When a person chooses to have surgery as a way to help lose weight, it is never a simple decision. In fact, for those who have been navigating life under the burden of 100 or more pounds of excess weight, the decision to undergo bariatric surgery usually follows years of struggle, including countless diet and exercise programs – many of which were temporarily successful – and considerable physical challenge, emotional pain, and social disappointment.
The fact that the candidate for bariatric surgery is overweight is rarely for lack of trying to be slim; for most, the surgery is actually considered the last resort. Which doesn’t make the decision any easier. “Bariatric surgery is a big step and a big commitment,” says Catherine Hambley, PhD, a psychologist who counsels candidates before and after the surgery at Community Hospital. “Prior to the surgery, I look at factors that may serve as predictors for success or failure. We don’t really know what the predictors are, but I can screen to get a sense of who might do well and who might not.”
For starters, says Hambley, obesity is not merely the result of a psychological problem, nor is it simply the manifestation of an eating disorder. Like so many diseases in America today, it calls for a multifaceted approach to understanding the condition, including but not limited to social status, heredity, financial situation, emotional stability, activity level, and even time.
For many, it is quicker, easier, and sometimes even cheaper to pick up pre-made food than to plan a shopping list, go to the grocery store, and head home to break out the pots and pans. A lack of time can result in a lifestyle high in fast food and low in exercise, the recipe for obesity.
For others, poor eating habits may accompany loneliness, boredom, anxiety, grief, or the demoralisation that often results from internalising the social or personal stigmas frequently applied to obesity. Among the surest ways to evoke further weight gain is to criticise someone for his or her weight, either publicly or privately, or to tell the person to lose weight.
“Demoralisation is a big factor in maintaining excess weight or gaining more,” says Hambley. “During weight-loss efforts, many people’s weight plateaus. They can’t lose any more, or they gain it back. Perhaps they’ve fallen off their routine or found the deprivations unrealistic. But this is not the whole story. It’s oversimplifying to say obesity is merely a psychological issue. It’s akin to saying alcoholism is.”
Nevertheless, the psychology of obesity is not to be ignored and can be very helpful in predicting a patient’s experience following bariatric surgery. Hambley pays particular attention to behaviour changes and self-esteem, recognising that people who have higher self-esteem also have a greater sense of self-efficacy, the “I can do what I set out to do” mentality that will help ensure the success of their weight-loss efforts.
“Patients whose self-esteem is low,” says Hambley, “and who feel discouraged or have a pessimistic outlook often feel defeated before they start. Part of combating that lies in clarifying the goal. Our intent is to focus not on weight loss but on lifestyle changes that can result in weight loss and better health following the surgery. Patients need to understand that bariatric surgery is just a tool; the key is a lifestyle change. Instead of setting them up for success or failure, we work on helping them take control of their lives.”
Understanding that many factors coalesce to cause obesity, both Hambley and Dr Mark Vierra, one of two surgeons who perform bariatric surgery at Community Hospital, recognise that the surgery requires a multidisciplinary approach.”We need physicians, psychologists, nutritionists, and family members working with the patient,” says Hambley. “And society has some responsibility in terms of the quantity and quality of food we make available, as well as how we treat overweight people.
“Once patients have lost weight, I hear all the time that they had never realised how much others’ opinions of them were all related to their obesity. Ironically, they say they were invisible; that, in retrospect, people didn’t see them for who they are, passing them by for jobs, promotions, and social interaction, and making inaccurate assumptions about them because they were fat.”
Part of preparing patients for the surgery involves preparing them for what comes afterwards – not only the nutrition and exercise protocols but dealing with shedding a cocoon of excess weight and the inevitable changes in their sense of self as well as the way others will see them.
“People need to be prepared for what life will be like,” says Hambley. “If they go into surgery still using food to manage their emotions and haven’t started to make lifestyle changes, they’ll have a hard time. Most people, however, feel very relieved. They don’t have the constant drive to eat, and they develop a sense of success by managing their nutrition and exercising, which increases their sense of well-being. This, in turn, enhances their ability to interact with others, who will respond to the person they now see.”
Hambley helps patients develop and commit to a plan of behaviour changes that will improve their lifestyle. “I try to make patients accountable,” she says, “so they don’t leave my office without telling me their plan: how they will fit exercise into their schedule and what they plan to do for meals. We make it practical, so they can do it, so they can feel a sense of success.”
Breda Grimley, WLSA Psychologist