BARIATRIC REALITIES: Causes of Obesity – What Factors can YOU Influence? (Part One of Three)

I’m guessing most of us understand that the disease of obesity is a complicated one. There are a number of factors that contribute to obesity. Some of these factors you may be very aware of; others you may be surprised about. Some of the causes of obesity are things you cannot do anything about; other causes of obesity are things you can influence. It’s important to recognize the difference. Why? For starters, you can stop beating yourself up over the things you can’t do anything about. It’s also important that you focus on putting forth effort where it will get you the best results! It’s essential for both doctors and those suffering from obesity to have a mutual understanding of these causes of obesity and which people can influence, so that:

1) Doctors can develop or increase empathy for the struggles of those suffering with obesity. When doctors better understand that many people with obesity have struggles that go beyond fighting their biology which negatively impact their weight, the doctors can more compassionately and appropriately address these issues and refer patients to see other professionals, if need be.

2) People struggling with their weight can evaluate the numerous factors impacting obesity and work toward accepting those things they cannot influence. In addition, they can take responsibility for putting forth effort into those aspects of their struggles with weight that they can positively impact.

All righty, then! Let’s look at three of the main contributing factors of obesity and then talk about each one, emphasizing what, if anything, each person can do to have a positive impact on their weight.


Culture and Environment



Obesity definitely has some genetic determinants, as researchers have clearly discovered. If there are a lot of obese people in your extended family, you have a better chance of being obese than someone from a family without a history of weight problems.

Although there are many more obese people in the current population than in previous generations, this cannot all be linked to genetics. The genetic composition of the population does not change rapidly. Therefore, the large increase in obesity reflects major changes in non-genetic factors. Listen to this…  According to the Centers for Disease Control and Prevention (2002): “Since 1960, adult Americans have increased in height an average of 1 inch but have increased in weight by 25 pounds.” So in 50 years, the human species has grown taller by only an inch but heavier by 25 pounds. That tells us there is more than genetics influencing weight gain in this country.

PATIENTS: Even if you have a genetic predisposition for obesity, there are other factors involved, including the food choices you make and whether or not you exercise on a regular basis. Some of these behavioral factors are habits learned in your family, so what appears to be a genetic predisposition may be a familial pattern of unhealthy habits that can be broken.

DOCTORS: Remind yourself that patients cannot “eat less/move more” and have any effect on their current genetic makeup. Acknowledge to patients their genetic predisposition for obesity in a compassionate manner. Help to gently educate them about the factors affecting their weight that they can influence. Do so in a “firm and fair” way, providing encouragement rather than admonishment.

Culture And Environment

In addition to one’s genes, a person’s culture and environment play a large role in causing people to be overweight and obese.

The environment and culture in which you were raised impacts how and what you eat. Some people were taught to eat everything on their plate and couldn’t get up from the table until they did so. Others never sat at a table for a meal but watched television while they ate. Some kids are fed well-balanced meals while others exist on fast food or microwaved mac and cheese with hot dogs. In some cultures, simple carbs make up a substantial part of every meal. In other cultures, fruits and vegetables are consumed regularly. When you are a child, you’re not in charge of buying the groceries or providing the meals. You did learn, however, about what and how to eat from those with whom you lived. And guess what that means? How you feed your children is what they will think of as “normal” and will most likely be how they eat as adults. (I’m always concerned when weight loss surgery patients tell me their kids are “just fine” even though they eat the same unhealthy foods as the obese parent. It’s only a matter of time before the kids start to gain weight and have health problems as a result of their unhealthy diet and learned eating behaviors.)

PATIENTS: Although your genetic composition cannot be changed, the eating behaviors you learned in your family, from your culture, or developed on your own can be changed. You alone now determine what kind, and how much exercise you do and what and when you eat. Your behavior is completely within your control. Work toward accepting the fact that you are in charge of, and responsible for, your behavior and every food choice you make. For every choice, there is a consequence, positive or negative. And NO EXCUSES! It doesn’t matter how busy you are, whether you get a lunch break at the office or whether you have to cook for a family. Even if you have five kids in different activities and spend your life taxi-ing them from one place to another, you are the adult and you are responsible for how you eat and how you feed your children. It takes a very responsible person to acknowledge, “Although I have a genetic predisposition for obesity, I am responsible for making healthy choices about my eating and exercise. For me and for my children.” Focusing on what you do have control over rather than that over which you are powerless, leads to believing in your capabilities. So take charge and make positive changes happen!

DOCTORS: Engage your patient in a discussion about the cultural and environmental factors that helped shape their current food choices and exercise behaviors. Empathize with them, noting they are going to have to put forth consistent effort to change years of bad habit formation. Encourage them to get support, whether it is from friends with a healthy lifestyle, a health coach, a personal trainer, or the use of free online exercise videos. Help them set a short-term, reasonable goal and set an appointment with you to follow up. Remember, docs: That which is reinforced is repeated. Reinforce even small steps forward you see in your patients. This can go a long way in encouraging them to continue making healthier choices. A step forward is a step forward. Notice and praise every single step forward your patient makes!

Resting Metabolic Rate

Resting Metabolic Rate (or RMR) is simply the energy needed to keep the body functioning when it’s at rest. In other words, RMR describes how many calories it takes to live if you’re just relaxing. Resting Metabolic Rate can vary quite a bit from one person to another, which may help explain why some people gain weight more quickly than others. And why some people seem to find it more difficult to lose weight than others. There are some factors related to metabolism that you can’t change, but there are actually some that you can influence and change.

Things you cannot change about metabolic rate:

·       Metabolic rate decreases with each passing decade, which means the older you are, the slower your metabolism gets, making weight loss more difficult.

·       Sorry ladies - Men generally have a higher metabolism, meaning they burn calories more quickly than women.

·       You can inherit your metabolic rate from previous generations- which can be a benefit… or not.

·       An underactive or overactive thyroid gland can slow down or speed up metabolism.

Some things you can do to influence your metabolism and burn more calories include: 

·       Eat small, frequent meals.

·       Drink ice water.

·       You can boost metabolism temporarily with aerobic exercise.

·       You can boost metabolism in the long run with weight training.

PATIENTS: I’ll bet you didn’t there was much of anything you could do that would increase your metabolism. I’m hoping you choose to implement the ways you can help your body burn more calories. And what do you know? They are completely consistent with healthy post-op behaviors that you’re supposed to do anyway: 1) Eat small, frequent meals. CHECK. 2) Drink water (so add ice and boost that RMR). CHECK. 3) Engage in exercise, both aerobic and weight bearing. CHECK. There’s no reason NOT to anymore! (That’s a slogan from a really old commercial…) The point is, your specific RMR is both something that is unique to you, and that will slow down with age, is gender-influenced, and can be affected by thyroid issues. Accept the things you cannot change and DO the things you can to get the most out of your own, unique RMR. You DO have choices! Opt not to make excuses and JUST DO THE THINGS YOU CAN!

DOCTORS: I’m pretty sure that educating patients is in your job description. Even though you have an allotted set of minutes during which to accomplish all your goals with a patient, point out the ways they can boost their metabolism while you’re looking into their ears, or hitting them on the knee with that little hammer. Present it as a, “Hey! Guess what I was reminded of today?” sort of thing. It’ll probably be absorbed better than a mini-lecture. Leave yourself a sticky note in the patient’s folder to bring it up in your next session… and then a new educational point for the next meeting, along with the small goal you set with them so you can be sure to praise them for their efforts!

 Patients and Doctors and all Allied Health Professionals: We need to work together to do the following:

1)     End Fat Shaming

2)    End Blaming

3)    End Lecturing

4)    Encourage reciprocal AWARENESS and ACCOUNTABILTIY

5)    Encourage reciprocal EDUCATION and DISCUSSION

6)    Encourage reciprocal GOAL-SETTING and FOLLOW-UP

Stay tuned for Part Two of BARIATRIC REALITIES: Causes of Obesity – What Factors can YOU Influence?

Bariatric Realities – Medical Professionals’ Guidelines about Alcohol Use & WLS

I know I said my next article was going to be on causes of obesity, but I got carried away tonight doing some investigating about the professional medical guidelines for alcohol use after weight loss surgery. In summary, the gist of the recommendations are: “Patients undergoing bariatric surgery should be screened and educated regarding alcohol intake both before and after surgery… patients should be made aware that alcohol use disorders (AUD) can occur in the long term after bariatric surgery.” (From:

Well, now. Those are some non-specific medical recommendations by medical professionals who are the predominant leaders and caregivers of the surgical weight loss population. Education and awareness. Hey – I am all about education and awareness. Great things, education and awareness.

And yet, I’m gonna say that as a recommendation, that is a very “PC” non-recommendation recommendation, when one considers that we are talking about 1) ALCOHOL and 2) WEIGHT LOSS SURGERY patients.

Consider these educational nuggets and facts I found that WLS patients really ought to be aware of:

·      Psychologist Stanton Peele, writes, “readers now know that scientifically, it's not alcohol that causes people to live longer, but it is simply being with others and that they are less socially isolated when they drink that prolongs their lives. After all, alcohol is a toxin.” (italics and bold added) (From

My comments: Yes – alcohol is a toxin, and that means POISON. Those of us in the medical field really ought to know that people are not supposed to ingest poison. But the recommendations do not say, “Do NOT ingest the toxin, alcohol.” No, no, no… they say be educated and aware.

·      Dr. Charles S. Lieber, M.D., M.A.C.P., in a publication for the National Institute on Alcohol Abuse and Alcoholism, writes, “A complex interplay exists between a person’s alcohol consumption and nutritional status,” and … alcohol and its metabolism prevent the body from properly absorbing, digesting, and using essential nutrients” (italics added.) Dr. Lieber does indeed, educate us about the nutritional value of alcohol: Alcohol would not fall under the category of an essential nutrient because not having it in your diet does not lead to any sort of deficiency. Alcoholic beverages primarily consist of water, pure alcohol (chemically known as ethanol), and variable amounts of sugars (i.e., carbohydrates); their content of other nutrients (e.g., proteins, vitamins, or minerals) is usually negligible.  Because they provide almost no nutrients, alcoholic beverages are considered ‘empty calories.’ Therefore, any calories provided by alcoholic beverages are derived from the carbohydrates and alcohol they contain.”  (italics added)

My comments: People who have weight loss surgery (other than the band) experience absorption issues to one degree or another. Nutritional deficiency is one of the concerns the medical professionals monitor in the months and years following WLS. We stress to patients the importance of taking vitamin supplements for the rest of their lives to help ensure proper nutritional balance.

And yet, rather than saying, “Alcohol use is unwise after WLS,” or “Don’t drink alcohol after WLS,” the governing body of health professionals for bariatric surgery recommends being “educated” and “aware.”

Is that happening? Are the physicians and surgeons and nutritionists and mental health professionals educating patients and making patients aware that ALCOHOL IS A TOXIN THAT CAN INTERFERE WITH VITAMIN ABSORPTION – and it should not be consumed after weight loss surgery? I can’t answer that, although I know we do this at the programs I work with. If it’s not happening, why not?

Having a background in direct sales, which, ironically, was incredible education for my later career as a psychologist, I was taught to “anticipate the objections.” Many health care professionals may be pooh-pooh’ing the vitamin deficiency issue associated with alcohol, stating it’s only those who drink heavily who are at risk for this type of vitamin deficiency. That information, to the best of my knowledge, is relevant for persons who have not had weight loss surgery. What’s more, we don’t know the extent to which people are drinking many years after WLS. Most of the research, as noted in the ASMBS Guidelines/Statements entitled ASMBS position statement on alcohol use before and after bariatric surgery, states, “The existing studies do not present a uniform picture regarding the overall prevalence of lifetime or current alcohol use disorders (AUD) in patients seeking bariatric surgery. The vast majority of the existing literature is retrospective, with small sample sizes, lack of control groups, and low response rates. There are also varying definitions of alcohol disorders (“high-risk” versus “misuse” versus “abuse/dependence”) in the bariatric surgery literature.” In other words, this research does provide some information, but remember, we don’t really know that much because there isn’t enough research on enough people over a long enough period of time. We don’t then, know the actual affect that alcohol use has on vitamin absorption for WLS patients. We DO know that vitamin deficiency is a concern, so WHY aren’t we telling people not to drink?

Not only is alcohol a toxin for our bodies,

·      “Alcohol is actually classified as a drug and is a known depressant. Under this category, it is the most widely used drug in the world. According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA)” (italics and underling added).

My comments: I am literally chuckling now at the absurdity of this situation. The situation being the medical professionals, all having a code of ethics that reflects the “do no harm” sentiment, ignoring potential harm for their patients. Please note that we would all consider alcohol as being “empty calories” and having sugar/carbohydrates and certainly no protein.

PLEASE let it be the case that the medical professionals around the world who deal with surgical weight loss patients are telling them, “Don’t eat empty calories. Eat a lot of protein. Limit the simple carbs and sugar. And refrain from consuming your calories from liquids. NO STARBUCKS. BUT, HEY - GO AHEAD AND DRINK THOSE SUGAR/CARB LADEN, EMPTY, NUTRITION-ROBBING TOXIC CALORIES IN ALCOHOL, THAT ARE, BY THE WAY, THE MOST WIDELY ABUSED DRUG IN THE WORLD.”

Honestly, that sentence should be the entire article.

But WAIT! There’s MORE!

I really love this last tidbit I’ll share with you. It’s so much nicer for me when I can find it online so it’s not that mean, alcohol-hating Dr. Stapleton being the one to blame!

·      “The truth is that no one needs alcohol to live, so regardless of what you've heard or want to believe, alcohol is not essential in our diets. Did you know that a glass of wine can have the same calories as four cookies? How about a pint of lager – surprised to hear it’s often the caloric equivalent of a slice of pizza? You do not need to be an alcoholic for alcohol to interfere with your health and life.”

Do you hear this, people in the medical profession? Are you giving the OK for your patients to eat four cookies “now and then,” or “in moderation,” or “not for the first six months, or year after surgery?” Do you realize that you may be DOING HARM by giving your patients “permission” to drink alcohol?

“But our job is not to be the watchdog or decision-maker for people.” Another potential objection to my dismay about the recommendations being for “education” and “awareness,” rather than a direct, “SAY NO TO ALCOHOL” stance. I agree that no one can make the decisions about what people can or cannot do, or what they will or will not do. People in the medical field do tell people things like, “Don’t get that wet or you could get an infection,” “Keep the splint on for the next six weeks if you want to heal properly.” There ARE dos and don’ts that are educational and increase awareness. What’s the real issue that medical professionals don’t take a hard stance on alcohol after WLS? I don’t know. I do know that I did my dissertation on medical doctor’s attitudes toward addiction. Turns out it is much like that of their attitudes toward obesity: many don’t know that much about it, very many do not feel comfortable working with it, and most don’t care about/understand it.

To top it all off, HERE’s the real kicker… Not only do the medical AND some of the WLS organizations not tell people, “Don’t drink alcohol,” THEY PROVIDE ALCOHOL AT THEIR EVENTS!

I can’t say any more.

Connie Stapleton, PhD
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Helping the MD's...

I’m writing this article as an invitation for each of you to help educate physicians about the issues that you face related to weight loss surgery and what you believe is needed to enhance your care, either before or after weight loss surgery.

The American Society for Metabolic and Bariatric Surgery (ASMBS) emails each new edition of “connect,” their official news magazine to its members upon publication. In it, they provide a synopsis of recent articles of interest related to WLS. One noted article this week is titled, “What Matters: What’s the magic behind successful bariatric patients?” and is written by Dr. Jon O. Ebbert, an internist at Mayo Clinic.

In the article, Dr. Ebbert states, “I was left wondering how I can best help my patients using this information.” Let’s help him help his patients!

I’ll share the short article, give my editorial (what I didn’t share with Dr. Ebbert) and then write the response I did share with him. Finally, I’ll provide the link where you, too, can share feedback directly about the article, or send it to me and I will be happy to forward it!

The article:

 “MARCH 3, 2016

A fair number of my patients have had or are undergoing bariatric surgery. Disconcertingly, a not insignificant number of them are regaining the weight after surgery. Weight regain will occur in 20% of patients undergoing bariatric surgery after initial weight loss.

When this occurs, not only do we have a patient with an altered gut putting them at risk for nutritional deficiencies if we are not fastidious in our follow-up, but they are discouraged and overweight again.

Add this to the concern that bariatric surgery has been associated with an increase in suicides (2.33-3.63 per 1000 patient-years), and we may have some cause for alarm.

So, what predicts success – and can we facilitate it?

Several factors have been shown to predict successful weight loss after bariatric surgery. An “active coping style” (that is, planning vs. denial) and adherence to follow-up after bariatric surgery have both been shown to be associated with a higher percentage of excess weight loss. Interestingly, psychological burden and motivation have not been associated with weight loss.

In a recent article, Lori Liebl, Ph.D., and her colleagues conducted a qualitative study of the experiences of adults who successfully maintained weight loss after bariatric surgery (J Clin Nurs. 2016 Feb 23. doi: 10.1111/jocn.13129). Success was defined as 50% or more of the excessive weight loss 24 months after bariatric surgery.

The voice of the successful bariatric patient is an interesting and important one. Several themes were identified: 1) taking life back (“I did it for myself”); 2) a new lease on life (“There are things I can do now that I am not exhausted”); 3) the importance of social support; 4) avoiding the negative (terminating unhealthy relationships in which “food is love”); 5) the void (food addiction and sense of loss); 6) fighting food demons; 7) finding the happy weight; and 8) a ripple effect (that is, if you don’t eat it, the rest of family doesn’t, either).

I was left wondering how I can best help my patients using this information.

First, I think the themes can mature our empathy for the struggles that these patients face, and perhaps help us combat bias. Second, I think this knowledge can inform early discussions around what sorts of things need to be lined up for after the procedure, such as social support.

Finally, I think the themes can be universalized and help us counsel patients who may be struggling with weight, but who are otherwise not candidates for bariatric surgery.”

My Editorial

I’m grateful that an internist is addressing the topic of WLS. I love that he is thinking about ways to use the information gleaned from the research he notes related to the behaviors of those who have “successful weight maintenance” following weight loss surgery.

Pardon my sarcasm, but, WOW! Getting information about the behaviors that led to weight loss from patients who have 50% or more of excessive weight loss 24 months after bariatric surgery? Does that really tell us anything? I’d venture to say that the majority of professionals in the field would note the surgery itself as being primarily responsible for the “success” of the weight loss at 24 months out. I’m NOT saying that many patients fail to put forth a great deal of effort at that point, because I know many do work very hard during those first 24 months. But come on… let’s talk to successful weight maintainers at 5 years after surgery to get a better indication of what they are doing to manage a healthy weight.

I’d also be curious to know at what point in time after surgery the statistic was obtained noting “Weight regain will occur in 20% of patients undergoing bariatric surgery after initial weight loss.” How much weight regain? After how much time? If you look closely at research in many fields, you can find numbers that vary widely on a particular topic.

Dr. Ebbert states, “Psychological burden and motivation have not been associated with weight loss.” I wasn’t at all sure what this meant. Questioning my comprehension skills, I asked some other people how they interpreted that statement, and they couldn’t tell, either. If the implication is that psychological issues have no impact on weight loss or lack thereof, I have to disagree. But then, I have no research to back up my hypothesis. I do have 11 years working in this field and the anecdotal evidence of hundreds of patients that says otherwise. I’d say depression interferes with the desire/ability to follow through with certain behaviors that require significant energy. I’d say that intense shame interferes with the perceived efficacy to follow through for the long haul with behaviors necessary to sustain weight loss – well past two years of having WLS. I don’t know… I believe poor self-esteem, a history of “failing” with “diets,” unresolved grief, loss, and abuse issues sometimes affect a person’s perceived ability to succeed. I also believe treating these psychological issues in conjunction with treating one’s physiology and teaching important skills such as healthy coping mechanisms, positive self-talk, and efficacy-enhancing skills is a recipe for better outcomes.

My Response to Dr. Ebbert (in an attempt to be brief):

“Dr. Ebbert -

With all due respect, the medical field is, in my opinion, missing several very large pieces of the puzzle with the surgical weight loss population in terms of treating them. I am a licensed clinical psychologist. I work in a surgical weight loss clinic and have spoken with literally thousands of patients who have had weight loss surgery. Obesity is a complicated disease that is more than just physiological. I treat the underlying and associated psychological co-morbidities, which the medical community largely ignores, except under the broad category of "Behavior Modification." I assure you that there is a lot more than changing behaviors that needs to be addressed with this population. A vast majority of this population suffers with deep shame and low self-esteem, both rendering them inefficient at maintaining motivation to follow through on a long-term basis with "behavior modification." I am working tirelessly to try to address the elephants in the OR, but surgeons don't really want to listen to myself - or the patients - who are clamoring for additional mental health care (MORE than behavior modification) following WLS when their "issues" interfere with healthy behaviors - just like before surgery. More suicides?  Maybe because in a sense, we take away the patients’ coping skill (food) and throw them to the wolves. I've created a video series that I require all of my patients to watch before surgery to help them understand the deeper issues they may face and to urge them to seek counseling. I could use help in the medical community. You in?”

I do believe, and I thank Dr. Ebbert for noting, “this knowledge can inform early discussions around what sorts of things need to be lined up for after the procedure.” Let’s all pitch in and share with Dr. Ebbert and other interested physicians what you need to be successful, on and off the scale, for years and years following WLS. Please share your comments at:

Or, post your comments here or contact me via my web page:

Let’s pitch in and help!

Connie Stapleton, Ph.D.