Morbidly obese patients' perceptions of social discrimination before and after surgery for obesity

The Importance of Language in Behavior Change

Communication between health care providers and patients is important for behavioral treatment in lifestyle medicine. Ineffective communication can lead to patient dissatisfaction, demotivation, and discontinuation of treatment. It is important for health care providers to understand their biases, praise patients' behaviors rather than health outcomes, and use language to prevent dichotomous thinking. These strategies may lead to sustained lifestyle behavior changes and better treatment outcomes among patients.

Patient-Surgeon Relationship Influences Outcomes in Bariatric Patients

Bariatric surgery is an important therapy in weight loss. However, adherence to follow-up is critical and may be influenced by the patient-surgeon relationship. To test this hypothesis, bariatric surgical patients were surveyed from March 2013 to March 2015 via the National Association for Weight Loss Surgery webpage and social media outlets. Surgical outcomes and adherence to follow-up were collected, and aspects of the patient-surgeon relationship were assessed via the Likert scale. Correlations between survey item responses were calculated using Fisher's exact test, Student's t test, and Spearman's rho rank correlation. Three hundred twenty patients responded (n = 287 completed in entirety and n = 33 partially completed); 48 months was the median time to survey from operation (interquartile range, 22–84 months). Eighty-six per cent (n = 276) of patients rated their relationship with their operative surgeon as “average” to “very good.” Thirteen per cent (n = 43) rated their relationship as “poor” to “very poor.” Positive relationship with the operative surgeon and lack of complication were associated with adherence to follow-up ( P = 0.0001 and P = 0.002, respectively). The presence of complication did not affect the overall patient-surgeon relationship ( P = 0.5), although aspects of the patient-surgeon relationship were correlated to complications. There was no association between weight loss at one year and patient-surgeon relationship ( P = 0.6) or presence of complication ( P = 0.1). The findings of this study support the role of a positive patient-surgeon relationship in achieving long-term follow-up in post-bariatric surgical patients.

Avoiding exercise mediates the effects of internalized and experienced weight stigma on physical activity in the years following bariatric surgery

Background

People living with severe obesity report high levels of weight-related stigma. Theoretically, this stigma undermines weight loss efforts. The objective of this study is to test one proposed mechanism to explain why weight loss is so difficult once an individual becomes obese: that weight-related stigma inhibits physical activity via demotivation to exercise.

Methods

The study focused on individuals who had bariatric surgery within the past 5 years (N = 298) and who report a post-surgical body mass index (BMI) ranging from 16 to 70. Exercise avoidance motivation (EAM) and physical activity (PA) were modeled as latent variables using structural equation modeling. Two measures of weight stigma, the Stigmatizing Situations Inventory (SSI) and the Weight Bias Internalization Scale (WBIS) were modified for people with a long history of extreme obesity for use as observed predictors.

Results

Exercise avoidance motivation (EAM) significantly mediated the association between both experienced (SSI) and internalized (WBIS) weight stigma and physical activity (PA) in this population.

Conclusion

Exercise avoidance motivation, influenced by weight stigma, may be a significant factor explaining the positive relationship between higher body weights with lower levels of physical activity.

Bariatric Surgery Patients' Perceptions of Weight-Related Stigma in Healthcare Settings Impair Post-surgery Dietary Adherence

Background: Weight-related stigma is reported frequently by higher body-weight patients in healthcare settings. Bariatric surgery triggers profound weight loss. This weight loss may therefore alleviate patients' experiences of weight-related stigma within healthcare settings. In non-clinical settings, weight-related stigma is associated with weight-inducing eating patterns. Dietary adherence is a major challenge after bariatric surgery.

Objectives: (1) Evaluate the relationship between weight-related stigma and post-surgical dietary adherence; (2) understand if weight loss reduces weight-related stigma, thereby improving post-surgical dietary adherence; and (3) explore provider and patient perspectives on adherence and stigma in healthcare settings.

Design: This mixed methods study contrasts survey responses from 300 postoperative bariatric patients with ethnographic data based on interviews with 35 patients and extensive multi-year participant-observation within a clinic setting. The survey measured experiences of weight-related stigma, including from healthcare professionals, on the Interpersonal Sources of Weight Stigma scale and internalized stigma based on the Weight Bias Internalization Scale. Dietary adherence measures included patient self-reports, non-disordered eating patterns reported on the Disordered Eating after Bariatric Surgery scale, and food frequencies. Regression was used to assess the relationships among post-surgical stigma, dietary adherence, and weight loss. Qualitative analyses consisted of thematic analysis.

Results: The quantitative data show that internalized stigma and general experiences of weight-related stigma predict worse dietary adherence, even after weight is lost. The qualitative data show patients did not generally recognize this connection, and health professionals explained it as poor patient compliance.

Conclusion: Reducing perceptions of weight-related stigma in healthcare settings and weight bias internalization could enhance dietary adherence, regardless of time since patient's weight-loss surgery.

How Formerly Overweight and Obese Individuals Negotiate Disclosure of Their Weight Loss

Overweight and obese individuals frequently experience weight-based stigma, and reducing stigma is one reason people want to lose weight. However, research suggests even after individuals become a normal weight, knowledge of their old body size can result in stigma. Through interviews of 30 formerly overweight or obese individuals and the framework of Communication Privacy Management theory, this study found the vast majority of participants perceived more benefits from disclosing their larger identity than risks, regardless of weight-loss method. Participants revealed their weight loss in order to inspire others, build relationships, or hold themselves accountable. Conversely, a few participants concealed to protect their thinner identity (i.e., they feared stigma) or to avoid coming across as boastful. In contrast to previous studies, this investigation suggests most participants were not dissuaded from revealing their former body size due to a threat of residual stigma. Participants' disclosure was overwhelmingly met with encouraging and supportive responses.

Weight-Biased Health Professionals and the Effects on Overweight Patients

A significant number of Americans are obese. Weight bias and negative attitudes have been documented among medical professionals, and these may cause obese patients to avoid seeking health care, leading to undiagnosed pathology. Some physicians lack adequate resources and patient counseling skills when addressing patient weight management. This may lead to continued weight problems and associated complications for the patient. Many physicians do not address patient obesity with urgency and determination, even though most physicians consider obesity a widespread, problematic disease. The purpose of this literature review is to assess weight discrimination and negative attitudes among health professionals and how those attitudes affect quality of care for overweight patients. Through these generalizations, sonographers can become aware of their own biases, which may lead to poor patient care.

Racial differences in the influence of female adolescents' body size on dating and sex

This paper investigates the effect of body size on dating and sexual experiences of white (non-Hispanic) and African American (non-Hispanic) female adolescents. Using data from Add-Health, we estimate the effects of obesity and BMI z-score on the probability of having been involved in a romantic relationship, having ever been touched in the genital area in a sexual way, and having ever engaged in sexual intercourse. We find that obese white teenage girls are less likely to have been in a romantic relationship compared to their non-obese counterparts. In addition, obese white girls are less likely to ever have had sex (intercourse) or to ever have been intimate. There are no systematic differences in relationship experiences and sexual behaviors between obese and non-obese black girls. Overall, the estimated relationships are very robust to common environmental influences at the school-level and to the inclusion of proxies for low self-esteem, attitudes toward sex and interviewer assessment of appearance and personality. Instrumental variables estimates and estimates from models with lagged weight status confirm the overall patterns.

Hypnobehavioral and hypnoenergetic therapy in the treatment of obese women: a pragmatic randomized clinical trial

This study compared the effectiveness of hypnobehavioral therapy (HypBe) and HypBe enhanced by elements of energetic psychotherapy (hypnoenergetic therapy, HypEn) for obese women. Sixty clients were randomized to either HypBe or HypEn. Body weight, BMI, eating behavior, and body concept were assessed at baseline, posttreatment, and at a follow-up. Mixed ANOVA models and effect sizes were used for statistics. Both treatments improved weight, BMI, eating behavior, and some aspects of body concept. Improvements in eating behavior and body concept were higher for those who also lost weight (responders). Weight and BMI reductions were not significantly different for the HypEn versus HypBe groups at follow-up.

The effects of facial adiposity on attractiveness and perceived leadership ability

Facial attractiveness has a positive influence on electoral success both in experimental paradigms and in the real world. One parameter that influences facial attractiveness and social judgements is facial adiposity (a facial correlate to body mass index, BMI). Overweight people have high facial adiposity and are perceived to be less attractive and lower in leadership ability. Here, we used an interactive design in order to assess whether the most attractive level of facial adiposity is also perceived as most leader-like. We found that participants reduced facial adiposity more to maximize attractiveness than to maximize perceived leadership ability. These results indicate that facial appearance impacts leadership judgements beyond the effects of attractiveness. We suggest that the disparity between optimal facial adiposity in attractiveness and leadership judgements stems from social trends that have produced thin ideals for attractiveness, while leadership judgements are associated with perception of physical dominance.

Safety and efficacy of laparoscopic adjustable gastric banding in patients aged seventy and older

BACKGROUND

Life expectancy is increasing, with more elderly people categorized as obese. The objective of this study was to assess the effects of laparoscopic adjustable gastric banding (LAGB) on patients aged ≥ 70 years.

METHODS

This was a retrospective analysis of patients aged ≥ 70 years who underwent LAGB at our university hospital between 2003 and 2011. The data included age, weight, body mass index (BMI), and percentage excess weight loss (%EWL) obtained before and after gastric banding. Operative data, length of stay, postoperative complications, and resolution of co-morbid conditions were also analyzed.

RESULTS

Fifty-five patients aged ≥ 70 years (mean 73 years) underwent gastric banding between 2003 and 2012. Mean preoperative weight and BMI were 123 kilograms and 45 kg/m(2), respectively. On average, each patient had 4 co-morbidities preoperatively, with hypertension (n = 49; 86%), dyslipidemia (n = 40; 70%), and sleep apnea (n = 31; 54%) being the most common. Mean operating room (OR) time was 49 minutes, with all patients discharged within 24 hours. There was 1 death at 4 years from myocardial infarction, no intensive care unit admissions, and no 30-day readmissions. Mean %EWL at 1, 2, 3, 4, and 5 years was 36 (± 12.7), 40 (± 16.4), 42 (± 19.2), 41 (± 17.1), 50 (± 14.9), and 48 (± 22.6), respectively. Follow-up rates ranged from 55/55 (100%) at 6 months to 7/9 (78%) of eligible patients at 5 years and 2/2 (100%) at 8 years. Complications included 1 band slip at year 5, 1 band removed for intolerance, and 1 port site hernia. The resolution of hypertension, dyslipidemia, sleep apnea, lower back pain, and non-insulin-dependent diabetes was 27%, 28%, 35%, 31%, and 35%, respectively.

CONCLUSIONS

LAGB as a primary treatment for obesity in carefully selected patients aged ≥ 70 can be well tolerated and effective with moderate resolution of co-morbid conditions and few complications.

Apparent height and body mass index influence perceived leadership ability in three-dimensional faces

Facial appearance has a well-documented effect on perceived leadership ability. Face judgments of leadership ability predict political election outcomes across the world, and similar judgments of business CEOs predict company profits. Body height is also associated with leadership ability, with taller people attaining positions of leadership more than their shorter counterparts in both politics and in the corporate world. Previous studies have found some face characteristics that are associated with leadership judgments, however there have been no studies with three-dimensional faces. We assessed which facial characteristics drive leadership judgments in three-dimensional faces. We found a perceptual relationship between height and leadership ability. We also found that facial maturity correlated with leadership judgments, and that faces of people with an unhealthily high body mass index received lower leadership ratings. We conclude that face attributes associated with body size and maturity alter leadership perception, and may influence real-world democratic leadership selection.

Weight change, psychological well-being, and vitality in adults participating in a cognitive-behavioral weight loss program

OBJECTIVE

Excess weight has been associated with numerous psychological problems, including depression and anxiety. This study examined the impact of intentional weight loss on the psychological well-being of adults participating in three clinical weight loss interventions.

METHODS

This population consisted of 588 overweight or obese individuals randomized into one of three weight loss interventions of incremental intensity for 12 months. Psychological well-being was measured at baseline and 6, and 12 months using the Psychological Well-Being Index.

RESULTS

Mean weight loss was 5.0 pounds at 12 months. Weight change at 12 months was associated with higher overall psychological well-being (r = -.20, p < .001), lower levels of anxiety (r = -.16, p = .001) and depression (r = -.13, p = .004), and higher positive well-being (r = -.19, p < .001), self-control (r = -.13, p = .004), and vitality (r = -.22, p < .001). Vitality was found to be the best predictor of weight change at 12 months (p < .001).

CONCLUSIONS

Weight loss was associated with positive changes in psychological well-being. Increased vitality contributed the largest percentage of variance to this change.

Residual obesity stigma: an experimental investigation of bias against obese and lean targets differing in weight-loss history

This study investigated stigma directed at formerly obese persons who lost weight and became lean (through behavioral or surgical methods), or lost weight but remained obese, relative to weight-stable obese and weight-stable lean persons. This study also compared stigma directed at obese persons following exposure to descriptions of persons who lost weight vs. remained weight stable. In a between-subject experimental design, participants (n = 273) were randomly assigned to read vignettes describing targets varying across two dimensions, weight stability (i.e., weight stable or weight lost) and current weight (i.e., currently obese or currently lean). Participants completed measures of stigma against specific targets and measures of stigma against obese individuals in general. Lean individuals who were formerly obese were stigmatized more on attractiveness than weight-stable lean individuals, and as much as currently obese individuals. Stigma across domains was greater among currently obese individuals (regardless of whether they had lost weight from a higher weight) than among currently lean individuals. After reading vignettes describing weight loss, participants demonstrated greater obesity stigma than after reading vignettes describing weight-stable individuals. These results suggest that residual stigma remains against people who have previously been obese, even when they have lost substantial amounts of weight and regardless of their weight-loss method. Exposure to portrayals of the malleability of body weight, such as those promoted in the popular media, may significantly worsen obesity stigma.

Experiences of weight stigmatization: a review of self-report assessment measures

BACKGROUND

Overweight and obese persons are vulnerable to frequent stigmatization and discrimination because of their weight. Despite widespread prejudice towards obese persons, many questions remain regarding the nature, extent, and impact of weight-based stigmatization experienced by so many people. However, improving our knowledge in this area will only be as good as the measures we have to study this phenomenon. Our paper is the first to provide a comprehensive summary of published quantitative self-report measures available for assessing experiences of weight stigmatization in children and adults.

METHODS

This review examined 22 measures of self-reported weight stigmatization and highlights the strengths and limitations of existing assessment.

RESULTS

Existing measures contain a number of limitations and have been assessed in samples lacking diversity. Improvements in measurement are needed to achieve a clearer understanding of the nature and extent of self-perceived weight stigmatization and to develop measures that accurately reflect this type of stigmatization.

CONCLUSIONS

Specific directions for future research that will help improve measurement of self-perceived weight stigmatization and advance this area of study are highlighted.

Differences in the nature of body image disturbances between female obese individuals with versus without a comorbid binge eating disorder: an exploratory study including static and dynamic aspects of body image

Various components of body image were measured to assess body image disturbances in patients with obesity. To overcome limitations of previous studies, a photo distortion technique and a biological motion distortion device were included to assess static and dynamic aspects of body image. Questionnaires assessed cognitive-affective aspects, bodily attitudes, and eating behavior. Patients with obesity and a binge eating disorder (OBE, n = 15) were compared with patients with obesity only (ONB; n = 15), to determine the nature of any differences in body image disturbances. Both groups had high levels of body image disturbances with cognitive-affective deficits. Binge eating disorder (BED) participants also had perceptual difficulties (static only). Both groups reported high importance of weight and shape for self-esteem. There were some significant differences between the groups suggesting that a comorbid BED causes further aggravation. Body image interventions in obesity treatment may be warranted.

Perceived discrimination and stigmatisation against severely obese women: age and weight loss make a difference

AIMS

Patients' perceptions about weight-related stigma and discrimination were assessed in 2 groups of patients, obese and laparoscopic adjustable gastric banding (LAGB).

METHODS

Seven focus group sessions were held including a total of 32 women, 8 obese (body mass index 35+) and 24 who had lost 50% of excess weight following bariatric surgery. During the sessions, participants were asked to consider their experiences in situations including general, family, friends, work place, medical, and educational settings.

RESULTS

Whilst perceptions of discrimination and stigmatisation were common and affected many life situations, they were less prevalent than previous reports. It appeared that it was not the frequency or number of events which affected an individual but the intensity of the experience. Younger women reported greater discrimination than older women and felt the social consequences of obesity to a greater extent. Older women were more concerned about the consequences of being overweight on their health.

CONCLUSIONS

Women who had lost weight considered that aspects of their own behaviours when obese contributed to their experiences of discrimination and stigmatisation. Perceptions of discrimination and stigmatisation appear to be influenced by age and current weight status.

Anti-fat prejudice reduction: a review of published studies

Prejudice against those who are perceived as 'fat' or obese (anti-fat prejudice) is rife, increasing, and associated with negative outcomes for those targeted for such treatment. The present review sought to identify and describe published research on interventions to reduce anti-fat prejudice. A systematic search of relevant databases (e.g. PsychInfo, PubMed, Scopus) found 16 published studies that had sought to reduce anti-fat prejudice. Most notable was the lack of research on interventions for reducing anti-fat prejudice. Methodological problems that limit the interpretability of results were identified in the majority of studies found. Interventions employing more rigorous experimental designs provided at best mixed evidence for effectiveness. Although several studies reported changes in beliefs and knowledge about the causes of obesity, reductions in anti-fat prejudice did not typically accompany these changes. Anti-fat prejudice interventions adopting social norm- and social consensus-based approaches appear encouraging but are scarce. The lack of prejudice reduction following most interventions suggests that psychological mechanisms other than, or additional to, those being manipulated may underpin anti-fat prejudice. New directions for researching anti-fat prejudice are suggested. Given the strength of antipathy displayed toward those who are perceived as 'fat' or obese, research in this area is urgently required.

Greater history of weight-related stigmatizing experience is associated with greater weight loss in obesity treatment

Experiences of obesity stigmatization and fear of fat, body image and self-esteem, were examined in relation to weight loss and weight maintenance. Participants in obesity treatment (N = 185) with more stigmatizing experiences had poorer body image and greater fear of fat. Higher initial BMI, more stigmatizing experiences, lower body dissatisfaction and greater fear of fat predicted greater weight loss. Higher initial BMI and more stigmatizing experiences predicted greater weight maintenance after six months in treatment. These findings suggest that despite the negative psychological correlates of stigmatization, experience and fear of obesity's negative consequences may also be associated with improved treatment outcome.

African Americans' perceptions of physician attempts to address obesity in the primary care setting

BACKGROUND

Obesity disproportionately affects African Americans and leads to several major co-morbidities. While guidelines recommend physicians identify obese patients and counsel them on weight management, little is known about how these efforts are received by patients.

OBJECTIVE

To elucidate how obese, urban African American patients perceive the physician role in the treatment of obesity and to identify specific provider behaviors that may motivate or hinder attempts at weight loss.

DESIGN

Qualitative study involving eight focus groups.

PARTICIPANTS

Forty-three obese African-American patients recruited from academic internal medicine practices participated in focus groups between September 2007 and February 2008.

MEASUREMENTS AND MAIN RESULTS

Four broad themes emerged: (1) dislike of the word obese, (2) importance of the physician manner and timing when discussing weight, (3) necessity of a personalized approach in discussing weight management issues, and (4) variable response to scare tactics. Within each theme participants identified specific physician behaviors that were perceived as either motivating or hindering attempts at weight loss.

CONCLUSIONS

Physicians must be cognizant of the potential unintended consequences of the techniques they use to educate and counsel African-American men and women on obesity, particularly those that may be perceived as negative and act to further alienate obese patients from seeking the care they need.

The obese patient in the ED

As in any setting, safety and sensitivity are the keys to optimal care.

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.

Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures

OBJECTIVE

Bariatric surgical procedures have increased exponentially in the United States. Laparoscopic adjustable gastric banding is now promoted as a safer, potentially reversible and effective alternative to Roux-en-Y gastric bypass, the current standard of care. This study evaluated the balance of patient-oriented clinical outcomes for laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass.

METHODS

The MEDLINE database (1966 to January 2007), Cochrane clinical trials database, Cochrane reviews database, and Database of Abstracts of Reviews of Effects were searched using the key terms gastroplasty, gastric bypass, laparoscopy, Swedish band, and gastric banding. Studies with at least 1 year of follow-up that directly compared laparoscopic adjustable gastric banding with Roux-en-Y gastric bypass were included. Resolution of obesity-related comorbidities, percentage of excess body weight loss, quality of life, perioperative complications, and long-term adverse events were the abstracted outcomes.

RESULTS

The search identified 14 comparative studies (1 randomized trial). Few studies reported outcomes beyond 1 year. Excess body weight loss at 1 year was consistently greater for Roux-en-Y gastric bypass than laparoscopic adjustable gastric banding (median difference, 26%; range, 19%-34%; P < .001). Resolution of comorbidities was greater after Roux-en-Y gastric bypass. In the highest-quality study, excess body weight loss was 76% with Roux-en-Y gastric bypass versus 48% with laparoscopic adjustable gastric banding, and diabetes resolved in 78% versus 50% of cases, respectively. Both operating room time and length of hospitalization were shorter for those undergoing laparoscopic adjustable gastric banding. Adverse events were inconsistently reported. Operative mortality was less than 0.5% for both procedures. Perioperative complications were more common with Roux-en-Y gastric bypass (9% vs 5%), whereas long-term reoperation rates were lower after Roux-en-Y gastric bypass (16% vs 24%). Patient satisfaction favored Roux-en-Y gastric bypass (P=.006).

CONCLUSION

Weight loss outcomes strongly favored Roux-en-Y gastric bypass over laparoscopic adjustable gastric banding. Patients treated with laparoscopic adjustable gastric banding had lower short-term morbidity than those treated with Roux-en-Y gastric bypass, but reoperation rates were higher among patients who received laparoscopic adjustable gastric banding. Gastric bypass should remain the primary bariatric procedure used to treat obesity in the United States.

Depressed mood in class III obesity predicted by weight-related stigma

BACKGROUND

Greater depressed mood in Class III obese surgery-seeking clients may be due to weight-related stigma, weight-related physical disability (e.g. mobility) or the presence of binge-eating (BE).

METHODS

60 Class III obese surgery-seeking adults were administered the Beck Depression Inventory (BDI), weight-related physical disability (IWQOL-PF) and another weight-related stigma (IWQOL-PD), and assessed for BE (SCID-1 or Questionnaire of Eating and Weight Patterns) before surgery.

RESULTS

In a hierarchical regression analysis, BMI, gender, and age of obesity onset did not account for a significant portion of the variance in BDI scores in the first step. The second step of the model was statistically significant (F(3,53)=8.469, P<0.000), accounting for 33.6% of the variance in BDI scores. IWQOL-PD scores were the only significant predictor of BDI scores (b=0.518, P=0.001), and this independently contributed to 32.6% of the variance in BDI scores.

CONCLUSION

This suggests that depressed mood seen in Class III obese surgery-seeking individuals may be most related to weight-related stigma rather than BE status, or weight-related physical disability.

Body image and explicit and implicit anti-fat attitudes: the mediating role of physical appearance comparisons

Prejudice against overweight people is rife. However, there is a paucity of research on the underlying reasons for it. In two studies the relationship between body image, the tendency to make physical appearance-related comparisons (PACS), and both explicit and implicit anti-fat attitudes was examined. In Study 1 (n = 227) people with a high tendency to make physical appearance-related comparisons (high PACS scorers) reported lower self-appearance evaluation, but higher appearance orientation and explicit anti-fat attitudes. The PACS fully mediated the relationship between appearance orientation and explicit anti-fat attitudes. Study 2 (n = 134) found that the PACS also mediated the relationship between appearance orientation and implicit anti-fat attitudes. Thus, individual differences in factors such as body image and the tendency to make appearance-related comparisons, appear to play a central role in both explicit and implicit anti-fat attitudes.

Psychological Outcome Two Years after Restrictive Bariatric Surgery

BACKGROUND

An essential outcome criterion of obesity surgery besides weight loss is the improvement of medical and psychological health status. Both dimensions influence quality of life. This study evaluates depressive symptoms, self-esteem and health-related quality of life 2 years after bariatric surgery.

METHODS

149 patients (47 males (32%), 102 females (68%), mean age 38.8 +/- 10.3 years) were assessed by standardized questionnaires before and 1 and 2 years after gastric restrictive surgery.

RESULTS

Mean BMI pre-surgery was 51.3 +/- 8.4 kg/m2. BMI decreased significantly to 38.6 +/- 6.8 kg/m2 at 1 year and to 37.9 +/- 7.4 kg/m2 at 2 years after surgery. Statistical analyses revealed a significant decrease in depressive symptoms and a significant improvement in self-esteem and the physical dimension of health-related quality of life. Pre-surgery, 40.5% (n=62) of the patients suffered from depressive symptoms of clinical relevance. These depressive symptoms persisted in 17.7% (n = 27) 1 year and in 16.4% (n = 25) 2 years after surgery.

CONCLUSION

Parallel with a considerable weight loss after bariatric surgery, important aspects of mental health such as depressive symptoms and self-esteem improved significantly. These effects appear 1 year after surgery, but do not seem to change considerably afterwards.

Wounds in Surgical Patients Who Are Obese

The number of surgical patients who are obese in the United States is rising, a trend that's likely to continue. Such patients are at higher risk than nonobese patients are for surgical site infections and other complications such as dehiscence, pressure ulcers, deep tissue injury, and rhabdomyolysis. This article details the factors that can contribute to such complications, including a high number of comorbidities, and offers practical suggestions for preventing them. Nurses should understand that special equipment, precautions, and protocols may be needed at every stage of care, and that obese patients aren't anomalies but rather a part of a growing population with particular needs.

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.

Fasting - the ultimate diet?

Adult humans often undertake acute fasts for cosmetic, religious or medical reasons. For example, an estimated 14% of US adults have reported using fasting as a means to control body weight and this approach has long been advocated as an intermittent treatment for gross refractory obesity. There are unique historical data sets on extreme forms of food restriction that give insight into the consequences of starvation or semi-starvation in previously healthy, but usually non-obese subjects. These include documented medical reports on victims of hunger strike, famine and prisoners of war. Such data provide a detailed account on how the body adapts to prolonged starvation. It has previously been shown that fasting for the biblical period of 40 days and 40 nights is well within the overall physiological capabilities of a healthy adult. However, the specific effects on the human body and mind are less clearly documented, either in the short term (hours) or in the longer term (days). This review asks the following three questions, pertinent to any weight-loss therapy, (i) how effective is the regime in achieving weight loss, (ii) what impact does it have on psychology? and finally, (iii) does it work long-term?

Predictors of early quality-of-life improvement after laparoscopic gastric bypass surgery

BACKGROUND

Quality of life is getting more attention in the medical literature. Treatment outcomes are now gauged by their effect on quality of life (QOL), along with their direct effect on diseases they are targeting. Similarly, in obesity, consensus has been reached on the importance of QOL as an independent outcome measure for obesity surgery along with weight loss and comorbidity. Therefore, the aim of this study was to assess the impact of patient demographics and comorbidities on short-term QOL improvement after laparoscopic gastric bypass (LGB) surgery.

METHODS

The change in QOL after LGB was assessed in 171 patients (147 women, 24 men; mean age, 43.1 y) using the Short-Form-36 (SF-36) questionnaire. Multivariate logistic regression analysis was used to identify patients' demographics and comorbidities predictive of major QOL improvement.

RESULTS

Body mass index decreased significantly at 3 months (48.5 +/- 5.8 to 38.4 +/- 5.4 kg/m2; P < .001) with excess weight loss of 37.4% +/- 9.2%. The SF-36 follow-up evaluation showed significant improvement (44.2 +/- 15.7 to 78.6 +/- 15.5; P < .001). A significant inverse correlation was found between QOL (before and after bypass) and the number of comorbidities (r = .29, P = .001; R = .22, P = .005; respectively), but the magnitude of QOL change did not correlate with the number of comorbidities (P = .5). When the entire cohort of patients was dichotomized according to their magnitude of change in SF-36 scores, the univariate analysis showed that the group of patients with no improvement or minor improvement in their SF-36 was characterized by a higher percentage of male sex and a lower prevalence of diabetes. These 2 preoperative factors remained statistically significant in the multivariate analysis. Preoperative diagnosis of type 2 diabetes increased the likelihood of major improvement in QOL after LGB by 6.2 times, whereas being a woman increased this likelihood by 16.1 times.

CONCLUSIONS

Significant weight loss was achieved as early as 3 months after LGB, causing substantial improvement in QOL in more than 95% of patients. Women with type 2 diabetes have the highest odds to achieve a major QOL improvement after LGB and therefore they should represent the ideal target population for surgical weight loss programs.

Bariatric surgery for pediatric extreme obesity: now or later?

Obesity is a multifactorial disease of epidemic and global proportions that poses the most significant threat to the health of our younger generations. Those who are the most extremely affected bear the largest burden of health problems. In the US, extreme obesity affects approximately 9 million adults and 2 million children, and is associated with both immediate health problems and later health risk, including premature mortality. Present medical and behavioral interventions for extreme obesity in adults and children rarely result in the significant, durable weight loss necessary to improve health outcomes, prompting a search for more aggressive measures. Weight loss (bariatric) surgery has been advocated as an intervention for those with extreme obesity. In adults, bariatric surgery results in prolonged weight control and improvement in serious obesity comorbidities, namely type 2 diabetes, dyslipidemias, hypertension and obstructive sleep apnea syndrome. A surge in weight loss operations for adolescents has been observed recently, with a threefold increase in case volumes nationwide from 2000 to 2003. Current evidence suggests that after bariatric surgery, adolescents lose significant weight and serious obesity-related medical conditions and psychosocial status are improved. Thus it is reasonable to propose that bariatric surgery performed in the adolescent period may be more effective treatment for childhood-onset extreme obesity than delaying surgery for extremely obese youth until adulthood. This position has been echoed by a number of groups and an independent systematic review. Finally, it is conceivable that bariatric surgery performed in adulthood for childhood onset extreme obesity may not be as effective for comorbidity treatment as surgery performed earlier during adolescence. The purpose of this review is to examine the evidence, which supports early rather than later use of bariatric surgery in the treatment of extreme obesity, and to present this information in light of the medical and surgical risks of bariatric surgery.

Extreme obesity: a new medical crisis in the United States

The prevalence of obesity has markedly increased in the past few decades, and this disorder is responsible for more health care expenditures than any other medical condition. The greater the body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters), the greater the risk of comorbidities, including diabetes mellitus, hypertension, obstructive sleep apnea, many cancers, dyslipidemia, cardiovascular disease, and overall mortality. Class III (extreme) obesity, defined as a BMI of 40 kg/m2 or greater, has also increased such that it now affects almost 1 in 20 Americans. The prevalence of extreme obesity is greater among women than among men and greater among blacks than among non-Hispanic whites or Hispanics. The effect of extreme obesity on mortality is greater among young than among older adults, greater among men than among women, and greater among whites than among blacks. The current permissive environment that promotes increased dietary energy intake and decreased energy expenditure through reduced daily physical activity coupled with genetic susceptibility is an important pathogenic factor. The number of bariatric surgical procedures performed annually is relatively small but increasing.

Weighing the Relevant Issues

The obesity epidemic has touched all segments of society and every health care sector including the nursing home industry. Understanding the issues related to the care of obese nursing home residents is important in light of this epidemic. Such issues include the difficulties related to access to nursing homes, the structural preparedness of nursing homes to care for obese patients, and the potential for staff injuries. Policies regarding strategies to improve nursing home access for obese patients, mitigate disparities in quality of care and health outcomes owing to obesity, and better prepare for the growing obesity epidemic are needed.

Prevalence of mental disorders in normal-weight and obese individuals with and without weight loss treatment in a German urban population

OBJECTIVE

The aim of the study was to evaluate the prevalence rates of mental disorders in normal-weight individuals and obese individuals with and without weight loss treatment.

METHODS

A sample of 251 participants in a conventional weight loss treatment, 153 pre-bariatric surgery patients, 174 normal-weight control participants, and 128 obese control participants not actively losing weight at the time of the investigation were examined.

RESULTS

Lifetime prevalence rates of mental disorders in obese women ranged from 46.7% to 60.1% compared with 41.7% in normal-weight women and from 48.0% to 54.4% in obese men compared with 29.8% in normal-weight men. Prevalence rates of mental disorders did not differ significantly between normal-weight and obese women not currently in weight loss treatment; however, the rates were significantly lower compared with both obese treatment groups. Compared with normal-weight men, obese men not currently in weight loss treatment and obese men participating in conventional weight loss treatment showed significantly higher prevalence rates of mental disorders.

CONCLUSION

Unlike obese male individuals, obese female participants not currently in weight loss treatment did not differ from normal-weight participants with regard to comorbidity of mental disorders. However, obese female participants who were engaged in weight loss treatment exhibited significantly higher prevalence rates than normal-weight participants.

Long-term health and psychosocial outcomes from surgically induced weight loss: results obtained in patients not attending protocolled follow-up visits

OBJECTIVE

Obesity management is focused at weight loss to obtain health, psychological and social benefits. Outcomes from controlled trials, however, do not reflect the everyday routine practice. Therefore, we aimed to investigate the results from surgically induced weight loss in patients devoid of a protocol-wise follow-up, who were visited at home.

PATIENTS AND METHODS

Patients who underwent a vertical banded gastroplasty or a gastric bypass between 1980 and 1997 were eligible. Body weight and height were measured. Patients filled out questionnaires on health status (Nottingham Health Profile (NHP)), psychological symptoms (Symptom Check List (SCL-90-R)), personality traits (Dutch Personality Questionnaire (DPQ)) and eating behaviour (Dutch Eating Behaviour Questionnaire (DEBQ)).

RESULTS

Out of 451 operated patients the addresses of 313 subjects could be traced and 236 (75%) agreed to participate. They maintained a mean (s.d.) loss of 32.1 (22.6) kg and 45.2 (29.3) % of excess weight, 8.2 (4.5) years after the operation, about two-third of the largest weight loss they achieved after 17 months postoperatively. The NHP and SCL-90-R conformed to norm values in males except for energy, sleep and emotional reactions. Females differed from norm values in every aspect and even women achieving a BMI<30 kg/m(2) did not catch up to norm values. Weight loss was inversely related to physical immobility and pain. Personality traits (DPQ) showed a higher grievance and dominance and a lower rigidity and self-esteem compared to norm values. Females scored higher in inadequacy and lower in social inadequacy. Eating patterns (DEBQ) showed mainly emotional eating and restrained eating. Effect sizes of >/=0.8 s.d. were chosen to reflect the clinical relevance of statistically significant findings. Pain, disturbances in sleep, energy and mobility and emotional and restrained eating proved to be clinically relevant. In subjects operated >5 years ago, a higher sensitivity, a higher inadequacy and a lower social inadequacy were observed compared to more recently operated subjects. A more restrained eating pattern was related to an operation of recent date.

CONCLUSIONS

Surgically induced weight losses are satisfactory in the long-term, even in patients not attending a strict follow-up protocol. Health, psychological symptoms, personality traits and eating behaviour were related to weight loss and time lapse since the operation and did not return to reference normal-weight subject values.