Bariatric surgery prep, more mind than stomach


Bariatric surgery can help you hit the reset button on your life, but surgeons, nutritionists and psychologists all agree the key to success has little to do with what happens in the operating room.
Lifestyle changes – including addressing mental and emotional health – must begin months before surgery.

Douglas Kramer, PsyD, a psychologist at Ohio State Wexner Medical Center who frequently works with weight-management patients, says unresolved issues or emotional health problems can easily derail the long-term success of bariatric surgery.

“Our goal is not just to help patients shed the weight that holds them down, but also shed the emotional baggage that prevents them from getting ahead,” says Kramer.

What are common mental health issues for prospective bariatric surgery patients?

Kramer says he often sees patients with untreated or undertreated mental health issues such as depression, anxiety, posttraumatic stress disorder and attention deficit hyperactivity disorder.

The rate of depression in people who are obese is twice the rate of the non-obese population. Moreover, depression, anxiety and impaired social interaction are three to four times higher in severely obese patients than in non-obese individuals. Obesity and mental health problems can create a vicious cycle, one reinforcing the other.

“For these reasons, I think every bariatric patient will experience psychological issues for which they should seek professional help,” says Kramer.

In weight-management cases where an underlying mental health problem is discovered, Kramer encourages applicants for surgery to treat their issues concurrently to maximize their chances for success.

What makes bariatric surgery so different than other procedures?

The lifestyle changes required for long-term successful weight loss following surgery are very demanding. Kramer, therefore, emphasizes the importance of pre-surgical preparation. 
“Surgery isn’t meant to be a band aid to the problem – we want it to last a lifetime. And to do that, we want to help you learn how to sustain success.”
Kramer and his team also assess a patient’s expectations, social support, life circumstances and cognitive capacity.

“Bariatric surgery patients are required to learn an incredible amount of information about nutrition, exercise and weight loss, which can be overwhelming for some.”

If needed, patients are connected with the right nutritionist, psychologist or other expert at Ohio State to learn those new skills.

How does mental health fit into long-term success of bariatric surgery?

The mental checklist can take up is just part of the pre-surgical process, which can take upward of nine months. But Ohio State bariatric team works with patients throughout this journey.

After patients have surgery, the mental and emotional effort with Kramer and his team is not yet complete.

Five stages of mental and emotional health AFTER surgery

Kramer notes every patient is different, but the below stages tend to occur more frequently:

1. Buyer’s remorse 

Immediately after the surgery, quite a few patients second-guess their decision; support group members affectionately refer to this as “buyer’s remorse.”  When it occurs, “buyer’s remorse” is a response to how long and difficult it can be at first to eat just one half cup of food. The newly designed digestive system behaves much differently than the old one and learning how to eat with a new stomach can be a challenging process. However, Kramer says these regrets are always short lived.
2. Unresolved feelings return

In the following weeks and months after bariatric surgery, some negative feelings may boil to the surface.

“Patients who have been using food for comfort will begin to feel emotions that they haven’t felt before, or at least not in a long time. We reassure them that this is part of feeling more ‘alive’ – not just physically but also emotionally,” shares Kramer.

3. Restarting adolescence 

Some patients who have been obese most of their lives discover that their social development stalled somewhere in adolescence.

“When they lose weight, they may have to actually learn how to handle attention and compliments.”

Some of our patients have never had a serious dating or romantic relationship. When they start to date, they feel awkward and anxious, but all these feelings are normal,” says Kramer.

“Effectively, their adolescent social development is just re-starting and they have the unique opportunity to experience and enjoy it with an adult capacity for reflection and self-observation.”

4. Challenges after 12 months

For most patients, the first year is a honeymoon period when most of the weight loss occurs and when weight loss is easiest. After weight loss slows and is more difficult, some discover that problems they secretly thought would resolve with weight loss did not.  For example, some patients are disappointed to find that they still lack confidence. They wrongly attribute their lack of self-confidence to their obesity. We help patients anticipate this possibility and predict that hard work in psychotherapy is often necessary to become more accepting of one’s self.

5. Redefining sense of self 

Patients who have been overweight or obese all their lives have a very durable – albeit negative – way of viewing themselves. After losing 100 or more pounds, their sense of self is often still the same as it was before the surgery.

The self-concept does change but it does so much more slowly than their reflection in the mirror changes. The process of revising the self-concept can take as many as three to five years!

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