When Governor Chris Christie announced this week that he had weight loss surgery this past February, he made headlines. Christie has often talked about his weight, has been the brunt of late night jokes and seemed to roll with the punches. But Christie, like 220,000 other Americans decided to take action on his personal war on obesity. He had gastric banding surgery, a type of weight loss surgery in which a small band (ring) is placed over the top of the stomach and tightened in order to reduce food intake .
When I read Christie’s reasons for the surgery, I was assured, having conduced pre-surgical psychological evaluations for weight loss surgery patients. The most important thing in terms of mental health is to have the surgery for the right reasons.
Surgical treatment for obesity is often recommended for patients whose obesity is refractory obesity or obesity-related medical conditions that pose serious health consequences. Surgical intervention is reserved for those with a BMI (body mass index) of 40 or greater, or a BMI between 30 and 40 with obesity related health conditions.
The two most used procedures are gastric bypass and gastric restriction. Surgery related death is less than 1% for low-risk patients, and less than 2% for high-risk patients for either procedure. The goal of surgery is to reduce the stomach reservoir so that a sense of fullness is gained from a smaller volume of food. Obviously with less food intake, weight loss occurs.
Surgery can achieve maintainable losses of 40% to 60% of pre-surgery weight. But weight loss is a complicated psychological as well as physical feat. Unfortunately, the psychological state of a patient is not always considered when recommending this option. Increasingly, more surgeons are interested in psychological screenings for medically qualified patients. Unfortunately, far too many surgeries are still performed without taking this necessary step.
Positive personality changes can accompany weight loss (Stunkard et al., 1986). Patients often report feeling less helpless, more stable, improved mood, etc. Other patients experience negative psychological post-operative changes (Loewig,1993). It is unsound practice not to screen for possible negative effects.
We know that those who have surgery for medical reasons do better than those who undergo surgery for psychosocial reasons. So we need to ask: What does weight loss mean to a patient? What are his/her expectations? Are there serious pre-operative psychological problems? Will weight loss negatively affect the person’s psychological functioning?
For example, those with severe psychological disturbance may see surgery as the end-all to their problems. When post surgery weight loss occurs and psychological disturbances remain, patients can dive into depression and other psychological disorders.
Some patients have used obesity to cover traumatic events such as sexual abuse. When pounds are dropped, they feel vulnerable and scared. If fear and anxiety were channeled through food and food is no longer available as a coping mechanism, problems can arise.
Obese people who spend years fighting social discrimination, attacks on self-esteem, and rejection may view surgery as a way to gain an acceptable body. When the physical body conforms to social expectation, the attention can be overwhelming and difficult to handle.
Furthermore, many obese patients do not know how to determine their internal emotional states. They often see all needs as hunger needs. Emotional based eating does not go away with surgical weight loss.
The key, then, is to screen patients for psychological issues prior to surgery and address those issues in an attempt to avoid negative long-term effects. It appears that those who do best with weight reduction via surgical treatment are those who are psychologically healthy.