The Benefits of Cognitive Behavioral Groups for Bariatric Surgery Patients

| September 18, 2012

by Megan A. McVay, PhD, and Kelli E. Friedman, PhD

Dr. McVay is from Duke University Medical Center, Department of Psychiatry, Durham, North Carolina. Dr. Friedman is from Duke Health System, Duke Center for Metabolic and Weight Loss Surgery, Durhan, North Carolina.

Bariatric Times. 2012;9(9):22–28

ABSTRACT
Group cognitive behavioral therapy has many benefits for bariatric surgery patients and the clinical practice. Group therapy, a standard modality of treatment in behavioral health, allows helpful interaction between patients and is guided by a mental health professional. It is also an effective use of staff resources. Cognitive behavioral therapy groups can assist both pre- and postoperative bariatric patients. Preoperatively, groups may help patients prepare both psychologically and behaviorally for the many changes associated with surgery. Postoperative groups may help patients by improving adherence to lifestyle change recommendations, thereby increasing weight loss and maintenance, as well as potentially reducing postoperative medical complications, such as dehydration, plugging, and vitamin deficiencies. Additionally, cognitive behavioral therapy groups can help patients adjust to the psychosocial changes that can accompany bariatric surgery. Cognitive behavioral therapy groups can help reduce the risk of patients developing rare, but serious, psychiatric concerns that may occur after bariatric surgery through early detection and referral to appropriate treatment sources. Cognitive behavioral therapy groups for nonsurgical weight loss have demonstrated the value of these techniques for assisting individuals in making diet and fitness related behavior change, and recent studies of cognitive behavioral therapy groups for bariatric surgery patients have shown a beneficial effect for these interventions. We suggest that cognitive behavioral therapy groups be conducted by licensed mental health professionals with experience in both cognitive behavioral therapy and bariatric surgery. When planning cognitive behavioral therapy groups for bariatric patients, practitioners should consider factors that will increase group attendance and consider inviting patients to attend groups during periods of greatest potential vulnerability.

introduction
Achieving and maintaining weight loss after bariatric surgery requires significant behavioral change. Further, bariatric surgery patients are often confronted with a myriad of psychosocial changes following surgery. Cognitive behavioral therapy (CBT) groups have promise for assisting patients in implementing dietary and medical recommendations, helping with psychosocial adjustment to bariatric surgery, and possibly minimizing certain post-surgical medical complications.

It is important to note that CBT groups are distinct from bariatric surgery support groups. Bariatric surgery support groups vary widely in that they can be patient-led or provider-led and can range from highly structured meetings to free-flowing discussions. At our clinic, in addition to CBT groups, we have monthly support groups that are led by the multidisciplinary staff and typically include an hour of presentation on topics pertinent to bariatric surgery, which may include a facilitated discussion followed by open time for patients to interact. Support groups provide patients with education about surgery, social reinforcement for positive behaviors and weight loss success, and advice and problem-solving assistance. While support groups are currently offered at most, if not all, bariatric surgery programs, CBT groups are not, though they can offer much to our patients and our practices. Whereas CBT interventions are presently not as widespread as support groups, some bariatric surgery programs require CBT interventions prior to surgery. Furthermore, several CBT programs for behavioral weight loss are currently being tested for their effects on post-surgical outcomes.

Pre-operative Concerns: Preparation for Surgery
CBT groups conducted preoperatively can help patients prepare for surgery both psychologically and behaviorally. In preoperative groups, CBT therapists teach patients relaxation exercises, such as imagery and deep breathing, to assist with managing potential presurgery anxiety or postoperative pain or nausea. A preoperative group also allows for a discussion of the importance of avoiding a high-fat, energy-dense diet prior to surgery, which reinforces the surgical team’s preoperative recommendations. Furthermore, preoperative groups provide patients with the opportunity to discuss their potential fears and concerns regarding their upcoming surgery. Discussing this with other group members allows patients’ own concerns to be normalized. It also provides the therapist an opportunity to dispel some myths that the patient may have regarding surgery, and to help the patient use cognitive strategies to cope with anxiety-provoking thoughts.

Postoperative concerns: Adherence and Weight Loss
Individuals who are undergoing bariatric surgery are asked to make numerous lifestyle changes, including consuming smaller, more frequent meals, avoiding foods that may limit weight loss or contribute to digestion problems, taking vitamins multiple times per day, and increasing physical activity. For many patients, meeting these recommendations requires dramatic changes from their presurgical lifestyle, and some patients struggle to follow these recommendations. A substantial number of bariatric surgery patients report that they are not adherent with the postbariatric surgery dietary and physical activity recommendations.[1,2] Thomas et al[1] found that only five percent of postoperative patients eat five or more meals per day, 15 percent consume adequate amount of liquids, and 24 percent meet exercise recommendations.1 Nonadherence to these behavioral recommendations is associated with poor weight loss outcomes.[2–4] The impact of nonadherence may be significant: an estimated 15 to 20 percent of bariatric patients do not achieve 50-percent excess weight loss(EWL),[5] and weight regain is not uncommon after the first year post-surgery.[6,7] Furthermore, nonadherence can lead to postoperative complications (e.g., dehydration, plugging, excessive vomiting).[40]

CBT may be beneficial in improving medical, dietary, and fitness adherence among bariatric surgery patients. CBT is a therapeutic modality that is goal-directed, collaborative, and time-limited. CBT has a strong base of empirical evidence for numerous psychological disorders, such as depression, anxiety disorders, and substance abuse disorders.[8] CBT has also been used to help patients with chronic medical conditions, such as chronic pain, diabetes, and asthma, improve their psychosocial functioning, and learn disease specific-management skills.[9] The approach of CBT to weight management has a strong research basis demonstrating significant weight loss and reductions in medical comorbidities in individuals with obesity.[10,11] As surgical and nonsurgical weight loss involve many similar behavioral change recommendations (e.g., increased physical activity, smaller portion sizes), CBT programs designed for bariatric surgery patients share several commonalities with behavioral weight loss interventions. CBT for bariatric surgery typically builds upon standard nonsurgical CBT weight loss approaches by addressing the many issues that are unique to bariatric surgery.

While the techniques utilized within CBT can vary depending on the specific problems or symptoms being treated, CBT generally involves cognitive strategies that identify and change cognitions that negatively influence mood, and incorporate behavioral strategies that draw upon learning theory principles. Regarding cognitive strategies, trained therapists help patients identify cognitions that are negatively impacting their function, and then help patients critically examine the accuracy and/or helpfulness of these thoughts. These techniques can help patients learn strategies for improving their adherence to postbariatric surgery recommendations. For example, a post-bariatric surgery patient in a CBT group who reports difficulty with physical activity can be assisted in identifying thoughts that interfere with motivation to exercise. The goal is to help the patient become aware of thoughts that are impacting the ability to be active (e.g., “Unless I exercise for an hour per day, there is no point in exercising at all.”). A CBT therapist can assist in examining the validity and the helpfulness of this thought. The therapist can also identify this thought as an example of “all-or-none thinking,” and discuss how this pattern of thinking may lead to negative outcomes, such as nonadherence to the physical activity recommendations. To help the patient restructure this thought, the CBT therapist may ask the patient probing questions. The therapist could ask if exercising for 10 minutes might actually have benefit, and may inquire if it would be easier to get motivated for a 10-minute workout or a 60-minute workout. By understanding the role of thoughts in influencing behavior and affect and learning how to challenge and restructure unhelpful or inaccurate thoughts, patients may improve their ability to make behavior changes following CBT.

The behavioral component of CBT facilitates change through the use of learning theory principles, including reinforcement, classical conditioning, and stimulus control. If a post-bariatric surgery patient is having difficulty eating with the recommended frequency, the CBT therapist might offer a number of suggestions based on these learning principles. A therapist might help the patient develop a plan to reward him or herself (e.g., utilizing a non-food reward) after completing a certain number of days of meeting his or her meal frequency goal. A therapist might also suggest that the patient structure his or her environment to increase the likelihood of eating five meals per day. For example, the patient might be encouraged to set reminder alarms, to recruit family members to assist in remembering when to eat, and to keep easily accessible, pre-planned, healthy food at work and in the car. Consistent with a cognitive and behavioral framework, self-monitoring, relaxation training, and problem-solving skills are other strategies utilized by CBT therapists working with bariatric patients.

The previously discussed strategies can help patients consume a diet consistent with recommendations and engage in more physical activity, thus contributing to greater weight loss. However, the effects of CBT groups on weight loss may be hypothesized to be greatest with regard to long-term outcomes. Some evidence suggests that psychosocial factors are not strongly related to weight loss in the first year after surgery but are more influential longer-term.[12] In fact, there is evidence that the strategies described previously may be particularly beneficial in producing optimal weight loss maintenance in the years following the first postoperative year.[12] Specifically, a study by Lanyon et al[12] found that weight change over the period from 1 to 3 years postoperatively was predicted by behavioral and cognitive coping skills, informational support, and expectations of increased self confidence. Additionally, Lanyon et al[12] found that a reduction in dysfunctional eating over the first postoperative year is related to greater weight loss at three years postsurgery. As CBT groups target many of these factors, groups may be particularly beneficial after the first postoperative year.

In addition to optimizing weight loss, CBT groups may also reduce behaviors related to some complications following surgery. For example, CBT groups can offer patients assistance in developing skills to minimize overeating or eating nonrecommended foods, which often lead to vomiting, plugging, and potentially dehydration. Further, the group leader may help reduce the risk for nutritional deficiencies by assisting the patient in problem solving through his or her daily routines and by providing information about the vitamin recommendations. Thus, CBT has the potential to assist patients in identifying risky behaviors, determining barriers to behavior change, and problem solving ways to make the needed changes.

postoperative concerns: Psychological Health and Psychosocial Functioning
For many patients, the goals of bariatric surgery extend beyond weight loss and reduction in medical comorbidities to include improvements in mental health and quality of life. In fact, the majority of bariatric surgery patients do experience improvements in their quality of life and psychological functioning following surgery.[13] However, it is not uncommon for some patients to face psychosocial struggles post-surgery (e.g., in regards to body image or social and romantic relationships).[14,15] More serious issues of depression, suicidality, and substance abuse occur in a minority of patients.[16,17] In addition to assisting with lifestyle change adherence, CBT groups may also help patients cope with psychological adjustment to bariatric surgery, such as those listed previously, and assist them in maintaining or achieving quality of life improvements.

An important issue among many bariatric surgery patients is body image. Though an improvement in body dissatisfaction occurs for most bariatric patients, the excess skin that results from massive weight loss is often of concern and, for some patients, may cause a significant amount of distress. Additionally, many bariatric patients report that, despite massive weight loss, they continue to perceive themselves as being the same size and shape as they were prior to the surgery. CBT has successfully been utilized to address body image problems as part of eating disorder treatment and as a standalone treatment[18,19] that can be incorporated into CBT for bariatric surgery patients to help them develop a healthier body image. An example of a CBT strategy for dealing with poor body image is to encourage patients to spend more time focusing on aspects of their appearance that they appreciate, as well as on nonappearance-related components of their self image. Patients might also be assisted in realistically exploring how their negative body image is impacting their ability to achieve their weight loss goals, including their motivation for change (e.g., increased physical activity).

For many patients, bariatric surgery results in an improvement in their romantic relationships.15 However, for some patients, struggles with jealousy, trust, or intimacy may develop post-surgery.[14] In a group CBT format, relationship changes can be discussed. The group leader and other patients can provide validation and helpful suggestions to each other.

In addition to relationship struggles, some patients report other difficult social interactions related to their weight loss. It is not uncommon for patients at our clinic to express frustration with family, friends, or coworkers who excessively ask about the patient’s weight loss. Teaching patients assertiveness skills can help them better manage these interactions. Cognitive techniques can also assist patients in viewing others’ comments in a different and perhaps more positive way. Patients also discuss how they are treated differently postsurgery. A small group format is a useful way to examine this and provide patients with validation and understanding about weight bias and how their weight loss may impact their interactions with others.

While the majority of bariatric patients report improvements in mood and psychological functioning following surgery,[13] some bariatric surgery patients experience worsening psychiatric symptoms following surgery.[20] For a very small subset of those patients, suicidality may increase following surgery, as suggested by a slight increase in the rate of suicide in post-bariatric surgery patients.[16,21] A CBT therapist can help patients learn cognitive and behavioral strategies for managing mood, such as restructuring negative thoughts and planning pleasant activities. CBT groups also provide the opportunity to remind patients to take their psychotropic medications as prescribed, to monitor for increased depression and suicidality, and to make referrals to more intensive psychological or psychiatric treatment when needed.

The vast majority of weight loss surgery patients do not abuse substances following surgery; however, there is some evidence that susceptibility to substance abuse may increase following bariatric surgery.[17] Unfortunately, little is known about the process whereby bariatric surgery may place individuals at higher risk for developing substance abuse problems. Openly discussing substance use patterns and risks of substance abuse after surgery during group sessions may facilitate earlier detection and treatment for substance use.

Mindfulness Practices in CBT groups
It has been suggested that incorporating mindfulness-based practices into a CBT group could prove particularly useful for bariatric surgery patients. Mindfulness has been defined as focusing on the present moment with an attitude of nonjudgmental acceptance.[41,42]

Mindfulness therapeutic approaches are consistent with a cognitive behavioral framework and have proven beneficial when incorporated in standard CBT for clinical problems, including eating disorders and obesity.[22,23] It has been suggested that mindfulness practices may be particularly beneficial for bariatric patients for several reasons.[24–26] Authors have pointed out that mindfulness can help patients become more aware of satiety cues and internal physical sensations, skills which are particularly important in avoiding the discomfort and risk that can come from overeating after bariatric surgery.[26] Mindfulness can also assist patients who tend to engage in emotional eating learn greater acceptance of their emotions, rather than using food to avoid negative emotion.[25] Additionally, the nonjudgemental acceptance stance of mindfulness-based therapy may assist patients in gaining acceptance with the results of their surgery, thus helping them adjust to life after surgery.[25]

Research Trials of CBT for Bariatric Surgery Patients
While extensive research indicates that CBT groups are beneficial for nonsurgical weight management and for improving psychosocial functioning, only recently have researchers begun to study the impact of CBT groups on bariatric surgery patients. One recent study[25] examined the effects of a CBT group that incorporated mindfulness-based practices. This CBT protocol was targeted toward individuals who engaged in binge eating postoperatively. Seven post-bariatric surgery individuals who met criteria for binge eating disorder and were 2 to 11 months postoperative were referred by their physician to join the group. Participants completed 10 weekly, 75-minute group sessions. Results showed a reduction in binge eating, an increase in eating self efficacy, improvements in emotional regulation, and reduced depressive symptoms following the program.[25] The absence of a control group and the small sample size make determining the effects of the group on weight loss difficult. However, this study suggests that a CBT intervention can help improve the patients’ psychological health and disordered eating behaviors of patients with binge eating habits. These effects may translate into weight loss or weight maintenance benefits in the years after bariatric surgery, though that has yet to be determined.

Some authors have examined the value of targeting interventions at individuals who have not achieved optimal weight loss benefits from bariatric surgery. In a study by Kalarchian et al,[27] participants who were at least three years post-bariatric surgery and who had lost less than 50 percent of their excess body weight were assigned to a six-month behavioral intervention or to a control group. Patients in the behavioral group achieved 5.8 percent EWL compared to 0.9 percent in the control group at 12 months after the intervention. In this study, it was found that participants who had more depressive symptoms and who had experienced less weight regain prior to entering the study lost more weight. These results support the value of CBT groups for producing weight loss in bariatric surgery patients who are many years postoperative. This study also suggests that patients with more significant depressive symptoms may benefit most from CBT groups.

In a study undertaken in Norway,28 individuals were assigned to either a control condition or a CBT group condition. Participants assigned to the CBT groups participated in six CBT group sessions prior to surgery, as well as postoperative group sessions occurring six months, one year, and two years after surgery. These groups incorporated mindfulness practices in addition to standard CBT approaches. Contrary to the authors’ hypotheses, the CBT intervention was not found to affect the amount of weight lost or adherence to eating behaviors or physical activity at one-year postoperative. Though these results may initially appear discouraging, it is important to note that results were only presented for the first postoperative year. As previously discussed, the effects of CBT groups on weight may be most apparent after the first year postsurgery. Thus, it may be that in the study by Lier et al[28] the researchers would have observed more benefit from CBT groups if the time point for comparison was further post surgery.

Individual CBT interventions with bariatric surgery patients have also have presented in the literature. In one study,[29] women who underwent vertical gastric banding between 2005 and 2006 were randomized to two treatment groups, typical treatment sessions or individual sessions focusing on behavioral principles.[29] The authors found greater weight loss in the intervention group at one, two, and three years post intervention. They also reported changes in dietary patterns and physical activity favoring the intervention group. While this study highlights the potential benefit of individual CBT for bariatric surgery patients, CBT groups may be able to provide similar therapeutic benefits but in a more cost effective and efficient manner. Further, there is evidence that group treatment is more effective for weight loss than individual treatment in nonsurgical behavioral treatment.[30]

These studies, combined with the strong evidence supporting CBT for weight loss in nonsurgical patients, have provided initial evidence that CBT can be beneficial for bariatric surgery patients. However, continued research is needed to study the impact of CBT groups on weight loss, particularly when utilized more than one year after surgery. Additional research also is needed to determine the effects of CBT groups on psychosocial adjustment, quality of life, and postsurgical medical or nutritional complications. Fortunately, clinical trials are currently underway that may help shed further light on the impact of CBT groups on bariatric patients. In a large trial, Kalarchian et al from the University of Pittsburgh, Pittsburgh, Pennsylvania, are randomizing patients to a control group or to a six-month behavioral weight loss lifestyle intervention delivered prior to bariatric surgery. In addition to weight outcomes, this study will be examining the impact on medical complications and medical care utilization after surgery. This trial will help demonstrate the potential value of group therapy in this population.
Though bariatric surgery support groups differ from CBT groups in important ways, the existence of some common elements suggests that it may be instructive to examine the impact of these groups on bariatric surgery outcomes. A few studies have examined the effects of attendance of bariatric surgery support groups on weight loss. Frequency of support group attendance has been shown to predict weight loss in several studies.[31–33] One study[33] showed that 12 months post-bariatric surgery, individuals who attended five or more monthly support group meetings lost 55.5 percent of excess weight, compared to 47.1 percent of excess weight loss in those who attended less than five groups. While the results are promising, these studies involve individuals self selected into support groups, and it may be that these are patients who are more adherent with treatment recommendations in general.

Potential Benefits to Surgical Practices
It is our perspective that CBT groups benefit not only the bariatric surgery patient, but also the surgical practice as a whole. Bariatric team members are often approached by patients with issues, such as psychosocial distress, difficulty with adherence, or mood problems. These professionals may have minimal training in addressing such concerns, as well as limited time. In a clinic that offers CBT groups, patients have an opportunity to address these issues during the groups thereby reducing the need for these topics to be addressed during the medical and nutrition follow-up appointments.

Structuring CBT Groups
Trained practitioners considering implementing CBT groups in their bariatric surgery practice may have questions regarding aspects of the delivery of CBT groups, such as the optimal “dosage” of intervention, the frequency and timing of CBT groups, and the selection of appropriate patients for CBT groups. Currently, there is no standard protocol for cognitive behavioral intervention pre- or post-weight loss surgery. Our recommendations are based on the existing literature (i.e., largely from nonsurgical populations) and clinical observations from our practice (Table 1).

Regarding the scheduling of groups, clinicians should consider strategies to maximize group attendance. Historically, at our clinic, an effort is made to schedule patients’ groups on the same day as their medical follow-up appointments to reduce travel burden. Patients are invited to attend therapy groups that meet 1 to 2 weeks preoperatively and postoperatively at three weeks, three months, six months, and one year after surgery. This structure was chosen largely to be consistent with the existing schedule for medical follow-up appointments. By scheduling patients’ medical and CBT group appointments together, patients may be more likely to attend. At our clinic, attendance rates at CBT postoperative groups are generally high. Recent data collected on patients who underwent Roux-en-Y gastric bypass (RYGB) between 2009 to 2010 showed that 59.8 percent of participants attended three out of four of our postoperative CBT sessions. Attendance rates decreased with length of time since surgery; however, 47.2 percent of patients attended group sessions at one year postoperative. In addition to scheduling these sessions in conjunction with medical appointments, we also highlight the benefit of these groups to patients from the beginning of the application process (e.g., at the informational seminar) and encourage all patients to attend. In fact, some patients have commented that they sought out our program because of the intensive preoperative preparation and postoperative care, including the CBT groups. We believe it is of great importance that the entire surgical team stresses the usefulness of attending these groups. Patients often look to their surgeons for advice on their postoperative treatment plan, and when the surgeons are supportive of behavioral treatments, it seems more likely that patients will be willing to participate in groups.

Though the optimal frequency of the groups has not yet been empirically determined, research from the behavioral weight loss literature can be instructive. This literature has demonstrated that more intensive patient contact is associated with greater weight loss.[34,35] However, we recognize that balancing the effectiveness of increased patient contact with patients’ interest in attendance and clinical resources is necessary.

An additional question that can be asked is “Who should attend CBT groups?” Historically, all patients who have surgery at our clinic were recommended to attend CBT groups. We believe that the skills taught during these groups and the interaction with a small number of other pre- and postoperative patients can be of value to every individual undergoing bariatric surgery.

However, other approaches can be imagined. For example, some clinicians may consider offering a standard group as well as a more intensive CBT group option for patients who have experienced slower than expected weight loss in the first six months or reach an earlier than expected weight loss plateau. Additionally, patients who experience significant weight regain in the years after surgery could be targeted for a specialized intervention. Indeed, some clinics have developed programs that focus on addressing inadequate weight loss and eating disorders.[25,27] Individuals who are having difficulty adjusting to psychosocial changes also may be targeted for interventions. Given evidence that depressive and anxiety disorders are common in bariatric surgery patients and that individuals with these conditions may lose less weight and may be less likely to reap the mental health benefits of surgery,[37] offering patients with these psychiatric conditions a CBT program that is more intensive and focuses more extensively on mood and anxiety management might be beneficial. CBT groups may provide the opportunity to identify patients for individual assistance or create tailored group interventions for those patients who develop more serious psychological symptoms. Recently, there has been a published manuscript outlining a group intervention for individuals who have substance-related issues.[36] Overall, in addition to providing support and skills for all patients, CBT groups may also provide the opportunity to identify patients for individual assistance or create tailored group interventions for those patients who develop more serious psychological symptoms.

The relative effectiveness of offering groups prior to surgery, after surgery, or at both time points is an important issue. The most vulnerable times for bariatric surgery patients may be the most valuable time to have a psychological intervention. For example, right before surgery patients often report increased anxiety. CBT groups could be used to help patients cope with this anxiety and to prepare for the many changes in the early post-surgery weeks. CBT may be helpful at three and six months postoperatively for patients who are already deviating from the postsurgical lifestyle changes at those times. Another sensitive time point for patients may be at 12 to 18 months postoperative, as this is the time when weight loss slows or stops and some patients begin regaining weight.[43] Patients’ interest in CBT groups at different time points should also be considered.

One study[38] examined differences in group attendance between pre- and postoperative patients who were offered group therapy and found that those patients referred to a behavioral intervention prior to surgery were less likely to attend than patients referred postoperatively. CBT groups may be valuable for patients who are many years postoperative. As described previously, Kalarchian et al[2]7 had good results with a behavioral therapy group for individuals who had undergone surgery three or more years prior to participating in the group.

The qualifications and experiences of CBT group leaders are also important. Group leaders should be licensed mental health providers who have training and experience working with both CBT and bariatric surgery populations. Our clinic has employed doctoral level clinical psychologists trained in CBT to conduct the majority of pre-operative psychological evaluations and also lead the pre- and postoperative groups. This approach facilitates the development of an ongoing relationship between therapist and the patients.

It may also be helpful to identify those patients who are less inclined to attend CBT groups so that strategies can be developed to increase their likelihood of attending. A recent study39 found that those bariatric surgery patients with social phobia and avoidant personality disorder were significantly less likely to attend group counseling sessions after bariatric surgery. Further research is needed to determine the characteristics that may impact attendance at CBT groups and the strategies that maximize involvement of all patients before and after surgery.

Conclusion
Individuals deciding to have bariatric surgery are typically seeking weight loss, improved health, and a greater quality of life. CBT groups can assist with these goals as well as help the surgical practice. CBT groups can help patients adhere to the many behavioral changes that are required after weight loss surgery, which has the potential of increasing weight loss and minimizing weight regain. Additionally, these groups may be able to contribute to reducing the frequency of certain postsurgical complications, such as nutritional deficiencies, plugging, recurrent vomiting, and dehydration. Bariatric surgery can result in changes in self image, relationships, and mood. Group CBT may help patients adjust to the normal psychosocial changes that occur after bariatric surgery. For most patients, the speed at which they lose weight is almost astounding and having the support of a trained therapist and other patients during this time can be helpful. A small minority of patients may experience more serious psychosocial difficulties after surgery, such as increased depression, suicidality, or substance abuse, and CBT groups provide the opportunity for assisting those patients who develop these more serious psychological symptoms. We also believe that groups are beneficial to the surgical practice. They allow treatment of several patients at once and can help streamline patient care. It is our belief that CBT groups are a valuable component to a comprehensive approach to surgical weight loss.

REFERENCES
1.    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.
2.    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.
3.    Edwards C. Success habits of long-term gastric bypass patients. Obes Surg. 1999;9(1):80–82.
4.    Evans RK, Bond DS, Wolfe LG, et al. Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery. Surg Obes Relat Dis. 2007;3(5):526–530.
5.    Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7):547–559.
6.    Magro DO, Geloneze B, Delfini R, et al. Long-term weight regain after gastric bypass: a 5-year prospective study. Obes Surg. 2008;18(6):648–651.

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

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