March #OBSM Chat
Far from the “Easy Way Out”: Early Psychological Complications of Bariatric Surgery
By Kasey P.S. Goodpaster, Ph.D.
Research has consistently demonstrated that bariatric surgery is the most durable and effective treatment for obesity, bringing about improvement in health problems including diabetes, high blood pressure, sleep apnea, and many other conditions, and in turn drastically improving quality of life. Feeling physically satisfied with less food can be a tremendous relief for individuals who have felt as if they were battling their bodies through countless weight loss attempts over their lifetime with only minimal long-term success.
While one might assume that weight loss, improved health, and increased quality of life would improve mood, a minority of patients experience serious psychological complications including depression (White et al., 2015), suicidal thoughts (Castaneda, Popov, Wander, & Thompson, 2019), and alcohol abuse (King et al., 2017), particularly after the “honeymoon period” (1-2 years) following surgery has passed. Research suggests that worsening mood after surgery may be due in part to more psychological concerns before surgery (Kalarchian et al., 2007; Mitchell et al., 2012), unrealistic expectations about weight loss and the changes it would bring about, different absorption of psychiatric medication after surgery (Roerig & Steffen, 2015), and other factors, many yet to be fully understood. Less is known about other psychological challenges that may occur earlier in the adjustment period after surgery. This #obsm chat will focus on psychological complications that may affect patients within the first few months post-surgery: grieving the loss of food, fear of weight regain, and relationship changes.
Grieving the Loss of Food
We eat for many reasons: Physical hunger, to soothe negative emotions, to celebrate, to connect socially, and simply because food tastes good. Patients who have undergone bariatric surgery sometimes describe a grieving process as they let go of the role food played in their lives. In one recent study of psychological complications between one and three months after surgery, approximately 5% of patients endorsed this grieving process (Heinberg et al., 2017). Those who felt out of control of their eating prior to surgery may feel disappointed if that feeling persists after surgery. Similar to mourning the loss of a loved one, grieving the loss of food may involve moving through stages of denial, anger, depression, bargaining, and acceptance, not always in a cyclical manner (see Kübler-Ross, 1969).
Caption: The Kübler-Ross model of the 5 stages of grief.
Fear of Weight Regain
By the time patients decide to pursue bariatric surgery, they have tried an average of 15 diets, with only short-term success and ultimately continued weight gain (Gibbons et al., 2006). Bariatric surgery can then seem like a “last resort,” and the pressure for the surgery to “work” is sky high. This pressure may be compounded by perceived or actual judgment from others who view surgery as “the easy way out.” Patients may face scrutiny about how much they lost, how they lost it, what they are eating, and if they are going to regain. Further, weight loss plateaus, a normal part of a more step-wise weight loss progression, can be reminders of the frustrating rollercoaster of weight loss and regain on diets and may lead to alarm or discouragement.
In contrast to grieving the loss of food, fear of weight regain increases over time (14.3% at one month, 20.7% at three months post op; Heinberg et al., 2017). Incidentally, while some mild anxiety may increase motivation for continued healthy eating habits, more severe symptoms may be counterproductive. Thus, it is key to help patients break down negative thought patterns and remember that, in comparison to diets, bariatric surgery is much more likely to bring about the long-term outcomes they desire.
Caption: The Yerkes-Dodson law of arousal (anxiety) and performance.
Even early on after surgery, many patients notice a mix of negative and positive relationship changes. As noted above, patients may need to field many questions about weight loss, eating, and surgery that may feel intrusive and increase feelings of vulnerability. Friends and family, some of whom may have weight-related concerns of their own, may feel rejected, left behind, unneeded, or jealous. They may also struggle with knowing how to show their love and appreciation for the patient without food, which may lead to “food pushing” (“Is that all you’re going to eat?”), intentional or unintentional sabotage, or uncertainty about how to socialize when food is no longer the primary focus. On the other hand, potential positive relationship changes include:
Increased physical ability to pursue in new or renewed interests, which may in turn lead to more pleasurable time spent with friends and family
Broader support network including other patients who have undergone bariatric surgery
Increased self-confidence and improved body image leading to better intimacy
Individual and/or couples therapy can help patients navigate relationship changes, improve assertive communication, and broaden social support networks.
What is clear from this small sampling of psychological complications is that bariatric surgery is far from the “easy way out.” Psychological/emotional changes after surgery can feel isolating. After the first few months, patients usually report that they have settled into their “new normal,” but choosing bariatric surgery is embarking on a life-long learning process about how to handle a different relationship with food and the body, underscoring the need for multidisciplinary support indefinitely.
What helps you or your patients move through the grieving process of letting go of the role food played before surgery?
Is fear of weight regain helpful or harmful?
How do relationships change, for better or worse, after surgery?
What are other common psychological complications that may occur soon after surgery?
What should be done before surgery to prevent psychological complications?
What support is needed after surgery to address psychological complications?
Castenada, D., Popov, V.B., Wander, P., & Thompson, C.C. (2019). Risk of suicide and self-
harm is increased after bariatric surgery-A systematic review and meta-analysis. Obesity Surgery, 29, 322-333.
Gibbons, L.M., Sarwer, D., Crerand, C.E., Fabricatore, A.N., Kuehnel, R.H., Lipschutz, P.E.,
Raper, S.E.,Williams, N.N., & Wadden, T.A. Previous weight loss experiences of bariatric surgery candidates: How much have patients dieted prior to surgery? Obesity, 14, 71S-76S.
Heinberg, L., Mohun, S., Goodpaster, K., Peterson, N., & Lavery, M. (2017). Early
psychological complications: Pre-operative psychological factors predict post-operative regret, fear of failure, and grieving the loss of food. SOARD,13(10), S42-S43.
Kalarchian, M.A., Marcus, M.D., Levine, M.D., Courcoulas, A.P., Pilkonis, P.A., Ringham,
R.M., Soulakova, J.N., Weissfeld, L.A., & Rofey, D.L. (2007). Psychiatric disorders among bariatric surgery candidates: Relationship to obesity and functional health status. Am J Psychiatry, 164(2), 328-334.
King, W.C., Chen, J., Courcoulas, A.P., Dakin, G.F., Engel, S.G., Flum, D.R., Hinjosa, M.W.,
Kalarchian, M.A., Matter, S., Mitchell, J.E., Pomp, A., Pories, W.J., Steffen, K.J., White, G.E., Wolfe, B.M., & Yanovski, S.Z. (2017). Alcohol and other substance use after bariatric surgery: Prospective evidence from a U.S. multicenter cohort study. SOARD, 13(8), 1392-1402.
Kübler-Ross, E. (1969) On Death and Dying. New York: The Macmillan Company.
Mitchell, J.E., Selzer, F., Kalarchian, M.A., Devlin, M.J., Strain, G.W., Elder, K.A., Marcus,
M.D., Wonderlich, S., Christian, N.J., & Yanovski, S.J. (2012). Psychopathology before surgery in the Longitudinal Assessment of Bariatric Surgery-3 (LABS-3) Psychosocial Study. SOARD, 8(5), 533-541.
Roerig, J.L. & Steffen, K. (2015). Psychopharmacology and bariatric surgery. European Eating
Disorders Review, 23(6), 463-469.
White, M.A., Kalarchian, M.A., Levine, M.D., Masheb, R.M., Marcus, M.D., & Grilo, C.M.
(2015). Prognostic significance of depressive symptoms on weight loss and psychosocial outcomes following gastric bypass surgery: A prospective 24-month follow-up study. Obesity Surgery, 25(10): 1909-1916.