The decision to pursue Bariatric Surgery is usually not an impulsive one. Some consider it for years; others for several months. The last straw may be the recommendation of primary care doctor; weight loss in order to have an orthopedic operation; the shame of being denied a ride at an amusement park; seeing the success of a friend, coworker or loved one after their surgery. The decision comes from many sources, but it is almost never an impulsive or lighthearted one. So the call to the bariatric surgeon is made: whether with excitement or dread that important first step is often filled with ambivalence and regret that one has got to this stage.

It is not surprising given how difficult the first step is that it is frustrating after having considered and then reconsidered the decision to be told that one must complete a series of tests before being seen or setting a surgery date : medical tests, psychological tests and nutrition sessions. It seems like once the decision is made it should be full steam ahead, let’s get the surgery over with and on to the new life. The medical and nutrition education make sense and seem to be straight forward, maybe frustrating to schedule but doable.

It’s the psychological evaluation that often causes further angst. Patients often come to the psychological evaluation anxious and defensive. It is not unusual for someone who has struggled with obesity to experience some depression, anxiety or difficulty dealing with stress. Feelings of shame over obesity and the stigma that one suffers at the hands of others takes a toll over time. Many of us eat emotionally…not just an obese person. It is not uncommon for patients to feel at fault, that they have failed at this most important thing and to fear they will be told something is “mentally wrong” with them. Fears that all too common symptoms will lead to being denied often lead to the defensive posture that “everything is completely okay, no problems, no stress, no past conflicts, no emotional eating, no, no and no”

Just as hypertension often occurs with obesity, several psychological disorders or symptoms seem to be prevalent. No one would want their bariatric surgeon to perform surgery if their blood pressure was so out of control that they would have severe complications from the operation. The same should be true for psychological issues. It is not the presence of symptoms, whether depression, anxiety, etc; it is how these can be treated either before or after surgery.

The psychological evaluation is to help design an effective treatment plan to address emotional issues that would adversely affect outcome. Many people believe that after the surgery, their lifestyle automatically changes. They will be able to change eating habits because of the surgery or adverse consequences of eating certain foods. Along with the smaller or new stomach, one will no longer want certain foods, will have time to prepare and cook meals, will not eat due to being tired, lonely, anxious, or stressed. Intellectually, we all know this is not true but we operate on this principle.

Keep this point in mind: during the 12-18 months after surgery, the most significant weight loss is to occur. If you think of the surgery as the Olympics, the call to the surgeon is signing up for to be considered for the Olympic team. You would train well before the actual Olympic event. Consider how successful a skier would be if the first time they strapped on skis was on the chairlift going up to that double black diamond. The months between the first call to the surgeon and the operation are your training time. You practice the dietary changes, you plan for exercise or even begin exercising if possible, you address emotional eating patterns, you learn to track intake, give up carbonated beverages, practice the 30/30/30 rule. The list goes on. This period is the time to fail, to recognize where your weakness are. Maybe it’s dining out or eating watching TV or the siren song of a Sundrop. We know that there are different types of hunger: stomach, mouth, eye and head. The surgery will almost eliminate stomach hunger. What about the others? What is the plan? Practicing the plan before surgery is a key to success. If depression and/or anxiety would interfere with success, often a treatment plan can be implemented without a long delay before surgery.

Finally you are cleared for surgery, a date is set. What does one do once they are accepted to the final Olympic team? Do you stop training: go on a food farewell tour, stop tracking your intake, have one last soda, stop practicing all the skills until it’s time to enter the Olympic village? Surgery is an event, like an Olympic contest. But whether you end up at Disney World and on the cover of Wheaties depends much more on your training.

The psychological evaluation is not another hoop to get through before the promised changes. It can hopefully be an honest exchange comprised of education and exploration of what will be the strengths and challenges one will face on their journey. What skills can be added to make that journey a success. As disappointing as delays can be they likely add up to just a moment in your new life, take the time to prepare. It will be well worth getting that Gold Medal.

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