**7. Psychological pre/post-surgical intervention for bariatric candidates**

Bariatric surgery is the most effective intervention for weight loss in the field of obesity management. Unfortunately, patients often do not achieve optimal results in term of weight loss maintenance over time and meet various difficulties related to eating behaviors and psychological functioning. Given the significant variation in weight long-term outcomes after surgery that could be partially attributed to a number of risk factors, including psychological factors, psychological pre-operative or post-operative interventions are increasingly being recommended for patients seeking or undergoing bariatric surgery [23].

The most delivered psychological interventions included Cognitive Behavioral Therapy (CBT) but promising evidence suggests the effectiveness of intervention based on Acceptance and Commitment Therapy (ACT) and Dialectical Behavioral Therapy (DBT).

Cognitive behavioral interventions typically include psychoeducation, goal setting, self-monitoring, stimulus control, problem solving, and reinforcement, for the promotion of lifestyle-related behavior change. Through the psychological intervention, patients are encouraged to recognize their problematic eating behaviors, learn strategies to cope with life stressors, and engage themselves in healthy eating behaviors and physical activity. Recently, David and colleagues [5] conducted a systematic review aimed to examine the effectiveness of cognitive behavioral interventions. Results showed that the most common techniques employed during the interventions were psychoeducation, self-monitoring, goal setting, stimulus control, cognitive restructuring, problem solving and reinforcement, as well as addressing ambivalence, improving self-care and prevention of relapse. Most of the interventions included in the study were delivered in person, or in combination with telephone or web. With respect to intervention outcomes, the main findings of the review revealed that 32% of included studies showed a significant impact on weight loss. Specifically, it seems that the higher impact on weight loss was found in post-operative intervention, than the benefits of pre-operative interventions which were not maintained at follow-up. Other interventions outcomes were lifestyle behaviors, eating pathology, and psychological functioning. Results showed that psychological interventions seem to have an inconsistent influence on change in dietary habits and physical activity, but a limited number of studies examined this outcome. With respect to eating pathology, psychological interventions included in the study revealed a significant impact on reducing binge eating and emotional eating. Similarly, interventions had a positive impact on psychological functioning. Both pre-operative and post-operative interventions improved quality of life and reduced depression and anxiety symptoms.

Recently, other forms of psychological interventions were applied to bariatric patients. In a pilot RCT, Weineland and colleagues [24] compared an intervention based on ACT (two face to face session in combination with internet-based support) to usual treatment. Results showed that patients in the ACT condition significantly improved in eating disorders, body dissatisfaction, quality of life, and acceptance of thoughts and feelings related to weight.

Promising results were also obtained in an observational study [25] in which a pre-operative intervention based on DBT skills training combined with treatment as usual compared to a treatment as usual group. The intervention of DBT was focused on regulating emotions with emotion regulation, mindfulness, distress tolerance, and interpersonal effectiveness training. The results offered preliminary evidence in support of the effectiveness of a brief DBT skills training intervention in combination with treatment as usual in reducing eating pathology (binge eating and emotional eating).
