Living with bariatric surgery

In April 2017, Dr Denise Ratcliffe, a Consultant Clinical Psychologist at Phoenix Health, UK and previously at Chelsea & Westminster Hospital, London, UK released her new self-help book: ‘Living with Bariatric Surgery - Managing your mind and your weight’, to help those who are considering bariatric surgery develop the psychological tools to make the necessary changes and adjustments for surgery to be successful. Bariatric News talked to Dr Ratcliffe about the aims of her book, the importance of understanding eating patterns and how managing post-surgical expectations can help people cope with the life changing aspects of bariatric surgery.

“Unfortunately, most people do not have regular or ongoing access to a psychologist when they are going through a bariatric surgery programme, so the aim of the book is to try and address that gap. I have worked in this area for over ten years and the book is really a culmination of all my knowledge and experience in the field,” Dr Ratcliffe began. “The target audience are patients who are in the process of having surgery as well as being a resource for those who have undergone surgery to help them adapt to the physical, psychological and relationship adjustments that occur.  It will also be useful for health professionals who are new to the area and who want to find out more about the psychological aspects of bariatric surgery.”

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Denise Ratcliffe

Although the benefits of bariatric surgery are significant, the psychological challenges it can present for patients have been overlooked. Consisting of 12 chapters in over 200+ pages, the book helps patients develop a realistic view of bariatric surgery and the changes required so they can adapt to life after surgery.

“There are no exact numbers on how many patients have access to a psychologist, but for most patients they will have a pre-operative assessment and perhaps some limited post-operative consultation. This lack of post-operative psychological input is very important as it is post-operatively where most of the psychological issues tend to arise.”

"We ask patients to look at what they want from surgery – more often than not weight loss is a proxy for something else – it is more important to them that they feel healthy, be more active with their children, be able to move more freely. Weight is just a number at the end of the day – whereas playing with their children is the real reward.”

According to Dr Ratcliffe, it is important that patients make the necessary psychological changes before and after surgery so that they are better prepared to negotiate the adjustments and achieve their goals, as well as helps normalise some of the issues that they might experience.

Bariatric myths

She explained that there are several myths surrounding bariatric surgery - one of the most common is that surgery will prevent patients from eating and they will never be able to put weight on again. A second myth is that after losing weight, patients will finally be happy and that all their problems will disappear.

“There is also a perception that bariatric surgery is somehow the ‘easy option’ – so some patients feel guilty or ashamed because they feel they are taking the easy route by having surgery – when actually they are choosing the most evidence-based treatment available.”

Many bariatric patients present with a range of psychological conditions ranging from binge-eating and emotional eating patterns, to depression and weight-related anxiety. Psychological difficulties that have occurred as a consequence of weight stigma are particularly prevalent.  These psychological difficulties are often longstanding, with some going back to childhood experiences of abuse and/or neglect. These issues can impact on the type of coping mechanisms that people develop.

“By the time the psychologist gets to meet them, people are often very focused on getting the operation. Quite often they have tunnel vision – they think about the surgery and losing weight and its hard to see beyond that,” she added. “They often cannot imagine what the consequences may be in terms of body image, changing their relationship with food, possible impact on their relationships with friends and family etc. It really is a journey of self-discovery – and there are lots of issues that can arise from surgery. On balance, most people get a real benefit from surgery, but patients need to understand that it is inevitable that there are going to be challenges and set-backs along the way.”

Dr Ratcliffe said it is often difficult for patients to imagine the issues and challenges that may arise after surgery, as they have often had to fight very hard to access the surgery or they have been very focused on losing weight because that is the problem they are trying to address. Therefore, it is essential patients are made aware of what the consequences of surgery might be and that they research possible consequences, as well as speak to other patients who have had surgery.

“For most patients, when they visit a psychologist it is the first time they have had an opportunity to think about the psychological aspects of their eating behaviour. Usually, they have done every diet under the sun and they have really good knowledge about what is in food, what they should and should not eat. However, it is their psychological relationship with food – whether it is emotional eating patterns or binge eating etc – that they often need to address. Many patients use food as a mechanism to cope, so their relationship with food needs to be addressed.”

Moreover, she stressed that it is important that patients think about actively managing mood issues, such as depression and anxiety, either before or alongside surgery. These are not necessarily factors which should prevent people from having surgery, she added, but it is vital that patients are aware so they are able to anticipate, recognise and manage themselves after surgery. By identifying these issues and how they are linking to eating, healthcare professionals can then help patients develop strategies and coping mechanisms, so patients can manage their issues in a different way rather than defaulting to their usual patterns.

Managing expectations

She explained that surgery is about appreciating both the positive aspects and the challenging aspects, so patients comprehend that surgery and the subsequent weight loss is not going to solve all of their problems and make them appreciate that patients will encounter some unexpected challenges and problems along the way.

“Managing expectations around weight loss is fundamental, many patients think that they will get into BMI <25 range. If they do not achieve that they often think that they have failed. So, it is important to communicate what is realistic and what is likely, it is a balance of positive aspects and challenging aspects. We ask patients to look at what they want from surgery – more often than not weight loss is a proxy for something else – it is more important to them that they feel healthy, be more active with their children, be able to move more freely. Weight is just a number at the end of the day – whereas playing with their children is the real reward.”

Dr Ratcliffe explained that many patients do not ‘update’ their body image after surgery, so they look in the mirror and see themselves as the same size that they were before surgery.  It can take the brain some time to catch up and she encourages patients to gather accurate information such as taking photos, paying attention to their new clothes size and noticing things they are physically able to do that were previously not possible.

 “Many patients are also incredibly self-critical about their appearance before surgery and this can continue post-operatively, so we try to get patients to step back from this mindset and focus on the positive aspects such as noticing what the body can do now, the improvements in how the body functions and what patients can do physically after surgery – such as walking up the stairs without becoming breathless - compared to before surgery.”

Excess skin is a really serious problem for many people post-operatively and can be extremely distressing, making people feel even more distressed about their body and their appearance after surgery. It is extremely difficult to access funding for body contouring surgery and so Dr Ratcliffe helps patients to find ways of coping with this (whilst also being realistic about how challenging this is).

“By working on the changes before surgery, patients undergo a much smoother transition. It is like training for a marathon, you would never just get up and run 26 miles, you have to do the training and preparation before-hand, it is really about synching a patients’ behaviour with the post-operative requirements.”

“In some cases, it is those patients who have been the most adherent to their post-surgical programme that present with excess skin. We all have positive, neutral and negative aspects and thoughts about our body and appearance. Many people have got used to being highly self-critical about their image so we ask them to step back and also pay attention to the neutral and positive aspects that they may be overlooking.”

Relationships

Bariatric surgery can have a considerable impact on relationships - in positive and negative ways and this is something patients need to be prepared for. Some of the changes can be unexpected – sometimes there can be elements of jealousy from friends and partners, especially if they struggle with their weight as well. For example, they may encourage them to eat inappropriate foods, so people need to think ahead, be aware this may happen and have a plan of what to do in that situation.

“This is particularly evident in relationships where people are overweight and as one starts to lose weight after surgery, this can cause tension as one partner tends to feel left behind as their partner moves on and more things become possible,” she added. “If there were problems in the relationship before this can become more of an issue post-operatively. It does not tend to impact people who are in happy and functional relationships before surgery.

In addition, she highlighted that often people avoid certain situations because of their weight, so after surgery they encounter new situations and relationships, and often they need support in how to form new relationships, as well as develop their confidence in new social situations, and quite often this will mean learning new skills.

“The process is all about making healthy changes and developing new habits. Bariatric surgery is only a tool and we know that the effects of the surgery will wane over time. Therefore, it is the behavioural aspects that are fundamental to achieving long-term success, patients who implement and adhere to those behavioural changes have much better outcomes, than those patients who are non-adherent,” she concluded. “By working on the changes before surgery, patients undergo a much smoother transition. It is like training for a marathon, you would never just get up and run 26 miles, you have to do the training and preparation before-hand, it is really about synching a patients’ behaviour with the post-operative requirements.”

To order your copy of ‘Living with Bariatric Surgery: Managing your mind and your weight’ by Dr Denise Ratcliffe, please visit the publisher here or purchase from Amazon here