmental and psychological factors play a significant role in many obese patients’ conditions.

 

This section discusses the multifactorial causes of obesity and lays a foundation for its treatment by weight-loss surgery.  The subject will be approached from an integrative perspective since research suggests that obesity cannot be successfully treated unless the relationship between the multifactorial causes of the disease is understood. 

 

Genetic and Physiological Contributors

 

Current research is focusing on isolating the genes that may predispose an individual to obesity as well as attempting to understand the brain-body chemistry influencing the hormones that may be directed by those genes.  These genes, and the hormones they regulate, are thought to contribute to obesity in a multitude of ways. A detailed analysis of the research concerning the genes and hormones involved in obesity is not possible in this course (See Bray and Bouchard, Handbook of Obesity: Etiology and Pathophysiology, 2004). The following discussion will provide an understanding of the complexity of factors that may be affecting obesity.

 

Genes/hormones/biochemistry. There are specific genetic disorders, such as the Bardet-Biedl syndrome, in which obesity manifests during infancy and remains problematic throughout adulthood. Most patients’ obesity, however, will not be traceable to a specific disorder. Rather, the obesity will be the result of the interaction between various genes, the physiological changes brought on through life events, the environment and the individual’s behavior.

 

The biology of weight has been a rich area of research. Scientists have identified genes that contribute to such things as birth weight, adult weight, fat mass, fat distribution, skin fold thickness, appetite, calories ingested, and ability to burn calories. This genetic contribution is manifested in the functioning of the body’s hormones, chemicals, and metabolism. At this time researchers have identified over 200 genes related to weight and some estimates suggest there may be as many as 1,000 genes involved in weight regulation. As an example, the perilipin gene has recently been identified as a weight-related gene. Current research indicates that this gene regulates the breakdown of fat in cells. Studies show that women with specific perilipin variations have more body fat and larger waists than women without these variations. Possibly because of hormone interactions, men do not seem to be affected the same way. 

 

Another example is how the body reacts under stress.  When under stress the body activates the hormones, adrenalin and cortisol. This is the fight or flight phenomenon, when the body expects to use its reserves to survive. Adrenalin and cortisol release fat into the bloodstream (for energy).  This fat comes from abdominal fat, which is closest to the liver and most quickly converted to energy. Once the stress is over, the fat stores need to be replaced.  Cortisol helps in this process by making us ravenous so we will eat enough to replenish the used fat stores. Fat storage in response to cortisol collects in the abdomen for later use.

 

For our ancestors, this worked very well. The stress response occurred as a matter of survival, for instance, when seeing a tiger. The hormones gave our ancestor the energy to run from the tiger which burned a significant amount of calories. After expending energy to avoid the threat, our ancestors needed to build up the body’s reserves to have the strength and speed to run from the next tiger.  For the modern person, stress is more likely to be stuck in traffic. Even though there is no actual threat, adrenalin and cortisol surge in response to the stress.  Also, unlike running from tigers, sitting in traffic under stress doesn’t take many calories. Even so, the body responds as it always has, by increasing appetite and, when we eat, increasing abdominal fat storage. So, in this type of non-threatening stress response, we are actually adding to our fat rather than merely replacing what we’ve used.

 

There are other hormones that affect weight or fat gain such as human growth hormone. If we are deficient in HGH, we will have more abdominal fat and less muscle mass. This hormone naturally decreases with age which may be why weight stabilization seems to become more difficult as we get older.  Leptin (located on chromosome 7 of the ob, short for ‘obese’, gene which was discovered in the early 1990’s) is a hormone produced in fat cells that inhibits food intake and increases energy expenditure. We will eat more and burn fewer calories if we are too low in leptin or, more commonly, if there is a malfunction in our body’s receptors for leptin.  In the latter case, the individual is producing enough but not able to use it appropriately.  Ghrelin is a hormone produced by the stomach and intestine that stimulates appetite and causes “hunger pangs”.  During attempted weight loss it can cause intense hunger pangs, as well as decrease metabolism and the breakdown of fat.  Insulin is a hormone that affects how much fat we store and an excess in the blood leads to increased fat storage.  The thyroid hormone controls metabolic rate which can also impact weight.

 

Chemicals perform numerous functions for us related to weight. To name a few:

 

     cholecystokinin (CCK) signals the body is full,

     peptide YY (PYY) sends a message to the brain to stop eating,

     glucagon-like peptide-1(GLP-1) creates a queasy feeling when we overeat

     neuropeptide Y (NPY) induces a strong appetite for carbohydrates.

 

If any of these don’t work properly, it will make it harder to regulate what we eat.

 

Metabolism.  Metabolism is the mechanism by which the body breaks down food to make it available for our use (e.g. burns calories). Metabolic rate varies from person to person. Broadly speaking, the body needs calories or energy for three purposes:

 

     basic bodily functions or the energy it takes to breathe, circulate blood, etc.  This is what is called our “resting metabolic rate” (RMR)

     the energy it takes to do things—any physical activity

     thermogenesis, which is primarily the energy it takes to digest the food we eat, but also includes the body’s response to cold or heat exposure, fear or stress, and certain hormones or drugs

 

By far, we use the most energy just “being” which is the RMR. ..”at any given body size and body composition, there is considerable variance in resting metabolic rate and ..part of this variance is genetically determined….fat free mass [most important], fat mass, age and sex are the major determinants of RMR” (Ravussin and Swinburn 1992). But there are other factors. For example, RMR increases with height, illness, stress hormones and environmental temperature changes. It decreases as we age, as we decrease muscle mass, and as we lose weight.

 

In general, we have a faster metabolic rate when we are heavier than when we are thinner. When we diet (eat fewer calories) we burn fewer calories digesting. When we lose weight, it takes less energy to live and move. Our body adjusts by slowing the metabolic rate and we burn fewer calories (The Physiology of Body Weight Regulation).  This is one of the reasons it is easier to gain weight after a diet than before and a significant contributor to NOT maintaining weight loss.

 

Generally speaking, the human body does not store nutrients in the form of protein or carbohydrates. The primary “storage” we have is fat. When we need more energy than our current food intake provides, our body releases fat into our blood stream to be used for our energy needs. Because food shortages were common in pre-historic times, those most likely to survive were those with the greatest ability to add fat or store nutrients. Large nutrient stores would help individuals survive during times of little or nothing to eat. The human body has a high capacity for energy storage and adjusts during food shortages in such a way that it takes less energy to perform its functions. It does more with less since, in times of shortage, the body’s metabolism slows down.

 

Our bodies store excess calories for later use in the form of fat. We automatically use less energy than normal during food shortages so that our nutrient or fat stores will last as long as possible. Each time we deplete our stores, the body is programmed to replace them and, perhaps, add a little extra for safety. This is life-saving if the food supply is severely limited and we can’t get enough to eat. However, if the reason we’re not getting enough to eat is that we’ve chosen not to eat (dieting), then it’s frustrating that our body is, in the name of survival, is actively working to maintain or increase our weight.

 

Individual variations. How this evolutionary tendency expresses itself in any particular person is a function of genes. With the exception of identical twins, we each have a unique genetic makeup that determines a wide range of characteristics, capabilities, and limitations.  For example, we each have a full-growth height potential—which varies considerably. Good nutrition during development will help achieve the taller end of an individual’s range, while the lack of good nutrition could keep the individual at the shorter end of his height range. But each person’s range is different. Verne Troyer is an actor who played Mini-Me in two of the Austin Powers movies. He’s 2’ 8” tall and no matter how good his nutrition was, he would never have grown to be 6 feet tall. And even if the 7’ 6” basket ball player, Yao Ming, suffered through a food shortage, he wouldn’t have stopped growing when he was 3 feet tall. So we all have our own, unique range of potential heights and these ranges vary along the human continuum. Some scientists have hypothesized that individual weight or fat ranges are similar to height ranges. This would mean that any individual would have a particular full-growth weight potential.  Accordingly, if we looked at several people of the same gender and height, we would see a natural variation in their weight. Further, even if the actual weights of some of them are the same, they could be at a different place in their weight range.

 

This indicates that the healthy weight range cannot be determined by cultural preferences but, perhaps more surprisingly, may not be identified by the height/weight tables currently in use.  The most common method used today to determine whether a person’s weight is healthy or not is Body Mass Index (BMI). BMI is a calculation based on height and weight—weight in kilograms divided by height in meters squared.  Charts and calculators have been developed as quick BMI references

 

Currently, overweight is defined as an excess body weight (muscle, bone, fat and/or body water may contribute to excess weight) and obesity is defined as an excess of body fat.  The BMI table does not account for lean body mass.  For example, contestants on “The Biggest Loser” and body builders would both be considered to have an unhealthy weight. This issue (overweight versus excess body fat) may not be the only flaw in the BMI measure.

 

As discussed previously, we each have our own potential for height and weight. We also have our own potential for fat cell size and number.  Estimates indicate that the average person is born with somewhere between 25 and 35 billion fat cells. As we gain weight, these cells expand. When a person becomes about twice normal size, he or she is vulnerable to creating more fat cells. A person who is severely obese may have as many as 100-200 billion fat cells. As we lose weight, our fat cells shrink. It is hypothesized that when these cells shrink below a biologically-determined level, the body starts increasing appetite and food storage—a biological response to what seems to be a dangerous situation. The higher the biologically determined level, and the more fat cells a person has, the more difficult it is to lose to a healthy weight and then sustain it.

 

Injuries and physical conditions. While rare, pituitary tumors and certain types of brain damage (e.g. various injuries to our hypothalamus) can affect weight gain (York 2004). The hypothalamus is a part of the brain with a number of regulatory mechanisms—some affect how much the person eats, insulin production, gastric motility, and so on.

 

Based on these findings, it may be that overeating is not a matter of uncontrolled appetite. One hypothesis is that hypothalamic injury leads the body to require a higher than normal level of fat. The person eats enough to sustain some elevated level of adipose tissue and is then able to maintain that weight (overweight). In this scenario, the person is biologically driven to eat enough to sustain an unusually high level of fat. There are other physical conditions that are likely to result in weight gain. Although this list is controversial, the most typically mentioned conditions related to weight gain are diabetes, polycystic ovary syndrome, hypothyroidism, and menopause. 

 

Recently, there’s been some emphasis on the connection between sleep disturbance and weight. Sleep deprivation alters metabolic functioning.  For example:

 

     Sleep deprivation causes a decrease in human growth hormone and leptin, both of which reduce fat storage.

     Sleep deprivation causes an increase in ghrelin and cortisol, both of which increase appetite and fat storage.

 

One study indicated that those who regularly get only four hours of sleep are 73% more likely to be obese than those who get seven hours of sleep.

 

If we have an injury or condition that requires bed rest, we are likely to gain weight simply because of the reduction in physical activity. And depending on the length of time we are confined, the weight increase can be significant.

 

 

Case Example

 

 

A 38-year old woman presented for gastric-bypass surgery. She had been well-within normal weight guidelines until the age of 28 when she was badly injured in a car accident. As a result of the accident, she had numerous surgeries and was virtually bed-ridden for two years. Following that she continued to have difficulty with mobility but gradually lessened time in a wheel chair and now could get around with a cane most of the time. Within the ten years following her accident, she gained 130 pounds—more than doubling her original weight.

 

 

Medication. Finally, if we look at the interaction between a person’s hormones, metabolism, biochemistry, physical condition, and medication, we come to another potential contributor to weight gain.  Several categories of medications can lead to weight gain.

 

     Obesity is a recognized factor in diabetes, and in an unfortunate vicious cycle, treatments for diabetes (e.g. insulin, avandia, actos, and glucotrol) can lead to weight gain. 

     Coticosteroids are anti-inflammatory drugs used for a variety of health problems including rheumatoid arthritis, lupus, asthma, leukemia, chemotherapy side effects, kidney disease, etc. (These drugs relate to the hormone cortisol discussed earlier and usually lead to weight gain.) 

     Treatments for high blood pressure can cause weight gain.

     Anti-histamines, anti-depressants, anti-psychotics and anti-convulsants can cause weight gain.

 

In summary, the treatment for a wide range of conditions might have the unpleasant side effect of weight gain. What is important to understand from all this is that the physiological contributors to excess weight are long-standing and complex.  Each patient will have a unique combination of these physiological factors. The individual looking for help with his or her weight, may have significant, complex physiological contributors to their weight struggle, only some of which may be confirmed. Any factors impacting the patient’s weight that can be identified will be important to consider in terms of the best treatment strategy.

 

Cultural Contributors

 

Biological predisposition toward obesity can be exacerbated or prevented by cultural attitudes and behaviors regarding what are normal dietary, activity, and aesthetic standards.  For most of humankind’s time on the planet, starvation was a much more likely health problem than obesity. Those most likely to survive and procreate were those most able to store enough fat to carry them through food scarcity. Only with the Industrial Revolution was it possible to significantly increase food production, improve preservation of what was produced, and distribute food easily.  All of this could be done with considerably less physical labor than that previously required for hunting and gathering.  The result is an environment where obesity could flourish.

 

Increased food intake. Since the 1950’s, there has been a shift away from homemaking which included meal planning and preparation. Given the rarity of stay-at-home parents and the complexity of daily life, it is the homemaking tasks that have diminished. It is not uncommon to hear stories of parents who eat fast food or take-out every night as they get home too late to manage homework AND cooking dinner.  The proliferation of fast food and take-out restaurants is a direct response to our wanting quick, easy meals. Many of the most successful fast food chains started in the 1950’s and 1960’s and have been growing ever since. People are eating out more and more often. In an effort to attract customers, many restaurants have tried to offer better value than their competitors by offering larger portions. How have portions increased?  As an example:

 

     In the 1950’s a typical fast-food hamburger, fries and a soda added up to 491 calories.

     In the 1980’s the average fast food burger, fries and soda added up to 625 calories.

     Today, a Famous Star, medium fries, and a medium soda add up to 1410 calories and that doesn’t include soda refills. Of course, a person could order a double bacon guacamole burger, chili cheese fries and a large coke for a total 2,470 calories.

 

Depending on one’s choices, a single fast-food meal could easily provide a whole day’s worth of calories!  In spite of the concern about obesity, this trend is continuing. Burger King, as an example, has at least one hamburger that has 1360 calories before adding the fries and a drink.  Calorie-dense food is plentiful, inexpensive and we can easily eat more than our bodies require. One estimate indicated that we ate 12% more calories in 2000 than in 1985 (Putnam, Allshouse & Kantor 2002).  There is more food and more high-fat, high sugar foods than ever before and we are eating more than ever before.

 

In addition to eating larger quantities of food, we eat more often. For example, how many of us get together with friends or family, whatever the occasion, without including food?  And it’s not just personal occasions, it’s also business. The typical workplace has food readily available including treats from vendors, potential vendors, and satisfied clients; food for employees, meetings with co-workers, and for employee-morale; periodic pot lucks, birthday celebrations, etc. There are also on-site vending machines, commissaries and break rooms filled with food.  For some, this cultural eating is so much a part of life they don’t realize how many calories they’re consuming. In effect, they don’t count them as part of their daily intake because they aren’t purposefully-chosen eating events. Other people will, however, be very aware of the difficulty they have avoiding overeating at work or when they socialize with family or friends.

 

Decreased caloric expenditure. In order to maintain a healthy weight given these extra calories, there would have to be a comparable increase in energy expenditure. But, in our culture, we’ve done just the opposite. There was a time when most people did daily, hard manual labor. That began to change with the industrial revolution and continues to change today. There are certainly those who have physically demanding jobs, but that is true of fewer and fewer of us. In this country today, the vast majority of working people have sedentary jobs. Whether it’s socializing, playing or working, it’s likely to take less energy than it did for our parents and grandparents. Now, we don’t even have to walk over to the phone to make or take a call, we simply use our cell phone. Most of us don’t get any closer to physical play than watching others do it. We watch a lot of TV and movies and we even have a remote control for every entertainment electronic device: TV, stereo, DVD player, and radio.  How many of us play and socialize via the computer? Computer games are helping our children (and some of us) develop our thumbs, but the rest of our bodies are fairly inactive.  Our daily physical expenditures of energy are significantly reduced from what they used to be.

 

So, we have a culture in which we have lots of high calorie food available just about everywhere we go and we burn relatively few calories in daily life. When you combine a significant REDUCTION in the physical demands of daily life and a significant INCREASE in food intake, you end up with significant weight gain; such as the 50% increase in obesity some statisticians report occurred in America in the 1990’s (Mokdad et al., 1999).

 

Cultural attitudes. There is another critical aspect of culture with regard to obesity that is important to consider: the treatment of the obese in our society. Many obese patients have experienced altered self-perception, diminished confidence in their ability to achieve a healthy weight, and emotional turmoil. In the 20th century, being fat became decidedly negative and dieting became commonplace. While people have dieted for centuries, it was during the 20th century that people came to firmly believe that we had control over our shape and size. All we had to do was eat few enough calories, exercise, and we could achieve the ideal shape. In this view, the “ideal” was attainable by anyone willing to work for it. This was the beginning of the widespread hostility toward obesity. If eating and exercising to achieve ideal weight was a simple matter of choice, then there must be something wrong with those who didn’t choose to achieve ideal weight. Due to these factors, obesity came to be associated with poor character.  Unfortunately, despite the fact that the majority of adults in the U.S. are overweight or obese, anti-fat prejudice is widespread, both implicitly and explicitly. One study asked participants what they would be willing to trade to avoid obesity. The following Table summarized what people of all sizes chose as less painful than obesity (Schwartz, Vartanian, Nosek, & Brownell 2006).

 

 

Prejudice and Obesity

 

 

When asked, people would trade the following to avoid obesity:

 

46%--one year of life

15%--10 or more years

30%--divorce

25%--no children

15%--severe depression

14%--alcoholic

5%--lose a limb

4%--blind

 

 

Prejudice against those who are heavy has had painful effects on relationships, educational and financial possibilities, availability of medical care and the efficacy of treatment for weight problems. Further, consuming certain foods and beverages is often a culturally sanctioned way of dealing with emotional distress.  Consider the serving of milk and cookies to children when they are upset or an adult having a few drinks after a difficult day at work.  In fact, many patients report that they eat for emotional reasons, including when they are feeling badly about their weight or the limitations they experience due to prejudice. Prejudice not only causes an emotional toll, it can lead to increased caloric intake and increased weight.

 

Prevalence of weight prejudice. A recent literature review (Puhl & Heuer 2009) provides a wealth of evidence of societal attitudes toward the overweight and obese. Part of what they found is summarized here.

 

Studies forty years apart have found a majority of children to prefer having a friend on crutches, in a wheel chair, with an amputated hand or a facial disfigurement to a friend who was obese. Anti-fat attitudes have been found in children as young as three-years old and negative attitudes toward obesity appear to increase with age.  These attitudes are both self- and other-directed. Older children report weight-related teasing and derogatory comments throughout elementary, middle and high school years. Significant percentages of teachers in junior and high schools have been found to perceive obese people as untidy, more emotional, less likely to succeed at work, and to be undesirable marriage partners for non-obese people.

 

Research has indicated that, all things equal, obese students were less likely to be accepted to college and that normal weight-students received more family financial support for college. College students asked to rank suitable marriage partners chose embezzlers, cocaine users, shoplifters and blind persons over obese persons.  Employers are known to discriminate against employees and potential employees on the basis of weight. Obese people are likely to be seen as lacking in self-discipline, lazy, less conscientious, less competent, sloppy, disagreeable, and emotionally unstable. These attitudes not only affect whether or not a person is hired or promoted, it affects wages. Studies in the 1990’s that included thousands of people found that obese women earn 12% less than non-obese women and that men are paid the same regardless of weight; however, obese men tend not to get the higher paid jobs.

 

There have been several studies assessing the attitudes of various groups of health care providers that have found an anti-fat bias. Surveys of medical students show the presence of substantial prejudice toward obese patients and physicians report spending less time with obese patients. About two-thirds of the physicians in one study did not feel it was their responsibility to manage their patients’ obesity. Surveys of physicians from a variety of specialties found that only a small percentage would discuss weight management with their overweight or obese patients. General practitioners deemed weight management professionally unrewarding and were frustrated by what they saw as poor patient compliance and motivation.

 

A majority of obese patients believe doctors don’t understand how difficult it is to be overweight and they are reluctant to seek treatment for their weight because they expect a negative reaction. One-third to one-half of overweight or obese patients report the reason they delay or cancel physician appointments is their embarrassment concerning their weight. In one survey, over 45% of morbidly obese patients reported they had been treated disrespectfully by a medical professional because of their weight.

 

Physicians are less likely to screen overweight patients for cervical and breast cancer than they are to do such screening for normal-weight women and many nurses say they are uncomfortable caring for obese patients and would rather not provide care to such patients.  According to the American Dietetic Association, nutrition specialists tend to believe that obese persons are self indulgent. Studies specifically targeted to dietitians found they tend to have ambivalent or negative attitudes toward the obese.  Mental health providers are not exempt. We are likely to rate obese patients more severely in terms of psychological functioning than normal-weight patients with equivalent symptoms.  Even health care professionals who specialize in researching and treating obesity have been found to associate the terms “lazy,” “stupid” and “worthless” with obese people.

 

Behavioral Contributors

 

Depending on biochemistry as previously discussed, a person can become obese by simply eating in response to physical hunger; however, that is not most people’s path to obesity. Most obese people eat for reasons besides hunger, and these are primarily psychosocial reasons. Among non-hunger reasons to eat are social factors or to “fit in”, habit, impulse, and to feel better.

 

Reasons to eat. Some people will eat because they’re in a social or business situation that would make them feel self-conscious if they do not eat since they don’t want to stand out. In our society, people are much more likely to notice, and comment on, whether an obese person eats than whether an average-weight person eats.

 

There are many typical eating cues in our culture. Over time, eating in response to these cues becomes a habit. For example, many of us eat at certain times of the day. It doesn’t matter whether we’re hungry or not, it matters that it’s the time we are accustomed to eating. For this person, attending a social function even in the mid-afternoon and enjoying the plentiful and calorie-rich food will not affect whether or how much is consumed at dinner. When it’s time to eat, it’s time to eat. Other cues to eat include:

 

     coming home after being gone for several hours,

     appetizing smells,

     the sight of appetizing food—in reality or in a commercial or advertisement,

     food-related activities such as attending a baseball game or going to a movie or watching TV

 

Think about the things that cue you to eat…like a starving child somewhere in the world, or the fear of hurting someone’s feelings, etc. One patient reported that she had developed the habit of eating when she returned home. She was surprised to realize that she actually ate every time she returned home, even if she had only been gone 20 minutes.

 

Dr. Cynthia Last has identified five common psychosocial reasons people eat. 

  

 

Psychosocial Reasons People Eat

 

 

Impulse eating.  The first category is what Dr. Last referred to as impulse eating. Those who eat impulsively don’t pay attention to what or how much they eat. They’re too preoccupied. They tend to eat on the run and are likely to overeat because food is NOT that important to them. They tend to eat quickly while they’re doing something—or several somethings—else. They grab something as they’re running out the door. They wolf down some food between meetings or while they’re driving from one place to the next. Because they eat fast and while they’re distracted, they don’t register how much they’re actually taking in. They end up getting more calories than they need—and therefore gain weight.

 

Feel good eating.  The four other types of overeating Dr. Last identified are what might be called “feel good” types. Most people probably engage in one or more of these eating patterns occasionally with no increase in weight.  When done frequently, weight gain is likely.

 

Eating for pleasure.  The second category refers to eating for the pleasure of the food—and the act of eating itself. People focused on the pleasure of eating tend to think about food, talk about it, watch the food channel, look forward to meals with pleasurable anticipation and look back on eating experiences with fond remembrance. They are likely to prefer high-fat and high-sugar foods. We all need pleasure in our lives, and some of us have learned to find it through food.

 

Eating and stress.  The third grouping refers to eating that is done in response to stress. Food can be calming. When we are uncomfortable, we want relief and we want it now. We can take an advil or aspirin etc. for temporary relief of physical pain, what can we do for stress or emotional pain? Most solutions for emotional pain are time consuming and difficult (e.g., learning introspection or relaxation techniques)—eating is quick and easy. 

 

Avoidance eating.  The fourth type of eating Dr. Last addresses is avoidance eating. Some people eat instead of thinking about and dealing with problems. Just as mom gave us a cookie to distract us from our unhappiness at being told “no” about something, we distract ourselves from the unpleasantness of our feelings with the pleasure of taste and texture. Some have gotten so good at pushing feelings away that they have difficulty recognizing their emotions when they occur.

 

Pick-me-up eating.  The last category Dr. Last identifies is eating as a “pick-me-up”—either physically or emotionally. Food can provide relief from being bored or tired or feeling down. Food can be (at least initially) energizing, especially high-fat, high-sugar food.

 

 

Food is the earliest symbol we have of love and nurturing. Beginning in infancy, when we appeared in distress, we were likely to be held and given food. It felt good and, in this way, we made the subconscious connection between food and nurturing.  As adults, we may still revert to “comfort foods” when we’re suffering. Comfort foods are most typically the soft, creamy, and/or sweet (high-calorie) types of foods we ate in our early years.  In addition to using food for comfort, many of us use food as a way to treat or reward. There are many variations of this, from candy for being good at the doctor’s office, to an after-school snack at McDonald’s if we did well in school, to dessert if we eat our vegetables, to Starbucks after a hard morning.  We have the historical precedence of food as a reward and it’s cheap and easy to obtain.

 

People may learn to eat more when stressed, anxious, or depressed due to the pleasant taste of sugar and fat, and to their learned appreciation of these foods based on how they were used in our past. In addition, there may be a physiologically or chemically-induced positive feeling in response to these foods. The chemicals most often associated with feeling good are dopamine, serotonin and endorphins and all of these chemicals are affected by the foods we eat.  One problem with eating for emotional reasons is that the emotional payoff doesn’t last very long. When we use food to meet pleasure or emotional needs, we only experience a benefit for a short time. The food doesn’t fix the problem; it only temporarily masks the symptoms.

 

Compulsive eating. If you combine the positive associations of food, the pleasant taste of sugar and fat, the physiological mood effects, and the brief nature of the relief, you have a recipe for compulsion. Compulsive eating is eating in response to a powerful urge that we feel unable to resist and it takes different forms. The simplest form of compulsive eating is in response to an emotional need. This “urge” is typically for comfort food and often a very specific food. It’s one thing to think about macaroni and cheese when you’re feeling down; it’s another thing for macaroni and cheese to be the most important thought you have and for it to totally dominate your thinking until you finally obtain it, even if it creates hardship to get it. It might be considered compulsive to drive two miles out of your way in rush hour traffic during a rain storm to get the Mac and Cheese.

 

Another form of compulsive eating is binge eating. The layperson may consider it a “binge” when they eat past the point of fullness or when they eat some food they’ve designated as “forbidden.” However, the technical definition of binge eating is, “eating in a discrete period of time… an amount of food that is definitely larger than most individuals would eat under similar circumstances” AND during the binge there is a “sense of loss of control…for example, “a feeling that one cannot stop eating or control what or how much one is eating” (American Psychiatric Association 1994).  A binge may be relatively brief or may last all day. Eating tends to be very rapid and to continue past the point of being uncomfortably full. Some researchers have indicated that during a binge food intake could range between 1,000 and 20,000 calories.

 

 

Case Example

 

 

A young lawyer was morbidly obese. She reported that she frequently “binged.” Upon inquiry, she reported that she was under severe stress due to extensive work hours and the fact that she was being sued for nonpayment of student loans. The amount she owed, with interest and penalties, was close to $250,000. Her work hours led to a reliance on fast foods so that she frequently consumed too many calories during her meals. To sooth stress, she would also stop at the store on her way home from work and purchase large amounts of junk food. Her estimate was that she would frequently consume up to 8,000 calories in the evening—between the time she finished dinner and went to bed.

 

 

Those who engage in this type of binge eating also tend to overeat generally. They tend to become overweight at an earlier age, be heavier, diet at an earlier age and diet more often than those who don’t binge. If a patient tells you they binge eat, don’t assume they have the same definition you do—ask them what they mean.

 

Another type of compulsive eating is called “night eating syndrome.” People with this syndrome tend to have no desire to eat in the morning, eat at least half the day’s calories after dinner, and suffer from insomnia. They often eat high calorie, primarily carbohydrate snacks when they awake during the night. These nocturnal snacks could easily be 300-400 calories per episode. Both binge eating and night eating syndrome tend to increase with increasing weight.

 

The last form of compulsive eating is overeating in response to a period of restrained eating. Clearly we are restraining or limiting our eating when we diet. But many who struggle with weight are restraining their eating even when they’re not on diets. They make food choices based on what they think they ought to eat as opposed to what they want to eat. As one woman put it, “I’m always on a diet. Even when I’m not on a diet, I’m on a diet.”  Once restrained eaters break their restraint (eat something they had been avoiding), they tend to continue eating high calorie-foods. This is the “I’ve blown my diet, so I might as well eat as much as possible before my next diet” phenomenon. As a rule, restrained eaters are more likely to eat greater quantities of food when they are stressed than are non-restrained eaters. What are the most common triggers for compulsive eating? Regardless of type, the two most common triggers are emotional stress or a small amount of a forbidden food.

 

Eating to maintain weight. We’ve addressed different categories of non-hunger eating. Another category has to do less with eating than with the weight itself. For some individuals excess weight serves an important purpose; as one patient eloquently put it, her fat is the “comforter she wraps herself in.” For some people, being heavy feels “safe” while being average weight does not. This is sometimes true of people who have been victims. Excess weight can feel safer because the person feels less attractive to predators and obesity feels safer because it tends to reduce our own expectations and that of others. The obesity provides a “wall of protection” against expectations. These expectations may be romantic, but because of the prejudice against obesity, could pertain to any personal, social, or professional issue. An individual may be aware of this motivation but it is sometimes out of awareness and only becomes apparent when weight loss becomes extremely anxiety-provoking.

 

For some people, weight loss puts important relationships at risk. Excess weight may function to balance power in a relationship and when a formerly obese person loses weight, one or more important people in his or her life have difficulty accepting the change. While a formerly obese person may be comfortable with the changes weight loss has brought, those very changes may upset the balance of a significant relationship. This can put the person in the unfortunate position of having to choose between new found health and a particular relationship. Some individuals choose to keep the relationship at the expense of their health.

 

In summary, there are the general cultural and environmental cues to overeat that we all have to manage. If we know a particular patient has developed eating habits based on external cues (e.g. time of day or the presence of food) or we see that the patient’s eating is impulsive or mindless, we have something specific upon which treatment can focus to help them reduce their unneeded calories. If we see that a patient is using food to manage certain emotions or relationships, treatment can naturally extend in other directions.

 

Traditional Treatment Methods

 

The only universally acknowledged method of weight loss is for a person to expend more calories than he or she takes in.  There is any number of ways to accomplish this. One can:

 

     exercise to increase energy expenditure,

     diet to limit intake in some fashion,

     take medication (pharmacotherapy) to limit intake by suppressing appetite or limiting absorption of nutrients or to increase energy expenditure chemically or hormonally,

     undergo surgery to limit intake through restriction and/or malabsorption.

 

Each of these methods may be used individually or in conjunction with education, behavior modification strategies, and emotional support.

 

Exercise. A patient who is reluctant to change his or her eating habits may prefer to increase physical activity in order to lose weight. This strategy is generally not very successful as the amount of physical activity necessary to significantly increase caloric expenditure is more than most people are able or willing to perform.  Studies have found that adding 30-60 minutes of physical activity three times a week to a low-calorie diet increases weight loss, on average, by about 4.5 pounds over the course of a six-month diet (Blair and Leermakers, 2002). Nonetheless, exercise plays a very important role in a patient’s life. Ideally it is part of whatever weight-loss strategy is employed. Exercise helps combat the reduction in resting metabolic rate that is caused by many diets. Strength training helps build and protect lean body mass so that the weight lost is mostly fat; further, regular physical activity appears to be essential in maintaining weight loss.

 

Diet. People have dieted throughout history. Diets have been created by physicians and dietitians, nutritionally sound or faddish, strictly an eating plan or part of an overall program including exercise and behavior modification, or primarily of social support. People have been successful with all these methods and many lose all the weight they want and keep it off. Others have lost the weight but been unable to keep it off, but most have been disappointed in the amount of weight lost.  People often attempt diets reported in the popular press, such as the cabbage soup diet, the grapefruit diet, the Atkins diet, the South Beach diet or one of the commercial programs such as Weight Watchers, Optifast, and Jenny Craig. If a person consults his or her physician, the typical recommendation is to exercise and go on a diet such as the diabetic exchange diet or to join one of the self-help (Take Off Pounds Sensibly, TOPS; Overeaters Anonymous, OA) or commercial programs. For the obese individual that has not had success with these diets, more restrictive diets may be recommended.

 

 

Examples of Restrictive Diets

 

 

Obese people (BMI>30) have likely tried various diets repeatedly and often gain more weight than originally lost following each diet. For these patients, bariatric physicians are likely to prescribe more restrictive diets such as the following. (“Bariatric” comes from the Greek words “Baros” meaning weight and “Iatrike” meaning treatment.)

 

Balanced Deficit Diets (BDDs) consist of ­reducing the patient’s caloric intake from 500 to 1000 calories daily. This level of caloric reduction can result in weight loss of one to two pounds per week and should not cause excessive loss of lean body mass. The composition of BDDs is typically low in fat, moderate in protein, and high in complex carbohydrates. For most patients, a multivitamin and up to 1500 mg of calcium is the only nutritional supplementation required. While this is a healthy way to lose weight, many obese patients become impatient and discouraged at the slow pace—and eventually stop following it. Also, depending on the weight-related co-morbidities, it may not be in the patient’s best interest to lose at such a slow pace.

 

Low Calorie Diets (LCDs) typically range from 800 to 1500 calories daily. As in BDDs, the composition of these diets is typically low in fat, moderate in protein, and highest in carbohydrates. They can be tailored to the food preferences of the patient and, if appropriate, can be combined with a prescribed appetite suppressant. Meal replacement products that support this calorie range, e.g., SlimFast, are readily available. Many commercial programs are consistent with this calorie range and provide products that support it, e.g., Weight Watchers’ frozen entrees. The success of an LCD is enhanced by a concurrent exercise program and ongoing behavior modification. In their clinical guidelines for treatment of obesity published in 1998, the National Heart, Lung, and Blood Institute recommended the use of LCDs for patients who wanted to lose 10% of their starting weight within six months.

 

Very Low Calorie Diets (VLCDs) typically range from 400 to 800 calories daily. They are below the resting metabolic rate of adults and so are likely to significantly reduce lean body mass as well as fat. The better programs include an exercise component (to help lessen loss of lean body mass) and, once the VLCD component is finished, assistance in developing appropriate dietary habits for weight maintenance.  

 

 

Research indicates that patients lose more weight initially on VLCDs than on LCDs. At the end of treatment however, regardless of its length, the weight loss maintained tends to be comparable for these two methods. (Tsai and Wadden, 2006) While it is possible to lose more weight initially with a VLCD, studies show that at the end of treatment both VLCD and LCD patients are typically down 5-11% from their starting weight (Wadden and Osei, 2002). Some physicians stimulate rapid weight loss by starting a patient on a very low calorie diet for some weeks and then, to avoid the health risks, change to an LCD or BDD for the remainder of the effort. 

 

Behavioral weight loss programs.  Behavioral weight-loss programs are typically diet and exercise programs that also take into account the environmental and psychological aspects of obesity.  These program include education, reinforcement techniques, goal setting, self-monitoring, stimulus control strategies, problem solving, preplanning, and relapse prevention (Wing & Phelan 2005, p. 302). Food intake is typically calorie driven (1000-1500 calories daily) and may include structured menus or meal replacements. Exercise is often prescribed at a level that burns about 1000 calories per week. These multifaceted programs have been found to be more effective than any single-faceted diet, exercise or behavior modification program (Wing, 2004).

 

The patient’s motivation and willingness to comply with the dietary plan is essential to its success. The healthiest, most efficient diet in the world will only succeed if the patient follows the plan. What we know about all of these methods is that a typical amount of weight loss for those who stick with the program for at least six months is around 5-10% of starting weight (Foster et al., 1997). Of course, these numbers are based on group statistics and some lose more, but most don’t. Unfortunately, whatever the diet or program, it is typical for dieters to regain all of their weight either immediately after stopping the diet or within one to five years (Perri and Corsica, 2002; Perri and Foreyt, 2004).

 

Pharmacotherapy. Can patients do better with chemistry?  Given what we know about biochemistry, there are a number of different treatment avenues that might be pursued. For example, we can use chemicals to:

 

     Suppress hunger

     Reduce the pleasure of eating

     Increase satiation

     Strengthen satiety

     Reduce absorption

     Modulate food preferences

 

Through medication, bariatric physicians attempt to:

 

     reduce energy intake by suppressing appetite (e.g. phentermine or sibutramine) or decreasing absorption (e.g., orlistat) or to

     increase energy output by speeding up metabolism (e.g. ephedrine and caffeine)

 

Sibutramine and Orlistat are approved for long-term use. Phentermine is approved for a period of weeks and is often prescribed intermittently.  In their Winter 2004 issue, The Bariatrician (official publication of the American Society of Bariatric Surgeons) published a meta analysis of the drugs most frequently prescribed for weight loss (Meridia, Orlistat, Fastin, Tenuate, Prozac, Wellbutrin, Topamax, and Zonegran).  The results of these medications have been evaluated in several studies, some more controlled than others. According to The Bariatrician, the best results in the more controlled studies were a loss of 6.5% of initial weight. The average result for all the studies, regardless of quality, was a loss of 7-10% of initial weight within six months.

 

With medication, most patients do not lose significantly more weight after the initial six months (Wadden and Osei 2002). If they stop taking the drug after the initial weight loss, however, patients typically regain all of their lost weight. In order to maintain their initial weight loss patients must continue taking the medication indefinitely. Bray (2002) makes the point that obesity is a chronic problem rarely cured and, like other chronic illnesses, may need lifelong treatment. As researchers learn more and more about the physiological aspects of energy intake and output, they continue to work at developing more and more effective pharmacotherapy solutions to the problem of obesity.  As one article in the Seattle Times summed it up, “Genetics made us ready to gain weight when the environment allowed it – and now the environment allows it all the time. People can prevail over their genes – though few succeed in the long term….most people can shave no more than 5 to 10 percent off their “natural” body weight by exercising and eating wisely….”.  Many patients are much more than 5-10% overweight and weight-loss surgery is becoming more and more popular.

 

WEIGHT LOSS SURGERY AS A TREATMENT FOR OBESITY

 

As discussed earlier, obesity is a disorder with a number of biological, psychological and social causes and treatments for the disorder have been disappointing.  No matter how hard they try, individuals who are obese typically lose only about 10% of their initial weight following the traditional treatments of dietary restriction and exercise, even when aided by medication.  Unless dieters are able to change their lifestyle enough to sustain a reduced weight, they will regain all if not more of the weight lost within two years.  Yo-yo dieting (losing weight only to regain it) is a frustrating process for most dieters.  Here’s how one dieter describes his dieting experience.

  

 

Case Example

 

 

“I am a compulsive overeater.  For most of my life, especially from my college years and beyond, my weight became untenable.  I tried all the various weight-loss programs around.  On more than one occasion, I lost in excess of 100 pounds.  Each time [when a diet was stopped] I put the weight back on—and more.  Once my weight reached 375 pounds, things in my life began to deteriorate.  I could no longer participate in many activities I loved—it only caused me to retreat more and more into food and denial.  I lived in denial for a couple of years.  I kept putting on more weight.  My weight began to affect my job performance and ultimately cost me my job.  I suffered from severe sleep apnea and arthritis.  I became a social recluse hiding in food and planning my next meal.  I felt like I was in a living hell with no hope of ever getting out.”

 

 

Of course, not every dieter’s experience is so dramatic but most of the obese feel a sense of helplessness and hopelessness. They are often desperate for a way to reduce their weight and improve or resolve weight-related medical conditions.  When an individual is about 100 pounds overweight, has repeatedly dieted and regained weight, especially if they have serious obesity-related medical conditions, they may look to surgery as a solution to their weight and health problems.

 

Bariatric surgery was an accidental discovery.  Surgeons found that patients with stomach cancers or ulcers who had portions of their stomach removed experienced a decreased appetite and lost weight. Since the 1950’s, experimentation has led to the design of three types of surgery to treat obesity. The amount of sustained weight loss patients have been able to achieve with surgery has been far superior to that accomplished via any other method.  These procedures typically help the obese patient lose between 47% and 80% of their excess weight. Five years after initial weight loss, many weight-loss surgery patients have maintained as much as 80% of their initial loss. 

 

This section serves as a basic primer on the various types of weight-loss surgery and their contribution to the successful treatment of obesity.  Three categories of weight-loss surgery will be discussed including restrictive, combined restrictive and malabsorptive, and malabsorptive surgical procedures. An in-depth medical discussion of each surgery is beyond the scope of this course but may be found in Update: Surgery for the Morbidly Obese Patient (Deitel and Cowan, 1998).  An alternative source is Bariatric Surgery: A Primer for Your Medical Practice (Farraye and Forse, 2006).

 

The Digestive System

 

To understand how weight-loss surgeries work to produce weight loss, it is important to know a little about how the digestive process works.  The mouth is the beginning of the digestive system (see Figure).  In the mouth solid foods are broken up in the process of chewing (mastication).  The salivary glands contribute liquid and enzymes to the chewed food making it easy to swallow.  Swallowed food passes into the esophagus which is a muscular canal about nine to ten inches long that connects the mouth to the stomach.  Muscular fibers throughout the length of the esophagus propel food and liquid to the stomach through the process of peristalsis.

 

figure1digestivesys400image

The stomach is an expandable organ that is a small wrinkled bag when empty.  When food passes from the esophagus into the stomach, the walls of the stomach stretch.  The average stomach stretches to hold about 32 ounces of food but larger stomachs may hold considerably more.  For example, legend has it that 19th century businessman, financier and philanthropist, Diamond Jim Brady, known for eating copious amounts of food, had a stomach capacity six times average.

 

In the stomach, food is mixed with several digestive juices (including pepsin, rennin, and hydrochloric acid).  No absorption of nutrients takes place in the stomach.  From the stomach, food passes into the small intestine (small bowel) which is divided into three portions:  the duodenum, the jejunum, and the ileum.  The entire length of the small bowel is approximately 22 feet.  Its internal walls are pleated, like the folds of an accordion and are lined with microvilli.  In the small intestine, food is broken down by a number of additional digestive juices (some produced within the small intestine and others produced by the liver, gallbladder and pancreas).  Nutrients in the food are absorbed in the small intestine for use by the body.  Most absorption of carbohydrates, proteins, and fats takes place in the jejunum and the first portion of the ileum. Large portions of the small intestine may be removed without greatly hampering the absorption of nutrients.  Because certain elements are primarily absorbed in a single area of the small intestine (such as B12 in the lowermost portion of the ileum, iron in the duodenum, and folic acid in the upper jejunum), surgical removal of these areas results in deficiency.  Taking nutritional supplements usually remedies the deficiency.

 

Once processed by the small bowel, the food residue passes into the large intestine.  The large intestine (colon) can be viewed as a waste processor that prepares the food residue to be eliminated from the body.

 

Early Weight Loss Surgeries

 

In the early days of weight-loss surgery, two procedures were developed:  the Jejunoileal Bypass (I-J), a malabsorptive procedure and the Horizontal Gastroplasty (HG), a restrictive procedure.  In the I-J, large portions of the small intestine were bypassed resulting in a significant reduction in calories and nutrients absorbed from the food consumed.  Following the procedure, patients did lose weight but they experienced many serious complications including such things as malnutrition, electrolyte imbalance, and chronic diarrhea.  Some complications could be resolved with reversal of the procedure but others could not. (Additional information on the I-J and other procedures is available at American Society for Metabolic & Bariatric Surgery).

 

The HG partitioned the stomach into a small upper pouch and a large lower pouch with a tiny outlet between the two.  The intent of the surgery was to produce satiety (the feeling of fullness and satisfaction) with a reduced amount of food and by delaying the emptying of the stomach.  The operation was relatively simple and had few complications but its long-term results were disappointing.  The upper pouch stretched and the opening between the pouches enlarged.  Patients felt hungry and were able to increase the amount and frequency of consumption and, as a consequence, they regained weight.

 

Because of the number of serious complications experienced with I-J and the high failure rate of HG, surgeries for weight loss became unpopular with many physicians and patients.  In spite of the disappointing results, dedicated surgeons continued their experimentation.  Over the years, they have altered the procedures enough to significantly improve the safety of surgical weight loss as well as reduce the severity of complications. Variations of the surgeries continue to be developed, but surgery for weight loss is no longer considered experimental.  Each year an increasing number of weight-loss surgery procedures are done and achieving considerable success. Public awareness and response has dramatically increased as more celebrities have positive experiences with weight-loss surgery such as the following:

 

     Roseanne Barr (Silastic Ring Vertical Gastroplasty, aka Fobi-Pouch),

     Carnie Wilson and Al Roker (Roux-en-Y Gastric Bypass)

     Sharon Osborn (Adjustable Lap-Band) shared

 

Recent and Current Weight Loss Surgeries 

 

Restrictive procedures. Restrictive surgical procedures are designed to facilitate weight loss by dramatically limiting the amount of food that can be consumed at one time.  Because the limitation in consumption is designed to be permanent, it is possible for weight loss to also be permanent. 

Figure 2 gastricbanding 

Restrictive surgeries include Gastric Bandings and Gastroplasties.  Gastric Banding involves placing a collar of synthetic material around the upper end of the stomach (see Figure above). The band is placed on the upper portion of the stomach to create a small pouch of about a 3 or 4-ounce capacity.  A narrow passageway allows food to flow from the small upper pouch into the larger lower portion of the stomach.

Figure3 vertical banded gastroplasty 

Vertical Banded Gastroplasty (VBG) and Silastic Ring Vertical Gastroplasty (SRVG) involve sectioning off a small stomach pouch from the large stomach.  During the procedure, a section along the small curve of the upper portion of the stomach near the esophagus is separated from the larger stomach with several rows of surgical steel staples.  In VBG a strip of plastic mesh is placed through the stomach wall at the bottom of the stapled pouch to reinforce the opening and to maintain its size and shape (see Figure above). 

Figure 4 srvg 

In SRVG the outlet of the stapled pouch is reinforced and maintained by a small silicone tube (see Figure above). The stapled pouch may or may not be divided from the larger stomach.  Immediately following surgery, the stapled pouch will hold approximately 1 or 2 ounces.  Gradually it stretches to a maximum capacity of about 4 to 8 ounces.

Figure 5al-b 

The newest form of gastric banding is the Adjustable Lap-Band.  The Adjustable Lap-Band uses a hollow silicone collar that is connected to a tube with an outlet (port) located under the skin on the upper abdomen (see Figure above).  The collar is made tighter or looser by adding or removing saline solution through the port.  Adding saline inflates the collar narrowing the passageway and slowing the flow of food into the lower stomach.  Removing saline solution deflates the collar enlarging the passageway and allowing food to flow more freely into the lower stomach.  Adjustments in the collar are made by inserting a needle into the access port. It typically takes several adjustments to get the band fitted properly and then as patients lose weight and their body changes, further adjustments become necessary.

 Figure 6 sleeve gastrectomy

Sleeve Gastrectomy is the newest restrictive procedure.  In the Sleeve Gastrectomy, the surgeon removes up to 90% of the greater curvature (left side) of the stomach.  The remaining stomach is roughly the size and shape of a small banana (see Figure above). For some patients Sleeve Gastrectomy is the only surgical procedure used to treat their obesity.  For patients with a BMI greater than 60 and/or who have medical conditions or a body shape that makes other weight-loss surgeries too risky or difficult, Sleeve Gastrectomy may be the first stage of a two-stage surgical process.  When medically safe, the Sleeve Gastrectomy is converted to a Gastric Bypass or Biliopancreatic Diversion/Duodenal Switch.

 

With the exception of the Sleeve Gastrectomy, most restrictive weight-loss surgeries do not remove any body organs or alter the normal digestive process.  As rapid weight loss may lead to the development of gallstones, the gallbladder may be removed at the time of surgery if preoperative tests reveal any sign of disease or if disease is evident at the time of surgery.

 

Reliable statistics about the success of weight-loss surgeries are difficult to obtain. For patients in the United States, sources report a success rate of 47 to 53% for restrictive weight-loss procedures (Bariatric Edge). As noted above, some patients lose less weight and others more.  To achieve the best possible weight loss, patients must follow a number of dietary and eating guidelines. The specific guidelines vary somewhat from program to program but are generally reflected in the following chart. (Additional information on restrictive procedures is also available at ASBS).

 

 

GENERAL dietary guidelines

 

 

·         Eat a prescribed number of small meals per day (typically 3 to 6)

·         Don’t snack between meals

·         Eat foods high in protein and low in sugar and fat

·         Limit food intake to a recommended portion size

·         Stop eating at the first sign of fullness

·         Eat slowly and chew food well

·         Don’t eat and drink at the same time

·         Avoid or limit use of alcoholic beverages and marijuana

·         Drink 64 ounces of calorie-free or low-calorie fluids per day

·         Take recommended vitamin and mineral supplements, as needed*

 

* Due to the significantly decreased food intake in restrictive procedures, a multiple vitamin is often recommended to replace the nutrients that are no longer being consumed in the food itself. Daily vitamin and mineral supplementation is mandatory following combined restrictive-malabsorptive and malabsorptive procedures.  In addition to a complete multivitamin, patients may need to take extra B1, B12, Vitamin D, iron, calcium, and folic acid.  RYGB/Distal, BPD and BPD/DS patients may need additional A, D, E, and K.  Failure to follow the nutritional guidelines may result in medical conditions associated with malnutrition. 

 

 

Failure to follow these guidelines may limit a patient’s weight loss or cause some weight regain.  Very poor dietary habits may result in a patient regaining all of, or even more than, the weight lost following surgery.  Patients who are unable to benefit from a restrictive surgery may choose to revise their procedure to one of the combined-restrictive or malabsorptive procedures. Revised procedures tend to be less successful however, as patients who do not successfully change their lifestyle with their first surgery frequently fail to consistently do so following a second surgery.

 

Combined restrictive and malabsorptive procedures. Combined restrictive and malabsorptive procedures maintain the creation of a small stomach pouch that reduces consumption capacity and adds a mildly to moderately malabsorptive component.  To create the malabsorptive component the large lower portion of the stomach and a portion of the small intestine are bypassed, delaying the mixing of food with gastric secretions, bile and pancreatic juices needed to allow nutrients to be absorbed from the food.  A side effect common to these surgeries is the “Dumping Syndrome”.  Dumping involves a number of unpleasant hypoglycemic symptoms that discourages the consumption of high sugar foods, which may sabotage weight loss. Consumption of foods high in fat content may lead to similar symptoms. The most common restrictive-malabsorptive weight-loss surgeries are the Roux-en-Y Gastric Bypass (RYGB/Proximal), elongated Roux-en-Y Gastric Bypass (RYGB/Distal), and Silastic Ring Gastric Bypass (SRGB).

 

Figure 7 rygbproximal

The RYGB/Proximal is the most frequently done surgery for weight loss in the United States. During the procedure, a small pouch at the top of the stomach just below the esophagus is stapled off completely (see Figure above).  The position of the pouch may be horizontal or vertical and it is typically divided (transected) from the large lower stomach.  The small intestine is divided beyond the duodenum (a length of about 2 to 3 feet) and the remaining portion of the intestine attached to the large intestine (the Roux limb, a length of about 19 to 20 feet) is attached to the stapled pouch.  The duodenum (bypassed portion) is then reattached to the Roux limb creating a Y-shape. 

 

Figure 8 rygbdistal

The RYGB/Distal is basically the same as the RYGB/Proximal procedure except for the length of the bypassed small intestine (see Figure above).  In this procedure the length of bypass is approximately 6 feet.  The longer bypass is designed to increase malabsorption, encourage greater weight loss, and discourage weight regain.  Because of the increased malabsorption, the procedure is sometimes classified as a malabsorptive procedure.  As it mainly works by restricting consumption, it is included here in the combined restrictive-malabsorptive procedures.

 

Figure 9 srgb fobi pouch

The SRGB (also known as the Fobi-Pouch) involves the creation of a stapled pouch of about 1 to 2 ounces (see Figure above).  The very small size of the pouch is maintained by placing a silastic ring at the outlet between the pouch and the small intestine.  The maintenance of the small size of the pouch is designed to keep consumption very restricted in order to promote better weight loss and maintenance.  The lower stomach and a portion of the small intestine are bypassed as in the RYGB/Proximal procedure. 

 

The consumption capacity of the RYGB/Proximal and Distal stapled pouch immediately after surgery is about 1 to 2 ounces.  Over time, the stapled pouch does stretch to a consumption capacity of from 4 to 8 ounces.  The size of the SRGB pouch is designed to remain at approximately 2 ounces. 

 

No organs are removed during the combined restrictive/malabsorptive procedures.  The digestive process is, however, altered by the bypassing of a portion of the intestine.  As with the restrictive procedures, the gallbladder may be removed if presurgical tests show signs of disease or disease is noted at the time of surgery.

 

See the previous Table for the recommended dietary guidelines. Note that the vitamin and mineral supplements are greater for patients who have had a combined restrictive/malabsorptive procedure. Failure to follow these guidelines may limit a patient’s weight loss or cause some weight regain.  Very poor dietary habits may result in a patient regaining all of, or even more than, the weight lost following surgery. Not taking the necessary vitamin and mineral supplements may contribute to conditions associated with malnutrition. Patients who are unable to benefit from a combined-restrictive or malabsorptive procedure may choose to have their surgery converted to a malabsorptive procedure.

 

Sources on the success of these procedures indicate a typical loss of 61.6% of excess weight loss for RYGB/Proximal patients and 64% for RYGB/Distal patients (Additional information on malabsorptive procedures is available at ASBS). As with all weight-loss surgeries, patients lose more or less weight depending on how diligently they follow post-surgical nutrition and exercise guidelines. (Additional information on restrictive and malabsorptive procedures is available at ASBS).

 

Malabsorptive procedures. The malabsorptive weight-loss surgeries are mildly restrictive and mainly malabsorptive.  These procedures include Biliopancreatic Diversion (BPD) and Biliopancreatic Diversion/Duodenal Switch (BPD/DS).  Extensive surgeries such as the BPD and BPD/DS involve the removal of a portion of the stomach and a bypassing of a significant amount of the small intestine.  The gallbladder and appendix are also removed in order to avoid possible confusion of symptoms of gallbladder disease or appendicitis with complications associated with the procedure.

 

Figure 10 bpd

In the BPD the surgeon creates a smaller sized, rounded shaped, pouch by removing about three-fourths of the stomach (see Figure above).  The pylorus (the small valve at the bottom of the stomach that regulates the release of stomach contents into the small intestine) is not retained.  The small intestine is divided approximately in half and reconfigured into two channels.  One channel is attached to the stomach and carries food.  The other channel carries digestive juices from the liver and pancreas.  The longer separation of food and digestive juices increases malabsorption (especially of fat) over that of the shorter gastric bypass procedures.  The two channels of the intestine join together in a short common channel where a significant amount of nutrients in the food consumed is absorbed. 

 

Figure 11 bpd-ds

The BPD/DS differs from the BPD in the shaping of the new pouch into a tube rather than a ball, the retaining of the pylorus, and the manner in which the small intestine is divided and diverted (see Figure above).  Surgeons who shape the stomach into a tube retaining the pylorus do so to prevent the dumping syndrome often experienced by gastric bypass patients and possibly experienced by BPD patients.  There is, however, some question as to whether BPD patients do, in fact, experience dumping at all.  In the BPD/DS the duodenum of the small intestine is left attached to the bottom of the pouch below the pylorus.  The intestine is divided just below the place where the bile duct intersects with the intestine so that the drainage of the pancreatic juices and bile are bypassed.  The remaining intestine is then divided approximately in half with the lower section reconnected to the duodenum.  This lower portion of the intestine is called the alimentary channel and is attached to the large intestine or colon.  The top portion of the divided intestine is reattached to the colon and becomes the common channel where food and digestive juices are combined for digestion.  This is called the biliopancreatic limb. 

 

Although limited in portion size immediately after surgery, BPD and BPD/DS patients can eventually eat average size portions of food.  A portion of the stomach, the gallbladder, and the appendix are removed.  As with the restrictive-malabsorptive procedures, the digestive process is altered.  Because the primary way in which these surgeries work to reduce weight is malabsorption of calories and nutrients, eating a nutritious diet is essential.  Available sources on the success of malabsorptive surgeries report an average weight loss of 70 to 80% of excess body weight with some patients losing less or more (Bariatric Edge).  Regaining a significant amount of weight following a malabsorptive procedure is rare. (Additional information on malabsorptive procedures available at ASBS).

 

Special Considerations

 

Each type of weight-loss surgery has inherent strengths and weaknesses, and advantages and disadvantages.  A comprehensive description of these is found in A Complete Guide to Obesity Surgery (Woodward, 2001).  In brief, some of these include the following:

 

     The more restrictive and less malabsorptive the procedure, the more behavioral change (caloric regulation and exercise) is required for success. 

     Restrictive procedures only limit consumption capacity, they do not prohibit the ingestion of high calorie foods and beverages.

     To protect the pouch from expanding so that increased amounts of food is needed to experience fullness, patients must practice dietary guidelines such as eating slowly and separating liquids and solids. 

     Failure to do these things will likely minimize weight loss or result in weight regain.

 

Each type of weight-loss surgery has the potential side effect of food intolerance.  Patients who have restrictive procedures often experience intolerance of high-density foods (those high in fiber), including discomfort and vomiting.  Both restrictive and combined restrictive-malabsorptive procedures require changes in eating behavior.  Eating too fast, not chewing food thoroughly, or overfilling the pouch may result in discomfort and, sometimes, vomiting.

 

Combined restrictive-malabsorptive procedure patients often have an intolerance of sweets.  Eating foods or drinking beverages high in sugar often contributes to the “dumping syndrome”.  The dumping syndrome involves a number of unpleasant physical sensations typical of hypoglycemia. Malabsorptive and combined restrictive-malabsorptive procedure patients may experience fat intolerance.  Eating foods high in fat often results in diarrhea.  Patients may also experience lactose intolerance with its symptoms of nausea, bloating, gastro-intestinal distress, and diarrhea.  The more malabsorptive procedures contribute to changes in bowel function.  Patients typically have several loose stools per day.  Flatulence and stool odor may be quite foul contributing to social embarrassment and, in severe cases, social isolation.  Eating “junk foods” may increase this problem.

 

Patients are at risk for nutritional deficit following the combined restrictive-malabsorptive procedures and the malabsorptive procedures.  To avoid deficiency, patients must take vitamin and mineral supplements for life.  Patients are encouraged to have regularly scheduled blood tests to assess nutritional health and to determine needed adjustment in vitamin and mineral supplementation.  Eating a diet high in protein is also recommended. As restrictive procedure patients have a significantly reduced food and calorie intake, taking a complete multivitamin daily is recommended.

  

Surgical Methods

 

The open method.  Traditionally, weight-loss surgeries have been done via an “open” surgical method.  The open method involves an incision down the midline of the torso from the breastbone to the navel or pubic area.  The advantage of the open method is that it enables the surgeon to perform the procedure with a clear view and with “hands-on” precision.  Depending on the type of weight-loss surgery done, and barring complications, hospitalization after an open procedure is 3 to 7 days with at-home recovery averaging 4 to 6 weeks.  Patients who have physically active jobs and are required to return to work without restriction may require a longer recovery period.

 

The laparoscopic method. Increasingly, restrictive and combined restrictive-malabsorptive weight-loss surgeries are done by the laparoscopic method.  The laparoscopic method is minimally invasive and has fewer risks and complications.  There is also minimal discomfort, scaring, and a briefer recovery time.  In the laparoscopic method, the surgery is performed with the aid of a fiberoptic tube and light source attached to a small video camera.  This instrument allows the surgeon to see the abdominal organs and manipulate the surgical instruments while viewing a TV monitor.  The surgical instruments are inserted through several small (4 to 6) incisions about ¼ to ½-inch in length that are located around the abdomen.  The surgeon applies the same surgical principles of doing weight-loss surgeries laparoscopically as would be done in open procedures.

 

The laparoscopic method is not without risk.  The procedure should be done by a surgeon who is experienced with weight-loss surgery in general and with laparoscopic weight-loss surgery in particular.  Depending on the type of surgery, and barring complications, hospitalization after a laparoscopic procedure is usually 1 to 2 days and at-home recovery is a few days to a few weeks.  Some surgeons do the laparoscopic Adjustable Lap Band procedure on an outpatient basis.

 

Not every patient is a candidate for the laparoscopic method.  Some surgeons may have size, shape, and distribution of fat requirements.  Adhesions from previous abdominal surgeries or size and placement of organs may rule out the laparoscopic method.  One of the most important goals for a surgeon is to complete surgery as safely as possible.  Surgeons advise patients before surgery about their appropriateness for the laparoscopic method and the possibility of needing to convert from a laparoscopic to an open method if it would be safer to do so.

 

Risks, Complications, and Side Effects

 

Weight-loss procedures have risks and complications common to all major surgeries.  These may include allergic reaction to drugs, excessive bleeding, abscess, pneumonia, blood clotting, pulmonary embolism, cardiac arrhythmia, wound separation or infection, lung collapse, and hernia.   Patient size and general health may influence risks and complications, with those who are very large or who are in poor health being especially vulnerable.  Each category of weight-loss surgery has some procedure-specific risk factors, complications, or possible side effects.  These include, but are not limited to, those listed below.

 

 

Weight-Loss Surgery Risks

 

 

Restrictive Procedures:

 

     Frequent vomiting

     Intolerance of some foods (especially fibrous foods)

     Constipation

     Blockage of the band or ring

     Poor emptying of the pouch due to constriction of the band or ring or to the build-up of scar tissue

     Staple-line leak or failure (stapling procedures only)

     Slippage of the band or ring or penetration of the band or ring into the stomach (lap-banding procedures only)

     Reduced weight loss or weight regain due to non-compliance with dietary and exercise guidelines.

     Loose and/or hanging skin

 

 

Combine Restrictive/Malabsorptive Procedures:

 

     Sugar intolerance leading to dumping

     Lactose Intolerance

     Peritonitis due to leak at staple line or stoma

     Small bowel obstruction

     Malnutrition due to malabsorption

     Anemia

     Liver abnormalities

     Osteoporosis

     Constipation

     Increased gas

     Temporary thinning of the hair or hair loss

     Inability to utilize time-released or enteric-coated pills

     Reduced weight loss or weight regain due to non-compliance with dietary and exercise guidelines.

     Loose and/or hanging skin

 

 

Malabsorptive Procedures:

 

     Fat intolerance leading to diarrhea

     Lactose intolerance

     Peritonitis due to leak at staple line or stoma

     Small bowel obstruction

     Malnutrition due to malabsorption

     Anemia

     Frequent, loose stools

     Gas and stool odor

     Temporary thinning of the hair or hair loss

     Inability to utilize time-released or enteric-coated pills

     Osteoporosis

     Liver abnormalities

     Reduced weight loss due to non-compliance with dietary and exercise guidelines

     Loose and/or hanging skin

 

 

Compounding any possible risk factors, complications, and side effects is patient compliance with pre- and post-surgical recovery guidelines.  Patients must be full-partners with their surgeon in protecting their health.  This means diligently following all pre- and post-surgical treatment recommendations carefully.  Failure to do so may increase risk, side effect, and complication rates.

 

Choice of Procedure

       

Surgeons and patients may have similar or differing goals regarding choice of weight-loss procedure.  Surgeons may focus on doing the procedure that is medically safe for a given patient and that reduces weight enough to improve or resolve medical conditions and improve quality of life.  For example, RNYGB has demonstrated remarkable success in putting Type 2 Diabetes in remission and, barring other relevant factors, would likely be a surgeon’s procedure of choice for a patient with the condition.  AL-B may not be recommended for patients who have medical conditions such as Crohn’s disease or a history of gastric ulcers.

 

Patients, however, may focus on a procedure they feel is the safest, least invasive, has minimal pain, a quick recovery, small scars, and contributes to the greatest weight loss.  Some patients are uncomfortable about the re-arranging or removal of organs, about having “foreign objects” in the body, or about the required follow-up for a procedure.  Also, many patients want a procedure that is reversible.  For example, some patients choose the Adjustable Lap-Band because it is done laparoscopically and no organs are removed or rearranged. Recovery time following the procedure is brief and there is little pain and only a few small scars.  In addition, the procedure is easily reversed; although, reversing the procedure usually results in weight regain. On the other hand, some patients are put off by the thought of having a foreign object in their body, the potential need to replace device parts, or by the ongoing need to adjust the band, commonly referred to as getting a “fill.” Fills are done by inserting a needle into the access port placed under the skin of the abdomen and injecting or withdrawing saline solution through the band via the tube connecting the band and the port. Patients may also want a greater weight loss than is typical for the Adjustable Lap-Band.

 

Another factor involved in procedure choice is appearance.  Most patients, and often surgeons, want to achieve a weight loss that results in a “normal” appearance.  By this they mean being of average size and shape where the patient no longer stands out as overweight or unshapely. For many weight-loss surgery patients this is an elusive, if not impossible, goal. As noted above, sources indicated a typical weight loss of between 47 and 80% of excess body weight following weight-loss surgery (Bariatric Edge).  That means that for every 100 pounds a patient is overweight, weight-loss surgery typically contributes to a loss of 47 to 80 pounds.  The typical patient will measure overweight or obese on the BMI tables even after significant weight loss. The patient’s surgery preference may depend on his or her pre-surgery weight and which procedure they think is most likely to achieve their goal. Many patients have to cope with the excess skin folds that result from significant or massive weight loss or manage the cost and rigors of cosmetic surgery. Some patients mistakenly believe that procedures yielding a slower weight loss will automatically result in less excess skin.  Additionally, some surgeons and most patients want a weight-loss procedure to work like “magic”, to be effortless.  While the procedures may initially control appetite and weight loss may be rapid, weight-loss surgeries are just tools.  Patients must learn and practice healthy lifestyle habits for a lifetime if they are to receive maximum benefit from their procedure.  This requires making a number of lifestyle adjustments and maintaining those adjustments in order to experience continuing success.

 

Lifestyle Adjustments

 

Studies of dieters who lose weight and keep it off show that successful weight loss and maintenance is possible if patients permanently replace unhealthy behavior with healthy lifestyle habits.  The most obvious healthy habits are eating less and moving more.  While surgery helps patients satisfy physical hunger when eating less, it does not address all the non-hunger reasons people eat.  Non-hunger eating is about satisfying a variety of social and psychological needs.  These include bonding with others, soothing distressing thoughts and feelings, managing or avoiding life stresses, having a treat or reward, or simply enjoying the taste and texture of food.  Successful weight management after surgery requires patients to identify the needs prompting their non-hunger eating and to find alternative ways to satisfy those needs.  Patients vary in how ready, willing, and able they are to make lifestyle changes. Here’s what one patient had to say about her readiness for change:

 

 

Case Example

 

 

“I binge on high fat foods for several reasons.  Eating soothes me.  It brings me comfort.  It takes me away from my problems.  I can distract myself from the reality of my life’s disappointments.  In some ways it is easier to hide in food and present myself to the world in a fat body than it is to admit that I have many disappointments in my life.

 

Having weight loss surgery and losing 95 pounds has forced me to hit a wall of reality.  But I have not yet made a real commitment to tackle the issues in my life that I need to.  For me the surgery is a tool.  It is not the magic wand I hoped for.  But it has enabled me to start on a difficult, long path—one that leads over a huge mountain.  I hope I can stay on the path and climb over the mountain.”

 

 

This patient initially lost 95 pounds but, unable to sufficiently resolve the issues behind her non-hunger eating and regained most of the lost weight.

 

Multifactoral Treatment

 

Surgeons provide the tool that can help obese patients lose and sustain a greater weight loss than possible with traditional dieting.  Dietitians provide useful information to help patients eat better so they can lose weight and be healthy.  Exercise specialists help patients of varying size and ability identify physical activities they can do comfortably and enjoy.  All these professionals are essential to patient success.  Some weight-loss surgery programs believe these professionals are enough, but they are not.  Each treatment team also needs at least one mental health professional.  Only the mental health professional has the training needed to help patients manage the psychosocial issues and obstacles involved in making lifestyle changes.  The next section will discuss the pivotal role the mental health professionals play in helping patients prepare for and make the lifestyle adjustments necessary to a successful surgery outcome.

 

PSYCHOSOCIAL ISSUES

 

While obesity is a medical disorder with potentially severe co-morbidities, research (and our more than 30 years of cumulative experience) indicates there is a significant psychological component to many patients’ weight and weight-loss problems.  The psychosocial aspects of the weight-loss surgery patient are critically important and should be addressed in every comprehensive weight-loss surgery program. The patient’s ability to lose weight and maintain that loss, as well as his or her overall quality of life, is significantly affected by psychosocial issues. The purpose of this section is twofold: to present a rationale for psychosocial evaluation and treatment and to recommend the elements to be included in a weight-loss surgery program.  To address these issues, we begin with a brief literature review.

 

O’Neil and Jarrell (1992) completed a review of psychological literature for inclusion in the book, Treatment of the Seriously Obese Patient. The information they gleaned was from studies on the severely obese patient presenting for treatment in a variety of weight-loss settings, including those treating with traditional dieting methods as well as surgery.  Studies focusing solely on the surgical weight-loss patient support add to their findings (See also Wadden, Womble et al., 2002; Sarwer, Wadden, and Fabricatore, 2005 for recent reviews). Psychosocial issues for the obese include painful psychological characteristics, destructive eating behaviors, body image distress, and emotional problems related to weight loss.  Regarding psychological characteristics, overweight individuals are described as “more depressed and self-conscious, and less assertive than normal-weight individuals” (p. 254). Studies have reported that surgical weight-loss candidates are frequently depressed, anxious, socially withdrawn, have an inaccurate and/or poor body image, and engage in some type of disordered eating (DiGregorio and Moorehead, 1994).

 

Our experience with several thousand weight-loss surgery patients supports the findings of these and many other studies.  There is a wide spectrum of psychosocial health among the clinically obese. The spectrum includes patients who do not demonstrate any psychosocial issues known to undermine successful weight loss following weight-loss surgery.  However, it includes numerous patients who demonstrate psychosocial distress significant enough to challenge or sabotage surgical outcome or to contribute to a complete surgical failure.  As DiGregorio and Moorehead (1994) sum up, “Surgical success requires that…patients initiate and maintain dramatic habit and attitude change. Of additional import, persons with morbid obesity bear a direct exposure to psychological risk and sequelae. These factors clearly establish the need for standardized comprehensive protocols of psychological care, across the continuum from prescreening through attainment and maintenance of desired post-surgical body weight” (p. 366).

 

The presence of psychosocial issues and patterns of eating that may negatively impact surgical outcome provides the rationale for including a psychosocial component in every weight-loss surgery program.  The focus should be two-fold: First, to provide the surgeon, multidisciplinary treatment team, and patient with information important to making an informed decision about weight-loss surgery.  Second, to provide the patient and treatment team with treatment guidelines, resources, and support designed to contribute to the best possible surgical outcome.  These rationales suggest that the basic elements of the pre-surgical psychosocial component of a weight-loss surgery program should include:

 

     An evaluation of each patient, including any necessary pre- and post-surgery treatment recommendations

     Patient education and support, including on-going consultation with the treatment team regarding each patient’s progress and needs

 

Pre-Surgical Psychosocial Patient Evaluation

 

The scope of psychosocial and eating disorder issues that may impact successful weight loss following weight-loss surgery warrants the pre-surgical evaluation of every patient.  It is critically important that the mental health professional (MHP) who conducts this psychosocial evaluation is trained and has experience in the potential issues and treatment of the weight-loss surgery patient. Those who are not trained often make the mistake of believing the surgeon is just asking for a “rubber stamp” approval so that surgery can occur. Alternatively, they may recommend against surgery because they believe any eating issues must be resolved before surgery can be effective or that surgery is a “cop-out” and if the patient is ready, he or she should be able to lose weight without surgery. Having the evaluation completed by a MHP who is a recognized member of the multidisciplinary treatment team contributes to a positive therapeutic alliance between the MHP and the patient.  The positive therapeutic alliance encourages the patient to see the MHP as an active member of the treatment team who is interested in his or her success.   The positive therapeutic alliance may encourage greater patient disclosure in the evaluation.  It also encourages the patient to seek the assistance of the MHP whenever needed following surgery. 

 

The evaluation process we recommend is similar to that used in the eating disorders program at the University of Pennsylvania (Wadden, Foster and Letizia, 1994). In the opinion of Wadden et al. (1994) the process has five principal goals (p. 290):

 

1.  Obtaining a psychosocial history

2.  Assessing the etiology of the patient’s obesity

3.  Identifying behavioral contraindications to treatment

4.  Determining goals of therapy

5. Preparing patients for treatment

 

Wadden et al. (1994) state unequivocally their belief “that the initial interview is best conducted by a mental health professional (i.e. psychologist, psychiatrist, social worker, or mental health counselor) who is knowledgeable of the causes and treatment of obesity.   Mental Health practitioners are better able to judge than are other health professionals (e.g., dietitian, exercise specialist, physician) whether patients have significant behavioral or psychiatric complications that require treatment or that might be affected by weight reduction therapy.  Mental health practitioners, however, should be aware that the initial behavioral interview… differs markedly from the psychosocial interview conducted with persons typically seeking psychiatric care.” (p. 307)

 

A number of years ago one of us (Dr. Andrews) chaired a group of MHP professionals in Dallas, Texas to discuss the psychosocial evaluation and treatment of the weight-loss surgery patient.  In that meeting, the professionals agreed that the psychosocial evaluation experience should be meaningful to the surgeon, his or her treatment team, and to the patient. 

 

 

Pre-Surgical EVALUATION components

 

 

1.   A statement to the patient regarding the purpose of the psychosocial interview and how it is designed to support a positive surgical outcome.  (The term psychosocial interview is used in lieu of psychological evaluation in order to be sensitive to the concern of the weight-loss surgery patient to be viewed as an individual in need of medical, rather than psychological, treatment.)

 

2.   A psychosocial interview and the completion of selected psychological assessment instruments

 

3.   A discussion about the specific weight-loss surgery for which the patient is presenting including the lifestyle changes recommended for successful weight loss and maintenance following surgery and the psychosocial adjustment challenges patients often experience.  Based upon the information provided by the patient in the interview, the specific psychosocial adjustments that may be of issue for the patient should be addressed.

 

4.   An opportunity for the patient to ask questions and have treatment issues and recommendations addressed.

 

5.   A written report for the surgeon including eligibility for surgery.

 

6.   A written summary of treatment issues and recommendations for the patient.

  

 

These guidelines have stood the test of time.  Patients who see knowledgeable MHPs before surgery typically say that, while they were initially intimidated by the requirement of a psychosocial interview, they feel that the experience has helped them in their preparation for surgery.  Surgeons echo the patient’s experience, saying that they find patients who have such a comprehensive interview are better prepared for surgery than patients who do not.  To further the goal of making the psychosocial process meaningful and helpful, it is important to expand on several of the items above.

 

In the patient education portion of the evaluation interview, it is important to emphasize the fact that weight-loss surgery is a valuable tool to help patients achieve and maintain a healthier body weight, but it is only a tool. The amount of excess weight patients lose varies considerably due to the type of surgery, comprehensiveness of surgical program, and patient characteristics and behavior. As noted previously, the success statistics reported range from 47 to 80% of excess weight lost and kept off.  Our experience is that the success rate accepted by the weight-loss community is generally unacceptable to most patients.  Most patients generally want to lose 90 to 100% of their excess weight.  Many believe they “should” get to an ideal weight and they may define ideal according to the BMI charts, their lowest adult weight, a previous size, a friend, family member, a celebrity’s size, a clothing size, etc. If they don’t reach this arbitrary goal or don’t expect to reach it within a reasonable time, they get discouraged and are much more likely to give up.  The MHP should address unrealistic expectations and, using the information obtained in the psychosocial evaluation, discuss any of the patient’s individual physical, medical, psychosocial and behavioral characteristics that may interfere with their ability to achieve their dream weight. In addition, the MHP should address common areas of psychosocial distress patients might experience in making the lifestyle adjustments recommended following surgery. Treatment guidelines and suggestions designed to address these potential problem areas should be presented. 

 

We have developed a general interview form that covers the basic information we feel important to obtain in evaluating the weight-loss surgery patient.  Samples of the adult and adolescent/dependent minor psychosocial interview forms are provided in Appendices 1 and 2.   The forms are suggestions and not meant to limit the MHP to the information noted.  Generally speaking, we feel it is important to obtain all information relevant to assessing a patient’s readiness for surgery and identifying any special treatment issues that may influence surgical outcome. 

 

If a patient presents a significant psychological issue for which he or she is currently receiving psychological treatment (e.g., Bipolar Disorder or Personality Disorder), it may be important to consult with the provider regarding the patient’s readiness for surgery and special treatment issues.  Rather than participate in the time-consuming process of “telephone tag”, and for purposes of documentation, we provide the MHP a consultation form to complete and return.  An authorization for release of records is, of course, obtained from the patient.  Samples of the Authorization for Release and Mental Health Consultation Form are provided in Appendices 3 and 4. 

 

Assessment instruments.  A comprehensive clinical interview is invaluable in the evaluation process. The interview can be supplemented with a variety of assessment instruments.  MHPs have preferences in the choice of psychological assessment instruments based on both training and experience.  For the assessment of the bariatric surgery patient, we suggest using as few instruments as possible, choosing those that can be completed and analyzed quickly, and selecting those that are patient-friendly and can be used to engage the patient in the development of a treatment plan.  As stated above, patients are sensitive about the psychosocial evaluation process and being psychologically labeled when they are presenting for medical treatment. Patients often travel long distances from home in order to have weight-loss surgery and completing long, tedious assessments that may appear to have no direct value to them is upsetting.  Assessment instruments that are complicated to analyze may make it difficult to provide the surgeon and patient with a timely statement of eligibility for surgery.  We have, and will continue to, experiment with a number of assessment instruments.  We currently use The Basic Personality Inventory (BPI) and the Eating Profile Questionnaire (EPQ). 

 

The BPI was developed by Jackson (1984) and correlates with the MMPI. There are 240 true-false statements measuring 12 different categories of personality and psychological functioning. The BPI is a paper and pencil inventory that can be completed by most patients in approximately 30 to 45 minutes. It can be hand-scored and analyzed by the MHP in just a few minutes.  The scale names do not use psychiatric labels. The number of questions to be answered and the non-psychiatric names of the scales make the BPI a patient-friendly tool for discussing assessment results and treatment recommendations.

 

The EPQ was developed by Last (1998) to identify different psychological causes underlying overeating behavior.  It is a 30-item, paper and pencil questionnaire that can be completed in approximately 10 minutes.  It can then be scored and analyzed very quickly.  The results of the questionnaire correspond to 5 categories of personality and eating behavior that are “shorthand descriptions of the (psychological) causes of overeating” (p. 18).

 

 

The EPQ 5 Categories of Overeating

 

        

     Impulsive Overeating:  Eating without thinking about why, where, when, and how much is being consumed.

     Hedonistic Overeating:  Consuming too much because of the enjoyment derived from the taste of food.

     Stress Reduction Overeating:  Using food to cope with life’s difficulties and challenges.

     Avoidance Overeating:  Eating to avoid dealing with the realities of life.

     Energizing Overeating:  Eating to improve feelings of depression, sadness, boredom, and fatigue.

 

 

The EPQ categories are simple for patients to understand and, as with the BPI, do not label the patient with psychiatric terms.  In her book, The 5 Reasons Why We Overeat, Dr. Last provides a step-by-step treatment plan for each of the five categories.  Patients can individually work through those treatment plans that apply to their overeating behavior.  The treatment plans can also be utilized in a group format.

 

Psychosocial reports.  It is not unusual for MHPs to write a simple letter stating that a patient has been evaluated and is or is not recommended for weight-loss surgery.  We feel this is insufficient and, at the very least, we recommend completion of an “Eligibility for Surgery Form” that has a section for the MHP to describe patient-specific treatment issues.  Appendix 5 provides a sample of an Eligibility for Surgery Form.

 

A written report or brief memo discussing for the surgeon the absence or presence of psychosocial and behavioral issues, and assessment results relevant to the patient’s readiness for surgery, is often of benefit. We currently use a memo format and Appendix 6 provides a sample.  At the end of the memo there is a page for describing the psychosocial or behavioral treatment issues for which a patient may have been referred for treatment.  If the patient was not referred for treatment, the page is deleted. A sample of an alternative version of a brief report is in Appendix 7.  Consistent with legal and ethical mandate, we require an Authorization and Informed Consent Form be signed by the patient to document his or her approval to release the psychosocial evaluation to the surgeon and/or treatment team.  Appendix 8 provides samples of Authorization Forms for adults and minors. 

 

In addition to providing valuable information for the surgeon and treatment team, our evaluation is psycho-educational for the patient.  In addition to the structured interview, available assessments are scored and the results are discussed with the patient.  The patient receives a form on which assessment results are recorded and any treatment recommendations are noted.  Appendix 9 is a sample of that form.  We also review the common lifestyle adjustments that are important for a successful surgical outcome.  We have a form that describes the lifestyle adjustments, patient specific issues and treatment recommendations (Appendix 10).  By the conclusion of the evaluation, it is our goal that the patient has a clear understanding of the lifestyle adjustments important to a successful surgical outcome, as well as an understanding of any patient-specific psychological or behavioral issues requiring monitoring, adjustment, or treatment. 

 

Occasionally the interview and assessment results indicate that a patient is not ready to proceed with surgery. In addition to doing the things noted above (discussing lifestyle adjustments and treatment issues) it may be useful to send a follow-up letter to the patient detailing treatment issues and recommendations. The documentation of patient-specific treatment issues gives the surgeon and multidisciplinary team a “heads-up” about issues that may interfere with weight loss following surgery.  It is also helpful to refer back to the form and report if the patient is not doing as well as expected following surgery, or presents with some atypical symptoms.

 

Eligibility for surgery.  One of the most challenging issues experienced by the MHP in completing a psychosocial evaluation is identifying contraindications to treatment.  The MHP who specializes in the treatment of surgical weight-loss patients tends to believe that weight-loss surgery would benefit all obese patients.  This belief must be tempered by the fact that some psychosocial issues may be exacerbated by weight-loss surgery and place the patient medically, psychologically, and socially at risk.  A great deal of professional judgment is also required to assess eligibility.  Among patients presenting with similar psychosocial disorders or profiles, some may be appropriate candidates for surgery while others may be inappropriate. Based upon available data, we propose the classification of patients into several sub-groups within the global population of weight-loss surgery patients.  These sub-groups help determine the need for psychosocial treatment and suggest the scope of treatment that may be necessary or helpful.

 

     The first sub-group of patients includes those for whom surgery is the only treatment required.  These patients possess the psychosocial health and resources necessary to make the recommended lifestyle changes important to successful weight loss and maintenance following weight-loss surgery.  These patients may enjoy participating in a social support group following surgery and successful patients may capably lead these groups.  Dietitians, medical or exercise specialists, and mental health professionals can be valued guest speakers for the groups.

 

     A second sub-group includes patients who demonstrate mild psychosocial issues and patterns of eating that may challenge successful weight loss following surgery.  These patients often do well when provided on-going support from a multidisciplinary treatment team that includes a surgeon, nurse, mental health professional, dietitian, and an exercise specialist.  Support may be provided individually or in a group.  

 

     A third sub-group of patients includes those who demonstrate psychosocial issues and patterns of eating that may sabotage successful weight loss and maintenance. Individual and group support provided by a mental health professional is strongly recommended.

 

     A fourth sub-group of patients includes those who demonstrate psychosocial issues and patterns of eating significant enough to question the patient’s ability to sustain or benefit from weight-loss surgery.  If surgery is medically necessary, individual and or group support provided by a mental health professional is a necessity.  If medically supported, the best course may be to postpone surgery until the patient has become psychosocially stable.  In rare cases, the patient may be unable to improve enough to sustain or benefit from surgery and, therefore, surgery is contraindicated.

 

     A final sub-group of patients includes those who experience psychological and psychosocial distress or dysfunction, or patterns of eating that are so severe, it is extremely unlikely they will successfully adapt post-surgically and therefore surgery is contraindicated.  

  

 

CASE CHALLENGE: ASSESSMENT RECOMMENDATIONS

 

 

As an example of the kinds of judgment the MHP may need to make, let’s consider two patients.  Most patients report unhealthy eating habits—some problematic and others disordered.   Both of our example patients report binge eating—they eat an unusually large amount of food in a discrete amount of time and feel out of control while doing it. The literature suggests that binge eating is typically NOT a contraindication for proceeding with weight-loss surgery.  

 

The first patient reports binging several times a week.  The patient is a fulltime student who also has a fulltime job.  The binges occur on days when her schedule is so overcommitted that she has no time to eat.  When she finally has time for a meal she is ravenous and eats more food than on a day with a more manageable schedule. Her binging has not been a lifelong pattern and there are no other notable psychosocial or behavioral issues.  The patient knows her binge eating needs to stop in order for her to experience the best possible surgical outcome.  She feels ready and willing to do whatever she needs to do to stop the behavior.

 

The second patient reports binge eating three to four times a month.  The binges are usually triggered by some emotional upset and uncontrolled eating may continue for several days. The patient reports a long history of binge eating and depression for which he has been in an out of treatment. He has few friends and difficulty keeping a job. He believes the surgery will magically control his binging and is surprised to find there are lifestyle adjustments he will need to make.  He says he will try to make the changes but is not sure he can.

 

If you were the MHP assessing these patients, what would you do? 

 

A.   Defer both patients for treatment before surgery?

 

B.   Approve both for surgery with the stipulation they have adjunctive treatment for their binge eating?

 

C.   Approve the first patient with the recommendation that she work to adjust her schedule so that she has time to eat regularly most of the time and a plan to have healthy foods readily available on days she is eating on-the-run.  Recommend she seek help if she cannot manage these things on her own.

 

D.  Defer the first patient until she is able to adjust her schedule so that she has time to eat regularly most of the time and a plan to have healthy foods readily available on days she is eating on-the-run.

 

E.   Defer the second patient referring him for treatment of his depression and binge eating.

   

 

You may already know what you’d recommend.  If not, the discussion below may help you decide or it may change your mind.  Contraindications for weight loss have not been well studied. Here again, the scope of training and experience of the MHP in treating surgical weight-loss patients is vitally important.   The recommendations we discuss are based on the extant research literature in this area and our own clinical experience and judgment.  To determine whether a patient is an appropriate candidate for surgery, we find it helpful to answer several questions.

 

 

IMPORTANT QUESTIONS

 

 

Is the patient competent to make an informed decision about having surgery and to understand and follow the dietary, exercise, and lifestyle guidelines important for good health and weight loss following weight loss surgery?

 

Does the patient engage in any behaviors that may place him or her at medical risk following weight loss surgery?

 

Is the patient’s life stable and/or relatively free of debilitating life crises?

 

Does the patient have positive, supportive relationships?

 

If there are psychological, behavioral, life, and relationship issues of concern, can they be addressed or managed sufficiently to allow the patient to proceed with surgery?

 

 

When answering these questions, we find it useful to visualize a traffic signal with its red, yellow, and green lights.  Answers that flash “red” suggest reasons to stop, at least for the time being, the patient’s progress toward surgery.  Answers that flash “yellow” suggest a need to proceed with caution.  Answers that flash “green” suggest the patient is free to proceed with surgery.  Using the concept of the traffic signal, the chart below delineates conditions or issues that we believe contribute to red, yellow, and green light classification regarding readiness for surgery.

 

 

READINESS FOR SURGERY

 

 

STOP!       

 

RED LIGHT ISSUES:

 

Severe mental retardation; delirium; dementia; amnesic disorders; Bulimia Nervosa and Pica; Ongoing Substance Abuse; Psychotic disorders; Suicidality; Acute Stress Disorder; Recent psychiatric hospitalization.

 

 

CAUTION!

 

YELLOW LIGHT ISSUES:

 

Below average IQ; History of eating disorder or substance abuse in remission for a long period of time or; History of psychological diagnosis with psychotic component that has been stabilized for a long period of time; History of depression or bipolar disorder being successfully managed by treatment; Suicidal ideation related to obesity; Posttraumatic Stress Disorder; Personality Disorders; Life crises such as recent loss of job, divorce, marital conflict, death of a loved-one; Close family member strongly opposed to surgery.  Lack of knowledge about the surgery or post-surgical lifestyle guidelines. Lack of readiness /confidence to follow the lifestyle guidelines and make recommended adjustments.

 

 

GO!

 

GREEN LIGHT ISSUES:

 

Average IQ; No history of significant psychological disorder, absence of suicidality, eating disorder or substance abuse; Stable life circumstances and environment; Stable, supportive relationships; knowledge of post-surgical lifestyle guidelines and confidence in ability to make recommended adjustments.

 

 

It is important to note that even “green light” patients will most likely have patterns of behavior (i.e. patterns of overeating and absence of exercise) and adjustment issues to address following surgery.

 

Thinking of the two binge eating patients discussed above, are your choices the same or have they changed?  Depending on our experience of the patient at the time of the evaluation and how much time the patient has before surgery to make lifestyle changes, our choices may be  “C” or “D” for the first patient.   If we select choice “C”, we schedule a brief pre-surgical follow-up interview to assess how the patient is doing in making lifestyle changes.  If she is doing well, choice “C” will stand; if not, we can revise our choice to “D”.  In the case of the second patient, we would select “E”. 

 

To further clarify we offer examples of “red light” and “yellow light” eligibility case experiences from our practices.  The cases may represent composites of cases.

 

 

RED LIGHT CASE STUDIES

 

 

Dr. LeMont

 

 

The patient presented as a candidate for gastric bypass surgery. The patient reported he used to drink alcohol to excess almost daily, but had cut back significantly. Lately his drinking had been limited to weekends and special events. The Saturday before his evaluation, he had drunk over 12 beers and had experienced a blackout. His friends told him his behavior had been unacceptable and he reported being highly motivated to stop drinking to excess. While the patient felt his problem was under control, it clearly wasn’t. The patient was referred for treatment of his substance problem and told that when he had been sober for six months, he could be re-evaluated for surgery.

 

 

Dr. Andrews

 

 

The patient presented as a candidate for gastroplasty.  In the course of the interview, the patient discussed the frequent ingestion of entire paperback books (an eating disorder known as pica).  The patient described the behavior as “beyond her ability to control.”  As the behavior would most likely lead to chronic vomiting, ring obstruction, malnutrition, and staple-line disruption, surgery was contraindicated.  The patient was referred for medical and nutritional evaluation.  A nutritional deficiency was identified.  With treatment the patient no longer engaged in the behavior.  After six months of being pica free, the patient underwent VSG.

 

 

Dr. LeMont

 

 

The patient presented as a candidate for gastric bypass surgery. She had a history of psychiatric hospitalizations, had previously attempted suicide, and was under the care of a psychiatrist. At times she heard voices that instructed her to hurt herself. She said she did not want to live if she could not lose significant weight. Her psychiatrist was called for a consultation—and before he responded the patient was once again hospitalized for suicidal depression and auditory hallucinations. This patient was not stable enough to go forward with surgery.

 

 

Dr. Andrews

 

The patient presented as a candidate for gastric bypass.  During the evaluation the patient demonstrated significant emotional distress.  The distress was related to the end of her long-term marriage.  In the midst of a rancorous divorce, the patient had no job, few assets, and few marketable skills. She had little emotional support from family and friends.  She expressed being in great despair, having difficulty making simple decisions, and seriously considering suicide.

 

The patient appeared to be inappropriate for surgery as she was significantly impaired by her depression and in the midst of a major life crisis.  As the patient was in psychotherapy, with her permission, her psychotherapist was consulted regarding a plan to prepare the patient for surgery.  Approximately two years later, the patient reapplied for surgery.  She had successfully recovered from her depression and created a stable life circumstance including a job and a network of supportive family and friends.   She was scheduled for surgery.

 

 

 

YELLOW LIGHT CASE STUDIES

 

 

Dr. LeMont

 

The patient presented as a candidate for gastric bypass surgery. She resided in an assisted living situation due to her below-average I.Q. Her mother brought her to the evaluation and supported the patient’s decision to have surgery. The patient appeared to understand the requirements of the post-surgical lifestyle and was highly motivated. Her mother supported her ability to follow through with the required behavioral changes.

 

The patient did have surgery and lost 55 pounds. She regularly attended support group meetings. When her weight loss slowed down and she reverted to her old behavior patterns, her mother lost confidence in the surgery. She pressured her daughter, wanting her to have an abdominoplasty and liposuction. The daughter became confused and unsure about what she should do. She ultimately acceded to her mother’s wishes and did not return to support group meetings.

 

 

Dr. Andrews

 

The patient presented as a candidate for gastric bypass.  During the interview she disclosed a history of Bi-Polar Disorder.  The patient demonstrated considerable knowledge of her disorder and responsible behavior with regard to her treatment.  The patient had been psychologically stable for several years.  The patient further demonstrated an understanding of the treatment challenges she faced having weight-loss surgery (possible post-surgical decompensation and medication management issues).  She had discussed these issues with her psychiatrist and psychologist and authorized them to work with members of her surgical treatment team.

 

The patient had surgery and did experience a post-surgical manic episode with difficulties in the management of her psychotropic medication.  As she had prior to surgery, the patient demonstrated the same self-responsible, proactive participation in her treatment, stabilized and continued losing weight.

 

 

Dr. LeMont

 

The patient presented as a candidate for gastric bypass surgery. She was severely depressed and taking anti-depressant medication. She reported that her depression was primarily due to her obesity and her inability to conquer it. With medication she was able to function successfully at work, though she avoided social occasions and was quite isolated in her personal life.

 

The patient’s therapist was supportive of her decision to have surgery, believed she was stable enough with her medication, and planned to work with her as she navigated her post-surgery challenges. The patient did have surgery and did well. At our last encounter, she reported she was still in therapy, was becoming more social and, with her doctor’s supervision, planning to reduce her anti-depressant medication.

 

 

Dr. Andrews

 

The patient presented for gastric bypass disclosing a history of alcohol abuse.  The patient had been sober for several years and was an active participant in AA.  The patient was advised of the medical risks, often increased by gastric bypass, should he resume drinking.  Surgery was scheduled following his agreement to continue participation in AA.  Approximately 1 year after surgery, the patient resumed drinking in response to a number of life stressors. The patient quickly experienced serious alcohol related medical issues.  He was hospitalized and, when medically stable, enrolled in an inpatient recovery program.

 

 

Regarding eligibility for surgery, it is important to remember that the physician(s) and surgeon treating the patient, along with the patient, may feel that surgery is medically necessary in spite of any psychosocial risks.  In such cases, the role of the MHP is to try to clarify the psychosocial risks and to develop a treat plan to minimize them.

 

Special Post-Surgical Treatment Issues

 

The emotional consequences of weight loss may or may not be positive. Some studies on obese individuals who have had weight-loss surgery suggest that psychosocial improvement can be a benefit of weight loss (O’Neill and Jarrell 1992).  “Patients losing significant weight often display increased self-confidence and self-esteem.  The affective component of body image may improve. . . . Patients may also find that opportunity for dating increases as they lose the social handicap of excess weight.  With increased self-esteem and reduced social discrimination may come increased assertiveness and optimism and the willingness to take on changes in other areas of life.” (O’Neil and Jarrell, 1992, p. 264).

 

Not all patients, however, report these positive psychosocial benefits of reduced weight.  Even after significant weight loss, some patients continue to experience psychosocial distress, as they are unable to fully integrate and experience the changes that are occurring.  Other patients mistakenly believe that all of their problems are related to their obesity and are disappointed when many psychosocial problems remain.  The inability to integrate and experience positive change and the disappointment of continuing problems often leads to poor self-esteem and eating behavior that contributes to weight regain.  Sometimes psychosocial issues masquerade as physical problems. When a patient has physical problems post-surgery that have no apparent medical cause, it is important to consider possible psychological factors. Consider the following example.

 

 

Case Example

 

 

A patient consulted her surgeon for post-surgical chronic vomiting, excessive weight loss and significant malnutrition.  Medical testing indicated none of her symptoms were associated with a side-effect or complication of her weight loss surgery.  Nothing in the patient’s pre-surgical medical or psychological evaluation accounted for the symptoms.   

 

The patient reported depression related to her medical condition but denied any other psychosocial issue.  The patient was repeatedly hospitalized for nutrition replacement.  One day at school a child of the patient’s attended an educational program on abuse.  The children were asked if anyone had ever behaved abusively to them.  The patient’s child said no one had abused him but his dad sure beat-up on his mom.  Department of Social Services was contacted and, on threat of losing her children, the patient admitted spousal abuse.  The couple was required to participate in treatment.  In treatment the spouse attributed his abusive behavior to a “personality change” that occurred with the patient’s significant weight loss. The personality changes included being less submissive, more social, and creating a small business that provided her with some financial independence. The patient considered a reversal of her weight loss surgery (likely to result in weight gain) to protect her marriage.  It is not known if the patient followed through with the reversal.

 

 

It is important to note that many psychosocial problems do not emerge or become apparent until months after weight reduction has occurred. In a study at East Carolina University (cited in Hildebrandt, 1998) it was found that patients with pre-existing psychological issues demonstrated “favorable improvements” at 6 and 12 months postoperatively but by the 24th and 36th month follow-up, “patients demonstrated a return to the preoperative state of mental health” (p. 536).

 

Based on their psychosocial history and experiences post-surgery, many patients will present with a variety of psychosocial issues, concerns, or complaints. Earlier in this section we mentioned destructive eating, body image distress, self-esteem, relationship issues, and psychological characteristics such as depression. Often, such difficulties can be successfully addressed through the education and support provided by the surgery program’s treatment team, especially the MHP. Occasionally, these difficulties will be severe enough that patients should be referred for individual psychotherapy and/or psychotropic medication.

 

Destructive eating.  Most of our patients have tried to lose weight repeatedly for years, even decades, and have been eager to learn about and try every possible weight-loss method proposed. They know extensive information about “calories in-calories out”; eating frequent small meals and drinking water; how binges derail their efforts; the importance of avoiding excessive sweets, fats, and alcohol; and, how to lose weight.  In most cases, the lack of success is due to failure to act on what they know rather than a lack of knowledge.  While some patients who request weight-loss surgery have learned to eat in a healthy and consistent manner, most patients frequently engage in destructive eating behavior of some sort. Destructive eating can come in many forms. Some of the more common destructive practices post-surgery include:

 

 

DESTRUCTIVE EATING BEHAVIOR

 

 

Compulsive eating—This is simply eating independently of the body’s signals. Patients feel out of control and unable to stop eating even if they are aware that they are not hungry or are uncomfortably full.

 

Binge eating—Eating exceptionally large quantities in a brief period.  Usually food choices are calorie dense or “forbidden.” Binge eating may be followed by purging (e.g., by vomiting, laxatives, diuretics) or fasting—to “make up” for the binge. Sometimes, however, there is no other change in behavior following a binge—though typically there are negative emotional consequences e.g., shame, self-directed anger, depression.

 

Skipping meals—Many patients have developed the habit of eating one or two meals a day. Often a result of misguided attempts to reduce their calorie intake, patients become “too busy” to eat more often—with the possible exception of high calorie snacks.

  

Night eating—Many patients partake most of their calories in the evening. Sometimes this is partly due to starving themselves during the day. Sometimes this is due to the freedom they feel in the privacy of their own homes to turn to food as their release and relief. (There is some evidence there might also be a hormonal component to this behavior.)

 

Rapid eating—Many people eat rapidly. There is also evidence that obese people take larger bites and chew their food less than non-obese people. Rapid eating can be a way of hiding (from self and others) how much is being eaten. It can be a quick emotional fix, a secret crutch. This is especially problematic post-surgery as it can, over time, permanently interfere with successful weight loss and maintenance.

 

Emotional eating—Whether or not they are aware of it, when and what many patients eat is often not related to their physical needs. Emotions such as boredom, depression, anxiety, loneliness, and even happiness can be strongly linked to the urge to eat. Many cannot identify any difference between physical hunger and this emotional urge.

 

Excessive/minimal fluids—Many patients pre-surgery drink excessive amounts of fluids, typically water or soda. Others drink very little. Both struggle after surgery—the first to get enough food in given the desire to drink fluids and the second to stay appropriately hydrated.

 

Poor nutritional balance—Some patients eliminate certain types of foods. Some eliminate most or all carbohydrates, believing that if they only eat protein, they will be successful. Some, typically restrictive-surgery patients, eliminate natural solid foods. Liquids and processed foods are easier to process through the band and become the food of choice.

 

Fear of eating—The constant regaining of weight post-dieting can result in patients who are afraid to eat normally. They become overly restrictive in their food choices, which can lead to malnutrition or a weight rebound when they can no longer tolerate the restriction. Some patients demonstrate this in their reluctance to progress from the liquid phase of the post-surgery diet. Some engage in purging (e.g., via vomiting, laxatives, diuretics) if they feel they have eaten “too much” at any given time.

 

 

The extent of change required in dietary and exercise habits may vary considerably depending on the patient and the type of weight-loss surgery. However, some permanent changes are necessary for the long-term health and well-being of every patient:  patients are likely to need practice in normal eating skills.  Some destructive eating patterns may simply reflect poor dietary habits that can be changed relatively easily with behavior modification but most destructive patterns are resistant to change as they are complicated by emotions. Eating may be the primary mode of coping with uncomfortable emotions and these may be even more intense after surgery. Some examples of how patients have used food to respond to emotions and what they could be taught to do instead include:

 

 

Emotion or

Challenge

 

 

Old Behavior

 

New Behavior Possibilities

 

Anxiety

 

Eat comfort foods, i.e., high calorie fats, sugars

 

Relaxation techniques, deep abdominal breathing, physical activity, self-soothing thought processes, directly address cause of anxiety

 

 

Hard day

 

Comfort or treat self with food

 

 

Comfort self in a healthy way, e.g., talk to a friend, watch sunset, listen to favorite music

 

 

Stressful situation

 

Go to vending machine to avoid and calm down

 

Walk—in or outside the building, deep breathing and self-soothing statements, stop encounter until able to think clearly about

best solution

 

 

Depression

 

Eat comfort foods

 

Do something physical, talk to a friend, journal, challenge thought processes supporting depression

 

 

Loneliness

 

Eat comfort foods

 

Reach out to family or friends, go to people-dense environment, e.g., a mall

 

 

Low self esteem

 

Eat comfort foods

 

Adjust faulty thinking, take appropriate action, become self-responsible, assertive

 

 

In order for patients to reach and maintain the level of success they desire after surgery, they have to learn how to change their counterproductive behavior to healthy, success-sustaining behavior. Changing compulsive or addictive behavior is complex and requires not only the initial change but the ability to recover from reverting to the old, rejected behavior (relapsing). Relapsing after weight loss is most common in three situations: mealtime, low arousal (boredom) and emotional upset.  Research has identified specific skills patients must learn and practice in order to minimize the frequency and effects of relapse (Marlatt and Gordon, 1985; Parks and Marlatt, 2000).  These include learning to recognize high-risk situations, to problem-solve solutions for such situations, and to cope positively and productively with the guilt or feelings of failure which can occur after a relapse.  In addition to the eating issues above, post-surgery patients may struggle with a number of other psychosocial issues. Some of the most common are described below.

 

Body image distress.  Rosen (2002) notes that “[o]bese persons are more prone to distort their body size, more dissatisfied and pre-occupied with physical appearance, and more avoidant of social situations. Thus, all three components of body image are affected: perception, cognition-affect, and behavior.” (p. 399).  Further, “[t]he relapse problem in obesity treatment extends to body image. Even a small weight regain predicts a slip in body image, a consequence that people rate as more distressing than losing physical health benefits.” (p.401). Most patients are self-conscious about their bodies and some have been painfully self-conscious as long as they can remember. One of the things they are looking forward to after weight loss is being “comfortable in their own skin.” They imagine the freedom of being able to comfortably wear shorts, sleeveless clothes, and even bathing suits. Some patients achieve this but many perceive themselves as not thin enough or believe their skin is too loose or sags too much.  In these cases, they remain uncomfortably self-conscious.

 

Some patients suffer from Body Dysmorphic Disorder, a psychological condition in which a person is excessively preoccupied with a (perceived or actual) defect in appearance to the point that it interferes with his or her ability to function normally (American Psychiatric Association, 1994, pp 466-468). Such a condition may have started pre-surgically in connection with obesity or occur post-weight loss when the body does not meet expectations.  As long as patients are not able to accept their bodies, they are at risk for relapse. They may feel that their weight-loss effort was a waste and they may limit their activities and socializing which can lessen the quality of their lives. They may feel a sense of hopelessness and they may return to eating as a way of comforting themselves and coping with their distress.

 

Self-esteem.  Healthy self-esteem consists of confidence in one’s ability to manage the challenges of life and in one’s right to be successful and happy (Branden,1994). This confidence is the result of consciously choosing how to live, taking responsibility for one’s actions, accepting and asserting oneself, living purposefully, and integrating one’s beliefs with one’s actions.  Many patients suffer from low self-esteem because of their (sometimes lifelong) inability to solve their eating and weight problems.  This lack of success robs them of confidence in themselves and in their worthiness to be happy in life. Every failure to follow dietary or exercise guidelines can be interpreted as proof of failure as a   human being.  Committing to surgery and the consequent lifestyle can give patients a significant boost in self-esteem. They may see themselves as finally taking control of the problem and finding a workable solution. This can be very empowering and help patients cope with the challenges they encounter. However, their newfound self-esteem can be very fragile. When they are losing or maintaining weight loss, they feel good about themselves. If they start to gain or stop following their diet and exercise plan, their self-esteem may decline and threaten their motivation and ultimate success.

 

Relationship issues.  When a person changes radically, his or her relationships are necessarily affected.  Relationships can become better and stronger, but many are damaged, sometimes irreparably. Some examples include:

 

     If a person has been “the fat one” in the family or social circle, the relationships take that into account, though not always openly. When a patient stops being the fattest, someone else acquires that unhappy designation. He or she may blame the patient for his or her newfound discomfort.

 

     In some cases, the patient has felt the need to sacrifice his or her desires to those of the thinner and therefore “better” member(s) of the relationship. Over time, such sacrifice can come to be expected. If the patient no longer feels the need to sacrifice, the others may feel wronged and expect the patient to feel guilty and revert back to the prior behavior.

 

     If a patient is empowered and gains confidence, others may feel threatened and in jeopardy of losing their importance in the relationship. This can lead to jealousy, sabotage and even violence as the threatened person blames the patient for causing his or her discomfort and fear.

 

All of these reactions from others may be conscious or subconscious. They may or may not realize why they are feeling and acting negatively toward the patient. This increases the difficulty in coming to a positive resolution within relationships.  In addition, new relationships may be more difficult than expected. Patients have sometimes blamed their obesity for all the negatives in their life. They expect that once they lose weight they will feel more comfortable and able to pursue a romantic relationship, friendship or new employment. If that comfort fails to appear with the drop in pounds, the patient may again feel helpless and hopeless.

 

Depression.  Some level of depression is common after surgery. The term “depression” may be used to describe short-term feelings of unhappiness or disappointment.  Patients may experience intense emotional pain when they realize that they can no longer change their minds that they have chosen to alter their bodies and must live with the consequences. For some, this engenders fear, guilt, and shame which trigger depression. Low energy is consistent with depression and it is one of the reasons patients want to lose weight in an effort to increase their energy. Those patients who take a long time after surgery to regain their energy may feel the surgery has failed them and may misinterpret the lack of energy as depression.  This can lead to discouragement and actual depression.  Patients may say they are “depressed” when they dislike having to eat certain foods or don’t lose weight as rapidly as they expect to after surgery.  They may report being “depressed” while experiencing personal, occupational, or financial adjustments brought on by surgery.  Such adjustments may include changes in relationships or job and financial concerns due to post-surgical complications or a prolonged period of disability leave from work.

 

While all patients experience the abrupt alteration in eating following surgery, some are more emotionally vulnerable than others to this change. Many patients are excited and happy that food has become unimportant while others continue to be very focused on food and wish they weren’t. When patients become aware they still want to eat emotionally, independent of physiological needs, they are disappointed and angry with themselves. They sometimes feel hopeless and are convinced that they will sabotage their surgery and be doomed to obesity and its consequences. These feelings can occur very soon after surgery or months or years later.  Whenever they occur, the patient is vulnerable to depression and to sabotaging their weight loss.

                       

The term “depression” may also be used to describe the prolonged feelings of despair typical of clinical depression.  Patients may feel so overwhelmed by the lifestyle changes or life challenges experienced after weight-loss surgery that they regret having surgery.  A weight plateau or regain may precipitate feelings of failure with no hope for success.   Patients who are clinically depressed may experience severe social and occupational impairment. The impairment may be complicated by the experience of psychotic features such as delusions, hallucinations, and marked confusion.  Patients with a history of depression are particularly vulnerable for psychological decompensation following weight-loss surgery. Especially at risk are those who are taking psychotropic medication and experience decreased absorption of medication following one of the malabsorptive weight-loss surgeries. Untreated, depression may lead to behavior that inhibits or even sabotages successful weight loss.  In cases of major depression, patients may demonstrate chronic neglect and engage in self-destructive acts that place them at medical risk or threatens their survival.  A quick diagnostic tool for depression is a checklist provided by Hales and Hales (1996) in Caring for the Mind: The Comprehensive Guide to Mental Health.

 

 

DIAGNOSTIC CHECKLIST FOR DEPRESSION

 

 

Individuals with a depressive disorder may:

 

     Feel chronically depressed, sad, empty, discouraged, tearful

     Lose interest or pleasure in once-enjoyable activities

     Eat more or less than usual and either gain or lose weight

     Have trouble sleeping or sleep much more than usual

     Feel slowed down or restless

     Be tired and listless and lack energy

     Feel helpless, hopeless, worthless

     Find it hard to concentrate or focus attention

     Become less effective or productive than in the past

     Have difficulty in thinking clearly or making decisions

     Be forgetful

     Have persistent thoughts of death or suicide

     Think poorly of themselves, put themselves down, feel inadequate

     Brood about the past

     Lack interest in sex or be less sexually active than usual

     Withdraw from others

     Develop physical symptoms (e.g., headaches, digestive problems, aches and pains).

 

 

The more boxes a patient checks, the more reason there is to be concerned about depression, especially if the person has felt depressed for a long time or several of the symptoms have lasted for at least two weeks. Patients with normal adjustment issues or mild symptoms of depression may benefit from participation in a post-surgical support group. Patients with symptoms of moderate depression may benefit from participation in a support group and individual psychotherapy. Patients with symptoms of moderate to severe depression may require more aggressive treatment. The treatment might include brief psychiatric hospitalization, taking psychotropic medication, and participating in individual psychotherapy.

 

The focus on depression is not to ignore or diminish other psychosocial issues that may require special treatment. Patients who have a history of mental disorder, substance abuse, eating disorder, sexual abuse, or significant marital discord must always be observed for re-emergence of these issues. Those without previous history may also develop psychosocial issues requiring treatment due to the stress of making the many lifestyle adjustments that accompany weight-loss surgery.

 

Patient Education and Support

 

Support groups.  In our experience, group support is an integral part of a successful surgical weight-loss program. Weight-loss surgery support groups may serve multiple functions leading to the success of the patients and the program: marketing, education, practical support, and emotional support. Consistent with patients who participate in traditional weight-loss programs, surgical weight-loss patients who attend professionally-led group meetings over time show a trend toward more weight loss than those who attend for brief periods of time (Hildebrandt 1998). 

 

 

SUPPORT GROUPS

  

 

Groups can provide:

 

Hope—the expectation that success is possible, which in itself increases the likelihood of success. Hearing how others have managed the same challenges helps patients realize they also can manage them.

 

Belonging—the experience of “fitting in,” of being similar to others in an important and validating way. Sharing experiences with others who know the struggle, believe success is possible, and are encouraging and empathetic makes the journey easier.

 

Reality checks—as important as encouragement and “cheerleading” can be, they are significantly enhanced by honest, reality-based feedback. A good support group will provide benevolently expressed reality checks. The group will recognize and point out self-sabotaging behavior. If someone is fooling him or herself about a potentially dangerous pattern, or has a blind spot about some important issue, fellow group participants and/or the facilitator can be relied upon to point out these risky behaviors.

 

Information—the best preparation for any difficult undertaking is knowledge. The surgeon and multidisciplinary treatment team should be the primary source of information about the surgery itself. Group participants add the richness of personal experience.  Facilitators and guest speakers can provide a wealth of general education concerning both the physical and psychological aftereffects of surgery.

 

Skills training—the methods by which patients can actually change to healthier behavioral, emotional, and interpersonal styles. These include the skills specifically aimed at successful weight loss and long-term maintenance and general life skills.

 

Giving—the opportunity to provide assistance and support to another, which most find gratifying, a boost to self-esteem, and a reinforcement of their own skills.       

 

 

Different programs have different philosophies about who should be included in the support groups they offer. Some programs have separate groups for prospective patients and post-operative patients, while other programs have one group for everyone. Prospective patients are likely to be focused on the risks of surgery and the benefits of successful weight loss. Once the decision to have the surgery is made, most patients say they are “ready.” They have tried everything and believe that with surgery they will achieve their objective of losing all or most of their excess pounds. The focus is on the weight coming off and being “normal,” healthy, and able to take part in activities with family and friends. Their thoughts about various issues include:  The new way of eating? - “Well, the hardest thing will be eating slowly, but I’ll learn.” Changing relationships? - “I’ll deal with them.” Changing my relationship with food so I only eat to meet my body’s needs? - “I can do it. It’s worth it.” At the pre-surgical stage, it is easy to focus on the positives and minimize the challenges and obstacles.

 

On the other hand, post-operative patients are likely to be focused on the physical and emotional challenges they are facing. Regardless of the amount of information gathered before surgery, dealing with the actual challenges as they arise is often more difficult than anticipated. Successful adjustment after surgery requires at a minimum coping with the loss of the old relationship with food, learning a multitude of new behaviors, coping with new physical experiences, experiencing a range of intense emotions, and dealing with the positive and negative reactions of others. At the very time patients have substantially increased their life stresses, they discover just how much they were using food as a coping mechanism and that is now no longer available to them.  While the primary focus of pre- and post-operative patients may be different, there is a valid reason (beyond efficiency) for combining these patients into one group. Prospective patients benefit by being better prepared for their challenges and less likely to maintain the myth of surgery as a “miracle cure” for their unhappiness. Post-operative patients benefit through the opportunity to provide value to others by sharing their experiences. They also are more likely to stay connected with “where they came from” which can be invaluable in helping them achieve an objective perspective of their progress. 

 

Some programs offer group attendance only to patients and some welcome family members and other supporters of patients. Both are valid approaches. Some patients appreciate the safety of being only with those who have had the surgery while others welcome the opportunity for family or friends to gain information and understanding from the meetings.  Those close to the patient may appreciate the opportunity to articulate how they are being affected by the patient’s process and, perhaps, ask for guidance in dealing with relevant issues. If non-patients are welcome, it is important that the patient decides for each meeting whether or not he or she would like anyone else to come. The patient may sometimes wish to discuss feelings or issues outside the presence of family or friends.  A good support group provides the safety and freedom to address issues on which a participant would like help, feedback, information, or acknowledgement. The group should combine sharing and empathic support with a problem-solving, success orientation.

 

Surgeons, program counselors, dietitians, or mental health professionals (MHPs) that attend or facilitate patient groups can provide invaluable quality control. They can spot misinformation and correct it. They can guide the participants in a positive, productive approach to the topics at hand. They can keep the group focused and on track, and direct patients to more individualized assistance when appropriate (e.g., consulting the surgeon, a therapist, or a dietitian).  MHPs can add important skills training. All surgical weight-loss patients are faced with radical changes in their day-to-day behavior and experiences. Education and training in how to modify specific dietary and exercise habits as well as in a multitude of life skills (such as assertive communication, increasing self-esteem, setting and achieving goals, overcoming fears of failure, achieving a positive body image, recognizing and correcting faulty thinking, etc.) can make the difference in whether patients are successful long-term in weight loss and in navigating the myriad consequences weight-loss surgery has brought to their lives (e.g., changes in personal and professional relationships, changes in personal style and self-concept, changes in values).

 

Patients are vulnerable to self-sabotage if they feel helpless in the face of their life challenges. Most have used food as an emotional coping mechanism and are at a loss when it comes to dealing with painful emotions without food. Many are frightened by their vulnerability to return to their old habits.  If they resist turning back to food to help them cope, there may be the tendency to turn instead to other counterproductive methods of coping, such as alcohol, drugs, and excessive shopping. MHPs can assist group members in finding constructive coping methods that promote healthy living and minimize the likelihood of destructive habits.

 

When a professional facilitator is not available, patient-led support groups can be useful. They provide the opportunity for sharing information and emotional support. They can be a place to discuss complaints and difficulties, and receive understanding and compassion. They can be a place to proudly claim one’s accomplishments without fear of being seen as arrogant or selfish. They can be a place to feel normal and to fit in, a rare experience for many of our patients.  These groups are limited, however, in that group discussions are vulnerable to getting off-track, misinformation may not be recognized or corrected, specific educational and training needs may go unmet, and serious problems may go unrecognized.

 

Structured behavior modification program. For many patients weight-loss surgery and the types of groups described above are all that is needed for them to modify their lifestyle enough to lose weight and keep it off.  For others, sooner or later, unhealthy eating habits return and they are struggling with food again.  Unhealthy eating inhibits further weight loss or causes weight regain.  When this happens patients may panic and they wonder what they will do if their surgery fails and they regain all of their weight, plus more.  Surgery was their last hope.

 

Along with colleague, Summer N. Perry, Ph.D., MFT, we have developed an eleven-session structured behavior modification program course based on cognitive-behavioral concepts and skills. Titled Eating Normally (EN), the program course is currently being used in five surgical weight-loss surgery programs.  The program course is sponsored by the surgery programs and patient participation is voluntary. 

 

In each of the eleven sessions of Eating Normally (EN) specific cognitive-behavioral concepts and skills are discussed, exercises for concept integration and skill development are practiced, and assignments for further integration and practice between sessions are provided.  Response to EN has been gratifying with patients saying this type of program is what they need to finally manage the thoughts, actions and emotions that have contributed to their unhealthy eating.   This course is one component of post-surgical support following surgery. All the programs involved also have general support groups for patients, pre- and post-operatively. We believe a course such as EN would be a valuable addition to every weight-loss surgery program (See also Saunders 2004).

 

Ongoing consultation.  As we have discussed, whatever the combination of factors that led to obesity (e.g., physiological, environmental, psychological and behavioral), adjustment to life after surgery can be extremely challenging. In the context of a busy life, patients must learn how to basically eat from scratch: when, how much, and what they eat is often radically different than anything they’ve done in the past. At the same time, there is renewed pressure to exercise, most or all of their interpersonal relationships are affected, their bodies are constantly changing, and eating is no longer an acceptable coping mechanism.  Whether chronic or acute in nature, the psychosocial issues may be caused or exacerbated by such things as:  the stress of surgery itself; dramatic changes in lifestyle behavior; or adjustments in self-perception and interpersonal functioning.  Issues such as increased feelings of vulnerability, changes in personal values, changes in marital dynamics, conflicted emotions about others’ reactions to their weight loss and learning non-dietary means of coping are only some of the psychosocial challenges researchers have explored (Wadden, Womble et al., 2002; Perri and Corsica, 2002).

 

Surgeons who may be accustomed to providing short-term surgery-focused care, may be surprised to find that patients bring long-term psychosocial issues to them for treatment. Given a patient’s medical history regarding obesity and the scope of lifestyle change initiated by weight-loss surgery, it is not surprising that patients look to their surgeon or multidisciplinary team for on-going treatment. First, patients develop a strong attachment to their surgeon and treatment team.  For the first time in their life the patient may feel a physician understands his or her struggle with obesity and has a solution to what is perceived as the most distressing life problem.  Through weight-loss surgery, the surgeon gives the patient the opportunity to be “normal” in size and to experience improved health and an enriched quality of life. 

 

Second, the process of presenting for surgery from initial evaluation to date of surgery may take many months and involve numerous meetings with the surgeon or team members.  In individual consults and while participating in a pre-surgical support group, patients may share personal details of their lives.  Frequent contact and the sharing of personal information often lead patients to feel that they have a special, ongoing, relationship with the surgeon and team members. Third, patients typically have numerous questions regarding living with their surgical procedure and coping with the lifestyle and psychosocial adjustments related to successful weight loss.  Indeed, the degree of success may greatly depend upon the ability to obtain reliable answers to questions or support in making lifestyle and psychosocial adjustments.  Physicians and allied healthcare professionals outside the weight management community are generally unprepared to address patient questions and to provide appropriate support. Feeling that they have nowhere else to turn, patients become dependent upon the multidisciplinary treatment team for information and support. 

 

For these reasons, like it or not, surgeons and team members must be prepared to address ongoing patient treatment needs. Surgeons and weight-loss surgery programs that have competent multidisciplinary healthcare professionals available to respond to patient needs have a distinct advantage over those who do not. 

 

CONCLUSION

 

The foregoing is designed to outline the complex nature of obesity, weight-loss and maintenance in general and specifically, weight-loss surgery. The psychological issues surgical weight-loss patients may encounter as they lose weight and work to maintain their weight loss are many and varied. While surgeons, program managers and fellow patients can offer understanding and sympathy for these challenges, most are not equipped to help the patient conquer them. That is the function of the MHP.

 

The fact is that patients may need education and training in monitoring and adapting their eating and exercise behavior, as well as in changing how they perceive themselves and their post-surgery life. Research indicates that such training alone may not be sufficient for some patients. These patients may need more structured programs and follow-up with mental health professionals to effectively deal with psychosocial issues that can interfere with long-term weight-loss and maintenance. Numerous studies have indicated that, regardless of weight-loss method, duration of treatment is one of the most significant factors associated with weight loss and maintenance. We believe that psychosocial support is essential for the success of the surgical treatment of obesity. Obesity is a chronic problem. Physically and psychologically, it is too complex for a “quick fix.” Lifestyle changes need to be lifelong and the psychological wherewithal to manage such changes are likely to require long-term effort.

 

 

APPENDIX 1

 

 

Adult Psychosocial Interview Form

 

Patient_______________________________________ Date_________________

 

Surgeon/Program_________ Fee___________ Paid_____ Contract___________

 

Personal  Sex:  M  F    Age______  DOB ________ Phone__________________

 

Education  Completed______________  Attending________________________

 

Occupation _______________________________________________________ 

 

 ____Retired    ____Unemployed, looking    _____Unemployed, not looking

 

Hours/shifts worked ___________________   Job Satisfaction? ____Yes ____No

 

If disabled   When?___________  Reason(s)____________________________

 

Important organizations_____________________________________________

 

Hobbies & recreational activities ______________________________________

 

Overall satisfaction with life:   

 

dissatisfied   1    2    3    4    5    6    7    8    9   10  satisfied   

 

Explain___________________________________________________________

 

Physical Health:   Medical conditions  _____Yes _____No  

 

Some associated with obesity _____Yes   _____No

 

Taking medications: _____Yes _____No        ____CPAP/BiPAP

 

Hours of sleep per night________   _____Mostly restful _____Mostly not restful ____ Varied

 

Have you experienced any recent changes in your sleep? ___________________

 

Substance Use:                 

 

Smoking   Current______  Past _______Stopped __________________________

 

If currently smoking, do you understand that you must stop smoking prior to surgery and are

advised not to resume after? _____Yes _____ No        

 

Alcohol Freq?  _______________________ 

 

_____Wine  _____Beer _____Mixed Drinks _____Hard Liquor

 

Drug Freq?   ________________________________________________________

 

What drugs? ________________________________________________________

 

Substance problems / TX / Status_______________________________________

 

Do you understand the need for and are you willing to avoid/limit the use of substances as

directed by your surgeon after WLS?    ____Yes    ____No

 

explain:

 

Height ___ Current wt.___ Highest adult wt. ___ Lowest adult wt. _______

 

Goal wt. ________________   Acceptable wt________________

 

Weight Prob Hx: 

 

Obesity common in family: __ Yes__ No __ Some  Age of onset for patient_____

 

Contributing factors__________________________________________________

 

Dieting History

 

Have you tried to lose weight? ___Yes ___ No  __________________________

               

If yes, methods: ____Commercial ____Medical ____RX ____OTC ____Fad

____Calorie Restriction _____Exercise   _____Vomiting  _____Laxatives    

 

Other:

 

What method did you try the longest?______________ How long?____________

                 

What method was most successful? _____________________________________   

 

What interferes with WL success?_______________________________________

 

Previous Bariatric Surgery  _______________Date of surgery_______________

 

How well did the WLS work? __________________________________________

 

What interfered? ___________________________________________________

 

                Wt. at surgery _________ Wt. lost with surgery ________________

 

                How will revision help? _____________________________________

 

Dietary Habits:  No. of meals per day____ Portion sizes   __________________ 

 

Meals? _____Home-prepared _____Packaged/Convenience _____ Fast food

_____Restaurant  _____All

 

Eat between meals or in the evening? ___Yes ___No   What do you eat?______

 

What beverages do you drink most? ___________________________________

 

Diet Balanced? _____Yes _____No  Higher in ____________________________

 

Eating Problem/Disorder (per Eating Behavior Chart)? _____None reported

 

Emotional/Compulsive ___Past  ___Present  ____Problem  ______ Disorder

 

Binge _____Past  _____Present   _____Problem  _____Disorder

 

Bulimia _____ Past   _____Present  ____Problem ____Disorder

 

Nocturnal/NES: _____Past  ­­_____Present   _____Problem  _____Eating

 

Other/explain________________________________________________________

                 

Treatment? _________________________________________________________­­­­­­­

 

How will you need to eat after your chosen surgery?________________________

 

What changes in your eating are you making in preparation for WLS? _________

 

Exercise Behavior

 

Current Exercise/Reason why not?

 

Post-surgery exercise plan:


 

Assessment of Lifestyle Changes

 

Why WLS? _________________________________________________________

 

How does your chosen WLS help you lose weight? _________________________

 

­­­ Do you understand that surgery is not “magic” and your choices and actions determine success?

 

 ___ Yes ___ No

 

Do you understand that weight loss may not help you achieve your goal weight/size/shape and

it may contribute to body image issues such as loose skin and temporary hair loss?          

    

_____ Yes  _____ No

 

How important is it for you to reduce your weight at this time?

 

  Not important   1   2   3   4   5   6   7   8   9   10   Very important

 

How willing are you to make changes in your eating and exercise behavior to support your surgery?

 

         Unwilling   1    2    3    4    5    6    7    8    9    10   Very willing

 

How able are you to make the required lifestyle changes?

 

          Not able   1   2   3   4   5   6   7   8   9   10    Very able

 

What lifestyle changes will be most challenging?  How will you deal with them?

 

Assessment of Coping Skills    

 

How stressful is your life?     

 

none    1    2   3    4    5    6    7    8    9    10  high stress 

 

Explain:

 

How do you cope with stress now? ______________________________________

 

Experience of Abuse   _____None

 

                Physical?         _____Child _____ Adult   _______________________

 

                Emotional?      _____Child_____  Adult  ________________________

 

                Sexual?           _____Child ______Adult

 

                Explain ­

 

Treatment?­____________   Resolved? _____Yes   _____No  _____Somewhat

 

Explain:

 

Has your abuse played any role in your obesity or past weight loss?

 

Description of Mental Health:  _____Good  _____Not Good  Explain ___________

 

Have you experienced any recent changes in your mood? __________________

 

­­­­­­­­­­­­­How are you feeling about yourself? ___________________________________­­­

 

Have you experienced any loss of interest/pleasure?

 

How do you feel about your future?

 

                Psych Diagnosis _____________________________________________

 

When Diagnosed? _____________________________________________________

 

Suicide attempts?  __No  __Yes   If yes, explain ____________________________

 

Current risk assessment __ No thoughts __ Thoughts/no plan __ Thoughts/plan

 

Psychiatric hospitalization?  _____Yes  _____No   Explain _____________________

 

Psych Meds? _No   _Yes   Symptoms well controlled with meds? __Yes   __No      

 

If no, explain:

 

Psych Meds:  Duration _______ Prescribed by ____PCP ____Psych or___________

 

Med__________________________   Dosage ____________________________

 

Med __________________________  Dosage ____________________________

 

Med___________________________ Dosage_____________________________

 

Med___________________________ Dosage _____________________________

 

Mental status:  Appropriate ____    (Appearance, Behavior, Thought Processes, Speech, Affect)

 

                If not appropriate, explain:

 

­­­Psychotherapy? __ None  ___ Past __ On-going  Explain______________________

 

Opinion about surgery    ________________________________________________

 

Willing to participate in psychological/behavioral treatment if recommended

to support weight-loss?   ____Yes      ____No    

 

If no, explain:

 

 

Relationships

 

Marital/Relationship status:

 

___________________  Length                                         #X____________ 

 

Children /Ages _____________________________________________________

 

Living arrangements:  _______________________________________________

 

Close family members  ___Yes ___No ___Some       Friends ___Yes _____No

 

How are things going in your important relationships? ______________________

 

Any relationship difficulties/concerns? ___________________________________

 

How have significant others responded to past dieting? 

 

_____Supportive _____Neutral _____Sabotaging    Explain: 

 

 

How do significant others feel about surgery? ______________________________

               

 If unsupportive, how does this feel/affect you? ____­­________________________

 

 How will you deal with the lack of support?


 

What additional information about you or your life would you like to share:

 

               

  

Opinion Regarding Surgery:

 

 _____Ready for surgery/No treatment issues  

 

 _____Ready for surgery/Issues typical of WLS Patients/No treatment required

 

  _____Ready for surgery/Issues typical of WLS Patients/Pt in treatment/Continue treatment

 

  _____Ready for surgery/Psychosocial Issues/Continue current treatment or begin treatment

 

  _____Not ready for surgery/Contraindicating Issues/Treatment recommended

 

Pt Category _____1 _____2 _____3 _____Deferred

 

Notes:

 

 

 

Copyright © 2009 by Gaye Andrews, PhD, MFT, Diane LeMont, PhD and Summer N. Perry, PhD, MFT

  

 

 

 

 

APPENDIX 2

 

 

 

Minor/Dependent Adult Psychosocial Interview Form

 

Patient ___________________________________________ Date ______________________

 

Surgeon/Program _____________________ Fee ___________________ Paid _____Contract

 

Personal Sex:  M     F     Age__________ DOB _____________Phone___________________

 

Grade __________________  Extracurricular activities _______________________________

 

School satisfaction _________________ Doing well? ____Yes ____No Explain ____________

 

Hobbies & recreational activities __________________________________________________

 

Job _____Yes ______No  Hours worked____________ Job satisfaction___________________

 

Physical Health:   Medical conditions   _____Yes _____No  

 

Some associated with obesity _____Yes   _____No

 

Taking medications: _____Yes _____No        ____CPAP/BiPAP

 

Hours of sleep per night________    _____Mostly restful _____Mostly not restful ____ Varied

 

Have you experienced any recent changes in your sleep? ____________________________

 

Substance use

Smoking:  Current________________ Past __________Stopped ______________________

 

If currently smoking, do you understand that you must stop smoking prior to surgery and

are advised not to resume after? _____Yes _____ No       

 

Will you comply?  _____Yes _____ No  

 

Alcohol Freq?  ___________    _____Wine  _____Beer _____Mixed Drinks _____Hard Liquor

 

Drug Freq?  __________________________________________________________________

 

What drugs? __________________________________________________________________

 

Substance problems / TX / Status _________________________________________________

 

Do you understand the need for and are you willing to avoid/limit the use of substances after WLS?

 

____Yes    ____No (If no, explain):         ­­­­

 

Height ____ Current wt._____ Highest wt. ______ Goal wt. ______   Acceptable wt______

 

Weight Prob Hx:  Obesity common in family: _____Yes _____No _____Some 

 

Age of onset for patient_________

 

Contributing factors ____________________________________________________________

 

Dieting History

 

Have you tried to lose weight? _____Yes _____ No  __________________________________

               

If yes, methods: __Commercial ___Medical ___RX ___OTC ___Fad _____Calorie Restriction

 

___Exercise   ___Vomiting  ____Laxatives     Other____________________________________

 

What method did you try the longest? _______________________ How long?______________

                 

What method was most successful? ______________________________________   

 

What interfered with WL success? ________________________________________

 

What causes you to gain the most weight? _________________________________

 

Dietary Habits:  No. of meals per day_____ Portion sizes   _____________________________ 

 

Meals?  __Home-prepared __Packaged/Convenience __ Fast food ___Restaurant  ___All

 

Eat between meals or in the evening? _____Yes _____No   What do you eat?_____________

 

What beverages do you drink most?_______________________________________________

 

Diet Balanced? _____Yes _____No  Higher in _______________________________________

 

Eating Problem/Disorder? _____None reported

 

Compulsive/Binge: ­­____Past  ____Present  ____Problem Behavior _____ Eating Disorder

 

Emotional:  _____Past  _____Present   _____Problem Behavior _____Eating Disorder

 

Nocturnal/NES: _____Past  ­­_____Present   _____Problem Behavior  _____Eating Disorder

 

Other/explain __________________________________________________________________

                 

Treatment?____________­­­­­­­­________________________________________________________ 

      

How will you need to eat after your chosen surgery? __________________________________

 

What changes in your eating are you making in preparation for WLS? ____________________

 

Exercise Behavior

 

Current Exercise/Reason why not? ________________________________________________

 

                 Post-surgery exercise plan?  ___________________________________________

 

Assessment of Lifestyle Changes

 

Why WLS? ____________________________________________________________________

 

How does your chosen WLS help you lose weight? ____________________________________

­

Do you understand that surgery is not “magic” and your choices and actions determine success?

 

      _____Yes  _____No

 

Do you understand that weight loss may not help you achieve your goal weight/size/shape

and it may contribute to upsetting body image issues such as loose skin and temporary

hair loss?_____ Yes  _____ No

 

How important is it for you to reduce your weight?

 

 Not important   1   2   3   4   5   6   7   8   9   10   Very important

 

How willing are you to make changes in your eating and exercise behavior to support your surgery?

 

 Unwilling   1    2    3    4    5    6    7    8    9    10   Very willing

 

How able are you to make the required lifestyle changes?

 

 Not able   1   2   3   4   5   6   7   8   9   10    Very able

 

What lifestyle changes will be most challenging?  How will you deal with them? ____________

 

How will you manage social eating/drinking activities?_________________________________

 

Assessment of Coping Skills    

 

How stressful is your life?      none    1    2   3    4    5    6    7    8    9    10  high stress 

 

Explain:

 

How do you cope with stress now?:

 

Experience of Abuse   _____None

 

                Physical?         _____Child _____ Adult   _________________________________

 

                Emotional?      _____Child _____  Adult  _________________________________ 

 

                Sexual?           _____Child ______Adult _________________________________

 

                Explain ­____________________________________________________________

 

Treatment?­_____________________   Resolved? _____Yes  _____ Somewhat _____No  

 

                Explain:

 

Has your abuse played any role in your obesity or past weight loss? _____________________

 

Description of Mental Health:  _____Good  _____Not Good  Explain_______________________

 

Have you experienced any recent changes in your mood? _______________________________

 

­­­­­­­­­­­­­                How are you feeling about yourself? _______________________________________

 

Have you experienced any loss of interest/pleasure? ___________________________________

 

How do you feel about your future? _________________________________________________

 

                Psych Diagnosis _______________________________________________________

 

                When Diagnosed? ______________________________________________________

 

Suicide attempts?  ____No  ____Yes   If yes, explain___________________________________

 

Current risk assessment       ____ No thoughts    _____ Thoughts/no plan   _____ Thoughts/plan

 

Psychiatric hospitalization?  ________________________________________________________

 

Psych Meds? _____No   _____Yes   Symptoms well controlled with meds? _____Yes   _____No

 

If no, explain:

 

Psych Meds:  Duration _______________ Prescribed by ____PCP ____Psych or____________

 

Med ___________________________________Dosage ___________________________

 

Med __________________________________ Dosage ___________________________

 

Med__________________________________  Dosage____________________________

 

Mental status:  Appropriate ____   (Appearance, Behavior, Thought Processes, Speech, Affect)

 

                If no, explain:

 

­­­Psychotherapy? ____ None  _____ Past ______ On-going  Explain:

 

Opinion about surgery:

 

Willing to participate in psychological/behavioral treatment if recommended to support weight-loss?

 

    ____Yes      ____No     If no, explain:

 

Relationships

 

Nuclear family______________________________________________________________

 

Extended family_____________________________________________________________

 

Living arrangements _________________________________________________________

 

Friends ____________________________________________________________________

 

How are things going in your important relationships? ______________________________

 

Any relationship difficulties/concerns? ___________________________________________

 

How have significant others responded to past dieting?  _____Supportive _____Neutral

 

_____Sabotaging    Explain:

 

How do significant others feel about surgery? ____________________________________

 

If unsupportive, how does this feel/affect you? ____________­­_______________________

 

                How will you deal with the lack of support? _____________________________

 

What additional information about you or your life would you like to share?

 

Family Assessment

 

How important is it that your child reduce his/her weight?

 

        Not important   1   2   3   4   5   6   7   8   9   10   Very important

 

Do you support surgery as your child’s weight-loss method? ___Yes   ___ No   Explain____

 

Do you understand that surgery is not “magic” and you and your child’s choices and actions

influence success? ___ Yes ___ No

 

Do you understand that weight loss may not help your child achieve his/her goal

weight/size/shape and it may contribute to side effects that might be upsetting and/or

require additional treatment (thinning hair/loose skin)?_____ Yes  _____ No

 

How willing are you to make changes in family eating and exercise behavior to support

your child’s surgery?                               

 

     Unwilling   1    2    3    4    5    6    7    8    9    10   Very willing

 

How able are you to make the required lifestyle changes?

 

     Not able   1   2   3   4   5   6   7   8   9   10    Very able

 

What lifestyle changes will be most challenging?  How will you deal with them? ________

 

How will you manage social eating/drinking activities? ____________________________

 

Willing to support psychological/behavioral treatment for your child if recommended to

support weight-loss? ____ Yes      ____No    

 

If no, explain:

 

Willing to participate in family psychological/behavioral treatment if recommended

to support your child?

 

_____Yes    _____No   If no, explain:

 

What additional information about your child or family would you like to share?

 

Opinion Regarding Surgery:

 

 _____Ready for surgery/No treatment issues  

 

 _____Ready for surgery/Issues typical of WLS Patients/No treatment required

 

  _____Ready for surgery/Issues typical of WLS Patients/Pt in treatment/Continue treatment

 

  _____Ready for surgery/Psychosocial Issues/Continue current treatment or begin treatment

 

  _____Not ready for surgery/Contraindicating Issues/Treatment recommended

 

Pt Category _____1 _____2 _____3 _____Deferred

 

Notes: 

 

 

 

Copyright © 2009 Gaye Andrews, Ph.D., MFT, Diane LeMont, Ph.D., Summer N. Perry, Ph.D., MFT

 

 

 

 

 

Appendix 3

 

 

CONSENT TO RELEASE CONFIDENTIAL INFORMATION PURSUANT THE CONFIDENTIALITY OF MEDICAL INFORMATION ACT BY PATIENT

 

 

By signing this document, I (patient)_________ hereby authorize,

 

(physician/psychotherapist):______________________________

 

Address:______________________________________________

 

City ___________________State _____________Zip__________

 

phone no ­___________fax no_____________________________

 

to disclose information and/or records including but not limited to treatment for mental health, alcohol and/or drug reasons, and services related thereto to (Mental Health Provider’s name, address, phone, fax).  The disclosure of information and records authorized herein is required to identify any significant concerns regarding my ability to successfully benefit from weight loss surgery and to provide information that Dr. (MHP) and my surgeon can use to assist me in making a successful transition to my new lifestyle. The specific uses and limitations on the types of medical information to be disclosed are as stated above. 

 

This authorization is subject to revocation at any time except where action has been taken in reliance hereon.  If not earlier revoked in writing, termination of this authorization shall be 90 days from the date signed.  A photocopy of this signed form is as good as an original.

 

 

______________________________ _____________________

Signature of patient                                      Date

 

 

______________________________ _____________________

Signature of witness                                      Date

 

 

Reference:  California Civil Code Section 56:11

 

 

 

 

APPENDIX 4

 

 

Weight-loss Surgery Patient

Psychological Consult Information Form

 

Patient___________________________________________Date_________________

 

Psychiatrist/Psychotherapist_______________________________________________

 

Mailing address_________________________________________________________

 

City_______________________State__________________Zip___________________

 

Phone #___________________________Fax #_______________________________

 

Emergency #_______________________Bariatric surgeon______________________

 

The patient named above is a candidate for weight-loss surgery with the surgeon named above.  As the patient reported being in treatment with you, the information below is requested to help determine readiness for surgery and to assist in the development of an appropriate pre- and/or post-surgery treatment plan.  Please complete the information and return this form within five (5) business days to: (Mental Health Provider’s name, address, phone, fax here).   Please call if you have any questions.  An authorization for the release of this information is provided.

 

DSM-IV diagnosis:

 

 

Nature and frequency of treatment:

 

 

Name(s) and dosage of psychotropic medication:

 

 

 

Length of treatment and compliance:

 

  

 

Issues that may question readiness for surgery and ability to benefit from surgery at this time (e.g., adverse psychiatric condition, such as psychosis, severe personality disorder, severe behavioral disorder, unremitting eating disorder, substance abuse, inability to understand and/or comply with treatment recommendations, recent trauma and/or chaotic lifestyle).  If issues are present, please explain:

 

 

  

Some weight-loss surgeries require patients to be NPO for a period of time/days. What is the length of time the patient may be without medication before symptoms occur?

 

 

 

What alternative forms of medication are recommended if pills cannot be taken (e.g., liquid, injection, IV)?

 

 

 

 

Additional information that may be helpful:

 

  

 

Do you wish to be contact should the patient decompensate? ___Yes  ____No

 

Contact #­____________________________________________

 

 

Thank you for your assistance.

 

 

 

Printed name ______________________________Date______________

 

Signature ___________________________________________________

 

 

 

 

 

Appendix 5

 

 

PSYCHOSOCIAL EVALUATION REGARDING

ELIGIBILITY FOR WEIGHT-LOSS SURGERY

 

Patient:                                                         DOB:

Program:                                                       Evaluation Date:

 

The patient was referred for a psychosocial consultation to assess readiness for weight-loss surgery.  The consultation was psycho-educational and designed to identify and advise the patient about psychological, environmental/social, and behavioral factors that may need to be addressed in order for them to manage the necessary postsurgical lifestyle adjustments.  The consultation consisted of a verbal interview and completion of the Basic Personality Inventory (BPI) and the Eating Profile Questionnaire (EPQ).  The interview was designed and the assessment instruments were selected for obese patients who wish to have weight-loss surgery and who are generally diagnosed DSM-IV 316 for ICD-10 278.01. Unless otherwise noted, the opinion that follows is based on the interview and assessment results.

 

I have completed the consultation and it is my opinion that:

 

_____   The patient appears to be ready for weight-loss surgery.

 

_____   The patient appears to be ready for weight-loss surgery.  During the consultation, psychological, environmental/social, and/or behavioral factors common among weight-loss surgery patients were noted. The patient was advised to continue any current psychological treatment or seek psychological services should any of these factors make it difficult to manage the necessary post-surgical lifestyle adjustments.

 

_____   The patient appears to be ready for weight-loss surgery.  During the consultation psychological, environmental/social, and/or behavioral factors were noted.  The patient was advised to continue current psychological treatment and/or seek psychological treatment before and/or after surgery to help them make the necessary post-surgical lifestyle adjustments.

 

 

 

CONFIDENTIAL

 

 

California State Law Section 5328, Welfare & Institutional Code, and Federal Law 42CFR Part 2 prohibit the inclusion of comprehensive psychological report data in a general medical file, as well as any further disclosure of this information without specific written consent of this person.  A general authorization of the release of medical or other information is NOT sufficient for this purpose.

 

  

Copyright © 2009 Gaye Andrews, Ph.D., MFT, Diane LeMont, Ph.D., & Summer N. Perry, Ph.D., MFT


 

 

 

 

APPENDIX 6

 

 

Memo

 

To:     

From:    

Date:   

Re:      Pt:           DOB:        Consult Date: 

 

THIS MEMO AND ITS ATTACHMENTS ARE FOR THE ADDRESSEE ONLY.  NO OTHER DISSEMINATION IS PERMISSIBLE.

 

The patient identified above was referred for a psychosocial consultation regarding readiness to manage the post-surgical lifestyle adjustments necessary for weight-loss surgery.  An Eligibility for Surgery Form has been completed and provided to your office. 

 

Assessment Results and Treatment Recommendations have been provided to the patient.  As information provided to the patient may be useful in his/her medical care following weight-loss surgery, a copy is attached for your review.  Unless otherwise noted, the information contained in the consultation summary that follows is based solely on patient report and/or assessment results.

 

 

In compliance with the Health Insurance Portability and Accountability Act (HIPAA), this memo and the accompanying documents are intended only for the use of the individual(s) or entity to which they are addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law.   The authorized recipient(s) of this patient information is/are prohibited from disclosing the information to any other party. If the reader(s) of these documents is/are not the intended recipient(s) or the employee or agent responsible for delivering the documents to the intended recipient(s), you are hereby notified that any dissemination, distribution or copying of these documents is strictly prohibited. If you have received these documents in error or they were forwarded to you without permission from the identified patient and/or Dr. Andrews, please return the documents to Dr. Andrews at the address indicated above.  If the documents have been electronically sent to you, DELETE them from all mailboxes and any other electronic storage medium and DESTROY all copies.  Thank you. 

 

 

PSYCHOSOCIAL EVALUATION SUMMARY

 

IF REVISION PATIENT:

 

(Patient Name) is presenting as a candidate for a revision of a previous weight-loss surgery.  (Patient Name) does not believe she can achieve and maintain a healthier body weight without a revision of her weight-loss surgery.

 

CONTINUED FROM ABOVE FOR REVISION PATIENT.  BEGIN HERE IF NEW PATIENT, MODIFY AS APPROPRIATE

 

(Patient Name) denies past and/or present psychological condition, suicidality, abuse, substance abuse, and/or eating disorder.  She reports drinking alcoholic beverages responsibly; she does not use street drugs.

 

(Patient Name) appears to understand the nature of weight-loss surgery and the required lifestyle changes.  She appears to have realistic expectations and understands that her success depends on her own choices and actions after surgery.  She describes herself as willing and able to follow the post-surgical guidelines.  She is willing to participate in psychological and/or behavioral treatment if it would support success.  She describes her family and friends as supportive of the lifestyle changes required by weight-loss surgery.

 

ASSESSMENT RESULTS

 

EATING PROFILE QUESTIONNAIRE (EPQ):

 

The EPQ is designed to identify and diagnose psychological factors that contribute to five common (non-clinical) reasons for overeating.  The results of the questionnaire suggest this patient may engage in the following patterns of overeating:

 

_____ No patterns of overeating were identified by the EPQ. 

 

However, during the interview the patient reported a history of:

 

 

OR

 

 

_____ Impulsive Overeating:  Eating without thinking about why, where, when, and how much is being consumed.

 

_____ Hedonistic Overeating:  Consuming too much because of the enjoyment derived from the taste of food.

 

_____ Stress Reduction Overeating: Using food to cope with life’s difficulties and challenges.

 

_____ Avoidance Overeating:  Eating to avoid dealing with the realities of life.

 

_____ Energizing Overeating:  Eating to improve feelings of depression, sadness, boredom, and fatigue.

 

_____ No patterns of overeating were identified by the EPQ.

 

In addition, during the interview the patient reported a history of:

 

BASIC PERSONALITY INVENTORY (BPI):

 

The BPI is designed to measure a number of broad facets of personality functioning.  The results indicate areas of psychosocial strength and stability and/or areas of distress and difficulty. 

 

_____ This patient scored within the normal range for all areas assessed.

 

OR

 

For the following areas, this patient scored in a way that suggests some distress or difficulty:

 

_____ Frequently concerned about being sick.  Complains regularly of peculiar pains or body dysfunction.

 

_____ Is inclined to be downhearted; considers self to be inadequate; looks at the future pessimistically.

 

_____ Lacks insight into feelings and causes of own behavior.

 

_____ Often annoyed by little inconveniences, frustrations, or disappointments; uncomfortable with rules, regulations, and criticism.

 

_____ Expresses attitudes markedly different from common social codes.

 

_____ Believes that certain people are hostile and trying to make life difficult and unpleasant.  Inclined to brood.

 

_____ Easily frightened or made anxious.

 

_____ Confused, distractible and disorganized. 

 

_____ May have difficulty thinking beyond the present and considering the consequences of actions; finds routine tasks boring.

 

_____ Uncomfortable around others; prefers asocial activities.

 

_____ Feels worthless, unpleasant, and undeserving.  Generally expresses a low opinion of self and may be unable to take credit for any accomplishment.

 

_____ Displays behavior patterns very different from most people.

 

 

 

__________________________________

Prepared By

 

 

 

References:

 

Fadia, Vijay (1999).  Eating Disorders, Homestead Schools Inc.

 

Jackson, D. (1989).  Basic Personality Inventory, Sigma Assessment Systems, Inc., Port Huron, MI.

 

Last, C. (1999).  The 5 Reasons Why We Overeat.  Carol Publishing Group, Secaucus, NJ.

 

 

 

Copyright © 2009 Gaye Andrews, Ph.D., MFT, Diane LeMont, Ph.D., & Summer N. Perry, Ph.D., MFT

 


 

TREATMENT RECOMMENDATIONS FOR THE WEIGHT-LOSS SURGERY PATIENT 

           

Patient:                                                           DOB:

 

Surgeons:                                                        Consult Date:

 

 Add patient-specific treatment issues and treatment recommendations here.

 

 

 

I acknowledge receipt of these treatment recommendations and letter of understanding.

 

_____ I agree to comply   _____ I do not agree to comply.

 

Signature__________________________________________  Date___________

   

 

 

 

APPENDIX 7

 

 

PSYCHOLOGICAL CONSULTATION

 

Candidate Name:                             DOB:

 

Program:                                       Consult Date:

         

The patient was referred for a psychosocial consultation to determine readiness for weight-loss surgery and/or to identify psychosocial issues, present conditions and/or patterns of behavior that may benefit from treatment before and/or after surgery. The consultation/evaluation consisted of a verbal interview and completion of the Basic Personality Inventory (BPI), Beck Depression Inventory – II (BDI-II), the Eating Profile Questionnaire (EPQ) and a weight and dieting questionnaire.  The interview and testing instruments were selected for morbidly obese patients who wish to have weight-loss surgery. Unless otherwise noted, information contained in the summary that follows is based solely on patient report and testing results.

 

(Patient Name) is a __ year old female.  She is _____ and has __ children.  She works as a _____.

 

(Patient Name) describes herself as always having had a weight problem (OR__ having a weight problem since the age of __). She is __ feet __ inches tall with a current weight of __ pounds. She has attempted to lose weight in the past and has lost up to __ pounds. (Patient Name) does not believe she can achieve and maintain a significantly healthier body weight without the aid of weight-loss surgery.

 

MODIFY BELOW AS APPROPRIATE

 

(Patient Name) denies past and/or present abuse, psychological disorder, suicidality, substance abuse, and/or eating disorder.  She drinks alcoholic beverages responsibly and does not use street drugs. (OR __ She does not drink alcohol or use street drugs).

 

(Patient Name) appears to understand the nature of weight-loss surgery and the required lifestyle changes.  She has realistic expectations and understands that her success depends on her own choices and actions after surgery.  She describes herself as willing and able to follow the post-surgical guidelines.  She is willing to participate in psychological and/or behavioral treatment if it would support success.  She describes her family and friends as supportive of the lifestyle changes required by weight-loss surgery.

 

(Patient Name) appears to be ready for weight-loss surgery.  She was advised to seek psychological services should any psychological, environmental/social, and/or behavioral factors make it difficult to manage the necessary post-surgical lifestyle adjustments.

 

 

 

__________________________________

Prepared By


 

 

 

 

 

APPENDIX 8

 

 

Weight-loss Surgery Patient

 

Authorization and Informed Consent

 

I give my consent for (MHP name and license here) to be a member of my weight-loss surgery treatment team.  I authorize (MHP) to:

 

1.   Conduct a clinical interview with me and evaluate my responses on the relevant assessment instruments in order to assess my readiness for weight-loss surgery. I understand that the goal of this consultation is to identify any psychological, environmental/social, and/or behavioral factors that should be addressed and/or treated before surgery and/or during weight loss and maintenance.  I understand that it may be important to my general health, as well as my long-term success that I answer the interview and assessment questionnaires completely and accurately.

 

2.   Provide my surgeon and his/her agents(s) a consultation summary and eligibility for surgery form.  Release of the consultation summary to anyone else is not covered by this authorization.  If my insurance provider requires information about my readiness for surgery or to approve the procedure, I understand my surgeon and/or his agents(s) will provide only a copy of the eligibility for surgery form.

 

3.   Consult with me, my surgeon and other members of the weight-loss surgery treatment team regarding psychological, environmental/social, and/or behavioral issues affecting my readiness for weight-loss surgery, my post-surgical adjustment, and weight-loss and maintenance throughout my participation in the medical weight-loss program.

 

I understand that (MPH) will not use information about me in any manner other than that described above without my explicit permission in writing except in situations required and/or allowed by law.  These situations include, but are not limited to:  (a) If I threaten harm to myself or another person, potential helpers, victims, and law enforcement will be notified, (b) If I reveal child abuse, elder abuse, or abuse of dependent adults, the appropriate social services agency and/or law enforcement will be notified, (c) If the court orders a legal subpoena of my records, the information required in the subpoena will be provided.  Complete details of when the law requires and/or allows the disclosure of confidential information without patient permission are described in the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices handout accompanying this Authorization and Informed Consent.

 

I have been informed of the fee for the consultation and that the total amount is due at the time of service.  I understand that the fee is for the consultation and does not guarantee any particular result.  Contract patients are exempted from fee.

 

I have read, understand, and agree to the terms described in this one-page document.

 

_______________________________       _________________________

Printed name of patient                                            Date

 

____________________________________________________________

Complete mailing address

 

____________________________________________________________

City, State, Zip

 

_____________________________________________________________

Signature of patient

 

This authorization is subject to revocation, in writing, at any time except where action has been taken in the reliance hereon.  A photocopy of this signed document is as good as an original.


 

 

Weight-loss Surgery Patient

(Minor or Dependent Adult)

 

Authorization and Informed Consent

 

We give our consent for (MHP), to be a member of the weight-loss surgery treatment team.  We authorize (MHP) to:

 

1.   Conduct a clinical interview and evaluate responses on the relevant assessment instruments in order to assess readiness for weight-loss surgery.  We understand that the goal of this consultation is to identify any psychological, environmental/social, and/or behavioral factors that should be addressed and/or treated before surgery and/or during weight loss and maintenance.  We understand that it may be important to general health, as well as long-term success, that the interview and assessment questionnaires be answered completely and accurately. 

 

2.   Provide the surgeon and his/her agent(s) a consultation summary and eligibility for surgery form.  Release of the consultation summary to anyone else is not covered by this authorization.  If the insurance provider requires information about readiness for surgery or to approve the procedure, we understand the surgeon and/or his/her agent(s) will provide only a copy of the eligibility for surgery form. 

 

3.   Consult with us, the surgeon and other members of the weight-loss surgery treatment team regarding psychological, environmental/social, and/or behavioral issues affecting readiness for weight-loss surgery, post-surgical adjustment, and weight-loss and maintenance throughout participation in the medical weight-loss program. 

 

We understand that (MPH) will not use information in any manner other than that described above without explicit permission in writing, except in situations required and/or allowed by law. These situations include, but are not limited to: (a) If there is threat to harm self or another person, potential helpers, victims, and law enforcement will be notified, (b) If child abuse, elder abuse, or abuse of dependent adults is revealed, the appropriate social services agency and/or law enforcement will be notified, (c) If the court orders a legal subpoena of records, the information required in the subpoena will be provided. Complete details of when the law requires and/or allows the disclosure of confidential information without permission are described in the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices handout accompanying this Authorization and Informed Consent.

 

We have been informed of the fee for the consultation and that the total amount is due at the time of service. *We understand that the fee is for the consultation and does not guarantee any particular result. Contract patients exempted from fee.

 

We have read, understand, and agree to the terms described in this one-page document.

 

___________________   ___________________      __________________

Printed name of patient           Signature                           Date

 

______________________________________________________________

Complete mailing address

 

______________________________________________________________

City, State, Zip                                            

      

______________________________    ______________________________

*Printed name of parent or guardian               Signature

 

______________________________    ______________________________

*Printed name of parent or guardian               Signature

 

*When only one (1) parent or a guardian is present, a Caregiver’s Authorization Affidavit must be completed.

 

This authorization is subject to revocation, in writing, at any time except where action has been taken in reliance hereon.  A photocopy of this signed form is as good as an original.

 

 

 

 

 

 

 

Appendix 9

 

 

Results of the Basic Personality Inventory (BPI)

 

Name_______________________________    Date ___________________

 

The BPI measures several areas of personality style and emotional strengths and stability.

 

_____ You scored within the normal range for all areas assessed.

 

_____ For some of the areas assessed, you scored in a way that suggests some distress or difficulty.

 

The areas of concern are checked below:

 

_____ Frequently concerned about being sick.  Complains regularly of peculiar pains or body dysfunction.

 

_____ Is inclined to be downhearted; considers self to be inadequate; looks at the future pessimistically.

 

_____ Lacks insight into feelings and causes of own behavior.

 

_____ Often annoyed by little inconveniences, frustrations, or disappointments; uncomfortable with rules, regulations, and criticism.

 

_____ Expresses attitudes markedly different from common social codes.

 

_____ Believes that certain people are hostile and trying to make life difficult and unpleasant.  Inclined to brood.

 

_____ Easily frightened or made anxious.

 

_____ Confused, distractible and disorganized. 

 

_____ May have difficulty thinking beyond the present and considering the consequences of actions; finds routine tasks boring.

 

_____ Uncomfortable around others; prefers asocial activities.

 

_____ Feels worthless, unpleasant, and undeserving.  Generally expresses a low opinion of self and may be unable to take credit for any accomplishment.

 

_____ Displays behavior patterns very different from most people.

 

During your interview you reported:

 

 

The indicated areas of concerns could interfere with your weight-loss/weight-maintenance success following weight-loss surgery.  It is important that you seek treatment if it does/they do.

 

 

Results for the Eating Profile Questionnaire (EPQ)

 

Name ______________________________________ Date ____________________

 

_____ Impulsive Overeating:  Eating without thinking about why, where, when, and how much is being consumed.

 

_____ Hedonistic Overeating:  Consuming too much because of the enjoyment derived from the taste of food.

 

_____ Stress Reduction Overeating: Using food to cope with life’s difficulties and challenges.

 

_____ Avoidance Overeating:  Eating to avoid dealing with the realities of life.

 

_____ Energizing Overeating:  Eating to improve feelings of depression, sadness, boredom, and fatigue.

 

_____ No patterns of overeating were identified by the EPQ.

 

During your interview you reported: 

 

 

Engaging in this/these eating behavior(s) after weight-loss surgery could interfere with your success in achieving and maintaining a healthy body weight.  It is important that you replace unhealthy eating behavior with healthier eating habits. If you find replacing these habits difficult to do on your own, you may find attending the “Eating Normally” course provided by your surgeon/program helpful and/or following any treatment recommendations provided.

 

I have received a copy of this two-page document noting the results of my Basic Personality Inventory (BPI) and Eating Profile Questionnaire (EPQ).  The results were reviewed with me and any needed treatment recommendations were discussed. At this time,

 

_____ Treatment is recommended to begin before surgery and continue for as long as needed.

 

_____ Treatment is recommended before surgery can be scheduled.

 

_____ Treatment is recommended if you experience emotional difficulty if you are unable to resolve or you are unable to follow post-surgical guidelines.

 

Printed name of patient ___________________________________   Date __________

 

Signature of patient ______________________________________________________

 

If minor, signature of parent(s)/guardian____________________________________________

 

 

 

 

Appendix 10

 

 

LIFESTYLE ADJUSTMENTS AFTER WEIGHT-LOSS SURGERY

 

A number of lifestyle changes are recommended and you will need to adjust to these changes as well as other consequences of striving to achieve and maintain a healthy body weight following weight-loss surgery.  Some of the most common are listed below.  Not making these changes and/or working through the adjustments required for your type of weight-loss surgery may limit the satisfaction and/or benefit you receive from your surgery.

 

NUTRITION:

 

1.   Following a postsurgical dietary program that allows the surgical procedure to heal correctly and completely.

2.   Practicing eating and drinking behaviors that encourage digestive comfort and food tolerance.

3.   Following dietary guidelines that support weight loss, weight-loss maintenance and general health.

 

The restrictive component of weight-loss surgery and behavior modification exercises may be all that is required to address counterproductive patterns of eating.   There are self-help books that could be helpful, such as Living a Lighter Lifestyle by Gaye Andrews, Ph.D., LMFT, The Rules of Normal Eating by Karen R. Koenig, and Eating Mindfully by Susan Albers, Psy.D.

 

If weight-loss surgery and self-help exercises are not sufficient, you may benefit from working with a psychotherapist who specializes in teaching behavior modification techniques or cognitive behavioral skills.  Patterns of eating not modified will likely limit the amount of weight lost and/or contribute to weight regain.  Studies indicate that patients who engage in binge eating behavior, especially those who are also depressed, may benefit from taking an antidepressant medication for a minimum of a year or two in conjunction with participating in behavior modification therapy.  You may wish to discuss such combined treatment with your physician and/or a psychotherapist.  Should you choose to take an antidepressant, one that does not contribute to weight gain is encouraged.

 

EXERCISE: (As authorized by your surgeon)

 

1.   Doing aerobic exercise 5 to 7 times a week to burn stored fat (e.g., walking).

2.   Doing strength training exercises 3 times a week to firm, tone, and increase muscle mass.

 

ATTITUDES:

 

1.   Willingness to follow eating, dietary, and activity guidelines.

2.   Willingness to modify sabotaging eating, drinking, or other lifestyle behaviors (e.g., avoiding or limiting snacking, high calorie beverages (juices, sodas, enhanced coffees), use of appetite stimulants (marijuana).

3.   Setting realistic expectations for goal weight, rate of weight loss, and body size, shape and appearance.

 

RELATIONSHIPS:

 

1.   Adjusting to changes in relationships with others.  People may have difficulty adjusting to the “new you” and/or your new lifestyle.  They may treat you differently (better or worse) because you have had bariatric surgery and/or have lost weight.

2.   Responding to questions about your surgery, weight loss, and dietary changes.

 

STRESS MANAGEMENT:

 

1.   Working through temporary emotional distress (e.g., regret of surgery and/or depression)  associated with:

 

Postsurgical stress, hormonal and other biopsychosocial (biological psychological social) adjustments, postsurgical complications, medication management issues, and/or hair loss

 

Food withdrawal, loss of appetite, and/or changes in taste

 

Unrealistic expectations and/or a variety of unexpected or unwanted life changes

 

2.   Using stress management, problem-solving, and appropriate coping skills (instead of eating) to address life challenges.

 

ALCOHOLIC BEVERAGES/STREET DRUG ADVISORY:

 

The malabsorptive component of some weight-loss surgeries, as well as significant weight loss, may increase sensitivity to alcoholic beverages.  Studies indicate that patients may become drunk on small amounts of alcoholic beverages after surgery.  Frequent drinking may contribute to alcohol-related life problems and/or medical conditions.  The high number of calories contained in alcoholic beverages may inhibit weight loss and/or contribute to weight regain.  Additionally, use of some street drugs (e.g., marijuana) may encourage snacking that inhibits weight loss and/or contributes to weight regain.  Your surgeon encourages patients to avoid or significantly limit drinking of alcoholic beverages and use of street drugs.  You are advised to discuss any alcohol or drug use questions with your surgeon.

 

PATIENTS WHO HAVE BEEN ABUSED:

 

Individuals who have been abused are advised that significant weight loss may uncover and/or intensify unresolved issues of abuse.  These may include, but are not limited to, fear of further abuse and the desire to retain weight as a protection from abuse.  If abuse issues are experienced with weight loss, psychological services are recommended.

 

PSYCHOLOGICAL TREATMENT AND/OR MEDICATION:

 

If you are currently receiving psychological treatment and/or taking medication for a psychological condition, you are encouraged to continue your current treatment for as long as necessary. You are advised that the malabsorptive component of some weight-loss surgeries, as well as significant weight loss, may influence the effectiveness of some medications taken for psychological conditions (e.g., enteric-coated or time-released medications).  Psychological symptoms may also occur or increase because of the stress of surgery and or biopsychosocial (biological psychological social) adjustments that may accompany weight loss.  In either case, some weight-loss surgery patients may require a change in type or dosage of medication.  Questions regarding your medication are best discussed with your prescribing physician or psychiatrist.  Please consult with your prescribing physician and/or your weight-loss surgeon regarding special instructions for taking your medication just before and/or just after surgery.

 

SUPPORT GROUP:

 

You are encouraged to participate in the patient education and support group provided by your surgeon and/or program as frequently as possible.  If for some reason this is not possible, you are encouraged to locate a weight-loss support group in your area/on line/or participate in a related support group (i.e. Weight Watchers or TOPS).  Should you participate in a support group not provided by your surgeon and/or program, you are advised to follow the nutritional guidelines provided by your surgeon and/or program to protect your health.

 

The items checked below indicate areas of lifestyle adjustment I was advised to monitor and/or address in order to experience the best possible weight-loss surgery outcome:

 

____EPQ identified and/or self-reported unhealthy eating habits

 

____BPI identified and/or self-reported psychosocial issues

 

____Exercise  ____Attitudes ____ Relationship Issues  ____Coping Skills  ____Substance Use

 

____Abuse Issues  ____Learn more about my surgical procedure and the lifestyle changes recommended

 

Note:

 

 

 

The items checked below indicate areas of lifestyle adjustment for which I was advised to continue or begin treatment in order to experience the best possible weight-loss surgery outcome.

 

____EPQ identified and/or self-reported unhealthy eating habits

 

____BPI identified and/or self-reported psychosocial issues

 

____Exercise  ____Attitudes ____ Relationship Issues  ____Coping Skills  ____Substance Use

 

____Abuse Issues  

 

Note:

 

 

I have received a copy of this two-page document.  The information outlined in the document has been reviewed with me and I was encouraged to ask questions.  I understand the information presented. 

 

 

Printed name of patient ______________________________     Date _______________

 

Signature _______________________________________________________________

 

If minor, signature of parent/guardian _________________________________________  

 

 

REFERENCES

 

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, American Psychiatric Association.

 

Andrews, G. (1997, 2000, 2003). Living a Lighter Lifestyle:  A Guide to Successful Weight Loss and Maintenance Following Weight Loss Surgery, Wheat Field Publications.

 

ASBS (American Society for Bariatric Surgery). (2000). Surgery for Morbid Obesity:  What Patients Should Know.

 

BioEnterics Corporation (2001). A Surgical Aid in the Treatment of Morbid Obesity:  Lap-Band Adjustable Gastric Banding System Information for Patients.

 

Blair, S.N. and Leermakers, E.A. (2002) “Exercise and Weight Management” in T.A. Wadden and A.J. Stunkard (Eds.), Handbook of Obesity Treatment (pp283-300). New York: Guilford Press.

 

Branden, N. (1994). The Six Pillars of Self-Esteem. New York: Bantam Books.

 

BRFSS, Behavioral Risk Factor Surveillance System. (http://www.cdc.gov/brfss/  accessed on 11-01-2009)

 

Bray, G.A. and Bouchard, C. (Eds.) (2004). Handbook of Obesity: Etiology and Pathophysiology Second Edition. New York: Marcel Dekker, Inc.

 

Brolin RD (2002).  Malabsorptive gastric bypass in patients with superobesity.  Journal of Gastrointestestinal Surgery, 6(2): 195-205 (MEDLINE, accessed 10/18/2009)

 

DiGregorio, J.M. and Moorehead, M.K. (1994). The Psychology of Bariatric Surgery Patients: A Clinical Report. Obesity Surgery, 4, 361-369.

 

Finkelstein, E.A., Fiebelkorn, I.C, and Wang, G. (2004). State-Level Estimates of Annual Medical Expenditures Attributable to Obesity. Obesity Research, 12, 18-24.

 

Fobi, Mathias A.L., Obesity an Underestimated Medical Problem - The Fobi-Pouch Operation for Obesity-Surgical Treatment Of Obesity, Center for Surgical Treatment of Obesity.

 

Foster, G.D., Phelan, S., Wadden, T.A., Gill, D., Ermold, J. & Didie, E. (2004). Promoting More Modest Weight Losses: A Pilot Study. Obesity Research 12, 8, August.

 

Foster, G.D., Wadden, T.A., Vogt, R.A., & Brewer, G. (1997) What Is a Reasonable Weight Loss? Patients’ expectations and evaluations of obesity treatment outcomes. J Consult Clin Psychol, 65, 1, 79-85.

 

Gilman, Tricia and Dale (1996), Living Happily and Healthily with Your Surgery, Gilman Enterprises

 

Hales, D. & Hales, R. E. (1995). Caring For The Mind: The Comprehensive Guide To Mental Health.  New York: Bantam Books.

 

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