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Treating the Bariatric Surgery Patient Brooke Schauder, PhD Erie Psychology Consortium Pacific Graduate School of Psychology
Obesity in America Mild/Moderate Obesity:  BMI over 25- mild (over 60 million – 30% of US) – doubled since 1980 BMI over 35 - moderate  9.6 million (8%) are moderately obese Morbid Obesity:  BMI of 40  OR being 100 lbs overweight.  6 million adults in America (2.8%)  Often a genetic component
Obesity Related Health Risks Increased mortality rates ranging from 2 – 12 x increase. Hypertension Cardiovascular Disease Diabetes Mellitus (2-10 x increase) High Cholesterol Skeletal/Joint Problems (knees, hips) Cancer Liver Disease Stroke Sleep Apnea Depression Anxiety
Why Surgery? The average patient loses 30-60% of excess weight with lap-band and 50-75% with gastric bypass. Effects are long lasting (effective after 10 years above 90%). Increased risk of mortality reverts to approximately normal following surgery. Behavioral intervention (dieting, exercise) is not statistically effective in the majority of people.
What is Bariatric Surgery?
Risks of Surgery Fatal  Any surgical procedure is fatal Risks of anesthesia (1.5 hours of surgery) Blood Clots / hemorrhage Internal Bleeding Severe Vomiting After surgery Typical Hospital LOS = 3-5 days
Risks Following Surgery Internal Leakage can cause death Pulmonary Emboli Hernia Malnutrition Vitamin Deficiency Overeating can cause vomiting (aka dumping syndromd), internal bleeding from ripping stitches, and even death.
Recovery From Surgery 6 months before a “normal” diet can be tolerated Patients are to eat slowly, chewing food “30 chews per bite,” use small plates, sip beverages slowly.
4 Diet Phases following surgery Phase I:  (2 weeks) total liquid diet / 1-3 oz each 30 minutes.  30 grams of protein and 500 calories per day. Phase II: (3 weeks) 40-50 grams protein and 500-800 calories/day  Food is pureed or thick liquid (yogurt, Carnation Instant, baby food, mashed potatoes, squash)
Phase III: soft foods (tuna, oatmeal, canned fruit, cooked vegetables) 800-1200 calories / day Phase IV: (stabilization) high protein, 800-1200 calories/day
Lifetime Diet Change Can NEVER have more than 1-1 ? cups of solid food at a time Patient must continue to eat fewer calories to sustain weight loss. Patients must take multivitamins with iron and additional calcium. Patients are to avoid high calorie, high sugar foods.
Common Problems Nausea and vomiting Dumping Syndrome Pain in shoulder or chest Dehydration Lactose intolerance Constipation Diarrhea Bloating Heartburn Stomach Blockage Staple Rupture Stomach Stretching
What makes one eligible for surgery? Previous attempts at weight loss Eating triggors: Holidays, stressors, certain people, work Eating styles: Overeating, Grazing, or Night Eating Binge Eating (in 30%) Physical Activity Substance Use
Assessment of Candidates Legal History Compulsive/Impulsive History Cognitive Functioning Coping Skills, Emotional Modulation, Boundaries Psychiatric History / Hospitilization 6 months of stabilization is key
Psychometric Tests Questionnaire on Eating and Weight Patterns – Revised (QWEP-R) -assesses binge eating and purging type bulimia Multidimensional Health Locus of Control (MHLC) Tells about the patient’s attribution of control to self, chance, and powerful others.
Millon Behavioral Medicine Diagnostic (MBMD) 165 item instrument that assesses psychological factors influencing treatment outcomes Scales include: Treatment Prognosis, Resilience, Medication Abuse, Problematic Compliance, Adjustment Difficulties, Psych Referral, and Oppositionality, and many more.
The Decision 1.  Patient is Excluded Active psychosis present Multiple suicide attempts within 5 years Substance use within past 6 months H/O poor compliance (appt. keeping, following recommendations, or MBMD risk) 2.  Delay Consideration Pending response to Treatment Poorly controlled mental illness or cognitive impairment. Severe binge eating disorder (QWEP) Unstable social environment Low self-efficacy (MHLC)
Decision 3.  Acceptable for surgery; provide psychological treatment before and after. Mild-moderate binge eating disorder Other mild-moderate behavior problems (MBMD) Moderately low self-efficacy (MHLC) Well-controlled mental illness, including schizophrenia, depression, bipolar, anxiety History of isolated suicide attempt Acceptable for Surgery
Psychological Comorbidities Mood Disorders – Major Depression (10 to 70%) Anxiety Disorders (48%) Bulimia (30%) All personality Disorders Substance Dependence Somatic Symptoms Possible link to Childhood sexual abuse Impulsivity Low Self-Confidence
Pre-Surgery Therapy Identify the Function of food Identify any misconceptions of surgery Understand the invasive nature of the surgery Identify Eating Triggers  Develop alternative Coping Mechanisms Increase Social Support
Locus of Control Internal:  Self is the source of problems as well as solutions Chance:  Fate is attributed to chance – outer influences. Powerful Others:  Other people are the source of good and bad outcomes.
Therapy Pre-Surgery Pre-operative weight loss proves beneficial. CBT for Pre-Operation Anxiety Increase medical compliance/ discuss hostility toward healthcare providers/ obstacles to following recommendations. Keep a Food Journal – Everything you put into your mouth Make “problem foods” unavailable Reward yourself for hard work.
Therapy Post-Surgery Those with self-defensive attitude, rigidity, psychopathic deviancy and hostility lost less weight following surgery. Set Achievable Weight Goals (5-10 lbs) Reward yourself for weight loss. Ask friends for support. Plan Ahead (parties, vacations, etc.)
Cognitive Behavioral Therapy Reduce cognitive Distortions  Dichotomous Thinking Catastrophic Thinking Teach Patients to use Problem focused Coping, rather than Emotion focused Coping Problem Focused:  re-conceptualizing a problem by minimizing effects or trying to solve Emotions Focused:  daydreaming, self-preoccupation, and emotional regulation.
Recommended Articles Gllnski, J., Wetzler, S., Goodman, E. (2001).  The psychology of gastric bypass surgery.  Obesity Surgery , 11, 581-588. LeMont, D., Moorehead, M., Parish, M., Reto, C., Ritz, S. (2004).  Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates.  American Society for Bariatric Surgery.

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Bariatric surgery

  • 1. Treating the Bariatric Surgery Patient Brooke Schauder, PhD Erie Psychology Consortium Pacific Graduate School of Psychology
  • 2. Obesity in America Mild/Moderate Obesity: BMI over 25- mild (over 60 million – 30% of US) – doubled since 1980 BMI over 35 - moderate 9.6 million (8%) are moderately obese Morbid Obesity: BMI of 40 OR being 100 lbs overweight. 6 million adults in America (2.8%) Often a genetic component
  • 3. Obesity Related Health Risks Increased mortality rates ranging from 2 – 12 x increase. Hypertension Cardiovascular Disease Diabetes Mellitus (2-10 x increase) High Cholesterol Skeletal/Joint Problems (knees, hips) Cancer Liver Disease Stroke Sleep Apnea Depression Anxiety
  • 4. Why Surgery? The average patient loses 30-60% of excess weight with lap-band and 50-75% with gastric bypass. Effects are long lasting (effective after 10 years above 90%). Increased risk of mortality reverts to approximately normal following surgery. Behavioral intervention (dieting, exercise) is not statistically effective in the majority of people.
  • 5. What is Bariatric Surgery?
  • 6. Risks of Surgery Fatal Any surgical procedure is fatal Risks of anesthesia (1.5 hours of surgery) Blood Clots / hemorrhage Internal Bleeding Severe Vomiting After surgery Typical Hospital LOS = 3-5 days
  • 7. Risks Following Surgery Internal Leakage can cause death Pulmonary Emboli Hernia Malnutrition Vitamin Deficiency Overeating can cause vomiting (aka dumping syndromd), internal bleeding from ripping stitches, and even death.
  • 8. Recovery From Surgery 6 months before a “normal” diet can be tolerated Patients are to eat slowly, chewing food “30 chews per bite,” use small plates, sip beverages slowly.
  • 9. 4 Diet Phases following surgery Phase I: (2 weeks) total liquid diet / 1-3 oz each 30 minutes. 30 grams of protein and 500 calories per day. Phase II: (3 weeks) 40-50 grams protein and 500-800 calories/day Food is pureed or thick liquid (yogurt, Carnation Instant, baby food, mashed potatoes, squash)
  • 10. Phase III: soft foods (tuna, oatmeal, canned fruit, cooked vegetables) 800-1200 calories / day Phase IV: (stabilization) high protein, 800-1200 calories/day
  • 11. Lifetime Diet Change Can NEVER have more than 1-1 ? cups of solid food at a time Patient must continue to eat fewer calories to sustain weight loss. Patients must take multivitamins with iron and additional calcium. Patients are to avoid high calorie, high sugar foods.
  • 12. Common Problems Nausea and vomiting Dumping Syndrome Pain in shoulder or chest Dehydration Lactose intolerance Constipation Diarrhea Bloating Heartburn Stomach Blockage Staple Rupture Stomach Stretching
  • 13. What makes one eligible for surgery? Previous attempts at weight loss Eating triggors: Holidays, stressors, certain people, work Eating styles: Overeating, Grazing, or Night Eating Binge Eating (in 30%) Physical Activity Substance Use
  • 14. Assessment of Candidates Legal History Compulsive/Impulsive History Cognitive Functioning Coping Skills, Emotional Modulation, Boundaries Psychiatric History / Hospitilization 6 months of stabilization is key
  • 15. Psychometric Tests Questionnaire on Eating and Weight Patterns – Revised (QWEP-R) -assesses binge eating and purging type bulimia Multidimensional Health Locus of Control (MHLC) Tells about the patient’s attribution of control to self, chance, and powerful others.
  • 16. Millon Behavioral Medicine Diagnostic (MBMD) 165 item instrument that assesses psychological factors influencing treatment outcomes Scales include: Treatment Prognosis, Resilience, Medication Abuse, Problematic Compliance, Adjustment Difficulties, Psych Referral, and Oppositionality, and many more.
  • 17. The Decision 1. Patient is Excluded Active psychosis present Multiple suicide attempts within 5 years Substance use within past 6 months H/O poor compliance (appt. keeping, following recommendations, or MBMD risk) 2. Delay Consideration Pending response to Treatment Poorly controlled mental illness or cognitive impairment. Severe binge eating disorder (QWEP) Unstable social environment Low self-efficacy (MHLC)
  • 18. Decision 3. Acceptable for surgery; provide psychological treatment before and after. Mild-moderate binge eating disorder Other mild-moderate behavior problems (MBMD) Moderately low self-efficacy (MHLC) Well-controlled mental illness, including schizophrenia, depression, bipolar, anxiety History of isolated suicide attempt Acceptable for Surgery
  • 19. Psychological Comorbidities Mood Disorders – Major Depression (10 to 70%) Anxiety Disorders (48%) Bulimia (30%) All personality Disorders Substance Dependence Somatic Symptoms Possible link to Childhood sexual abuse Impulsivity Low Self-Confidence
  • 20. Pre-Surgery Therapy Identify the Function of food Identify any misconceptions of surgery Understand the invasive nature of the surgery Identify Eating Triggers Develop alternative Coping Mechanisms Increase Social Support
  • 21. Locus of Control Internal: Self is the source of problems as well as solutions Chance: Fate is attributed to chance – outer influences. Powerful Others: Other people are the source of good and bad outcomes.
  • 22. Therapy Pre-Surgery Pre-operative weight loss proves beneficial. CBT for Pre-Operation Anxiety Increase medical compliance/ discuss hostility toward healthcare providers/ obstacles to following recommendations. Keep a Food Journal – Everything you put into your mouth Make “problem foods” unavailable Reward yourself for hard work.
  • 23. Therapy Post-Surgery Those with self-defensive attitude, rigidity, psychopathic deviancy and hostility lost less weight following surgery. Set Achievable Weight Goals (5-10 lbs) Reward yourself for weight loss. Ask friends for support. Plan Ahead (parties, vacations, etc.)
  • 24. Cognitive Behavioral Therapy Reduce cognitive Distortions Dichotomous Thinking Catastrophic Thinking Teach Patients to use Problem focused Coping, rather than Emotion focused Coping Problem Focused: re-conceptualizing a problem by minimizing effects or trying to solve Emotions Focused: daydreaming, self-preoccupation, and emotional regulation.
  • 25. Recommended Articles Gllnski, J., Wetzler, S., Goodman, E. (2001). The psychology of gastric bypass surgery. Obesity Surgery , 11, 581-588. LeMont, D., Moorehead, M., Parish, M., Reto, C., Ritz, S. (2004). Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates. American Society for Bariatric Surgery.

Editor's Notes

  1. First of all, obesity has been linked directly to increased mortality – not even including other health problems. -More importantly though, it is linked with a number of fatal diseases, including high blood pressure, type II diabetes, high cholesterol, joint and muscle problems (knee and hip problems) there’s been a link to cancer
  2. Read: so they’ve found that the effects of obesity may be reversible in many cases, if caught before it begins to interfere with other system functions, such as heart disease, etc. Also, and this is very unfortunate for our field, but alternative treatments, including diets and exercise are not very effective in the morbidly obese population. On average, in many of the clinical trials, patients only lost 1-2 lbs over the course of a few months and most gained that and more back.
  3. This is a video showing laparoscopic surgery – most common way to perform gastric bypass – uses slendar surgicla instruments and a camera called a laaroscope and moniters it through a lense to perform surgery There is a major incision – an invasive and traumatic surgery. The stomach is divided into 2 parts and then sealed with staples and stitches. This leaves a pouch the size of a golf ball where food is received. The small intestine is then cut lower down and brought up to go directly into the new pouch. The old stomach and intestine is connected below to another portion of the small intestine. Food then bypasses the old stomach entirely, however the stomach still secretes normal digestive juices and enzymes into the lower intestine in order to digest food and so that nutrients are absorbed normally.
  4. The majority of complications following surgery arise from the patient’s non-compliance with treatment. Not only is the diet extremely restricted, which I’ll go into next, but there is a lot of care required for the healing of the large wound. Not following up with routine check –ups increases these odds, so the patient must make all scheduled appointments.
  5. If they don’t chew their food, can cause obstruction as the stomach and intestine openings are much smaller
  6. The surgery is not a magic tool – patient must continue to restrict calories. For many, appetite is decreased, but it is possible to stretch the stomach and still overeat or rip stitches
  7. Has this patient tried a number of different weight loss attempts and failed? It is important that they have made signfiicant efforts and haven’t simply heard of surgery and decided to try. Asking if they plan to exercise often reveals whether they have a realistic plan for weight following surgery – if they do not, it strongly suggests that they see surgery as a magic tool and they do not have to provide their own effort to become healthy Substance use is strongly contraindicated, both because it may harm their judgment following surgery and also because it suggests they do not have healthy coping mechanisms in place for dealing with the stress of a surgery
  8. 6 months of stable psychiatric status is key – recommended as the minimum by much of the literature. Therefore, when I make my recommendations for therapy for those who are not ready, I suggest at least 6 months.
  9. .
  10. Most research does show that rates of mental disorders are somewhat higher in this population of morbidly obese people seeking surgery. Rates of those with psychiatric diagnosis are about 50%.
  11. in addition to treating any comorbid psychiatric disorder, such as substance abuse or dealing with an Axis II disorder, there are a number of steps bariatric patients must go through emotionally before they are ready. The first step with a pre-surgical patient is to identify the cause or source of their overeating. Did it start in childhood - what need were they meeting with food? Whether they were sexually or physically abused is very important in the beginning of therapy. Next, find out if the patient sees surgery as a magic tool for getting a perfect life : do they plan to exercise – help them understand the strict limitations and restrictions following surgery and that it will not be easy. This is when it is very important that they understand all of the regulations on the phases of eating after surgery – they may start to grasp the intensity of this procedure and realize it is too much. -Then, they should fully comprehend the traumatic nature of the surgery – they will be cut open. How have they before handled medical problems. Have they ever undergone medical procedure? Some desensitization at this point may be necessary. -Identify eating triggers or weaknesses (holidays, family stress) and develop plans for coping with this stress – relaxation therapy may be very beneficial for these patients -Next, the patient needs new coping mechanisms now that their major one, food, is no longer available – exercise, hobbies -Many need to develop better social networks – so encouraging to develop family supports – social networks, plan for ongoing group treatment
  12. Often bariatric candidates have external locus of control – attribute negative and positive events in life to outside forces, as either chance or other people. It’s important to help them realize that they control their own fate. This can be done by setting behavioral plans, goals, and rewarding themselves for accomplishments. By visually keeping track of failures as well as setbacks, they can realize they have influence over what happens to them. This is why it is very important to keep a food jounral prior to surgery – this way they have to stop attributing weight to chance.
  13. It has been found that losing 5-10 % of weight before surgery usually correlates with better outcomes – for a couple of reasons. It separates those who can comply with treatment from those who cannot and it also decreases the mortality rate during the surgical procedure (one study found shorter hospital LOS post surgery, easier breathing under anesthesia) Patient’s may argue that they cannot lose this or they would not be opting for surgical procedure, however remind them that this is only f or approx 6 months prior to surgery and they are not expected to “keep it off” without extra help that surgery will provide Some may also have a lot of anxiety about the surgery – relaxation training – understanding exactly what they will do during the surgery, and identifying what exactly the fear is is helpful - is it a blood phobia, phobia of being under anasthesia, etc. Some may have a problem with following Dr’s orders – being compliant with medicines – practicing taking vitamins is a good way to behaviorally habituate to a daily routine. As for hostility toward medical staff, find out if it is anger toward authority in general – possibly more of an antisocial type character Food journal is important at this point – in order to determine if the patient is really ready to comply with strict eating pattern following surgery
  14. Continuing to work on a non-defensive attitude is important following the surgery as well -Patient should have a reward system for achievable small goals – don’t make the goal too big -Often right after surgery the patient second guesses their decision – very difficult adjustment period with that diet as well as pain from healing and restriction of activity. Weight loss happens fast, but not immediately. After a short period of time though, weight loss often happens quickly.
  15. CBT therapy is probably the best approach – many of them in particular struggle with black and white thinking around eating: They feel like a failure if they stray in any way from the diet and therefore go off of it all together. Attempting to help them see partial success and partial loss, rather than giving up, which is extremely dangerous. Catastrophic thinking often happens if the weight loss is slower than expected – they start to get scared that the whole thing was a mistake and they will never meet target weight, again this can become dangerous because they may feel the desire to “give up” Teach them to assume that there WILL be setbacks and relapses
  16. 2 nd is on the web
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