CARING FOR THE SURGICAL WEIGHT LOSS PATIENTby Diane LeMont, Ph.D., Gaye Andrews, Ph.D., MFT.
Course content © Copyright 2009 - 2013 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. 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.
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 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.
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.
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.
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.
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.
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.
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.
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).
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.
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. 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).
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).
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.
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.
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.
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.
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.
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:
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.
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 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.
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.
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.
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.
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.
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:
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:
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.
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).
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.
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