Preparing forWeight Loss Surgery:

Therapist Guide

Robin F. AppleJames Lock

Rebecka Peebles

OXFORD UNIVERSITY PRESS

Preparing for Weight Loss Surgery

--

David H. Barlow, PhD

Anne Marie Albano, PhD

Jack M. Gorman, MD

Peter E. Nathan, PhD

Bonnie Spring, PhD

Paul Salkovskis, PhD

G. Terence Wilson, PhD

John R. Weisz, PhD

Preparing for Weight Loss SurgeryT h e r a p i s t G u i d e

Robin F. Apple James Lock Rebecka Peebles

1

1Oxford University Press, Inc., publishes works that furtherOxford Universitys objective of excellencein research, scholarship, and education.

Oxford New YorkAuckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto

With oces inArgentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright by Oxford University Press, Inc.

Published by Oxford University Press, Inc. Madison Avenue, New York, New York

www.oup.com

Oxford is a registered trademark of Oxford University Press

All rights reserved. No part of this publication may be reproduced,stored in a retrieval system, or transmitted, in any form or by any means,electronic, mechanical, photocopying, recording, or otherwise,without the prior permission of Oxford University Press.

Library of Congress Cataloging-in-Publication DataApple, Robin F. (Robin Faye)Preparing for weight loss surgery : therapist guide / Robin F. Apple, James Lock, and Rebecka Peebles.

p. cm.(Treatments that work)Includes bibliographical references.ISBN- ----; ---- (pbk.) ISBN ---; --- (pbk.). ObesitySurgery. . Weight loss. I. Lock, James. II. Peebles, Rebecka. III. Title. IV. Series.RD.A .'3dc

Printed in the United States of Americaon acid-free paper

Stunning developments in health care have taken place over the last sev-

eral years, but many of our widely accepted interventions and strategies

in mental health and behavioral medicine have been brought into ques-

tion by research evidence as not only lacking benet but, perhaps, induc-

ing harm. Other strategies have been proven eective using the best cur-

rent standards of evidence, resulting in broad-based recommendations

to make these practices more available to the public. Several recent devel-

opments are behind this revolution. First, we have arrived at a much

deeper understanding of pathology, both psychological and physical, which

has led to the development of new, more precisely targeted interventions.

Second, our research methodologies have improved substantially, such

that we have reduced threats to internal and external validity, making the

outcomes more directly applicable to clinical situations. Third, govern-

ments around the world and health care systems and policymakers have

decided that the quality of care should improve, that it should be evi-

dence based, and that it is in the publics interest to ensure that this hap-

pens (Barlow, ; Institute of Medicine, ).

Of course, the major stumbling block for clinicians everywhere is the ac-

cessibility of newly developed evidence-based psychological interven-

tions. Workshops and books can go only so far in acquainting responsible

and conscientious practitioners with the latest behavioral health care prac-

tices and their applicability to individual patients. This new series, Treat-

mentsThatWork, is devoted to communicating these exciting new in-

terventions to clinicians on the front lines of practice.

The manuals and workbooks in this series contain step-by-step detailed

procedures for assessing and treating specic problems and diagnoses.

But this series also goes beyond the books and manuals by providing an-

About TreatmentsThatWork

cillary materials that will approximate the supervisory process in assisting

practitioners in the implementation of these procedures in their practice.

In our emerging health care system, the growing consensus is that evidence-

based practice oers the most responsible course of action for the health

professional. All behavioral health care clinicians deeply desire to pro-

vide the best possible care for their patients. In this series, our aim is to

close the dissemination and information gap and make that possible.

This therapist guide and companion workbook for clients addresses psy-

chological and behavioral aspects of weight loss surgery for the morbidly

obese. This approach has been shown to be highly eective as a treatment

of last resort for substantially obese individuals who are subject to the

dramatically increased risk factors to health associated with this condi-

tion. And indeed, the rapid growth of obesity in North America, and

much of the developed world, has been referred to by most health care

professionals as an epidemic. Illnesses and conditions exacerbated by

obesity cover all of the major organs and functional systems within the

body, including the development of cancer in various organs. The oc-

currence of most of these obesity-related conditions, particularly type II

diabetes, is rising dramatically. But these surgical procedures are not

without risks, as has been detailed in the scientic literature as well as the

popular press. Thus, most surgeons and health care professionals insist

on accompanying psychological treatment to prepare patients for sur-

gery and to assist them in complying with their post-operative routine.

The patient who is not properly prepared for surgery or does not under-

stand the surgical procedures will be bitterly disappointed and likely

noncompliant following surgery. Similarly, the patient who does not

comply with the recommended post-surgery regimen will fail to main-

tain any weight loss and will put themselves at further physical risk.

The approaches detailed in this treatment program explain the nature of

morbid obesity, then go on to describe, in a very user-friendly manner,

the most up-to-date procedures for dealing with attitude, emotional,

and behavioral factors associated with successfully transitioning to a very

dierent lifestyle.

David H. Barlow, Editor-in-Chief,

TreatmentsThatWork

Boston, Massachusetts

vi

Chapter Introductory Information for Therapists

Chapter Understanding Your Patients Eating Behavior

Chapter Helping Your Patient Keep Track of

His or Her Eating

Chapter Educating Your Patient About Weighing Behaviors

Chapter Pleasurable Alternative Activities

Chapter Challenging Eating Situations:

People, Places, and Foods

Chapter Teaching Your Patient About Problem Solving

and Cognitive Restructuring

Chapter Working With Your Patient on Body Image Issues

Chapter Congratulations! Your Patient Is on the Way

to the O.R.

Chapter What Happens After Surgery?

References

About the Authors

Contents

This page intentionally left blank

Preparing for Weight Loss Surgery

This page intentionally left blank

Background Information and Purpose of This Program

Obesity has quickly become an American epidemic. Patients suering

from signicant overweight often have to contend with a lifetime of sig-

nicant co-morbidities, social stigma, and lower quality of life. Many ap-

proaches have been tried to combat obesity and its multiple co-morbid

medical illnesses, including pharmacotherapy, psychotherapy, diet, exer-

cise, and other lifestyle change. Weight loss surgery has been used as a

modality for many years but has been increasingly recognized as a durable

tool for weight management over the last decade. Because the success of

traditional diet programs and other therapies has been sporadic and usually

short term, and recent literature has shown signicantly more weight

loss sustained over time in patients who undergo surgery, patients have

been approaching their health care teams about the option of surgery

and asking to learn more.

Table 1.1 oers a detailed description of the dierent types of weight

loss surgery procedures.

Research Support for CBT and Changing Eating Behaviors

Although systematic research has yet to be conducted on the specic

utility of psychotherapy for patients undergoing weight loss surgery, there

is a substantial body of research on related conditions (bulimia nervosa

and binge eating disorder) that suggests cognitive behavioral therapy

(CBT) may be useful.

1

Chapter 1 Introductory Information for Therapists

2Table 1.1 Surgical Procedures

Name of Procedure Description

Restrictive Vertical Banded In this procedure, the stomach is divided by a line ofProcedures Gastroplasty (VBG) staples to produce a new gastric pouch, much smaller

only about an ounce in size. The outlet of the new pouchis similarly small, extending about mm in diame-ter. This outlet empties into a section of old, larger stom-ach, which then empties as it used to into the small intes-tine. The surgeon usually reinforces the outlet with meshor GORE-TEX to reinforce it. The VBG may be per-formed with an open incision or laparoscopically.

Siliastic Ring Vertical A variant of the gastroplasty described above. Here, the Gastroplasty stomach is again divided by a row of staples to produce a

small gastric pouch. In this procedure, the new, smalleroutlet of the new gastric pouch is reinforced by a siliconeband to produce a narrow exit into the old section ofstomach, as detailed above.

Laparoscopic Adjustable This is a newer surgery, known as the LAP-BAND, ap-Silicone Gastric proved by the U.S. Food and Drug AdministrationBanding (LASGB) in . It is only performed laparoscopically, as its name

implies. Here, a new gastric pouch is formed with sta-ples, as with the gastroplasty, but the band surroundingthe outlet from the new pouch into the old part of thestomach is adjustable. This is achieved because the bandis connected to a reservoir that is implanted under theskin. The surgeon can then inject saline (saltwater) intothe reservoir, or remove it from the reservoir, in an out-patient oce setting. This means that your surgeon canthen tighten or loosen the band, adjusting the size of thegastric outlet.

Restrictive Roux-en-Y Gastric The RYGB is the procedure most commonly performedMalabsorptive Bypass (RYGB) and accepted. It involves creating a small (13 oz) gas-

tric pouch by either separating or stapling the stomach.This pouch then drains via a narrow passageway to themiddle part of the small intestine, the jejunum. Thisbypasses the duodenum, which food would normallytraverse before arriving at the jejunum. The older portionof stomach then goes unused and maintains its normalconnection to the duodenum and the rst half of thejejunum. This end of the jejunum is then attached to anew small intestine created by the procedure above.This creates the Y referred to in the name of the proce-dure. This redirection of the small intestine creates amalabsorptive component to the procedure, in

Aaron Becks seminal work on CBT for depression was modied by Fair-

burn and colleagues for use with patients with bulimia nervosa (BN)

(Fairburn, ). CBT has been tested in numerous controlled studies

and has been found to be the most eective psychotherapeutic approach

to the treatment of BN. CBT has been found more eective than delayed

treatment, nondirective therapy, pill placebo, manualized psychodynamic

therapy (supportive-expressive), stress management, and antidepressant

treatment. Becks work has since been further modied for use with pa-

tients who compulsively overeat or binge, such as many of those who

have developed obesity.

The main focus of CBT, when working with overweight or obese indi-

viduals, is to address the negative thoughts that cause and maintain the

behaviors associated with being overweight. Interventions are designed

3

Name of Procedure Description

addition to the restrictive gastric pouch. RYGB may beperformed with an open incision or laparoscopically.

Biliopancreatic Diversion This surgery is considered more technically dicult(BPD) and is less commonly performed. It involves a gastrec-

tomy that is considered subtotal, meaning that it leavesa much larger gastric pouch compared with the other op-tions described above. The small intestine is divided atthe level of the ileum (the third and nal portion of thesmall intestine), and then the ileum is connected directlyto this midsize gastric pouch. The remaining part of thesmall intestine is then attached to the ileum as well. Thisprocedure thereby bypasses part of the stomach and theentire duodenum and jejunum, leaving only a small sec-tion of small intestine for absorption.

Biliopancreatic Diversion BPDDS is a variation of the BPD that preserves the rstwith Duodenal Switch portion of the duodenum, the rst section of the (BPDDS) small intestine.

Jejunoileal Bypass This surgery bypasses large portions of the small intes-tine; it is no longer recommended in the United Statesand Europe due to an unacceptably high rate of compli-cations and mortality.

to combat these cognitive distortions in order to produce lasting change.

In addition, more generally, CBT has been used to help with depressed

mood, anxiety problems, and low self-esteem, all of which are common

to obese patients, as well as to those contemplating surgery or recover-

ing from it.

In the last few years, increasing interest in treating a subset of BN pa-

tients who binge eat but do not purge (binge eating disorder or BED)

has arisen. It appears that despite considerable symptomatic overlap in

terms of both behavior (binge eating) and psychological concerns (low

self-esteem and weight and shape concerns) there is a growing consen-

sus that they are a distinct diagnosis. The most eective treatments for

BED are similar to those eective for BN, particularly CBT. Generally

CBT has the most evidence to support its use, and CBT-based self-help

manuals may be even more eective in those suering from BED com-

pared to those with BN (Hay et al., ).

Although patients with BN and BED dier from typical bariatric sur-

gery candidates, there is convergence in some important areas that sup-

ports the use of therapeutic treatments such as CBT to help with simi-

lar problems among bariatric surgery candidates. Problems such as binge

eating, dissatisfaction with body shape and weight, and issues concern-

ing control over eating are examples of common concerns. In addition,

depressed mood and anxiety, as well as low self-esteem, are common in

many patients considering bariatric surgery or recovering from it. Thus,

it appears reasonable to extrapolate from the current database of sys-

tematic research for eating disorders, anxiety, and depression to the popu-

lation of patients seeking bariatric surgery. In addition, it is unlikely that

systematic research in the specic area of psychological treatments for

bariatric surgery will be forthcoming soon. The current manual is there-

fore an extension of the existing research in a novel area based on its util-

ity for related concerns for which there is an extensive database.

Working With the Pre-Operative Patient

Recent media reports about surgical success stories may make many pa-

tients unrealistic about their goals or the ease of surgery as a choice. A

lot of patients arent prepared for the radical changes they need to make

4

to their lifestyle and eating habits post-operatively in order to ensure they

reap the maximum benets of their surgery. Making a commitment to

eat healthfully and nutritiously and to exercise regularly is the key to

guaranteeing long-term success. Sustaining weight loss after undergoing

bariatric surgery of any type requires that the patient adhere to a strict

diet while following the very specic recommendations of his or her

primary care physician, dietician, surgeon, and other members of the

team. Without the patients strong level of commitment to a future as

a thinner and healthier person, the probability of the surgery leading to

permanent weight loss maintenance is limited.

The program outlined in this guide will help you teach your pre-operative

patients the skills required to adapt to the lifestyle and dietary changes

that are necessary in order for them to sustain weight loss after surgery.

Based on CBT techniques as described above, the program incorporates

basic cognitive restructuring and problem-solving skills to help your pa-

tients change their negative thoughts about food, eating, their bodies,

and themselves. Through this program they will develop a more thor-

ough understanding of all aspects of their past and current problems

with food and weight. It will also help your patients establish a regular

pattern of eating, teach them about self-care and how to replace their

negative eating habits with other, more pleasurable activities, and assume

a lifestyle consistent with long-term weight loss maintenance.

Use of the Workbook

The corresponding patient workbook will aid you in delivering this

CBT-based treatment to your pre-operative patients. It is organized by

skill (e.g., monitoring and recording eating habits, establishing a sched-

ule for weighing-in, replacing eating with alternative, pleasurable activi-

ties, etc.) and correlates directly to this therapist guide. You may spend

as many sessions covering each skill as necessary. The workbook contains

user-friendly and interactive exercises, forms, work sheets, and checklists

that your patient will complete either in-session or as homework as a

way to reinforce these skills. All of these documents can be photocopied

from the workbook or downloaded from the TreatmentsThatWork Web

site at http://www.oup.com/us/ttw so that your patient is able to extend

the therapeutic experience outside of the oce.

5

This page intentionally left blank

Materials Needed

Figure .. The Cognitive Behavioral Model of Overeating

Outline

Teach patient about the cognitive behavioral (CBT) model for under-standing the development of weight and eating issues

Personalize the CBT model based on patients experiences

Help patient understand the way in which weight loss surgery is likelyto aect these issues

If your patient is obese, that means that he has been overeating in one

way or another (e.g., taking in more calories than the body needs and

storing the excess as increased body weight or body fat.) It might surprise

your patient, as you discuss the contributions to his weight problem, to

nd out that there are dierent forms of overeatingand that he might

engage in some, but not others. It is important to help your patient iden-

tify the types of overeating problems that she or he has, so that appro-

priate interventions can be developed. As you discuss the following sec-

tion with your patient, you can help him identify the types of overeating

behaviors that she or he might engage in most frequently and help the

patient to understand the various contributions to these behaviors, as

well as ways to stop.

7

Chapter 2 Understanding Your Patients Eating Behavior

(Corresponds to chapter of the workbook)

Types of Overeating

You will want to educate your patient about dierent types of overeating.

Overeating can come in various shapes and sizes. For example, there can

be binge eating episodes, e.g., typically quite large and out of control

eating episodes in which a sizable quantity of food is consumed in a

short period of time and in a manner that is considered to be quite dif-

ferent from an average persons eating experience. A binge episode is one

that usually leads to a feeling of being uncomfortably full or stued.

On the other hand, overeating can sometimes take the form of grazing

throughout the day, e.g., taking in relatively small amounts of food fre-

quently between standard snack and meal times, usually in response to

cravings, boredom or other emotions, or the mere availability of food.

For some individuals, overeating episodes are followed by a strong resolve

to eat less, under-eat, starve for a few days, exercise more, or in extreme

cases, to purge the excess food. Those who follow episodes of overeating

with purging (or extreme or compulsive exercise or starving) on a regu-

lar basis are classied as having bulimia nervosa as opposed to binge

eating disorder. Most individuals who eventually become obese have

not been engaging in regular, successful purging; if they had, it is much

less likely that they would be as overweight as they are. On the other

hand, if your patient has been purging regularly (but has still managed

to become obese) it is probably wise to encourage the patient to delay

surgery until the purging behaviors are fully resolved.

Once you help your patient to understand the specic nature of the

overeating habits, you can help him t these into a larger model based

on cognitive behavioral theory that takes into account other aspects of

lifestyle and current circumstances. As you discuss this model with your

patient, keep in mind that your goal is to help the patient better under-

stand the interrelationships between eating behaviors and weight, other

factors in his personal history, and the current situations, thoughts, and

feelings that he encounters.

An Illustration of the Cognitive Behavioral Model of Overeating

You will want to spend considerable time educating your patient about

the CBT model of overeating and later helping draw out a form of the

8

model that reects the patients unique experiences. The CBT model of

overeating and overweight links the overvaluation of thinness in our cul-

ture; pressure and intentions or attempts to diet; resulting feelings of

deprivation, loss of control, and overeating (sometimes compounded by

factors of low mood, conicts with others, feelings of fatness, etc.); over-

eating (whether by grazing, compulsive overeating, or binge eating); loss

of clear hunger and fullness cues; weight gain; increasingly negative emo-

9

WEIGHT GAIN AND OBESITY

CULTURAL FACTORS/WORRIES MOODS, CONFLICTS,

ABOUT HEALTH ALL LEAD STRESSORS TO ATTEMPTS TO DIET

LOSS OF CONTROL, OVEREATING

MOMENTARY PLEASURE FROM FOOD

FEELINGS OF SHAME, GUILT, REGRET, FAILURE,

DEPRESSION

Figure 2.1

The Cognitive Behavioral Model of Overeating

tions (from all kinds of sources: negative view of the self, interpersonal

conicts, specic failure experiences); and resignation/giving up, as well

as increasingly turning to food as a primary source of gratication.

The Cognitive Behavioral Model of Overeating

Figure . illustrates the vicious cycle of overeating followed by subse-

quent attempts of various types to control eating that applies even to

those who are overweight and for that reason deemed failures at being

restrictors. You will want to discuss the model and the rationale for the

model at length with your patient.

The CBT model of overeating, as described above, suggests that there

are specic links between certain eating behaviors, attitudes, feelings,

and weight. For example, in our culture as a whole, most people tend to

value, if not overvalue, thinness or even in some cases, extreme thinness.

The pressure to eat less felt by those who are overweight who also place

signicant value on thinness can be overwhelming and at times lead ex-

actly to the behavior that is most unwelcome: that of overeating. For

some, overeating in the short term is quite pleasurable and therefore mo-

mentarily combats the stress and depression that can accompany the ex-

perience of being overweight or obese. In some instances, eating has be-

come the primary tool for gratication and pleasure that an overweight

individual has learned to use to soothe himself in the event of negative

emotions or problem situations.

Typically after a brief period of pleasure, however, overeating can lead to

negative feelings and thoughts about oneself and an overidentication

with the experience of failure, at least with respect to eating and weight

control. While massive eorts to diet and exercise, even unsuccessfully

(e.g., sometimes just hypervigilance or emotional energy about these areas

or simple good intentions without a lot of productive action), can fol-

low bouts of overeating, this extreme eort might lead to feelings of

stress and deprivation (even if the actual amount of food consumed and

physical exertion through exercise remains about the same). Your pa-

tients eorts to diet might leave him feeling as if he isnt allowed to eat

to satisfaction or doesnt have the right to eat the foods that he likes. Fre-

quently, these feelings can trigger episodes of overeating no matter what

10

their source (e.g., actual, successful dieting and weight loss or intentions

to diet that fall short of the goal of actually cutting back).

In addition to the experience of deprivation, other aspects of a persons

life might contribute to a lowered threshold for overeating. For example,

general stress, intense emotions of other types (low mood, euphoria, anxi-

ety, grief ), conicts with others, and a distorted sense of hunger and full-

ness from a history of overeating and purging can create a situation in

which it is impossible to clearly discern hunger and fullness cues.

Finally, there are often historical factors associated with overeating and

becoming overweight. These might include: the early experience of being

teased and labeled fat; having been forced to diet as a young child; re-

treating into overeating and weight gain to avoid certain challenges as-

sociated with growing up; or attempting to cope with trauma of one

type or another. In adulthood, overweight and overeating can often be

associated with pregnancy, raising children, becoming more sedentary

after starting to work again (or leaving a job), or having been forced to

give up certain sports or physical activities due to medical conditions or

injuries. For some, excessive weight gain might be associated with exces-

sive alcohol intake, eating more due to drinking less, or discontinuing

either smoking or stimulant drugs.

You will want to spend a considerable amount of time talking with your

patient about all of the aspects of his life, past and present, that have

played a role in his having become overweight, so that ample time can

be spent understanding and working through the issues.

Your patient will be using the blank space that is provided in his work-

book to draw out a version of the CBT model that best ts his own ex-

perience. An example is shown below in Figure .. During sessions in

which you discuss the CBT model, you might help the patient start link-

ing it to his experiences by thinking about and noting a few of the rele-

vant factors in his growing up years (that he is aware of ) or any other as-

pects of his history that have aected his eating behaviors and his weight

over time. Then you might want to encourage your patient to write in

more detail about his particular experiences as they relate to the various

aspects of the CBT model, as presented in the following exercise. Fol-

lowing this exercise, you will be discussing with your patient the speci-

11

12

It seems that overweight and depression run in my family. So I was

overweight from a fairly young age. The problem seemed to get worse over

time. As I became an adolescent and looks started to be more important, I

retreated somewhat socially and started to eat as a way to make myself feel

better. Obviously, this made the weight problem worse . . . It has been hard

ever since. Even though I have dieted a number of times, none of the weight

losses that I have accomplished have stuck for more than a few months.

Then when I started to have kids my weight just got higher and higher . . .

until the point where it seemed futile to try to do anything about it. Although

I exercised in the past, with increasing weight it has been more and more

difficult to move around, and for that reason I havent done much exercise at

all in the past couple of years, again making the weight problem even worse.

So the surgery seems to be my only solution at this point.

Family history of weight problems and depression

Increasing weight led to decreasing physical activity and more weight

gain

When I dieted I would feel deprived and then eat more as a result . . .

Eating to feel better e.g., to get over social isolation and depression

Diets didnt work anymore and frustration led to more eating and weight

gain and lower mood.

Also stress of any type has usually triggered some overeating.

Figure 2.2

Sample of Patients CBT Model

c emotional, cognitive, and behavioral eects of problems with weight

and overeating.

The Effects of Overeating: Emotional, Cognitive, and Behavioral

For many people, overeatingwhether triggered by available food; crav-

ings; negative emotions such as depression, anger, or boredom; conicts

with other people; or a desire to distract oneself by creating a new

focus for negative energycan lead to a variety of dierent outcomes.

As stated in the section above, it can be gratifying or uplifting in one way

or another. For example, it can provide a form of pleasure when there

are few pleasures available; it can distract from dicult thoughts or feel-

ings about any number of problem situationsin a sense it shifts the

focus from one problem to another; it can provide a method for acting

out or breaking the rules for someone who otherwise is quite compli-

ant and sensitive to doing only what is right.

No matter what causes an episode of overeating, in response to its oc-

currence, in many cases one feels not only an urge or desire to restrict in-

take, but also usually a whole host of negative emotions, thoughts, be-

liefs, and behaviors about oneself in relation to having overeaten, which

develop fairly soon after the episode, even if the eating episode was on

some level gratifying. These thoughts and beliefs might take the form of

I am never going to lose weight, I am the only person who engages in

this behavior, or even more negatively I am a fat pig or I am a loser.

These thoughts and beliefs can generate an array of negative feelings.

Some of these may include: sadness, self-disgust, anger at oneself and

others for having gotten into the situation in which overeating occurred,

despair, and resolve not to do it again and a commitment to start diet-

ing or restricting intake on some level as soon as possible after the over-

eating episode is completed. For some people, overeating in the form of

continuous grazing and consuming excessively large meals and snacks

might not trigger so many extreme reactions but rather strengthen or ig-

nite a sense of resignation and inevitability of future overeating and con-

tinued weight gain. In many cases, the negative thoughts, feelings, and

beliefs also lead to compromised behaviors such as not getting out so-

cially to see friends, feeling too full to do other tasks, whether chores or

13

recreational activities, or even additional overeating that may be an at-

tempt to further escape from the bad feelings.

Gastric Bypass Surgery and the CBT Model

Since the experience of weight loss surgery will change your patients re-

lationship to food quite dramatically, the issues discussed above need to

be considered in a dierent light. Mostly, weight loss surgery will help

your patient better manage his reactions to both hunger and fullness

(satiety). Specically, after weight loss surgery of any type, your patient

can expect to feel hungry less frequently and less intensely than before

(for those who do actually experience hungersome obese people do

not). Also it will take much less food to ll your patient up once he does

start to eat after becoming hungry. And your patients method of eating,

which will involve taking very small bites of food, chewing them very

well, and eating very, very slowly, will also increase the likelihood that he

will feel full on much less food. Also, your patient will be given infor-

mation about which foods to include in his diet and which to avoid, as

well as strategies for alternating his intake of foods and liquids.

While, ultimately, the goal of weight loss surgery is to reduce your pa-

tients hunger level so that he can make wiser and less impulsive deci-

sions about food, this surgery benet can also come with certain costs.

These might include the experience of deprivation that can accompany

regular dieting when certain foods in certain quantities are restricted or

the experience of being left without tools if your patient has used food

as a primary means for coping with problem emotions and situations.

Without replacing food with other positive and well-practiced tools for

coping, any individual who is even enthusiastically attempting to restrict

intake by choice can be left feeling unsettled, frustrated, deprived, or out

of control. These feelings can lead to urges to overeat. Solutions for the

problem of being left without tools will be discussed in a later chapter.

You will discuss with your patient the reality that even after weight loss

surgerywhich by now he should understand is no magical cure

overeating can happen, in one form or another. For example, your pa-

tient might nd himself unintentionally experimenting with creative

strategies for overeating. These might include: frequent ingestion of

14

small quantities of indulgence foods that are not ideal, such as very small

amounts of sweets, candy, or peanut butter, or taking in increasingly

larger quantities of food, particularly once the new stomach pouch

stretches some. He may deliberately overeat certain foods that are no

longer digestible because of the particular type of surgery he had (e.g.,

fats after the duodenal switch procedure) and come to rely on the mal-

absorption syndrome, or dumping, as a method of purging the excess

calories.

Despite the surgerys assistance in controlling your patients eating, at

least some of the fundamental features of the CBT model will still apply

to his struggle to manage his intake. In your therapy sessions, you will

want to determine those areas that might prove to be high-risk. For ex-

ample, while your patient might not feel physically hungry after surgery

in the same manner as before, he might still struggle with physical and

psychological cravings for particular types of foods or for food in gen-

eral. Associated with these cravings may be emotions of frustration, loss,

sadness, or even despair. He may feel that he will never be able to con-

sume any of these foods again or that he will always struggle with intense

cravings. While the use of words like always and never signies that your

patient may have been triggered into a cognitive lapse that involves

clearly problematic and unhelpful thoughts, these errors in thinking can

be addressed and modied using cognitive restructuring procedures (see

chapter ). By the same token though, no matter how skillfully you might

address the problematic thoughts with your patient, it is equally impor-

tant to help him get his behaviors onboard so that he doesnt inadver-

tently contribute to any of the problems noted above.

Similarly, it is important to address any problem emotions your patient

might notice in association with his surgery. In some cases, losing a sig-

nicant amount of weight even after weight loss surgery can lead to the

experience of excessive hunger, cravings, and eventual overeating, as the

body struggles to reestablish its former set point. Also, in some cases,

negative emotions can accompany even desirable, radical weight loss and

can lead to a pattern of emotional eating.

As you discuss your patients personalized version of the CBT model and

work hard to understand all of the issues involved, you will be able to

more clearly help your patient ascertain the areas that need the most re-

15

habilitative work prior to surgery. No matter what, it is likely that one

or more of the following chapters will help your patient address the is-

sues that are most troubling.

Homework

Read about and review the CBT model for understanding eating andweight issues.

Create a personalized version of the CBT model and discuss this withyour therapist.

Review the implications of weight loss surgery on the CBT formulation.

16

Materials Needed

Form: Food Record

Outline

Explain to patient the rationale for establishing a regular pattern ofeating

Teach patient to establish a regular pattern of eating

Introduce patient to food records

Teach patient a method for keeping track of eating using food records

The CBT model of overeating explains the interrelationships between

eating, thoughts, emotions, weight gain, and other behaviors and situa-

tions, and purports that the rst steps toward making changes in this

vicious cycle need to be taken at a behavioral level. For example, a key

component in your patient overcoming her problem eating habits or at-

titudes involves her making a commitment to gathering more data about

her eating behaviors by keeping some form of eating record. Another key

factor involves her willingness to establish a regular pattern of eating, in-

cluding keeping to a schedule of healthy, balanced, and not overly in-

dulgent nor overly stingy meals and snacks to interrupt any problematic

cycles of overeating followed by compensatory under-eating. You will

want to discuss both of these principles and the following rationale in

more detail with your patient in the sessions that deal with these issues.

17

Chapter 3 Helping Your Patient Keep Track of His or Her Eating

(Corresponds to chapter of the workbook)

You will want to sell your patient on the CBT belief that the prescrip-

tion of a healthy, regular pattern of eating can disrupt the strength of the

links in the model of problematic eating. Helping your patient to dis-

entangle these links and clean up her eating patterns by eating on a

regular but modiable schedule can help her free up her eating behav-

iors from inappropriate inuences (those that arent related to hunger or

fullness). In this way your patient can slowly achieve healthier eating be-

haviors and associated attitudes. In many cases, too, this plan for regu-

lar eating can help your patient slowly work toward her weight goals, since

the pattern can help her combat any episodes of impulsive overeating.

The Importance of a Regular Pattern of Eating

The treatment of choice for problematic overeating behaviors that occur

in response to triggers of any type has been the prescription of a regular

and healthy pattern of eating (such as three meals and two snacks a day).

Obviously the specics of the planned eating pattern (e.g., the exact

contents and quantities) will dier from individual to individual and

will also depend upon the exact nature of the surgery that your patient

is planning to have and the recommendations of her particular surgery

center. By and large, though, these recommendations will include the

suggestion to consume three small meals and two or three small snacks

a day (or ve or six small meals) that are eaten not fewer than about

hours apart and not more than about hours apart. The rationale behind

this recommendation is that by eating in response to a exible but pre-

determined schedule, nonessential and inappropriate food and eating

cues such as those described above (e.g., emotions, cravings, the avail-

ability of food, and various interactions with people) will be washed out

over time. As you will explain to your patient, the belief is that this me-

chanical style of eating by the clock will gradually become more auto-

matic and natural, and increasingly will correspond to the ebb and ow

of hunger and satiety signals as these are progressively retrained through

adherence to the schedule. In this way, over time, eating will be initiated

appropriately albeit somewhat exibly at meal and snack times, approxi-

mating the pattern that your patient will need to adopt post-operatively.

18

Your patient will obviously learn a lot about nutrition pre- and post-op

from her dietician. However, you will also discuss the importance of eat-

ing nutritionally dense meals and snacks after surgery with your patient

during the sessions focused on establishing a regular pattern of eating.

At the same time, you will talk to your patient about the fact that in ad-

dition to super-nutritious food and correct eating and uid intake pat-

terns, healthy eating (in both the physical and psychological sense) must

also involve some allowances for certain small treats that are at least

somewhat indulgent. This will help stop problem cravings and depriva-

tions that lead to out of control episodes of overeating (to the extent that

that is possible after weight loss surgery). As you will review time and

again with your patient, the essential tool for getting eating behaviors that

have gone awry back on track is a normalized relationship with food.

If your patient has had particular diculties making a commitment to

eating by the clock, suggest that she try hard to gure out in advance

just about when, just about what, just about how much, and just about

where each meal and snack will take place. Furthermore, she will get the

most mileage out of this type of exercise if she sketches out these plans

in some sort of draft or meal plan, either in a journal or an actual food

record. Working in this way on a regular basis will represent a very sub-

stantial step toward her liberating her eating habits from inappropriate

inuences not really connected to physical hunger.

Using Food Records

The rst step in helping your patient try to understand more about her

eating patterns and associated thoughts and feelings, and the contexts or

situations in which she struggles with these, involves learning to record

all of her behaviors in journal form, using what is commonly known as

a food log or food record that provides details beyond the sketch-

ing a plan in advance noted above. Explain to your patient that the food

record is all about gathering data so that she wont have to rely on her

memory alone to understand the details of her eating patterns, all that

contributes to them, and how her weight is aected by the current pat-

terns and any changes to them. Inform your patient that when she com-

pletes food records, she also has created a written record of her eating be-

19

havior that can be discussed in detail with you during sessions. You can

talk with your patient about her prior experiences, if any, with food

records and any associated thoughts and feelings that she has about food

records based on those experiences.

Your patient might be quite skeptical about food records if she has

worked with them before, perhaps in a structured diet program, while

meeting with a dietician for consultation, or in some type of behavior

therapy. Her reaction might be this is not going to workit never did

before! Or she might feel as if keeping food records is all about being

controlled by her therapist or dietician. No matter what, all of these

sentiments need to be explored in your sessions with her. Forewarn your

patient that to succeed with this program she will need to transcend her

tendency toward skepticism and trust that this experience with food

records can be dierent, that is, that she can productively and therapeu-

tically use these records to her advantage, rather than feel as if she is

completing an assignment for someone else. Assure your patient that

regularly completing food records in the context of this particular CBT

therapy will be a dierent experience than any she has had before, if she

uses them as recommended in the program. Remind her that if she

wants to really succeed with her food records, the best way for her to pro-

ceed is to make a commitment to recording her food intake (all meals,

snacks, binges, or grazing episodes and uid intake) as close to the time

of eating as possible. Any delay in her recording can lead to inaccuracies

and even more importantly, the experience of disconnect between her

eating and what she will later record in her food records. Remind her

that she should raise any questions about the food records with you.

A sample completed food record is included in Figure .. A blank copy

for your patients use is available in the workbook. Your patient may pho-

tocopy the blank record from the workbook or download multiple

copies at the TreatmentsThatWork Web site at http://www.oup.com/

us/ttw.

Encourage your patient to use the food records daily and to make her en-

tries as close as possible to the time that she is eating. She can also use

the records to plan her eating patterns and specic snacks and meals in

advance, and then cross-check to ensure that she has followed through

on her plan. Either way, educate your patient that if done correctly, the

20

food record can be an invaluable addition to her self-care plan around

food. Go through the various features of the food record with your pa-

tient, noting that there are places on the record to indicate the time that

she is eating, the amount and contents of the food and liquid consumed,

and whether or not she considered the eating episode to be a meal or a

snack, to be pro-plan or anti-plan, and what the situation or context

was surrounding that particular eating episode. Where was she? Who

was around? What was she thinking? What was she feeling?

21

Amount of Food and Meal, Snack, Purge Thoughts, Feelings,Time Place Liquid/Description Binge, Graze? Y/N Situation/Context

8:00 a.m. Standing 1 corn dog with bun, Breakfast Just a typical morningin kitchen 1 hot dog with bun,

mustard, ketchup, cheese with both1 glass orange juice

10:30 Work 1 package Hostess Snack My usual snackat desk Ho Hos from

vending machine11:30 Friends handful of M&Ms Grazing a bit They were there,

Desk so I ate them.12:30 p.m. In car, 3 tacos, a burrito, and Lunch At least I didnt

drive-thru a large Coke have dessert.Taco Bell

3 p.m. At desk glass water, handful Snack I am trying to be peanuts good with the

water.6 p.m. In kitchen several slices cheese Just snacking I will try to eat less

preparing and 610 Ritz while I cook at dinner.dinner crackers dinner

6:30 Kitchen plate of spaghetti with Dinner I made it so I wanted table with meat sauce, salad with to enjoy it.family ranch dressing, 3

pieces garlic bread with butter, slice applepie, 1 glass 2% milk

Figure 3.1

Sample Completed Food Record

Food Record

Your patients keeping an ongoing record of her eating in this way (in-

cluding the situation/context column) will make it possible for her, in

the context of her therapy with you, as well as any consultation sessions

with the dietician and surgeon, to really understand all of the eating and

other behaviors and thoughts that are contributing to and perpetuating

her eating problems, as well as the exact nature of the problems. With-

out records, and left to rely only on a memory of what happened with

food (given that eating tends to be an activity during which many people

space out, disassociate, or simply forget exactly what they were doing),

it is highly likely that your patients recollection of her eating will be in-

complete and inaccurate.

Discuss with your patient that in many respects, the whole point of food

records has to do with the idea of connection, that is, that she stays

connected to her own eorts to regularize her eating. Remind her that

the food record can help her track her progress on a meal-by-snack basis,

thus providing reinforcement and motivation to stay on track each and

every step of the way. Along the same lines, the record can also serve as

a tool of intervention when she is at risk for lapsing into a nondesirable

eating behavior. Every time she is able to examine completed portions of

her food record and note the number of success experiences that she has

had, she can ease herself back into the groove when she might have

been tempted to feel negatively about her progress and throw in the

towel. Discuss with your patient the fact that when she uses her food

record as a tool of motivation and intervention, she will be taking full

advantage of the methodology. Of course, her food records will also be

helpful in providing an accurate record for you. Remind her, however,

that food records are really most powerful when used to make day-to-

day choices about each and every meal, snack, (and glass of water) that

she decides to consume.

Working With Adolescents

If your patient is a teenager, there are some important factors that aect

his or her ability to establish a healthy routine for eating. The teenager

may not control either the foods that are in the home or the times that

the family eats. So, it is important that you work with your patients par-

22

ents, and to a certain extent the entire family, to promote their under-

standing and acceptance to change things. This will likely require that

you meet with parents together with your patient to discuss how a struc-

tured eating program can be undertaken at their home. This involves

identication of very specic obstaclesnot eating meals at regular times,

parents not preparing meals, fast food as the main or common meal type,

and so on. Each of these will need to be addressed and solutions identied.

Sometimes this will involve asking parents to shop with their teenager

for a period of time in order to make sure the right foods are available.

Sometimes teenagers dont like to keep food records. There is enough

homework already, and keeping track of what they eat seems like a waste

of time. However, it is important to try to overcome these hesitations.

You will learn a lot about what and how they eat that will be essential to

therapy. When you are rst getting started, you and your patient will

likely complete food records in-session to give her the idea and to show

her how they can be useful. Sometimes, you may ask parents to remind

their teenagers to complete the food records. Over time, these food records

will also be helpful when your teenage patient meets with his or her doc-

tors to illustrate how they have changed eating patterns and food choices.

This will help demonstrate their commitment to lifestyle changes needed

to support weight loss after bariatric surgery.

Homework

Review the rationale for maintaining a regular pattern of eating anddiscuss this with your therapist.

Read and review the rationale for keeping food records and discuss thiswith your therapist.

Review the instructions for use of food records.

In your therapy session, set appropriate goals for the number of daysyou will record your eating during the next week.

23

This page intentionally left blank

Educating Your Patient About Weighing Behaviors

(Corresponds to chapter of the workbook)

Materials Needed

Weight Graph

Appearance and Weight Compliments Log

Outline

Educate patient about the rationale for and method of regular weighing

Teach patient about the importance of other means for checking onand measuring his body weight, size, shape, and general appearance

Help patient understand the link between healthfully monitoring hisbody size and keeping track of other healthy attitudes and behaviors

A Regular Pattern of Weighing

Most likely, your patient has discussed with you, as well as with his sur-

geon and dietician, and possibly with his internist, a regimen for weighing

himself regularly before weight loss surgery that makes sense. As your

patient prepares for his surgery, it can be helpful for him to weigh in

weekly with one of his doctors, so that changes in his weight in either

direction can be observed on a regular basis before too much time passes.

In this way, any necessary modications (e.g., increasing or decreasing

intake or activity) can be made as needed. In some cases, because your

patient might still require a special scale for weighing (most likely if his

weight is still pounds or above), it might actually be impossible for

25

Chapter 4

him to weigh at home and therefore necessary for him to use a doctors scale

to get an accurate reading of his weight until it drops into a lower range.

The rationale for regular or weekly weighing is easy to understand, and

your patient has probably experienced certain thoughts and feelings

about weighing himself (or being weighed by someone else) that will sup-

port the rationale. For example, for many people with weight and eating

problems, weighing themselves has over time become fraught with an

incredible amount of stress and pressure, perfectionism, self-doubt and

self-blame, anger directed inward and outward, and a number of other

perceptions and feelings (some positive, when the numbers were going

in the right direction). Typically, these issues and complexities in relation

to weighing have developed over time in response to your patient hav-

ing made a number of ultimately unsuccessful dieting eorts (as evi-

denced by the patients decision to undergo weight loss surgery). As a re-

sult of this level of sensitivity that your patient carries about his weight,

including potentially becoming too upset in response to unwanted weight

gain and too excited in response to weight loss, he has become over-

invested in what will be revealed about him by the numbers in any par-

ticular instance of weighing. And most likely that has led to the devel-

opment of certain patterns in the way that he weighs himself, which you

will be discussing in detail during the sessions devoted to this topic. For

example, you will want to spend some time educating your patient about

common patterns in weighing among those with eating and weight con-

cerns. Some people who are highly vigilant and reactive to the numbers

on the scale, and who use the numbers to dene crucial aspects of them-

selves such as their self-worth or lovability, may check the scale daily or

even more frequently (if this is possible given their weight) to ensure

that the numbers have changed, or havent changed, or in any case to get

a sense of what the numbers are saying about them. Others might

avoid the scale altogether to avoid the emotional impact that the num-

bers are likely to have.

The Risks of Weighing Too Frequently

This pattern of weighing (less likely for obese individuals than patterns

of avoidance) is problematic because it allows people to overreact (e.g.,

cognitively, emotionally, behaviorally) to very minute changes in their

26

weight that virtually have no meaning at all. Shifts of one or more pounds

in either direction that might reect sodium or uid intake changes from

the day or days before can cause fairly exaggerated responses in these

scale-sensitive individuals of either self-denigration or elation. Both

responses are inappropriate given the predictable and meaningless na-

ture of those types of weight changes, which are most likely to be tem-

porary and not indicative of actual fat or lean body mass.

Avoiding the Scale

On the other side of the continuum is the problem of weighing too in-

frequentlyor even avoiding the scale altogether. Some people with

weight and eating issues have had such negative or emotionally power-

ful experiences with the scale that they feel unable to tolerate any relation-

ship at all with the numbers and therefore avoid the scale at all costs.

In some cases, even at physicians oces, these individuals might ask to

stand backward on the scale and request that the health care professional

who is weighing them not even comment on the numbers. While this

pattern of scale avoidance might in fact spare an individual with this type

of extreme sensitivity from some short-term unpleasantness or overly

strong emotional reactions, it can, on the other hand, collude with their

perceived need to distance from the scale. Maintaining this type of dis-

tant or avoidant stance can contribute quite a lot to a person unknow-

ingly allowing their weight to change in the undesired direction (e.g.,

weight gain in the obese population). This happens easily due to the

absence of a feedback loop, that is, no source of reasonable feedback

about what is happening with the persons weight over time in response

to the various eating habits that have been sustained since the last weigh-

in (which in some cases involving highly avoidant people might have

been years ago).

It is important to inform your patient that avoiding the scale for too long

can lead to an actual fear or phobia of the scale or the experience of

weighing-in, which is not unlike other types of phobias (e.g., a fear of

heights). In these instances, not only is the fear of weighing incredible,

but the pressure to avoid is extremely powerful, too, and as time goes on

without the person normalizing contact with the scale or the experi-

27

ence of weighing-in, the numbers take on an even more exaggerated

level of importance to the point where they become even more extreme

in their power to determine how the person feels about himself. As you

discuss the patterns of weighing with your patient, you can explore the

various meanings attached to his pattern of using the scale. Typically, a

pattern of too-frequent weighing suggests extreme anxiety and some

magical ideas about controlling the outcomes through hypervigilant

checking, while a pattern of avoidance suggests that the numbers on the

scale have come to mean something to the person that extends way be-

yond the domain of eating and weight control and has huge implica-

tions for his emotions and self-concept.

No matter what the particulars of the pattern your patient might be en-

gaging inone of overly frequent weighing or avoidance of the scale

these relationships to weighing are problematic in that they suggest an

overly strong emotional attachment to the numbers. This type of attach-

ment interferes not only with your patient developing a straightforward

and healthy pattern of tracking weight changes as they relate to eating

but also with his maintaining an appropriate and unembellished rela-

tionship between his weight and his sense of self (e.g., worthiness, lov-

ability, value, etc.).

Corrective Strategies: Weekly Weighing and Other Measurements

As you and your patient will discuss, one helpful strategy to address

problem patterns of weighing is to prescribe a pattern of weighing-in on

a regular and preplanned basis, such as once a week on a specic day, at

a specic time. Weighing regularly in this manner also is the best method

for obtaining accurate comparison data week to week, particularly as

changes in eatingalong the lines of weight loss dietingand possibly

activity patterns are made. This strategy can work for those who have

been weighing too frequently, by cutting into the overweighing pat-

tern in a very deliberate way. For example, once the day and time for

weighing are selected, and the weekly weigh-in has taken place, the scale

can be deemed o-limits either by encouraging the patient to put it into

a closet or other hard-to-reach place or by limiting access to it by taking

out the batteries or hanging a sign or do not cross rope as a reminder

28

and a motivator to stay away from the scale until the designated weigh-

in time rolls around again. Alternatively, if the excessive weighing has

been done in some other setting, problem solving and motivational ex-

ercises (e.g., analyzing costs and benets) pertaining to limiting access

to that scale or limiting visits to that place only to the weigh-in day can

help. In addition, relaxation, distraction, and cognitive-restructuring meth-

ods might be useful in addressing problem mood states such as anxiety

or despondence that might occur when your patient has contact with the

scale (or is denied contact with it, as the case may be). (These methods,

discussed in detail in chapters and , can be introduced here if neces-

sary; just encourage the patient to also skip ahead to the appropriate

place in the workbook.)

The strategy of committing to a specic day and time for weighing-in

also applies to those who have been scale avoiders. For those individ-

uals, it may be necessary to either purchase an appropriate scale for the

home or identify an alternative location (such as the doctors oce)

where the scale can be easily accessed once a week on a specic day and

at a specic time. For this group, weekly weighing might also warrant

supplementation with CBT tools such as problem-solving strategies, re-

laxation techniques (to combat anxiety that occurs before, during, and

possibly even after the weigh-in), and cognitive restructuring exercises to

combat any extreme or distorted thoughts that accompany the sight of

the numbers.

Explain to your patient that using a variety of measures related to weight

can be helpful, in part to take the onus and importance o of the num-

bers on the scale. Use of a weekly weight chart can help your patient

maintain a visual image of his progress toward weight loss before surgery

(as well as after). In your sessions, you can help your patient design a

weight graph using the blank graph included in chapter of the work-

book, in a form that will be maximally helpful to him. Your patient may

photocopy the graph from the workbook or download multiple copies

at the TreatmentsThatWork Web site at http://www.oup.com/us/ttw.

In addition to the weight graph, a number of other indices of body size

and shape can be useful in providing information about how the pa-

tients body is changing, without relying on the scale. These include the

obvious: tting into certain pieces of clothing or certain chairs (whether

29

at home, at work, in a movie theater, or on an airplane), measuring var-

ious parts of the body by using a tape measure or recording body com-

position (e.g., percentages of lean body mass and fat) by undergoing a

battery of tests that can determine this, and paying attention to an indi-

rect measure of weight loss by noting increased stamina in doing any

number of physical activities, including formal physical exercise (such as

walking, biking, and the like) and incidentals such as walking up the

stairs. It can be quite helpful for your patient to record some of the

data over time, as well as his perceptions of all of these changes in his

body by using a log similar to the food records. You can also encourage

your patient to think about keeping a record of compliments received

pertaining to his weight loss, which can be particularly helpful and in-

spiring. You can discuss some of the following areas in detail with your

patient.

How Your Patients Clothes Fit

Another very simple and easy way for your patient to gure out whether

or not hes on a weight loss trajectory is to try on various items of cloth-

ing to determine their t. If they are becoming more and more loose, he

is losing weight; if they are becoming tighter, he is gaining weight.

How the Furniture Fits Your Patient

This is another very simple way for your patient to track changes in his

body over time. It is important to remind your patient to notice that he

is much more easily tting into chairs and other furniture that proved

difcult for him in the past.

Taking Measurements

Another option that might appeal to your patient for tracking bodily

changes separately from the scale involves using a tape measure to mea-

sure various parts of his body (the obvious choices being waist, hips,

30

chest, upper arms, thighs, calves, etc.). This method can be effective in

offering additional information about the changes your patients body is

undergoing, as long as he measures fairly accurately. It can be difcult to

always get the correct or exact same spot, so your patient might have

to practice or ask for some assistance from a signicant other or possibly

his personal trainer, if he has one, if the results of the measurements

seem off in any way.

Changes in Body Composition: Percentages of Fat and Lean Body Mass

These days, it is not difcult to nd scales that measure body fat (al-

though the accuracy of some of these might be questionable), and your

patient might already have access to one of these scales. A more accurate

determination of body composition would be an evaluation at a health

club, gym, or medical center that offers such testing using calipers, under-

water weighing, or other even more sophisticated techniques. Finally, your

patients surgeon, dietician, or internist might also have access to the

most state-of-the-art techniques for tracking body composition over time

as your patient loses weight. You might encourage your patient to think

of the body composition measurement as a fun type of measurement

to obtain before and after his surgery.

Food Records

Remind your patient that food records, discussed in the previous chap-

ter, ultimately will describe everything that he needs to know about which

direction his weight will be heading in the near future. For instance, if

your patient is maintaining a caloric intake or food plan that is provid-

ing less energy than his bodily needs require, he will lose weight, and if

he is taking in more calories than he is expending, he will be on a weight

gain trajectory. By focusing on completing daily food records and exam-

ining actual behaviors, including the food intake and the output of exer-

cise and any other physical activity, your patient will feel more empow-

ered by recognizing that behavior has an actual impact on the outcome.

31

Ease in Moving Around

Your patient might want to keep track of general activities, such as ei-

ther how long he is able to engage in a certain activity, such as walking

at the mall, around the block, or on the treadmill, or swimming laps (or

walking laps) in the pool, etc. Your patient might alternatively want to

rate his level of exertion while doing an activity, which will provide yet

another helpful measure of how his weight loss and level of condition-

ing is progressing.

Compliments

You will be talking at length with your patient, at various stages of the

treatment, about his response to compliments about his weight loss. Ob-

viously, when losing weight, your patient may be, on the one hand, un-

comfortable to be noticed more than before or to be on the receiving

end of a lot of compliments about weight loss, particularly when there

is a lot to lose and when there may be a lot of thoughts and emotions of

a complicated nature tied up in the issue of his weight. But explain to

your patient that often it is these external sources of feedback (not un-

like the scale, to some extent) that can help a person work through dis-

tortions he might have in his perceptions of his weight. Obviously, these

should not be relied on as the only source of pride-generating thoughts

and feelings; in the end, your patients view of himself should serve as

his own primary source of enthusiastic feedback. However, in a pinch

or a low spot, others reactions can help bridge the gap from feeling low

to feeling better.

Remind your patient that, on the other hand, an absence of compli-

ments about weight loss does not have to mean much because in our cul-

ture of sensitivity to weight issues, some people may be reluctant to say

much of anything at all about a persons weight loss for a very long time

(until it is very obvious and visible) for fear of intruding or oending.

Your patient should remember not to let the absence of compliments get

him down as one can never know what is going on for another person

in terms of them perceiving, but not commenting on, the transforma-

tion that is taking place. Also, your patient might nd that he can expe-

32

rience a range of reactions to others compliments about his weight, from

feeling proud and grateful for the acknowledgement to feeling shy, overly

exposed, intruded upon, or even skeptical at times about what is being

said (this is common when a person does not yet feel their weight loss in

the way others see it). Help your patient gure out strategies he might

like to consider for responding to compliments and questions about his

weight loss that might come up simultaneously. Remind your patient

that there is never any obligation to fully explain anything to anyone

about how the weight loss was achieved; the fact that he had weight loss

surgery can be something that he decides to keep to himself. You can let

your patient know that an explanation that can suce in many dierent

situations is I made a commitment to eat healthy and exercise more and

that is how I lost weight! The reality is that those behaviors will be the

ones that best predict the long-term success of weight loss surgery and

are also the optimal result when an individual is compliant with all of

the recommendations made relative to the surgery.

A compliment log in your patients workbook provides space to docu-

ment the dates and types of compliments received from others regard-

ing his weight as it decreases over time. A sample lled-out Appearance

and Weight Compliments Log is shown below in Figure .. (In a later

chapter, there will be a broader discussion of body image issues that also

includes some assessment of others responses to your patients changing

appearance.)

Whatever combination of approaches your patient decides to use to mea-

sure body changes as he loses weight before surgery, it is important for

33

My Appearance and Weight Compliments Log

Date Source Positive Comments

10/31 man on street you look beautiful

11/10 friend youre really looking great

Figure 4.1

Sample Appearance and Weight Compliments Log

him to make a commitment to use at least a few of the assessment tools

on a weekly basis and write about them in a log similar to his food

record. This will allow him to review the changes over time, rather than

rely on his memory of them. Some of the more complicated methods

such as measuring body parts you might encourage your patient to do

just once a month, to increase accuracy and decrease overreactions to

disappointing results.

Homework

Find a place where you can weigh in regularly.

Begin to document your weight on the weight log.

Read and think about the other issues presented in this chapter.

Begin to make entries in your appearance and weight compliments log.

34

Materials Needed

List of Pleasurable Alternative Activities

Sleep Enhancement Strategies

Meaningful Roles and Activities Checklist

Outline

Educate patient about the importance of including pleasurable alterna-tive behaviors (e.g., those that dont involve food and eating) in her life

on a regular basis

Help patient establish a list of various types of these activities that canbe used in dierent situations

Enhance patients understanding of the issues of self-care in general andfacilitate patients improving various aspects of her self-care regimen

When Eating Has Been the Pleasure of Choice

Your patient might note that eating has become over time a primary form

of relaxation, pleasure, and enjoyment that always seems to be available

and literally at her ngertips. She might recognize that during certain

periods of time she has lapsed into a pattern of overeating to give her

pleasure because she has literally lost touch with other interesting, cre-

ative, fun, and active endeavors that she might have engaged in with en-

thusiasm in the past. Perhaps your patient began not only to avoid cer-

35

Chapter 5 Pleasurable Alternative Activities

(Corresponds to chapter of the workbook)

tain activities but also to avoid people and social situations in general,

due to shame or embarrassment about her weight.

In addition, your patient might have experienced certain emotions that

triggered an eating episode that may or may not have been primarily re-

lated to her weight, including depression, anxiety, or uctuating mood

states, that might have lifted temporarily when she ate something. As

you will discuss with your patient in the sessions that address this chap-

ter, food can briey and to some extent enhance mood by slightly chang-

ing brain chemistry in the direction that certain antidepressants do.

Sometimes, even intense, positive emotions might trigger your patients

urge to eat, since eating can provide a form of distraction and serve as an

anesthetic by calming and soothing a person in response to any form

of arousal.

On the other hand, your patient might believe that she is simply a per-

son who loves to eat and might attribute any or all overeating behav-

iors that happen (instead of other forms of recreation) to a fondness for

food. This view of food and eating might stem in part from your pa-

tients experiences as part of a certain cultural or ethnic community,

family, or social group whose relationships revolved to a great extent

around the experience of eating. Your patient might also ascribe to the

view of herself as someone who, in spite of eating a lot much of the

time, never really gets to the point of feeling full after a meal. Your pa-

tient might experience hunger or strong cravings for food despite know-

ing in her head that her appetite for eating is not reective of a real

need for more food. There are also some people who ultimately end up

overeating because food takes over or lls in a void where some other

type of substance abuse has left o. Your patient might be someone who

fought hard to withdraw from addictions to other substances, such as al-

cohol or drugs, only to nd that whatever was driving her to use these

substances resurfacedwith a vengeancein the form of appetite, crav-

ings, and motivation for food and eating. Finally, since many of those

who have struggled with weight and eating issues are in so many other

areas of their lives model citizens, overeating might have represented

one of the only opportunities for your patient to rebel or do exactly

what she wanted without allowing others to control or dictate her ac-

tions and without very extreme consequences (aside from obesity and all

that accompanies it).

36

Why Does Eating Food Feel So Good?

In any case, while your patient might be extremely frustrated about her

weight and her relationship to food and eating, it is likely that food by

this time is also strongly associated with her experiencing a form of easy

pleasureto the point that few if any alternatives may feel quite as

good, even if she pushes herself to give other options a try. (And, truth-

fully, it may be that no other activity will ever feel quite as good, or as

simple as food has, at least for some time, no matter how hard your pa-

tient tries. It is helpful to predict this dilemma to her and discuss it at

length.) Nevertheless, in order to aggressively combat weight and eating

problems, your patient must stay focused on the importance of replac-

ing her relationship with food with other pleasurable and meaningful ac-

tivities that dont involve food. As you discuss these issues with your

patient, make it clear that the reality is that turning to pleasurable alter-

native activities other than food will have to become part of her lifestyle

and her coping repertoire, even if initially or for some extended period

of time, they dont feel particularly great or do the trick in the way that

food has. Remind your patient that with time, practice, and experimen-

tation these activities will become more and more like second nature,

in the same way that her new and healthier eating habits and exercise

routines will become more automatic over time. Reassure your patient

that although it might feel quite dicult to turn away from food as the

primary source of pleasure and comfort, these alternative and pleasur-

able activities will not only be available to her in a pinch when she feels

that she is at risk for overeating for any reasonin need of some quick

tools that can help her cope without giving in to the urges to eatthey

will also serve to enrich her life away from food in every sense.

Physical Activities May Be Best

As you will discuss with your patient, many people combating food prob-

lems report that in their initial eorts to nd other activities to replace

the comfort, stimulation, distraction, and so on that accompanied eating,

activities that involve physical movement seem to be more eective than

those that are sedentary in nature. Why would this be so? Usually, when

people are motivated to eat, it is to nd some method for stimulating

37

themselves, whether to rev up, calm down, or numb out. After all, eating is

itself a physical activity that has a variety of eects on all aspects of the body,

from the brain on down. It makes sense then that to replace eating as the

source of the stimulation, other physical activities would work best, cer-

tainly better than stationary activities such as watching TV at home (which

by all accounts can be linked to a pattern of overeating and weight gain).

As you will discuss with your patient, the following general categories of

pleasurable activities, as well as certain specic activities, are known to

be helpful as replacements to eating.

Pleasurable Activities

Taking a hot shower or bubble bath

Going for a walk or participating in some other type of exercise

Getting a manicure

Giving yourself a facial

Working in the garden

Engaging in sexual relations

Going shopping (but not for food!)

Activities That Are Incompatible With Eating

In addition to requiring some energy output, most of the activities listed

above are physically impossible to do while eating (or at least would

make eating dicult). When trying out some new forms of pleasurable

activities, your patient must not allow them to become paired with eat-

ing cues. That means not eating while she is engaged in the activity. The

reason for this is that once a given activity includes eating, it can send a

signal to your patient that she should be eating every time she partici-

pates in the particular activity. For example, if she has been one to go to

a lot of drive-through restaurants, she might notice a desire to drive by

and pick up something to eat whether or not she is hungry, every time

she is in the vicinity. Similarly, if there is a certain vending machine at

work from which your patient buys a snack every afternoon at .., she

38

might nd it quite dicult, if not impossible, to pass by without pur-

chasing anything.

Getting Out of the House

While it will not always be possible for your patient to leave home to do

something distracting and pleasurable to avoid overeating, often it is help-

ful to do so if she is feeling tempted to overeat particularly while at home

alone with stocks of tempting foods (or even not-so-tempting foods). Going

out might even involve your patient making the decision to get some-

thing (moderately portioned) to eat as a compromise position as she

considers the various options that she has. While this involves giving in

to the urge to eat on some level, still, this decision would be much better

than your patient running the risk of overindulging at home where there

may be large amounts of food and no particular controls (such as the

presence of others or a limited supply of food) in place. Keep in mind

that every time your patient experiences a success in preventing herself

from engaging in an unnecessary overeating episode, she decreases the

strength of the pull to eat for reasons other than appropriate hunger as

she simultaneously strengthens her skill set for choosing more healthy al-

ternative behaviors when she is tempted to inappropriately use food.

Realistic and Manageable Activities

As you help your patient to brainstorm about alternative forms of plea-

sure other than eating, it is important that she learns to do so in a way

that is realisticthat is, that she comes up with activities that she can

actually aord, and do easily, in a variety of problem situations (e.g.,

such as at night at home alone, during the middle of a work day, on a

weekend, or rst thing in the morningwhenever it is that she feels at

risk for overusing food). For example, remind your patient that while it

is nice to think about getting together with friends for a walk or an out-

ing of some sort, people are not always available when we want them to

be and dont always want to do what we want them to do at the times

when we are available. While it is probably benecial for your patient to

include some social activities on her list, as well as a range of activities

39

she can do alone, she wouldnt want to include only pleasurable alterna-

tives that rely on others company. Given that others are frequently un-

available, this might leave your patient feeling frustrated and disappointed,

and with those emotions onboard, possibly more inclined to turn to

food for comfort.

Big Ticket Activities

While some major activities such as traveling or redecorating should be

included on your patients list for special circumstances, these are best re-

served as global lifestyle enhancers rather than in the moment strate-

gies that can help her stay away from food. Similarly, if your patient lives

in a cold climate, certain activities such as outdoor tennis or golng,

while nice in theory, and wonderful in the summer months, are not re-

ally possible during the winter months. Still, there would be nothing

wrong with your patient listing these activities as distant or far o

possibilities to be used to enhance her lifestyle when feasible or at some

designated point in time.

Discuss with your patient the importance of staying open to the indi-

viduality of her own list of interests and activities. There are no set an-

swers about what types of activities should be relaxing for any individ-

ual. The important idea here is to create a list of or things that she

loves (or likes) to do that can help her to feel calmer, more at peace, re-

laxed, fullled, gratied, proud, and so on. The list might include some

of the bigger ticket items that might interest her such as traveling to

distant locations, signing up for a course on an interesting topic, redeco-

rating a certain room in her house or apartment, or writing a short story

or book. The list should also include several in the moment forms of

pleasure that can be used in a pinch when your patient is feeling a rather

immediate need to alter her mood state (or simply nding herself with

free time) without access to many of the other more serious endeavors.

While the list will of course be individually tailored to her needs and in-

terests, it might include the types of activities that are available to her,

for example, in the middle of the day or at night, when no one else is

around, without generating great expense. These could be reading a fun

magazine or book; taking a hot bath or shower; doing her own facial,

40

manicure, or pedicure