What is the role of psychology in bariatric surgery? A survey of the differing views of psychologists, the multidisciplinary team, and patients in the UK.

Although psychologists are a key member of the bariatric multidisciplinary team (MDT), there is a lack of clarity about the specific remit of their role. This exploratory study was conducted to identify differences, priorities and clarify how the role of psychology is perceived in the United Kingdom. We conducted surveys of three major stakeholder groups (psychologists, patients, and the bariatric multidisciplinary team) which focused on their perception of psychology in bariatric surgery. The results showed that in UK bariatric services, psychologists are spending the majority of their clinical time providing pre-operative assessments. Differences emerged between psychologists and MDT in how they viewed the purpose of these assessments, with the MDT viewing them as identifying contraindications to surgery whereas psychologists viewed them as identifying readiness for surgery. A total of 51% of patients reported they had not been able to access psychology services when needed and viewed provision of post-operative psychological support to be a key priority. Key themes and tensions emerged around (a) high demand for services yet limited psychology resource, (b) the purpose of the pre-operative assessment and (c) the provision of pre-operative versus post-operative support. These themes combine and interact in a way that currently makes it extremely challenging to provide coherent psychology services. There is clearly a need for education, consensus and adequate resourcing of the psychology role within bariatric surgery services in the United Kingdom.

Global variations in preoperative practices concerning patients seeking primary bariatric and metabolic surgery (PACT Study): A survey of 634 bariatric healthcare professionals.

BACKGROUND: Bariatric and Metabolic Surgery (BMS) is a popular weight loss intervention worldwide, yet few scientific studies have examined variations in preoperative practices globally. This study aimed to capture global variations in preoperative practices concerning patients planned for BMS. METHODS: A 41-item questionnaire-based survey was designed and the survey link was freely distributed on social and scientific media platforms, email groups and circulated through personal connections of authors. The survey included eight parts: basic information; criteria for BMS; preoperative nutritional screening; preoperative weight loss; preoperative diets for liver size reduction; preoperative glycemic control; other laboratory investigations and preparations; decision making, education, and consents. Descriptive statistics were used to analyse data and graphs were used for representation where applicable. RESULTS: Six hundred thirty-four bariatric healthcare professionals from 76 countries/regions completed the survey. Of these, n = 310 (48.9%) were from public hospitals, n = 466 (73.5%) were surgeons, and the rest were multidisciplinary professionals. More than half of respondents reported using local society/association guidelines in their practice (n = 310, 61.6%). The great majority of respondents routinely recommend nutritional screening preoperatively (n = 385, 77.5%), mandatory preoperative diets for liver size reduction (n = 220, 53.1%), routine screening for T2DM (n = 371, 90.7%), and mandate a glycemic control target before BMS in patients with T2DM (n = 203, 55.6%). However, less than half (n = 183, 43.9%) recommend mandatory preoperative weight loss to all patients. Most respondents (n = 296, 77.1%) recommend psychological intervention before surgery for patients diagnosed with psychological conditions. Variations were also identified in laboratory investigations and optimisation; and in the aspects of decision making, education and consent. CONCLUSIONS: This survey identified significant global variations in preoperative practices concerning patients seeking primary BMS. Our findings could facilitate future research for the determination of best practice in these areas of variations, and consensus-building to guide clinical practice while we wait for that evidence to emerge.

Exploring the Experiences of Women Who Develop Restrictive Eating Behaviours After Bariatric Surgery.

OBJECTIVE: This study aimed to explore the experiences of women who had developed excessively restrictive eating behaviours following bariatric surgery. METHOD: Five female participants, who were at least nine months post-bariatric surgery and exhibiting restrictive eating behaviours, were recruited from Bariatric Surgery Psychology Services and asked to complete qualitative face-to-face semi-structured interviews. The data was analysed using interpretative phenomenological analysis (IPA). RESULTS: Three super-ordinate themes emerged: (1) experiences of weight stigma and weight history on self, (2) the impact of loose skin, (3) thoughts about food and disordered eating patterns. These captured the impact of past weight-related experiences-including weight stigma, intense fears of weight gain, negative cognitions about the self, the impact of excess skin, changes in the way the women thought about food and restrictive eating behaviours. DISCUSSION: This study is one of the first to specifically explore restrictive eating disorders after bariatric surgery using a qualitative approach. The findings of this study may offer helpful aspects for professionals to hold in mind when identifying individuals with problematic restrictive eating behaviours following bariatric surgery. Body contouring surgery, internalised weight bias and weight stigma are explored in relation to the post-bariatric surgery treatment pathway. The current diagnostic criterion for anorexia nervosa are discussed to highlight difficulties in diagnosing this presentation in the post-bariatric surgery population, where people can have BMIs over 25 kg/m2 but are severely restricting energy intake.

British Obesity Metabolic Surgery Society endorsed guidelines for psychological support pre- and post-bariatric surgery.

Research teams have argued that some bariatric patients require psychological input pre- and post-surgery and that weight loss surgery should only be undertaken by a multidisciplinary team (MDT) that can provide psychological support. To date, no guidelines exist for the provision of psychological support pre- and post-bariatric surgery. The authors were approached by British Obesity Metabolic Surgery Society (BOMSS) in September 2017 to produce guidelines for the provision of psychological support for patients pre- and post-bariatric surgery. These guidelines were developed using seven stages: (a) review of evidence base; (b) expert input; (c) feedback from BOMSS delegates; (d) feedback from the special interest group; (e) service user feedback; (f) presentation to BOMSS council; and (g) presentation to the Association for the Study of Obesity. The guidelines describe two stepped care service models for the delivery of psychological support pre-surgery and 6 to 9 months post-surgery involving online resources, group workshops and one-to-one with a clinical psychologist. They are founded upon the following principles: (a) a living document to be modified over time; (b) flexible and pragmatic; (c) advisory not prescriptive; (d) broad based content; (e) skills based delivery. These guidelines are feasible for use across all services and should minimize patient risk and maximize patient health outcomes.

Obesity and internalized weight stigma: a formulation model for an emerging psychological problem.

BACKGROUND: Obese individuals frequently experience weight stigma and this is associated with psychological distress and difficulties. The process of external devaluation can lead to negative self-perception and evaluation and some obese individuals develop "internalized weight stigma". The prevalence of weight stigma is well established but there is a lack of information about the interplay between external and internal weight stigma. AIMS: To synthesize the literature on the psychological effects of weight stigma into a formulation model that addresses the maintenance of internalized weight stigma. METHOD: Current research on the psychological impact of weight stigma was reviewed. We identify cognitive, behavioural and attentional processes that maintain psychological conditions where self-evaluation plays a central role. A model was developed based on clinical utility. RESULTS: The model focuses on identifying factors that influence and maintain internalized weight stigma. We highlight the impact of negative societal and interpersonal experiences of weight stigma on how individuals view themselves as an obese person. Processing the self as a stigmatized individual is at the core of the model. Maintenance factors include negative self-judgements about the meaning of being an obese individual, attentional and mood shifts, and avoidance and safety behaviours. In addition, eating and weight management behaviours become deregulated and maintain both obesity and weight stigma. CONCLUSION: As obesity increases, weight stigma and the associated psychological effects are likely to increase. We provide a framework for formulating and intervening with internalized weight stigma as well as making therapists aware of the applicability and transferability of strategies that they may already use with other presenting problems.

Bariatric psychology in the UK National Health Service: input across the patient pathway.

BACKGROUND: Providers of bariatric surgery within the National Health Service (NHS) are required to provide psychological assessment and intervention, yet operational definitions regarding the purpose and scope of this input are lacking. This has led to significant variation in the provision of psychology, with some providing an assessment-only service and others providing a more comprehensive package of intervention throughout the patient pathway. The aims of this paper are to document the current psychology provision and service models of National Health Service (NHS) bariatric surgery services in the UK. Psychologists belonging to a bariatric psychology forum completed a survey. This focused on provision of psychological assessment and intervention throughout the bariatric pathway as well as the ratio between psychology resources and number of bariatric procedures per year. We obtained information from 22 NHS services which provide 3691 procedures per year. RESULTS: There is significant variation in the ratio between psychology resources and number of bariatric procedures undertaken per service. Whilst all services offer pre-surgery psychology assessments, less than one-third routinely assess all potential bariatric surgery candidates. Over 90% of services offer pre-surgery individual interventions and 41% offer pre-surgery groups. None of the services routinely offer post-surgery assessments but 68% offer post-surgery assessment and intervention following referral. None offered post-operative structured psychological group interventions. CONCLUSION: There are significant disparities and inconsistencies in the provision of psychology resources in relation to surgery volume in the NHS. Most of these resources are directed at pre-surgery assessment and this raises issues regarding the function of these assessments. Rather than focusing on assessing psychological (un)suitability for surgery, an evidence-based approach involves psychologists offering pre-operative interventions to improve readiness for surgery and post-operative interventions to address recurring or emerging difficulties which impact on outcomes.