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  • Q&A with Australian Health Practitioners

    What psychological conditions could cause problems with weight loss surgery?

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    Lorna is an experienced sports dietitian and nutritionist providing general and individual high performance eating advice to people throughout Australia. Lorna Garden is a dietitian … View Profile

    Weight loss surgery can include gastric banding, gastric resection or gastric bypass surgery and is considered a viable option for a number of morbidly obese people.
    Today, there is usually a multidisciplinary approach to the pre and post surgical care of patients, with pre surgery assessments carried out by not only the surgeon and anaesthetist, but also a dietitian,  a psychologist, and possibly a psychiatrist.   Psychological intervention and treatment, both preoperatively and postoperatively is considered particularly important for the best outcome for the patient.
    There are a number of psychological conditions which may contra-indicate weight loss surgery and they could include an existing uncontrolled eating disorder,  a uncontrolled personality or emotional disorder, and low probability of the patient's postoperative compliance.   Where there is psychological contraindication for surgery, a psychologist will offer suitable psychotherapeutic or psychiatric alternative treatment.

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    Dr Kevin Dolan

    Bariatric (Obesity) Surgeon, Laparoscopic Surgeon

    Dr Dolan has been performing weight loss surgery in WA for 20 years, providing a long-term commitment to achieving and sustaining weight loss in conjunction … View Profile

    The most common psychological disorder in the morbidly obese is anxiety and depression. However, not all these patients will have these symptoms, but all of the patients should be given the option of referral to a psychologist who deals with morbidly obese patients. Many studies have shown improvements in psycho-social status following weight loss associated with bariatric surgery.

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    Arlene is a registered practising dietitian, with a private practice in the Eastern Suburbs of Sydney, and has built a strong business over the last … View Profile

    Although no formal standard exists, there is growing recognition of the important elements to be addressed to determine psychological readiness for bariatric / weight loss surgery. Unlike traditional diets for which risks are low and discontinuation can occur at any time, bariatric surgery has inherent risks and requires highly restrictive, long-term behavioural changes afterwards. Therefore, these patients typically are required to complete a thorough evaluation, including psychological assessment, to determine their appropriateness for surgery.  Patients meet with a psychologist for a clinical interview that focuses on behaviour, psychiatric symptoms, and understanding of the surgery; they then complete psychological testing, which provides an objective measure of their presentation style, psychological adjustment, and readiness for surgery. This approach matches the growing body of evidence regarding the important elements for inclusion in this assessment.
    Although patients often are hesitant and uncomfortable with the notion of seeing a psychologist before surgery, the information discussed during the clinical interview is critical not only for assessing their appropriateness for surgery but also for enhancing their success during the post surgery adjustment. The core parts of the clinical interview include reasons for seeking surgery, weight and diet history, current eating behaviours, understanding of the surgery and its associated lifestyle changes, social supports and history, and psychiatric symptoms (current and past). Most patients describe a desire to lose weight to improve current medical problems, enhance mobility and energy, and promote health and longevity. Further discussion of this issue is needed when patients report external pressure to have the surgery (which is not a good reason to have the surgery), an overemphasis on physical appearance, and unrealistic ideas regarding the changes that will come about in their lives following weight loss. If the reason for having the surgery is unrealistic and fails to match what the surgery can achieve, patients are at risk for possible mood issues and for noncompliance after surgery. Patients are also asked their goal weight and anticipated time frame for achieving that goal, which provides additional information about realistic expectations. Expectations must be realistic for patients to be satisfied with the surgery otherwise mood changes can occur eg. Depression, and it would be better not to have the surgery.
    Patients have to understand the lifestyle changes required after surgery and must be psychologically assessed to ascertain whether they can make these changes.
    Surgery is a drastic choice after all else has failed and psychological support from family and friends is required – it is not an easy option!

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    Mr Niruben Rajasagaram

    Bariatric (Obesity) Surgeon, General Surgeon, Upper GI Surgeon (Abdominal)

    Niruben Rajasagaram - Consultant Bariatric, Oesophagogastric & General Surgeon. He specialises in benign/malignant conditions that affect the upper gastrointestinal tract, as well as obesity and … View Profile

    I agree that the whole psychology of eating is important as part of a patients initial assessment in terms of getting an understanding of the behavioural patterns that a patient exhibits. In most circumstances this can be ascertained during the initial consultation with a bariatric surgeon. In saying this i regularly do send my patients to be seen by a psychologist as managing this aspect of a patients weight loss journery needs to be addresed. 

    In regards to your initial question eating disorders would be one of the main issues we would want to pick up prior to a patient undergoing any weight loss surgery. 

    The whole notion of surgery being an extreme choice needs to change. Obesity is robbing people of years in terms of life expectancy. No one ever says surgery is a drastic choice when it comes to cancer; as everybody wants the cancer gone. I am not saying everybody should have surgery but lets not keep saying it should be a last resort. The overall complication for all the main weight loss procedures done in australia is about 2%. Most people go home between 1-5 days depending on the type of surgery they have undergone. Majority of this s done laparoscopically (one or two extra 1cm cuts compared to having your gall bladder or appendix removed with key hole surgery )There is great joy that i see in my patients (and i feel myself) when they start winning the battle against this disease that they have been strugling with for years.

    I have to say i would be very ressistant to offering a weght loss procedure to anyone who is beig pressured externally. There has to be a degree of insight in an individual to know that they need to take charge of this disease. 

    Kind regrads

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    Dr Katie Richard

    Clinical Psychologist, Psychologist

    I'm a USA-trained clinical psychologist with over 15 years post-doctoral clinical experience working primarily in the areas of Binge Eating Disorder, Weight Management and Nicotine … View Profile

    There are several psychological conditions that can cause negative outcomes to bariatric surgery.The first one is having a “food addiction” which is formally known as Binge Eating Disorder. The second one is related to Mood Disorders (including Premenstrual Dysphoric Disorder, Major Depressive Disorder and the like)The third one is Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) as the hyperactivity is not the typical restlessness but the “hyperactivity” of binge/overeating. Post Traumatic Stress Disorder is commonly related to problems with weight loss as the “fat as protection from further assault” is a common barrier to weight loss. The above psychological disorders can be caused by any trauma including sexual, physical abuse and neglect but also emotional abuse (e.g. bullying).

    They need to be treated prior to bariatric surgery (which may even make bariatric surgery redundant). ADD and ADHD can be treated with Strattera (Atomoxetine) or Adderal (Vyvanse/lisdexamphetamine) which also reduces appetite.

    If you're still considering bariatric surgery, keep in mind it's suitable only for those with a BMI of 40 kg/m2 or more and those who have comorbid conditions (i.e. health problems). The positives of bariatric surgery is that it gives a sense of feeling fuller sooner; it also tends to lead to improved body image as well as improved quality of life. Having surgery also doesn't mean you don't have to change your diet and exercise. It simply makes “dieting” easier. However, it doesn't lead to an end of the need to cope by eating which means that even with a restricted stomach “cheat” either by eating large amounts, vomiting and then eating again or by 'grazing.' This, unfortunately, then leads to weight regain. Therefore, surgery unfortunately can help, but is not the answer. Firstly, food cravings are unlikely to diminish. Rapid and loss of large amount of weight can also lead to loose skin and gallstone formation.

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