**5. Behavior modification**

Behavioral modification is an increasingly studied element of long-term obesity management. As a key component of obesity pathogenesis, behaviors before and after bariatric surgery are important but poorly documented or followed. Surgery, like medical therapy, is essentially an adjunct to what becomes a comprehensive, long-lasting management plan that addresses the multifactorial etiology of obesity.

Weekly self-weighing, eating cessation when feeling full, and not eating continuously during the day are three habits shown to improve post-operative weight loss by up to 14%, compared with individuals that do not engage in these behaviors [18]. Baseline cognitive restraint and strong adherence to the recommended postoperative diet are associated with an additional 4.5% weight loss after bariatric surgery [19]. Results like these suggest the importance of pre- and postoperative dietary counseling to improve postoperative outcomes. A significant minority of patients appear to experience suboptimal weight loss after bariatric surgery. The reasons for this are not well understood, but suboptimal weight loss is often attributed to preoperative psychosocial characteristics and/or eating behaviors, as well as poor adherence to a recommended postoperative diet.

Important components of long-term obesity management include assessing eating problems, weight control practices, and prior or current substance abuse such as the problematic use of alcohol, smoking, and illegal drugs. In addition to recognizing these detrimental factors, it is important to have a process in place to address problematic eating behaviors and eating patterns.

Preconditioning is an element of preparation for bariatric surgery that sets expectations, lays the groundwork for behavioral modification, and helps get candidates ready for a lifestyle change. It involves coursework and counseling by a multidisciplinary team on a one-on-one basis or in a group setting. This provides multiple perspectives and education by a dietitian, occupational and/or physical therapist, psychologist, and surgeon. Variations of preconditioning include the amount of coursework and didactics required, the need to pass exams, and objective clearance parameters by the multidisciplinary team. Nutritional education is a large part of preconditioning, since evaluating a candidate's relationship with food, triggers for eating, and implementation of management techniques for healthy eating is such a large part of long-term success with weight loss. Additionally, cognitive behavioral therapy courses can also be included. Intensive preconditioning in addition to close multidisciplinary follow-up postoperatively, has been shown to improve weight loss outcomes after bariatric surgery [20].
