Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review

Loss of control over eating predicts outcomes in bariatric surgery patients: a prospective, 24-month follow-up study

OBJECTIVE

This study examined the clinical significance of loss of control (LOC) over eating in bariatric surgery patients over 24 months of prospective, multiwave follow-ups.

METHOD

Three hundred sixty-one gastric bypass surgery patients completed a battery of assessments before surgery and at 6, 12, and 24 months following surgery. In addition to weight loss and LOC over eating, the assessments targeted eating disorder psychopathology, depression levels, and quality of life. The study was conducted between January 2002 and February 2008.

RESULTS

Prior to surgery, 61% of patients reported general LOC; postsurgery, 31% reported LOC at 6-month follow-up, 36% reported LOC at 12-month follow-up, and 39% reported LOC at 24-month follow-up. Preoperative LOC did not predict postoperative outcomes. In contrast, mixed models analyses revealed that postsurgery LOC was predictive of weight loss outcomes: patients with LOC postsurgery lost significantly less weight at 12-month (34.6% vs 37.2% BMI loss) and 24-month (35.8% vs 39.1% BMI loss) postsurgery follow-ups. Postsurgery LOC also significantly predicted eating disorder psychopathology, depression, and quality of life at 12- and 24-month postsurgery follow-ups.

CONCLUSIONS

Preoperative LOC does not appear to be a negative prognostic indicator for postsurgical outcomes. Postoperative LOC, however, significantly predicts poorer postsurgical weight loss and psychosocial outcomes at 12 and 24 months following surgery. Since LOC following bariatric surgery significantly predicts attenuated postsurgical improvements, it may signal a need for clinical attention.

Obesity and bariatric surgery

Laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are the most commonly performed weight reduction operations in the United States. Preoperative assessment and selection should be performed by a multidisciplinary team to obtain optimal results. The most devastating complication of bariatric surgery is leak, which can carry a high risk of mortality if not detected and treated expediently. New nationwide databases have been developed to monitor outcomes and facilitate better understanding of the mechanisms of bariatric surgery. New horizons for the advancement of bariatric surgery are in the realm of surgery in adolescent and geriatric populations, the use of weight-loss surgery in lower body mass index (<35 kg/m(2)) populations, and the use of surgery to cure the comorbidities of obesity.

Current psychological assessment practices in obesity surgery programs: what to assess and why

PURPOSE OF REVIEW

The present editorial review examines current psychological assessment practices in obesity surgery programs, reasons for making such assessments and data obtained prior to surgery and during follow-up. It summarizes findings from previous review articles and reports on new research findings that have been published between August 2006 and August 2009.

RECENT FINDINGS

Patients with morbid obesity applying for weight loss are commonly administered extensive psychiatric and psychological assessment prior to surgery. Although the value of psychopathological factors for predicting weight loss and mental health after surgery remains controversial, the presence of psychopathology should be taken into account in the presurgery as well as in the postsurgery management of patients undergoing weight-loss surgery.

SUMMARY

Morbid obesity is associated with high rates of psychopathology, including depression, anxiety, eating disorders, abnormal personality traits and personality disorders. There is a decrease in psychopathology after obesity surgery in many, though not all, individuals. There is some evidence for poorer postsurgery outcome in individuals with significant presurgery psychopathology, but there is a clear need for more substantial information with regard to reliable psychological predictors of weight loss and mental health after surgery. Whatever the predictive value of psychopathology prior to surgery, it is essential to detect patients in need of psychiatric and/or psychological support after surgery.

Preventing Weight Regain After Bariatric Surgery: An Overview of Lifestyle and Psychosocial Modulators

Bariatric surgery is being increasingly used as a treatment for obesity. With this weight loss intervention, obesity-specific disease remission and mortality reduction benefits are undeniable. After surgical weight loss is complete, one of the greatest challenges becomes long-term weight loss maintenance, which is largely behavior-ally based. The fundamental behavioral components to maintaining surgical weight loss include dietary control, commitment to regular physical activity, and behavior modification. Changing these longstanding lifestyle habits, however, is a serious challenge and, unfortunately, many formerly obese individuals ultimately experience weight regain due to noncompliance. Further research is needed to identify optimal treatment strategies for postoperative bariatric surgery patients to minimize weight regain.

Behavior therapy for obesity: where are we now?

PURPOSE OF REVIEW

To describe the short-term and long-term results of lifestyle modification for obesity.

RECENT FINDINGS

Randomized controlled trials, which compared different diet and activity interventions were reviewed. Studies that investigated the efficacy of new technologies to provide lifestyle modification, such as web-based delivery, also were examined.

SUMMARY

In general, comprehensive lifestyle modification programs delivered in person induce a loss of approximately 10% of initial weight in 16-26 weeks of treatment. The use of portion-controlled diets, which typically involve the use of meal replacement products, was associated with significantly larger weight losses in the short term. In contrast, interventions delivered via the Internet induced a loss of approximately 5%. However, web-based programs appear to have potential in facilitating the continuation on patient-provider contact, which along with high levels of physical activity, appear to be key strategies for successful long-term weight control. Recent studies also have suggested that the combination of lifestyle modification with long-term use of pharmacotherapy holds promise for maximizing initial weight losses and promoting long-term maintenance.

Does weight loss immediately before bariatric surgery improve outcomes: a systematic review

BACKGROUND

Preoperative weight loss before bariatric surgery has been proposed as a predictive factor for improved patient compliance and the degree of excess weight loss achieved after surgery. In the present study, we sought to determine the effect of preoperative weight loss on postoperative outcomes.

METHODS

A search of MEDLINE was completed to identify the patient factors associated with weight loss after bariatric surgery. Of the 909 screened reports, 15 had reported on preoperative weight loss and the degree of postoperative weight loss achieved. A meta-analysis was performed that compared the postoperative weight loss and perioperative outcomes in patients who had lost weight preoperatively compared to those who had not.

RESULTS

Of the 15 articles (n = 3404 patients) identified, 5 found a positive effect of preoperative weight loss on postoperative weight loss, 2 found a positive short-term effect that was not sustained long term, 5 did not find an effect difference, and 1 found a negative effect. A meta-analysis revealed a significant increase in the 1-year postoperative weight loss (mean difference of 5% EWL, 95% confidence interval 2.68-7.32) for patients who had lost weight preoperatively. A meta-analysis of other outcomes revealed a decreased operative time for patients who had lost weight preoperatively (mean difference 23.3 minutes, 95% confidence interval 13.8-32.8).

CONCLUSION

Preoperative weight loss before bariatric surgery appears to be associated with greater weight loss postoperatively and might help to identify patients who would have better compliance after surgery.

Comprehensive interview assessment of eating behavior 18-35 months after gastric bypass surgery for morbid obesity

BACKGROUND

Weight loss surgery induces a marked change in eating behavior. However, not much work has been done characterizing the eating behavior after weight loss surgery. We conducted a detailed analysis of patients' eating behavior 18-35 months after Roux-en-Y gastric bypass surgery, determined whether preoperative eating disorders might be associated with non-normative postoperative eating, and examined the association of such eating behaviors with weight loss and psychopathology.

METHODS

A sample of 59 patients who had undergone Roux-en-Y gastric bypass was interviewed in person after surgery about a range of eating behaviors, including binge eating, chewing and spitting out food, picking at and nibbling food, and nocturnal eating and compensatory behaviors such as vomiting and laxative and diuretic misuse. An established semistructured interview was used. The prevalence of preoperative eating disorders was assessed retrospectively. The eating-related and general psychopathology and quality of life were assessed using self-report questionnaires before and after surgery.

RESULTS

Subjective bulimic episodes were reported by 25% and vomiting for weight and shape reasons by 12% of the participants, on average, 2 years after surgery. Subjective bulimic episodes were significantly associated with a preoperative binge eating disorder, with more eating-related and general psychopathology after surgery, and with less weight loss.

CONCLUSION

A substantial subgroup of patients with a preoperative eating disorder will develop binge eating after surgery that might be associated with less weight loss. A subsample will start vomiting for weight and shape reasons after bariatric surgery. Clinicians must probe carefully for these behaviors postoperatively to identify patients in need of treatment of pathological eating behaviors.

Body mass index as a predictor of 1-year outcome in gastric bypass surgery

BACKGROUND

The aim of this study was to determine if presurgery (T1), post-surgery (T2), or the change in body mass index (BMI) between these time points are useful predictors for predicting longer-term (T3) outcome in gastric bypass surgery.

METHODS

The sample consisted of 72 gastric bypass surgery patients with an average age of 40.5. The mean presurgery BMI was 54.7 (SD = 8.6). T2 assessments (BMI, depressed mood, binge eating status) occurred on average 21 weeks (SD = 19) after surgery and T3 assessments occurred on average 63 weeks (SD = 34) after surgery.

RESULTS

Three separate hierarchical linear regressions were performed to assess the predictive value of (1) BMI at T1, (2) BMI at T2, and (3) change in BMI from T1 to T2 on the dependent variable, BMI at T3, when age, sex, ethnicity, education status, age of overweight, binge eating status, depressed mood, and number of weeks after surgery were controlled for. When these demographic and psychological variables were controlled for, lower BMI at T1 and lower BMI at T2 predicted lower BMI at T3. However, change in BMI from T1 to T2, did not significantly predict BMI at T3 (p < .001).

CONCLUSIONS

Higher presurgery BMI and post-surgery BMI predict poorer 1-year follow-up BMI in gastric bypass surgery, and these measures can be used as easy "rules of thumb" for predicting longer term outcome.

Obesity and mental health

Mental health factors contribute to the onset and maintenance of overweight and obese status in children, adolescents, and adults. Binge eating disorder (BED), body image, self-esteem, mood disorders, and social and family factors affect individuals in different ways and contribute to weight gain and failure in weight loss management. Assessment of these mental health factors and treatment by 1 of several mental health treatment models may not only improve self-worth but also weight loss and maintenance.

[Evolution of psychopathological alterations in patients with morbid obesity after bariatric surgery]

BACKGROUND AND OBJECTIVE

The aims of this study were to know the prevalence of the psychopathological alterations among patients with morbid obesity (MO) candidates for bariatric surgery in our centre, to analyze its predictive value on the surgical outcome and to study the evolution after weight stabilization was achieved.

PATIENTS AND METHODS

One hundred and forty five patients of the University Hospital Foundation Alcorcón (122 women) candidates for bariatric surgery (108 finally operated) were included in the study. A clinical interview was carried and several scales of psychopathology were applied before and after surgery: Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Maudsley Obsessive-compulsive Interview (MOCI), Barrat Impulsiveness Scale (BIS), Eating Disorder Inventory (EDI), Eating Attitudes Test (EAT), Bulimic Investigation Test Edinburg (BITE), and Body Shape Questionnaire (BSQ). A comparison of means between the initial and final scores of the psychometric tests and a logistic regression analysis to identify the predictive variables of positive evolution after surgery (defined as percentage of lost overweight> 50% and final IMC <35) were performed.

RESULTS

An improvement in the scores of BDI, BAI and in the subscales of EDI, Impulse to the thinness (EDI-DT) and corporal Dissatisfaction (EDI-BD) was observed. The differences were not significant for the rest of the psychometric tests. The multivariate analysis identified 3 predictive factors for postsurgical evolution: BDI (OR 0.91, IC95% 0.82-1.02), BIS (OR 1.08, IC 95% 1.0-1.16) y EDI-DT (OR 1.18, IC 95% 1.0-1.39).

CONCLUSIONS

In our study, the scales of depression, anxiety, impulse to thinness and corporal dissatisfaction improved in patients with MO after bariatric surgery. Some baseline psychometric variables may predict a favourable postsurgical evolution of these patients.

Compensatory eating disorder behaviors and gastric bypass surgery outcome

OBJECTIVE

This study prospectively examined the role of compensatory eating disorder behavior on gastric bypass (GB) surgery weight-loss outcome.

METHOD

The compensatory behaviors of 199 GB patients were evaluated presurgically using the Questionnaire of Eating and Weight Patterns. Hierarchical linear regression was used to assess the presence of compensatory behavior on 6-month postsurgery body mass index (BMI), and 1-year postsurgery BMI, controlling for age, sex, race, age becoming overweight, number of weeks postsurgery, and presurgery BMI.

RESULTS

The presence of presurgery compensatory behavior emerged as a small but significant predictor of lower BMI 6-months postsurgery although not at 1-year postsurgery. Other common predictors for lower BMI at 6-months and 1-year postsurgery were lower presurgery BMI and greater number of weeks postsurgery. Female sex also predicted lower BMI 1-year postsurgery.

DISCUSSION

These results must be taken with caution as they contradict clinical guidelines. Future research is needed to replicate these findings.

Clinical application of laparoscopic bariatric surgery: an evidence-based review

BACKGROUND

Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

METHODS

This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

RESULTS

Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

CONCLUSIONS

Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Best practice updates for pediatric/adolescent weight loss surgery

The objective of this study is to update evidence-based best practice guidelines for pediatric/adolescent weight loss surgery (WLS). We performed a systematic search of English-language literature on WLS and pediatric, adolescent, gastric bypass, laparoscopic gastric banding, and extreme obesity published between April 2004 and May 2007 in PubMed, MEDLINE, and the Cochrane Library. Keywords were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. In light of evidence on the natural history of obesity and on outcomes of WLS in adolescents, guidelines for surgical treatment of obesity in this age group need to be updated. We recommend modification of selection criteria to include adolescents with BMI >or= 35 and specific obesity-related comorbidities for which there is clear evidence of important short-term morbidity (i.e., type 2 diabetes, severe steatohepatitis, pseudotumor cerebri, and moderate-to-severe obstructive sleep apnea). In addition, WLS should be considered for adolescents with extreme obesity (BMI >or= 40) and other comorbidities associated with long-term risks. We identified >1,085 papers; 186 of the most relevant were reviewed in detail. Regular updates of evidence-based recommendations for best practices in pediatric/adolescent WLS are required to address advances in technology and the growing evidence base in pediatric WLS. Key considerations in patient safety include carefully designed criteria for patient selection, multidisciplinary evaluation, choice of appropriate procedure, thorough screening and management of comorbidities, optimization of long-term compliance, and age-appropriate fully informed consent.

Behavioral and psychological care in weight loss surgery: best practice update

The objective of this study is to update evidence-based best practice guidelines for psychological evaluation and treatment of weight loss surgery (WLS) patients. We performed a systematic search of English-language literature on WLS and mental health, quality of life, and behavior modification published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. Key words were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. Our literature search identified 17 articles of interest; 13 of the most relevant were reviewed in detail. From these, we developed evidence-based best practice recommendations on the psychological assessment and treatment of WLS patients. Regular updates of evidence-based recommendations for best practices in psychological care are required to address the impact of mental health on short- and long-term outcomes after WLS. Key factors in patient safety include comprehensive preoperative evaluation, use of appropriate and reliable evaluation instruments, and the development of short- and long-term treatment plans.

The relationship between weight loss and psychosocial functioning among bariatric surgery patients

BACKGROUND

Success after bariatric surgery should also reflect improvement in psychosocial functioning. The objective of this study was to assess the relationships between both mental health and eating disorders and weight loss in morbidly obese patients 2 years after gastric bypass.

METHODS

Forty-three obese women (mean age, 39.3 +/- 1.4 years; mean body mass index, 44.7 +/- 0.4 kg/m2) were evaluated before and 1 and 2 years after gastric bypass. The Beck Depression Inventory and the Hospital Anxiety and Depression Scale were used for depression and anxiety evaluation and the Eating Disorder Inventory for eating disorder assessment.

RESULTS

Decreases in depression (P <.01), anxiety (P <.05), and eating disorder (P <.01) scores were measured 2 years after surgery. Both excess weight loss and change in body mass index were associated with improvements in all measured psychologic outcomes 2 years after surgery.

CONCLUSIONS

The importance of weight loss is in relation to mental health 2 years after bariatric surgery. Psychologic outcomes and eating disorders did not predict weight loss 2 years after gastric bypass. However, these factors improved significantly after weight loss.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Psychosocial predictors of weight loss and psychological adjustment following bariatric surgery and a weight-loss program: the mediating role of emotional eating

OBJECTIVE

To examine a structural equation model of the effects of personal and interpersonal factors on treatment outcome of bariatric surgery and weight-loss program.

METHOD

Forty-four participants of the surgery group and 47 participants of the diet group completed questionnaires before treatment and 1 year afterward. Predictor measures are as follows: social support, motivation for control, sense of control, self-esteem, neuroticism, fear of intimacy, and emotional eating (EE).

OUTCOME MEASURES

Weight loss, quality of life, and mental health.

RESULTS

Neurotic predisposition (NP), a latent variable indicated by neuroticism, low self-esteem, and fear of intimacy, had an effect on weight loss that was fully mediated by EE. NP also had an effect on quality of life improvement that was fully mediated by EE and weight loss in both treatment groups.

DISCUSSION

Both NP and EE predict outcome of obesity treatments, but EE is the more proximal variable that mediates the effect of NP.

Bariatric psychology, psychological aspects of weight loss surgery

Obesity is the 'disease of the 21st century' and results in physical and psychosocial co-morbidities as well as poor quality of life (QoL). In contrast to the nonsurgical treatment of obesity, bariatric surgery is treatment of choice for morbid obesity. Since improved QoL and enhanced psychosocial functioning are important goals of bariatric surgery, success following bariatric surgery should not only include weight loss and improvement or cure of co-morbid conditions, but also improvements in eating behavior, psychosocial variables, and QoL. Unfortunately, bariatric surgery does not lead to identical results in every patient. Patients who fail to adjust their eating behavior and lifestyle after bariatric surgery may experience adverse reactions. Compliance and adjustment may be attributed largely to psychological factors, implying that the operation on its own represents only one element in bariatric surgery. Considering the role of psychosocial factors in the outcomes of bariatric surgery and the impact of the operation on the psychological and social situation, mental health professionals should be a part of the process of evaluation and treatment of bariatric surgery patients. In the Netherlands, between 2000 and 2005, bariatric surgery has increased tremendously, and most Dutch hospitals have a multidisciplinary selection process.

Depression and anxiety: their predictive function for weight loss in obese individuals

OBJECTIVE

To investigate the impact of current mental disorders on weight loss with special consideration of depressive and/or anxiety disorders as well as binge eating behavior in obese individuals undergoing different weight loss treatments.

METHODS

Three different samples of obese individuals were investigated in a prospective, longitudinal study: participants in a conventional weight loss treatment program (CONV TREAT; n = 250), obesity surgery patients (OBES SURG; n = 153), and obese control individuals (OC; n = 128). Current mental disorders and BMI were assessed at baseline and at 4-year follow-up.

RESULTS

OBES SURG patients with a depressive and/or anxiety disorder lost significantly less weight compared with those without a comorbid mental diagnosis. This result was not detected for CONV TREAT participants. A trend to gain weight was seen in OC participants with a depressive and/or anxiety disorder, whereas OC participants without current mental disorders at baseline lost some weight. Binge eating behavior at baseline did not predict weight loss at 4-year followup.

CONCLUSIONS

These results underline the importance of addressing current depressive and anxiety disorders in obese patients, especially when such patients are undergoing obesity surgery.

Self-reported stigmatization among candidates for bariatric surgery

The popularity of bariatric surgery has increased the focus on the psychological aspects of extreme obesity. Although a growing literature has documented the psychosocial burden associated with extreme obesity, surprisingly little attention has been paid to the experience of weight-related stigmatization among extremely obese individuals. The present study investigated self-reported experiences of weight-related stigmatization, weight-related quality of life, and depressive symptoms among 117 extremely obese individuals (BMI = 48.2 +/- 7.5 kg/m2) who presented for bariatric surgery at the Hospital of the University of Pennsylvania. In general, these individuals reported infrequent weight-related stigma, which was unrelated to BMI. Some specific forms of stigmatization, however, appear to be related to body size. The occurrence of stigmatization was associated with poorer weight-related quality of life and greater symptoms of depression.

Personality and attrition from behavioral weight-loss treatment for obesity

OBJECTIVE

Some personality features, as measured by the Temperament and Character Inventory (TCI), have recently been found to be related to successful weight outcome after both behavioral and surgical therapies for obesity. However, personality features could possibly influence attendance in obesity treatments as well. Thus, the aim of this study was to explore whether personality variables assessed by the TCI predict attrition from a behavioral weight-loss program for obesity.

METHOD

The TCI was administered to 92 obese patients [body mass index (BMI) >30 kg/m2] applying for a 6-month behavioral weight-loss program. Logistic stepwise regression analysis was performed to evaluate whether TCI scores predicted 6-month treatment attrition, after controlling for baseline psychiatric comorbidity, current age, gender, age at onset of obesity and initial BMI.

RESULTS

Sixty-two subjects (67.4%) completed the 6-month program, while 30 (32.6%) dropped out. Treatment attrition was predicted only by low reward dependence (P=.03) and the presence of mental disorders (P=.004).

CONCLUSION

Personality features denoting difficulty relying on others' support (low reward dependence) are associated with treatment noncompletion in obese patients attending a behavioral weight-loss program. These data may possibly serve to inform clinicians how to proceed in order to reduce dropout risk.

Psychological characteristics of morbidly obese candidates for bariatric surgery

BACKGROUND

Morbid obesity has multiple negative consequences for psychological health. These patients are described as depressed, anxious, and impulsive, with low self-esteem and impaired quality of life. The severity of these psychological disorders has been related to the degree of obesity. The aim of this study was to analyze the psychopathological characteristics of obese candidates for bariatric surgery, determining differences and similarities in general and specific psychopathologic symptoms among patients with different degrees of obesity and normal-weight individuals.

METHODS

The study included 50 patients (26 type III obesity, 24 type IV obesity) and 25 normal-weight volunteers. They were all assessed for: stress (CED44-B), anxiety-depression (General Health Questionnaire), self-esteem (Rosenberg Self-Esteem Scale), family function (Apgar Family Function Questionnaire), quality of life (Spanish version of the Quality of Life Index), personality (Eysenck Personality Questionnaire-Revised), food craving (Food Craving Questionnaire-Trait), and eating behavior disorder (EBD) symptomatology (Eating Disorders Examination-Questionnaire Version-4).

RESULTS

The obese patients had higher levels of stress, anxiety, depression, food craving, and EBD symptoms and lower levels of self-esteem and quality of life compared with normal-weight controls. No personality or family function disorders were observed in any of the obese or normal-weight subjects. Patients with type III and type IV obesity differed only in anxiety and personality findings.

CONCLUSIONS

Although the presence of psychological disorders cannot be taken as an absolute criterion for exclusion of candidates for obesity surgery, a better understanding of the relationship of these variables with weight loss and other outcomes of bariatric surgery may improve patient selection and facilitate more appropriate interventions.

Prediction of long-term outcome after gastric bypass surgery

BACKGROUND

To investigate the predictability and sustainability of weight loss in gastric bypass (GBP) surgery after the first year, we conducted a 3-year follow-up of patients who had already been comprehensively studied preoperatively and after 1 year.

METHODS

Preoperative data had been obtained for 131 morbidly obese patients on a 273-item interview and five psychological assessment instruments, and some of these data had been obtained again after a mean of 12.8 months. For this study, weight data were obtained on 79 patients at a mean of 3.2 years postoperatively.

RESULTS

Over the 1-3 year interval, mean simple weight loss and simple BMI decrease were essentially zero, compared with 45.61 kg and 16.52 respectively over the 0-1 year interval. Further, the 0-1 year and 1-3 year losses were uncorrelated. Optimal predictor variables for 1-3 year loss included three preoperative measures (expectation of increased self-confidence, amount of informational support, and total coping skills) plus functional eating behaviors after 1 year. Together they showed a multiple correlation of .55 with weight loss and .55 with BMI change. These predictors differed from the predictors of change over 0-1 year, and they continued to be significant after controlling for several preoperative characteristics.

CONCLUSIONS

The factors influencing long-term continuing weight loss after GBP are different from those influencing initial loss, and involve positive characteristics such as skills, information, and expectations. The results suggest the importance of actively teaching such skills during the first postoperative year.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Preoperative psychological testing--another form of prejudice

Preoperative psychological screening of bariatric surgery candidates has become routine, and a significant proportion of patients have their surgery deferred as a consequence. If psychological testing is being used as a form of preoperative triage, both patients and surgeons are entitled to know whether there is sufficient evidence to justify its use in this way. We define the argument for psychological screening as consisting of four premises (p1-p4) and a conclusion (C) as follows: (p1) A significant minority of obese patients will not be successful in losing weight following bariatric surgery-the "failure" group; (p2) A significant minority of patients will exhibit abnormal psychological profiles during preoperative testing; (p3) The majority of individuals referred to in (p2) will be found in group (p1) i.e., abnormal psychological profiles identified preoperatively predict less favorable weight loss outcomes postoperatively; (p4) Identifying patients with adverse psychological profiles preoperatively would allow either exclusion of those at high risk of failure or provide a more secure rationale for targeted pre- and postoperative support; (C) Psychological screening should be part of the routine preoperative assessment for patients undergoing obesity surgery. We reviewed the literature to find evidence to support the premises and show that (p1) can be justified but that (p2) is problematic and can only be accepted in a heavily qualified version. We find no evidence for (p3) and since (p4) and (C) are predicated on (p3), the argument clearly fails. There is no evidence to suggest that preoperative psychological screening can predict postoperative outcomes and no justification for using such testing as a means of discriminating between candidates presenting themselves for bariatric surgery.

Psychosocial predictors of success after vertical banded gastroplasty

BACKGROUND

Psychosocial and behavioral factors contribute to successful postoperative outcomes. Patients' psychological factors may be predictive of postsurgical adjustment. The identification of these factors would allow targeting patients at risk of a poor outcome. Furthermore, it would enable better patient selection and preoperative and/or postoperative counseling to improve long-term outcomes. Unfortunately, no such consistent and reproducible predictors have been found so far.

METHODS

The present study investigated in morbid obese patients who underwent vertical banded gastroplasty (VBG) the predictive value of preoperative parameters, especially health-related quality of life (HRQoL), personality, psychosocial functioning, body image, and eating behavior for 2-year changes in these variables, as well as weight loss.

RESULTS

Two years after VBG, patients had significant weight loss and reported improvements in physical HRQoL, personality and psychosocial functioning, body image, and eating behavior. Although we were not able to find psychosocial predictors of excess weight loss or excess body mass index loss 2 years after VBG, we did find psychosocial predictors of 2-year changes in HRQoL, personality and psychosocial functioning, body image, and eating behavior.

CONCLUSION

Preoperative psychological assessment may not be necessary with respect to weight loss. However, it is helpful in targeting patients at risk of poor psychological outcomes after VBG.

Psychological profile of obese patients

Nowadays obesity is recognized to be one of the greatest public health problems worldwide. There is no indication that the huge increase in obesity seen the last decades is declining. The examination of psychological aspects of persons with morbid obesity is essential. Identification of the psychological factors associated with weight loss expands our knowledge about behaviors which are crucial in order to avoid failures in treatment. Most information on this is obtained preoperatively. Although there is no single personality type characteristic of the morbidly obese, they differ from the general population as their self-esteem and impulse control is lower. They have passive dependent and passive aggressive personality traits, as well as a trend for somatization and problem denial. Their thinking is usually dichotomous and catastrophic. Obese patients also show low cooperativeness and fail to see the self as autonomous and integrated. In the morbidly obese before undergoing surgical treatment, unusual prevalence of psychopathology, namely depression and anxiety disorders, is observed. They are subject to prejudice and discrimination and should be treated with concern to help alleviate their feelings of rejection and guilt. Information on the psychological profile of obese persons is limited. Future studies are warranted, since there is a pressured need for these people to built cognitive skills and control their body weight.

Changes in depression following gastric banding: a 5- to 7-year prospective study

BACKGROUND

Long-term outcomes of gastric banding regarding depression and predictors of change in depression are still unclear. This prospective, controlled study investigated depression and self-acceptance in morbidly obese patients before and after gastric banding.

METHODS

A total of 248 morbidly obese patients (mean body mass index [BMI] = 46.4, SD = 6.9) seeking gastric banding completed questionnaires for symptoms of depression (Beck Depression Inventory) and self-acceptance. One hundred twenty-eight patients were treated with gastric banding and 120 patients were not. After 5 to 7 years, patients who either had (n = 40) or had not (n = 42) received gastric banding were reassessed.

RESULTS

In the preoperative assessment, 35% of all obese patients suffered from clinically relevant depressive symptoms (BDI score > or =18). The mean depression score was higher and the mean self-acceptance score was lower than those of the normal population. Higher preoperative depression scores were observed among patients living alone and who had obtained low levels of education. After 5 to 7 years, patients with gastric banding had lost significantly more weight than patients without gastric banding (mean BMI loss 10.0 vs. 3.3). Gastric banding patients improved significantly in depression and self-acceptance, whereas no change was found in patients without gastric banding. Symptoms of depression were more reduced in patients who lost more weight, lived together with a partner, and had a high preoperative depression score.

CONCLUSION

Morbid obesity is associated with depressive symptoms and low self-acceptance. Gastric banding results in both long-term weight loss and improvement in depression and self-acceptance.

Psychiatric considerations of the massive weight loss patient

As bariatric surgery for extreme obesity continues to grow in popularity, so does interest in postbariatric surgery body-contouring surgery. There is an extensive literature on the psychological characteristics of persons with extreme obesity who undergo bariatric surgery and the psychological changes that typically occur postoperatively. Far less, however, is known about the psychological aspects of body contouring following massive weight loss. This article reviews the psychosocial characteristics of individuals with extreme obesity who undergo bariatric surgery, as well as the changes in these traits that typically occur postoperatively. Because there have been few studies of the psychological aspects of patients who have lost massive amounts of weight, we use related literatures on the relationship between body image dissatisfaction and other plastic surgical procedures to identify the most relevant research and clinical issues for this unique patient population. Appropriate psychiatric screening and management of these patients is believed to play an important role in successful postoperative outcomes.

The impact of race on weight loss after Roux-en-Y gastric bypass surgery

BACKGROUND

Gastric bypass surgery for morbid obesity has dramatically increased in volume over the past decade. Caucasian patients have been noted previously to lose more weight after bariatric surgery than African-Americans patients. Data regarding predictors of maintaining weight loss after surgery are minimal. We sought to determine predictors of long-term weight loss after bariatric surgery.

METHODS

Retrospective analysis using a multivariate logistic regression model of all patients undergoing Roux-en-Y gastric bypass surgery at the Medical University of South Carolina from May 1993 to December 2004 for whom 2 years of follow-up data was available. Our dependent variable was the percentage of weight lost from baseline, dichotomized at +/-35%. Our primary independent variable was race, defined as Caucasian, African-American, or other. Relevant covariates were added to the model to control for their potential effects on outcome.

RESULTS

One hundred eleven patients (17 male/94 female; 85% Caucasian, mean age 44 years (range 18-68 years). In our model, Caucasian subjects (adjusted odds ratio [OR] = 7.60, 95% confidence intervals [95%CI] = 1.83-31.5) and late post surgical complications (adjusted OR = 2.67, 95%CI = 1.05-6.80) significantly predicted weight loss at 2 years, after controlling for relevant confounders. Other covariates did not significantly impact the model.

CONCLUSION

Race and late post surgical complications significantly impacted the percentage of weight loss at 2 years for patients undergoing Roux-en-Y gastric bypass surgery at our institution. Future research should be directed at determining potential genetic and/or social reasons for these differences.

Psychiatric issues in bariatric surgery

WLS is a proven, effective intervention for severely obese patients. There are four broad categories of surgery, but all reduce excess body weight to an extensive extent. Using surgery in the treatment of a disease with a large behavioral component may seem counterintuitive, but numerous studies have shown the ineffectiveness of diet and exercise in the morbidly obese. The ineffectiveness of these methods is the result, in part, of an alteration in hormones and peptides involved with long-term regulation of energy and weight. The WLS procedures have been shown to alter the anatomic and physiologic function of the stomach. In a motivated patient, this change in the gastrointestinal tract results in weight loss and a significant reduction in weight-related health problems. Evaluating a patient for WLS can be challenging, and multiple organizations have suggested that a multidisciplinary approach be used. The mental health professional often is called on to assess many different domains of psychologic function. This evaluation should go beyond the standard interview and should pay attention to the patient's eating behavior, knowledge of surgery, and motivation for surgery. The use of standardized instruments will facilitate accuracy and further research in the field of WLS. Because there are few absolute psychologic contraindications to WLS, the assessment should also focus on risk management, with the goal of improving the patient's postoperative quality of life.

Psychological predictors of outcome in vertical banded gastroplasty: a 6 months prospective pilot study

BACKGROUND

At present, bariatric surgery is the most effective treatment for morbid obesity. Several factors appear to influence the patient's ability to adjust to the postoperative condition, but reliable predictors are lacking. The aim of this study was to assess whether psychological presurgical variables can predict outcome of vertical banded gastroplasty (VBG) in the short term.

METHODS

38 severely obese patients (6 men and 32 women) underwent laparoscopic VBG. All were assessed prospectively at TO (before surgery) and at T6 (6 months after surgery) with a semi-structured interview and a battery of psychological tests: State Trait Anger Expression Inventory (STAXI), Eating Disorder Inventory (EDI-2), Symptom Checklist 90 (SCL-90), Beck Depression Inventory (BDI), Binge Eating Scale (BES), Body Shape Questionnaire (BSQ), and (only at TO) the Temperament and Character Inventory (TCI).

RESULTS

The comparison between TO and T6 found a significant weight loss and an improvement in several dimensions of EDI-2, BDI, and BSQ, together with an increase in the frequency of vomiting. Self-directedness (TCI) and Body Dissatisfaction (EDI-2) appear to be predictors of short-term outcome regarding weight loss. Self-transcendence (TCI) is associated with emerging side-effects.

CONCLUSION

Although larger and longer studies are necessary to confirm these data, Self directedness and Self trascendence emerge as predictors of 6 months clinical and psychological outcome of VBG.

Sexual abuse survivors and psychiatric hospitalization after bariatric surgery

BACKGROUND

Some investigators have postulated that a history of being the victim of childhood sexual abuse may impact outcome of bariatric surgery.

METHODS

In this retrospective chart review, we examined the electronic medical records of 152 adults with morbid obesity who underwent Roux-en-Y gastric bypass and who had a weight recorded in their medical record or reported in a follow-up surgery at 2 years after the RYGBP. The purpose of this retrospective chart review was to examine the relationship between psychosocial factors assessed preoperatively and the percent of excess weight lost (%EWL) at 2 years after bariatric surgery.

RESULTS

We found a high prevalence of being the victim of childhood sexual abuse (27%), adult sexual trauma (9%), and/or physical abuse (19%) at the initial evaluation. There was no association between these factors and %EWL at 2 years. However, when we examined participants' medical records for post-operative psychiatric hospitalizations at our medical center, 8 of 11 hospitalized patients reported a history of childhood sexual abuse (73%).

CONCLUSIONS

History of being the victim of childhood sexual abuse is reported frequently by patients seeking bariatric surgery. Our finding that having been the victim of childhood sexual abuse may be associated with increased risk of psychiatric hospitalization after RYGBP has several clinical implications. First, we recommend that clinicians assess carefully for a history of sexual or physical abuse, and secondly, abuse survivors may need to be told that there is an increased risk of psychiatric morbidity after bariatric surgery. Finally, perhaps close monitoring of these patients may prevent psychiatric difficulties after surgery. Further research to verify these preliminary findings is clearly needed.

Surgical treatment of obesity

Obesity is very prevalent. Most treatments fail owing to hard-wired survival mechanisms, linking stress and appetite, which have become grossly maladaptive in the industrial era. Antiobesity (bariatric) surgery is a seemingly drastic, efficacious therapy for this serious disease of energy surfeit. Technical progress during the last two decades has greatly improved its safety. The surgical principles of gastric restriction and/or gastrointestinal diversion have remained largely unchanged over 40 years, although mechanisms of action have been elucidated concomitant with advances in knowledge of the molecular biology of energy balance and appetite regulation. Results of bariatric surgery in large case-series followed for at least 10 years consistently demonstrate amelioration of components of the insulin-resistance metabolic syndrome and other comorbidities, significantly improving quality of life. Furthermore, bariatric surgery has convincingly been demonstrated to reduce mortality compared with nonoperative methods. This surgery requires substantial preoperative and postoperative evaluation, teaching, and monitoring to optimize outcomes. In the absence of effective societal changes to restore a healthy energy balance, bariatric surgery is an important tool for treating a very serious disease.

Weight loss and quality of life after bariatric surgery: a study of 200 patients after vertical gastroplasty or adjustable gastric banding

BACKGROUND AND OBJECTIVES

Long term evaluation of bariatric surgery must include quality of life measurement.

METHODS

Quality of life (QoL) was evaluated using the original Moorehead-Ardelt questionnaire for 200 patients operated for massive obesity in a single centre between 1994 and 2003. QoL and physical data were obtained by retrospective mail questionnaire. Surgical procedures were vertical-banded gastroplasty according to Mason (VBGM) and adjustable gastric banding (AGB) in 61 and 39% of patients, respectively. The aim of the study was to assess the nutritional outcome and QoL according to the procedure.

RESULTS

Overall, the body mass index (BMI) decreased from 50+/-8 kg/m(2) before surgery to 35.2+/-7.5 kg/m(2) at the time of the questionnaire. The percentage of weight loss was 28.8+/-12.2%. In the group treated with VBGM, the mean initial weight (P=0.003) and the percentage of weight loss (P<0.001) were significantly higher, and the QoL was better (P=0.003) than in the group treated with AGB. On the basis of the time spent since surgery, a regular weight loss was observed during the first 5 years, whereas weight subsequently increased over the five following years. Similarly, the total QoL score gradually improved during the first 5 years and worsened thereafter. However, it remained better than before surgery. A linear regression analysis showed a positive correlation between the percentage of weight loss and the QoL score (P<0.001).

CONCLUSIONS

This study suggests that the bariatric surgery, particularly the VBGM technique, improved the QoL of obese patients, at least in the first 5 years following surgery.

Predictors of outcome after gastric bypass surgery

BACKGROUND

Weight loss outcome predictions after gastric bypass (GBP) surgery based on individual findings have shown relatively little consistency. The present study took a more comprehensive approach, utilizing extensive pre-surgery interview and psychological test data both individually and in composite predictors.

METHODS

Pre-surgery data were obtained for 131 morbidly obese patients on a 273-item interview and 5 psychological assessment instruments, and weight loss measures (simple weight change and BMI change) were obtained at a mean of 12.8 months following surgery.

RESULTS

Individual predictor variables based on existing research findings showed expected but mostly nonsignificant correlations with weight loss. Optimal composite predictor variables were constructed for 4 general areas of pre-surgery assessment as represented in the literature: physica/medical health, psychological health, interpersonal support, and eating disorder. Each composite variable significantly predicted weight loss, and together they showed multiple correlations of .50 with simple weight change and .54 with simple BMI change.

CONCLUSIONS

Sustained weight loss after GBP was related to a rather wide range of pre-surgery variables, each of which made a small contribution, but composite variables grounded in the general literature provided more effective prediction. It is cautioned that continued success after > or =2 years could be dependent on yet other variables, with a possible contribution from some post-surgery factors.

Emotional Eating in a Morbidly Obese Bariatric Surgery-Seeking Population

BACKGROUND

The impact of presurgical eating patterns on postoperative outcomes is poorly understood. The results of previous studies are mixed regarding the impact of presurgical binge eating on weight loss after surgery. However, many patients describe other maladaptive eating patterns prior to surgery, such as eating in response to emotions. The goals of this study were to describe presurgical emotional eating patterns in morbidly obese individuals, determine whether these individuals were binge eaters, and assess the effect of this eating behavior on weight loss after surgery.

METHODS

Prior to surgery, 144 Roux-en-Y gastric bypass (RYGBP) patients completed the Questionnaire of Eating and Weight Patterns (QEWP) or QEWP-Revised (QEWP-R) and the Emotional Eating Scale to assess eating patterns prior to surgery. Their eating behavior, levels of depression, and weight were assessed after surgery.

RESULTS

High emotional eaters tended to have higher levels of depression, binge eating, and eating in response to external cues than low emotional eaters prior to surgery. However, there appeared to be a distinct group of individuals who were high emotional eaters but who did not engage in binge eating. At a mean of 8 months after surgery, High Emotional Eaters and Low Emotional Eaters were indistinguishable on these subscales and there were no differences in weight lost.

CONCLUSIONS

RYGBP has an equally positive impact on eating behavior and weight loss for both High Emotional Eaters and Low Emotional Eaters. Further replication is needed with longer follow-up times and larger samples.

Health-related quality of life after gastric banding

BACKGROUND

Bariatric surgery ameliorates obesity-associated diseases, resulting in psychological and social benefits. Long-term studies of its effects on quality of life (QOL) assessed with well established instruments are lacking. This prospective study investigated the long-term effects of gastric banding on health-related QOL using an obesity-specific validated measure.

METHODS

The Health Related Quality of Life (HRQL) questionnaire was completed by 50 severely obese patients before surgery and at 1, 2.5 and 5 years after gastric banding. Ninety-eight subjects with normal weight, matched for age, sex and education, also completed the HRQL questionnaire as controls.

RESULTS

Surgery was successful in all patients. Mean excess weight loss after 1, 2.5 and 5 years was 42.1, 42.2 and 41.6 per cent respectively. General wellbeing, health distress, depression, perceived attractiveness and self-worth improved significantly over the 5 years and, except for general wellbeing, were still improving after 5 years. There were increases in physical activity and work productivity. Successful weight loss was the main determinant of general wellbeing and health distress, and these were adversely affected by band-related complications. In subjects with a body mass index below 30 kg/m(2), scores improved to values for subjects of normal weight.

CONCLUSION

Bariatric surgery resulted in sustained improvement in health-related QOL even though not all excess weight was lost. Normalization of health-related QOL may necessitate greater weight losses.