When I first met my friend and colleague, Nancy King, MS, RDN, we discovered a shared value of being caring and compassionate in all we contribute as nutrition professionals. We both treasure being on the journey with a human being releasing a battle with food and their body as they become empowered to be their own person.
For over the past decade I’ve had the honor of working with clients who have undergone, or are considering bariatric surgery. A caring and compassionate approach requires thorough knowledge of anatomy and physiology, understanding of disordered eating, food relationships, as well as body and self- image development and transformation.
Nancy and I sat down for an interview to discuss how Health at Every Size and bariatric surgery can be combined.
Nancy: How does HAES fit with bariatric surgery treatments? Although this seems like an odd combination, it is something that I’ve combined over my past 10 + years of working in the bariatric surgery realm.
Many people can approach bariatric surgery as a treatment for diabetes, less insulin resistance, regulation of digestive hormones (think leptin, ghrelin, GLP1, CCK, OXY) and newly mapping both homeostatic and hedonistic brain feeding circuits. These changes can actually be independent of weight changes, depending on the type of bariatric surgery. There can be marked improvements in these health measures and quality of life without focusing on a particular size or resultant appearance. When the approach is health, metabolic improvement can be the highest value—as opposed to aligning closer with prevailing social values of body size and shape determining competency and lovability.
The flip side of the coin is when an individual has undergone a bariatric surgery and now needs further assistance with disordered eating or altered food relationships that have appeared after bariatric surgery. There is no shame or blame in undergoing a surgery, and it’s an important part of someone’s history. We may have to work together on how they physically and mentally feel with their surgery, the information that they understand with surgery and shifting perspective on eating behaviors.
Changes in one’s experience of body cues post bariatric surgery call for a deepening connection with one’s body. For example, hunger and fullness cues feel different, there’s a need to eat more slowly and mindfully as well as becoming attuned to digestive processes. Eating disorder behaviors after surgery may appear in similar ways to ED behaviors before or without surgery, however, criteria for Binge Eating Disorder is changed slightly due to anatomical changes that prevent the high volume of intake. In this case, we look to the same feelings of loss of control that appear during a binge episode and the cycle of guilt/restriction that follows afterwards. The physicality of this cycle may look a bit different, but the thought process is the same.
What treatments fall under the Bariatric umbrella? There are many types of surgeries available that fall under the bariatric surgery umbrella. The most common are the Roux-en-Y gastric bypass, sleeve gastrectomy and adjustable gastric band. The band is now becoming less popular than it once was. There are more malabsorptive type surgeries called the biliopancreatic diversion with or without a duodenal switch. And now, there are newer options that are considered less invasive such as a gastric balloon or endoluminal sleeve. Each of these comes with their own unique changes in gut function, body cuing, and potential micronutrient deficiencies.
Are there people who don’t have an eating disorder and are good candidates for bariatric surgery? This is a great question! Yes, a surgery may be useful for someone that does not have active or history of eating disorders or addiction and needs assistance with insulin regulation. I’ve also had clients who desire to be more physically active, currently eat in a balanced and healthy way and are not experiencing a shift in weight despite concerted effort. Surgery could potentially be a tool in the hormonal shift required to help weight loss in some individuals. In all cases, we want to ensure every avenue is considered and the decision is well thought through.
When might a clinician refer a client for a bariatric consultation? A bariatric consultation is typically with a surgeon and is usually at the point when someone is considering surgery. Unfortunately, not all surgeons are able to have a compassionate conversation while objectively reviewing the types of surgery, the pros and cons of each surgery, and if that surgery will support the client’s objective. Some surgeons do have a lean towards surgery since that is their expertise and an Internet search may not present the most comprehensive information. This conversation may need to be done with another expert in this field, such as myself, or a trusted member of the client’s personal healthcare team.
Does someone always end up in surgery? Bariatric surgery is considered an elective surgery and, therefore, at any moment someone can decide to not proceed with surgery. From a surgery perspective, there may be certain insurance or individual surgeon requirements that need to be met prior to bariatric surgery. This could delay surgery or remove it as an option altogether. Of course, there may be times that surgery is considered unsafe due to other health conditions.
I tell clients they always have a choice. Bariatric surgery can be an incredible tool to assist with some medical and hormonal concerns, such as changing hunger or fullness hormones and improve insulin control. What it cannot do is transform one’s relationship with food, body or movement, develop healthy emotional coping skills, foster self-care practices, or increase self-worth. If there is uncertainty or need for more preparation at any point in the discovery process, we pause and give attention to these matters.
What if they’ve had a failed outcome? First and foremost, it is important to remember that a different outcome doesn’t mean that someone failed or did something wrong. Possibly, the approach towards this health outcome has to be different; there is a new part to the picture or information received; or we may need to further explore the perspective surrounding the surgery. Regardless, considerate and conscious assessment is a required foundation in approaching this topic.
If you or a client has experienced bariatric surgery or are considering this approach, I’m available. A compassionate conversation about this subject can allow for healing and a truly informed decision.