Upload
staryk
View
219
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Preparing for Weight Loss Surgery
Citation preview
Preparing forWeight Loss Surgery:
Therapist Guide
Robin F. AppleJames Lock
Rebecka Peebles
OXFORD UNIVERSITY PRESS
Preparing for Weight Loss Surgery
--
David H. Barlow, PhD
Anne Marie Albano, PhD
Jack M. Gorman, MD
Peter E. Nathan, PhD
Bonnie Spring, PhD
Paul Salkovskis, PhD
G. Terence Wilson, PhD
John R. Weisz, PhD
Preparing for Weight Loss SurgeryT h e r a p i s t G u i d e
Robin F. Apple James Lock Rebecka Peebles
1
1Oxford University Press, Inc., publishes works that furtherOxford Universitys objective of excellencein research, scholarship, and education.
Oxford New YorkAuckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto
With oces inArgentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam
Copyright by Oxford University Press, Inc.
Published by Oxford University Press, Inc. Madison Avenue, New York, New York
www.oup.com
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,stored in a retrieval system, or transmitted, in any form or by any means,electronic, mechanical, photocopying, recording, or otherwise,without the prior permission of Oxford University Press.
Library of Congress Cataloging-in-Publication DataApple, Robin F. (Robin Faye)Preparing for weight loss surgery : therapist guide / Robin F. Apple, James Lock, and Rebecka Peebles.
p. cm.(Treatments that work)Includes bibliographical references.ISBN- ----; ---- (pbk.) ISBN ---; --- (pbk.). ObesitySurgery. . Weight loss. I. Lock, James. II. Peebles, Rebecka. III. Title. IV. Series.RD.A .'3dc
Printed in the United States of Americaon acid-free paper
Stunning developments in health care have taken place over the last sev-
eral years, but many of our widely accepted interventions and strategies
in mental health and behavioral medicine have been brought into ques-
tion by research evidence as not only lacking benet but, perhaps, induc-
ing harm. Other strategies have been proven eective using the best cur-
rent standards of evidence, resulting in broad-based recommendations
to make these practices more available to the public. Several recent devel-
opments are behind this revolution. First, we have arrived at a much
deeper understanding of pathology, both psychological and physical, which
has led to the development of new, more precisely targeted interventions.
Second, our research methodologies have improved substantially, such
that we have reduced threats to internal and external validity, making the
outcomes more directly applicable to clinical situations. Third, govern-
ments around the world and health care systems and policymakers have
decided that the quality of care should improve, that it should be evi-
dence based, and that it is in the publics interest to ensure that this hap-
pens (Barlow, ; Institute of Medicine, ).
Of course, the major stumbling block for clinicians everywhere is the ac-
cessibility of newly developed evidence-based psychological interven-
tions. Workshops and books can go only so far in acquainting responsible
and conscientious practitioners with the latest behavioral health care prac-
tices and their applicability to individual patients. This new series, Treat-
mentsThatWork, is devoted to communicating these exciting new in-
terventions to clinicians on the front lines of practice.
The manuals and workbooks in this series contain step-by-step detailed
procedures for assessing and treating specic problems and diagnoses.
But this series also goes beyond the books and manuals by providing an-
About TreatmentsThatWork
cillary materials that will approximate the supervisory process in assisting
practitioners in the implementation of these procedures in their practice.
In our emerging health care system, the growing consensus is that evidence-
based practice oers the most responsible course of action for the health
professional. All behavioral health care clinicians deeply desire to pro-
vide the best possible care for their patients. In this series, our aim is to
close the dissemination and information gap and make that possible.
This therapist guide and companion workbook for clients addresses psy-
chological and behavioral aspects of weight loss surgery for the morbidly
obese. This approach has been shown to be highly eective as a treatment
of last resort for substantially obese individuals who are subject to the
dramatically increased risk factors to health associated with this condi-
tion. And indeed, the rapid growth of obesity in North America, and
much of the developed world, has been referred to by most health care
professionals as an epidemic. Illnesses and conditions exacerbated by
obesity cover all of the major organs and functional systems within the
body, including the development of cancer in various organs. The oc-
currence of most of these obesity-related conditions, particularly type II
diabetes, is rising dramatically. But these surgical procedures are not
without risks, as has been detailed in the scientic literature as well as the
popular press. Thus, most surgeons and health care professionals insist
on accompanying psychological treatment to prepare patients for sur-
gery and to assist them in complying with their post-operative routine.
The patient who is not properly prepared for surgery or does not under-
stand the surgical procedures will be bitterly disappointed and likely
noncompliant following surgery. Similarly, the patient who does not
comply with the recommended post-surgery regimen will fail to main-
tain any weight loss and will put themselves at further physical risk.
The approaches detailed in this treatment program explain the nature of
morbid obesity, then go on to describe, in a very user-friendly manner,
the most up-to-date procedures for dealing with attitude, emotional,
and behavioral factors associated with successfully transitioning to a very
dierent lifestyle.
David H. Barlow, Editor-in-Chief,
TreatmentsThatWork
Boston, Massachusetts
vi
Chapter Introductory Information for Therapists
Chapter Understanding Your Patients Eating Behavior
Chapter Helping Your Patient Keep Track of
His or Her Eating
Chapter Educating Your Patient About Weighing Behaviors
Chapter Pleasurable Alternative Activities
Chapter Challenging Eating Situations:
People, Places, and Foods
Chapter Teaching Your Patient About Problem Solving
and Cognitive Restructuring
Chapter Working With Your Patient on Body Image Issues
Chapter Congratulations! Your Patient Is on the Way
to the O.R.
Chapter What Happens After Surgery?
References
About the Authors
Contents
This page intentionally left blank
Preparing for Weight Loss Surgery
This page intentionally left blank
Background Information and Purpose of This Program
Obesity has quickly become an American epidemic. Patients suering
from signicant overweight often have to contend with a lifetime of sig-
nicant co-morbidities, social stigma, and lower quality of life. Many ap-
proaches have been tried to combat obesity and its multiple co-morbid
medical illnesses, including pharmacotherapy, psychotherapy, diet, exer-
cise, and other lifestyle change. Weight loss surgery has been used as a
modality for many years but has been increasingly recognized as a durable
tool for weight management over the last decade. Because the success of
traditional diet programs and other therapies has been sporadic and usually
short term, and recent literature has shown signicantly more weight
loss sustained over time in patients who undergo surgery, patients have
been approaching their health care teams about the option of surgery
and asking to learn more.
Table 1.1 oers a detailed description of the dierent types of weight
loss surgery procedures.
Research Support for CBT and Changing Eating Behaviors
Although systematic research has yet to be conducted on the specic
utility of psychotherapy for patients undergoing weight loss surgery, there
is a substantial body of research on related conditions (bulimia nervosa
and binge eating disorder) that suggests cognitive behavioral therapy
(CBT) may be useful.
1
Chapter 1 Introductory Information for Therapists
2Table 1.1 Surgical Procedures
Name of Procedure Description
Restrictive Vertical Banded In this procedure, the stomach is divided by a line ofProcedures Gastroplasty (VBG) staples to produce a new gastric pouch, much smaller
only about an ounce in size. The outlet of the new pouchis similarly small, extending about mm in diame-ter. This outlet empties into a section of old, larger stom-ach, which then empties as it used to into the small intes-tine. The surgeon usually reinforces the outlet with meshor GORE-TEX to reinforce it. The VBG may be per-formed with an open incision or laparoscopically.
Siliastic Ring Vertical A variant of the gastroplasty described above. Here, the Gastroplasty stomach is again divided by a row of staples to produce a
small gastric pouch. In this procedure, the new, smalleroutlet of the new gastric pouch is reinforced by a siliconeband to produce a narrow exit into the old section ofstomach, as detailed above.
Laparoscopic Adjustable This is a newer surgery, known as the LAP-BAND, ap-Silicone Gastric proved by the U.S. Food and Drug AdministrationBanding (LASGB) in . It is only performed laparoscopically, as its name
implies. Here, a new gastric pouch is formed with sta-ples, as with the gastroplasty, but the band surroundingthe outlet from the new pouch into the old part of thestomach is adjustable. This is achieved because the bandis connected to a reservoir that is implanted under theskin. The surgeon can then inject saline (saltwater) intothe reservoir, or remove it from the reservoir, in an out-patient oce setting. This means that your surgeon canthen tighten or loosen the band, adjusting the size of thegastric outlet.
Restrictive Roux-en-Y Gastric The RYGB is the procedure most commonly performedMalabsorptive Bypass (RYGB) and accepted. It involves creating a small (13 oz) gas-
tric pouch by either separating or stapling the stomach.This pouch then drains via a narrow passageway to themiddle part of the small intestine, the jejunum. Thisbypasses the duodenum, which food would normallytraverse before arriving at the jejunum. The older portionof stomach then goes unused and maintains its normalconnection to the duodenum and the rst half of thejejunum. This end of the jejunum is then attached to anew small intestine created by the procedure above.This creates the Y referred to in the name of the proce-dure. This redirection of the small intestine creates amalabsorptive component to the procedure, in
Aaron Becks seminal work on CBT for depression was modied by Fair-
burn and colleagues for use with patients with bulimia nervosa (BN)
(Fairburn, ). CBT has been tested in numerous controlled studies
and has been found to be the most eective psychotherapeutic approach
to the treatment of BN. CBT has been found more eective than delayed
treatment, nondirective therapy, pill placebo, manualized psychodynamic
therapy (supportive-expressive), stress management, and antidepressant
treatment. Becks work has since been further modied for use with pa-
tients who compulsively overeat or binge, such as many of those who
have developed obesity.
The main focus of CBT, when working with overweight or obese indi-
viduals, is to address the negative thoughts that cause and maintain the
behaviors associated with being overweight. Interventions are designed
3
Name of Procedure Description
addition to the restrictive gastric pouch. RYGB may beperformed with an open incision or laparoscopically.
Biliopancreatic Diversion This surgery is considered more technically dicult(BPD) and is less commonly performed. It involves a gastrec-
tomy that is considered subtotal, meaning that it leavesa much larger gastric pouch compared with the other op-tions described above. The small intestine is divided atthe level of the ileum (the third and nal portion of thesmall intestine), and then the ileum is connected directlyto this midsize gastric pouch. The remaining part of thesmall intestine is then attached to the ileum as well. Thisprocedure thereby bypasses part of the stomach and theentire duodenum and jejunum, leaving only a small sec-tion of small intestine for absorption.
Biliopancreatic Diversion BPDDS is a variation of the BPD that preserves the rstwith Duodenal Switch portion of the duodenum, the rst section of the (BPDDS) small intestine.
Jejunoileal Bypass This surgery bypasses large portions of the small intes-tine; it is no longer recommended in the United Statesand Europe due to an unacceptably high rate of compli-cations and mortality.
to combat these cognitive distortions in order to produce lasting change.
In addition, more generally, CBT has been used to help with depressed
mood, anxiety problems, and low self-esteem, all of which are common
to obese patients, as well as to those contemplating surgery or recover-
ing from it.
In the last few years, increasing interest in treating a subset of BN pa-
tients who binge eat but do not purge (binge eating disorder or BED)
has arisen. It appears that despite considerable symptomatic overlap in
terms of both behavior (binge eating) and psychological concerns (low
self-esteem and weight and shape concerns) there is a growing consen-
sus that they are a distinct diagnosis. The most eective treatments for
BED are similar to those eective for BN, particularly CBT. Generally
CBT has the most evidence to support its use, and CBT-based self-help
manuals may be even more eective in those suering from BED com-
pared to those with BN (Hay et al., ).
Although patients with BN and BED dier from typical bariatric sur-
gery candidates, there is convergence in some important areas that sup-
ports the use of therapeutic treatments such as CBT to help with simi-
lar problems among bariatric surgery candidates. Problems such as binge
eating, dissatisfaction with body shape and weight, and issues concern-
ing control over eating are examples of common concerns. In addition,
depressed mood and anxiety, as well as low self-esteem, are common in
many patients considering bariatric surgery or recovering from it. Thus,
it appears reasonable to extrapolate from the current database of sys-
tematic research for eating disorders, anxiety, and depression to the popu-
lation of patients seeking bariatric surgery. In addition, it is unlikely that
systematic research in the specic area of psychological treatments for
bariatric surgery will be forthcoming soon. The current manual is there-
fore an extension of the existing research in a novel area based on its util-
ity for related concerns for which there is an extensive database.
Working With the Pre-Operative Patient
Recent media reports about surgical success stories may make many pa-
tients unrealistic about their goals or the ease of surgery as a choice. A
lot of patients arent prepared for the radical changes they need to make
4
to their lifestyle and eating habits post-operatively in order to ensure they
reap the maximum benets of their surgery. Making a commitment to
eat healthfully and nutritiously and to exercise regularly is the key to
guaranteeing long-term success. Sustaining weight loss after undergoing
bariatric surgery of any type requires that the patient adhere to a strict
diet while following the very specic recommendations of his or her
primary care physician, dietician, surgeon, and other members of the
team. Without the patients strong level of commitment to a future as
a thinner and healthier person, the probability of the surgery leading to
permanent weight loss maintenance is limited.
The program outlined in this guide will help you teach your pre-operative
patients the skills required to adapt to the lifestyle and dietary changes
that are necessary in order for them to sustain weight loss after surgery.
Based on CBT techniques as described above, the program incorporates
basic cognitive restructuring and problem-solving skills to help your pa-
tients change their negative thoughts about food, eating, their bodies,
and themselves. Through this program they will develop a more thor-
ough understanding of all aspects of their past and current problems
with food and weight. It will also help your patients establish a regular
pattern of eating, teach them about self-care and how to replace their
negative eating habits with other, more pleasurable activities, and assume
a lifestyle consistent with long-term weight loss maintenance.
Use of the Workbook
The corresponding patient workbook will aid you in delivering this
CBT-based treatment to your pre-operative patients. It is organized by
skill (e.g., monitoring and recording eating habits, establishing a sched-
ule for weighing-in, replacing eating with alternative, pleasurable activi-
ties, etc.) and correlates directly to this therapist guide. You may spend
as many sessions covering each skill as necessary. The workbook contains
user-friendly and interactive exercises, forms, work sheets, and checklists
that your patient will complete either in-session or as homework as a
way to reinforce these skills. All of these documents can be photocopied
from the workbook or downloaded from the TreatmentsThatWork Web
site at http://www.oup.com/us/ttw so that your patient is able to extend
the therapeutic experience outside of the oce.
5
This page intentionally left blank
Materials Needed
Figure .. The Cognitive Behavioral Model of Overeating
Outline
Teach patient about the cognitive behavioral (CBT) model for under-standing the development of weight and eating issues
Personalize the CBT model based on patients experiences
Help patient understand the way in which weight loss surgery is likelyto aect these issues
If your patient is obese, that means that he has been overeating in one
way or another (e.g., taking in more calories than the body needs and
storing the excess as increased body weight or body fat.) It might surprise
your patient, as you discuss the contributions to his weight problem, to
nd out that there are dierent forms of overeatingand that he might
engage in some, but not others. It is important to help your patient iden-
tify the types of overeating problems that she or he has, so that appro-
priate interventions can be developed. As you discuss the following sec-
tion with your patient, you can help him identify the types of overeating
behaviors that she or he might engage in most frequently and help the
patient to understand the various contributions to these behaviors, as
well as ways to stop.
7
Chapter 2 Understanding Your Patients Eating Behavior
(Corresponds to chapter of the workbook)
Types of Overeating
You will want to educate your patient about dierent types of overeating.
Overeating can come in various shapes and sizes. For example, there can
be binge eating episodes, e.g., typically quite large and out of control
eating episodes in which a sizable quantity of food is consumed in a
short period of time and in a manner that is considered to be quite dif-
ferent from an average persons eating experience. A binge episode is one
that usually leads to a feeling of being uncomfortably full or stued.
On the other hand, overeating can sometimes take the form of grazing
throughout the day, e.g., taking in relatively small amounts of food fre-
quently between standard snack and meal times, usually in response to
cravings, boredom or other emotions, or the mere availability of food.
For some individuals, overeating episodes are followed by a strong resolve
to eat less, under-eat, starve for a few days, exercise more, or in extreme
cases, to purge the excess food. Those who follow episodes of overeating
with purging (or extreme or compulsive exercise or starving) on a regu-
lar basis are classied as having bulimia nervosa as opposed to binge
eating disorder. Most individuals who eventually become obese have
not been engaging in regular, successful purging; if they had, it is much
less likely that they would be as overweight as they are. On the other
hand, if your patient has been purging regularly (but has still managed
to become obese) it is probably wise to encourage the patient to delay
surgery until the purging behaviors are fully resolved.
Once you help your patient to understand the specic nature of the
overeating habits, you can help him t these into a larger model based
on cognitive behavioral theory that takes into account other aspects of
lifestyle and current circumstances. As you discuss this model with your
patient, keep in mind that your goal is to help the patient better under-
stand the interrelationships between eating behaviors and weight, other
factors in his personal history, and the current situations, thoughts, and
feelings that he encounters.
An Illustration of the Cognitive Behavioral Model of Overeating
You will want to spend considerable time educating your patient about
the CBT model of overeating and later helping draw out a form of the
8
model that reects the patients unique experiences. The CBT model of
overeating and overweight links the overvaluation of thinness in our cul-
ture; pressure and intentions or attempts to diet; resulting feelings of
deprivation, loss of control, and overeating (sometimes compounded by
factors of low mood, conicts with others, feelings of fatness, etc.); over-
eating (whether by grazing, compulsive overeating, or binge eating); loss
of clear hunger and fullness cues; weight gain; increasingly negative emo-
9
WEIGHT GAIN AND OBESITY
CULTURAL FACTORS/WORRIES MOODS, CONFLICTS,
ABOUT HEALTH ALL LEAD STRESSORS TO ATTEMPTS TO DIET
LOSS OF CONTROL, OVEREATING
MOMENTARY PLEASURE FROM FOOD
FEELINGS OF SHAME, GUILT, REGRET, FAILURE,
DEPRESSION
Figure 2.1
The Cognitive Behavioral Model of Overeating
tions (from all kinds of sources: negative view of the self, interpersonal
conicts, specic failure experiences); and resignation/giving up, as well
as increasingly turning to food as a primary source of gratication.
The Cognitive Behavioral Model of Overeating
Figure . illustrates the vicious cycle of overeating followed by subse-
quent attempts of various types to control eating that applies even to
those who are overweight and for that reason deemed failures at being
restrictors. You will want to discuss the model and the rationale for the
model at length with your patient.
The CBT model of overeating, as described above, suggests that there
are specic links between certain eating behaviors, attitudes, feelings,
and weight. For example, in our culture as a whole, most people tend to
value, if not overvalue, thinness or even in some cases, extreme thinness.
The pressure to eat less felt by those who are overweight who also place
signicant value on thinness can be overwhelming and at times lead ex-
actly to the behavior that is most unwelcome: that of overeating. For
some, overeating in the short term is quite pleasurable and therefore mo-
mentarily combats the stress and depression that can accompany the ex-
perience of being overweight or obese. In some instances, eating has be-
come the primary tool for gratication and pleasure that an overweight
individual has learned to use to soothe himself in the event of negative
emotions or problem situations.
Typically after a brief period of pleasure, however, overeating can lead to
negative feelings and thoughts about oneself and an overidentication
with the experience of failure, at least with respect to eating and weight
control. While massive eorts to diet and exercise, even unsuccessfully
(e.g., sometimes just hypervigilance or emotional energy about these areas
or simple good intentions without a lot of productive action), can fol-
low bouts of overeating, this extreme eort might lead to feelings of
stress and deprivation (even if the actual amount of food consumed and
physical exertion through exercise remains about the same). Your pa-
tients eorts to diet might leave him feeling as if he isnt allowed to eat
to satisfaction or doesnt have the right to eat the foods that he likes. Fre-
quently, these feelings can trigger episodes of overeating no matter what
10
their source (e.g., actual, successful dieting and weight loss or intentions
to diet that fall short of the goal of actually cutting back).
In addition to the experience of deprivation, other aspects of a persons
life might contribute to a lowered threshold for overeating. For example,
general stress, intense emotions of other types (low mood, euphoria, anxi-
ety, grief ), conicts with others, and a distorted sense of hunger and full-
ness from a history of overeating and purging can create a situation in
which it is impossible to clearly discern hunger and fullness cues.
Finally, there are often historical factors associated with overeating and
becoming overweight. These might include: the early experience of being
teased and labeled fat; having been forced to diet as a young child; re-
treating into overeating and weight gain to avoid certain challenges as-
sociated with growing up; or attempting to cope with trauma of one
type or another. In adulthood, overweight and overeating can often be
associated with pregnancy, raising children, becoming more sedentary
after starting to work again (or leaving a job), or having been forced to
give up certain sports or physical activities due to medical conditions or
injuries. For some, excessive weight gain might be associated with exces-
sive alcohol intake, eating more due to drinking less, or discontinuing
either smoking or stimulant drugs.
You will want to spend a considerable amount of time talking with your
patient about all of the aspects of his life, past and present, that have
played a role in his having become overweight, so that ample time can
be spent understanding and working through the issues.
Your patient will be using the blank space that is provided in his work-
book to draw out a version of the CBT model that best ts his own ex-
perience. An example is shown below in Figure .. During sessions in
which you discuss the CBT model, you might help the patient start link-
ing it to his experiences by thinking about and noting a few of the rele-
vant factors in his growing up years (that he is aware of ) or any other as-
pects of his history that have aected his eating behaviors and his weight
over time. Then you might want to encourage your patient to write in
more detail about his particular experiences as they relate to the various
aspects of the CBT model, as presented in the following exercise. Fol-
lowing this exercise, you will be discussing with your patient the speci-
11
12
It seems that overweight and depression run in my family. So I was
overweight from a fairly young age. The problem seemed to get worse over
time. As I became an adolescent and looks started to be more important, I
retreated somewhat socially and started to eat as a way to make myself feel
better. Obviously, this made the weight problem worse . . . It has been hard
ever since. Even though I have dieted a number of times, none of the weight
losses that I have accomplished have stuck for more than a few months.
Then when I started to have kids my weight just got higher and higher . . .
until the point where it seemed futile to try to do anything about it. Although
I exercised in the past, with increasing weight it has been more and more
difficult to move around, and for that reason I havent done much exercise at
all in the past couple of years, again making the weight problem even worse.
So the surgery seems to be my only solution at this point.
Family history of weight problems and depression
Increasing weight led to decreasing physical activity and more weight
gain
When I dieted I would feel deprived and then eat more as a result . . .
Eating to feel better e.g., to get over social isolation and depression
Diets didnt work anymore and frustration led to more eating and weight
gain and lower mood.
Also stress of any type has usually triggered some overeating.
Figure 2.2
Sample of Patients CBT Model
c emotional, cognitive, and behavioral eects of problems with weight
and overeating.
The Effects of Overeating: Emotional, Cognitive, and Behavioral
For many people, overeatingwhether triggered by available food; crav-
ings; negative emotions such as depression, anger, or boredom; conicts
with other people; or a desire to distract oneself by creating a new
focus for negative energycan lead to a variety of dierent outcomes.
As stated in the section above, it can be gratifying or uplifting in one way
or another. For example, it can provide a form of pleasure when there
are few pleasures available; it can distract from dicult thoughts or feel-
ings about any number of problem situationsin a sense it shifts the
focus from one problem to another; it can provide a method for acting
out or breaking the rules for someone who otherwise is quite compli-
ant and sensitive to doing only what is right.
No matter what causes an episode of overeating, in response to its oc-
currence, in many cases one feels not only an urge or desire to restrict in-
take, but also usually a whole host of negative emotions, thoughts, be-
liefs, and behaviors about oneself in relation to having overeaten, which
develop fairly soon after the episode, even if the eating episode was on
some level gratifying. These thoughts and beliefs might take the form of
I am never going to lose weight, I am the only person who engages in
this behavior, or even more negatively I am a fat pig or I am a loser.
These thoughts and beliefs can generate an array of negative feelings.
Some of these may include: sadness, self-disgust, anger at oneself and
others for having gotten into the situation in which overeating occurred,
despair, and resolve not to do it again and a commitment to start diet-
ing or restricting intake on some level as soon as possible after the over-
eating episode is completed. For some people, overeating in the form of
continuous grazing and consuming excessively large meals and snacks
might not trigger so many extreme reactions but rather strengthen or ig-
nite a sense of resignation and inevitability of future overeating and con-
tinued weight gain. In many cases, the negative thoughts, feelings, and
beliefs also lead to compromised behaviors such as not getting out so-
cially to see friends, feeling too full to do other tasks, whether chores or
13
recreational activities, or even additional overeating that may be an at-
tempt to further escape from the bad feelings.
Gastric Bypass Surgery and the CBT Model
Since the experience of weight loss surgery will change your patients re-
lationship to food quite dramatically, the issues discussed above need to
be considered in a dierent light. Mostly, weight loss surgery will help
your patient better manage his reactions to both hunger and fullness
(satiety). Specically, after weight loss surgery of any type, your patient
can expect to feel hungry less frequently and less intensely than before
(for those who do actually experience hungersome obese people do
not). Also it will take much less food to ll your patient up once he does
start to eat after becoming hungry. And your patients method of eating,
which will involve taking very small bites of food, chewing them very
well, and eating very, very slowly, will also increase the likelihood that he
will feel full on much less food. Also, your patient will be given infor-
mation about which foods to include in his diet and which to avoid, as
well as strategies for alternating his intake of foods and liquids.
While, ultimately, the goal of weight loss surgery is to reduce your pa-
tients hunger level so that he can make wiser and less impulsive deci-
sions about food, this surgery benet can also come with certain costs.
These might include the experience of deprivation that can accompany
regular dieting when certain foods in certain quantities are restricted or
the experience of being left without tools if your patient has used food
as a primary means for coping with problem emotions and situations.
Without replacing food with other positive and well-practiced tools for
coping, any individual who is even enthusiastically attempting to restrict
intake by choice can be left feeling unsettled, frustrated, deprived, or out
of control. These feelings can lead to urges to overeat. Solutions for the
problem of being left without tools will be discussed in a later chapter.
You will discuss with your patient the reality that even after weight loss
surgerywhich by now he should understand is no magical cure
overeating can happen, in one form or another. For example, your pa-
tient might nd himself unintentionally experimenting with creative
strategies for overeating. These might include: frequent ingestion of
14
small quantities of indulgence foods that are not ideal, such as very small
amounts of sweets, candy, or peanut butter, or taking in increasingly
larger quantities of food, particularly once the new stomach pouch
stretches some. He may deliberately overeat certain foods that are no
longer digestible because of the particular type of surgery he had (e.g.,
fats after the duodenal switch procedure) and come to rely on the mal-
absorption syndrome, or dumping, as a method of purging the excess
calories.
Despite the surgerys assistance in controlling your patients eating, at
least some of the fundamental features of the CBT model will still apply
to his struggle to manage his intake. In your therapy sessions, you will
want to determine those areas that might prove to be high-risk. For ex-
ample, while your patient might not feel physically hungry after surgery
in the same manner as before, he might still struggle with physical and
psychological cravings for particular types of foods or for food in gen-
eral. Associated with these cravings may be emotions of frustration, loss,
sadness, or even despair. He may feel that he will never be able to con-
sume any of these foods again or that he will always struggle with intense
cravings. While the use of words like always and never signies that your
patient may have been triggered into a cognitive lapse that involves
clearly problematic and unhelpful thoughts, these errors in thinking can
be addressed and modied using cognitive restructuring procedures (see
chapter ). By the same token though, no matter how skillfully you might
address the problematic thoughts with your patient, it is equally impor-
tant to help him get his behaviors onboard so that he doesnt inadver-
tently contribute to any of the problems noted above.
Similarly, it is important to address any problem emotions your patient
might notice in association with his surgery. In some cases, losing a sig-
nicant amount of weight even after weight loss surgery can lead to the
experience of excessive hunger, cravings, and eventual overeating, as the
body struggles to reestablish its former set point. Also, in some cases,
negative emotions can accompany even desirable, radical weight loss and
can lead to a pattern of emotional eating.
As you discuss your patients personalized version of the CBT model and
work hard to understand all of the issues involved, you will be able to
more clearly help your patient ascertain the areas that need the most re-
15
habilitative work prior to surgery. No matter what, it is likely that one
or more of the following chapters will help your patient address the is-
sues that are most troubling.
Homework
Read about and review the CBT model for understanding eating andweight issues.
Create a personalized version of the CBT model and discuss this withyour therapist.
Review the implications of weight loss surgery on the CBT formulation.
16
Materials Needed
Form: Food Record
Outline
Explain to patient the rationale for establishing a regular pattern ofeating
Teach patient to establish a regular pattern of eating
Introduce patient to food records
Teach patient a method for keeping track of eating using food records
The CBT model of overeating explains the interrelationships between
eating, thoughts, emotions, weight gain, and other behaviors and situa-
tions, and purports that the rst steps toward making changes in this
vicious cycle need to be taken at a behavioral level. For example, a key
component in your patient overcoming her problem eating habits or at-
titudes involves her making a commitment to gathering more data about
her eating behaviors by keeping some form of eating record. Another key
factor involves her willingness to establish a regular pattern of eating, in-
cluding keeping to a schedule of healthy, balanced, and not overly in-
dulgent nor overly stingy meals and snacks to interrupt any problematic
cycles of overeating followed by compensatory under-eating. You will
want to discuss both of these principles and the following rationale in
more detail with your patient in the sessions that deal with these issues.
17
Chapter 3 Helping Your Patient Keep Track of His or Her Eating
(Corresponds to chapter of the workbook)
You will want to sell your patient on the CBT belief that the prescrip-
tion of a healthy, regular pattern of eating can disrupt the strength of the
links in the model of problematic eating. Helping your patient to dis-
entangle these links and clean up her eating patterns by eating on a
regular but modiable schedule can help her free up her eating behav-
iors from inappropriate inuences (those that arent related to hunger or
fullness). In this way your patient can slowly achieve healthier eating be-
haviors and associated attitudes. In many cases, too, this plan for regu-
lar eating can help your patient slowly work toward her weight goals, since
the pattern can help her combat any episodes of impulsive overeating.
The Importance of a Regular Pattern of Eating
The treatment of choice for problematic overeating behaviors that occur
in response to triggers of any type has been the prescription of a regular
and healthy pattern of eating (such as three meals and two snacks a day).
Obviously the specics of the planned eating pattern (e.g., the exact
contents and quantities) will dier from individual to individual and
will also depend upon the exact nature of the surgery that your patient
is planning to have and the recommendations of her particular surgery
center. By and large, though, these recommendations will include the
suggestion to consume three small meals and two or three small snacks
a day (or ve or six small meals) that are eaten not fewer than about
hours apart and not more than about hours apart. The rationale behind
this recommendation is that by eating in response to a exible but pre-
determined schedule, nonessential and inappropriate food and eating
cues such as those described above (e.g., emotions, cravings, the avail-
ability of food, and various interactions with people) will be washed out
over time. As you will explain to your patient, the belief is that this me-
chanical style of eating by the clock will gradually become more auto-
matic and natural, and increasingly will correspond to the ebb and ow
of hunger and satiety signals as these are progressively retrained through
adherence to the schedule. In this way, over time, eating will be initiated
appropriately albeit somewhat exibly at meal and snack times, approxi-
mating the pattern that your patient will need to adopt post-operatively.
18
Your patient will obviously learn a lot about nutrition pre- and post-op
from her dietician. However, you will also discuss the importance of eat-
ing nutritionally dense meals and snacks after surgery with your patient
during the sessions focused on establishing a regular pattern of eating.
At the same time, you will talk to your patient about the fact that in ad-
dition to super-nutritious food and correct eating and uid intake pat-
terns, healthy eating (in both the physical and psychological sense) must
also involve some allowances for certain small treats that are at least
somewhat indulgent. This will help stop problem cravings and depriva-
tions that lead to out of control episodes of overeating (to the extent that
that is possible after weight loss surgery). As you will review time and
again with your patient, the essential tool for getting eating behaviors that
have gone awry back on track is a normalized relationship with food.
If your patient has had particular diculties making a commitment to
eating by the clock, suggest that she try hard to gure out in advance
just about when, just about what, just about how much, and just about
where each meal and snack will take place. Furthermore, she will get the
most mileage out of this type of exercise if she sketches out these plans
in some sort of draft or meal plan, either in a journal or an actual food
record. Working in this way on a regular basis will represent a very sub-
stantial step toward her liberating her eating habits from inappropriate
inuences not really connected to physical hunger.
Using Food Records
The rst step in helping your patient try to understand more about her
eating patterns and associated thoughts and feelings, and the contexts or
situations in which she struggles with these, involves learning to record
all of her behaviors in journal form, using what is commonly known as
a food log or food record that provides details beyond the sketch-
ing a plan in advance noted above. Explain to your patient that the food
record is all about gathering data so that she wont have to rely on her
memory alone to understand the details of her eating patterns, all that
contributes to them, and how her weight is aected by the current pat-
terns and any changes to them. Inform your patient that when she com-
pletes food records, she also has created a written record of her eating be-
19
havior that can be discussed in detail with you during sessions. You can
talk with your patient about her prior experiences, if any, with food
records and any associated thoughts and feelings that she has about food
records based on those experiences.
Your patient might be quite skeptical about food records if she has
worked with them before, perhaps in a structured diet program, while
meeting with a dietician for consultation, or in some type of behavior
therapy. Her reaction might be this is not going to workit never did
before! Or she might feel as if keeping food records is all about being
controlled by her therapist or dietician. No matter what, all of these
sentiments need to be explored in your sessions with her. Forewarn your
patient that to succeed with this program she will need to transcend her
tendency toward skepticism and trust that this experience with food
records can be dierent, that is, that she can productively and therapeu-
tically use these records to her advantage, rather than feel as if she is
completing an assignment for someone else. Assure your patient that
regularly completing food records in the context of this particular CBT
therapy will be a dierent experience than any she has had before, if she
uses them as recommended in the program. Remind her that if she
wants to really succeed with her food records, the best way for her to pro-
ceed is to make a commitment to recording her food intake (all meals,
snacks, binges, or grazing episodes and uid intake) as close to the time
of eating as possible. Any delay in her recording can lead to inaccuracies
and even more importantly, the experience of disconnect between her
eating and what she will later record in her food records. Remind her
that she should raise any questions about the food records with you.
A sample completed food record is included in Figure .. A blank copy
for your patients use is available in the workbook. Your patient may pho-
tocopy the blank record from the workbook or download multiple
copies at the TreatmentsThatWork Web site at http://www.oup.com/
us/ttw.
Encourage your patient to use the food records daily and to make her en-
tries as close as possible to the time that she is eating. She can also use
the records to plan her eating patterns and specic snacks and meals in
advance, and then cross-check to ensure that she has followed through
on her plan. Either way, educate your patient that if done correctly, the
20
food record can be an invaluable addition to her self-care plan around
food. Go through the various features of the food record with your pa-
tient, noting that there are places on the record to indicate the time that
she is eating, the amount and contents of the food and liquid consumed,
and whether or not she considered the eating episode to be a meal or a
snack, to be pro-plan or anti-plan, and what the situation or context
was surrounding that particular eating episode. Where was she? Who
was around? What was she thinking? What was she feeling?
21
Amount of Food and Meal, Snack, Purge Thoughts, Feelings,Time Place Liquid/Description Binge, Graze? Y/N Situation/Context
8:00 a.m. Standing 1 corn dog with bun, Breakfast Just a typical morningin kitchen 1 hot dog with bun,
mustard, ketchup, cheese with both1 glass orange juice
10:30 Work 1 package Hostess Snack My usual snackat desk Ho Hos from
vending machine11:30 Friends handful of M&Ms Grazing a bit They were there,
Desk so I ate them.12:30 p.m. In car, 3 tacos, a burrito, and Lunch At least I didnt
drive-thru a large Coke have dessert.Taco Bell
3 p.m. At desk glass water, handful Snack I am trying to be peanuts good with the
water.6 p.m. In kitchen several slices cheese Just snacking I will try to eat less
preparing and 610 Ritz while I cook at dinner.dinner crackers dinner
6:30 Kitchen plate of spaghetti with Dinner I made it so I wanted table with meat sauce, salad with to enjoy it.family ranch dressing, 3
pieces garlic bread with butter, slice applepie, 1 glass 2% milk
Figure 3.1
Sample Completed Food Record
Food Record
Your patients keeping an ongoing record of her eating in this way (in-
cluding the situation/context column) will make it possible for her, in
the context of her therapy with you, as well as any consultation sessions
with the dietician and surgeon, to really understand all of the eating and
other behaviors and thoughts that are contributing to and perpetuating
her eating problems, as well as the exact nature of the problems. With-
out records, and left to rely only on a memory of what happened with
food (given that eating tends to be an activity during which many people
space out, disassociate, or simply forget exactly what they were doing),
it is highly likely that your patients recollection of her eating will be in-
complete and inaccurate.
Discuss with your patient that in many respects, the whole point of food
records has to do with the idea of connection, that is, that she stays
connected to her own eorts to regularize her eating. Remind her that
the food record can help her track her progress on a meal-by-snack basis,
thus providing reinforcement and motivation to stay on track each and
every step of the way. Along the same lines, the record can also serve as
a tool of intervention when she is at risk for lapsing into a nondesirable
eating behavior. Every time she is able to examine completed portions of
her food record and note the number of success experiences that she has
had, she can ease herself back into the groove when she might have
been tempted to feel negatively about her progress and throw in the
towel. Discuss with your patient the fact that when she uses her food
record as a tool of motivation and intervention, she will be taking full
advantage of the methodology. Of course, her food records will also be
helpful in providing an accurate record for you. Remind her, however,
that food records are really most powerful when used to make day-to-
day choices about each and every meal, snack, (and glass of water) that
she decides to consume.
Working With Adolescents
If your patient is a teenager, there are some important factors that aect
his or her ability to establish a healthy routine for eating. The teenager
may not control either the foods that are in the home or the times that
the family eats. So, it is important that you work with your patients par-
22
ents, and to a certain extent the entire family, to promote their under-
standing and acceptance to change things. This will likely require that
you meet with parents together with your patient to discuss how a struc-
tured eating program can be undertaken at their home. This involves
identication of very specic obstaclesnot eating meals at regular times,
parents not preparing meals, fast food as the main or common meal type,
and so on. Each of these will need to be addressed and solutions identied.
Sometimes this will involve asking parents to shop with their teenager
for a period of time in order to make sure the right foods are available.
Sometimes teenagers dont like to keep food records. There is enough
homework already, and keeping track of what they eat seems like a waste
of time. However, it is important to try to overcome these hesitations.
You will learn a lot about what and how they eat that will be essential to
therapy. When you are rst getting started, you and your patient will
likely complete food records in-session to give her the idea and to show
her how they can be useful. Sometimes, you may ask parents to remind
their teenagers to complete the food records. Over time, these food records
will also be helpful when your teenage patient meets with his or her doc-
tors to illustrate how they have changed eating patterns and food choices.
This will help demonstrate their commitment to lifestyle changes needed
to support weight loss after bariatric surgery.
Homework
Review the rationale for maintaining a regular pattern of eating anddiscuss this with your therapist.
Read and review the rationale for keeping food records and discuss thiswith your therapist.
Review the instructions for use of food records.
In your therapy session, set appropriate goals for the number of daysyou will record your eating during the next week.
23
This page intentionally left blank
Educating Your Patient About Weighing Behaviors
(Corresponds to chapter of the workbook)
Materials Needed
Weight Graph
Appearance and Weight Compliments Log
Outline
Educate patient about the rationale for and method of regular weighing
Teach patient about the importance of other means for checking onand measuring his body weight, size, shape, and general appearance
Help patient understand the link between healthfully monitoring hisbody size and keeping track of other healthy attitudes and behaviors
A Regular Pattern of Weighing
Most likely, your patient has discussed with you, as well as with his sur-
geon and dietician, and possibly with his internist, a regimen for weighing
himself regularly before weight loss surgery that makes sense. As your
patient prepares for his surgery, it can be helpful for him to weigh in
weekly with one of his doctors, so that changes in his weight in either
direction can be observed on a regular basis before too much time passes.
In this way, any necessary modications (e.g., increasing or decreasing
intake or activity) can be made as needed. In some cases, because your
patient might still require a special scale for weighing (most likely if his
weight is still pounds or above), it might actually be impossible for
25
Chapter 4
him to weigh at home and therefore necessary for him to use a doctors scale
to get an accurate reading of his weight until it drops into a lower range.
The rationale for regular or weekly weighing is easy to understand, and
your patient has probably experienced certain thoughts and feelings
about weighing himself (or being weighed by someone else) that will sup-
port the rationale. For example, for many people with weight and eating
problems, weighing themselves has over time become fraught with an
incredible amount of stress and pressure, perfectionism, self-doubt and
self-blame, anger directed inward and outward, and a number of other
perceptions and feelings (some positive, when the numbers were going
in the right direction). Typically, these issues and complexities in relation
to weighing have developed over time in response to your patient hav-
ing made a number of ultimately unsuccessful dieting eorts (as evi-
denced by the patients decision to undergo weight loss surgery). As a re-
sult of this level of sensitivity that your patient carries about his weight,
including potentially becoming too upset in response to unwanted weight
gain and too excited in response to weight loss, he has become over-
invested in what will be revealed about him by the numbers in any par-
ticular instance of weighing. And most likely that has led to the devel-
opment of certain patterns in the way that he weighs himself, which you
will be discussing in detail during the sessions devoted to this topic. For
example, you will want to spend some time educating your patient about
common patterns in weighing among those with eating and weight con-
cerns. Some people who are highly vigilant and reactive to the numbers
on the scale, and who use the numbers to dene crucial aspects of them-
selves such as their self-worth or lovability, may check the scale daily or
even more frequently (if this is possible given their weight) to ensure
that the numbers have changed, or havent changed, or in any case to get
a sense of what the numbers are saying about them. Others might
avoid the scale altogether to avoid the emotional impact that the num-
bers are likely to have.
The Risks of Weighing Too Frequently
This pattern of weighing (less likely for obese individuals than patterns
of avoidance) is problematic because it allows people to overreact (e.g.,
cognitively, emotionally, behaviorally) to very minute changes in their
26
weight that virtually have no meaning at all. Shifts of one or more pounds
in either direction that might reect sodium or uid intake changes from
the day or days before can cause fairly exaggerated responses in these
scale-sensitive individuals of either self-denigration or elation. Both
responses are inappropriate given the predictable and meaningless na-
ture of those types of weight changes, which are most likely to be tem-
porary and not indicative of actual fat or lean body mass.
Avoiding the Scale
On the other side of the continuum is the problem of weighing too in-
frequentlyor even avoiding the scale altogether. Some people with
weight and eating issues have had such negative or emotionally power-
ful experiences with the scale that they feel unable to tolerate any relation-
ship at all with the numbers and therefore avoid the scale at all costs.
In some cases, even at physicians oces, these individuals might ask to
stand backward on the scale and request that the health care professional
who is weighing them not even comment on the numbers. While this
pattern of scale avoidance might in fact spare an individual with this type
of extreme sensitivity from some short-term unpleasantness or overly
strong emotional reactions, it can, on the other hand, collude with their
perceived need to distance from the scale. Maintaining this type of dis-
tant or avoidant stance can contribute quite a lot to a person unknow-
ingly allowing their weight to change in the undesired direction (e.g.,
weight gain in the obese population). This happens easily due to the
absence of a feedback loop, that is, no source of reasonable feedback
about what is happening with the persons weight over time in response
to the various eating habits that have been sustained since the last weigh-
in (which in some cases involving highly avoidant people might have
been years ago).
It is important to inform your patient that avoiding the scale for too long
can lead to an actual fear or phobia of the scale or the experience of
weighing-in, which is not unlike other types of phobias (e.g., a fear of
heights). In these instances, not only is the fear of weighing incredible,
but the pressure to avoid is extremely powerful, too, and as time goes on
without the person normalizing contact with the scale or the experi-
27
ence of weighing-in, the numbers take on an even more exaggerated
level of importance to the point where they become even more extreme
in their power to determine how the person feels about himself. As you
discuss the patterns of weighing with your patient, you can explore the
various meanings attached to his pattern of using the scale. Typically, a
pattern of too-frequent weighing suggests extreme anxiety and some
magical ideas about controlling the outcomes through hypervigilant
checking, while a pattern of avoidance suggests that the numbers on the
scale have come to mean something to the person that extends way be-
yond the domain of eating and weight control and has huge implica-
tions for his emotions and self-concept.
No matter what the particulars of the pattern your patient might be en-
gaging inone of overly frequent weighing or avoidance of the scale
these relationships to weighing are problematic in that they suggest an
overly strong emotional attachment to the numbers. This type of attach-
ment interferes not only with your patient developing a straightforward
and healthy pattern of tracking weight changes as they relate to eating
but also with his maintaining an appropriate and unembellished rela-
tionship between his weight and his sense of self (e.g., worthiness, lov-
ability, value, etc.).
Corrective Strategies: Weekly Weighing and Other Measurements
As you and your patient will discuss, one helpful strategy to address
problem patterns of weighing is to prescribe a pattern of weighing-in on
a regular and preplanned basis, such as once a week on a specic day, at
a specic time. Weighing regularly in this manner also is the best method
for obtaining accurate comparison data week to week, particularly as
changes in eatingalong the lines of weight loss dietingand possibly
activity patterns are made. This strategy can work for those who have
been weighing too frequently, by cutting into the overweighing pat-
tern in a very deliberate way. For example, once the day and time for
weighing are selected, and the weekly weigh-in has taken place, the scale
can be deemed o-limits either by encouraging the patient to put it into
a closet or other hard-to-reach place or by limiting access to it by taking
out the batteries or hanging a sign or do not cross rope as a reminder
28
and a motivator to stay away from the scale until the designated weigh-
in time rolls around again. Alternatively, if the excessive weighing has
been done in some other setting, problem solving and motivational ex-
ercises (e.g., analyzing costs and benets) pertaining to limiting access
to that scale or limiting visits to that place only to the weigh-in day can
help. In addition, relaxation, distraction, and cognitive-restructuring meth-
ods might be useful in addressing problem mood states such as anxiety
or despondence that might occur when your patient has contact with the
scale (or is denied contact with it, as the case may be). (These methods,
discussed in detail in chapters and , can be introduced here if neces-
sary; just encourage the patient to also skip ahead to the appropriate
place in the workbook.)
The strategy of committing to a specic day and time for weighing-in
also applies to those who have been scale avoiders. For those individ-
uals, it may be necessary to either purchase an appropriate scale for the
home or identify an alternative location (such as the doctors oce)
where the scale can be easily accessed once a week on a specic day and
at a specic time. For this group, weekly weighing might also warrant
supplementation with CBT tools such as problem-solving strategies, re-
laxation techniques (to combat anxiety that occurs before, during, and
possibly even after the weigh-in), and cognitive restructuring exercises to
combat any extreme or distorted thoughts that accompany the sight of
the numbers.
Explain to your patient that using a variety of measures related to weight
can be helpful, in part to take the onus and importance o of the num-
bers on the scale. Use of a weekly weight chart can help your patient
maintain a visual image of his progress toward weight loss before surgery
(as well as after). In your sessions, you can help your patient design a
weight graph using the blank graph included in chapter of the work-
book, in a form that will be maximally helpful to him. Your patient may
photocopy the graph from the workbook or download multiple copies
at the TreatmentsThatWork Web site at http://www.oup.com/us/ttw.
In addition to the weight graph, a number of other indices of body size
and shape can be useful in providing information about how the pa-
tients body is changing, without relying on the scale. These include the
obvious: tting into certain pieces of clothing or certain chairs (whether
29
at home, at work, in a movie theater, or on an airplane), measuring var-
ious parts of the body by using a tape measure or recording body com-
position (e.g., percentages of lean body mass and fat) by undergoing a
battery of tests that can determine this, and paying attention to an indi-
rect measure of weight loss by noting increased stamina in doing any
number of physical activities, including formal physical exercise (such as
walking, biking, and the like) and incidentals such as walking up the
stairs. It can be quite helpful for your patient to record some of the
data over time, as well as his perceptions of all of these changes in his
body by using a log similar to the food records. You can also encourage
your patient to think about keeping a record of compliments received
pertaining to his weight loss, which can be particularly helpful and in-
spiring. You can discuss some of the following areas in detail with your
patient.
How Your Patients Clothes Fit
Another very simple and easy way for your patient to gure out whether
or not hes on a weight loss trajectory is to try on various items of cloth-
ing to determine their t. If they are becoming more and more loose, he
is losing weight; if they are becoming tighter, he is gaining weight.
How the Furniture Fits Your Patient
This is another very simple way for your patient to track changes in his
body over time. It is important to remind your patient to notice that he
is much more easily tting into chairs and other furniture that proved
difcult for him in the past.
Taking Measurements
Another option that might appeal to your patient for tracking bodily
changes separately from the scale involves using a tape measure to mea-
sure various parts of his body (the obvious choices being waist, hips,
30
chest, upper arms, thighs, calves, etc.). This method can be effective in
offering additional information about the changes your patients body is
undergoing, as long as he measures fairly accurately. It can be difcult to
always get the correct or exact same spot, so your patient might have
to practice or ask for some assistance from a signicant other or possibly
his personal trainer, if he has one, if the results of the measurements
seem off in any way.
Changes in Body Composition: Percentages of Fat and Lean Body Mass
These days, it is not difcult to nd scales that measure body fat (al-
though the accuracy of some of these might be questionable), and your
patient might already have access to one of these scales. A more accurate
determination of body composition would be an evaluation at a health
club, gym, or medical center that offers such testing using calipers, under-
water weighing, or other even more sophisticated techniques. Finally, your
patients surgeon, dietician, or internist might also have access to the
most state-of-the-art techniques for tracking body composition over time
as your patient loses weight. You might encourage your patient to think
of the body composition measurement as a fun type of measurement
to obtain before and after his surgery.
Food Records
Remind your patient that food records, discussed in the previous chap-
ter, ultimately will describe everything that he needs to know about which
direction his weight will be heading in the near future. For instance, if
your patient is maintaining a caloric intake or food plan that is provid-
ing less energy than his bodily needs require, he will lose weight, and if
he is taking in more calories than he is expending, he will be on a weight
gain trajectory. By focusing on completing daily food records and exam-
ining actual behaviors, including the food intake and the output of exer-
cise and any other physical activity, your patient will feel more empow-
ered by recognizing that behavior has an actual impact on the outcome.
31
Ease in Moving Around
Your patient might want to keep track of general activities, such as ei-
ther how long he is able to engage in a certain activity, such as walking
at the mall, around the block, or on the treadmill, or swimming laps (or
walking laps) in the pool, etc. Your patient might alternatively want to
rate his level of exertion while doing an activity, which will provide yet
another helpful measure of how his weight loss and level of condition-
ing is progressing.
Compliments
You will be talking at length with your patient, at various stages of the
treatment, about his response to compliments about his weight loss. Ob-
viously, when losing weight, your patient may be, on the one hand, un-
comfortable to be noticed more than before or to be on the receiving
end of a lot of compliments about weight loss, particularly when there
is a lot to lose and when there may be a lot of thoughts and emotions of
a complicated nature tied up in the issue of his weight. But explain to
your patient that often it is these external sources of feedback (not un-
like the scale, to some extent) that can help a person work through dis-
tortions he might have in his perceptions of his weight. Obviously, these
should not be relied on as the only source of pride-generating thoughts
and feelings; in the end, your patients view of himself should serve as
his own primary source of enthusiastic feedback. However, in a pinch
or a low spot, others reactions can help bridge the gap from feeling low
to feeling better.
Remind your patient that, on the other hand, an absence of compli-
ments about weight loss does not have to mean much because in our cul-
ture of sensitivity to weight issues, some people may be reluctant to say
much of anything at all about a persons weight loss for a very long time
(until it is very obvious and visible) for fear of intruding or oending.
Your patient should remember not to let the absence of compliments get
him down as one can never know what is going on for another person
in terms of them perceiving, but not commenting on, the transforma-
tion that is taking place. Also, your patient might nd that he can expe-
32
rience a range of reactions to others compliments about his weight, from
feeling proud and grateful for the acknowledgement to feeling shy, overly
exposed, intruded upon, or even skeptical at times about what is being
said (this is common when a person does not yet feel their weight loss in
the way others see it). Help your patient gure out strategies he might
like to consider for responding to compliments and questions about his
weight loss that might come up simultaneously. Remind your patient
that there is never any obligation to fully explain anything to anyone
about how the weight loss was achieved; the fact that he had weight loss
surgery can be something that he decides to keep to himself. You can let
your patient know that an explanation that can suce in many dierent
situations is I made a commitment to eat healthy and exercise more and
that is how I lost weight! The reality is that those behaviors will be the
ones that best predict the long-term success of weight loss surgery and
are also the optimal result when an individual is compliant with all of
the recommendations made relative to the surgery.
A compliment log in your patients workbook provides space to docu-
ment the dates and types of compliments received from others regard-
ing his weight as it decreases over time. A sample lled-out Appearance
and Weight Compliments Log is shown below in Figure .. (In a later
chapter, there will be a broader discussion of body image issues that also
includes some assessment of others responses to your patients changing
appearance.)
Whatever combination of approaches your patient decides to use to mea-
sure body changes as he loses weight before surgery, it is important for
33
My Appearance and Weight Compliments Log
Date Source Positive Comments
10/31 man on street you look beautiful
11/10 friend youre really looking great
Figure 4.1
Sample Appearance and Weight Compliments Log
him to make a commitment to use at least a few of the assessment tools
on a weekly basis and write about them in a log similar to his food
record. This will allow him to review the changes over time, rather than
rely on his memory of them. Some of the more complicated methods
such as measuring body parts you might encourage your patient to do
just once a month, to increase accuracy and decrease overreactions to
disappointing results.
Homework
Find a place where you can weigh in regularly.
Begin to document your weight on the weight log.
Read and think about the other issues presented in this chapter.
Begin to make entries in your appearance and weight compliments log.
34
Materials Needed
List of Pleasurable Alternative Activities
Sleep Enhancement Strategies
Meaningful Roles and Activities Checklist
Outline
Educate patient about the importance of including pleasurable alterna-tive behaviors (e.g., those that dont involve food and eating) in her life
on a regular basis
Help patient establish a list of various types of these activities that canbe used in dierent situations
Enhance patients understanding of the issues of self-care in general andfacilitate patients improving various aspects of her self-care regimen
When Eating Has Been the Pleasure of Choice
Your patient might note that eating has become over time a primary form
of relaxation, pleasure, and enjoyment that always seems to be available
and literally at her ngertips. She might recognize that during certain
periods of time she has lapsed into a pattern of overeating to give her
pleasure because she has literally lost touch with other interesting, cre-
ative, fun, and active endeavors that she might have engaged in with en-
thusiasm in the past. Perhaps your patient began not only to avoid cer-
35
Chapter 5 Pleasurable Alternative Activities
(Corresponds to chapter of the workbook)
tain activities but also to avoid people and social situations in general,
due to shame or embarrassment about her weight.
In addition, your patient might have experienced certain emotions that
triggered an eating episode that may or may not have been primarily re-
lated to her weight, including depression, anxiety, or uctuating mood
states, that might have lifted temporarily when she ate something. As
you will discuss with your patient in the sessions that address this chap-
ter, food can briey and to some extent enhance mood by slightly chang-
ing brain chemistry in the direction that certain antidepressants do.
Sometimes, even intense, positive emotions might trigger your patients
urge to eat, since eating can provide a form of distraction and serve as an
anesthetic by calming and soothing a person in response to any form
of arousal.
On the other hand, your patient might believe that she is simply a per-
son who loves to eat and might attribute any or all overeating behav-
iors that happen (instead of other forms of recreation) to a fondness for
food. This view of food and eating might stem in part from your pa-
tients experiences as part of a certain cultural or ethnic community,
family, or social group whose relationships revolved to a great extent
around the experience of eating. Your patient might also ascribe to the
view of herself as someone who, in spite of eating a lot much of the
time, never really gets to the point of feeling full after a meal. Your pa-
tient might experience hunger or strong cravings for food despite know-
ing in her head that her appetite for eating is not reective of a real
need for more food. There are also some people who ultimately end up
overeating because food takes over or lls in a void where some other
type of substance abuse has left o. Your patient might be someone who
fought hard to withdraw from addictions to other substances, such as al-
cohol or drugs, only to nd that whatever was driving her to use these
substances resurfacedwith a vengeancein the form of appetite, crav-
ings, and motivation for food and eating. Finally, since many of those
who have struggled with weight and eating issues are in so many other
areas of their lives model citizens, overeating might have represented
one of the only opportunities for your patient to rebel or do exactly
what she wanted without allowing others to control or dictate her ac-
tions and without very extreme consequences (aside from obesity and all
that accompanies it).
36
Why Does Eating Food Feel So Good?
In any case, while your patient might be extremely frustrated about her
weight and her relationship to food and eating, it is likely that food by
this time is also strongly associated with her experiencing a form of easy
pleasureto the point that few if any alternatives may feel quite as
good, even if she pushes herself to give other options a try. (And, truth-
fully, it may be that no other activity will ever feel quite as good, or as
simple as food has, at least for some time, no matter how hard your pa-
tient tries. It is helpful to predict this dilemma to her and discuss it at
length.) Nevertheless, in order to aggressively combat weight and eating
problems, your patient must stay focused on the importance of replac-
ing her relationship with food with other pleasurable and meaningful ac-
tivities that dont involve food. As you discuss these issues with your
patient, make it clear that the reality is that turning to pleasurable alter-
native activities other than food will have to become part of her lifestyle
and her coping repertoire, even if initially or for some extended period
of time, they dont feel particularly great or do the trick in the way that
food has. Remind your patient that with time, practice, and experimen-
tation these activities will become more and more like second nature,
in the same way that her new and healthier eating habits and exercise
routines will become more automatic over time. Reassure your patient
that although it might feel quite dicult to turn away from food as the
primary source of pleasure and comfort, these alternative and pleasur-
able activities will not only be available to her in a pinch when she feels
that she is at risk for overeating for any reasonin need of some quick
tools that can help her cope without giving in to the urges to eatthey
will also serve to enrich her life away from food in every sense.
Physical Activities May Be Best
As you will discuss with your patient, many people combating food prob-
lems report that in their initial eorts to nd other activities to replace
the comfort, stimulation, distraction, and so on that accompanied eating,
activities that involve physical movement seem to be more eective than
those that are sedentary in nature. Why would this be so? Usually, when
people are motivated to eat, it is to nd some method for stimulating
37
themselves, whether to rev up, calm down, or numb out. After all, eating is
itself a physical activity that has a variety of eects on all aspects of the body,
from the brain on down. It makes sense then that to replace eating as the
source of the stimulation, other physical activities would work best, cer-
tainly better than stationary activities such as watching TV at home (which
by all accounts can be linked to a pattern of overeating and weight gain).
As you will discuss with your patient, the following general categories of
pleasurable activities, as well as certain specic activities, are known to
be helpful as replacements to eating.
Pleasurable Activities
Taking a hot shower or bubble bath
Going for a walk or participating in some other type of exercise
Getting a manicure
Giving yourself a facial
Working in the garden
Engaging in sexual relations
Going shopping (but not for food!)
Activities That Are Incompatible With Eating
In addition to requiring some energy output, most of the activities listed
above are physically impossible to do while eating (or at least would
make eating dicult). When trying out some new forms of pleasurable
activities, your patient must not allow them to become paired with eat-
ing cues. That means not eating while she is engaged in the activity. The
reason for this is that once a given activity includes eating, it can send a
signal to your patient that she should be eating every time she partici-
pates in the particular activity. For example, if she has been one to go to
a lot of drive-through restaurants, she might notice a desire to drive by
and pick up something to eat whether or not she is hungry, every time
she is in the vicinity. Similarly, if there is a certain vending machine at
work from which your patient buys a snack every afternoon at .., she
38
might nd it quite dicult, if not impossible, to pass by without pur-
chasing anything.
Getting Out of the House
While it will not always be possible for your patient to leave home to do
something distracting and pleasurable to avoid overeating, often it is help-
ful to do so if she is feeling tempted to overeat particularly while at home
alone with stocks of tempting foods (or even not-so-tempting foods). Going
out might even involve your patient making the decision to get some-
thing (moderately portioned) to eat as a compromise position as she
considers the various options that she has. While this involves giving in
to the urge to eat on some level, still, this decision would be much better
than your patient running the risk of overindulging at home where there
may be large amounts of food and no particular controls (such as the
presence of others or a limited supply of food) in place. Keep in mind
that every time your patient experiences a success in preventing herself
from engaging in an unnecessary overeating episode, she decreases the
strength of the pull to eat for reasons other than appropriate hunger as
she simultaneously strengthens her skill set for choosing more healthy al-
ternative behaviors when she is tempted to inappropriately use food.
Realistic and Manageable Activities
As you help your patient to brainstorm about alternative forms of plea-
sure other than eating, it is important that she learns to do so in a way
that is realisticthat is, that she comes up with activities that she can
actually aord, and do easily, in a variety of problem situations (e.g.,
such as at night at home alone, during the middle of a work day, on a
weekend, or rst thing in the morningwhenever it is that she feels at
risk for overusing food). For example, remind your patient that while it
is nice to think about getting together with friends for a walk or an out-
ing of some sort, people are not always available when we want them to
be and dont always want to do what we want them to do at the times
when we are available. While it is probably benecial for your patient to
include some social activities on her list, as well as a range of activities
39
she can do alone, she wouldnt want to include only pleasurable alterna-
tives that rely on others company. Given that others are frequently un-
available, this might leave your patient feeling frustrated and disappointed,
and with those emotions onboard, possibly more inclined to turn to
food for comfort.
Big Ticket Activities
While some major activities such as traveling or redecorating should be
included on your patients list for special circumstances, these are best re-
served as global lifestyle enhancers rather than in the moment strate-
gies that can help her stay away from food. Similarly, if your patient lives
in a cold climate, certain activities such as outdoor tennis or golng,
while nice in theory, and wonderful in the summer months, are not re-
ally possible during the winter months. Still, there would be nothing
wrong with your patient listing these activities as distant or far o
possibilities to be used to enhance her lifestyle when feasible or at some
designated point in time.
Discuss with your patient the importance of staying open to the indi-
viduality of her own list of interests and activities. There are no set an-
swers about what types of activities should be relaxing for any individ-
ual. The important idea here is to create a list of or things that she
loves (or likes) to do that can help her to feel calmer, more at peace, re-
laxed, fullled, gratied, proud, and so on. The list might include some
of the bigger ticket items that might interest her such as traveling to
distant locations, signing up for a course on an interesting topic, redeco-
rating a certain room in her house or apartment, or writing a short story
or book. The list should also include several in the moment forms of
pleasure that can be used in a pinch when your patient is feeling a rather
immediate need to alter her mood state (or simply nding herself with
free time) without access to many of the other more serious endeavors.
While the list will of course be individually tailored to her needs and in-
terests, it might include the types of activities that are available to her,
for example, in the middle of the day or at night, when no one else is
around, without generating great expense. These could be reading a fun
magazine or book; taking a hot bath or shower; doing her own facial,
40
manicure, or pedicure