Bariatric Patients and Weight Loss Surgery Maintenance

Bariatric Patients Bariatric Patients and Weight Loss and Weight Loss

Surgery Surgery Maintenance Maintenance

Bariatric Patients Bariatric Patients and Weight Loss and Weight Loss

Surgery Surgery Maintenance Maintenance

A Brief Psychosocial A Brief Psychosocial ConsiderationConsideration

Dr. Michael J. Alicea, Ed.D., MSW, MSDr. Michael J. Alicea, Ed.D., MSW, MSSouth Miami HospitalSouth Miami Hospital

February 27, 2014February 27, 2014

A Brief Psychosocial A Brief Psychosocial ConsiderationConsideration

Dr. Michael J. Alicea, Ed.D., MSW, MSDr. Michael J. Alicea, Ed.D., MSW, MSSouth Miami HospitalSouth Miami Hospital


BackgroundBackground BackgroundBackground

It is said that having weight loss It is said that having weight loss surgery (WLS) is like being born surgery (WLS) is like being born into a newly created body. into a newly created body.

It is said that having weight loss It is said that having weight loss surgery (WLS) is like being born surgery (WLS) is like being born into a newly created body. into a newly created body.

Bocchieri, Meana & Fisher, 2007

BackgroundBackgroundBackgroundBackground

Patients must learn to (all over again):Patients must learn to (all over again):

EatEat

DrinkDrink

WalkWalk

SitSit

Stand Stand

Dress Themselves Dress Themselves

Patients must learn to (all over again):Patients must learn to (all over again):

EatEat

DrinkDrink

WalkWalk

SitSit

Stand Stand

Dress Themselves Dress Themselves

Ogden & Clementi, 2010; Throsby, 2008

Patients must relearn key social skills Patients must relearn key social skills and assert themselves into new roles by and assert themselves into new roles by relating in new ways to:relating in new ways to:

Patients must relearn key social skills Patients must relearn key social skills and assert themselves into new roles by and assert themselves into new roles by relating in new ways to:relating in new ways to:

Attitudes about Attitudes about BariatricsBariatrics


• FriendsFriends • ParentsParents• SiblingsSiblings • ColleaguesColleagues• MentorsMentors • BossesBosses• MatesMates • Potential MatesPotential Mates



• Many celebrate the day of weight loss Many celebrate the day of weight loss surgery as a new birthdaysurgery as a new birthday.

• Before they know it, they step into a Before they know it, they step into a new life with a new identity.new life with a new identity.

• Many celebrate the day of weight loss Many celebrate the day of weight loss surgery as a new birthdaysurgery as a new birthday.

• Before they know it, they step into a Before they know it, they step into a new life with a new identity.new life with a new identity.

Bocchieri, Meana & Fisher, 2007

WLS DefinedWLS DefinedWLS DefinedWLS Defined

As either not losing 50% excess body As either not losing 50% excess body weight or regaining that same weight weight or regaining that same weight after having lost it. If weight loss is not after having lost it. If weight loss is not permanent, the surgery has failed. permanent, the surgery has failed.

The primary reason cited for failure is The primary reason cited for failure is non-compliancenon-compliance

As either not losing 50% excess body As either not losing 50% excess body weight or regaining that same weight weight or regaining that same weight after having lost it. If weight loss is not after having lost it. If weight loss is not permanent, the surgery has failed. permanent, the surgery has failed.

The primary reason cited for failure is The primary reason cited for failure is non-compliancenon-compliance

Elkins et al., 2005; Reedy, 2009

Social Implications Social Implications Social Implications Social Implications

Weight Loss Surgery (WLS) is not the Weight Loss Surgery (WLS) is not the panacea it panacea it was once thought to be.was once thought to be.

Between 20% and 40% of WLS patients Between 20% and 40% of WLS patients begin regaining weight by 24 months begin regaining weight by 24 months post surgery.post surgery.

Weight Loss Surgery (WLS) is not the Weight Loss Surgery (WLS) is not the panacea it panacea it was once thought to be.was once thought to be.

Between 20% and 40% of WLS patients Between 20% and 40% of WLS patients begin regaining weight by 24 months begin regaining weight by 24 months post surgery.post surgery.

Boeka, Prentice-Dunn & Lokken, 2010; Elkins, Whitfield, Marcus, Symmonds, Rodrigues & Cook, 2005

Psychological Psychological Implications Implications Psychological Psychological Implications Implications

The physical aspects of WLS are well The physical aspects of WLS are well understood, but the psychological understood, but the psychological aspects of WLS are not.aspects of WLS are not.

It is vital that the psychological It is vital that the psychological processes beyond surgery are well processes beyond surgery are well understood.understood.

It is important to note that the It is important to note that the psychological processes involved in WLS psychological processes involved in WLS involve not just the patient, but their involve not just the patient, but their entire social community, making this a entire social community, making this a psychosocial problem.psychosocial problem.

The physical aspects of WLS are well The physical aspects of WLS are well understood, but the psychological understood, but the psychological aspects of WLS are not.aspects of WLS are not.

It is vital that the psychological It is vital that the psychological processes beyond surgery are well processes beyond surgery are well understood.understood.

It is important to note that the It is important to note that the psychological processes involved in WLS psychological processes involved in WLS involve not just the patient, but their involve not just the patient, but their entire social community, making this a entire social community, making this a psychosocial problem.psychosocial problem.Davin & Taylor, 2009; Maggard, Shugarman,

Suttorp, Maglione, Sugerman, Surgerman, Livingston, 2005

Psychological Psychological Implications Implications Psychological Psychological Implications Implications

Success in WLS requires that patients Success in WLS requires that patients make behavioral and psychosocial make behavioral and psychosocial changes.changes.

Those whose development closely aligns Those whose development closely aligns with psychosocial theory have a higher with psychosocial theory have a higher levels of psychosocial adaptation.levels of psychosocial adaptation.

A higher level of psychosocial A higher level of psychosocial adaptation is correlated with higher adaptation is correlated with higher levels of social connectedness and levels of social connectedness and positive health outcomes.positive health outcomes.

Success in WLS requires that patients Success in WLS requires that patients make behavioral and psychosocial make behavioral and psychosocial changes.changes.

Those whose development closely aligns Those whose development closely aligns with psychosocial theory have a higher with psychosocial theory have a higher levels of psychosocial adaptation.levels of psychosocial adaptation.

A higher level of psychosocial A higher level of psychosocial adaptation is correlated with higher adaptation is correlated with higher levels of social connectedness and levels of social connectedness and positive health outcomes.positive health outcomes.

Erikson, 1963; Wilt, Cox & McAdams, 2010; Martikainen, Bartley & Lahelma, 2002; Wilt et

al, 2010

Literature ReviewLiterature ReviewLiterature ReviewLiterature Review

According to the National Health and According to the National Health and Nutrition Examination Survey (NHANES) Nutrition Examination Survey (NHANES) program conducted in 2007-2008.program conducted in 2007-2008.

68% of adults in the United States are 68% of adults in the United States are overweight or obese; defined as body overweight or obese; defined as body mass index (BMI) mass index (BMI) ˃25˃25..

5% are morbidly obese with a BMI of 5% are morbidly obese with a BMI of over 40 (Typically qualify for obesity over 40 (Typically qualify for obesity surgery).surgery).

According to the National Health and According to the National Health and Nutrition Examination Survey (NHANES) Nutrition Examination Survey (NHANES) program conducted in 2007-2008.program conducted in 2007-2008.

68% of adults in the United States are 68% of adults in the United States are overweight or obese; defined as body overweight or obese; defined as body mass index (BMI) mass index (BMI) ˃25˃25..

5% are morbidly obese with a BMI of 5% are morbidly obese with a BMI of over 40 (Typically qualify for obesity over 40 (Typically qualify for obesity surgery).surgery).

C.L., Ogden & Carroll, 2010; Shah, Simha & Garg, 2006; Echols, 2010; Stewart et al, 2010

Literature ReviewLiterature ReviewLiterature ReviewLiterature Review

The World Health Organization coined a The World Health Organization coined a term “term “GlobesityGlobesity” with respect to this ” with respect to this worldwide epidemic.worldwide epidemic.

The World Health Organization coined a The World Health Organization coined a term “term “GlobesityGlobesity” with respect to this ” with respect to this worldwide epidemic.worldwide epidemic.

World Health Organization, 2003, p.1

ComorbiditiesComorbidities ComorbiditiesComorbidities

The prevalence of morbid obesity has The prevalence of morbid obesity has increased twice as fast as the increased twice as fast as the prevalence of obesity and is associated prevalence of obesity and is associated

with a number of comorbiditieswith a number of comorbidities..

The prevalence of morbid obesity has The prevalence of morbid obesity has increased twice as fast as the increased twice as fast as the prevalence of obesity and is associated prevalence of obesity and is associated

with a number of comorbiditieswith a number of comorbidities..

Echols, 2010; Mehler, Lasater & Padilla, 2003; Stewart et al, 2010

Comorbidities IncludesComorbidities Includes Comorbidities IncludesComorbidities Includes

Type 3 DiabetesType 3 Diabetes

Coronary Heart DiseaseCoronary Heart Disease

HypertensionHypertension

Sleep ApneaSleep Apnea

Gallbladder DiseaseGallbladder Disease

Certain Types of CancerCertain Types of Cancer

Type 3 DiabetesType 3 Diabetes

Coronary Heart DiseaseCoronary Heart Disease

HypertensionHypertension

Sleep ApneaSleep Apnea

Gallbladder DiseaseGallbladder Disease

Certain Types of CancerCertain Types of Cancer

Morbid Obesity Morbid Obesity Morbid Obesity Morbid Obesity

Morbid obesity shortens life expectancy Morbid obesity shortens life expectancy and is one of the biggest threats to and is one of the biggest threats to health and well-being in the world health and well-being in the world today.today.

Diet, exercise, psychological and Diet, exercise, psychological and pharmacological therapies have not pharmacological therapies have not been effective in treating morbid been effective in treating morbid obesity.obesity.

Morbid obesity shortens life expectancy Morbid obesity shortens life expectancy and is one of the biggest threats to and is one of the biggest threats to health and well-being in the world health and well-being in the world today.today.

Diet, exercise, psychological and Diet, exercise, psychological and pharmacological therapies have not pharmacological therapies have not been effective in treating morbid been effective in treating morbid obesity.obesity.

World Health Organization, 2003

Obesity Surgery Failure Obesity Surgery Failure Obesity Surgery Failure Obesity Surgery Failure

Unfortunately, obesity surgery failure Unfortunately, obesity surgery failure rates are rising with the increased rates are rising with the increased numbers of surgeries performed.numbers of surgeries performed.

Unfortunately, obesity surgery failure Unfortunately, obesity surgery failure rates are rising with the increased rates are rising with the increased numbers of surgeries performed.numbers of surgeries performed.

Elkins et al., 2005; Pontiroli et al., 2007; Sarwer et al., 2008; Stewart et al., 2010

Literature Review Literature Review LimitationsLimitations

Literature Review Literature Review LimitationsLimitations

Success after bariatric surgery requires Success after bariatric surgery requires behavioral modification.behavioral modification.

There is very little information on the There is very little information on the psychological and social-relational psychological and social-relational changes and the resulting adjustments changes and the resulting adjustments after WLS.after WLS.

One misconception is that obesity is a One misconception is that obesity is a ““cheatcheat” or is taking the “” or is taking the “easy way outeasy way out” ” of an obesity problem, rather than of an obesity problem, rather than losing the weight without the aid of losing the weight without the aid of surgery.surgery.

Success after bariatric surgery requires Success after bariatric surgery requires behavioral modification.behavioral modification.

There is very little information on the There is very little information on the psychological and social-relational psychological and social-relational changes and the resulting adjustments changes and the resulting adjustments after WLS.after WLS.

One misconception is that obesity is a One misconception is that obesity is a ““cheatcheat” or is taking the “” or is taking the “easy way outeasy way out” ” of an obesity problem, rather than of an obesity problem, rather than losing the weight without the aid of losing the weight without the aid of surgery.surgery.Boeka, 2009; Elkins et al., 2005; Zalesin, et al, 2010; Davis-Berman & Berman, 2009; Grimaldi & Van Etten,

2010

Psychosocial FactorsPsychosocial FactorsPsychosocial FactorsPsychosocial Factors

A higher level of psychosocial adaptation is correlated A higher level of psychosocial adaptation is correlated with high levels of social connectedness and positive with high levels of social connectedness and positive health outcomes.health outcomes.

Mediating the effects of social structural factors on Mediating the effects of social structural factors on individual health outcomes.individual health outcomes.

Conditioned and modified by social structures and Conditioned and modified by social structures and contexts in which they exist.contexts in which they exist.

A higher level of psychosocial adaptation is correlated A higher level of psychosocial adaptation is correlated with high levels of social connectedness and positive with high levels of social connectedness and positive health outcomes.health outcomes.

Mediating the effects of social structural factors on Mediating the effects of social structural factors on individual health outcomes.individual health outcomes.

Conditioned and modified by social structures and Conditioned and modified by social structures and contexts in which they exist.contexts in which they exist.Martikainen et al., 2002; Wilt et al., 2010

NOTENOTENOTENOTE

““Psychosocial adjustment can influence Psychosocial adjustment can influence health through psychobiological health through psychobiological processes or through behavior processes or through behavior modifications in lifestyles.”modifications in lifestyles.”

““Psychosocial adjustment can influence Psychosocial adjustment can influence health through psychobiological health through psychobiological processes or through behavior processes or through behavior modifications in lifestyles.”modifications in lifestyles.”

Martikainen et al., 2002

Literature Review: Literature Review: Key Word SearchKey Word Search

Literature Review: Literature Review: Key Word SearchKey Word Search

Psychosocial adjustments after WLP.Psychosocial adjustments after WLP.

Identity transformations and weight Identity transformations and weight loss.loss.

Identity formation, and;Identity formation, and;

Physiological effects of WLS.Physiological effects of WLS.

Psychosocial adjustments after WLP.Psychosocial adjustments after WLP.

Identity transformations and weight Identity transformations and weight loss.loss.

Identity formation, and;Identity formation, and;

Physiological effects of WLS.Physiological effects of WLS.

International Journal of Epidemiology, 2012

Search EnginesSearch EnginesSearch EnginesSearch Engines

Health and Psychosocial InstrumentsHealth and Psychosocial Instruments

Academic Search CompleteAcademic Search Complete

CINAHLCINAHL

Plus with Full TextPlus with Full Text

Education Research CompleteEducation Research Complete

MEDLINE with Full TextMEDLINE with Full Text

Mental Measurements YearbookMental Measurements Yearbook

PsycARTICLESPsycARTICLES

PsycBOOKSPsycBOOKS

PsycCRITIQUESPsycCRITIQUES

PsycEXTRAPsycEXTRA

PsycINFOPsycINFO

SocINDEXSocINDEX

Health and Psychosocial InstrumentsHealth and Psychosocial Instruments

Academic Search CompleteAcademic Search Complete

CINAHLCINAHL

Plus with Full TextPlus with Full Text

Education Research CompleteEducation Research Complete

MEDLINE with Full TextMEDLINE with Full Text

Mental Measurements YearbookMental Measurements Yearbook

PsycARTICLESPsycARTICLES

PsycBOOKSPsycBOOKS

PsycCRITIQUESPsycCRITIQUES

PsycEXTRAPsycEXTRA

PsycINFOPsycINFO

SocINDEXSocINDEX

HypothesisHypothesisHypothesisHypothesis

Since there is sufficient evidence in the Since there is sufficient evidence in the literature review to predict that there literature review to predict that there are changes in identity that accompany are changes in identity that accompany large weight losses, it is (in theory) large weight losses, it is (in theory) possible that these changes happen possible that these changes happen through a developmental process.through a developmental process.

It is also possible that a failure to It is also possible that a failure to successfully pass through these successfully pass through these developmental changes will correlate developmental changes will correlate with weight regain.with weight regain.

Since there is sufficient evidence in the Since there is sufficient evidence in the literature review to predict that there literature review to predict that there are changes in identity that accompany are changes in identity that accompany large weight losses, it is (in theory) large weight losses, it is (in theory) possible that these changes happen possible that these changes happen through a developmental process.through a developmental process.

It is also possible that a failure to It is also possible that a failure to successfully pass through these successfully pass through these developmental changes will correlate developmental changes will correlate with weight regain.with weight regain.

Finfgeld, 2004; Granberg, 2001; Schafer & Ferraro, 2011; Throsby, 2008

Existing TheoryExisting TheoryExisting TheoryExisting Theory

A growing number of researchers are A growing number of researchers are working with the idea that identity working with the idea that identity change is necessary for permanent change is necessary for permanent weight lossweight loss

Understanding the specific processes that Understanding the specific processes that promote identity change is another promote identity change is another matter.matter.

It is important to understand that It is important to understand that changes in identity are part of lasting changes in identity are part of lasting health behavior changes, but health behavior changes, but understanding how identity is changes is understanding how identity is changes is at the heart of the issue.at the heart of the issue.

A growing number of researchers are A growing number of researchers are working with the idea that identity working with the idea that identity change is necessary for permanent change is necessary for permanent weight lossweight loss

Understanding the specific processes that Understanding the specific processes that promote identity change is another promote identity change is another matter.matter.

It is important to understand that It is important to understand that changes in identity are part of lasting changes in identity are part of lasting health behavior changes, but health behavior changes, but understanding how identity is changes is understanding how identity is changes is at the heart of the issue.at the heart of the issue.

Bocchieri et al., 2007; Epiphanious & Ogden, 2010b; Granberg, 2001; 2011; Johnson, 1990; Ogden & Hills, 2008; Throsby, 2008

Phenomenon IdentifiedPhenomenon IdentifiedPhenomenon IdentifiedPhenomenon Identified

Researched the core phenomenon into Researched the core phenomenon into what identity restructuring and its what identity restructuring and its effect on weight loss maintenance.effect on weight loss maintenance.

Why WLS is failing for a significant Why WLS is failing for a significant number of patients.number of patients.

Failure estimates from 20% to 40% of Failure estimates from 20% to 40% of patients who have WLS.patients who have WLS.

Researched the core phenomenon into Researched the core phenomenon into what identity restructuring and its what identity restructuring and its effect on weight loss maintenance.effect on weight loss maintenance.

Why WLS is failing for a significant Why WLS is failing for a significant number of patients.number of patients.

Failure estimates from 20% to 40% of Failure estimates from 20% to 40% of patients who have WLS.patients who have WLS.

Elkins et al., 2005; Livhits et al., 2010; Pontiroli et al., 2007

WLS Failure WLS Failure ConsequencesConsequencesWLS Failure WLS Failure

ConsequencesConsequencesMorbid obesity results in lower health Morbid obesity results in lower health related quality of life.related quality of life.Severe social and economic Severe social and economic consequences to those who are consequences to those who are morbidly obese.morbidly obese.Higher rates of :Higher rates of :

DepressionDepressionAnxietyAnxietyPersonal RejectionPersonal RejectionDiscriminationDiscriminationGeneral Public PerceptionsGeneral Public Perceptions

Morbid obesity results in lower health Morbid obesity results in lower health related quality of life.related quality of life.Severe social and economic Severe social and economic consequences to those who are consequences to those who are morbidly obese.morbidly obese.Higher rates of :Higher rates of :

DepressionDepressionAnxietyAnxietyPersonal RejectionPersonal RejectionDiscriminationDiscriminationGeneral Public PerceptionsGeneral Public PerceptionsGreenberg, 2003; Hall, 2010; Herdon, 2005

WLS DilemmaWLS DilemmaWLS DilemmaWLS Dilemma

Weight loss maintenance in general is a problem Weight loss maintenance in general is a problem that has yet to be solved by either medicine or that has yet to be solved by either medicine or psychology.psychology.

That there is a “That there is a “curecure” for obesity, despite ” for obesity, despite volumes of claims to the contrary, to this date, volumes of claims to the contrary, to this date, no surgery, no medicine, no psychological no surgery, no medicine, no psychological therapy, has been able to adequately and therapy, has been able to adequately and permanently address this global problem.permanently address this global problem.

Many who lose weight regain it because they Many who lose weight regain it because they think that in the process of losing the weight, think that in the process of losing the weight, they have been cured of obesity and do not they have been cured of obesity and do not need to attend to it any longerneed to attend to it any longer..

Weight loss maintenance in general is a problem Weight loss maintenance in general is a problem that has yet to be solved by either medicine or that has yet to be solved by either medicine or psychology.psychology.

That there is a “That there is a “curecure” for obesity, despite ” for obesity, despite volumes of claims to the contrary, to this date, volumes of claims to the contrary, to this date, no surgery, no medicine, no psychological no surgery, no medicine, no psychological therapy, has been able to adequately and therapy, has been able to adequately and permanently address this global problem.permanently address this global problem.

Many who lose weight regain it because they Many who lose weight regain it because they think that in the process of losing the weight, think that in the process of losing the weight, they have been cured of obesity and do not they have been cured of obesity and do not need to attend to it any longerneed to attend to it any longer..Kroger & Green, 1996; Pulkkinen & Kokko, 2000; Wilt et

al., 2010

Future Research Future Research Study on WLSStudy on WLS

Future Research Future Research Study on WLSStudy on WLS

Issues related to patient behavioral Issues related to patient behavioral compliance.compliance.

Addressing compliance and motivational Addressing compliance and motivational issues to increase further issues to increase further understanding of WLS issues.understanding of WLS issues.

Researching long term psychosocial Researching long term psychosocial impacts of WLS (Longitudinal Study).impacts of WLS (Longitudinal Study).

Researching practice implications for Researching practice implications for creating programs to assist with creating programs to assist with psychosocial adjustments after WLS.psychosocial adjustments after WLS.

Issues related to patient behavioral Issues related to patient behavioral compliance.compliance.

Addressing compliance and motivational Addressing compliance and motivational issues to increase further issues to increase further understanding of WLS issues.understanding of WLS issues.

Researching long term psychosocial Researching long term psychosocial impacts of WLS (Longitudinal Study).impacts of WLS (Longitudinal Study).

Researching practice implications for Researching practice implications for creating programs to assist with creating programs to assist with psychosocial adjustments after WLS.psychosocial adjustments after WLS.

WLS: Final WordWLS: Final WordWLS: Final WordWLS: Final WordIts important to understand that WLS does not Its important to understand that WLS does not happen in a social vacuum.happen in a social vacuum.

A patient’s life revolve around social systems that A patient’s life revolve around social systems that include family members, significant others, co-include family members, significant others, co-workers and friends who are equally affected by the workers and friends who are equally affected by the WLS.WLS.

For some patient’s, no amount of weight loss will For some patient’s, no amount of weight loss will change how they see themselves.change how they see themselves.

If the public’s perception of obesity are ever going to If the public’s perception of obesity are ever going to change it will be at least in part be through increased change it will be at least in part be through increased understanding and facilitating a compassion for understanding and facilitating a compassion for people who suffer with this disease.people who suffer with this disease.

Its important to understand that WLS does not Its important to understand that WLS does not happen in a social vacuum.happen in a social vacuum.

A patient’s life revolve around social systems that A patient’s life revolve around social systems that include family members, significant others, co-include family members, significant others, co-workers and friends who are equally affected by the workers and friends who are equally affected by the WLS.WLS.

For some patient’s, no amount of weight loss will For some patient’s, no amount of weight loss will change how they see themselves.change how they see themselves.

If the public’s perception of obesity are ever going to If the public’s perception of obesity are ever going to change it will be at least in part be through increased change it will be at least in part be through increased understanding and facilitating a compassion for understanding and facilitating a compassion for people who suffer with this disease.people who suffer with this disease.

Thank YouThank YouThank YouThank You

Dr. Michael J. Alicea, Ed.D., MSW, Dr. Michael J. Alicea, Ed.D., MSW, MSMS

South Miami HospitalSouth Miami Hospital


Dr. Michael J. Alicea, Ed.D., MSW, Dr. Michael J. Alicea, Ed.D., MSW, MSMS

South Miami HospitalSouth Miami Hospital


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Bariatric Patients and Weight Loss Surgery Maintenance