Support vs. sabotage : The importance of social support in achieving lifestyle changes for weight loss management in morbidly obese individuals has been acknowledged in the literature. Shared family dynamics among those in the same home can commonly lead to shared negative health behaviours (including poor eating and lifestyle habits, substance use, and other high-risk health behaviours) highlighting the importance of targeting the family unit for obesity treatment and intervention. Of particular importance is the role of significant others throughout all stages of the weight loss journey. In bariatric clinics, it is helpful for psychosocial clinicians to have clients reflect on whether or not they would anticipate a significant weight loss negatively affecting any of their important relationships. This may allow the client to work with the clinician in identifying potential challenges and problem-solve around preventing interpersonal strain. Additionally, if a client identifies one of his/her primary supporters as being a potential saboteur in his/her weight loss journey, it is recommended that, at a minimum, an opportunity be provided by the clinician for the client to be seen with this significant other prior to weight loss surgery or treatment in order to facilitate a discussion around helpful versus unhelpful support for the individual [42]. It has also been suggested to overtly include the potential saboteur in the entire treatment process as much as is possible by encouraging their participation in clinical consultations, educations sessions , and support groups. At all of these encounters, benefits and stressors to the relationship subsequent to weight loss intervention/bariatric surgery can be explored and brainstorming strategies to cope with identified stressors can be collaboratively negotiated [43]. As such, empowering significant others of morbidly obese patients to serve as effective supporters may also indirectly help the patient towards successful adherence to lifestyle changes. It should be recognized that clinicians may encounter individuals who engage in self-sabotaging behaviours themselves based on their own rational of a perceived lack of social support [24].

Perception plays a role in effecting change in individuals pursuing weight loss and therefore the perceptions of support or sabotage within different support systems is an important area to address clinically. Exploring clients’ perception of support, as compared to what their family and friends believe is supportive behaviour, will help clinicians better understand the social environments of their patients in order to more accurately provide them with what they need to be successful in their weight loss journey. It may simply be the case that support systems may not know the right things to do or say for fear of doing the wrong thing. Perceived support is a subjective measure and should be bolstered as best as possible within the clinical setting although it should be recognized that this can be more challenging than helping patients obtain the provision of practical/structural support [19].

Helping significant others adjust to client changes: Although significant others are generally welcomed and encouraged to attend appointments with individuals pursuing surgical and behavioural weight loss management treatments, there is no official forum for them to explore their own perspectives and experiences and to elicit their support despite the known impact on patients’ lifestyle modifications. This is especially crucial for significant others who also battle their own weight and who struggle with adapting to the changes. Providing psychoeducation to both clients and their significant others on the potential impacts of lifestyle modification and/or surgery on family members, or for what may be experienced as a couple, is also of benefit to ensure that a more thorough understanding is gained by all those closely involved, as well as to manage significant others’ expectations following surgery . This could be done verbally through one-on-one individual appointments, through a group session, or conveyed in writing in an informational handout provided to clients at their appointments.

Helping support persons understand the change process can aid in decreasing any uncertainty they may feel and help them to better prepare for upcoming changes. Resistance from family members in adjusting to lifestyle changes required after bariatric surgery has been noted [11, 20, 44] and adjustment challenges with respect to a partner’s lifestyle changes post-surgery has reportedly disturbed the balance within relationships [43], at times leading to spousal conflict and even divorce [45].

Changes in family dynamics serve to highlight both strengths and weaknesses during a difficult time. Research by Chi and colleagues [46] found that how couples experienced and coped with the stressor of bariatric surgery was related to relationship dynamics that were present prior to the surgery; that is, positively functioning couples continued to work collaboratively to navigate the changes brought on by one partner undergoing surgery while interpersonally strained couples demonstrated difficulty in coming together throughout the change process. The lifestyle change process was, for most couples, one that led to a new, more harmonious, “normal”. It was also noted that supporting partners who struggled with their own weight were more likely to be challenged in making lifestyle changes alongside the patient though these support persons did demonstrate greater empathy towards their partner’s weight struggles due to sharing a similar experience.

Related to bariatric surgery specifically, significant others should be informed to recognize that there is a transitional stage right after surgery wherein they may have a tendency to gain weight (e.g. “the garbage can effect” or “clean your plate syndrome”) and in turn should be provided with the appropriate education to help them avoid the potential pitfall of possible weight gain in the first place. Also, providing education and supporting significant others in adopting the lifestyle changes of bariatric patients, which have been shown in some studies to result in collateral weight loss effects [31], may provide significant others with the motivation to implement these changes. Due to the significant impact of bariatric surgery specifically on the family unit, it has been argued that health care professionals should shift their focus from client-centred practice to family-centred practice in order to target all individuals involved/affected by surgery which can contribute to enhanced family functioning as a whole and better success overall [44].

Given the salient role of peer support groups in the success of individuals pursuing weight loss management, it is important for clinicians to encourage their patients to be a part of bariatric communities, both in person and online. If providing a support group through a professional clinic, factors that may contribute to increased attendance and engagement include offering flexible meeting times or weekend meetings for better accommodation, and structuring the provision of new information related to topics of interest [34]. Desired topics identified by bariatric patients include: adjustment and difficulties following surgery, best foods to eat for individual needs, nutrition, exercise, helpful tips after surgery, how to deal with weight loss plateaus, life-altering changes, societal changes, and plastic surgery [47].

Offering a support group for preoperative and newly post-operative patients separate from longer term post-operative patients (e.g. 1-year post-surgery and greater) is a way to better cater to all individuals as the experiences, concerns, and challenges of these groups usually differ [20]. This can help prevent patients feeling alienated by ongoing discussion and provide more opportunities for greater coverage of pertinent topics by weight loss journey stage.

Additionally, opening up bariatric patient support groups to include family and friends can offer significant others the opportunity to share and receive information pertaining to their concerns, increase their understanding of the surgical and medical treatment processes from the patient perspective, receive guidance on how best to provide support to their loved ones, and may incite motivation towards making lifestyle modifications themselves.

Clinically in practice, patients have at times expressed concern over a lack of comprehension and sensitivity from their “normal sized” health care practitioners. It is not unusual for a patient to present their motivations for wanting to lose weight and accentuate their perspective by providing the clinician, “wouldn’t understand”, or at a minimum thinking this without overtly vocalizing it. In bariatric clinical settings specifically, health professionals may also at times sense that patients provide calculated answers to assessment questions in order to demonstrate themselves as “suitable” surgical candidates. There is also the concern that weight loss management clinicians are professionally and financially motivated to provide unquestioning support to their patients [11] although this may be of less concern in countries where the weight loss surgery is government funded. Such challenges can prove difficult to navigate when trying to establish a positive therapeutic rapport with clients. The ability of clinicians to draw from their cumulative experiences in working with this population in order to arrive at genuine empathic understanding is something that should be strived for. Interaction should be framed in a manner that assumes the client perspective, conveying appreciation for the affective and cognitive experiences of the client over time (even though he or she has not shared a similar lived experience firsthand), and reflecting back to the client the essence of the personal struggle they have undergone [11, 48]. Arriving at a joint understanding with patients allows them to feel validated, supported, and invested in.