Mental Health Aspects of Bariatric Surgery

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@AllCEUS.com Counselortoolbox. Between writing notes, filing insurance claims and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of therapy notes by just using the promo code CEU when you sign up for a free trial at therapynotes.com. I'd like to welcome everybody to today's presentation on mental health aspects of bariatric surgery. I am Dr. Donnelly Snipes and I would like to mention that this course, this topic, was actually selected by one of you who listens to the podcast or comes to the class. So please, if you have topics that you want to learn about, let me know because it's a whole lot more fun when I'm doing something that I know people are interested in. The objectives for today we're going to learn about bariatric surgery, explore reasons for the surgery and increase in popularity in bariatric surgery. We're going to identify the psychosocial outcomes of bariatric surgery, identify some common presenting issues in people seeking the surgery, explore current recommendations for assessment protocols and pre surgical preparation, and identify post operative mental and physical health issues which may occur and which need to be addressed. Usually by us, you know, we're talking about the mental health aspects. So there's been an increasing amount of evidence for bariatric surgery as a more effective treatment for morbid obesity compared to dietary advice, exercise, lifestyle changes and medication. A lot of times people seek out bariatric surgery because they have a impending or current physiological health condition that needs to be addressed rapidly. The procedure is more effective in achieving significant weight loss longer term maintenance, not permanent maintenance. They find that people, a lot of people, the majority of people, tend to regain some of their weight, if not all of their weight within somewhere around three to five years. There's a significant proportion that gain back a lot of their weight, but it does help them achieve significant weight loss for a period. So hopefully during that window they can learn better lifestyle habits. And there are improvements in physical comorbidities and reductions in mortality related to cancer, eating disorders, heart disease, hypertension, osteoarthritis and stroke. Bariatric surgeries all aim to make the stomach smaller so it can hold less food through removal of part of the stomach banding or bypassing. Now There are three or four major types of bariatric surgery that are out there. Didn't figure it was important to go into the different types. If you're working with this population, you will want to be familiar. Some of these surgeries also bypass a smart of the small intestine, which inhibits calorie absorption, but it also inhibits nutrient absorption, which can lead to malnutrition. In as many as 30% of people who have the surgery, concerns have been raised about potential ongoing risks of mental health disorders, including substance abuse, self harm and suicidality, especially following bariatric surgery. Surgery is often not associated with an improvement in mental health quality of life. So there is a significant improvement potentially in physical health and there is a potential significant improvement in the reduction in comorbid physical health conditions. But mental health quality of life seems to be relatively unchanged or get worse. Two main hypotheses have been proposed to help explain these findings. 1 Patients who choose to undergo the surgery are at a higher baseline risk of psych complications. So they may already be depressed or they may be at higher risk of depression. Or the surgery itself increases the risk for adverse mental health outcomes. Sometimes it's because people expect the surgery to do more than it's intended to do. The surgery will help them lose weight initially. They're still going to have to make lifestyle changes and it isn't going to make their spouse come back. It isn't going to make their life suddenly wonderful. There's a lot of other work that needs to be done. So when those things don't magically happen, then after the person loses the weight, then they may feel defeated and frustrated, depressed. Bariatric surgery is often associated with weight loss and improved physical health status for severely obese individuals. And 20 to 30% of patients undergoing bariatric surgery experience premature weight stabilization or post operative weight regain. And that's important to recognize. And the number, depending on what study you look at, the number can go even higher. Regarding weight regain, it depends on what you're looking at. Are you talking about total weight regain? Well, that stays around 20 to 30%, but that's still one in three will potentially regain all of their weight. But then there's also a group of people who get down to their target weight and then regain, you know, 15, 20 pounds and they may feel frustrated about that or premature weight stabilization so they never get down to their target weight, which can reduce their self efficacy. Many patients also experience changes in their social scenes, as many American holidays and activities are centered on a big meal. Let's think about it, Thanksgiving, Christmas, birthdays, Halloween, you know, pretty much any fourth of July you have all these cookouts. Memorial Day, you have these cookouts. People tend to focus a lot of gatherings around food. Even at work, when you have, you know, annual celebrations and get togethers, there's food involved and it can be very daunting for a person who is trying to control their weight and or who has had bariatric surgery or who has eating disorders. The way patients interact with the significant people in their lives can change dramatically and their social structure can be irreparably broken. If they tended to go out every Friday night with their friends and go out for dinner and a movie or something, and now going out for dinner is not as easy as it used to be. So if those people are not willing to make changes in the restaurants they go to or forego the pre movie meal altogether, it could be a problem. We'll also learn shortly that there is a difference in the. Way people who've had bariatric surgery metabolize alcohol. So anything involving alcohol may also be something that a person who's had bariatric surgery can't do. Mental health related quality of life improvement Mood often improves in the immediate aftermath of surgery, but psychiatric disturbances, so mental health issues often reemerge within two to three years. So during this initial period of rapid weight gain and everything, when all of a sudden their life is changing in so many different ways, a lot of times there is a sense of optimism and encouragement and you know, they're just barreling forward. And then when things start to stabil, psychiatric disturbances may start to re emerge because they may start to realize that some of the problems they hoped were going to be solved by their surgery weren't solved at all. Or they may start experiencing that weight gain again. These patients were almost three times more likely to attempt suicide than the general population. Let that sink in. Three times more likely. So if you're working with a client, even if it's not specifically to handle their post surgical issues, if you're working with a client who's had bariatric surgery, especially one who had surgery two or more years ago, you may want to be alert to the fact that they are at a higher risk of suicide. Another study looked at self harm emergencies, including suicide attempts, and found that these increased by 50% after surgery. So people and these people that we're looking at are only people who went to the hospital. So people who attempted suicide or self harm or what have you and didn't go to the Emergency room aren't being included or, you know, so those numbers aren't even calculated. The number of people who experience negative psychiatric issues after the surgery really goes up significantly. And we'll talk about some of those reasons in a few minutes. Does one et al investigated the course of anxiety and depressive disorders over the first two years post surgery. Depression decreased immediately after surgery. Okay. We already knew that participants with both depressive and anxiety disorders preoperatively lost significantly less weight after surgery. So if they had a pre existing psychiatric issue before surgery, then that is likely going to impede their weight loss after surgery. And the reasons for that are a little bit unclear, but there is a direct correlation. Longer term studies suggest minimal improvements in mental health and psychosocial well being after surgery compared to those people who just chose behavioral interventions and chose to change their lifestyle. Now, I will mention that bariatric surgery sort of forces people to change their lifestyle in the, at least in the short term. They gradually can go back to their old lifestyle they're not supposed to, but you know, you can see that happen. But when the stomach is made smaller, it's downright uncomfortable to eat the same size meals that you used to eat. And it's downright uncomfortable for it due to a condition called dumping to eat foods that are high in sugars and potentially fats. So other issues of note, bariatric patients are at risk of becoming addicted to alcohol, more at risk than the general population because alcohol is absorbed more quickly into the body after surgery. So, you know, that's one of those things. You shorten that GI tract, make the stomach smaller and go to the large intestine, the alcohol can be absorbed more quickly. Additionally, the absorbed alcohol is more potent. And studies have demonstrated that bariatric patients reach a higher alcohol level and maintain those higher levels for a longer period. So their blood alcohol concentration stays up longer than people who have not had the surgery who are matched in terms of, you know, body fat percentage, hydration and gender. This is really important for our clients to understand. Most bariatric physicians are not going to prohibit the use of alcohol, but it is really important for clients to understand that they will get buzzed and drunk faster and they will stay buzzed and drunk longer, which means their potential for DUI goes up significantly. If you want to just put it down into practical reasoning for them. Studies have also shown that drugs, alcohol and food trigger similar reward responses in the brain. If we look at binge eating as an addiction, as a way of coping with the stress, then when somebody can't Binge eat anymore and they experience distress, they may turn to alcohol and drugs to substitute for overeating after bariatric surgery. So there is a higher risk of substance use of all types. Bariatric patients are also more likely to develop chronic opioid use issues, especially in patients who had postoperative complications or lost less weight. So let's think about that. Postoperative complications, they may have more pain, need more surgeries, be exposed to opioids for a longer period of time because of those things which can lead to chronic opioid use or if it's not managed effectively. But remember, those who lost less weight tended to be the ones that were suffering from depression or anxiety preoperatively. So if we want to go from there, then we can look at what is the function of the opioids for the people who lost less weight. Do they start taking these opioids and they feel a sense of relief? Remember we talked a couple weeks ago about the fact that ketamine is being used as a emergency intervention, if you will, for people with acute treatment resistant depression who have suicidal ideation, because opioids actually do act in some people to elevate their mood and reduce depressive symptoms. So there could be a reward factor in there where the people who are depressed, preoperative, operatively may be at higher risk of opioid use. Common presenting issues. 84% of people who present for bariatric surgery have some sort of mental health issue. 50% of the people presenting for surgery have three or more mental health issues. So this means that this population, in and of itself, is at a higher risk for mood disorder. Postoperatively, the prevalence of binge eating disorder ranges around 10 to 27% in this population. Now, let's think about binge eating disorder. Binge eating disorder is not just, you know, eating a lot because you love food. Binge eating disorder is eating behavior that is characterized by eating large amounts of food, usually prompted by a desire to escape from some dysphoric emotional state. Well, if you take somebody who has binge eating disorder and they're using food as a coping skill, you yank that coping skill out from under them. What do you think's gonna happen? You think they're gonna start having more anxiety and depression? Probably. So you think they might find other ways to cope? Yeah, hopefully it's a good way, but we can't guarantee that, which is why preoperative and postoperative counseling is so important. The prevalence of night eating syndrome is between 2 and 20%. And it increases with the index. Your clients that have a higher body mass index, who tend to be heavier, are at greater risk or have a greater prevalence of night eating syndrome, which is characterized by a shift in the circadian pattern of eating, resulting in frequent night awakenings linked to nocturnal eating and a lack of appetite in the morning. Some people even report they don't remember getting up and eating in the middle of the night. Well, this is, again, a problem. If they can only eat so much and they're eating basically in their sleep, then we're gonna have to help them figure out how to stop that behavior so they don't accidentally overeat at night. And we're gonna have to help them get on a schedule that resets their feeding circadian rhythms. It's going to be a collaboration between you, the patient, and the psychiatrist to help or physician in order to try to help get this rebalanced. But night eating syndrome is a real issue for a lot of people. What do we need to assess? If somebody comes to you and says, my doc said I have to have an assessment before I can do this surgery. What do we need to look at? We need to make sure the client understands the surgery, what it can do and what it cannot do. And what's going to happen when you have the surgery. What's it going to be like? And what is your life going to be like after the surgery? Because most people don't really fully conceptualize how restrictive their eating and their patterns and habits and stuff become after the surgery. They need to understand the necessary lifestyle changes that will be forever. There are certain things that are forever. We need to assess their motivations to make sure that they're understanding, again, what the surgery can do. And they're not trying to get this surgery because they want an easy way to lose weight. Because this ain't easy. Don't get me wrong. This is not easy. Nor do we want them going into it thinking that if they lose weight, then, you know, their partner will fall in love with them again or whatever the case may be. We want to make sure that they have realistic expectations regarding the results. Not everybody, you know, based on your bone structure and everything else. We all come in different sizes. And we want to make sure that people don't think that they're going to have bariatric surgery and be able to get down to 2% body fat and a size 0. That is not realistic for most anybody, let alone people who are undergoing bariatric surgery. We want to make sure they have the ability, ability to Adhere to post operative recommendations. We want to talk to them about their eating behavior to understand how did they get to the point where they needed bariatric surgery? What's their weight history? Maybe they've been overweight since they were kids. Okay. What is their diet? Do they eat a healthy diet and they're still gaining weight? Or do they eat all kinds of junk food, which after the surgery they ain't going to be able to eat anymore? Do they exercise and what do they think about as exercise? Because exercise is not necessarily going to the gym. It is anything that moves your body. If it's going on a walk, if it's playing with your dog, if it's clean in the house, I know I can work up a good sweat clean in the house. But it's movement. We want to talk to them about binge eating and be real frank about it. Just about everybody binge eats at some point in their life for some reason. Whether you're on a cruise and the food is just oh my gosh. And you eat an amazing amount of food and you just binge on everything in sight because it was just so amazing. That's once you know, that's not binge eating disorder, that's just a binge. But we want to assess them for binge eating disorder and any sort of other eating disorders, especially your purging type disorders. Because purging after the surgery can be extraordinary, even more dangerous than usual. We want to understand why they eat. Is it because they're craving certain foods? Because they've got gaps in their nutrient profile in their diet? Is it because they eat out of habit? Or do they eat for emotional reasons to help calm themselves? Or do they have night eating syndrome? So there's a lot of stuff we want to understand about their relationship with food. We want to see what their awareness is of their eating habits and their sense of control over eating. If they feel like they don't have any control over eating and they're thinking the surgery is going to change that, they're wrong. And we're not probably going to tell them that quite that directly. But the surgery may make it uncomfortable. But think about a time, and at least after I had my kids, for example, you know, I did not fit back into the same clothes I wore pre pregnancy for quite a while. But I was stubborn. So I would, as soon as I could get those pants on, I button them and they would be way too tight and it would be uncomfortable to eat too much in a sitting. And that pales in comparison to what happens when they actually make your stomach smaller? But if you have no control over your eating, think about, you know, for those of us who haven't had the surgery, wearing pants that are way too tight and then, you know, would you be able to control how much you ingest it? And if you couldn't, what would that do to your quality of life? Assess for psychiatric comorbidities, current and previous, because even if they're currently asymptomatic, if they have a history of mental health disorders, it's important to be aware because this, the changes could trigger a relapse. What's their social support like for the surgery? But also those important people in their life who might not be supportive of the surgery, how are they going to handle that and what does that look like? What's their conjugal satisfaction pre surgery and what are they expecting post surgery? What's their cognitive functioning? Are they able to understand exactly what's going on? What's their self esteem like? If they're thinking that if they lose the weight, then magically their self esteem is going to flourish, it may go up some for some people, for others it doesn't change at all. So we want to look at what is it about your self esteem that is keeping you down? Some people experience some declines in self esteem post surgery because they lose so much weight and then they have all this loose skin. There's a high percentage of people post operatively who seek cosmetic surgery for loose skin in order to tighten things up again because they feel even worse after they lose the weight. We want to assess their history of trauma or abuse. Eating and weight gain in some cases has been correlated, if you will, or thought to occur as a way of comforting oneself after abuse or making oneself less appealing to the abuser in some cases. You know, there are several hypotheses for these, but trauma and abuse can affect outcomes of bariatric surgery. We want to assess their current quality of life and current quality of life, we'll say it's a five on a scale of one to 10. What is keeping it from being a 10 and how many of those things have to do with the person's current weight? There may be a lot of things like they love to play golf, but being the weight that they are right now, it's too exhausting to do a whole 18 holes, especially in the heat or whatever. Suicidal ideation. Definitely want to check that out. Their medical history and medically related weight problems such as diabetes, hypertension, and their social, occupational, recreational and physical impairment due to weight. There's a lot of stuff we need to assess to really get a good picture of what's going on with this person. Now I will mention the Cyberi is a 115 item instrument that was developed in 2010. I could not find research journal articles, PDFs, anything where you could see it, buy it, yada yada, but if you can find it. That was an instrument that was specifically developed to assist in the pre surgical assessment of bariatric surgery patients. Preoperative psychopathology and patient expectations that life will dramatically change after a surgery can also negatively impact the psychological health after surgery. Substance addiction, eating disorders, psychotic disorders, depression and suicide are the most common mental health contraindications to surgery. You wouldn't want somebody who is actively abusing substances going under surgery. You know, we can't guarantee that they're going to be clean and sober or their body can handle it. We can't guarantee that they're going to be able to remain treatment compliant afterwards. Eating disorders. Same way we want to make sure that the person is physically and mentally healthy enough to undergo the surgery. Other factors that can postpone the surgery are a lack of understanding regarding the procedure, a reluctance to adhere to the postoperative recommendations. You already hear them talking about ways they're going to cut corners and make it a little more tolerable, be concerned. Severe life stressors. You know, they may be getting ready for the surgery and then their parent dies or they get into a car, car crash or they lose their job. Probably not the best time to undergo something that is going to change their life dramatically. And interestingly enough, nicotine use. I don't know how many doctors prohibit nicotine use, but that is a potential contraindication noted in the literature. 67.4% of patients post surgery felt poorly prepared psychologically before the surgery. So almost 70% of people said I wasn't prepared for what was coming after this surgery. I wish I would have known more. People with morbid obesity on a waiting list for surgery improved their physical health after attending a tailored patient educational course. And these improvements seem to endure for the two years of the study post surgery. So there is a lot of evidence indicating that psychoeducation pre surgery is really important and really useful. We can provide psychoeducation about the changes resulting from the surgery in their body, in their relationships, in their self esteem, in their lifestyle. We can offer psychological support for what they're going through now, what their expectations are and postoperatively what to expect. And we can prepare the person for behavioral modifications that must occur in the postoperative period. Some articles and places that I read indicated it's really helpful to start these activities pre surgery. So start making some of these lifestyle changes to get used to doing this eating, these eating changes and these lifestyle changes. So start changing your activities with your friends so they're not all revolving around food. Start paying attention to your eating so you're eating slowly and in small bites and smaller portions and, you know, lots of those things. We'll talk about those more. But there are a ton of lifestyle changes that people can start making preoperatively. So once they're postoperative, it's not going to be as hard on them in the early post operative period. The main goals of office visits, and this includes the doctor, are to assess their proper nutritional status. For us as mental health clinicians, we may talk with them about how they're doing, whether they're eating, you know, if they're keeping their food journal and meeting with their dietitian. We're not going to make food recommendations. We do want to be on the outlook for maladaptive eating behaviors. So if they're starting to restrict a lot or binge or whatever, we do want to be on the lookout for that. Doctors will typically be the ones evaluating the potential complications, such as hernias or ulcers. But if patients start to complain, you know, we want to ask them about their pain and their physical comfort since the surgery. And if they start to complain about pain, we want to make sure to refer back to their medical doctor. We also need to monitor the status of their comorbidities. When medications go into a smaller stomach, and especially the ones that bypass part of the small intestine, the absorption rate and the breakdown of the pharmacological medic, the medications that the person is taking, that's all going to change. So they are probably going to absorb less and it may not be broken down as well. It's important to be very aware and make the patient aware that, okay, if you were taking 150 milligrams of sertraline presurgically, that amount will probably need to be adjusted post surgically. And we're going to need to look at, or you're going to need to work with your psychiatrist to monitor your moods and identify what the best dosing is for you. Now we can start encouraging regular exercise even before surgery, reminding them that exercise is any kind of movement. Now, doctors may talk about going to the gym or, you know, power walking for 20 minutes. I some people, that's just not their thing. So we want to help them brainstorm ways they can get their body moving and enjoy it. Zumba classes, whatever, discuss their weight loss progress with them and how they feel about it and review. As clinician, mental health clinicians, all we're going to be able to do is review the sheets that give us their laboratory values on their nutrition and metabolic profile. And it's important if you're working with this population in depth, that you're aware of what values should be where so you can understand what you're looking at. After surgery, patients will have medications that will be taken for a few months and others will be taken for life. For most patients, the body could not absorb whole pills as well as before. So there are special procedures for medication administration. Some pills need to be crushed. In many cases, time delay medications can't be taken. There are a lot of changes that need to happen. Patients will usually experience dumping syndrome in the couple months after surgery. And some can say this could be viewed as a teaching tool. Dumping occurs when food, especially sugar, moves from your stomach into your small bowel too quickly. Signs and symptoms include cramps and diarrhea 10 to 30 minutes after eating, up to three hours after eating. Yeah, it's a pretty aversive consequence to eat sugar and then all of a sudden, you know, experience these symptoms. Prevent dumping syndrome. It can be accomplished often and they need to talk to their doctor by eating smaller meals and limiting high sugar foods. This is one of the big changes that people have have to make postoperatively because the dumping syndrome isn't going to go away. It's not like in six months they can return to eating high sugar foods and not have a problem. The main goals after any bariatric surgery are to maximize weight loss and absorption of nutrients, maintain adequate hydration, that stomach smaller. So it's not going to be, you're not going to chug 24 ounces and feel real comfortable and avoid vomiting and dumping syndrome. Much of the nutritionist's work is related to informing patients on how to eat properly and judge fluid, protein, carbohydrate and fat intake and educate them about the importance of self monitoring by keeping daily nutrition journals. So the nutritionist is going to be an integral part of this multidisciplinary team. For us, it's important to recognize and educate the patients that ghrelin, the hunger hormone, is decreases after bypass surgery. Great. So you're not as hungry after bypass surgery. Not only is your stomach smaller, you're not as Hungry. Win, win. But within six to nine months, it stabilizes and food urges start to come back. For the majority of patients that I was reading about in the, in the research, some complain that they're supposed to eat really frequently but have no appetite, especially right after surgery when that ghrelin level is low. It's important to work with them to make sure that they are eating because they need the nutrients their body needs, the building blocks in order to make everything else function effectively. Others who are emotional eaters may struggle because the reasons they ate are still there, but they have no alternate behavior to replace the eating. Bariatric bypass surgeries carry a greater risk for nutritional deficiencies than restrictive procedures due to malabsorption and the shortened digestive tract. Roughly 30% of patients develop conditions due to malnutrition, such as anemia and osteoporosis. Why am I covering this? Well, another symptom that they often develop, you know, if we're, when we're talking about malnutrition, can be Wernicke Korsakoff syndrome, which we typically used to think of as only related to alcoholism and a thiamine deficiency as a result of alcoholism. But they found that people who have had bariatric surgery are also at greater risk of developing Korsakoff syndrome. Why do I bring this up? Because we need to be on the lookout for these symptoms and not misappropriate them to something else. Fatigue is one symptom. Fatigue is caused by a lot of things, so I don't want to get too upset about that necessarily. If it's just fatigue, polyneuropathy, and this can come in the form of aching muscles and tingling in the feet, calves, or hands. That's a warning sign when you've got something like that going on. Definitely refer to the physician. Nystigmus is when the eyes have uncontrolled movements. They're bouncing back and forth. Now, this can be a sign of intoxication. It can be a sign of something much more serious. Ophthalmologia. Anyway, the eyes are paralyzed, and I had this occur in one of my patients. She wasn't a bariatric patient, but her eyes rolled up and froze. That way she could not move her eyeballs. And ataxia, which is characterized by unsteady gait and slurred speech many times. We might attribute that to intoxication as well, but it could be malnutrition. The person may also have confusion lower limb hypotonia, which means they just have no muscle tone in their lower Limbs seizures and even hearing loss. Be aware of these symptoms. Severe thiamine deficiency is also associated with beriberi. Basically, if you see any of these symptoms, it is really, really important to get people referred to their doctor if they're having any polyneuropathy. My feeling is, and it would be up to your risk management team to develop a protocol of when to send them directly to the error. But for Korsakoff syndrome, the sooner they get the IV with thiamine, the less likely the brain damage and the neurological damage will be permanent. So it's really, it is a medical emergency. Post operative mental health can be improved by treatment focusing on emotional regulation and cognitive behavioral skills, lifestyle change and psychopharmacological interventions, especially for impulsivity. Vyvanse is the first FDA approved drug to treat binge eating disorder. Other drugs that have been used to some effectiveness, SSRIs and SNRIs. They found that norepinephrine or noradrenaline may play a role in reducing impulsivity and improving the symptoms of both ADHD and binge eating disorder. When you're looking at the medications, you know if your patient is on an SSRI and they still are experiencing binge eating sort of symptoms, then they may want to talk to their doctor about switching over to an snri. Unless that medication they're on, the SSRI is really effectively controlling their mood issues, then you probably don't want a monkey with that. But you know, just know that there are options. And Topiramate, which is an anti seizure medication, might work better for binge eating than certain antidepressants. Those are all medical interventions if clients are having difficulty with their binge eating. Interestingly, adults who got approximately one hour a week, just one hour a week of moderate, vigorous, moderate to vigorous intensity exercise, we're less likely to have significant mood issues. Again, we want to encourage physical activity post operative lifestyle changes. Mealtime guidelines are provided to encourage fluid intake and maximize satiety between meals. They don't want people doing a whole bunch of grazing. Some doctors say three meals and two snacks. Other doctors say six small meals. It's going to be dependent, dependent on your team's recommendations, but the person will be discharged with postoperative mealtime guidelines for fluid consumptions. They are no longer allowed to drink liquids at meals and they need to wait at least 30 minutes after a meal to start fluids. This is because if you drink when you're eating, you're going to fill that limited pouch up too quickly and they may not get the Nutrients that they need because they filled up on fluid. It's important to avoid overfilling and stretching the stomach pouch. If you've ever had the flu, you know, you didn't eat much for like a week, and then when you started eating again, you didn't seem like you could eat near as much as you could eat beforehand. Well, your stomach, which when it's not stressed out, stretched out, is about the size of your fist in your own body. You know, we typically eat way more than that. Look at your plate at lunch or at dinner tonight and then compare it to your fist and you're like, oh, yeah, I'm eating way more than that. But it can be stretched out. So it gets, it develops more give to it. And over time, even though it started out post surgically only being, you know, very, very small, a third the size of your fist, it can be stretched out again so it's closer to the size of your fist if you consistently overeat. Encourage people to sip beverages. Don't use a straw, which increases swallowed air. They're supposed to drink six cups of fluid per day, including high protein liquid supplements, skim milk, and sugar free non carbonated beverages. Stop eating and drinking when a full feeling occurs. Most of the patients that I've worked with have difficulty identifying that full feeling. And they're so used to eating quickly that they don't give their brain time to register. It takes the brain 20 minutes, give or take, to register that it's full. And I know for me, I have bad eating habits. I'll admit I can wolf down my entire dinner in 10 minutes. And then I'm like, I'm still hungry. Well, it's because my brain hasn't even figured out that I ate food yet. So do as I say, not as I do. That's not a recommendation. It's important for people to start eating more slowly so their brain has a chance to tell them, hey, you're full. And carbonated beverages can distend the pouch because of the gas bubbles. Food guidelines Eat three to six small meals a day based on the physician's recommendations. Eat very slowly, at least 20 minutes. Chew food extremely well. Eat only small amounts, and the nutritionist will work with them on how much they should be eating at each meal. Stop eating when they're feeling full and avoid high calorie foods and liquids. Those types of things, such as ice cream, are one of the main reasons for people for therapeutic failures. If they're eating high density calorie foods, like high fat foods or things like ice cream, then they could very easily pack on the calories and the weight again quickly. The mean body mass index and the duration of follow up are significant moderators of negative psychological outcomes. So the more weight people lose and the more follow up they have, the better their mental health. For most patients, this is a time of emotional turmoil. If patients were previous stress eaters and become stressed after surgery, they no longer have the ability to eat for stress relief. So we have to help them develop those tools, preferably preoperatively. Obviously that's a hot button for me. I really don't like throwing somebody into the deep end and then trying to teach them how to swim. I think they need to learn how to swim before, before they get in the pool at all. Patients complaining of weight regain should be referred back to the bariatric team to be evaluated for surgical complications or excess calorie intake. And other patients may be struggling with their body image and self esteem, causing them to skip meals or even starve themselves. Psychological issues are related to inadequate weight loss or weight regain, unrealistic expectations or dissatisfaction after the surgery. You know, they may have unrealistic physical expectations. They think they're going to be a size 0, or they may think that everybody's going to love them once they lose their weight, or they may think that once they lose their weight, they're suddenly going to be happy. And, you know, there's a lot of stuff that goes into being happy besides just our size. Body image issues. We want to work with people. People with eating disorders tend to have very distorted body images. I worked on a study when I was in undergraduate, and the researcher that was doing the study, we took pictures of a bunch of young women in one piece, leotards. And then we would project their image onto a screen and we would use knobs to greatly distort the image. So it was clear that that's not what they looked like. And we had them use the knobs to readjust the picture to what they think they looked like. And the disparity was shocking. For the people with eating disorders, they tended to view themselves, they saw themselves as 20 to 40% heavier than they actually were. So people with body image issues may still see themselves as a lot heavier than they are. Additionally, when we lose weight really, really quickly, except for the fact that our clothes are fitting differently, we may still see the same thing in the mirror. Sometimes it's hard to see changes that take place really quickly. They may have issues related to lack of improvement in quality of life after surgery or Grief over the loss of their old life. They miss being able to eat whatever they wanted or get fast food. They miss or they regret having to do concentrated meal planning all the time. They may have irritability due to a lack of access to their old coping skills. You know what they used to do when they got frustrated, when they would get in this fight with their spouse or whatever would be to eat or to drink. And now they can't do that because of the complications after the surgery. They may have continued or recurrent physical mobility restrictions if they were overweight and it caused heart problems or you know, knee problems. They may not, you know, bounce back to the body of a 20 year old after they have their surgery. Persistent or recurrence of sexual dysfunction, relationship problems and low self esteem. Other issues we may need to look at include a history of abuse, including sexual abuse. As the client gets down to the weight at which that abuse may have taken place, it may trigger a or at the size, it may trigger a resurgence of memories of the abuse. Inadequate absorption of psychiatric medications we need to be on the lookout for. We talked about that. There's also systems systemic imbalances due to nutritional changes causing alterations in the ever important gut microbiota and the gut brain axis. And there are tons of articles if you go on PubMed, you can get lost for literally days reading about it. But basically the bacteria in the gut, remember, helps make like 70 to 90% of our neurotransmitters and our hormones. Well, we're disrupting the balance of all that by changing the structure of the digestive system, which can disrupt the gut brain axis and may be responsible in part for some people's depression or anxiety increases. Some people may have difficulty with pain control postoperatively, especially in the first three months. Others may not. There may be complications requiring further treatment such as hernias or gallbladder problems or you know, lots of things can come up when you start messing. Changing how the machine operates, it can throw other systems out of whack. And difficulty complying with or dissatisfaction with new eating patterns. That's one of the most common complaints. A change in self perception is also an area that we can help people work on. Some people experience a discordance between their objective post surgical weight and their perceived body image and identity. Like I was talking about a few minutes ago, the body loses the weight, but the mind still stays the same. They still tell themselves those same awful things. They still see what they used to see in the mirror even though their physical body has changed. They may experience a loss of self identity. One person said, once I lost over a hundred pounds and looked in the mirror at myself. I didn't know the person looking back and it frightened me. You know, that can be really scary if all of a sudden they see this person that maybe they've never been and they don't know how to handle their new selves, they don't know who this person is. Persistent dissatisfaction with their body image despite marked weight loss and comments from others that, oh my gosh, you look so good. Increased self confidence after weight loss. So this is good. We want to help them increase their self confidence which resulted in the increased ability to engage professionally and socially. This is one of those outcomes we want, is for those people that feel like, I can conquer the world now look what I'm doing, look at all these hard changes I'm making and I'm doing it, I can do anything. And another positive outcome could be the psychological factors becoming more aware of those factors that contributed to their pre surgical weight, including emotional eating or not wanting to go to the gym or all of the above. So there are potentially some positive things that we can build on, not just things that we've got to try to mitigate. Some relationships are going to be strengthened due to increased self confidence and ability to engage in new activities if the person now has the energy to go walk in the park or go to the amusement park or you know, whatever the activity is. But other relationships may experience distress because the activities they used to do together, they're not doing together anymore, or the expectations between the two, the changes in the person who had the surgery, the changes in their lifestyle is not what the other person wanted to do and or not having the same outcome. So it may cause some conflict. There can also be partner dissatisfaction. One person I read about said, you know, Doc, that's why I married her. I wanted her that size. Don't let her lose too much weight. And so there can be difficulties there. Another person reported that he or she almost got divorced because they were changing so fast. You know, everything was happening. They were getting this new, you know, upsurgence of confidence and energy and things were changing so fast and they were making new friends and people were recognizing them who never even noticed them before. And it was just kind of a whirlwind and it had a negative impact on their relationship with their significant other. Some friends and family will be jealous due to their weight loss and you know, kind of grumble and a lot of them, which takes us to our next one A lot of them, in their jealousy, may accuse the client of taking the easy way out. Well, you had the surgery. You didn't have to, you know, go to the meetings or whatever. Well, it's important to educate family and supportive people that this isn't just about surgery. The surgery ain't gonna do much of anything if the person doesn't make the lifestyle changes. And the client needs to know that ahead of time, too. Some people may be really upset if they're not recognized by acquaintances after their weight loss. You know, we all have those people, like from high school that we haven't seen them in 15 years. And we go back and their body, they've either gained a ton of weight or they've lost a ton of weight and you don't even recognize them. That can be hurtful to some people. Other people go, yeah, look what was, look what what was under all that. It just depends on the person. Other people are just giddy with the fact that they don't no longer feel invisible. People who used to ignore them now want to be, be their friends. And maybe they used to eat lunch by themselves all the time before, and now people want to eat with them. Our society is really cruel towards people who are overweight, but that's a whole different topic. Other psychosocial issues people may need assistance with is meal planning. People who've had the surgery cannot just stop by a fast food restaurant and pick up something to eat. There are very prescribed things that they have to eat. They have to get a certain amount of protein in. They can only eat a certain quantity of food at any one sitting. They need to limit how much fat and sugar they take in. They need to work on. And meal planning can be a challenge if somebody hasn't been doing that all their life to, you know, on Sunday, you know, do all their meal planning for the, for the day. Refusal skills are very important when people offer them, you know, you can just have one more piece of cake, or they go to a family gathering. And my step grandmother was like this, and she would offer it Italian. She would offer you food. Oh, honey, you need to eat more. And you have to be able to say no and stand by that. Even if you're looking at it going, oh, I'd really love to have another piece. But the person who goes through the surgery has to be able to refuse the food even if they want it. They need to work on time management. So they do have the time to do their meal planning. So they do have the time to do the shopping. They need to do and to go exercise and do those sorts of things. Now some of those services that you can order fresh meals to your door may have options that are bariatric approved. I don't know, I didn't look into that. But for people who are really busy that might be something to look into. We need to help people who emotionally dysregulate and help them identify their eating triggers and alternate ways to deal with them. And distress tolerance skills bolster those in people so they have a list of things they can do when they're exposed to triggers. Weight loss surgery is merely a tool that helps people get a new start toward maintaining long term good health. The surgery alone will not help someone lose weight and keep it off. They're going to have to make significant lifestyle changes. Intensive mental health follow up post surgery should be routinely considered is a recommendation. Cognitive behavioral therapy is helpful for patients preparing for bariatric surgery to reduce disordered eating and improve mental health. Again ideally before surgery. So they go in it and they have improved mental health and they are already using making some of these lifestyle changes. So post operatively it's not as quite as big of a shock. Ideal candidates are seeking surgery to mitigate health consequences of obesity, not to do some, not to have a psychosocial result. And post surgically patients will need to deal with an array of issues due to their new lifestyle. Which is why support groups are really recommended and really important for this group. Not just support groups with a nutritionist, but also mental health support groups to help people deal with all of these changes in themselves and in their families and everything else. So we went through a lot of stuff really quickly. Bariatric surgery is a huge area and it's potentially a niche area if it's something that you want to study. And my recommendation is if you're working with these patients that you become very familiar with the research related to what it can and can't do and prepare patients ahead of time for the on demand class and potentially later. I've been working on a set of activities for a support group. So it's, you know, pre formatted worksheets and activities that you can do if you decide to start running a bariatric psychosocial program. And the on demand class for this for bariatric surgery is going to be somewhere in the range of six hours. I think I'm looking at the reading that I have to be done. So just so you know that it's there, if that's something that you're interested in, keep an eye out and that class should be out by the end of the week. The On Demand version and it will include this lecture plus a bunch of readings to go more in depth into what we talked about today. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allceus.com podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allce.com sponsor thank you.