Margarita Cozzan, M.S., a Registered Dietitian since 2009, has a Master of Science degree in Nutrition and has been an ACE Certified Personal Trainer since 2006. With more than 15 years of experience in coaching and supporting lifestyle change, Margarita has supported clients in variety of settings including an outpatient bariatric surgery clinic, skilled nursing and rehabilitation facilities, doctors’ offices, spas, and gyms.
Coaching Considerations for Bariatric Surgery Clients
As a health coach, working with people who have had bariatric surgery can be exceptionally rewarding. After bariatric surgery, clients may experience weight loss in the tens to hundreds of pounds, and the health coach has the privilege of being there to witness major, sometimes life-saving wins for their clients.
For many, however, the loss of excess body weight only comes naturally for the first year after bariatric surgery. There are two main challenges when coaching clients after bariatric surgery: Guiding them to create life-long lasting behavior change despite the seemingly small effort needed to lose weight during the “honeymoon phase” after surgery, and doing so while they are navigating a myriad of unique post-surgical side effects.
Health coaches need to be familiar with the unique considerations of individuals who have undergone bariatric surgery. This article covers a wide range of topics, including weight bias, people-first language, how to refer a client to the proper clinicians to protect his or her safety, and how to gain insight into your client’s journey, which allows for empathy and is the foundation of a strong coaching relationship. Additionally, recognizing the importance of building your knowledge and expertise in this area will, in turn, increase your credibility and referrals, which are foundational to a solid health coaching practice.
Recognize That Bariatric Surgery is Not the “Easy Way Out”
The most common reason why people seek out and receive bariatric surgery is to drastically improve existing health problems. Obesity coupled with related chronic diseases such as hypertension, obstructive sleep apnea and diabetes increases a person’s risk of further complications, including progression to heart disease and kidney failure. Successful weight loss after bariatric surgery can slow this progression or even resolve these obesity-related diseases that decrease quality of life and life expectancy.
Obesity is a disease caused by multiple factors including environment and genetics, and it requires life-long treatment and maintenance. The idea that obesity is simply caused by a lack of will or self-control has been disproven, as evidenced by its recognition as a disease by the American Medical Association in 2013.
Individuals affected by obesity need our compassion, non-judgment and empathy as coaches and fellow human beings. As much as we want to help our clients change on their own, some people are perfect candidates for bariatric surgery, and who those people are is not for us to decide, particularly as this lies outside of our scope of practice.
Clinicians, health coaches and, most importantly, clients need to recognize that bariatric surgery is not a quick and easy solution to health and weight-loss challenges. As a health and exercise professional, you must understand that clients who opt for bariatric surgery have not given up on attempting to change their lifestyles. Similarly, it is vital that clients considering bariatric surgery understand that the procedure does not eliminate the future challenges of making behavior change. On the contrary, while clients are focusing on planning and implementing new behaviors, they will also be navigating the daily challenge of how their new digestive system functions.
Address Weight Bias
The Obesity Action Coalition recommends that professionals working with clients affected by obesity perform a self-assessment of their weight bias. Weight bias in healthcare professionals has been shown to decrease outcomes in patients with obesity. Ask yourself the following questions to assess whether you need to employ strategies to reduce your weight bias or improve your communication with and about the clients you serve:
- How do I feel when I work with clients of different body sizes?
- Do I make assumptions regarding a person’s character, intelligence, abilities, health status or behaviors based only on their weight?
- What stereotypes do I have about persons with obesity?
- How do my clients affected by obesity feel when they leave my office?
- Do they feel confident and empowered, or otherwise?
It is also important to check in with the language that you use, both with your clients present and in your everyday communication without them present. Are you using people-first language? Are you avoiding victimizing words? For example, a “person affected by obesity” is preferred language to “an obese person.” Similarly, it is better to refer to a “person with diabetes” rather than “a diabetic” or a “person suffering from diabetes.” Table 1 presents the least and most stigmatizing and motivating words for clients.
Table 1. Common Words and Alternatives
Least Stigmatizing/Blaming Words
Most Stigmatizing/Blaming Words
Most Motivating for Weight Loss
Least Motivating for Weight Loss
Source: Weight Bias in Healthcare, Obesity Action Coalition
Identify Your Role in the Integrated Healthcare Team
The bariatric clinic’s physician will manage your client’s bariatric-related medical care before and after surgery and for life. The clinic will likely utilize the services of a team of allied health professionals, which usually consists of a nurse, registered dietitian and psychologist, and may include others. This integrated healthcare (IH) team assists with presurgical screening, helps patients prepare for surgery, and supports them in both the short- and long-term postoperative phases.
After bariatric surgery, your client will likely experience side effects of the procedure and may need to work through some more serious physical or psychological issues. Many if not all of these challenges will likely require the expertise of the rest of the IH team. However, the long-term success of the client following bariatric surgery depends largely on his or her ability to create and sustain healthy behaviors.
The key roles of health coaches working with clients after bariatric surgery are to:
- Draw upon the principles of positive psychology to help clients shift their focus away from any difficulties or setbacks after surgery and focus on the progress they have made
- Apply effective communication strategies that empower clients to leverage their strength and self-efficacy
- Support clients in setting goals and making the behavior changes that they will need to maintain their new healthy weight for life
- Refer clients to their bariatric clinic when side effects or complications arise
Actions outside the scope of practice of health coaches include:
- Mental health counseling. Anxiety, depression, binge eating disorders, food addiction and distorted body image are examples of psychological conditions that are known to decrease the short- and long-term effectiveness of bariatric surgery and must be addressed in professional counseling. In fact, preoperative psychological screenings that identify unstable conditions such as these may disqualify a patient from receiving the surgery until he or she receives proper treatment. After surgery, negative body image issues may arise when people lose a lot of weight so quickly that mentally they do not yet feel like a “thin person.” This lag can lead to lowered self-efficacy, reduced mental health and overall loss of vitality.
- Meal planning and recommendation of nutrition supplements. Before surgery, the bariatric clinic may require that candidates go on a very low-calorie diet (VLCD) to decrease the size of the liver. This has been shown to be effective in reducing surgery times and surgical complications. After surgery, under the nutritional management of a registered dietitian, clients will be progressed from clear liquid diets to full liquid diets, pureed diets, soft foods and eventually normal textures. Depending on the type of procedure the client underwent, some foods may have to be permanently eliminated. These may include bread, carbonated beverages, fried foods, dairy and foods high in sugar. For some clients, eating such foods may result in unpleasant side effects such as acid reflux, vomiting, dumping syndrome, a blocked pouch or potential life-threatening complications. (Dumping syndrome is the sudden passage from the pouch to the small intestine after gastric bypass. If the food bolus that passes from the pouch is too large and undigested, the body reacts by flooding the small intestine with hormones and water, leading to stomach cramping, pain, nausea, chills, sweating, dizziness, diarrhea and even heart palpitations or fainting.) It is important to keep in mind that the recommendations for foods that patients need to completely avoid are individualized and should be left to the client, physician and registered dietitian to decide. Furthermore, since bariatric surgeries involve permanent changes to the digestive system, the body’s absorption of key nutrients is altered. Most, if not all, of the recommended micronutrient supplements are continued for the rest of the client’s life.
- Exercise programming. Health coaches who are not exercise physiologists, physical therapists or certified exercise professionals may not recommend specific exercise plans for their clients to engage in after surgery. Because the client will be recovering from an abdominal surgery, the return to physical activity is dictated by the surgeon based on the type of surgery and how the client is healing. Qualified exercise professionals should verify clearance with the bariatric clinic before recommending physical activity to their clients. When in doubt about whether specific movements are safe for the client, always check with the bariatric clinic. In general, surgeons typically recommend walking in small five- to 10-minute bouts as tolerated as soon as possible after surgery.
- Diagnosis of medical issues. Challenges after bariatric surgery range from occasional acid reflux due and consuming food too quickly to life-threatening complications that need to be addressed immediately. Especially within the first month after surgery, the health coach should never assume that a physical symptom a client is experiencing is normal. Always refer clients to their bariatric clinic when physical symptoms arise.
Instead, health coaches play a key role in:
- Stress management and improving self-efficacy. Self-esteem that results from successes in positive behavior change has been found to play a role in improving body image. In addition, helping clients adopt healthy stress-management strategies after surgery will help with long-term success. If eating was a way for your client to cope with stress before surgery, those habits are likely to find a way back into his or her life long-term unless the client starts practicing mindful eating and learns to properly manage stress.
- Goal-setting and creating healthy habits. The Dietary Guidelines for Americans may no longer apply to clients after bariatric surgery. What health coaches can help with is assisting clients with their awareness around eating, offering education about meal preparation, goal-setting as it relates to following the registered dietitian’s individualized nutrition treatment plan and encouraging hydration.
- Communicating progress with the physician and IH team. Ideally, you have received permission from your client to establish communication with his or her bariatric clinic. Clients may have visits with you more frequently than their visits with their physicians and IH teams. This means you can share your visit summaries with them, including weight information, progress toward goals, new goals, and questions that you and your clients may have about their care. Discuss with the clinic how to best share this information and in what frequency.
- Relapse prevention. Best practices for follow-up after bariatric surgery include having regularly scheduled check-ins for life. The restrictive aspects of bariatric surgery can diminish over time. Relapse is therefore more likely after the first year of surgery, especially if clients have not made changes to their eating and movement habits. As with any coaching practice, relapse prevention should always be a focus of sessions with clients. Strategies to manage relapse include identifying and avoiding triggers, setting up social support and using cognitive behavioral coaching.
Increase Your Knowledge of Bariatrics
The sidebar below includes brief descriptions of the three most common types of bariatric surgeries. For more information, visit the following websites: https://www.niddk.nih.gov/health-information/weight-management/bariatric-surgery and https://asmbs.org/patients.
The American Society of Metabolic and Bariatric Surgeries (ASMBS) and the American College of Surgeons (ACS) have established best practices to advance the field of bariatrics. For information about their efforts, and the gold standards in the field, visit https://www.obesityaction.org/community/article-library/bariatric-surgery-centers-of-excellence-why-they-are-important-when-selecting-your-surgeon-and-hospital/ and https://www.facs.org/quality-programs/mbsaqip.
Types of Bariatric Surgeries
Adjustable Gastric Band
The adjustable gastric band (AGB) is sometimes referred to as the “gastric band” or the Lap-Band®, which is currently the only FDA-approved brand of this surgical device. In this surgery, a small inflatable tube is fastened and cinched around the upper portion of the stomach, creating a smaller opening to the rest of the stomach. The smaller, upper portion above the band is referred to as the “pouch.” Food empties from the pouch to the rest of the stomach at a slowed rate as dictated by how inflated and tight the band is adjusted. This restricts the amount of food the patient can consume to whatever volume the pouch can tolerate. No other changes to the digestive system are made in this surgery, making the gastric band the least invasive of the bariatric surgeries.
During surgery, a “port” is placed just under the skin on the abdomen and is connected by a tube to the band. Afterward, the surgeon can easily find this port via palpation and, using a syringe, inject saline solution into the band via the port to incrementally fill the band, restricting the opening between the two portions of the stomach even more. This is called an “adjustment” and is performed in minutes during regular office visits. The band can be tightened as the patient loses weight, causing the amount of visceral fat between the band and the stomach to decrease. The band can also be deflated during doctors’ visits by removing saline via the port. This may be necessary if it was filled too much during the last adjustment, or if the patient becomes severely ill or pregnant and needs to increase the amount of food he or she is able to consume. The AGB surgery evokes the slowest rate of weight loss when compared to the other two common types of surgeries, and fewer people successfully lose at least 50% of excess body weight with this surgery compared to the other two types.
The Roux-en-Y gastric bypass [named after its first surgeon and the Y-shaped appearance of the modified gastrointestinal (GI) tract] has been found to be the most effective of the weight-loss surgeries. It is also the most invasive of the three discussed here, meaning the risk of complications is higher. In the gastric bypass, most of the lower portion of the stomach is cut away, leaving a dramatically smaller-sized pouch behind and rerouting the lower part of the small intestine directly to the new pouch, bypassing the lower stomach, the duodenum and part of the jejunum. This means that not only is food consumption physically restricted, it creates life-long malabsorption of nutrients since many vitamins and minerals are absorbed in these portions of the gastrointestinal tract. The bypassed portions of the GI tracts remain unused but intact in the abdominal cavity, making the surgery reversible, though this is not recommended or common due to the likelihood of more complications and the return of weight and comorbidities. A major aspect to the success of this surgery, especially as it relates to improving control of diabetes, is its positive effect on the gut hormones that help the body utilize blood glucose. Normal nerve and gut bacteria functions involved in hunger and metabolism are also positively affected.
In this surgery, about 80% of the stomach is vertically cut away and removed from the body, leaving behind a tube-like stomach that looks like a “sleeve.” Whereas the gastric bypass involves a horizontal incision near the top of the stomach, rendering parts of the GI tract unusable, the gastric sleeve keeps the natural flow of digestion intact. Because the stomach is now significantly smaller, the amount of food one can eat is physically restricted and the stomach’s production of gut hormones that control hunger, satiety and blood sugar control is altered. Success rates of this surgery appear to be similar to those of the gastric bypass but without the greater risk of complications, and the number of nutrients that are malabsorbed after this surgery is smaller than with the gastric bypass. The gastric sleeve is not reversible.
Contact a Bariatric Surgery Center of Excellence
An estimated 228,000 bariatric surgeries were performed in the United States in 2018. The opportunities for health coaches in bariatrics are many and can make a significant impact to the long-term success of people who have received bariatric surgery. If you are interested in working with this population as a health coach, start by visiting https://www.facs.org/search/bariatric-surgery-centers to find a bariatric surgery Center of Excellence near you. Contact the clinic after putting together a one-page professional summary of your services that includes information such as your credentials, suggested appointment frequencies, scope of practice, benefits of “the coach approach,” and any success stories. Give specific information as to the level of support you provide your clients, such as online and email support, daily motivational text messages, individualized goal-setting, or specific coaching tools and strategies such as agenda mapping or cognitive behavioral coaching. Indicate any active memberships to major obesity or bariatric surgery-related professional organizations, such as the Obesity Society or the ASMBS, you have joined.
Furthermore, consider applying your services as a coach in a group setting in addition to the one-on-one visits with clients to make yourself even more marketable to the clinic. The ASMBS requires that all clinics have regularly scheduled support groups. Perhaps other members of the IH team take turns hosting the support groups and you could enter the rotation. Give the physician and IH team confidence in your abilities to effectively consult with clinicians while remaining firmly within your scope of practice.
Clients can experience significant health improvements after bariatric surgery in a relatively short amount of time. A reduction in both excess weight and the number of prescriptions taken, coupled with improvements other health measures, may be lifesaving for individuals who receive bariatric surgery. As a health coach, you have the opportunity to be there with your clients through the challenges and the wins, sharing the joys with your clients and their families.
Coaching Behavior Change Throughout the Phases of Bariatric Surgery
- Gauge your client’s readiness to make lifestyle change and adjust coaching strategies according to which stage of change they are currently in (precontemplation, contemplation, action, maintenance or relapse).
- Pending your client’s permission, establish HIPAA-compliant communication with the clinic.
- Assess your client’s understanding of the doctor’s pre- and postoperative orders; refer to the bariatric clinic if the client needs clarification.
- Respecting the client-led relationship, offer your help with accountability in his or her efforts to follow clinic orders for the weeks to come.
- Assist your client in harnessing social support.
- Perform a values interview and perhaps lead the client through an agenda-mapping exercise to help him or her recognize and build intrinsic motivation.
Post-op Coaching: 0 weeks-3 months
- Goal-setting during the healing phase after surgery should focus on small goals related to maximizing healing, such as stress management or closely following post-op orders such as following new vitamin or medication orders. Because the doctor and registered dietitian will set specific activity restrictions and therapeutic diets, avoid setting any other physical activity or nutrition-related goals at this time.
- Check in regularly to see how your client is doing with post-op pain or side effects. Start inquiring as to how dealing with these issues may affect any goals the client sets and discuss any other potential barriers he or she might identify.
- Be prepared to reassess goals at every session as your client deals with the early side effects of surgery and post-op healing.
- Some highly eager and motivated clients may need help keeping their goals realistic and relevant during this time.
Coaching After Surgery: 3-12 months
- By this phase, your client is likely healed and no longer experiencing side effects as frequently. This is the key time to focus on behavior-modification strategies such as cognitive behavioral coaching, environmental control, practicing “change talk” and problem-solving.
- During this time, weight loss is still likely happening at a significant rate independent of unhealthy habits. Coach your client through creating and implementing SMART goals to create new habits and prepare him or her for the fact that weight loss will naturally begin to slow.
- The length of time between doctor visits may increase as per clinic protocol; suggest increasing the frequency of check-ins.
Long-term Coaching: 1 year +
- Success with continued weight loss during this phase depends on the creation of sustainable habits. Setting new stretch goals and helping clients recall why they embarked on this endeavor may help as well.
- Weight regain and/or plateau before reaching a goal weight may occur. Reevaluate current strategies, assess stage of change and discuss barriers to bring your client back into the preparation and action phases.
- Some clients may continue to lose weight even though they have reached their goal body mass index (BMI). Refer these clients to the bariatric clinic to address this issue and reassess previous goals based on clinician recommendations.
- Your client may be at risk for relapse for the rest of his or her life. Continue to discuss prevention strategies and check in on stress management, and refer your client to a personal trainer, psychologist, registered dietitian or other clinicians as needed.
Summary: Ongoing Strategies for Every Phase
- Meet your clients where they are and constantly assess what stages of change they are in and adjust coaching strategies accordingly.
- Perpetually incorporate relapse prevention by rehearsing how to manage difficult situations and avoid triggers.
- Offer regularly scheduled and frequent motivational messages and check-ins.
- Check in with your clients about their most recent visits to the clinic. Would they like to share any changes in their biometric data or any new orders or recommendations from the clinicians?
- Focus on “non-scale victories” and creating small wins with behavioral-focused goals to build self-efficacy as opposed to focusing on weight.
- Bridge your clients’ values with the major steps they have already take
Starting a Health Coaching Practice in Bariatrics
Prepare to support your client’s autonomy without judgment. Practice people-first language and assess/address your own weight bias. Familiarize yourself with bariatric surgery, including the types of procedures, common side effects, coaching strategies, and the American Society of Metabolic and Bariatric Surgeries (ASMBS) standards of care. Know your scope of practice in the integrated bariatric team. Present your services to an ASMBS Center of Excellence.