Katie Jay, MSW

The WLS Stages of Transformation™
A Prescription for Improved Patient Outcomes

By Katie Jay, MSW, CTA-certified Wellness Coach

Director, National Association for Weight Loss Surgery

The WLS Stages of Transformation™ is more than a description of the process of change patients move through after weight loss surgery (WLS). It is also an explanation about how to move through the common post-surgical stages, with an emphasis on the mental and emotional transformations that take place. The WLS Stages of Transformation™ describes, normalizes, and demonstrates the process to improve a patient's long-term WLS outcome potential.

Discussion

Ory B., who is 3 years post-op, confessed the following: “I was well informed when I had my weight loss surgery. I just didn't think I would be one of those people who would struggle. I didn't know it would be this hard for this long!”

She wrote to me in response to an article I had written in my Small Bites newsletter about the first stage of transformation for WLS patients: Decision Point.

Ory is not alone. In fact, at least 30 more people wrote to me with a similar admission. They are upset with themselves and, some of them, feeling hopeless, because they are not having the WLS experience for which they had hoped. Many of them are not having the experience they were told they would have.

Kelly B. shared with me: “When I heard about Roux-n-y, I thought I had reached heaven. I had the surgery in February of 2004 and I have never reached ‘goal.' It is an every moment battle with me. I still hate myself as [much as] I did when I weighed 301…. I am not sorry that I had the surgery, but I wish it had been a cure all.… I feel like my life is only what [I can] and … cannot eat. I wish I could find more joy in being me.”

Why is there a seeming disconnect between what so many patients expect to have happen and what really happens after their weight loss surgery?

It's complicated.

There are thousands of bariatric professionals with a variety of backgrounds, opinions, protocols, and colleagues. And there are hundreds of thousands of patients, with varying backgrounds, conditions, perspectives, and interpretive abilities, being given information from numerous sources.

And some patients are simply told the surgery will cure them.

This disconnect between expectations and experience is common, regardless of why it happens. The solution lies in educating patients about realistic expectations – or about the normal, expected process.

Let's look at an analogy. In most places, the Division of Motor Vehicles (DMV) is busy and requires people who wish service to take a number. If you are holding number 378-B, and the person with number 382-A is called up to the counter before you, you may get confused, frustrated, or even angry. You might think, “Hey! I'm 378, why did 382 get called before me?!”

WLS patients get confused, frustrated, and angry, too. Complicated processes can push people to their limits.

At the DMV, if the uniformed woman at the information desk had explained to you at the start that the A's always get called before the B's, then you would have more realistic expectations. And when 382-A is called, you don't worry so much. “He's an ‘A' you say to yourself,” understandingly. “It's not my turn, yet.”

The key to avoiding the WLS disconnect is to educate patients in a simple way about the WLS Stages of Transformation™ they will go through after surgery -- not just physically, but mentally and emotionally, as well. Then show them how to move through those stages for maximum benefit.

Prochaska and DiClemente (1986) describe a model of six common stages people go through with any change. The stages are pre-contemplation, contemplation, preparation, action, maintenance, and relapse.

While the WLS Stages of Transformation™ take into account the stages identified by Prochaska and DiClemente, the WLS Stages of Transformation™ is more than a description of the process. It is also an explanation about how to move through the process. It illustrates and exhibits the process to improve the long-term WLS outcome potential.

A Brief Overview of the WLS Stages of Transformation™

Decision Point – This stage involves a patient's decision to have weight loss surgery and their surrender to an outside force to help them lose weight. It is a difficult decision for many people and can be very frightening. Some people feel elated, hoping they will finally be free. At this stage, some patients are information seekers and some are not. The goal is to provide a step-by-step approach for patients through which they can collect and evaluate information -- with the goal of identifying challenges and developing strategies to deal with them that are well-suited to their eating style, mental status, emotional makeup, and physical circumstances. At this stage, bariatric professionals should begin an ongoing dialog with patients that communicates to them the full nature of the process they are undertaking -- physical, mental, and emotional.

Shock and Awe – This stage is when a patient thinks, “What have I done?” At this stage, sometimes “buyer's remorse” can set in. The reality of the situation may feel different from what the patient imagined. They have made a drastic change in their bodies and their lives. They are recovering from surgery and one of their most basic functions, eating, has been totally disrupted. Adjusting to a new way of eating and living can be quite dramatic. Conversely, some people experience great joy at this stage. They are excited about the possibilities and are in awe of how little food they can eat.

Grief and Loss – Grief can set in when a patient realizes there will be losses other than their weight. Their eating changes, they may have food intolerances or other short-term problems with eating. They also may not be able to enjoy food with their “eating buddies,” and they may not want to be around others who are eating foods they are unable to eat. Relationships often change, too. Many people report sadness, confusion, or frustration regarding the loss of friendships, rituals, and self-soothing eating behaviors. The old ways of living and relating to others may not work anymore.

The Miracle – Once patients get used to the WLS lifestyle and their weight begins to fall fast, they can experience a new sense of well being. They may feel more in control of their eating than they ever have. And even if they do “cheat” a little, the weight keeps coming off. Also, patients may enjoy increased attention from others who notice their weight loss and patients may receive nearly constant positive reinforcement. At this stage, patients feel invincible and “cured.” Some can't imagine ever having a problem with eating and overweight again. Others experience a sense of freedom, while also feeling dread about what's to come. They are waiting for “the other shoe to drop.”

Testing Limits – This stage takes place gradually, as patients can tolerate more food and different foods. Instead of sticking with what has been working, they might decide to taste foods that used to trigger them to overeat, like sugar and refined carbohydrates: candy, desserts, crackers, etc. Many people realize at this stage that they don't experience “dumping syndrome” when they eat sweets. Some may see a slowdown in their weight loss or cease to lose weight, but it is a gradual process that may not be recognized as such for a period of time. Also, at this stage, patients who are sensitive to carbohydrates can trigger physiological processes that drive them to crave more carbohydrates. They may experience a feeling of being out of control with their eating.

Behavioral limits are tested, too, in this stage. Relationships can change, interpersonal boundaries can shift, and transfer addictions can begin to take hold.

End of Invincible – After a period of time, usually between 18 and 24 months, WLS patients realize their miracle time, also known as the honeymoon, has ended. Rapid weight loss is over and the novelty of the “new and improved you” wears off. Patients start to see their eating impact their weight and this can be devastating. Many people struggle to lose weight, or even regain. Patients may feel like they are a slave to food again. Even if the ramifications of eating are minor, or the patient is still losing, a fear of regain intensifies, and intuitively some patients realize something has changed. Their honeymoon is over, and they are off course. Some patients are in denial at this phase, blaming a variety of things for their lack of progress or their backsliding.

Give Up or Change – A decision point is reached when patients know that if they don't do something, they will gain weight and lose the benefits of the surgery. The shame at this stage can be overwhelming and isolation is common. Many patients fail to continue with follow-up care. The emotional aspect of this stage has both physiological and emotional underpinnings, but most people do not know what to do about their situation. Many surgeons and other bariatric professionals are baffled or frustrated with patients at this stage and engage in communication with patients that is perceived as shaming or judgmental. An understanding and acknowledgment of the normal, expected process of transformation will help both patients and the bariatric professionals serving them to recognize and more effectively plan for and deal with this stage. If a patient is unwilling to change, they may drift away at this point and not seek further help. Some people become resigned to what they think is inevitable. In reality, this stage is the gateway to long-lasting recovery -- if it is recognized, acknowledged, and treated as a starting point for self responsibility and growth.

Learning – Keeping an open mind and embarking on a discovery process is the next stage, if a patient has made the decision to change. Their task is to pinpoint what their real problems are, not what they think they might be. During this stage they will learn about all the possible causes of their regain, and learn what solutions can really work, based on research and not on people's varying beliefs (which may or may not be based on facts). These “arbitrary” beliefs exist in both patients and bariatric professionals. The bariatric professional has an opportunity to educate patients about all the possible reasons for their challenges, including physiological, mental, and emotional influences. Patients will also become clearer about themselves and their behaviors by keeping logs that they can analyze. It is critical to have an exhaustive list of possibilities and of opportunities for change, as well as to have reference materials in a variety of formats to appeal to different learning styles and preferences.

Experimenting – Even with good knowledge about themselves and their situations, patients will need to begin a trial and error process to discover their specific needs and the solutions that will work for them, given their unique psychological and physical strengths and challenges. As they undertake intentional experiments and observe the results, they start to amass even better knowledge about themselves and their most viable solutions. They tweak their plans, try again, and reevaluate often. Through this trial and error process, patients begin to identify a way of living that will support long-term WLS success and improve their life satisfaction.

Self Trust – At this stage, patients have regained some control and have begun to turn things around. Maybe their unrelenting food cravings have subsided. Or they have lost some weight. It can be very surprising the first time they realize that they got way off track, but were able to make changes and see positive results. They gain perspective and begin to see the possibility for long-term peace of mind with food, their bodies, and the scale. They experience a sense of self trust that leads to improved self esteem, even self love.

Mastery – At this stage, patients live fully with the self trust that was previously nonexistent. They consistently work toward their goal of managing their weight (and other areas of their lives) and when they slip up, they can easily get back on track. They don't become perfect; patients become disciplined in a way that makes them feel great about themselves and hopeful for their future. They clearly see and are planning for a future that includes long-term weight loss and weight maintenance -- and, by this time, a future that holds many other exciting possibilities.

Freedom – This stage can be difficult to maintain all the time, but the goal is for patients to spend as much time as possible free from the burden of obsession with food, their bodies, and the scale. It is when what patients want to do and what they must do to stay healthy are one and the same. This is WLS “Nirvana,” and while it is not always permanent, patients know without a doubt that freedom will be a regular part of their long-term WLS experience.

Case Studies

Sally S. (4-year-post-op, RNY patient)

Terri came to me when she was 3 years out from her RNY surgery. She had regained 20 pounds, and the scales were still going up. Her surgeon had encouraged her to take action, but did not offer further advice or resources, other than the traditional once-a-month support group (mostly targeted to early post-ops). Terri was at the “Learning” stage, because she had decided to change, but did not know what to do.

As a bi-monthly coaching client, Terri learned about the WLS Stages of Transformation™ and self-identified as being at the “Learning” stage. The biggest breakthrough Terri had was to realize that she could spend time learning about herself and her specific challenges, rather than constantly judging herself and trying to white-knuckle it through each day.

When Terri realized it was okay to observe her behavior; record what she was eating, doing, feeling, and thinking; and then learn how to deal with the discoveries she made, she was freed from her shame. When it came time for her to experiment with what might work for her, she enthusiastically set out to discover her best WLS lifestyle. She switched from thinking her WLS life was a “pass or fail test” to thinking of it as a “grand experiment.” That reframing of her experience made a huge difference for her.

Terri is fully engaged in the change process at this point. She is feeling hopeful, has significantly modified her eating behaviors, and has found a form of exercise that actually appeals to her. She believes she will lose what she regained -- and has taken responsibility for her process. While when she came to me she was actively gaining, she has been maintaining for several months and is getting ready to experiment with a weight-loss plan.

Ellen R. (6-year-post-op, RNY patient)

Ellen joined NAWLS after hearing my presentation entitled, “Do YOU Have a Fat Personality?” After learning about the WLS Stages of Transformation™, she identified herself as being in the “Give Up or Change” stage. She did not know if she had it in her to try again, and did not believe she could ever lose what she regained (she continued to be morbidly obese).

Over time, Ellen opened up to the possibility that there were things she had not learned that may help her understand her situation. She joined a coaching group to increase her knowledge about what might be causing her challenges. She listened to books on tape (her preferred learning style) and interviewed people who were having some longer-term success with their WLS.

Then, Ellen developed a plan and began to experiment. Through trial and error, she realized she is extremely sensitive to carbohydrates and that the more she ate the more she craved.

So she experimented with quantities and types of carbohydrates until she found types and amounts she could tolerate without setting off cravings. She also studied her emotional life and found that she needed to learn and practice new ways to deal with her emotions.

Ellen has lost weight and feels she is in the “Self Trust” stage now. I see her as having developed some “Mastery” at this point. She is overjoyed to trust that she can take the necessary steps to feel in control. She does not feel she is “out of the woods,” but she is on her way. She is making far more healthy choices than she used to. She is listening to books on tape about emotional eating, and is applying the change process she learned through the WLS Stages of Transformation™ to that issue, as well.

Jenna G. (5-year-post-op, RNY patient)

Jenna is an interesting case because she reached her weight-loss goal when she was 18 months out from surgery and has maintained that loss; however, she was not happy with her life and was not following all of her surgeon's guidelines. Jenna's relationships had deteriorated, and she was struggling to set boundaries. She was not taking her vitamins and did not feel she had enough time to do that. She also did not feel worthy of help.

As a NAWLS retreat participant, Jenna identified herself as being in the “Surrender or Decision Point” stage. She knew that her way of approaching her WLS lifestyle was not working and that her health was at risk.

She moved through “Shock and Awe” (She said, “I don't think I can make the changes I need to make -- why did I admit to this?”), “Grief and Loss” (“My husband is going to be so angry with me if I set limits with him!”), and continued moving along to her present stages: “Mastery” and, sometimes, “Freedom.”

At the “Learning” stage, Jenna met with a dietitian to develop a food plan that would work better for her. She listened to the NAWLS Train to Maintain™ Home Study Program and learned about how to take charge of her WLS lifestyle and set her priorities. She studied boundary setting and began to experiment with saying no. She experimented with strategies to get on track with her vitamins and supplements -- and experimented with asking for help with this.

What helped Jenna the most was the simple idea that there was a process she could go through and that it was going to take some time and some willingness on her part to find her freedom. She embraced the process out of desperation; her satisfaction with her surgery has improved tremendously. She also feels better physically, now that she is taking her vitamins and eating enough protein.

She has announced to her NAWLS friends that she plans to apply the stages to all areas of her life -- so that she can develop a much deeper satisfaction with her life.

Jennifer C. (3-year-post-op, gastric band patient)

Jennifer had gastric-band surgery, but she was not losing very much weight. At first, her course was relatively normal, but then she had a fill that was probably too much. She began to vomit when she ate most solid foods, but did not tell her surgeon. Instead, she switched to a soft diet, including milk shakes and other sugary beverages. She was afraid an “unfill” would be a sign that she was failing somehow. In general, she demonstrated a lack of understanding about how to eat with a gastric band and how to utilize the band for optimal weight loss.

Jennifer was in shock that she had spent so much money on her surgery only to have it not work. She also was grieving the loss of her dream to be thinner, and she missed her old way of eating. In her case, it was helpful for her to identify that she was in the “Grief and Loss” stage, that this stage was normal, and it would pass. Once she understood the bigger picture, she was able to see that to move forward she would need to visit her surgeon, which she did. She had some fluid removed from her band and has begun to make progress again with her weight loss. She is looking forward to “The Miracle.”

Susie G. (4-year-post-op, gastric band patient)

By the time I met Susie, she was at goal and at peace, probably living somewhere between “Mastery” and “Freedom.” She reported that she was proud of the work she had done to overcome a very rough spot at about 2 years post op.

Intrigued by her success story, I asked her to describe her process for me. Without exception, she had unknowingly passed through all of the WLS Stages of Transformation™ and was able to look at my framework and show how she had experienced each stage.

The most remarkable stage for Susie was “Experimenting.” During that stage, she chose to apply the “band rules” she had relearned -- with a deeper understanding -- during her “Learning” stage. She struggled to find a food plan that fit her lifestyle. She had to get a better support system in place. She had some harmful habits she needed to let go of and healthier ones to establish. “This stage was scary, hard work,” she recounted, “but well worth the effort.”