WEIGHT LOSS SURGERY: A MAGIC BULLET?
A REALISTIC LOOK AT THE MEDICAL AND PSYCHOLOGICAL RISKS

Sharon K. Farber, PhD
reprinted by permission, co. 2003, all rights reserved. please contact author for re-print information

As a psychotherapist who specializes in treating people with eating problems, I have known for a long time that binge eating and compulsive eating are the most common eating disorders around and play a major part in the development of obesity. I do individual and group therapy for people with these problems and find often that what they really want is some kind of magic. Of course, no one will say so openly, or if they do, it is in the form of a joke. But underlying the hope and expectation they bring to meeting with me is the very human and understandable wish for magic, even in the most intelligent and sophisticated people. Sometimes I wish I had a magic wand that I could wave to alleviate their pain. But of course, I don’t have that kind of power and neither does anyone else. And now that I have am doing pre-surgical consultations for people considering bariatric or weight loss surgery, I am still hearing the expectation of magic. There isn’t any magic. What I have and what the bariatric surgeons have are tools for helping people who eat far too much to modulate their eating. These tools are not magic.

The weight loss industry has always profited from people’s desperation to lose weight. When Weight Loss Surgery is presented as the only viable solution for obesity, as is so often the case, this preys upon the sense of desperation that so many obese people have. As bariatric surgery, the highest paying general surgical procedure there is, has become part of that industry and surges in popularity, with even obese teenagers having the surgery, the Journal of the American Medical Association (JAMA April 2003) has raised very serious and scientific questions about the effectiveness of weight loss surgery, about the safety of the procedures, and has raised ethical questions about the way the surgery is promoted in the media. With such aggressive promoting of these surgeries, it is easy for someone who is feeling desperate to remain in the dark regarding the serious medical and psychological risks to these surgeries.

What are the medical risks? Of those who have gastric bypass surgery, over one-third develop gallstones and ten to twenty percent will require a second surgery to repair a complication, most commonly a hernia. Other complications are the staples pulling loose, so there is no longer a pouch or the opening from the pouch to the stomach becoming stretched. It is also possible for a leak to occur from the stomach into the abdominal cavity, which will result in peritonitis, a serious infection. It is also possible for the plastic band to begin to wear through the stomach wall. Some may have persistent problems with vomiting, especially if trying to eat more than the pouch can hold. This can also cause the pouch to stretch, thus eliminating any benefit from the surgery. European research notes that complications of laparoscopic stomach stapling include abscess, leaks, fistulas, and pulmonary complications. There is a small risk of death from the surgery. The European research found that the complications of laparoscopic gastric banding include an inability to eat (food intolerance), wound infections, band slippage, and pouch enlargement. Second operations may be necessary in 13 out of 100 operations. About 1 in 200 (0.5%) people die from the surgery.

The AMA advised surgeons to tell patients that weight loss surgery is 'investigational' and that it is not known whether these procedures will help the patient. The JAMA article acknowledged that the short term results of weight loss surgery were impressive, showing large weight losses as well as improvement of disorders like diabetes type II. But it also stated that the long term consequences remain uncertain, such as whether weight loss is maintained and what the long-term effects of altering nutrient absorption are. The available data indicate that the outcome of bariatric surgery, although usually good in the short term, is variable and weight regain sometimes occurs at 2 years after surgery. A 1998 literature review found that on average, most patients lose 60% of excess weight after gastric bypass and 40% after vertical banded gastroplasty, but that weight regain occurs at 18 months to 2 years after surgery in about 30% of patients.

What are the psychological risks? Binge eaters or compulsive overeaters eat in an addictive-like way for emotional reasons, to distract themselves from anxiety, to push angry feelings down, or to anesthetize themselves to depression. Just as many compulsive eaters can defeat diets, the nature of their eating disorder can defeat the purpose of the surgery. Binge eating serves a powerful psychological function for those who do it, and the need for it will not disappear once surgery is performed. How many people do you know who can lose a good deal of weight, but cannot maintain their weight loss? That is because they become quite anxious or depressed when they cannot use their overeating or binge eating to keep those feelings at bay. It is much like the way alcohol functions for the alcoholic, and drugs for the addict. Even if they regain the weight they have lost, or “blow out” ” their staples or stretch out their bands, this is the price they will pay in order not to experience those disturbing feelings. Weight Loss Surgery makes it more difficult to eat large quantities in this way, but it does not make it impossible and it does not make the compulsion to eat disappear. This is why many will regain much of the weight they may have lost initially. A study of psychosocial adjustment to the initial weight loss found it to be generally encouraging over the short term, but there are reports of poor adjustment after weight loss, including alcohol abuse and even suicide.

For some compulsive eaters, bariatric surgery does feel like magic. It is a tool that helps them to eat less, feel satisfied with less, and lose weight and maintain the loss. When put to the test, they discover that they have more ability to withstand the impulse to binge than they ever thought, and this itself boosts their self-esteem, improves their health, and empowers them. They are the fortunate ones.

The key question here is how can you know in advance how you will respond psychologically to bariatric surgery? Unfortunately, with presurgical psychological screening, we can have a general sense of who is more likely to do better and who might do poorly, but we cannot predict this with any certainty. Certainly someone with a history of severe depression, anxiety, or psychosis, or addiction to alcohol or drugs is an especially poor candidate. The best you can do is to make yourself as knowledgeable as possible and not allow yourself to rely on magical thinking. This website and www.Obesityhelp.com are good sources of information to start with. Ask the surgeon to connect you with patients who are willing to share their experience, both positive and negative, and look for such accounts on the Internet. I think that all patients considering bariatric surgery should seek an independent (not affiliated with the surgeon or hospital) pre-surgical consultation with an experienced psychiatrist, clinical psychologist, or clinical social worker who is a good diagnostician and has had extensive clinical experience in evaluating and treating patients with binge eating or compulsive eating disorder. Patients should be apprised of the psychological risks involved.

 Traditional psychotherapy has not had a good track record with compulsive eaters, but I have found that an approach that combines helping them to develop a tolerance for feeling difficult emotions with the use of certain behavioral tools can be enormously effective, and a safer alternative to bariatric surgery. Some patients who choose the surgery may do well with the weekly or monthly post-operative support groups offered at some medical centers, but many will need psychotherapy to help them deal with the psychological consequences of their surgery.

Sharon Klayman Farber, Ph.D., B.C.D. maintains a private psychotherapy practice in Hastings-on-Hudson, NY and is the founder of Westchester Eating Disorders Consultation Services. She treats people with compulsive eating problems individually and in a group therapy, and provides pre-surgical consultation to people considering bariatric surgery as well as pre-and post-surgical psychotherapy. She has taught at medical schools, schools of social work, and training institutes. Her work has been featured in The New York Times and Parents' Magazine. She is on faculty at the Cape Cod Institute. She is the author of When the Body Is the Target: Self-Harm, Pain, and Traumatic Attachments (Aronson 2000) and other publications.

Visit her website at www.Drsharonfarber.com
 

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