The Importance Of Pursuing The Patient’s Definition of Success Following Weight Loss Surgery: Strategies and Considerations for the Bariatric Team

by Warren L. Huberman, PhD

Dr. Huberman is Clinical Assistant Professor, NYU School of Medicine, Department of Psychiatry, New York, New York.

Funding: No funding was provided.
Disclosures: The author reports no conflicts of interest relevant to the content of this article.

ABSTRACT
All members of the bariatric team must be aware that their definition of success may not be the same as the patient’s. While the primary objective of weight loss surgery is weight loss, the patient’s true objective is to achieve the goals they believe losing weight will allow. These objectives are often broadly referred to as quality of life (QoL), but may specifically include improvements in romantic relationships, social relationships, and career functioning in addition to improvements in overall health and physical functioning. Therefore, care providers need to be aware of and address emotional and behavioral impediments to losing weight as well as keeping weight off and working to help patients achieve their definition of “true” success. Psychological obstacles to weight loss and weight loss maintenance as well as factors that contribute to patient dissatisfaction despite significant weight loss are reviewed.

INTRODUCTION
An ever-growing number of studies demonstrate that bariatric surgery is the most effective treatment for morbid obesity both in the short and long-term.[1–3] Furthermore, much data confirm that numerous measures of health, physical functioning, quality of life, and various measures of psychological well being all generally improve as a consequence of significant weight loss.[4–9]

While there are a number of ways to measure success following weight loss, the bariatric surgery community typically defines the concept of a “successful” outcome in terms of percentage of excess weight loss (%EWL) following surgery.[10] Longer-term studies of bariatric surgery outcomes have extended the definition of success from excess weight loss to excess weight lost and maintained over a longer period of time, beyond the first two years after surgery. A sustained weight loss of greater than 50 percent EWL is commonly used as an indicator of longer-term “success” from bariatric surgery.[11]

While weight loss itself is certainly the primary objective of surgery and the appropriate metric to judge surgical success, there is reason to believe that from the patient’s perspective, a successful outcome is one where not only has the patient lost and maintained a significant amount of weight, but also one where the patient is able to make changes in his of her life that he or she believes the significant weight loss will allow.

Every individual patient has a reason or reasons for wanting to lose weight. For many, these reasons include wanting to improve health, physical functioning, and longevity. For others, reasons include wanting to improve their personal, social, professional, and other functioning. In other words, the significant weight loss that results from surgery is often the first step in a much longer process toward achieving other important life goals. Viewed in this way, success in the eyes of the patient is not measured only in terms of weight loss or improvements in functioning, but also in terms of what he or she is able to accomplish as a result of the weight loss.

With this new and more comprehensive definition of success, it is conceivable that a patient could achieve a significant weight loss from surgery but still not feel that she is truly successful. Ironically, a patient may fail to achieve the expected weight loss, yet still be mostly satisfied with his or her outcome from surgery and consider him or herself to be successful. In fact, these are common experiences in working with postoperative bariatric patients. It is because the patient’s definition of success is not a fixed endpoint but rather a very personal definition. Evaluating patient expectations from surgery is an important element to address during the pre-surgical psychological evaluation.[12,13]

While it is important to be aware of and address the factors that may cause patients to feel dissatisfied despite significant weight loss following surgery, there is also the problem of explaining why many patients do not lose the expected amount of weight or regain weight in the years following surgery. It is estimated that up to 20 percent of bariatric patients do not achieve a 50-percent EWL and weight regain following surgery is common.[6,14]

There are occasions where these two definitions of success collide. Specifically, there are instances where bariatric patients lose a significant amount of weight following surgery but continue to struggle with behavioral and emotional issues that lead them to relapse and resume former habits, often resulting in weight regain. It is becoming clear that bariatric surgery is not a cure-all and that patients face a myriad of behavioral, emotional, and interpersonal issues both before and after surgery and it is essential that these issues be addressed to maximize patient outcomes.[15]

There is a minority of patients who do not lose the expected amount of weight following bariatric surgery. Some patients lose a very small percentage of weight following surgery (i.e., 20% EWL), while others lose more weight but plateau prematurely and do not lose the expected amount of weight (i.e., less than 50%EWL).[6,14] Finally, there are those patients who lose a significant amount of weight, but regain some or most of the weight in the years after surgery.[6,14]

PATIENTS WHO STRUGGLE TO LOSE WEIGHT FOLLOWING SURGERY OR WHO STRUGGLE TO KEEP IT OFF
A good question to ask is, “Why don’t some of our patients lose the amount of weight expected?” In the case of those who either fail to lose weight following surgery or who plateau prematurely, it seems reasonable to implicate surgical failure, surgical complications, or other medical factors rather than patient-specific factors, such as eating behavior or emotional factors. The robustness of the surgery is at its peak in the months immediately following surgery, and research demonstrates that the percentage of excess weight lost by most patients is greatest in the first two years following surgery and is often statistically insignificant thereafter.[11]

Research supports the notion that a number of clinical factors contribute to surgical outcome,[16] and that even genetic variation may play a role in predicting surgical outcome.[17] Additionally, there are studies that suggest that postoperative complications are often responsible for weight regain in the years further out following weight loss surgery.[11,18–20]

While it may be true that patient behavior is not the primary factor in explaining poor weight loss following surgery, there are clearly circumstances where patient behavior and those variables contributing to patient behavior are believed to play a role in determining the reason for less than expected weight loss. It is especially important to note that psychologists, nutritionists, nurses, and other integrated health professionals as well as surgeons commonly work with patients who acknowledge that they are not being adherent or are struggling to be adherent to post-surgical recommendations. Many such patients will blame themselves for their inability to be adherent; however, bariatric surgery itself does not teach patients new eating behaviors. Therefore, most patients need to make a concerted effort to learn how to make such changes to their eating and other behaviors and not rely on surgery to force them to make these changes.

In the nonsurgical weight management literature, a significant focus is placed on key behavior change strategies, such as self-monitoring, stimulus control, and developing behaviors to substitute for eating. Patients in behavioral weight management programs are advised to document what they eat and possibly the calorie content or other information regarding food consumed. In addition, identifying specific “triggers” (stimuli) for eating, such as emotional states as well as environmental cues and learning new behaviors (e.g., exercise, drinking water, journaling), is seen as essential in making lasting behavioral change.[21,22]

An important method to help both patients and caretakers avoid blaming the patient for nonadherence is to focus on making small but important behavior changes rather than focusing solely on weight loss. Even then, it must be understood that behavior change is not linear and often involves lapses and setbacks. It is critical to inform patients that it is common to struggle to make behavior change following surgery and that weight loss is generally not linear. For example, patients commonly report that they were informed that they would lose 1 to 2 pounds per week. Many patients believe that they should lose weight every single week; however, this is often not the case as the 1 to 2 pound figure is an approximation. Similarly, learning an array of new eating behaviors, such as slowing down while eating and chewing food more completely and having to avoid some foods while trying to substitute and increase consumption of others, can take several months before feeling “normal.”

It is especially important to address patient expectations regarding weight loss and the difficulties involved in making such extensive behavior change because when patients become frustrated and blame themselves for their struggles, they may drop out and avoid contact with the surgeon and the bariatric practice. This is particularly important to address as patient contact with care providers is a factor that is closely associated with positive outcomes from weight loss in general[23] and from bariatric surgery in particular.[24,25] Patients as well as the staff of the bariatric program must be informed that changing behavior is a difficult process that will take some time and that, while a consistent loss of weight over the months following surgery is the objective, there will likely be weeks where patients do not lose weight or, possibly, gain some weight every now and then.

An additional reason why it is important for both patients and caretakers to avoid blaming the patient is that the larger society continues to view the patient population with morbid obesity as responsible for their disease. Even with the recent news that the American Medical Association declared obesity as a diseasse, getting the public to accept obesity as a disease remains a challenge. As a result, many patients with obesity report feeling persecuted by others, including medical and other professionals.
The media represents another challenge. Popular “reality” television shows are obsessed with weight loss and lead many people with morbid obesity to believe that they too should be able to lose 100 pounds or more if only they could live apart from the stressors of their daily lives for a few months on a ranch with a prepared, very low-calorie diet provided each day along with personal training for several hours per day free of charge. While they may recognize that these “reality” programs are not reality at all, many bariatric patients continue to blame themselves for their inability to stick with dietary regimens and lose weight. In my experience, it is quite common for bariatric patients to express feelings of shame and embarrassment during the pre-surgical psychological evaluation about needing surgery because they could not resolve their obesity themselves. In my opinion, it is because so many patients endorse this irrational way of thinking about weight loss that bariatric professionals must be especially careful to not fall into the trap of blaming the patient.

COMMON REASONS why SOME PATIENTS STRUGGLE TO LOSE WEIGHT FOLLOWING SURGERY OR STRUGGLE TO KEEP IT OFF
Bariatric surgery requires significant, long-term behavioral changes and ongoing adherence to medical, dietary, and behavioral recommendations.

There is extensive literature on the generally poor state of adherence across all medical disciplines[,26] and similar results are found in the bariatric population.[27,28] Needless to say, it is common that patients do not do as they are told. The majority of bariatric programs provide nutritional counseling pre- and post-surgery. In my opinion, it is unlikely that bariatric surgery patients fail to lose weight because they are not properly educated about the need for specific dietary changes as well as the need to make substantial change in their eating behaviors. Most patients know what they “should” and “should not” be eating. This difficulty in adhering to dietary recommendations following bariatric surgery is no different than adherence issues among patients participating in traditional, nonsurgical weight loss programs.

Obstacles to patient adherence. In his recent article regarding motivational interviewing, Zuckoff suggests that bariatric professionals should “listen” to patients rather than “tell” them what to do.[26] Again, patients are not struggling with obesity because they are ignorant about proper eating, nor are they failing to lose weight because they do not desire to be thinner. Yet, over and over, patients describe how physicians, nutritionists, personal trainers, psychologists, and others have historically “told” them what they “should” do to lose weight, and many report that they were informed that if they were not doing these things, they must subconsciously wish to remain obese. This explanation is misguided, destructive, and is another way of blaming the patient.

Instead of providing more information, we should consider meeting patients where they are and being aware of their obstacles to adherence. Patients often know what they need to be doing and, with encouragement and support, may very well be willing to do so. However, patients often do not have answers as to why they cannot adhere. In these situations, we should partner with them to explore possible reasons for nonadherence.

The literature indicates that there are a number of behaviors that are associated with successful weight loss, and patients can be encouraged to engage in as many as possible.[25,29] These behaviors include attending post-operative support groups and increasing physical activity. Similarly, keeping a food diary has repeatedly been shown to be associated with long-term weight loss among nonsurgical patients, and there is reason to believe this behavior would be beneficial among bariatric patients as well.[22,30]

As previously stated, making modifications in the environment, known as stimulus control, and developing behaviors to substitute for eating would also be advisable. A growing number of researchers are making reference to the “toxic” food environment in which we live where we find ourselves faced with an onslaught of unhealthy processed foods that are rich in fat, sugar, and other ingredients that promote obesity.[31,32] It is imperative for postoperative bariatric patients to make these modifications in their environment (at home and in the workplace), as they are likely to be particularly vulnerable to such cues. It is reasonable to recommend that patients make many of these behavior changes, but only after assessing the patient’s readiness to change and work through potential obstacles to adherence.

Specific maladaptive eating patterns. Some presume that gastric band, gastric sleeve, and gastric bypass patients eat less following bariatric surgery because they have a reduced appetite and desire to eat and secondarily because the capacity of their stomach has been reduced. Gastric bypass surgery creates changes in gut hormones that lead to further weight loss.[33] Research suggests that restriction alone is not responsible for the weight loss.33 While all of the mechanisms of action in surgery are not known, the resulting reduced caloric intake and absorption of calories helps with weight loss.

Patients who are nonadherent to dietary recommendations and engage in specific eating behaviors that circumvent the effects of the surgeries are at greater risk for weight regain.[28] Maladaptive eating following weight loss surgery includes grazing, sweet eating, binge eating, and consuming an excess of liquid calories.[34] Poor adherence to the recommended schedule of band adjustments also compromises outcomes among patients.[35]

“Grazing” refers to consuming large quantities of calories over an extended period of time. “Bingeing” is consuming a large amount of calories over a short period of time. Bariatric surgery can inhibit both the urge and ability to binge on most foods. However, the restrictive effect and inhibition of desire to binge are generally greater shortly after surgery.

Unfortunately, I have found through my own experience that a minority of patients who recognize that they can no longer binge on foods commonly consumed at meals (e.g., meats, pasta, etc.) instead resort to grazing on foods that are more easily consumed in larger quantities, such as high-calorie liquids or foods that melt (e.g., ice cream, chocolate) or dissolve (e.g., potato chips, corn chips).

Treatments for some of these maladaptive eating behaviors have been found effective among nonbariatric patients. Most notably, cognitive behavior therapy (CBT) interventions that are designed to be short-term and problem-focused are quite effective for many of these concerns in the obese population.[36,37] CBT treatments can be delivered both individually and in groups, and follow a modular format with each weekly meeting addressing specific objectives with the ultimate goal of eliminating maladaptive eating patterns.

Patient-specific sources of anxiety and depression. Maladaptive eating patterns are addressed specifically as behavioral issues, with treatments focusing on breaking unhealthy patterns while promoting healthier patterns of eating. For example, binge eating and grazing are to be replaced with controlled eating in the form of planned meals and snacks with patients documenting all food consumed and learning specific coping behaviors. When addressing patient-specific sources of anxiety and depression, the focus is on factors that are specific to individual patients. Such patients may have personal obstacles to weight loss that cannot be changed simply through a modular behavioral group format.

For example, a patient who has been the victim of sexual abuse may experience genuine panic-like symptoms when he or she feels that others are observing or admiring him or her following significant weight loss.[38,39] Similarly, I have encountered patients who reported having been physically and emotionally abused as children by parents who accused them of being “conceited” or “too full of themselves” for displays of confidence and pride for certain accomplishments. When these patients lost weight following surgery and experienced compliments and kudos from others, they reported experiencing anxiety and fear of negative consequences for possibly seeming proud.

Emotional eating. A significant number of patients seeking bariatric surgery report a past history of “emotional eating”—eating either in response to or as a method of coping with high levels of emotion. Some patients describe emotional eating as an automated reaction to emotional distress while others see it as more of a purposeful, choice behavior. Often it is both. While the term “emotional eating” is admittedly not one cohesive set of behaviors, but rather an all-inclusive “garbage pail” term, we all seem to know what it means and so do patients.

To some extent, “emotional eating” seems to be a normal part of the human experience. There is reason to believe that the pleasure derived from eating may be one of the most basic pleasures that the human brain was designed to experience. In this way, food may be considered the original drug. Evolutionarily, this would make sense. The species would not have survived very long if there were not inherent rewarding consequences of eating. Indeed, there is much research on the effects of eating on neurotransmitter activity and its similarity to the brain’s response to more traditional substances.[40]

Most individuals, with or without weight problems, enjoy eating and many associate positive mood states with eating. It is not difficult to understand how eating could become a strategy to cope with unpleasant emotions. In fact, some cultures seem to promote and encourage eating in response to negative emotions. What person has not experienced being offered food in times of emotional distress? Common examples include grandmothers offering chicken soup or cookies to distraught children and baskets of treats being delivered to celebrate accomplishments or to console those who are grieving.

However, some patients have learned to use food and eating as a universal emotional cure-all, and a combination of high levels of emotional distress with a learned history of eating in response to emotional distress can become dangerous. Weight loss surgery does not teach patients alternate methods of coping to substitute for eating; therefore, patients who are identified in the pre-surgical psychological assessment as being “emotional eaters” need to be encouraged to work on this problem or participate in treatment that will teach them alternate methods of coping with emotional distress. Similarly, patients who are experiencing high levels of emotional distress at the time of the surgery and who identify themselves as emotional eaters may want to consider learning such skills before having surgery.

It is essential that patients be informed that it is possible to learn strategies to combat emotional eating. Unfortunately, in this psychologist’s experience, two of the more common explanations that patients express for continuing to engage in emotional eating or binge eating is their conviction that they are a “food addict” or that they are “addicted to eating,” and that they must be trying to “sabotage” themselves. These terms commonly appear in the lay media and the former in particular increasingly appears in clinical journals and professional publications even though there continues to be an ongoing debate as to whether a true “food addiction” exists or if it is a useful concept.[41–43]

The concept of “sabotage” stems from society’s tendency to “blame the patient” for his or her obesity. The logic is that “if the patient isn’t consistently doing everything possible to lose weight, he or she must not really want to lose weight.” A patient’s inability to lose weight is used as proof that he or she does not really want to. While it is true that some patients may experience elevated anxiety as they lose weight due to earlier life experiences, and that such patients, if they are “emotional eaters,” may resume eating in a manner similar to their behavior prior to surgery, it is not reasonable or accurate to conclude that they are purposefully trying to not lose weight.
What the explanations of “food addiction” and “sabotage” have in common is their reliance on hypothesized underlying constructs to explain the nonadherence and a circular logic to support it. The argument is that the patient continues to eat because he or she is a “food addict” and the evidence used to prove that he or she is a “food addict” is that he or she continues to eat in this manner. Similarly, the patient continues to eat because he or she is trying to “sabotage” him or herself and the evidence of his or her desire to “sabotage” his or her weight loss is his or her continual eating.

While morbid obesity is now rightly being considered a disease, the jury is still out on the “disease” of “food addiction.” While future research may confirm the existence of a true “food addiction” in some patients, what is destructive at the present time is the widely held belief by many bariatric patients that they have a “disease” that is completely beyond their control. This belief often results in relative apathy toward behavior change and an adoption of the principles of the twelve-step approach to addiction treatment. In this model, abstinence from the “substance” is seen as the only effective treatment, where patients are encouraged to avoid consumption of dangerous foods often called “trigger foods.” Sugar, commonly in the form of white flour or other simple carbohydrates, is often viewed as the substance in question.

Ironically, there is significant evidence from the cognitive behavioral literature that compulsive eating problems such as binge eating or grazing may be caused by rigid and strict dieting, particularly when dieters fail to meet specific arbitrary goals.[44] Further, there is growing evidence that binge eating in particular can be treated with CBT and that patients can learn new skills to assume a more normal pattern of eating.[45] One key for some patients might be to encourage learning new behaviors, particularly regarding how to eat highly palatable foods that patients often describe as being “dangerous” rather than necessarily avoiding them entirely.

If patients do not learn how to responsibly eat highly palatable foods, there is a chance that they will resort back to compulsively eating them after surgery. Gastric band patients, in particular, are made aware that excessive consumption of foods that are liquids or that can melt (such as chocolate or ice cream) will prevent significant weight loss. It is not possible to keep the gastric band tight enough to prevent consumption of such foods, and attempting to do so will greatly limit a patient’s food choices and increase the probability that they will experience regurgitation or patterns of disordered eating.

PATIENTS WHO EXPERIENCE BEHAVIORAL AND EMOTIONAL DIFFICULTIES DESPITE SIGNIFICANT WEIGHT LOSS
It is interesting to note that I have seen a near equal number of patients who have objectively been successful following surgery in terms of significant and sustained weight loss, but who continue to struggle on their path toward this new definition of “success.” The diversity of issues experienced by these patients is remarkable, and while there is discussion of some of them in the literature, there is little systematic research in bariatric journals on their treatment.

This highlights the need to assess quality of life in addition to actual weight loss, as these two measures of outcome are often independent of each other. The Bariatric Analysis and Reporting Outcome System (BAROS) may be particularly useful in this regard as it measures overall surgical outcome as a combination of several domains, including weight loss, improvement in obesity comorbidities, and quality of life.[46] The Moorehead-Ardelt Quality of Life Questionnaire (M-A QoLQ) was specifically created to be included into the BAROS and includes measures of self-esteem, physical activities, social life, working conditions, and sexual activity. A more recent update to the BAROS has altered the M-A QoLQ into the MA-II, which now includes an additional question measuring the patients’ relationship to food.[47] The BAROS has been used extensively on different populations and on patients having different surgical procedures.[48–50] Two additional quality of life instruments that have been used extensively in the bariatric population include the IWQOL-Lite and the SF-36.[51–54]

Different Types of Patients
In many regards, there are at least two types of patients who present for weight loss surgery: those who are generally satisfied with their lives and are pursuing surgery to enable them to better enjoy it; and those who do not have a satisfying life and are hoping to be able to lose weight to begin pursuing what it is they believe would make them happier and more fulfilled.

Patients in the former group are those enjoying most areas of life such as their personal, social, intimate, and professional lives. Such patients are often happily married, in other satisfying relationships, or are secure in their single life. They are likely employed in satisfying work and have many social relationships. Those in the latter group would be those who are unhappily married or undesirably single. They may have difficulties in their occupation and have limited social lives. These are over generalizations to be sure, but the point being made is that the more unhappy a patient is in his or her life and the more he or she attributes his or her unhappiness and dissatisfaction to his or her obesity, the more he or she has invested in the outcome from bariatric surgery.

It is this latter group of patients who have much more at stake on the outcome of surgery and to whom we must pay greater attention. This again highlights the importance of understanding patient expectations prior to having surgery, to be better able to monitor their progress and to make appropriate recommendations and referrals following surgery so that such patients can achieve what they believe to be true success.

COMMON PSYCHOLOGICAL REASONS THAT PATIENTS REMAIN DISSATISFIED DESPITE LOSING A SIGIFICANT AMOUNT OF WEIGHT FOLLOWING SURGERY
Weight loss surgery does not correct body image concerns. Many patients who undergo weight loss surgery have a long history of being dissatisfied with their appearance and this is one of the more common reasons patients wish to have surgery. After surgery, many patients recognize that they are objectively thinner, but continue to feel self-conscious about their appearance. Perhaps the most common concern expressed is regarding excess skin.[55] Some post-operative patients report feeling that they have exchanged “excess fat” for “excess skin.” Patients should be informed of the possibility of excess skin prior to surgery so that whatever steps can be taken to address it could be taken as soon as possible. Unfortunately, such steps (e.g., exercise) may prove ineffective, and patients need to either consider reconstructive surgery options or accept the excess skin. The rates of reconstructive surgery following bariatric surgery continue to rise and the psychological issues surrounding these surgeries is only beginning to be explored.[56]

Unfortunately, it is my experience that one of the more common strategies that patients use to cope with the excess skin following weight loss surgery is avoidance. Some patients avoid activities where the excess skin is visible while others will wear excess clothing that hides the skin. While patients may experience temporary relief from feelings of embarrassment or fear that they may have to answer questions about the excess skin, the longer-term result is continued anxiety about the consequences of others seeing the skin. As a general rule, avoiding experiences that create anxiety generally exacerbates anxiety.[57] While others may briefly stare or ask a question regarding the skin, the patient’s focus on and concern about his or her appearance is generally far worse than the reaction of others. By encouraging patients to participate in activities where the skin could be visible and to stop “hiding” underneath excessive clothing, they can confront their anxiety and acclimate to their new body and its effect (or lack thereof) on others.

Mental health professionals spend a great amount of time focusing on beliefs regarding weight, shape and body size (body image), as well as overall beliefs about oneself (self image), when working with patients struggling with obesity or eating disorders. Many of these patients, as well as patients who present for bariatric surgery, endorse maladaptive or irrational beliefs about their weight and size. Additionally, many of these patients believe that there is something wrong with them because they are morbidly obese. Therefore, for some patients to truly experience their surgery as having been “a success,” it is essential that these distorted or maladaptive beliefs be addressed so that they may be at peace with their bodies, despite the possibility of continued imperfections such as excess skin. Again, CBT interventions have been found to be helpful in addressing body image concerns.[58]

Weight loss surgery does not teach dating and other social skills. Many weight loss surgery patients, especially those who have been obese for most or all of their lives, report that their weight has affected their social and intimate personal functioning. This is a common point of discussion during the pre-surgical psychological evaluation and can also be assessed using instruments such as the BAROS. Some have limited social contacts and have avoided dating and intimate relationships and therefore have little experience in these areas. After losing a significant amount of weight, there is often a desire to improve their social and intimate lives, but many feel uncertain and anxious about how to proceed.[59] Most people learn social skills through years of exposure to peers in school, work, and other settings in the course of daily life. Many morbidly obese adults report experiencing shame and embarrassment or were subject to teasing and taunting in their younger years that limited their efforts to socialize and therefore may not have learned such skills or have limited confidence in them. A growing number of studies on adolescents seeking bariatric surgery demonstrates that their day-to-day quality of life, including their self-esteem and social functioning, is severely impaired on multiple measures of quality of life.[60,61]

While surgery is helpful in producing weight loss, it does not teach patients social and dating skills. A number of patients report anxiety about improving their social and intimate lives now that they are thinner. Such patients might eventually learn social and dating skills if they persisted in making efforts to socialize; however the anxiety often inhibits their ability to do so. Once again, CBT can be quite helpful, particularly in a group format where patients can learn and try out social skills with others in the group. Individual therapy targeting specific concerns can also be useful.

Losing weight has been such a daunting long-term goal, many patients never planned for “what’s next?” Patients may not have goals for post-weight loss. It is common for such patients to report feeling “lost” or “empty” after the initial months or years when they were completely focused on losing weight. For many, their weight loss goals seemed so daunting that little consideration was paid to what would follow. Not surprisingly, these patients often describe feeling like they are starting life over again, which, while exhilarating for some, is terrifying for others.

Mental health professionals can assist these patients in constructing new goals and new pursuits. For some, the above goals of focusing on social and intimate relationships as well as career goals would be appropriate. For others, helping patients consider and discover new interests is desirable. For example, many patients who successfully lose weight want to fully experience life in their new body. Having spent the better part of their lives feeling that their body was an enemy, enjoying their bodies is an unfamiliar experience. Many bariatric patients enjoy becoming more physically active and possibly even enjoying athletic pursuits such as running, hiking, and biking now that they are more comfortable being active. By participating in such activities, patients can discover new interests and pursue new goals, while simultaneously improving their social functioning, and engaging in behaviors that improve the sustainability of their weight loss.

Changes in personal relationships. Dramatic weight loss creates a number of changes in intimate and social relationships both positive and negative.[62] Formerly obese people can clearly notice that there is a difference in how they are treated by others now that they have lost weight.[38] From strangers and coworkers to friends and family, weight discrimination is widespread. Many bariatric patients comment on how obvious the difference is, and while they may be enjoying the benefits of accolades from others, they often remark about how upsetting it is that they were treated less well for all those years.[38,63]

Ironically, there are times when patients experience negative reactions from others as a result of their weight loss. I can recall more than one patient indicating that they had friends who no longer wanted to dine in restaurants with them or go shopping for clothes with them believing they would no longer understand or empathize with others’ struggles with eating and weight. This adversity and change in their relationships had to be addressed and worked through to restore their friendships.

After the weight loss there can be great pressure from self and others to address other issues. After losing weight many patients are eager to move forward with the other areas of their life; however, it can be annoying and possibly anxiety-provoking to constantly feel the pressure of friends and family if one isn’t ready to proceed for many of the reasons described above. Again, such patients should be encouraged to pursue psychological support to help them pursue longer-term goals described above.
This psychologist has seen several patients who experienced anxiety as a result of family members pushing them to begin to pursue an intimate relationship shortly after beginning to lose weight following surgery. One patient was quite distressed to find that her mother had created an online dating profile for her and she began receiving emails and other communications from men, which she was not emotionally prepared to address. While this patient was interested in dating in the future, she was understandably quite angry with her mother for her actions. Therapy with this patient involved creating boundaries with family and additionally focused on helping prepare her to begin pursuing relationships on her own schedule in her own manner.

Missing the “food-centric” lifestyle. Articles in lay publications make mention of patients who experience depression following weight loss resulting from their inability to eat following bariatric surgery. While all weight loss surgery patients can obviously continue to eat, few can eat in a manner similar to the way they did before surgery. Although weight loss surgery patients are informed of this fact prior to having surgery, many cannot anticipate just how different their eating behavior would be.

Not surprisingly, many patients presenting for bariatric surgery describe their love of food and eating. Many patients will report that eating and cooking are among their favorite activities. Some have indicated that they have taken vacations revolving around dining at restaurants featured on popular food television program. Many of these patients jokingly refer to themselves as “foodies.”

There are some bariatric patients who struggle with social situations, holidays, restaurants, and other situations where food is the focus. While experiencing satisfaction with the weight loss and additional benefits of bariatric surgery, there are those who experience feelings of loss and frustration that they cannot fully participate in “food-centric” events, such as the summer backyard barbeque, Thanksgiving, other holidays, or eating certain cultural delicacies. Some will unnecessarily avoid these events in an effort to avoid experiencing unpleasant emotions. However, as described earlier, avoidance can lead to greater anxiety and despair and also prevents patients from learning how to continue to attend such events while eating in a responsible manner consistent with the requirements of surgery.

Most bariatric patients will pleasantly discover that they can eat many of their favorite foods in limited quantities, but many do report missing the ability to truly indulge as they once did. While it may be tempting to conclude that their former behavior was “bingeing” and should be completely discouraged, it is quite common for people without weight problems to eat in this manner on occasion with little consequence. Weight loss surgery patients may never be able to eat in this manner again, and some experience this as a loss. Strategies for coping with “food-centric” events can be discussed and patients can learn to participate in these events and eat in a manner consistent with their surgical limitations. Interestingly, some patients will report that they more fully enjoy the taste of food and the act of eating now that they must eat slower and chew food more thoroughly before swallowing.

Difference in self-perception after weight loss. There are occasions when a patient will indicate that he or she does not recognize him or herself after significant weight loss. Such patients are often not just referring to their appearance. After losing over 100 pounds, some patients report that the difference in their self-perception is profound. One particular female patient remarked: “I don’t feel like a thinner version of myself…I almost feel like I’m a person of a different race. Not a new, improved me…a completely different me.”

There have been a number of patients who report that the changes in their self-perception could not keep pace with the speed of the weight loss. As I often remark to my patients, “fat body changes faster than fat brain.” The reasons for these feelings generally stem from all of the difficulties described above, and until patients can find a new equilibrium, it is understandable why they may feel emotionally uncomfortable. Bariatric professionals focus greatly on changes in patients’ eating behaviors and on patients’ weight; we also need to be aware that patients’ emotional lives are often greatly in flux during this time as well.

Addressing these concerns
Fortunately, mental health professionals are part of the multidisciplinary team in the overwhelming majority of bariatric programs and work with patients both before and after surgery. Requiring pre-surgical psychological evaluations of patients to assess many of these areas remains the norm and continues to be strongly recommended by ASMBS and other accrediting organizations for many of the reasons previously described. Similarly, a sizable percentage of bariatric programs offer support groups either run by patients or professionals and, as stated earlier, there is significant evidence to demonstrate their benefit.[64,65]

As described above, CBT can be a particularly useful form of psychotherapy for bariatric patients as it follows a short-term, problem-focused approach. Common components of CBT involve self-monitoring, challenging irrational or maladaptive beliefs and teaching adaptive coping behaviors. Through CBT, many of the problems described above can be effectively treated. For example, patients can learn new behaviors such as mindful breathing and positive self-statements to replace “emotional eating” when experiencing feelings of anxiety or depression. Similarly, patients can learn and practice social skills to improve their ability to socialize and pursue intimate relationships. Irrational beliefs regarding body shape, size, and weight can be challenged and replaced with more rational, self-accepting beliefs. Treatment can be delivered individually or in cognitive behavior therapy groups, which research indicates is effective in the bariatric population.[66]

Conclusion
In the eyes of the bariatric surgery patient, true success often involves more than weight loss. While every effort should be made to help patients lose weight and remove obstacles to doing so, bariatric professionals must also be sensitive to the reasons patients want to lose weight. For patients, the end goal is not only weight loss, rather it also includes measurable improvement in quality of life, such as physical functioning, improved intimate and personal relationships, and improved professional functioning, among others. By partnering with patients and “listening” to them rather than “telling” them what to do, we can assist in helping them achieve not only their weight loss goals, but their life goals as well.

References
1.    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–1737.
2.    Garb J, Welch G, Zagarins S, et al. Bariatric surgery for the treatment of morbid obesity: a meta-analysis of weight loss outcomes for laparopscopic adjustable gastric banding and laparoscopic gastric bypass. Obes Surg. 2009;1447–1455.
3.    Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547–559.
4.    Bastis JA, Romero-Corral A, Collazo-Clavell ML, et al. Effect of weight loss on predicted cardiovascular risk: change in cardiac risk after bariatric surgery. Obesity. 2007;15(3):772–783.
5.    Kushner RF, Noble CA. Long-term outcome of bariatric surgery: an interim analysis. Mayo Clin Proc. 2006;81(10)(suppl):S46–S51.
6.    Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683–2693.
7.    Sjostrom L, Gummesson A, Sjostrom CD, et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish obese subjects study): a prospective, controlled intervention trial. Lancet Oncol. 2009;10(7):653–662.
8.    Kolotkin RL, Crosby RD, Gress RE, et al. Two-year changes in health related quality of life in gastric bypass patients compared with severely obese controls. Surg Obes Relat Dis. 2009;5:250–256.
9.    Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005:13:639–648.
10.    Scinta W. Measuring success: a comparison of weight loss calculations. Bariatric Times. 2012; 9(7):18–20.
11.    Magro DO, Geloneze B, Delfini R, et al. Long-term weight regain after gastric bypass: a 5-year prospective study. Obes Surg. 2008;18:648–651.
12.    Lemont D, Moorehead MK, Parish MS, et al. Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates. Presented at: American Society for Metabolic and Bariatric Surgery annual meeting; 2004; Gainesville, Florida.
13.    Huberman WL. One psychologist’s 7-year experience in working with surgical weight loss: the role of the mental health professional. Primary Psychiatry. 2008;15(8):42–47.
14.    Sjostrom L, Narbro K, Sjostrom CD, et al. Swedish obese subjects study: effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–752
15.    Huberman WL. Through Thick and Thin: The Emotional Journey of Weight Loss Surgery. Niskayuna, New York: Graphite Press; 2012.
16.    Hatoum IJ, Stein HK, Merrifield BF, Kaplan LM. Capacity for physical activity predicts weight loss after Roux-en-Y gastric bypass. Obesity. 2009;17(1):92–99.
17.    Kaplan LM, Seeley RJ, Harris JL. Myths associated with obesity and bariatric surgery: Patient behavior is the primary determinant of outcomes after bariatric surgery. Bariatric Times. 2012;9(8):8–10.
18.    Barham K, Lautz DB, Thompson CC. Gastrojejunal stoma diameter predicts weight regain after Roux-en-Y gastric bypass. Clinical Gastroent and Hepat. 2011;9(3):228–233.
19.    Filho A, Kondo W, Nassif L, et al. Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass. JSLS. 2006;10(3):326–331.
20.    Heneghan H, Yimcharoen P, Brethauer S, et al. Influence of stoma size on weight loss after gastric bypass. Surg Obes Relat Dis. 2011;8(4):408–415.
21.    Brownell KD. The LEARN Program for Weight Management. 10th Edition. Dallas, Texas: American Health Publishing Company; 2004.
22.    Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature. J Am Dietetic Assoc. 2011;111(1):92–102.
23.    Svetkey LP, Stevens VJ, Brantley PJ, et al. Comparison of strategies for sustaining weight loss: the weight loss maintenance randomized controlled trial. JAMA. 2008;299:1139–1148.
24.    Gould JC, Beverstein G, Reinhardt S, Garren MJ. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surg Obes Relat Dis. 2007;3:627–630.
25.    Sarwer DB, Dilks RJ, West-Smith L. Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success. Surg Obes Relat Dis. 2011;7:644–651.
26.    Zuckoff A. “Why won’t my patients do what’s good for them?” Motivational interviewing and treatment adherence. Surg Obes Relat Dis. 2012;8(5):514–521.
27.    Thomas JG, Bond DS, Ryder BA, et al. Ecological momentary assessment of recommended postoperative eating and activity behaviors. Surg Obes Relat Dis. 2011;7(2):206–212.
28.    Sarwer DB, Wadden TA, Moore RH et al. Preoperative eating behavior, postoperative dietary adherence, and weight loss after gastric bypass surgery. Surg Obes Relat Dis. 2008;4(5):640–646.
29.    Livhits M, Mercado C, Yermilov I, et al. Behavioral factors associated with successful weight loss after gastric bypass. Am Surg. 2010;76(10):1139–1142.
30.    Hollis JF, Gullion CM, Stevens VJ, et al. Weight loss during the intensive intervention phase of the weight-loss maintenance trial. Am J Prev Med. 2008;35(2):118–126.
31.    Brownell KD. Get slim with higher taxes (editorial). New York Times. December 15, 1994: A29.
32.    Horgan KB, Brownell KD. Confronting the toxic environment: environmental public health actions in a world crisis. In: Wadden T, Stunkard A, eds. Handbook of Obesity Treatment. New York, New York: Guilford Press; 2004:95–106.
33.    Kaplan LM, Seeley RJ, Harris JL. Myths associated with obesity and bariatric surgery: Bariatric surgery induces weight loss primarily by mechanical restriction and nutrient malabsorption. Bariatric Times. 2012;9(5):12–13.
34.    Friere R, Borges M, Alvarez-Leite J, et al. Food quality physical activity, and nutritional follow-up as determinant of weight regain after Roux-en-Y gastric bypass. Nutrition. 2012;28(1):53–58.
35.    Valle E, Luu MB, Autajay K, Francescatti AB, et al. Frequency of adjustments and weight loss after laparoscopic adjustable gastric banding. Obes Surg. 2012;22(12):1880–1883.
36.    Wing R. Behavioral weight control. In: Wadden T, Stunkard A, eds. Handbook of Obesity Treatment. New York, New York: Guilford Press;2004:301–316.
37.    Ashton K, Drerup M, Windover A, Heinberg L. Brief four-session group CBT reduces binge eating behaviors among bariatric surgery candidates. Surg Obes Relat Dis. 2009;5(2):257–262.
38.    Bocchieri LE, Meana M, Fisher BL. Perceived psychosocial outcomes of gastric bypass surgery: a qualitative study. Obes Surg. 2002;12(6):781–788.
39.    Wadden TA, Sarwer DB, Womble LG, et al. Psychosocial aspects of obesity and obesity surgery. Surg Clin North Am. 2001;81(5):1001–1024.
40.    Johnson PM, Kenney PJ. Dopamine D2 receptors in addiction-like reward dysfunction and compulsive eating in obese rats. Nat Neurosci. 2010:3:635–641.
41.    Blumenthal DM, Gold MS. Neurobiology of food addiction. Curr Opin Clin Nutr. 13(4):359–365.
42.    Ziauddeen H, Fletcher PC. Is food addiction a valid and useful concept? Obes Rev. 2013;14(1):19–28.
43.    Sogg S. Alcohol misuse after bariatric surgery: epiphenomenon or “Oprah” phenomenon? Surg Obes Relat Dis. 2007;3(3): 366–368.
44.    Fairburn CG. Overcoming Binge Eating. New York, New York: Guilford Press;1995:44–47.
45.    Brownley KA, Berkman ND, Sedway JA, et al. Binge eating disorder treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007; 40(4) 337–348.
46.    Oria HE, Moorehead MK. Bariatric Analysis and Reporting Outcome System (BAROS). Obes Surg. 1998;(8):487–499.
47.    Oria HE, Moorehead MK. Updated Bariatric Analysis and Reporting Outcome System (BAROS). Surg Obes Relat Dis. 2009;(5):60–66.
48.    Favretti F, Cadiere GB, Segato G, et al. Bariatric Analysis and Reporting Outcome System (BAROS). Obes Surg. 1998;(8):500–504.
49.    Nguyen NT, Goldman C, Rosenquist CT, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;(11):265–270.
50.    Marinari GM, Murelli F, Camerini G, et al. A 15-year evaluation of biliopancreatic diversion according to the Bariatric Analysis Reporting Outcome System (BAROS). Obes Surg. 2004;14:325–328.
51.    Kolotkin RL, Crosby RD, Kosloski KD, Williams GR. Development of a brief measure to assess quality of life in obesity. Obes Res. 2001;9(2):102–111.
52.    Wee CC, Davis RB, Huskey KW, et al. Quality of life among obese patients seeking weight loss surgery: the importance of obesity-related social stigma and functional status. J Gen Intern Med. 2013;28(2):231–238.
53.    Dymek MP, LeGrange D, Neven K, Alverdy J. Quality of life after gastric bypass: a cross-sectional study. Obes Res. 2002;10(11):1135–1142.
54.    Muller MK, Wenger C, Schiesser M, et al. Quality of life after bariatric surgery—a comparative study of laparoscopic banding vs. bypass. Obes Surg. 2008;18:1551–1557.
55.    Steffen KJ, Sarwer DB, Thompson JK, et al. Predictors of satisfaction with excess skin and desire for body contouring after bariatric surgery. Surg Obes Relat Dis. 2012;8(1):92–97.
56.    Sarwer DB, Thompson JK, Mitchell JE, Rubin JP. Psychological considerations of the bariatric surgery patient undergoing body contouring surgery. Plast Recostr Surg. 2008;121(6);423e–434e.
57.    Aldao A, Nolen-Hoeksema, S, Schweizer S. Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psych Rev. 2010;30(2):217–237.
58.    Jarry JL, Ip K. The effectiveness of stand-alone cognitive-behavioral therapy for body image: A meta-analysis. Body Image. 2005;2(4):317–331.
59.    Applegate KL, Friedman KE. The impact of weight loss surgery on romantic relationships. Bariatr Nurs Surg Patient Care. 2008;3(2):135–141.
60.    Zeller MH, Modi AC, Noll JC, et al. Psychological functioning improves following adolescent bariatric surgery. Obesity. 2009;17(5):985–990.
61.    Zeller MH, Roehrig HR, Modi A, et al. Health-related quality of life and depressive symptoms in adolescents with extreme obesity presenting for bariatric surgery. Pediatrics 2006;117(4):1155–1161.
62.    Sogg S, Gorman MJ. Interpersonal Changes and Challenges after weight-loss surgery. Primary Psychiatry. 2008;15(8):61–6.
63.    Bocchieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. J Psychom Res. 2002;52(3):155–165.
64.    Elakkary E, Elhorr A, Aziz F et al. Do support groups play a role in weight loss after laparoscopic adjustable gastric banding? Obes Surg. 2006;6(3):331–334.
65.    Latner JD, Stunkard AJ, Wilson GT, Jackson ML. The perceived effectiveness of continuing care and group support in the long-term self-help treatment of obesity. Obesity. 2006;14(3):464–471.
66.    McVay MA, Friedman KE. The benefits of cognitive behavioral groups for bariatric surgery patients. Bariatric Times. 2012;9(9):22–28.

Category: Past Articles, Review