Is Bariatric Surgery Right for You?

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Bariatric surgery is a significant intervention for individuals struggling with obesity. It offers the potential for substantial weight loss, but it also presents a complex array of psychological and nutritional challenges. Understanding these effects can help clients make a fully informed decision about whether to move forward, and it helps the clinician expand the assessment process. Deepening the initial exploration process will also help the clinician implement strategies before and after surgery, should the client move ahead, to mitigate negative consequences and ensure a more successful outcome.

Bariatric surgery works by restricting food intake and altering the appetite to decrease hunger and increase satiety. Despite the physical benefits, predicting who will successfully lose weight and maintain weight loss is difficult due to genetic variations affecting success (Hatoum et al., 2013).

Some patients can experience improved self-esteem, body image, and quality of life post-surgery. Blood sugar may return to normal, and type 2 diabetes can be resolved. As physical health improves and confidence grows, symptoms of depression and anxiety can decrease. However, rapid weight loss and drastic changes in body appearance can be overwhelming, especially where there has been previous body dysmorphia, or they can potentially lead to unrealistic expectations. Additionally, some patients may experience a resurgence of unresolved psychological issues that were previously masked. This is especially so where there is a history of adverse childhood events and sexual abuse.

A concerning aspect of post-surgery life is the risk of substance abuse, known as "addiction transfer" or "cross-addiction." This phenomenon occurs when individuals replace food with other substances, such as alcohol or drugs, to cope with stress or emotional discomfort. The altered physiology post-surgery can also change how substances are metabolized, increasing the risk of dependency (King et al., 2012; Ivezaj, Saules, & Wiedemann, 2014). Furthermore, patients are at risk of continuing or developing disordered eating patterns post-surgery, including restrictive eating, binge eating, or unhealthy methods to control weight.

The Importance of an Integrative Assessment

Before undergoing bariatric surgery, a thorough psychological assessment is essential. Most people consider bariatric surgery after many years of attempted weight loss. Nevertheless, every effort should be made to combine a weight loss program with exercise and adjunctive methods to improve well-being. Differentiation should be made between morbidly obese individuals who have life-threatening conditions associated with obesity and the population of people who wish to undergo surgery to lose weight.

A comprehensive assessment can define whether an individual is a candidate from a mental health and nutrition perspective. Because bariatric surgery is a business, a therapist must serve as an advocate for the client.

Disordered Eating and Sexual Abuse

When compulsive eating and being overweight are associated with a history of childhood sexual abuse, weight loss can trigger memories and flashbacks, and it is advisable to address childhood trauma before surgery. Many people show improvement in physical health and self-esteem due to weight loss, yet many continue to struggle psychologically. Bariatric surgery patients show higher suicide rates than the general population (Peterhänsel, Petroff, Klinitzke, Kersting, & Wagner, 2013).

An assessment should include a history of exposure to complex trauma. There are high rates of traumatic stress and developmental trauma disorders leading to higher rates of somatic symptoms. Caution should be taken to ensure that bariatric surgery is not suggested as another in the list of surgeries in the attempt to "cut out" the trauma that is held in the body's memory.

A qualitative interview should include comprehensive weight and diet history, general eating behaviors, history of past or present eating disorders, purging or compensatory behaviors, night eating syndrome, emotional eating, exercise, substance abuse, trauma history, treatment history, stressors and coping skills, and social support. The assessment should include psychoeducation about the surgery and post-surgery nutrition and include expectations of surgical outcomes.

Comprehensive Nutritional Assessment

A comprehensive nutritional assessment should be undertaken before surgery to assess the nutrition status of the patient. This can be done with laboratory workups with a functional nutritional therapy practitioner. While bariatric-specific recommendations focus on thiamine, vitamin B12, folate, iron, calcium, zinc, and vitamin D, a more comprehensive nutritional analysis will benefit the client along with specialized food allergy/sensitivity testing. Specialized blood tests are available that can measure vitamin and mineral status before surgery, so the client can elect to optimize their nutritional status. Because small intestinal bacterial overgrowth (SIBO) is common after bariatric surgery, attending to gut health in advance is essential.

Following a comprehensive evaluation, the clinician can provide a report to the bariatric medical team or make recommendations for mental health treatment required before surgery. The client may also require further education about the lifestyle changes required after surgery. Suggestions to attend a post-bariatric surgery support group may also be beneficial.

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Diet After Bariatric Surgery

Following bariatric surgery, intensive nutritional care becomes crucial. This involves using specialized formulas rich in easily absorbed vitamins, minerals, healthy proteins, and fats that support immune function and tissue healing. If pre-existing nutritional imbalances persist, they can worsen after surgery. Addressing food habits, including emotional and social aspects, and managing eating disorders are essential.

Common complications like "dumping syndrome," exacerbated by sugary and high-glycemic foods, are frequent. Opting for low-glycemic and complex carbohydrates, along with adequate proteins and fats, is advised.

Major nutritional complications of bariatric surgery continue for more than 20 years after surgery. Decreased intestinal absorption of iron (Bal, Finelli, & Koch, 2011); vitamin B12; folate; thiamin; calcium; vitamins A, D, E, and K; protein; zinc; magnesium; copper; and selenium are common. Deficiencies related to red blood cell production and bone metabolism are especially common.

Despite the suggested use of routine vitamin and mineral supplements after surgery, micronutrient deficiencies are significant in postoperative gastric bypass patients due to the impaired ability of the intestines to absorb nutrients.

Finally, the client should understand the risk of failure to achieve and maintain weight loss. Studies indicate that around 20 to 35 percent of patients may experience significant weight regain within 2 to 5 years post-surgery (Christou, Look, & Maclean, 2006).

Read more about nutrition for bariatric surgery and the food-mood connection in my book Nutrition Essentials for Mental Health.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the 988 Suicide & Crisis Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.