Life After Bariatric Surgery

Most bariatric surgery programs have patients participate in an extensive preoperative assessment and educational process. They meet not only with the surgeon and other medical consultants, but also undergo a mental health evaluation to assess a patient’s suitability for surgery at a given point in time. These evaluations are typically required by insurance companies in the United States; they are not necessarily required in other countries around the world. These assessments serve two main purposes. First, they evaluate whether or not there are mental health contradictions to surgery. Second, they provide a good amount of psychoeducation around the dietary and behavioral changes required of surgery. Many comprehensive bariatric surgery programs also will offer specialized pre- and post-operative support groups for patients. One specific example is for patients with binge eating disorder. This book that I co-edited with Dr. Andrew Block provides an overview of the structure of these evaluations, as well as other pre-surgical evaluations that mental health professionals are asked to perform. https://www.amazon.com/Presurgical-Psychological-Screening-Understanding-Improving/dp/1433812428

Despite being the most effective treatment for obesity—producing larger and more durable weight losses than other forms of treatment and of the majority of patients--it is estimated that only 1% of potential patients undergo these procedures each year. My colleagues and I have written a great deal in the past few years on the underutilization of bariatric surgery. There are likely several reasons for this. While many private insurance companies cover the procedures, as do forms of Medicaid and Medicare, specific elements of insurance benefits design can make it challenging for patients to complete all of the preoperative consultations and testing. Many patients may not believe that they are heavy enough for surgery, mistakenly believing that only people who weigh over 300 pounds have surgery. Both patients and providers likely overestimate the risks of surgery, not appreciating that in high volume programs, these procedures are as safe as gallbladder surgery. As we recently wrote, we also believe there are two other factors – the occurrence of weight stigma and bias as well as suboptimal communication between patients and providers – which also serve as barriers to greater utilization. Here are the links to some of the work we have done in this area. These articles are available to purchase. https://www.sciencedirect.com/science/article/pii/S1550728919303582 https://www.sciencedirect.com/science/article/pii/S1550728921000502 https://www.sciencedirect.com/science/article/pii/S1550728921003567

Bariatric surgery is the most effective treatment for obesity currently available. Patients typically lose 25-35% of their weight in the first two years after surgery. The majority maintain much of this weight loss for at least the first decade. These outcomes are far superior to those seen with even the most robust lifestyle modification interventions and weight loss medications approved by the Food and Drug Administration. In addition, these weight losses are associated with profound improvements in a great number of weight-related health problems. Most patients also report substantial improvements in psychosocial functioning. In well-established programs, the procedures are as safe as other routine abdominal procedures. This book provides a detailed overview of the efficacy and safety of bariatric surgery https://www.amazon.com/ASMBS-Textbook-Bariatric-Surgery/dp/3030270203.

Currently, there are no formal training programs or credentialing procedures for mental health professionals who would like to conduct these evaluations. Most thought leaders in the field use the basic tenants of a standard intake assessment as the framework for these evaluations. Many are informed by cognitive-behavioral theory, as that is the foundation for much of the work that psychologists and others have done in obesity over the past 40 years. Additional training in health psychology and disordered eating can be helpful. The best evaluations also include a significant psychoeducational component.

This book provides an overview of the structure of these evaluations, as well as other pre-surgical evaluations that mental health professionals are asked to perform. https://www.amazon.com/Presurgical-Psychological-Screening-Understanding-Improving/dp/1433812428

This special issue of the American Psychologist was published in 2020 and provides an overview of the contributions that psychologists have made to our understanding the development, prevention, and treatment of obesity. It is available by purchase. https://www.apa.org/pubs/journals/special/amp-obesity-psychosocial-behavioral-aspects-pdf

Obesity is associated with a significant psychological burden. Rates of psychopathology are higher among persons presenting for bariatric surgery than in the general population. Lifetime mood, anxiety, and substance use disorders are particularly high. Depressive symptoms are elevated, and patients typically report issues with self-esteem, body image, and quality of life. All of these features are common, if not predictable, in persons who present for bariatric surgery. The procedures are contraindicated for those with severe, uncontrolled psychopathology, such as schizophrenia, depression, and active substance abuse.

This article is a comprehensive review of this literature. It is available by purchase. https://www.sciencedirect.com/science/article/pii/S1550728918304489

Many patients stop losing weight approximately two years after surgery. So, this could be the case with your patient. The average weight loss with a gastric band is approximately 20-30% of initial body weight. If your patient is in this range, she is having an expected result. These outcomes are typically seen in patients who follow the post-operative dietary recommendations taught to them prior to surgery. They also are more likely to be seen in patients who engage in high levels of physical activity. Relatively few patients are as active as your patient. She may be doing much better than she thinks. One thing you may be able to give to her is to normalize her result, celebrate that accomplishment, and help her develop realistic expectations for the future. Those expectations should be focused on weight and health maintenance.

Approximately three-quarters of patients do well after surgery without additional mental health intervention. However, 20-30% report a suboptimal weight loss or significant weight regain in the first few years after surgery. Others report struggles with their mood, body image, and some misuse substances, particularly alcohol. A number of studies have suggested that psychological and/or dietary intervention can help address these issues. However, they are not yet the standard of bariatric surgical care.

We believe that issues of weight stigma at multiple levels likely impacts the underutilization of bariatric surgery. At the population level, mistaken beliefs about the variables that contribute to the development obesity likely prevent many individuals from seeking care. While we would like to think that medical and mental health professionals are immune to such biases, the evidence tells us that is not the case. We can be as guilty of holding these biases as anyone. Finally, some patients self-stigmatize. They believe that their own perceived moral or behavioral failings contributed to their inability to control their weight. While this is an erroneous belief, this self-stigma may prevent some individuals from seeking treatment and has been associated with a number of weight-related comorbidities. Thus, weight stigma is far from innocuous.

This article discusses our belief that weight stigma, as well as suboptimal patient-provider communication around obesity treatment, both contribute to the underutilization of bariatric surgery. Shared-medical decision making, which also can be used by a treating mental health professional, may improve utilization. This article is available by purchase. https://www.sciencedirect.com/science/article/pii/S1550728921003567