Interpersonal Changes and Challenges After Weight-Loss Surgery

CME

CLINICAL FOCUS

3

Primary Psychiatry. 2008;15(8):61-66

Interpersonal Changes and Challenges After Weight-Loss Surgery Stephanie Sogg, PhD, and Mark J. Gorman, PhD

ABSTRACT

Needs Assessment: Weight-loss surgery patients present with issues specific to the weight-loss surgery experience and substantial weight loss. Awareness of the challenges these patients typically face will enable physicians to provide appropriate health and mental health care.

Weight-loss surgery literature suggests that the majority of patients experience the changes that occur as a result of dramatic weight

Learning Objectives:

• Identify at least four positive interpersonal changes likely to occur after weightloss surgery.

• Identify at least four potential interpersonal challenges arising after weight-loss surgery.

• Provide medical or mental health care sensitive to interpersonal changes after weight-loss surgery.

loss after weight-loss surgery as being overwhelmingly positive.

However, even positive change may pose a variety of psychosocial challenges. In the case of weight-loss surgery, these changes and

Target Audience: Primary care physicians and psychiatrists.

CME Accreditation Statement: This activity has been planned and implemented in

challenges often manifest themselves in a variety of interpersonal realms, including everyday social interactions and relationships

accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

with close friends and loved ones. In addition, patients must learn to function in certain interpersonal situations they may not have had

Credit Designation: The Mount Sinai School of Medicine designates this educational

to navigate in years or have never encountered before. This article

activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

examines some of the interpersonal changes and challenges arising

Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School

of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.

This information will be available as part of the course material.

after weight-loss surgery, with a brief review of empirical literature on this topic. It concludes with a discussion of the ways healthcare providers can facilitate smooth adjustment to interpersonal changes after weight-loss surgery.

This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: June 23, 2008.

INTRODUCTION

Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Due to the rapidly increasing prevalence of weight-loss surgery in recent years,1-4 healthcare professionals of all disciplines are more likely to encounter weight-loss surgery patients in their clinical practices. Therefore, it is important for clinicians who do not specialize with this population to become knowledgeable about weight-loss surgery and the common post-operative experiences patients face

To receive credit for this activity: Read this article and the two CME-des-

ignated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation found on page 84. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by August 1, 2010 to be eligible for credit. Release date: August 1, 2008. Termination date: August 31, 2010. The estimated time to complete all three articles and the posttest is 3 hours.

Drs. Sogg and Gorman are staff psychologists at the Massachusetts General Hospital Weight Center and instructors in psychology at the Harvard University School of Medicine in Boston, MA. Disclosure: Drs. Sogg and Gorman report no affiliation with or financial interest in any organization that may pose a conflict of interest.

Please direct all correspondence to: Stephanie Sogg, PhD, MGH Weight Center, 50 Staniford St, 4th Fl, Boston, MA 02114; Tel: 617-726-6761; Fax: 617-724-6565; E-mail: ssogg@partners.org.

Primary Psychiatry

© MBL Communications

61

August 2008

S. Sogg, M.J. Gorman

to ensure the provision of appropriate care and referrals.

A growing body of empirical literature suggests that after weight-loss surgery, the majority of patients experience overwhelmingly positive changes,5-10 including dramatic improvements in medical comorbidities2,11-16; enhanced energy, mobility, mood, and self-esteem; and increased desire and ability to engage in a variety of activities.5,6,8,11,17 However, even positive change may pose a variety of psychosocial challenges.5 For weight-loss surgery patients, these changes and challenges often manifest themselves in a variety of interpersonal realms. Weight-loss surgery may affect spheres ranging from everyday social interactions to relationships with close friends and loved ones. In addition, patients must learn to function in certain interpersonal situations they may not have had to navigate in years or have never encountered before.

This article examines some of the interpersonal changes and challenges arising after weight-loss surgery, including a brief review of empirical literature on this topic. Ways to facilitate smooth adjustment to interpersonal changes after weight-loss surgery are discussed as well.

It should be noted that there is a relative dearth of empirical literature examining this topic6; many of these studies were published decades ago, involve small samples, and pertain to bariatric procedures that are now rarely performed.

Examination of interpersonal outcomes tends to be done in broad strokes,6 with patients rating general satisfaction or improvement, rather than focusing on specific types or mechanisms of change. Thus, patient report and clinical experience must often be used to inform the effect of weight-loss surgery on interpersonal functioning.

Challenges While receiving compliments is pleasurable for most people, it is not uncommon for weight-loss surgery patients to feel uncomfortable when this occurs, especially if they were not accustomed to receiving compliments in the past. Numerous patients express concern that they will appear conceited if they do not downplay or reject compliments. Frequently, it takes some time before a patient’s self-concept becomes consistent with his or her changed outward appearance.18 Therefore, compliments may be perceived as uncomfortably discordant with the patient’s self-image; one patient described the experience of receiving a compliment as causing “a short-circuit in my brain.”

In other cases, patients simply have not developed the basic skill of responding to a compliment by merely saying, “Thank you.” Fortunately, this skill can be developed through a very brief intervention of guided role-playing (and some practice), greatly easing this type of social transaction.

For some patients, changes in the way others respond to them can be experienced as insulting. Some patients report feeling resentful about being treated better by other people simply because they lost weight.5,6 Patients may interpret a sudden increase in compliments to mean that before surgery, people found them unappealing; one patient reported responding to enthusiastic compliments with the thought, “Wow, what must they have thought of me before?”

Before weight-loss surgery, patients frequently report experiencing significant stigma and discrimination related to their weight.6,19-23 Numerous patients complain about bias at work, within their families, and from strangers; empirical investigations substantiate the reality of widespread prejudice and discrimination against individuals with obesity.21,22,24-30 It has been found that medical professionals,18,25,31-35 even those who specialize in studying and treating obesity,29,36 hold such prejudices. It has been noted that obesity is “one of the last acceptable forms of prejudice” in our society.37 Further, unlike members of other stigmatized groups, it has been found that people with obesity tend to internalize these biases.20,22,25,28,38,39 Because of the stigma related to obesity, research has demonstrated that people with obesity are more susceptible to depression and lowered self-esteem.40-46 Fortunately, after weight-loss surgery, as patients lose weight, they encounter fewer of these experiences.23 However, they often remain acutely aware of and troubled by the prejudice that exists toward individuals with obesity in Western culture.5 It can be particularly uncomfortable when patients catch themselves engaging in this type of stigmatizing behavior. One patient described feeling horrified and saddened when, having just been cut off by another driver in a parking lot, she found herself making disparaging observations about that driver’s being overweight.

EVERYDAY SOCIAL INTERACTIONS Positive Changes Almost immediately after surgery, patients report receiving increased attention from supportive family and friends around taking an important step in addressing their health risks. As patients lose weight, positive attention often takes the form of compliments, which many patients report finding pleasurable and gratifying. In addition, patients frequently report that both strangers and acquaintances tend to be more likely to approach and generally act more positively toward them. Patients typically attribute these changes directly to improved appearance.

Though this may be the case, it is likely that this change is partly attributable to changes in the way the patients interact with others. As their mood, self-confidence, and self-esteem improve, patients may approach others more often and more positively, effecting a change in how others respond to them.

Primary Psychiatry

© MBL Communications

62

August 2008

Interpersonal Changes and Challenges After Weight-Loss Surgery

Weight-loss surgery may also lead to unwanted inquiries by others. For many reasons, the topic of weight-loss surgery seems to be quite interesting to the lay public, and weightloss surgery patients often find themselves reluctantly assuming the role of “weight-loss surgery ambassador” to their family and friends. Patients report being subjected to frequent questions about the surgery and post-operative regimen. Although patients often report being enthusiastic about their experiences and wanting to share them with others, some patients find it tiresome to answer repetitive questions about weight-loss surgery or find that conversations with others too frequently focus on this topic. In addition, patients sometimes report being asked intrusive personal questions, such as “How much weight have you lost?” or “What did you weigh before?” Patients also often report that others appear to be inordinately curious about what, how much, and how fast they can eat.

One of the more distressing challenges that weight-loss surgery patients sometimes face is being subjected to the opinions of people who mistakenly believe that weight-loss surgery is somehow “cheating” or “taking the easy way out,” when the patient “should have been able to lose the weight on his or her own.” This is yet another expression of the bias and misapprehensions about obesity among the general public, and it leaves the patient in an unpleasant position of having to justify his or her decision to have surgery. Unfortunately, in Western society, obesity is often believed to be the result of a psychiatric or behavioral disorder, laziness, or failure of will power.24-26 However, a growing body of research strongly indicates that biologic factors are very powerful in determining body weight.26,47 In fact, it has been estimated that 40% to 85% of the individual variation in obesity may be attributable to genetic factors.48,49 In addition, once it has developed, obesity is notoriously resistant to nonsurgical treatments such as lifestyle change or weight-loss medications regardless of etiology,12,50-56 leaving weight-loss surgery as most patients’ best hope for improvement or reversal of the dangerous comorbidities of obesity.1,12,14,15,57-59 It is often incumbent upon weight-loss surgery patients to explain these facts to others, which can be tedious at best and, at worst, demoralizing.

the desire to engage in a variety of activities.42,60,61 After weight-loss surgery, improvements in health, mobility, energy, mood, and self-confidence render patients more able and eager to engage in a wider spectrum of activities.5,6,10,11,18,62 This can translate into more enjoyable time spent with friends and loved ones and participation in or rediscovery of activities and hobbies that had been abandoned in the past. Patients report being able to take long walks with their spouses or chase their grandchildren around the backyard. One patient reported feeling elated by the simple pleasure of being able to cook a meal for her spouse, an activity that was impossible before weight-loss surgery, as she could not stand at the stove for more than a few minutes at a time.

Additionally, improved mood and self-confidence make social situations more enjoyable after weight-loss surgery.

Patients report that after weight-loss surgery, they appreciate becoming free of the constant awareness of their size; the fear of being evaluated negatively by others diminishes.6,11,18,62,63 Patients who, before surgery, tended to avoid parties and other social situations because they were self-conscious about their appearance no longer feel they have to refuse invitations.

The vast majority of weight-loss surgery patients report that having surgery has affected their romantic relationships in a positive way.8,62,64-69 As noted above, weight-loss surgery offers patients the opportunity to engage in more shared activities with their partners62,68 or to resume a larger share of household responsibilities. Additionally, weight-loss surgery appears to lead to significant improvements in most patients’ sexual functioning.62,64,67,70,71 Patients often report that improved mood, body image, and self-confidence significantly increase their sexual desire and level of comfort with physical intimacy.8,66,70 Sexual activity becomes mechanically easier due to increased endurance, improved mobility, and smaller body size.5,66,70 Some patients report that their partners show a renewed or increased sexual interest toward them as they lose weight.62 One study70 found that patients’ partners reported being even more satisfied with sexual changes after weight-loss surgery than the patients themselves.

Challenges Despite the positive changes described, challenges may arise in close relationships after weight-loss surgery. As the patient loses weight, friends or family members may become envious or competitive.5,6,72 It is not uncommon for patients to report that a close friend or relative has commented, “Wow, you are getting close to my size, now–I should go on a diet!” In some cases, the weight-loss surgery patient was part of a friendship, family, or social group in which he or she played the role of “the fat one,” someone who was less assertive or posed less of a threat or competition for the opposite sex. As the patient loses weight after surgery, this dynamic may be changed, disrupting the equilibrium of the friendship, family, or social group.

INTIMATE RELATIONSHIPS Positive Changes Another realm of interpersonal changes after weight-loss surgery is in the sphere of intimate relationships: close friendships, family relationships, and romantic partnerships. Before surgery, patients frequently report that their weight diminishes both the ability and Primary Psychiatry

© MBL Communications

63

August 2008

S. Sogg, M.J. Gorman

Relationships that in the past had centered around eating, cooking, or visiting restaurants may have to undergo some adjustments after the patient undergoes weight-loss surgery, and friends and family members may also be concerned about losing an “eating buddy.” In Western culture, it can be difficult to find opportunities for socialization that do not focus on food or drink.6 In addition, as patients create healthier eating patterns for themselves, eating in the entire household is likely to be affected.

In some cases, patients may feel guilty about the possibility that family meals will be disrupted or worry that loved ones will feel deprived of certain favorite foods. Conversely, some weight-loss surgery patients find that friends or family begin to act as the “food police,” monitoring and commenting on each bite the patient eats. Although this behavior may reflect genuine caring and concern on the part of the friend or family member, it can be quite aversive to the patient.

Another potential challenge is possible sabotage by a friend or family member in the form of exhortations to eat more or expressions of concern about the patient losing too much weight. This type of behavior may be either intentional or unintentional, driven by envy, insecurity, or a lack of knowledge of the post-operative regimen. Examples of this type of challenge can range from a concerned relative repeatedly asking, “Is that all you’re going to eat?” or serving the patient too much at family dinners, to a partner complaining because there is no longer any ice cream in the house or refusing to buy healthier foods for the home.

Although the effect of weight-loss surgery on romantic relationships tends to be overwhelmingly positive, some patients report significant disruption in their romantic relationships.

Family systems theory holds that a homeostatic balance is established and maintained within relationships by each member fulfilling his or her specific role in relation to the other.

When one person in a relationship changes, this disrupts homeostasis, and if the relationship does not change accordingly, balance will not be re-established and destabilization will occur.73 Empirical investigation of marital changes after weightloss surgery suggests that relationships that were strong before surgery tend to stay that way, while relationships that were less healthy originally are more likely to be destabilized.17,62,64,66 For example, an improved self-image and feelings of self-worth may make a patient less willing to tolerate a relationship in which he or she is not treated with kindness and respect.5 In one study, wives rated themselves as more sociable and interesting after surgery, while rating their husbands as less sociable and interesting than they did before surgery.63 As the patient develops a stronger sense of self-worth, the balance of power may shift in a friendship or romantic relationship.5 In a healthy relationship, a new, positive equilibrium is reached, while in an unhealthy one, this shift in power may lead to the dissolution Primary Psychiatry

© MBL Communications

of the relationship. Similarly, because of the disability and illhealth that may accompany severe obesity, some patients may have become reliant on their partners in a variety of ways. As health improves and autonomy grows, the relationship may be disrupted if, as the patient asserts newfound independence, his or her partner feels that he or she has lost an important role or is no longer needed.5,62,63,72 In addition, some patients report that their partners become jealous, or express anxiety about patients leaving the relationship as they lose weight and become more attractive to others.5,66,72 It is worth noting that although patients commonly report improvements in their sexual functioning and sexual relationships after weight-loss surgery, a significant minority of patients report a negative impact on their sex lives.66 For some, wound complications or other early surgical sequelae interfere with sexual functioning.62,70 Some patients may experience a short-term decrease in sex drive after weight-loss surgery5,62,66 Though most patients experience improvement in their body image and improvements in their sexual functioning, for some patients, excess skin, which can develop after a significant weight loss, may actually worsen body image10 and increase inhibitions toward sexual intimacy.66

NEW EXPERIENCES As weight-loss surgery patients lose weight and regain energy, mobility, and self-confidence, they may begin to find themselves in a variety of situations that they have not encountered in the past, or which they had avoided for some time because of the functional or psychological impact of their obesity.5,74 For example, before surgery many patients find that because of their obesity people do not really see or pay attention to them. After losing weight, however, weightloss surgery patients sometimes note that they are no longer “invisible.”5 Although in general this is likely to be a positive change, it can be uncomfortable and it may take patients time to become accustomed to being “visible” again.

This newfound visibility may lead to increased romantic or sexual attention, which is welcome and exciting for most patients and contributes to improved confidence, mood, selfesteem, and body image. However, for others, this type of attention may be disruptive. Some patients with a history of sexual abuse may find increased sexual or romantic attention to be threatening.5,17 It has been hypothesized that these patients may experience their extra weight as a defense or protective factor that minimizes the risk of receiving sexual attention or finding themselves in sexual situations,41,75,76 and losing this buffer may lead to feelings of vulnerability.5,17 One study found that patients with a history of sexual abuse lost less weight at 12 months post-surgery.71 Another77 found that while there

64

August 2008

Interpersonal Changes and Challenges After Weight-Loss Surgery

was no difference in weight loss 2 years after surgery between patients with and without a history of sexual abuse, those with an abuse history were significantly more likely to report having had a psychiatric hospitalization in the first 2 post-operative years. However, it is important to note that a history of sexual abuse is not considered to be a contraindication for weight-loss surgery, and research studies have typically found that such a history has no impact on post-surgical weight loss or psychosocial adjustment in the long term.78-81 Even for those patients for whom an increase in romantic opportunities is a welcome change, this new situation may still pose challenges. Some patients, particularly those who are younger at the time of surgery, report that they had never been involved in romantic relationships before and may never have grown accustomed to dating or developed necessary dating “skills.”5 Learning how to navigate the world of romantic relationships can be a complicated experience, even if it is an enjoyable one. For other patients, it may have been years since they were involved in dating, and they may find that their skills are “rusty,” or that the norms in the dating world have changed.

For example, expectations about which party asks or pays for the date, or how quickly sexual activity is introduced, may be quite different now than they were when the patient last dated.

For some patients, vigilance about sexually transmitted diseases is a new development that requires some consideration.

Those whose fertility may have been impaired by their obesity may not appreciate the increased need for protection against unplanned pregnancy. This is particularly problematic, since there is risk for birth defects in pregnancies occurring within the first 12–18 months after weight-loss surgery.82,83

opportunity to help the patient to proactively formulate appropriate coping strategies. Educating the patient about potential challenges is an important and powerful tool for enhancing adjustment after surgery.84 Further, the evaluating clinician need not be relegated to the role of “gatekeeper”; a mental health practitioner can also serve as the facilitator of whatever intervention is needed to clear the patient’s path to surgery and increase the safety and efficacy of this important medical procedure.45,84-87 During the perioperative and early adjustment period, clinicians who are mindful of the potential changes and challenges discussed above can provide appropriate psychosocial intervention; this may be done within the surgical program itself or, if no appropriate clinician is on staff, referrals can be made to clinicians in the community who have experience working with weight-loss surgery patients.

It is also important that ongoing psychosocial support is available in the long term after weight-loss surgery.17,84,86,88 It is recommended that routine follow-up visits extend beyond the first 6–12 months after surgery, as many of the challenges described above may emerge at a longer latency after surgery.88 Regular, long-term follow up fosters working relationships in which the patient feels comfortable discussing any challenges that may arise, as well as increasing opportunities for doing so. Programs that incorporate or have a close association with mental health providers can provide appropriate referrals for patients to receive assistance in coping with adjustment to life after weight-loss surgery. In addition, other healthcare providers can be helpful to patients navigating the interpersonal challenges that may arise after weight-loss surgery by being aware of the common issues. Sensitivity to these issues will allow medical and mental health providers to provide better care, make sensitive inquiries during routine visits, and make the appropriate referrals when necessary. PP

CONCLUSION Although patients presenting for weight-loss surgery are highly motivated to achieve and maintain significant weight loss, they may not anticipate the impact the surgery could have on their interpersonal functioning. Weight-loss surgery typically results in changes experienced as extremely positive and enriching, especially in the interpersonal realm. However, these changes may also present significant challenges. Clinicians caring for weight-loss surgery patients must be aware of the significant changes and challenges that may arise. As noted above, these may include changes in everyday social interactions and close interpersonal relationships, and facing situations with which the patient had little experience before losing weight.

There are numerous opportunities for healthcare providers to facilitate successful adjustment to weight-loss surgery.

This may begin even before surgery, with the pre-operative psychosocial evaluation. This evaluation serves the function of identifying potential post-surgical challenges and affords the Primary Psychiatry

© MBL Communications

REFERENCES 1. Elder KA, Wolfe BM. Bariatric surgery: a review of procedures and outcomes. Gastroenterology.

2007;132(6):2253-2271.

2. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142(7):547-559.

3. Saber AA, Elgamal MH, McLeod MK. Bariatric surgery: the past, present, and future. Obes Surg.

2008;18(1):121-128.

4. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294(15):1909-1917.

5. Bocchieri LE, Meana M, Fisher BL. Perceived psychosocial outcomes of gastric bypass surgery: a qualitative study. Obes Surg. 2002;12(6):781-788.

6. Bocchieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. J Psychosom Res. 2002;52(3):155-165.

7. Burgmer R, Petersen I, Burgmer M, de Zwaan M, Wolf A, Herpertz S. Psychological outcome two years after restrictive bariatric surgery. Obes Surg. 2007;17(6):789-795.

8. Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W, Hebebrand J. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord. 2003;27(11):1300-1314.

9. Hrabosky JI, Masheb RM, White MA, Rothschild BS, Burke-Martindale CH, Grilo CM. A prospective study of body dissatisfaction and concerns in extremely obese gastric bypass patients: 6- and 12-month postoperative outcomes. Obes Surg. 2006;16(12):1615-1621.

10. van Hout GC, Boekestein P, Fortuin FA, Pelle AJ, van Heck GL. Psychosocial functioning following bariatric surgery. Obes Surg. 2006;16(6):787-794.

11. Karlsson J, Sjostrom L, Sullivan M. Swedish obese subjects--an intervention study of obesity. Two-year follow-up of health-related quality of life and eating behavior after gastric surgery for severe obesity. Int J Obes Relat Metab Disord. 1998;22(2):113-126.

65

August 2008

S. Sogg, M.J. Gorman

12. Karlsson J, Taft C, Ryden A, Sjostrom L, Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes (Lond).

2007;31(8):1248-1261.

13. Korenkov M, Shah S, Sauerland S, Duenschede F, Junginger T. Impact of laparoscopic adjustable gastric banding on obesity co-morbidities in the medium- and long-term. Obes Surg. 2007;17(5):683-687.

14. Kushner RF, Noble CA. Long-term outcome of bariatric surgery: an interim analysis. Mayo Clin Proc.

2006;81(10 suppl):46-51.

15. O’Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med. 2006;144(9):625-633.

16. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in swedish obese subjects. N Engl J Med. 2007;357(8):741-752.

17. Wadden TA, Sarwer DB, Womble LG, Foster GD, McGuckin BG, Schimmel A. Psychosocial aspects of obesity and obesity surgery. Surg Clin North Am. 2001;81(5):1001-1024.

18. Ogden J, Clementi C, Aylwin S. The impact of obesity surgery and the paradox of control: a qualitative study. Psychol Health. 2006;21(2):273-293.

19. Ashmore JA, Friedman KE, Reichmann SK, Musante GJ. Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eat Behav. 2008;9(2):203-209.

20. Friedman KE, Reichmann SK, Costanzo PR, Zelli A, Ashmore JA, Musante GJ. Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults. Obes Res. 2005;13(5):907-916.

21. Puhl RM, Andreyeva T, Brownell KD. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. Int J Obes. 2008;32:992-1000.

22. Puhl RM, Moss-Racusin CA, Schwartz MB, Brownell KD. Weight stigmatization and bias reduction: perspectives of overweight and obese adults. Health Educ Res. 2008;23(2):347-358.

23. Rand CS, Macgregor AM. Successful weight loss following obesity surgery and the perceived liability of morbid obesity. Int J Obes. 1991;15(9):577-579.

24. Andreyeva T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 19951996 through 2004-2006. Obesity. 2008;16(5):1129-1134.

25. Crandall CS. Prejudice against fat people: ideology and self-interest. J Pers Soc Psychol. 1994;66(5):882-894.

26. Friedman JM. Modern science versus the stigma of obesity. Nat Med. 2004;10(6):563-569.

27. Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001;9(12):788-805.

28. Schwartz MB, Vartanian LR, Nosek BA, Brownell KD. The influence of one’s own body weight on implicit and explicit anti-fat bias. Obesity (Silver Spring). 2006;14(3):440-447.

29. Teachman BA, Brownell KD. Implicit anti-fat bias among health professionals: is anyone immune? Int J Obes Relat Metab Disord. 2001;25(10):1525-1531.

30. Teachman BA, Gapinski KD, Brownell KD, Rawlins M, Jeyaram S. Demonstrations of implicit anti-fat bias: the impact of providing causal information and evoking empathy. Health Psychol. 2003;22(1):68-78.

31. Chambliss HO, Finley CE, Blair SN. Attitudes toward obese individuals among exercise science students.

Med Sci Sports Exerc. 2004;36(3):468-474.

32. Falkner NH, French SA, Jeffery RW, Neumark-Sztainer D, Sherwood NE, Morton N. Mistreatment due to weight: prevalence and sources of perceived mistreatment in women and men. Obes Res. 1999;7(6):572-576.

33. Foster GD, Wadden TA, Makris AP, et al. Primary care physicians’ attitudes about obesity and its treatment.

Obes Res. 2003;11(10):1168-1177.

34. Hebl MR, Mannix LM. The weight of obesity in evaluating others: a mere proximity effect. Pers Soc Psychol Bull. 2003;29(1):28-38.

35. Puhl RM, Schwartz MB, Brownell KD. Impact of perceived consensus on stereotypes about obese people: a new approach for reducing bias. Health Psychol. 2005;24(5):517-525.

36. Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003;11(9):1033-1039.

37. Stunkard AJ, Sorensen TI. Obesity and socioeconomic status--a complex relation. N Engl J Med. 1993;329(14):1036-1037.

38. Puhl RM, Moss-Racusin CA, Schwartz MB. Internalization of weight bias: Implications for binge eating and emotional well-being. Obesity (Silver Spring). 2007;15(1):19-23.

39. Wang SS, Brownell KD, Wadden TA. The influence of the stigma of obesity on overweight individuals. Int J Obes Relat Metab Disord. 2004;28(10):1333-1337.

40. Chen E, Bocchieri-Ricciardi L, Munoz D, et al. Depressed mood in class III obesity predicted by weightrelated stigma. Obes Surg. 2007;17(5):673-675.

41. Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders among bariatric surgery candidates: Relationship to obesity and functional health status. Am J Psychiatry. 2007;164(2):328-334.

42. Kasen S, Cohen P, Chen H, Must A. Obesity and psychopathology in women: a three decade prospective study. Int J Obes (Lond). 2007;32(3):558-566.

43. Stout AL, Applegate KL, Friedman KE, Grant JP, Musante GJ. Psychological correlates of obese patients seeking surgical or residential behavioral weight loss treatment. Surg Obes Relat Dis. 2007;3(3):369-375.

44. van der Merwe MT. Psychological correlates of obesity in women. Int J Obes (Lond). 2007;31(suppl 2):14-18.

45. Wadden TA, Butryn ML, Sarwer DB, et al. Comparison of psychosocial status in treatment-seeking women with class III vs. class I-II obesity. Obesity (Silver Spring). 2006;14(suppl 2):90-98.

46. Wadden TA, Sarwer DB, Fabricatore AN, Jones L, Stack R, Williams NS. Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin N Am. 2007;91(3):451-469.

47. Bouchard C. The biological predisposition to obesity: beyond the thrifty genotype scenario. Int J Obes (Lond). 2007;31(9):1337-1339.

48. Farooqi IS, O’Rahilly S. Genetic factors in human obesity. Obes Rev. 2007;8(suppl 1):37-40.

49. Wardle J, Carnell S, Haworth CM, Plomin R. Evidence for a strong genetic influence on childhood adiposity despite the force of the obesogenic environment. Am J Clin Nutr. 2008;87(2):398-404.

Primary Psychiatry

© MBL Communications

50. Bray GA, Ryan DH. Drug treatment of the overweight patient. Gastroenterology. 2007;132(6):2239-2252.

51. Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: the effect of dietary counseling for weight loss. Ann Intern Med. 2007;147(1):41-50.

52. Elfhag K, Rossner S. Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obes Rev. 2005;6(1):67-85.

53. Foster GD, Makris AP, Bailer BA. Behavioral treatment of obesity. Am J Clin Nutr. 2005;82(1 suppl):230-235.

54. Mun EC, Blackburn GL, Matthews JB. Current status of medical and surgical therapy for obesity.

Gastroenterology. 2001;120(3):669-681.

55. Wadden TA, Butryn ML, Byrne KJ. Efficacy of lifestyle modification for long-term weight control. Obes Res. 2004;12(suppl):151-162.

56. Wadden TA, Butryn ML, Wilson C. Lifestyle modification for the management of obesity. Gastroenterology.

2007;132(6):2226-2238.

57. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-761.

58. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724-1737.

59. Buchwald H. Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. J Am Coll Surg. 2005;200(4):593-604.

60. Fabricatore AN, Wadden TA, Sarwer DB, Faith MS. Health-related quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery. Obes Surg. 2005;15(3):304-309.

61. Wadden TA, Sarwer DB. Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach. Obesity (Silver Spring). 2006;14(suppl 2):53-62.

62. Rand CS, Kowalske K, Kuldau JM. Characteristics of marital improvement following obesity surgery.

Psychosomatics. 1984;25(3):221-223,226.

63. Hafner RJ. Morbid obesity: effects on the marital system of weight loss after gastric restriction. Psychother Psychosom. 1991;56(3):162-166.

64. Applegate KL, Friedman KE, Grant JP. Assessments of relationship satisfaction and stability one year after weight loss surgery: a prospective study [abstract]. Surg Obes Relat Dis. 2006;2(3):310.

65. Cooper KM, Wells M. Effects of bariatric surgery on marital satisfaction [abstract]. Surg Obes Relat Dis. 2006;2(3):334.

66. Kinzl JF, Trefalt E, Fiala M, Hotter A, Biebl W, Aigner F. Partnership, sexuality, and sexual disorders in morbidly obese women: Consequences of weight loss after gastric banding. Obes Surg. 2001;11(4):455-458.

67. Kinzl JF, Traweger C, Trefalt E, Biebl W. Psychosocial consequences of weight loss following gastric banding for morbid obesity. Obes Surg. 2003;13(1):105-110.

68. Rand CS, Kuldau JM, Robbins L. Surgery for obesity and marriage quality. JAMA. 1982;247(10):1419-1422.

69. Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005;13(4):639-648.

70. Camps MA, Zervos E, Goode S, Rosemurgy AS. Impact of bariatric surgery on body image perception and sexuality in morbidly obese patients and their partners. Obes Surg. 1996;6(4):356-360.

71. Ray EC, Nickels MW, Sayeed S, Sax HC. Predicting success after gastric bypass: the role of psychosocial and behavioral factors. Surgery. 2003;134(4):555-563.

72. Andrews G. Intimate saboteurs. Obes Surg. 1997;7(5):445-448.

73. Klein D, White J. Family Theories: An Introduction (Understanding Families). 2nd ed. Thousand Oaks, CA: Sage Publicatons; 2002.

74. Hsu LK, Benotti PN, Dwyer J, et al. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med. 1998;60(3):338-346.

75. Felitti VJ. Childhood sexual abuse, depression, and family dysfunction in adult obese patients: a case control study. South Med J. 1993;86(7):732-736.

76. Wiederman MW, Sansone RA, Sansone LA. Obesity among sexually abused women: an adaptive function for some? Women Health. 1999;29(1):89-100.

77. Clark M, Hanna B, Mai J, et al. Sexual abuse survivors and psychiatric hospitalization after bariatric surgery. Obes Surg. 2007;17(4):465-469.

78. Buser A, Dymek-Valentine M, Hilburger J, Alverdy J. Outcome following gastric bypass surgery: impact of past sexual abuse. Obes Surg. 2004;14(2):170-174.

79. Fujioka K, Yan E, Wang HJ, Li Z. Evaluating preoperative weight loss, binge eating disorder, and sexual abuse history on Roux-en-Y gastric bypass outcome. Surg Obes Relat Dis. 2008;4(2):137-143.

80. Larsen JK, Geenen R. Childhood sexual abuse is not associated with a poor outcome after gastric banding for severe obesity. Obes Surg. 2005;15(4):534-537.

81. Oppong BA, Nickels MW, Sax HC. The impact of a history of sexual abuse on weight loss in gastric bypass patients. Psychosomatics. 2006;47(2):108-111.

82. Wax JR, Pinette MG, Cartin A, Blackstone J. Female reproductive issues following bariatric surgery. Obstet Gynecol Surv. 2007;62(9):595-604.

83. Woodard CB. Pregnancy following bariatric surgery. J Perinat Neonatal Nurs. 2004;18(4):329-340.

84. Sogg S, Mori DL. Revising the Boston Interview: incorporating new knowledge and experience. Surg Obes Relat Dis. 2008;4(3):455-463.

85. Bauchowitz A, Azarbad L, Day K, Gonder-Frederick L. Evaluation of expectations and knowledge in bariatric surgery patients. Surg Obes Relat Dis. 2007;3(5):554-558.

86. Lanyon R, Maxwell B. Predictors of outcome after gastric bypass surgery. Obes Surg. 2007;17(3):321-328.

87. Sogg S, Mori DL. The boston interview for gastric bypass: determining the psychological suitability of surgical candidates. Obes Surg. 2004;14(3):370-380.

88. Greenberg I, Sogg S, Perna F. Behavioral and psychological care in weight loss surgery--best practice update. Obesity. In press.

66

August 2008