Obesity is a growing concern in South Africa, particularly because of the lifestyle diseases associated with it, including type 2 diabetes, hypertension and heart disease.
Gastric bypass surgery is an increasingly popular treatment option for appropriate patients, however surgery alone cannot address the unhealthy relationship with food that frequently leads to obesity.
“Often people reward or comfort themselves with food, which is eating for psychological rather than nutritional reasons, and, over time, this can become deeply ingrained and may lead to obesity,” explains Charlene McIntosh, one of the psychologists in the multidisciplinary team supporting gastric bypass patients of general surgeon, Dr Gert du Toit, and his surgical partner Dr Ivor Funnell, who head up the bariatric surgery centre at Netcare St Augustine’s Hospital.
“Another aspect that appears to be driving obesity is the central role of food in South African culture, by which I mean that many of our social interactions tend to revolve around eating,” she explains.
“We often meet friends and family for a meal, tea and cake, shisinyama or a braai. For people who are grappling with their weight, this can make it even harder for them to exercise self-control, particularly if they feel social pressure to eat,” says McIntosh.
Dr Du Toit, who specialises in complex digestive laparoscopic procedures, says that gastric bypass surgery is not to be undertaken lightly and is not appropriate for all patients with obesity and related conditions.
“We are committed to helping patients achieve positive health outcomes, and there is a growing body of evidence to suggest that conditions such as type 2 diabetes and hypertension can be well controlled, if not fully alleviated, with gastric bypass surgery and behavioural change,” Du Toit notes.
In line with the protocols of the South African Society for Surgery, Obesity and metabolism (SASSO), prospective patients must be assessed for suitability, and supported through the surgery and afterwards by a multidisciplinary team of healthcare professionals.
“Patients must be dedicated and committed to making a lifelong change, otherwise the surgical intervention will be far less likely to help the individual achieve better health over the long term. For this reason, it is sometimes advisable for patients to prepare for a few additional months to make absolutely certain that they are ready for the significant lifestyle changes to ensure that they get the best out of the treatment,” explains Du Toit.
Du Toit likens the preparation for gastric bypass surgery to that of climbing a mountain. “If you consider people who climb Mount Everest, it is the ones who never look back who are most likely to make it to the summit. Our team needs to ensure that the surgical candidates have a similar mindset and commitment before the gastric bypass is performed.”
A vital aspect of preparation for the surgery is dealing with the emotional aspects, as McIntosh explains: “The role of the psychologist is to identify and address underlying emotional trauma that may be at the root of some people’s compulsion to eat. This is a vital aspect of the holistic treatment for patients undergoing gastric bypass surgery, because the operation can change the body but the person’s mindset also needs to change to achieve lasting outcomes.”
“We emphasise that there is a distinction between eating because you are hungry and eating for psychological or social reasons. People need to redefine their relationship with food, and in the case of obese patients we essentially have to teach them to eat again.”
Addressing the social pressures around eating often requires the individual’s support base, including family and friends, to develop greater awareness. “Instead of organising time together around food, as in ‘let’s meet for lunch’, it is a good idea to sensitise the person’s social circle to rather meet for a walk or other activities that do not centre around eating,” she advises.
This is one of the messages conveyed in the monthly meeting of the support group for people who have either had or are considering gastric bypass surgery, hosted by dietitian Mandy Read, who is also part of the multidisciplinary team at the bariatric surgery centre. The meetings are also open to the family and friends supporting patients through their journey.
“A key aspect of changing people’s emotional reliance on food is replacing comfort eating or reward eating with another pleasurable activity, such as going for a massage, having a relaxing bubble bath or learning to play a musical instrument. Interestingly, we have found that people who replace emotional eating with a creative outlet, such as painting, photography, music or gardening, tend to have better outcomes in general,” McIntosh observes.
“Perhaps the most important factor is for the person to realise that they can shape their future and have real belief that their lives can be different. If a person has been morbidly obese for many years, sadly they often become used to sitting at home and feeling isolated, and cannot imagine a life beyond that.”
“Imagine clothes shopping, and being so limited in your choice because you are trying to find something that is large enough to fit you, rather than shopping for clothing that makes you look and feel good. We try to help people realise that there is a life beyond obesity, and help them to get to the stage where they can get full enjoyment out of life without an overreliance on food,” she adds.
According to McIntosh, people who have lost a lot of weight may have some difficulty reconciling the changes in their bodies with the way they see themselves. “Some patients have managed to get down to a healthy weight but will still turn sideways to go through doors as they had to when they were morbidly obese. Often there is a process of re-building a person’s self-esteem so that they can make the best of the physical transformation they have achieved,” she concludes.