An article by Dan Orzech "Social Work Today"
"More and more obese Americans are going under the knife to lose weight. Bariatric surgeryâthe medical term for weight-loss surgeryâis growing dramatically in popularity in the United States as increasing numbers of people struggle to lose large amounts of weight.
Surgically shrinking the size of your stomach will definitely make you lose weight. But according to social workers, doctors, and others who work with people who are significantly overweight, bariatric surgery alone will not necessarily enable people to keep the weight off.
Nor will it necessarily make them happy. âWe see a lot of clients who believe that all of their problems are based on their weight, and that once they lose weight, their quality of life is going to improve,â says Julie Latimer-Spears, LCSW, team leader of the obesity program at Resources for Living, an Austin, TX-based behavioral wellness organization that works with weight-loss patients. âItâs a common misconception that this is a magic bullet, that if they get the surgery everything is going to be better.â
While weight-loss surgery has been around for nearly 50 years, it only began to be accepted by the medical mainstream in the late 1990s. Until then, says John Pilcher, MD, FACS, a bariatric surgeon in San Antonio who does more than 150 weight-loss surgeries per year, âit was kind of like black magic.â Today, itâs a well-accepted medical procedure.
The psychosocial issues surrounding the surgery, however, have not received the same amount of attention as the medical aspects. âThe emotional support issues and psychological aspects of the surgery have been recognized,â says Pilcher, âbut they havenât been well addressed. Thereâs decent research on the surgical techniques today, but thereâs very little on the mental health aspects.â
An Epidemic of Obesity
The past 20 years have seen what the Centers for Disease Control and Prevention (CDC) call âa dramatic increaseâ in obesityâwhat many health officials are starting to call an obesity epidemic. CDC research, according to the nonprofit American Obesity association, has found that some 9 million Americans, or 4.7% of the population, are morbidly obese. Thatâs jumped from 2.9% of the population in 1994.
Morbid obesity, also called clinically severe or extreme obesity, is defined as having a body mass index of 40 or more, which typically translates to 100 pounds or more of excess body weight. That much extra weight increases the risk of a host of medical problems, including type 2 diabetes, breast, prostate and colon cancer, gallbladder problems, sleep apnea, stroke, and heart disease.
In a society obsessed with being thin, people who are severely overweight are often socially stigmatized and subject to discrimination in the workplace or school.
As surgeons have gained experience with techniques such as gastric bypass, which uses surgical staples to shrink the stomach, or gastric banding, where the stomach is surrounded by a plastic band, and laparoscopic surgery has minimized the size of the incision, more and more morbidly obese people have turned to surgery to help them lose weight.
The number of weight-loss operations has grown dramatically, from roughly 18,000 per year a decade ago to more than 170,000 today, according to the American Society for Bariatric Surgery.
The well-publicized bariatric surgery experiences of celebrities, such as singer Carnie Wilson and New York City TV personality Al Roker have also helped make the procedure more popular.
But many weight-loss patients, according to experts in the field, are not prepared for the amount of work involved in the process of losing weight after surgery, or for the changes that it may bring to their lives.
With gastric bypassâthe most common surgical procedureâfor example, âyour stomach goes from the size of a fist, to a little bit larger than a grape,â says Mary Beth Chalk, chief operating officer at Resources for Living. âSo your meals can never exceed 3 ounces at a sittingâthe amount in one of those small plastic containers of water with the peel-off top that the airlines give you. That means you have to eat six to eight times a day.â
The surgery also bypasses part of the small intestine. âThe purpose of the small intestine is to absorb nutrition,â says Chalk, âso these patients face an ongoing challenge with getting the nutrients they need, and they have to pay close attention to their nutritional supplement program.â
The result, says Chalk, is that âin short order, they have fairly complex lifestyle issues that they have to manage.â
Losing Half Your Weight
Thatâs not all they have to contend with. âBariatric surgery patients find themselves having to deal with the sea change that happens in their life as they lose half of their weight, or half of themselves,â says Pilcher. âTheir whole relationship with food changes, as do their relationships with spouses or partners, their family, and their coworkers.â
In the first year after surgery, Pilcher says, patients often find themselves âtrying to figure out who this new and different person is that they see in the mirror. Adjusting their self-image is not easy. They know theyâre wearing different clothes, and the number on the scale is different but, if they close their eyes, patients tell us that they still picture themselves as fat.â
The divorce rate after weight-loss surgery is extremely high, according to Pilcher. So is the rate of job change.
Thatâs not always a bad thing. Morbidly obese people, subject to a lifetime of discrimination, often come to feel helpless and accept situations others would not, says Pilcher. âMany patients, through the weight loss, become empowered to get themselves out of situationsâwork or marriageâthat were bad,â he says.
Not everyone is affected in the same way, however. âIf a patient in a long-term marriage was a normal weight when the marriage began,â Pilcher says, âthat marriage is probably in pretty good shape to withstand the changes following surgery. If the patient was heavy at the time the marriage or the relationship began, however, thereâs an 80% to 85% chance that that relationship is going to break up within two years of surgery.
âIt may be that the patientâs partner becomes nervous because the patient becomes more attractive. It may be that thereâs an abusive relationship going on, and the patient wonât tolerate it anymore. Or they might just decide that there are better options out there.â
The sudden discovery of many new options for relationships can be a challenge for some patients. âPromiscuity becomes a problem with some people, especially those who were overweight younger,â says Vickie Norrod, MFT, a marriage and family therapist in New Hampshire who has worked with bariatric surgery patients. âIf they were obese during the years that they should have been developing a sense of themselves as a male or female and a sexual being, much of that development got sidelined.â
Defining Success
Whether patients get help dealing with these changes can be hit or miss. While thereâs a growing awareness of the importance of the psychosocial aspects of bariatric surgery, says Chalk, âthereâs not a lot of consistency across programs, and thereâs not a lot of information out there about what constitutes best practices.â
Psychiatric evaluations before surgery are common, says Chalk. Beyond that, programs range from no psychosocial support at all to interventions that begin three to six months prior to surgery and then continue as much as a year or more of postsurgery support.
At the hospital in San Antonio where Pilcher operates, for example, psychiatric nurses and clinical nurse specialists provided mental health support for bariatric surgery patients for a period of time. Since those services were not covered by insurance, however, the hospital eventually reassigned the nurses to other duties. Now, Pilcherâs patients can attend a variety of support groupsâif they pay cash out of pocket. âWe see the need for more support than we currently are able to provide,â Pilcher says.
One reason patients are not getting that support may be the relatively narrow definition of success the medical community applies in evaluating bariatric surgery.
The generally accepted medical definition of the success of a bariatric operation, according to Pilcher, is whether a patient loses one half of his or her excess weight and keeps it off for five years. By that definition, the national success rates for bariatric surgery are in the 80% to 85% range, Pilcher says, âeven without much psychological support.â
From a medical standpoint, it makes sense to call losing 100 or more pounds a success. When you get people to lose that much weight, says Pilcher, âyouâve made a very substantial lifetime impact on the medical comorbidities. Diabetes, high blood pressure, sleep apnea, and joint pain all tend to improve dramatically with 50% excess weight loss.â
But most surgeons, and most patients, would probably agree with Pilcher that this is not a fully adequate definition of success.
Take a patient who weighed 350 pounds before surgery, for example, and whoâs lost 120 pounds thanks to the operation. If sheâs 5â6â and in her mid-40s, her ideal weight may be 150 pounds, says Pilcher, so sheâs lost more than one-half of her 200 pounds of excess weight.
But now, her goals may have changed. âWhen she weighed 350,â says Pilcher, âshe may have told me âall I want to do is get rid of my diabetes medicines.â And she meant it. But now, she sees a normal self within reach, but sheâs not there. Thatâs where the psychological support becomes essential.â
Thatâs because gastric bypass surgery will generally cause patients to lose 100 to 175 pounds in the first 12 to 18 months after surgery, âpretty much no matter what the patient does,â he says.
Getting Help
What happens after that, says Pilcher, âreally depends much more on the patient than the surgical procedure.â To maintain their weight loss, or to continue to lose, patients must make significant changes in what and how they eat and how much they exercise. For people who have been hundreds of pounds overweight, that almost inevitably involves significant lifestyle changes, says Susan Crum, LCSW, service delivery manager, health and wellness division at Resources for Living.
Many people have a tendency to use food to manage stress or deal with feelings such as sadness or boredom, she says. âA huge piece of the psychosocial work is just acknowledging what youâre using food for.â
Beginning these lifestyle changes early is key. âThe stomach can eventually stretch after surgery, so itâs important to start working with patients long before the surgery to help them establish these behavior changes ahead of time,â Crum says. âMost bariatric surgeons like to see some successful weight loss before they conduct the surgery.â
Making the necessary lifestyle changes around food can involve every arena of patientsâ lives, including how they relate to other people. Dealing with relationships is âa huge pieceâ of the work that patients must do after the surgery, according to Norrod. âIf the way you relate to your friends is to go out every Wednesday for dinner, youâre going to have to find other ways to maintain your friendships. And what do you do if the only way Aunt Mary knows to tell you she loves you is to bring you your favorite pieâand you have to say, âI canât have that any more?ââ
Our culture, says Norrod, âhas a huge emphasis on celebration through eating and nurturing through eating. Itâs how you say, âI love you, I care for you, youâll feel better.ââ
In the bariatric surgery support groups Norrod has led, âthe patients spent a lot of time trying to come up with their own ideas about how they could celebrate and nurture themselves and each otherâin ways that didnât involve food,â she says.
The most successful patients in Norrodâs groups were those who were able to make changes in their lives and who were realistic about the impact of the surgery. They recognized, she says, âthat you can go in and cut out a piece of your body, and it will have an impact on your weight, but the majority of your life is going to stay the same. You donât cut out your mother-in-law or your ex-husband or your boss. You donât cut out lifeâs problems.â
