CPEU ARTICLE. The 12-Steps with support group highlights:

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1 CPEU ARTICLE Understanding and guiding the bariatric post-surgery patient through a 12-step food addictions support group By Jennifer A. Naples, MS, RD, LD, CDE & Mary Jo Rapini, M.Ed., LPC Jennifer A. Naples, MS, RD, LD, CDE Mary Jo Rapini, MEd, LPC Learning Objectives The reader will be able to: 1. Identify and understand the 12-Steps of the Food Addictions Support Group. 2. Understand patients fears and the critical importance of claiming their Higher Power. 3. Identify 5 emotions on the selfinventory list, understanding why Step 4 is a foundation for recovery. 4. List 5 alternatives which can help guide patients when tempted with trigger foods. Introduction Addiction, defined: Compulsive need for and use of a habit-forming substance (such as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly: persistent compulsive use of a substance known by the user to be harmful. (Merriam Webster Online Dictionary) Data on food addiction have become more visible in recent years. Addictions may be associated with obesity (1-4). Food addictions are generally characterized by an obsessive, compulsive relationship to food. Having a food addiction does not infer addiction to all foods just to those foods termed trigger foods. These tend to be sweets, dairy foods, and/or starches. Neal Barnard, MD, President and Founder of Physicians Committee for Responsible Medicine, states, these foods contain chemical compounds that stimulate the brain s secretion of opiate-like, feelgood chemicals such as dopamine which drives cravings for them (5). For these populations, food addiction can be a lifelong challenge. Patients undergoing bariatric weight loss surgery are often taught self-management skills that include diet and lifestyle behavior modifications to aid in long-term weight loss success. However, patients frequently have the perception that surgery is a cure for comorbidities stemming from weight loss, that appetite will be curbed after surgery, and that overall long-term caloric intake will be reduced permanently. In addition, preparing the bariatric weight loss surgery patient for the emotional aspect of eating post-op is essential to address food addictions and any sources of disordered eating. Patients find that diligence regarding diet choices and behaviors after surgery MUST remain a lifelong commitment to achieve success. Support Group after Bariatric Surgery Study - Structure Support Group is based on the original 12- Step Alcoholics Anonymous program, which highlights the spiritual journey of recovery (6). The Food Addictions group focuses on meeting the emotional needs of the postsurgery bariatric population. With each step, members must admit powerlessness, accept a Higher Power, and embark on a spiritual journey to maintain strength and discipline in daily practice and relationships with others. While there are currently Twelve Step programs focusing on food addictions for the general population, none have extended to the bariatric weight loss surgery population. The Methodist Hospital Weight Management Center s 12-Step Food Addictions Healing Support Group in the Texas Medical Center is co-led by psychotherapist, Mary Jo Rapini, LPC, and registered dietitian (RD), Jennifer Naples, RD, LD, CDE. Along with group leadership, participants receive a 12-Step workbook in which they discuss and complete self-reflections (6). During the progression of Steps, participants are dealing with their direct addiction to food, and with self-reported issues including dysfunctional relationships, emotional struggles, and underlying abuse since these can all contribute to compulsive food addiction behaviors (7). Willingness of participants to work through the progressive steps by participating in group discussion and journaling in a 12-Step workbook are essential for self-discovery of their source of addiction while learning healthier coping mechanisms during the healing process. The 12-Steps with support group highlights: Twelve Steps to Recovery Step 1 Admitted we were powerless over the effects of addiction- that our lives have become unmanageable. Step 2 Came to believe that a power greater than ourselves could restore us to sanity. Step 3 Made a decision to turn our will and our lives over to the care of God as we understood God. Step 4 Made a searching inventory and fearless moral inventory of ourselves. Step 5 Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 4

2 Step 6 Were entirely ready to have God remove all defects of character. Step 7 Humbly asked God to remove our shortcomings. Step 8 Made a list of all persons we had harmed and became willing to make amends to them all. Step 9 Made direct amends to such people wherever possible, except when to do so would injure them or others. Step 10 Continued to take personal inventory and when we were wrong, promptly admitted it. Step 11 Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for knowledge of God s will for us and the power to carry that out. Step 12 Having had a spiritual awakening as the result of these Steps, we tried to carry this message to others and to practice these principles in all our affairs. Group members begin Step 1, by answering the questions of unmanageability, which challenges them to begin their journey of recovery, naming sources (persons or situations) related to their associated unmanageable fears. Their ability to claim their current unmanageability is the critical component of the first step, which requires them to claim their Higher Power to help them through this experience. Step 1 Reinforcement of post-surgery diet essentials is discussed and reviewed. This includes macronutrients, necessary micronutrient supplementation, and appropriate fluids with recommendations for volumes/ portions at various post-surgery stages. An important focus is targeting healthy food choices as a consistent behavior change, with reinforcement of a daily adequate protein intake for optimal nutrition. Introduction of food records to the patients begins at this time. Although patients may have completed food records in the past with prior weight loss attempts, these records include: time of day, food or fluid, amount (ounces), degree of Volume 8 No. 2 hunger (i.e., not hungry, hungry, very hungry), location when eating, and thoughts and feelings at that time. During the twelve month program, keeping track of food intake has been an effective but challenging component for patients. Some patients did not want to keep a record, as it was a reminder of their poor food choices. Other patients commented that they believed surgery would fix their obsession with food; in some cases, keeping food records was a constant reminder that food consumed their thoughts. Most patients consciously understood that unhealthy foods were defeating their weight loss goals, yet commented often that they wanted something sweet or had a bad day. Even though patients in the 12-step group are at different post-surgery stages, ranging from several months post-surgery to years postsurgery, individual food histories showed that these patients, regardless of amount of weight loss after surgery and current weight, can display maladaptive behaviors. Step 2 Poses the acceptance of the existence of a God or Higher Power to patients. A patient s past traumatic experience might interfere with both understanding and acceptance of a Higher Power, questioning why the trauma occurred. Oppong reports approximately 30% of the weight loss surgery population has been a victim of sexual abuse (8). In our findings within the 12-Step group, up to 40% of women had reported sexual abuse prior to surgery. This and other dysfunctional relationships are barriers to trusting in God. Individuals begin to find their meaning of God whether religious, spiritual, or in nature. At this point, group leaders encourage open discussion. Some patients are closed, quiet, unaware of the connection of their eating issues and their addiction, not yet ready to share their story, not feeling connected to the group, while questioning the spiritual overtone. The patient s feelings are acknowledged, addressed and reassured with encouragement to keep working on their issues at the present level. Step 3 Requires introspection while trusting and turning over their lives to God. Patients need to learn to embrace a personal Higher Power, which is essential for allowing oneself to let go and continue 5 the Steps. The 12-Step group encourages embracing other members. Members serve as sponsors for one another. Trusting relationships develop within the group, serving to support and reassure, while further trusting in God. When such trust is established, patients begin to realize the possibility of trust generalized to other people and settings. Patients who were unable to embrace a concept of a true God were encouraged to embrace other patients within the group. This stage is critical for their development in managing their addiction after leaving the group. Step 4 Offers members an introspective self-inventory of various aspects of their lives: resentment, fear, repressed or inappropriately expressed anger, approval seeking, caretaking, control, fear of abandonment, fear of authority figures, frozen feelings, irresponsibility, isolation, low self-esteem, overdeveloped sense of responsibility, and inappropriately expressed sexuality. Having had bariatric weight loss surgery and still struggling with food choices and portions, a written inventory allows time for directly addressing the potential source of their addictions. When patients have lived in denial and have not openly admitted weaknesses to family, others or themselves, this step can be extremely challenging. Important for group leaders and group members, this step is a foundation for recovery. Step 5 Involves using inventory information from Step 4 to honestly admit wrongs to a Higher Power and another human being. Patients have used weight as a protective mechanism against the abuses suffered by them usually in childhood by immediate family members who often are deceased. Food serves as continual medication. Patients now learn to admit and confront their past faults and remember their strengths, while seeking balance from the psychosocial imbalance which developed within them. Talking openly within the group allows patients to receive validation and acceptance. Patients can be inspired to write letters to the person wronged, later burning or letting go of the letter and the wrong. It is important for the group members and group leaders to understand the significance of (Continued on page 6) Weight Management Matters

3 (Continued from page 5) this step as it deals with deep psychological issues and is essential to moving on to the next step. With ongoing recovery, patients are continually encouraged to address and discuss nutrition issues and eating patterns. Step 6 Involves careful consideration and meditation from group members. At this point in the program, the question of trust in one s God or a Higher Power re-emerges as one prepares for God to remove personal shortcomings. This step is the turning point in the 12-Step Food Addictions group. The group begins to solidify and bond as they take on ownership of the group; the facilitators can begin to step back. It is very important that the group leaders reinforce this concept with the patients. They should acknowledge the groups cohesiveness, encouraging them to verbalize positive comments about one another and reinforce their helpfulness toward one another. Patients often begin to relax during this stage, feeling less threatened. During an individual setback, patients become more comfortable sharing their situation via to the group members and talking about their struggle more easily within the group. Whether relationship issues, work situations, or internal struggles lead to overeating or eating unhealthy foods, other patients within the group can be very supportive under leader supervision. Step 7 Requires patients to reflect and pray while leaders discuss the patient s patterns of prayers, feelings, and thoughts which may be affected by experiences prior to surgery. At this point, humility in asking one s Higher Power to remove one s shortcomings is an essential component for the patient. Patients often remark that they are beginning to see their prayer lives change. For some patients, this change occurs easily as it was already instituted in their life. For others, this change occurs with more resistance as prayer was not a part of their life. Regardless, patients in the groups are receptive to prayer with positive effects. Step 8 Requires group members to compile a second inventory, this time listing wrongs. These could be spiritual, physical, material, or moral in nature against others. Step 9 Follows up by making apology or direct amends to the specific person when appropriate. Again, personal character is discussed in the group. Steps 8 and 9 are difficult but often less emotional since the group is now more cohesive and less tense. Patients generally begin to practice more healthy coping mechanisms and turn to food less for comfort and more as nourishment. During this time, patients often initiate discussion regarding their nutrition progress, making the association between emotional healing and greater control with food choices. Step 10 Recognizes the importance of creating balance and nurturing oneself by reviewing strengths and weaknesses. Follow-up in the form of a long-term inventory of the patient s relationship with one s Higher Power is addressed as well as the introspection of recovery from various areas of Step 4 inventory. We begin preparing patients for Step 12. It is never easy for groups to end and say goodbye. Patients become close so it is important for the facilitators to begin mentioning the end date of the group. This adds intensity to relationships within the group while members continue to be more open and honest with one another. Step 11 Members use prayer and meditation to stay in communication with God or their Higher Power; reflecting on their daily behaviors, practices, and eating patterns. This step further nurtures their relationship with God. Group leaders encourage patients to share favorite prayers, quotes, or poems regarding their faith and/or beliefs, which is done by mass . It is not uncommon to receive a poem, prayer, or quote every day of the week from group members. Step 12 Celebrates the members and reinforces the use of the Steps each day for continued self-discipline and success in their goals for change. Group leaders facilitate this last step by focusing on the progress attained as individuals and as a group, reminiscing about the patients transitions in their spiritual and physical journey from the beginning to completion of the program. Patients share healthier coping mechanisms. The group applauds members who demonstrate a change in their ability to adapt and engage in a healthy activity when tested and tempted by food. It was interesting to note that some patients who initially have difficulty with finding a Higher Power make a complete transformation by the official end of the 12-Step program. Each group celebrated personal stories, emotions, and support. Support Group after Bariatric Surgery Study Background The purpose of this pilot study was to examine the change in food addictions, quality of life, and depression at the beginning, midpoint, and end after entering a 12-step food addiction healing support group program in the post-bariatric surgery population. Methods: Questionnaires used include: Eating Attitudes Test (EAT-26) (9), Quality of Life Inventory (QOLI), and Beck Depression Index-II (BDI-II). Demographic information and body weight was collected upon questionnaire distribution. The Methodist Hospital Weight Management Center 12-Step Food Addictions Support Group met once per month for a twelve month period. Recruitment: Up to 25 persons were allowed in the group. Both males and females were able to participate in the study. Age requirement was 18 years or older. A monthly was sent to all postsurgery bariatric patients who had voluntarily provided their address to be added to the list at The Methodist Hospital Weight Management Center. Information regarding the 12-Step Food Addictions Support Group was included. Additionally, announcements were made at the monthly bariatric surgery patient support group meeting regarding the 12- Step Food Addictions Support Group. Once patients entered the group, they were informed of the research study. Results and Analysis: Sixteen women enrolled in the 12-Step program and seven completed all sets of questionnaires. The ages of those seven women varied from 31 to 67 years with a mean of 48 years. Because of the small sample size, 6

4 Friedman s ANOVA was used to analyze differences among the baseline, point two (6-month) and point three (12-month). Body weight at the beginning of the group varied from 175 to 330 pounds. At point three, body weights varied from to 262 pounds. Five of the seven women (71.4%) lost weight. This was a significant weight loss between point one and point three at less than BDI-II Scores at baseline varied from minimal (3; 42.8%), to mild (1; 14.3%), to moderate (2; 28.6%), to severe (1; 14.3%). At point three, the scores varied from minimal (6; 85.7%) to mild (1; 14.3%). However, this difference measured at point three was not statistically significant (p=.446). At point three, the scores of four women (57%) had decreased and those of three had slightly increased. At point three, none of the women s scores indicated more than mild depression. The one woman who scored in the severe range at baseline was referred for counseling and scored in the minimal range for the next two measurements. There were no significant differences in the depression scores from baseline score to measurement three (p=.459). The EAT-26 scores varied from 4 to 30 at baseline. Scores above 20 indicate concerns about body weight, body shape, and eating pathology. Five women (71.4%) scored at or above 20. At point three, scores varied from 3 to 31 with three (42.8%) scoring above 20. There were no significant differences in the EAT-26 scores from baseline to points two and three (p=.446). On the QOLI for point one, two scored 0 (Very low quality of life), two scored 1 (Low quality of life), and three scored 2 (Average quality of life). At point three, two scored 1, three scored 2, and two scored 3 (High quality of life). An increase of 1 point is considered clinically significant. However, there were no statistically significant differences in these scores (p=.200). Conclusion and Discussion: Although the participants scores for depression, eating attitudes, and quality of life improved, there were no statistically significant differences. A major limitation of this study was its small size. During group conversation, it became apparent the group was a source of strength for individuals that positively influenced their Behavioral Alternatives Used During 12-Steps Groups Throughout the group meetings, patients voiced frustration several times, needing help with substitutions or pleasurable alternatives when tempted to eat trigger foods. Patients in general need to have a plan for such situations. Examples of suggested alternatives are discussed in the group. They include: 1. Take a walk or march in place for five minutes. 2. Sip on fluids (sugar-free, caffeine-free, non-carbonated) instead of eating. 3. Call a friend who is a supportive listener. 4. Keep healthy protein-dense foods available in pre-portioned servings. 5. Choose a healthy food when hungry: baby carrots, raw broccoli, seedless cucumbers, grape tomatoes, apple, celery, plain rice cakes. 6. Rinse with mouthwash to help eliminate a food craving. 7. Toss out trigger foods in the pantry or give them to a local food pantry. 8. Write down how food is helping you cope. 9. When the urge to compulsively eat is strong, have a list of chores or activities to replace eating. Make sure the list is always easily accessible. Completion of a diversion on the list will give one a sense accomplishment. 10. Write down how body weight is a protective mechanism. 11. Walk a dog. Take a walk with a neighbor or friend who has a dog. One study found persons with dogs had a higher physical activity level, walking approximately 300 minutes per week, 132 minutes more than persons that did not own dogs (10). 12. Find other people who struggle with their weight. Talk and be open with them. 13. After an episode of eating a trigger food, be kind to one self, and begin again. Do not spend time with destructive self-punishment or continued feelings of guilt. 14. Welcome positive support from family and friends. personal lives. The women were empowered to be more assertive in the group and to form their own support group at the end of this process. Since this study was conducted, other 12-Step groups have completed their programs and participants have extended their support for one another via ongoing s and casual get-togethers as a show of the cohesiveness these groups produce. Patients have provided positive feedback; some have enrolled in another group consisting of members who have already completed the initial 12-Step program. The leaders role is to help patients maintain insight and control as they desire positive group support and strive for continued development of self-control with their addictions. REFERENCES: 1. Acosta MC, Manubay J, Levin FR. Pediatric obesity: parallels with addiction and treatment recommendations. Harv Rev Psychiatry. 2008;16: Corsica JA, Pelchat ML. Food addiction: true or false? Curr Opin Gastroenterol. 2010;26: Hetherington MM, Cecil JE. Geneenvironment interactions in obesity. Forum Nutr. 2010;63: (Continued on page 8) Volume 8 No. 2 7 Weight Management Matters

5 (Continued from page 7) 4. Barry D, Clarke M, Petry NM. Obesity and its relationship to addictions: is overeating a form of addictive behavior? Am J Addict. 2009;18: Barnard N. Breaking the Food Seduction. Neal Barnard. New York, St. Martin s Griffin Friends in Recovery. The 12 Steps: A Way Out. California, RPI Publishing Apple RF, Agras WS. Overcoming Your Eating Disorder. New York, Oxford University Press Oppong BA, Nickels MW, Sax HC. The impact of a history of sexual abuse on weight loss in gastric bypass patients. Psychosomatics. 2006;47: Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine. 1982;12: Brown SG, Rhodes RE. Relationship among dog ownership and leisure-time walking in western Canadian adults. Am J Prev Med. 2006;30: CPEU PROCESS Access the CPEU Assessment and obtain your Certificate via the online WM DPG CPEU Assessment Create a new account if you have not used this system in the past for newsletter or webinar CPEU. Once logged in, you can take the CPEU quiz for this newsletter article. You will have three attempts to receive a minimum 70% correct score and receive your CPEU certificate. Before taking the CPEU quiz you will be asked for an Enrollment Key. When prompted, please enter: wmfall10 Jennifer A. Naples, MS, RD, LD, CDE, is a senior dietitian with Food and Nutrition Services at The Methodist Hospital, Texas Medical Center, Houston, Texas. She specializes in bariatrics and diabetes education, gives lectures and presentations, and co-leads bariatric patient support groups. In addition to 12-Step food addictions study, Jennifer is primary investigator on two additional studies dealing with binging and female self-concept/sexual satisfaction in the female bariatric surgery patient. Mary Jo Rapini, MEd, LPC, is an intimacy and sex counselor, specializing in empowering relationships. She is the intimacy/sex psychotherapist for the pelvic restorative center at The Methodist Hospital in conjunction with the Methodist Weight Management Center. Mary Jo was featured on TLC s Big Medicine seasons 1 & 2. She is a popular speaker across the nation and hosts a local Fox show Mind, Body, Soul with Mary Jo. Mary Jo is the author of Is God Pink? Dying to Heal, and co-author of Start Talking: A Girl s Guide for You and Your Mom about Health, Sex or Whatever. 8