When a surgeon assesses patients for bariatric surgery, he/she ascertains their general health, with the idea of identifying those for whom surgery is too risky and those who have conditions that need to be treated, stabilized, or managed for surgery to be worth its risk. Behavioral health specialists can no more “predict” a particular psychological outcome than the physician can “predict” a surgical or medical complication. We can, however, via the pre-operative behavioral health assessment, identify psychosocial risk factors and make recommendations to both the client and surgical group that are aimed at facilitating the best possible outcome for the patient.
Patients are typically faced with initial dietary restrictions, permanent changes in eating and dietary habits, altered body sensations and experiences, shifting body image and self care behaviors, new cognitions and feelings, and an emerging and different lifestyle. In addition, they may realize sometimes unexpected and significant changes in relationships that may result in marked stress. Bariatric surgery is a highly effective procedure that not only reconfigures and/or restricts a patient’s stomach, but significantly affects their psyche as well. Generally patients will need a secure identity, sound psychological resources, resiliency, effective coping strategies, and willingness to access meaningful support from others.
When problematic pre-surgery psychosocial factors are identified, the clinician is able to alert the treatment team and the patient, and make appropriate recommendations. Recommendations may include pharmacological interventions, psycho-education, psychotherapy to address potential post surgery stumbling blocks, nutritional consultation, close aftercare monitoring, and/or bariatric surgery support group attendance.
Previous Attempts at Weight Management
It is well documented that non-surgical attempts at weight management for patients with morbid obesity have little if any long-term efficacy. Nonetheless, a thorough weight and diet history can provide valuable information regarding the psychological, behavioral, and physiological contributors to the progression of morbid obesity. Patterns of loss and regain provide information regarding eating habits and lifestyle as well as behavioral and emotional factors that have contributed to past successes or failures—and may be relevant post surgery.
Eating and Dietary Styles
The assessment of dietary habits and eating styles provide the clinician with vital information that not only points to the client’s readiness for surgery but may indicate issues that will either support or interfere with issues of post surgical compliance and adherence. Tracking eating behaviors over time and across situations (e.g., stressful situations or holidays) can offer valuable insights and information regarding these issues. If the candidate demonstrates difficulties in one or more of these areas, we make an effort to identify these areas of vulnerability, help the client predict and prepare for these situations, and propose appropriate interventions.
Assessing how a particular mindset influences eating can also provide important information. For example, it may be useful to track changes in eating and drinking habits prior to the time the client made the decision to pursue a bariatric surgical procedure, those habits at the time of making the decision to become a surgery candidate, and after attending the information (or orientation) seminar for surgery. Documenting the candidate’s efforts over time to modify eating behavior and fluid intake and to cultivate a healthy lifestyle can serve to capture the degree to which the candidate understands the basic principles of healthy eating, reveal whether the candidate is motivated to modify behavior, and suggest the extent to which unhealthy eating (and other unhealthy lifestyle habits) is ingrained.
Accurately distinguishing between different types of maladaptive eating behaviors serves many purposes. Primarily it helps delineate maladaptive patterns of eating that are subsequent to dieting and restriction versus those styles of eating that are clearly emotionally driven.
- Binge eating: Studies suggest that approximately 30% of individuals presenting for the treatment of obesity engage in binge eating. 1 It is important to distinguish between binge eating that is driven by psychological factors and binge eating that is driven by physiological factors. 2 Keys, et al. 3 uniquely demonstrated that the direct biological consequences of semi starvation and restricted eating include preoccupation with food, increased pressures to eat, and the likelihood of binge eating. Other types of physiologically driven binge eating may be triggered if eating is initiated in an intense state of hunger (reactive overeating) or if restrained eating is disrupted via disinhibition or counterregulation.
- Overeating: Overeating may represent a lack of interoceptive awareness and an inability to discern internal cues such as hunger, appetite, satiety, or fullness. Alternatively, overeating may represent a conscious decision to eat “just because” or eating that is more emotionally driven. Many times early incidences of binge eating convert to discrete periods of overeating that are no longer hallmarked by the indicators of control associated with binge eating.
- Grazing: Grazing may stem from habit and mindlessness or may be compulsive or emotional in nature.
- Night eating syndrome is defined as skipping breakfast = 4 days per week, consuming more than 50% of calories after 7 PM, and difficulty falling asleep or staying asleep = 4 days per week. 4 The prevalence of night eating syndrome in presurgical bariatric candidates has been reported to be as high as 26% 5 and as high as 27% in a bariatric sample 32 months after surgery. 6