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PSYCHOLOGICAL ASPECTS OF EXTREME OBESITY AND BARIATRIC SURGERY

by David B. Sarwer, Ph.D..


3 Credit Hours - $69
Last revised: 06/29/2017

Course content © Copyright 2010 - 2017 by David B. Sarwer, Ph.D.. All rights reserved.



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COURSE OUTLINE

Introduction

Learning Objectives

Defining Obesity

The Obesity Problem

Causes of Obesity

Treatment for Obesity

Self-directed Diets and Exercise Programs

Commercial Weight Loss Programs

Nutritional Counseling

Physician Counseling

Hospital Based Programs

Low Calorie Diets

Weight Loss Medications

Residential Programs

The Mental Health Professional’s Role in Obesity Treatment

Bariatric Surgery

Surgical Procedures and Outcomes

Patient Selection for Bariatric Surgery

Medical and Dietary Evaluations

The Mental Health Evaluation

Structuring the Evaluation

Psychosocial Characteristics of Bariatric Surgery Candidates

Mood Disorders

Eating Disorders

Anxiety

Substance Abuse

Ongoing Mental Health Treatment

Psychiatric Status and Postoperative Outcomes

Additional Preoperative Psychosocial Issues

Motivations and Expectations

Self Esteem

Quality of life

Body Image dissatisfaction

Postoperative Psychosocial Outcomes

Psychological Complications Following Bariatric Surgery

Depression and Suicide

Suboptimal Weight Loss

Malnutrition

Gastrointestinal Symptoms

Disordered Eating

Body Image Dissatisfaction

Sexual Abuse, Romantic Relationships, and Sexual Functioning

Substance Abuse

Adolescent Bariatric Surgery

Summary

References

INTRODUCTION

Over the past several decades obesity has become one of the biggest public health issues in the United States. Approximately one-third of the American population is obese and another one-third is overweight, putting them at risk for developing obesity in the future. Obesity is associated with a number of significant medical conditions the treatment of which significantly impact health care costs in the United States. While there are a number of treatments for excess body weight, several of them are limited by the amount of weight loss they produce and the problem of weight regain over time. Treatment success also can be limited by a number of psychosocial and behavioral factors.

Bariatric surgery currently holds the greatest promise for the successful treatment of obesity. The weight losses seen with surgery are much greater and far more durable than those seen with more conservative weight loss treatments. The improvements in morbidity and mortality are similarly impressive. However, many individuals who present for bariatric surgery do so with a range of psychosocial and behavioral issues. As a result, almost all bariatric surgery programs in the United States (and most insurance companies) require that patients undergo a psychological evaluation prior to surgery. These evaluations are primarily designed to identify psychiatric conditions that may contraindicate bariatric surgery as well as provide patients with psychoeducation regarding the dietary, behavioral, and lifestyle changes that they will need to make postoperatively. Learning how to appropriately conduct these evaluations can be a valuable addition to the mental health professionals’ services.

Even with preoperative psychological assessment, a number of individuals who undergo bariatric surgery experience a range of psychological symptoms and conditions postoperatively. As a result, many return to the mental health professional for additional treatment. This also may represent another area for the development of new professional skills and competencies and provide an opportunity for practice growth.

LEARNING OBJECTIVES

List four of the treatment options for obesity.

Discuss the role of psychosocial factors in the selection of weight loss treatments.

Explain the role of the mental health professional in the treatment of extreme obesity with bariatric surgery.

Describe the psychological evaluation process that occurs prior to bariatric surgery.

Discuss the potential psychosocial and behavioral issues that can occur following bariatric surgery.

Defining Obesity

Obesity is a serious medical condition. Obesity is defined by an individual’s body mass index (BMI) which evaluates a person’s weight relative to his or her height. Although it is not a perfect measure of the potential impact of body weight on health, BMI correlates highly with percent body fat, morbidity and mortality (NHLBI, 1998). 

Table 1. BMI Classifications

Underweight. Individuals with a BMI < 18.5 kg/m 2 are considered to be underweight (and may meet the DSM-IV-TR diagnostic criteria for Anorexia Nervosa).

Normal weight. Those with a BMI between 18.5 and 24.9 kg/m2 are considered to be of normal weight.

Overweight. Persons with a BMI between 25.0 and 29.9 kg/m2 are overweight. These individuals are believed to be at risk for the development of obesity as well as a number of health problems associated with excess body weight, such as type 2 diabetes, hypertension, and heart disease.

Obese. Individuals with a BMI > 30 kg/m2 are clinically obese, while those who have a BMI > 40 kg/m2 (for example, those who are 100 pounds or more above their recommended body weight) are extremely (or morbidly) obese.  See the NHLBI Body Mass Index Chart.

 

The Obesity Problem

Obesity is one of the world’s most pressing health problems. In the United States, approximately one-third of the adult population is clinically obese (BMI > 30 kg/m2) (Ogden et al, 2010). Another third is overweight and, as a result, is at risk of developing obesity in the future. Thus, two-thirds of the American population is at risk of developing health problems associated with excess body weight. Other Westernized countries report similar rates of obesity and a growing number of non-Westernized countries are seeing an increase in the rate of obesity. (See the most recent statistics for the United States.) 

Rates of obesity differ by ethnicity. In the United States at present, more than 60% of adults of European-American heritage are overweight or obese. Among African-Americans, approximately 75% are overweight (31%) or obese (45%). Among Mexican-Americans, 39% are overweight and 37% are obese. This table shows the rates of obesity broken down by ethnicity.

Obesity also is a growing problem in America’s youth. The rate of obesity or overweight (>95th percentile for age and gender) has doubled in children and tripled in adolescents over the last 20 years (Ogden et al., 2002). Furthermore, recent estimates suggest that 4% of American children and adolescents are above the 99th percentile and, thus, are extremely obese (Freedman et al., 2006). This percentage is larger than the number of children and adolescents affected by cancer, cystic fibrosis, HIV and type I diabetes mellitus combined. The unfortunate reality is that the vast majority of children and adolescents who become obese will remain so throughout their adult lives. This may represent the most concerning aspect of the current obesity problem and is perhaps best reflected by the observations of experienced pediatricians who comment that they now see children with weights and health conditions, like type 2 diabetes, that they simply did not see in their practices 20 and 30 years ago. 

While obesity is often seen as an aesthetic issue—that an individual should lose weight in order to look better—it is a significant medical condition. The presence of obesity increases the risk of a number of other health problems, including cardiovascular disease, type 2 diabetes, hypertension, sleep apnea, musculoskeletal problems and several cancers. It also is believed to be associated with an increased risk of premature death.   

 

Causes of Obesity

Prior to the 1970s the rates of obesity in the United States and other countries were relatively stable at approximately 20% of the population. Since that time, the number of Americans with excessive body weight has increased dramatically. There are a range of possible explanations for the increase, which include genetic, physical, environmental, and psychological factors.

For some individuals, there is clearly a genetic contribution to their obesity. Up to 200 genes may influence an individual’s body weight. Nevertheless, when the obesity problem is considered on the population level, it is unlikely that some genetic mutation has occurred in the past 30 to 40 years that explains the dramatic increase in obesity in the United States and throughout the world.

For some individuals, certain medical illnesses may contribute to the development of obesity and some examples can be seen in this table. The presence of certain acquired medical conditions, including heart disease, atherosclerotic disease, hypertension, and impaired glucose tolerance, can account for an increase in body weight. Medications and other treatments for certain medical conditions (such as thyroid conditions, diabetes, and severe psychiatric illnesses) can contribute to the development of obesity.

Many experts believe that the increase in obesity seen in the past several decades is best explained by environmental factors. While genetics may “set the stage” for the development of obesity, the environment likely influences to what extent the potential for obesity is realized.

The social environment in many Westernized countries, and the United States in particular, has been described as a “toxic environment” (Brownell and Horgen, 2004). In these cultures, high calorie foods are widely available, heavily advertised, inexpensive, and often highly palatable. Many Americans are fascinated by large, if not excessively large, portion sizes to the point that recommended portion sizes seem overly small in comparison. (These issues are informatively and entertainingly underscored in the movie "Supersize Me" which can be a useful resource for both professionals and lay individuals looking for additional information on the environmental contribution to obesity.)

Likely for these and other reasons, Americans eat about 300 more calories each day than they did 20 years ago (Kant, 2006). While the United States Department of Agriculture recommends that individuals consume a diet of 2000 calories per day, many individuals consume 3000 or more calories per day. Over time, these additional calories contribute to weight gain. The Food Guide Pyramid provides more specific information on the United States Department of Agriculture’s recommendations on daily caloric consumption as well as the composition of the diet.

Another feature of the “toxic environment” is a decrease in amount of calories we burn each day in physical activity. A survey conducted by the National Center for Health Statistics in 2003 found that nearly 60% of adults incorporate no vigorous physical activity (defined as activity lasting 10 minutes or more) in their leisure time (Lethbridge-Cejku & Vickerie 2005).  America’s youth are similarly inactive. According to the Surgeon General and the U.S. Department of Health and Human Services (U.S. Department of Health and Human Services), only 50 percent of adolescents regularly engage in vigorous physical activity, while 14 percent report no recent vigorous or only light-to-moderate activity (See The Surgeon General’s Call to Action to Prevent and Decrease Overweight in Children and Adolescents for a further discussion of the issue and recommendations for increasing physical activity).

Our reliance on modern technology such as remote controls, cellular and smart phones, email, and the Internet has made physical movement less necessary than ever before. The infrastructure of many cities and towns also has made physical activity much less necessary, if not difficult or impossible. For individuals who are overweight or obese, the physical and, for some, emotional discomfort caused by their weight further discourages regular exercise. When all of these variables are considered, the increasing rate of obesity is not particularly surprising.  

Treatment for Obesity

There are a wide range of recommended treatments for weight loss and these are listed in Table 2.

Table 2.  Treatments for Obesity

  • self-directed diets
  • commercial weight loss programs
  • dietary counseling
  • physical activity
  • hospital-based programs
  • low calorie diets
  • FDA-approved weight loss medications
  • residential weight loss facilities
  • bariatric surgery

 

Self-directed Diets and Exercise Programs

Likely just about everyone has tried a self-directed diet at some point in their lives. There is a wide range of self-directed diets, ranging from A (The Atkins Diet) to Z (The Zone Diet) with countless others in between. Most include a book and some also have their own brand of food. While these diets are popular, the typical weight losses seen with them are quite modest. The average weight loss with these approaches is approximately 5 lbs at the end of one year, with little evidence to suggest that individuals keep the weight loss off if they return to their previous eating habits. 

For those looking for social support with their weight loss efforts, there are organized self-help programs such as Take Off Pounds Sensibly (TOPS) and Overeaters Anonymous (OA). While there are anecdotal reports of persons who have had success losing weight with these programs, there are no recent studies demonstrating their short, and more importantly, long-term efficacy. There also are a number of web-based weight loss programs available that can help patients lose a modest amount of weight.  Most of these, however, are commercial enterprises that have little or no evidence supporting their efficacy.  

There are many misperceptions about the role of physical activity in weight loss.  Many people believe that increasing physical activity can lead to a significant weight loss independent of changes in diet. There is little evidence supporting this. Others believe that only high intensity, strenuous aerobic activity leads to weight loss. Several studies, however, have suggested that increasing the amount of “lifestyle activity”, by increasing the amount of steps taken in daily activity, can lead to as much weight loss as higher intensity aerobic activity, when combined with a reduced calorie diet. As a result, the current belief is that physical activity, in any amount and at any level of intensity, is better than no activity.

Commercial Weight Loss Programs

Programs such as Weight Watchers are only slightly less popular than self-directed weight loss approaches. While at least one study has suggested that the weight losses seen with Weight Watchers are larger than those seen with self-directed diets, patients, on average only lost 10 lbs at the end of one year and slightly more than 6 lbs at the end of 2 years (Heshka et al., 2003).  While these weight losses may lead to health benefits in persons who are defined as overweight, they may have limited effects on those who are heavier or those who are struggling with weight-related health problems.

Dietary Counseling

Registered dietitians often work with individuals who are overweight or obese. Many of these professionals work in conjunction with medical practices and wellness centers or have specialized expertise in work with individuals with specific diseases. Others may have independent practices and specialize in weight loss. Regardless of the setting, dietitians can help teach individuals healthy eating habits and behaviors that can promote weight loss. Unfortunately, the services provided by many of these professionals are not covered by insurance, making it difficult for many individuals to access their expertise.

Physician Counseling

Physicians from a number of medical specialties would appear to be well positioned to help obese individuals lose weight. Unfortunately, the vast majority of physicians do not assist patients with weight loss. Physicians may encourage patients to lose weight, but rarely provide active counseling. This is likely because of a number of factors. Many doctors lack specific training in weight loss. Others see treatment as ineffective and time-consuming, which is not surprising given that only a selected number of insurance companies reimburse physicians for weight loss treatment.

Despite these barriers, physicians can play a central role in the management of obesity. At a minimum, they can provide a comprehensive assessment of the health problems associated with obesity. There is some evidence suggesting that physicians can help patients lose weight with brief counseling, either alone or in combination with pharmacotherapy. The role of physicians and allied health professionals in providing effective weight loss treatment is the focus of a number of large scale studies currently supported by the National Institutes of Health. Even if physicians are not interested in actively providing treatment, they can play a central role in appropriately referring patients for more intensive treatments for obesity, including bariatric surgery.  

Hospital Based Programs

Some hospital and medical centers offer weight loss programs. These can vary tremendously in structure, content and costs. Some hospitals may have weekly or monthly weight loss groups which are led by a dietitian or nutritionist and are offered at a nominal cost. Other hospitals may offer comprehensive weight management programs with multidisciplinary staffs of physicians, dietitians, mental health professionals and personal trainers.

Some major medical centers may provide persons the opportunity to participate in research studies testing the effectiveness of a range of treatments for obesity. Many of these study behavioral treatment, which is a set of principles and techniques designed to help people modify their eating and activity habits.  This often includes a self-monitoring of food intake with the goal of reducing caloric intake by 500 to 1000 calories per day, often by reducing portion sizes and reliance on high fat and high calories foods. In addition, patients are instructed to increasing physical activity by about 150 minutes a week.  This approach has been shown to produce a weight loss of approximately 8 to 10% within the first 4 to 6 months of treatment (Wadden et al., 1994).  These losses are relatively well maintained as long as patients continue with their new behaviors.

Low Calorie Diets

Low (800 to 1200 calories per day) or very low (800 calories per day) calorie diets frequently use meal replacement products to help patients reduce their caloric intake in a safe and nutritious manner. These programs are usually hospital based and physician supervised. Patients typically use the products for 12 to 16 weeks and then are slowly returned to regular meals. Studies have suggested that patients lose approximately 15 to 20% of their weight after about 12 weeks of treatment (Tsai & Wadden, 2005). Unfortunately, patients regain approximately 35% to 50% of their weight loss in the year following treatment.

Weight Loss Medications

Pharmacologic treatment for obesity has a checkered past. Numerous medications  have been investigated as potential weight loss treatments, often with disastrous results (Click here for a Table of medications that promote weight loss). At present, the FDA has approved two mediations for the long-term treatment of obesity. Sibutramine is a serotonin and norepinephrine reuptake inhibitor that increases feelings of fullness, ultimately decreasing appetite. Orlistat is a gastrointestinal lipase inhibitor that prevents the absorption of fat in the digestive system. Despite the very different mechanisms of action, both medications produce weight losses of approximately 7% to 10% of body weight. These losses are comparable to those seen with behavioral treatments. Both medications, like all medications, have side effects and, therefore, should only be used under close medical supervision. The weight losses seen with these medications, like those seen with other more conservative treatments, may improve the health of those with moderate obesity, but may have little effect on the health and well being of those with extreme obesity (Sarwer, Wadden & Fabricatore, 2005).

Residential Programs

Residential treatment programs typically involve the use of a multidisciplinary team of professionals who provide medical assessment and management but also nutritional counseling, physical activity training, and often mental health counseling. Patients can stay in these programs for relatively brief periods of time or up to several weeks. These programs are typically very expensive and not covered by personal health insurance. While they may help persons lose weight during the length of stay at the clinic, there is little evidence suggesting that the majority of patients maintain their weight losses once they have returned home.

 

The Mental Health Professional’s Role in Obesity Treatment

Mental health professionals often contribute to a number of the above mentioned programs. They often work as part of a team—along with physicians, nurses, dietitians, exercise physiologists and other professionals—brought together to provide multidisciplinary care of individuals with obesity. In many programs that offer group treatment, the mental health professional will lead the “mental health lessons” in the curriculum. This can include topics such as emotional eating/binge eating, body image, and social support. Much of this work, particularly with regard to behavioral modification strategies such as stimulus control, will overlap with the material presented by the dietitian.

In other programs, the mental health professional may only become involved in a patient’s care if they endorse specific behavioral issues, such as binge eating or body image dissatisfaction. The most efficacious interventions for these issues are adapted from cognitive behavioral principles. However, many patients will present to the mental health professional wanting to know “why” they struggle with their weight and eating behavior. Unfortunately, there is little evidence to suggest that insight-oriented therapy is an effective treatment for overeating/binge eating or obesity. There is similarly little empirical support for the role of hypnosis in the treatment of obesity.

The following case illustrates the typical history of a woman who is considering weight loss treatment.

Case Example: Considering Weight Loss Treatment

Ms. G is a 55 year old, European-American female. She is 5’6” with a weight of 184.0 lbs and a body mass index (BMI) of 30 kg/m2.  She reported a college degree. She reported that she is divorced and lives alone. She reported no children. She indicated that she is employed as a claims adjuster for an insurance company.

Ms. G reported that she first recognized being overweight at the age of 5. She reported that she is currently below her highest adult weight of 225 lbs reached at the age of 40. She reported that she was able to lose weight from that weight, but has gained approximately 25 lbs in the past two years. She attributed this weight gain to her eating more in response to the stress of her divorce and her use of Metformin for the treatment of type II diabetes.

Ms. G reported that her mother was obese and father overweight in middle adulthood. She reported that her sister is of average weight. Ms. G reported a history of type 2 diabetes for the past year.  This is her only significant medical condition.  She is currently under the care of both a primary care physician and endocrinologist who are recommending weight loss to help her improve her diabetes status. 

Ms. G reported typically eating 3 meals and 2 snacks each day. She reported eating large amounts of high calorie foods on a regular basis, but that this behavior has decreased in the past year since she was diagnosed with type 2  diabetes. She reported that she often eats in response to emotional distress. She also reported that she drinks one to two glasses of wine with dinner or in the evening most nights of the week. However, she denied any symptoms of alcohol abuse or dependence. She denied any symptoms of binge eating upon questioning. She denied any features of the night eating syndrome. She denied any history of purging or other compensatory behaviors after overeating. 

Ms. G has made several previous weight loss attempts, including self-directed diets, commercial weight loss programs, nutritional counseling, and prescription weight loss medications (Meridia or sibutramine; as well as Byetta). Her previous weight loss efforts have typically resulted in a 5-10% weight loss. Unfortunately, she has been unable to maintain these losses over long periods of time. She reported no experience with hospital based weight loss programs. Ms. G reported walking her dog on a daily basis.

Ms. G reported a course of psychotherapy after her divorce several years ago. She otherwise denied a history of psychiatric treatment past or present. Her Beck Depression Inventory-II score was 4, suggestive of few depressive symptoms. She described her mood as “good”. Her affect was appropriate. She denied any symptoms of depression, anxiety or excessive stress. She denied any suicidal ideation. No evidence of a thought disorder was found.

Summary:  Ms. G appears to be an appropriate candidate for weight loss treatment. She is obese and has type 2 diabetes. Her family history, coupled with her early onset of overweight, provides evidence for a biological predisposition to obesity. Furthermore, Ms. G’s eating habits, coupled with her modest amount of physical activity, are likely contributors to her obesity.  She displayed no symptoms of significant psychopathology that would influence her weight loss treatment options. 

The question now becomes which treatment. She has tried a number of more conservative weight loss approaches without long-term success. Her eating behaviors and physical activity levels are actually quite good for someone presenting for treatment. One possible recommendation would be for her to undertake a second trial of a commercial weight loss program. Another option would be for her to participate in a medically supervised portion-controlled diet program (like  Nutrisystem) that may help her lose weight and improve her diabetes status while receiving appropriate supervision from her physicians.

 

Bariatric Surgery

Bariatric surgery is presently reserved for individuals with a BMI > 40 kg/m2 or those with a BMI > 35 kg/m2 in the presence of major weight related health conditions such as diabetes, high blood pressure or heart disease (NIH, 1994; Mechanick et al., 2008). Recent statistics suggest that approximately 5% of American’s have a BMI > 40 kg/m2, including one in every eight African-American women (Odgen et al., 2010). While the rate of individuals with a BMI > 30 kg/m2 doubled between 1986 and 2000, the number of persons with a BMI > 40 kg/m2 increased by a factor of seven (Sturm et al., 2007). Thus, there are about 24 million adults who currently meet the NIH criteria to qualify for bariatric surgery.

The rise in number of persons with extreme obesity has likely contributed to the growth in bariatric surgery. Less than 20,000 bariatric surgical procedures were performed in the United States in 1998. This number increased to over 110,000 in 2003 with estimates suggesting that approximately 200,000 procedures are performed annually at present. 

Surgical Procedures and Outcomes

There are a number of bariatric procedures currently performed in the United States. The most common surgical procedures include laparoscopic adjustable gastric banding (LAGB) and Roux-en-Y gastric bypass (RYGB). In both procedures, food intake is restricted by the creation of a gastric pouch (approximately 30 ml in size) at the base of the esophagus. RYGB also is thought to induce weight loss through selective malabsorption and favorable effects on gut peptides. The RYGB, performed laparoscopically, is the current procedure of choice in the United States.

 

Within 12 to 18 months postoperatively, individuals typically lose 25-35% of initial body weight with RYGB procedures and 20-25% with LAGB.  Weight loss with both procedures is associated with significant improvements in obesity-related co-morbidities. At least 8 studies have documented decreased mortality among bariatric surgery patients as compared to individuals who have not undergone surgery.

 

These impressive outcomes must be balanced by the incidence of complications. Early postoperative complications occur in 5-10% of patients, while late complications, including anemia and B12 deficiency, have been reported in at least 25% of patients. Of greater concern, 20-30% of patients fail to reach the typical postoperative weight loss or begin to regain large amounts of weight within the first few postoperative years. As seen in the Swedish Obese Subjects trial, both gastric banding and RYGB patients began to regain weight between the first and second postoperative years (Sjostrum et al., 2004) At 10 years postoperatively, approximately 10% of patients who underwent RYGB and 25% of patients who underwent gastric banding failed to maintain at least a 5% reduction in initial weight. Suboptimal results following RYGB and LAGB are typically attributed to poor adherence to the postoperative diet or a return of maladaptive eating behaviors, rather than surgical or medical reasons.

Bariatric surgery requires regular, if not lifelong, follow-up. Patients who undergo RYGB are recommended to return to the bariatric surgery program at least every 6 months in the first two postoperative years and annually thereafter. Adjustments of a gastric band can require follow-up appointments as regularly as every 4-6 weeks in the first postoperative year and quarterly through the first three postoperative years. These postoperative visits can be used to both monitor patients’ weight loss, but to counsel patients on issues related to dietary adherence and eating behavior. Clinical reports have suggested that postoperative follow-up with the bariatric surgery program is frequently suboptimal and can negatively impact weight loss, in some cases within the first postoperative year. In recent reports, only 40% patients returned for each of their annual follow-up visits with the surgeon within the first four years of surgery. Those who returned for all of their annual follow-up visits lost significantly more weight than those patients who did not return.  The latter group regained weight between the first and third postoperative years.

While the weight losses following bariatric surgery are impressive, some patients wonder why they don’t lose more weight.  Some may wonder why they don’t get down to their “ideal” body weight for their height or to a “normal” body mass. The regulation of body weight is influenced by many factors; for example, when people gain weight, their metabolic rate often increases. This occurs because as someone becomes heavier, their body needs to work harder to move them around. As they lose weight, however, their metabolic rate decreases. As a result, they need to eat less and less food to lose weight at the same rate, which, for most people, becomes difficult, if not impossible, at some point. In turn, weight loss slows, and many people become discouraged with sticking with the demands of a specific weight loss plan.

Patient Selection For Bariatric Surgery

Medical and Dietary Evaluations

The preoperative evaluation of the patient seeking bariatric surgery involves multiple professional disciplines, including surgery, internal medicine, cardiology and mental health professionals, among others.  Proper evaluation of patients allows for diagnosis of relevant comorbidities which can then be managed preoperatively to improve surgical outcomes. 

Pre-existing medical conditions should be optimally controlled prior to surgery.  This optimization may require the input of various medical specialists, including cardiologists, pulmonary specialists and gastroenterologists.  The Registered Dietitian (RD) skilled in pre- and postoperative bariatric care should interact with the patient preoperatively for their evaluation and initiate a continuing nutrition education experience. 

A comprehensive preoperative evaluation should be performed on all patients seeking bariatric surgery. This assessment includes an obesity-focused history, physical examination, and pertinent laboratory and diagnostic testing. A detailed weight history includes a description of the onset and duration of obesity, severity, and recent trends in weight.  Causative factors to note include a family history of obesity, use of weight gaining medications, and dietary and physical activity patterns.  One need not document all previous weight loss attempts in detail, but a brief summary of personal attempts, commercial plans, and physician supervised programs should be reviewed, along with the greatest duration of weight loss and maintenance.  This information is useful in documenting that the patient has made reasonable attempts to control weight prior to considering obesity surgery.  These issues also may be reviewed in greater detail by the program registered dietitian.  Some programs will have patients meet with these professionals one time to review both current eating habits and to discuss the postoperative diet. Other programs will ask patients to meet with a dietitian several times. These visits can help patients understand the eating habits and dietary choices that contributed to the development of their obesity. More importantly, they can help patients begin to learn about the dietary and behavioral changes necessary for the most successful postoperative outcome.

Patients are encouraged to use these visits to improve their eating habits in preparation for surgery. It may be quite challenging for patients to go from eating 2500 calories a day or more to the small postoperative portion sizes that will total about 1200 calories per day. While it is normal for patients to go to their favorite restaurant or make their favorite meal in the weeks prior to surgery, these behaviors should be kept to a minimum to avoid weight gain prior to surgery.

 

The Mental Health Evaluation for Bariatric Surgery

The vast majority of bariatric surgery programs in the United States request that candidates undergo a mental health evaluation prior to surgery. These evaluations are often required by insurance companies, who will not provide reimbursement for surgery without mental health clearance. Most of these evaluations are performed by psychologists and social workers; psychiatric nurses and psychiatrists appear to perform them less frequently. Many of these mental health professionals work full or part time with the bariatric surgery program. Others have developed active consulting relationships with these programs and are interested in providing these services as part of a more general mental health practice. Ideally, these professionals have an appropriate working knowledge of the psychosocial issues involved in obesity and bariatric surgery.

In general, the psychosocial evaluation serves two purposes. First, it can identify potential contraindications to surgery, such as substance abuse, poorly controlled depression or other major psychiatric illness. The evaluation also can help identify potential postoperative challenges and facilitating behavioral changes that can enhance long-term weight management (Wadden & Sarwer, 2006).

In this regard, the evaluation takes on more of a psychoeducational component. Although there are published recommendations regarding the structure and content of these evaluations, consensus guidelines have yet to be established.  Almost all evaluations rely on clinical interviews with patients; approximately two-thirds also include instrument or questionnaire measures of psychiatric symptoms and/or objective tests of personality or psychopathology.  More comprehensive evaluations assess the patient’s knowledge of bariatric surgery, weight and dieting history, eating and activity habits, as well as both potential obstacles and resources that may influence postoperative outcomes.

Structuring the Evaluation

Most mental health professionals who conduct these evaluations rely on a clinical interview of the patient. Some will use questionnaires that will be sent to the patient prior to the evaluation and then used to structure the interview. One example of this is the Weight and Lifestyle Inventory (WALI). Other mental health professionals will use personality assessment tools or other paper-and-pencil measures of psychological symptoms or psychopathology, such as the Beck Depression Inventory (BDI-II).

At the onset of the evaluation, patients are typically informed about the nature and purpose of the interview. They are told that the information will be used to generate a letter to the patient’s surgeon, which also will be forwarded to the patient’s insurance company, which will summarize the evaluation and the recommendations of the mental health professional. It also is useful to share the summary of the impressions with the patient at the end of the evaluation, although this may not be possible if the mental health professional needs to contact the patient’s mental health provider(s) to confirm psychiatric status and appropriateness for surgery.  

Weight and dieting history. Although often covered by the registered dietitian, it is useful to review patients’ weight and dieting histories. This includes assessing the age of onset of obesity and the history of the condition in parents and other family members. Persons with extreme obesity typically have an earlier age of onset of obesity and stronger family history of the disorder than do less obese persons. Such characteristics may well be associated with a greater genetic (or biological) predisposition to obesity.

Many candidates for bariatric surgery are “dieting veterans” who have had multiple attempts at a range of more conservative weight loss treatments. Some have truly exhausted their more conservative treatment options and, coupled with the degree of obesity and related health-problems, see bariatric surgery as their best (and perhaps last) chance to successfully control their weight.  A small minority of patients, however, have not participated in any organized weight loss programs prior to surgery. As a result, they do not have the fund of dietary knowledge seen in other patients. With these patients, it is often useful to recommend some preoperative diet counseling as well as attendance in the program’s preoperative support group to help provide additional education on the dietary requirements of bariatric surgery.

Eating behavior and physical activity. The WALI provides an overview of the candidate's dietary intake, focusing on the number of meals and snacks consumed daily and whether the individual has a structured eating plan. It also inquires about foods typically eaten and favorite foods. The goal is to identify changes in food intake that will be required after surgery, particularly a reduction in sweets (associated with the dumping syndrome following RYGB). The need to consume multiple small meals throughout the day is also discussed and how such an eating pattern will fit the candidate's work and social schedule.

The WALI also includes the Questionnaire on Eating and Weight Patterns, used to diagnose BED and bulimia nervosa, and the Night Eating Questionnaire, which assesses symptoms of the Night Eating Syndrome. As detailed below, these conditions are not considered absolute contraindications to surgery. Persons with these conditions often are recommended to engage in cognitive behavioral therapy prior to surgery. In contrast, bulimia nervosa is a contraindication to bariatric surgery. Patients with this disorder would seem at high risk of excessive vomiting after surgery with its attendant effects on oral health, electrolyte balance, and cardiac function. Bulimia nervosa is quite rare among persons presenting for surgery and these individuals are referred to psychotherapy prior to being recommended for bariatric surgery.

Physical activity is briefly assessed to determine the patient's pattern of lifestyle and programmed activity and any physical conditions that limit mobility. Most bariatric surgery candidates report low levels of activity.

 

Psychological status and history. Much of the evaluation focuses on patients’ psychological status and history, as would be done in most mental health assessments. Attention is paid to patients' appearance, speech, thought, mood, and appropriateness of affect in describing themselves and in responding to questions. This global assessment is complemented by reviewing the patient's history of psychiatric illness and any treatment received, including pharmacotherapy. We also examine responses to the Beck Depression Inventory-II that yields ratings of minimal (0 to 13), mild (14 to 19), moderate (20 to 28), and severe (>29) symptoms of depression. Approximately three-quarters of surgery candidates report minimal to mild symptoms of depression that generally are not of clinical concern, unless patients have suicidal ideation.

Approximately 40% of patients report that they are currently engaged in some form of mental health treatment at the time that they present for bariatric surgery. The most common form of treatment is the use of anti-depressants or anti-anxiety medications, typically prescribed by the patient’s primary care physician. For many patients, these medications are appropriately controlling their symptoms. For patients who present with symptoms that do not appear to be well controlled, the mental health professional should contact the primary care physician and, within the guidelines of appropriate ethical care, discuss the results of the evaluation and possible need for additional treatment. This may involve a change in medication dosage or type, or referral to a psychiatrist and/or psychologist for further treatment.

For patients who are under the care of a mental health professional, the professional who is conducting the evaluation for bariatric surgery should contact the provider. The current provider should be aware of the patient’s interest in bariatric surgery and confirm that the patient is stable from a psychosocial perspective and appropriate for surgery at the present time. For medical-legal reasons, these contacts with outside professionals should be documented in the letter sent to the bariatric surgeon.

Some candidates for bariatric surgery score in the moderate to severe range of depressive symptoms but report no history of depression or other emotional complications. They often deny that they feel depressed or believe that their dysphoria and related symptoms are attributable to their obesity. This “weight related depression” is not uncommon in candidates for surgery, but the mental health professional should confirm that the patient is not suffering from an underlying mood disorder. For persons with significant symptoms of depression, even after accounting for conditions associated with their weight, mental health treatment (psychiatric medication, psychotherapy, or their combination) is recommended.  Depending on the patient’s functioning and life circumstances (relationship with primary care physician, access to mental health treatment, etc) patients can be encouraged to speak with their primary care physician or are provided with a mental health referral.  Patients are reminded that the goal of this treatment is to optimize their psychological functioning so that they are best prepared to take on the postoperative dietary and behavioral demands of bariatric surgery.

Most candidates for surgery are receptive to recommendations that they seek assistance their psychosocial functioning prior to surgery. In these cases, patients are recommended to return for a follow-up evaluation typically 3 months later to assess their progress. Most patients who follow these recommendations and return for a re-evaluation are ultimately recommended for surgery.

A small number of individuals disagree with the recommendations of the mental health professional to receive mental health treatment prior to bariatric surgery. On the one hand, clinical intuition and experience will often suggest that these patients are likely to have a less-than-optimal outcome from surgery. On the other hand, an argument can be made that the mental health professional is limiting access to an appropriate medical intervention in the absence of compelling evidence that psychiatric status predicts postoperative outcomes, as detailed below. In these situations, mental health professionals, like other medical consultants to the bariatric surgery program, are providing an assessment of risk of a poor postoperative outcome.  The ultimate decision to go forward with surgery subsequently falls to the surgeon. 

Family support. The decision to seek bariatric surgery is a significant one, not only for the patient, but for his or her family members. Thus, patients are asked about living arrangements, their satisfaction with their spouse (partner) and other intimate relationships, and whether family members and friends support the decision to undertake surgery. In rare cases, family members may be opposed to surgery or may try to sabotage their weight loss efforts. Candidates who report they are dissatisfied with their marriages (or other intimate relationships) are informed that surgery and weight loss are unlikely to resolve these problems. It also is useful to ensure that patients have identified relatives or friends who will assist in their care in the initial days after surgery.

Weight loss expectations. Toward the end of the evaluation, it is useful to discussing the patient’s expected weight loss after surgery. Most persons lose approximately 30% of their initial weight after GBP and 25% of their initial weight after a LAGB  and reach these weight losses approximately 18 months after surgery. It’s also useful to ask patients about their other expectations for their lives after surgery.

Timing for surgery.  The timing of surgery in relationship to other life events should be assessed to ensure that the candidate has chosen an appropriate time to undergo surgery, relatively free of stressors such as starting a new job, changing homes, or getting a divorce. Ideally, the patient should have 3 to 4 weeks of protected time to undergo the operation, recover from it physically, and begin to adopt new lifestyle habits, the most important of which is adhering to the postoperative diet. In cases in which candidates report extremely stressful life events, it may be useful to recommend that they delay surgery until the stressors have resolved.

Knowledge about bariatric surgery. Throughout the interview, it is important to determine how well informed candidates are of the nature of the operation they plan to have, of its potential risks and benefits, and of the changes they must make in their eating and lifestyle habits, both short- and long-term. A majority of candidates seem well informed, having researched the operation by talking with their surgeon, attending support groups, or by using the Internet. A small minority of candidates seem to have only marginal knowledge of the operation they seek and its requirements. They decide on surgery after having heard about it in a media report and speak in the vaguest of terms about risks, expected outcomes, and postsurgical dietary requirements. While the psychological evaluation can augment the education process, such individuals are typically recommended to the program's dietitian and attend several meetings of the program's support group. These practices are intended to ensure that candidates are fully informed about the surgery, its risks, and its behavioral consequences. On rare occasions, there may be questions about a patient’s mental competency to make a decision concerning surgery.

 

Concluding the evaluation.  The evaluation should conclude with a brief summary of findings concerning weight and dieting histories, eating and activity habits, social/psychological status, and readiness for bariatric surgery.  The ultimate recommendation regarding surgery should be communicated clearly to the patient, although the final recommendation may be delayed pending contact with the patient’s mental health professional. Patients also should be given an opportunity to ask any questions they may have.

In general, approximately 70% of patients are unconditionally recommended for surgery. Other patients are recommended to undergo additional treatment (mental health and/or dietary) and are asked to return for further evaluation, typically in about 3 months. As noted above, most patients who follow these treatment recommendations ultimately have bariatric surgery. A patient’s inability to follow these recommendations is likely a poor prognostic sign regarding the ability to make the dietary and behavioral changes required by bariatric surgery.

The case report below illustrates a woman who is appropriate for surgery from a physical perspective, but may not be ready from a psychosocial perspective.

Case Example: Ready for Surgery?

Ms. V is a 28 year old, European-American female. She is 5’1” with a weight of 270.0 lbs and a body mass index (BMI) of 51 kg/m2.  She reported a high school education. She reported that she is employed as a dispatcher for a police and fire department. She is single and lives with her grandparents and three year old daughter. She indicated that she has plans to marry her boyfriend in a few months.  

Ms. V reported that she first recognized being overweight at the age of 12. She reported that she is currently below her highest adult weight of 278 lbs reached last year.  She reported that she was able to lose this weight in the past several weeks and in preparation for surgery. Prior to this weight loss, she reported that her weight has been relatively stable over the past two years. 

Ms. V reported that her mother and father were obese in middle adulthood. She reported 2 siblings both of whom are obese. Ms. V reported a history of sleep apnea as well as spinal fusion surgery which still leaves her in a good deal of physical discomfort on a daily basis.   

Ms. V reported typically eating three meals and one to two snacks each day.  She reported eating large amounts of high calorie foods on a regular basis, as she often orders in take out food while at work. She also reported drinking regular soda and milk regularly. She displayed little awareness of the impact of these behaviors on her weight. She denied any history of binge eating or night eating. She denied any history of purging or other compensatory behaviors after overeating. 

Ms. V has made several previous weight loss attempts, including self-directed diets, commercial weight loss programs, and portion controlled diets. Her previous weight loss efforts have typically resulted in a 5-10% weight loss. Unfortunately, she has been unable to maintain these losses over long periods of time. She reported no experience with hospital based weight loss programs, nutritional counseling, or prescription weight loss medications. She reported no physical activity at present secondary to her chronic back issues.

       

Ms. V has suffered with depression, anxiety and panic attacks for the past five years. She reported that at that time she was involved in a car accident (which contributed to her current issues with her back) and broke off an engagement. She indicated that she subsequently went through a period of time where she “craved love” and had approximately 25 sexual partners in 2 years. She also reported ending three other engagements. She reported that she has re-committed to her religion, found a new romantic partner, and has put these issues behind her. She also reported that she has not had a panic attack in 3 years. She indicated that she is currently taking Effexor XR 75 mg/d as prescribed by her primary care physician. She otherwise denied a history of psychiatric treatment past or present. She denied a history of psychiatric hospitalizations.

Her Beck Depression Inventory-II score at today’s visit was 14, suggestive of an average number of depressive symptoms. She described her mood as “not happy” and attributed it to a fox that was making noise in her back yard last night. Her affect was flat and she was quite guarded throughout the evaluation.  She was observed to have an expressionless stare at several points in the evaluation and became quite defensive when asked about her social history. She displayed little awareness of the degree of turbulence in her life over the past few years or of how she presents herself to others. She denied any symptoms of depression, anxiety or excessive stress upon questioning. She denied any suicidal ideation.

Overview:  In some respects, Ms. V is a good candidate for bariatric surgery. Her BMI is > 40 and she reported a history of sleep apnea. Her family history, coupled with her own childhood onset of overweight, provides evidence for a biological predisposition to obesity. She has tried a number of more conservative weight loss efforts without success and her chronic back injury is unlikely to improve without significant weight loss, thereby further limiting her ability to engage in physical activity and prevent additional weight gain as she gets older.

However, her psychosocial history and presentation are of concern.  While she does not report excessive symptoms of depression or anxiety, she has clearly dealt with some significant stressors in the past few years and engaged in a pattern of self-defeating and self-destructive behaviors. While she believes that her symptoms are well controlled by medication and that she has put these issues behind her, her chronological age and lack of insight into her behavior suggest that these issues may be unresolved. There is concern that they may re-appear postoperatively and interfere with her ability to make the dietary and behavioral changes required of surgery.

To obtain additional information about her history, Ms. V’s primary care physician was contacted by phone. He indicated that he also finds her presentation to be guarded and defensive. He also reported that he had no knowledge about the profound events in Ms. V’s life over the past few years.

Because of these issues, it was recommended that Ms. V enter into psychotherapy prior to surgery and return for further evaluation in 3-4 months. 

 

Psychosocial Characteristics of Bariatric Surgery Candidates

Between 20-60% of persons with extreme obesity who pursue bariatric surgery suffer from a psychiatric illness. In a study of 288 bariatric surgery candidates who were assessed by the Structured Clinical Interview based on DSM-IV (SCID), 38% received a current Axis I diagnosis and 66% were given a lifetime diagnosis. In a separate study of 174 candidates for bariatric surgery, 24% met criteria for a current disorder and 37% were found to have at least one lifetime diagnosis. The most common lifetime diagnoses were affective disorders (22.4%), anxiety disorders (15.5%) and eating disorders (14%) (Kalarchian et al., 2007).  The presence of psychopathology is believed to negatively impact postoperative outcome. In a recent observational study, patients with a lifetime diagnosis of any Axis I clinical disorder, particularly mood or anxiety disorders, experienced smaller weight losses six months after RYGB as compared to those who never had an Axis I disorder. Bariatric surgery patients with two or more psychiatric diagnoses were found to be significantly more likely to experience weight loss cessation or weight regain after one year as compared to those with zero or one diagnosis. Psychiatric status also appears to impact longer term weight loss.

Mood Disorders

Several studies have suggested a relationship between excess body weight and depression. Persons with extreme obesity, for example, are almost five times more likely to have experienced an episode of major depression in the past year as compared to average weight individuals (Onyike et al., 2003). This relationship appears to be stronger for women than men, again perhaps because of our society’s emphasis on female physical appearance. Obese women were more likely to experience a major depressive episode in the past year as compared to average weight women (Carpenter, Hasin, Allison, & Faith, 2000). In contrast, in men, obesity was associated with significantly reduced risks of depression as compared to men of average weight.

Between 25 to 30% of candidates for bariatric surgery report clinically significant symptoms of depression at the time of surgery and, as detailed above, up to 50% report a lifetime history of depression.  The reasons for this are not well understood, but could include the experience of weight-related prejudice and discrimination, the presence of physical pain or other impairments in quality of life, or the occurrence of disordered eating.

 

Eating disorders

Disordered eating is common among candidates for bariatric surgery and likely contributed to the development of extreme obesity. Many patients report that they engage in eating for emotional reasons. Others have formally recognized eating disorders. The most common eating disorder among bariatric surgery patients is binge eating disorder (BED), which is characterized by the consumption of a large amount of food in a brief period of time (less than 2 hours), during which the individual experiences a loss of control (American Psychiatric Association, DSM-IV-TR). While initial reports suggested up to half of all bariatric surgery patients had BED, more recent studies have indicated that the disorder occurs in 5 to 15% of patients who present for surgery. Smaller percentages of patients have bulimia nervosa, where the binge eating is accompanied by self-induced vomiting or other compensatory behaviors, such as inappropriate laxative use or excessive exercise.

Studies have suggested that the presence of binge eating is associated with either suboptimal weight losses or premature weight regain following bariatric surgery (Hsu et al., 1996; Hsu et al., 1997; Kalarchian et al., 2002; Mitchell et al. 2001). Other studies, however, suggested that binge eating is unrelated to postoperative weight loss. Thus, the presence of binge eating is not considered an absolute contraindication to bariatric surgery at present. It is, however, considered a potential poor prognostic indicator of postoperative outcome and patients who are binge eating on a regular basis are often recommended for mental health treatment with the goal of being able to demonstrate an ability to control or eliminate the behavior prior to surgery.

Anxiety

Anxiety disorders also are common among bariatric surgery candidates. In the study by Kalarchian and colleagues (2007), almost 24% of surgery candidates were found to have an anxiety disorder. The most common disorder was social anxiety disorder, found in 9% of patients. In a society that puts such a premium on physical appearance and thinness, it is perhaps not surprising that a significant minority report of persons with extreme obesity report increased anxiety in social situations.  Despite these rates of anxiety disorders, there is no evidence suggesting that they contraindicate surgery. However, intuitive thought and clinical experience suggests that uncontrolled anxiety may negatively impact surgical decision making, postoperative recovery, as well as the patient’s ability to adhere to the postoperative diet.

Substance Abuse

A minority of bariatric surgery patients report a history of substance abuse. Approximately 10% of patients report a history of illicit drug use or alcoholism. Active use or abuse of illegal drugs or alcohol is widely considered a contraindication to bariatric surgery. There also is concern that substance abuse problems may reappear postoperative, as discussed below.

Ongoing Mental Health Treatment

Studies have found that between 16-40% of patients report ongoing mental health treatment at the time of bariatric surgery. Up to 50% have reported a history of psychiatric treatment, most commonly the use of anti-depressant medications, which are often prescribed and managed by primary care physicians. Unfortunately, little is known about how these medications interact with the different surgical procedures. Potentially dramatic changes in absorption of medications may occur due to a reduction in gastrointestinal surface area and other changes. Rapid changes in body weight and fat mass may also affect the efficacy and tolerability of antidepressant medications.  To date, there has been little guidance on the management of these medications peri- or postoperatively.

 

Psychiatric Status and Postoperative Outcomes

At present, the relationship between preoperative psychological status and postoperative outcomes is unclear (Bocchieri et al. 2002; Greenberg et al., 2005; Herpertz et al., 2004, Sarwer et al., 2005; van Hout et al., 2005).  Several studies have suggested that preoperative psychopathology and eating behavior are unrelated to postoperative weight loss; others have suggested that preoperative psychopathology may be associated with untoward psychosocial outcomes, but not with poorer weight loss.  Unfortunately, the complex relationship between obesity and psychiatric illness, as well as a number of methodologic issues within this literature, make drawing definitive conclusions difficult, if not impossible. It may be that psychiatric symptoms that are largely attributable to weight, such as depressive symptoms and impaired quality of life, may be associated with more positive outcomes; whereas, those symptoms representative of psychiatric illness, that is,  independent of obesity, are associated with less positive outcomes.

Nevertheless, most mental health professionals who perform these assessments agree that significant psychiatric issues contraindicate bariatric surgery. Typically cited contraindications include active substance abuse, active psychosis, bulimia nervosa, and severe, uncontrolled depression. Nevertheless, even the presence of severe psychopathology must be balanced with the severity of the health issues of the patient.

Below is a case example of a woman with significant psychopathology who was recommended for additional treatment prior to undergoing surgery.

Case Example: Psychopathology and Delaying Surgery

                         

Ms. K is a 59 year old, European-American female. She is 5’6” with a weight of 264.6 lbs and a body mass index (BMI) of 43 kg/m2.  She reported a high school education. She reported that she married and lives with her husband and adult son. She is employed as a cashier at a retail store.

Ms. K reported that she first recognized being overweight at the age of 14. She reported that she is below her highest adult weight of 273 lbs reached earlier this year. She indicated that she has been able to lose some weight in recent weeks and in preparation for surgery. Over the past two years, however, she reported that she has gained approximately 20 lbs. She attributed this weight gain to her eating habits and being less physically active.

Ms. K reported that her mother was obese and father of average weight in middle adulthood. She indicated that her four siblings are obese. Ms. K reported a history of hypertension and sleep apnea.

       

Ms. K reported typically eating 3 meals and 1-2 snacks each day. She reported eating large amounts of high calorie foods, such as cakes, cookies and ice cream, on occasion. She reported a long standing history of binge eating in the evenings most days of the week. She also reported a current history of purging after overeating, with the most recent episode being two nights ago. 

Ms. K has made several previous weight loss attempts, including self-directed diets and commercial weight loss programs. Her previous weight loss efforts have typically resulted in a 5-10% weight loss. Unfortunately, she has been unable to maintain these losses over long periods of time. She reported no experience with nutritional counseling, portion controlled diets, hospital based weight loss programs, or prescription weight loss medications. Ms. K reported physical therapy twice each week at present to address osteoarthritis in her knee.    

       

Ms. K reported a complicated psychosocial history. She reported that she was physically and sexually abused in childhood. She indicated that these experiences led to long standing problems with her mood. Approximately 20 years ago, she was diagnosed with dissociative identity disorder and several years later was hospitalized several times for this condition and for bulimia nervosa. She also reported multiple suicide attempts during that period.

For much of the last 15 years, she has been under the care of a psychologist who specializes in the treatment of dissociative identity disorder. She also reported that she is currently taking a number of psychiatric medications, including Wellbutrin 100 mg/tid, Effexor 37.5 mg/d, BuSpar 15 mg/bid, and Xanax 1 mg/prn which are prescribed by her primary care physician but in consultation with her psychologist.

Her Beck Depression Inventory-II score at today’s visit was 27, suggestive of an elevated number of depressive symptoms. She described her mood as “anxious” with regard to this evaluation. Her affect was somewhat guarded but otherwise appropriate. She reported long standing issues with her sleep, including a fear of going to sleep most nights. She reported some increased irritability as of late. She denied any additional symptoms of depression, anxiety, or excessive stress upon questioning. She denied any suicidal ideation at present and reported that she last thought about suicide last year. She also reported that she sometimes has thoughts of cutting herself, but has not done this for several years. She displayed no dissociative behaviors during the evaluation.

Overview: In some respects, Ms. K appears to be an appropriate candidate for bariatric surgery. Her BMI is above 40, she reported a history of hypertension and symptoms of sleep apnea, and she has tried more conservative weight loss approaches without long-term success. Weight loss following bariatric surgery will likely have a positive impact on her health and quality of life. Ms. King’s family history, coupled with her early onset of being overweight, provides evidence for a biological predisposition to obesity. Her eating habits, history of binge eating, and limited amount of physical activity are likely contributors to her obesity.

However, there also are concerns about her appropriateness for surgery at this time. After speaking with her psychologist, it is clear that she has made great progress regarding her dissociative identity disorder. He reported that her personality is almost fully integrated. In that regard, he sees her has being much more stable than she has been in the past. She seems to be managing this severe psychiatric illness well. However, I am concerned about her active binge eating and purging several nights a week which is widely considered to be a poor prognostic sign for bariatric surgery. Her psychologist was unaware of this behavior. Her BDI-II score is also somewhat of a concern, but also perhaps not all that surprising given her mental health history.

To address this issue, the psychologist indicated that he would attempt to see Ms. K more frequently. (They were seeing each other every-other-week secondary to financial considerations.) It was recommended that Ms. K go three months without bingeing and purging.

Ms. K returned for a follow-up evaluation approximately 4 months later. During that time she reported that she made a number of changes to her diet, reducing her consumption of ice cream and candy. These changes likely contributed to her 8 pound weight loss over the 4 months.  Ms. K also reported that she decreased the frequency of binge eating and did not engage in any purging behavior over the past few months. She reported that she has experienced no dissociations in the past few weeks, except while in session with her psychologist. Her BDI-II score was 33, which has increased from 26, four months ago. In a telephone conversation, her psychologist reported that he also is pleased with Ms. K’s progress and that she is beginning to talk about issues related to weight loss and her sexuality postoperatively. He was not concerned about the increase in her BDI-II score and there was agreement that she was stable from a psychiatric perspective and appropriate for surgery at this time.  

Mental health professionals unconditionally recommend approximately 75% of bariatric surgery candidates for surgery. In the remaining patients, the recommendation typically is to delay surgery until specific psychosocial and/or nutritional issues are addressed with additional assessment or treatment.  The benefits of recommending such a delay, however, should be weighed against the risk of patients not eventually returning for surgery. Patients who are not unconditionally recommended for surgery are typically asked to enter into some additional mental health and/or dietary treatment for a period of time (e.g., 3 to 6 months), and then to return for a re-evaluation of their preparedness for surgery. While some patients appreciate the recommendation to engage in additional treatment prior to surgery, others respond to these recommendations with anger and denial.

This is a continuation of the case of Ms. K detailed above. It illustrates the reaction of some patients to the recommendation for additional treatment.

Case Example: Patient Reaction to Surgery Delay (Ms. V Continued)

Approximately one week after her evaluation, Ms. V spoke with her bariatric surgeon by phone. She was informed that he recommended (based on the psychological report) that she enter into psychotherapy prior to undergoing surgery and be re-evaluated by the psychologist in approximately 3-6 months. Ms. V then called the consulting psychologist. Even though she was informed at the end of the evaluation that the psychologist would be in contact with her primary care physician and, based on the evaluation, would likely recommend psychotherapy prior to surgery, she was angry that her surgery was being “cancelled” because of the psychological evaluation. She accused the psychologist of “exaggerating” her history. She also accused the psychologist of “malpractice”, demanded her money back from the evaluation, and said she would be consulting an attorney.

Ms. V subsequently called the coordinator of the bariatric surgery program. She reiterated her claim of “malpractice” against the psychologist and also accused the psychologist of “discriminating against me because I am Roman Catholic.” (While she mentioned being religious in her evaluation, she never specified which religion.)

Overview: Ms. V’s behavior following the consultation further highlighted the psychologist’s initial concerns about the possibility of underlying psychopathology as well as Ms. V’s difficulty in coping with stress. In consultation with the psychologist, the program coordinator reiterated to Ms. V the need to enter into psychotherapy for a period of time prior to being further evaluated for surgery.

Upon re-evaluation, most individuals are found to have been adherent to the recommendations of the mental health professional and, thus, are recommended for surgery.  Occasionally, however, more time is needed if a patient’s psychiatric disorder has not stabilized (resolution is not necessarily the goal) or if the patient has not demonstrated the capacity to make behavioral changes that support surgical success (e.g., scheduling regular meals, choosing lower-fat and lower-sugar foods).

Additional Preoperative Psychosocial Issues

Motivations and Expectations

Given the comorbid medical problems associated with extreme obesity, improvement in overall health and longevity are likely the primary motivation for bariatric surgery for most people. Without question, concerns about body image and physical appearance likely motivate the pursuit of surgery as well. It is important that patients are “internally” motivated for bariatric surgery—that they are seeking surgery for improvements in their health and well being. Patients who are “externally” motivated for surgery, interested in surgery for some secondary gain such as saving a troubled marriage, are unlikely to be good candidates for surgery.

The weight losses associated with all of the bariatric surgical procedures are quite impressive when compared to those seen with behavioral modification or weight loss medications. Regardless, individuals who present for bariatric surgery often have unrealistic expectations regarding the amount of weight they will lose.  Unrealistic expectations are common regardless of the weight loss approach. Individuals enrolled in behavioral modification programs have been shown to have “goal” weight losses of 33%, comparable to the weight losses seen with bariatric surgery. While these unrealistic expectations were once thought to put individuals at risk for weight regain, it appears that they may be unrelated to weight losses following bariatric surgery. Nevertheless, individuals interested in bariatric surgery are encouraged to listen carefully to their surgeon regarding the amount of weight loss and improvements in their health that they can realistically expect after surgery.

Individuals interested in bariatric surgery may have expectations about the impact of surgery on other areas of their lives. Many people who present for surgery do so with the hope that it will improve not only their health, but also their physical appearance and body image.  Individuals who are overweight or obese report greater body image dissatisfaction than average weight individuals and those who lose weight, whether by behavioral modification, weight loss medications, or surgery, report improvements in their body image. However, the massive weight loss typically seen with bariatric surgery may result in the development of loose and/or sagging skin of the abdomen, thighs, legs and arms that may lead to body image dissatisfaction.  This may lead some patients to present to a plastic surgeon for body contouring surgery, which is discussed below.

Other individuals may have expectations about the impact of bariatric surgery on their interpersonal relationships. Many people may intuitively think that as they lose weight, and feel better about themselves, their social and/or romantic relationships will improve. This does occur for many individuals. However, for some, the experience of a major weight loss becomes an unsettling experience. Some individuals may experience unwanted attention related to their weight loss and physical appearance that may make them uncomfortable. Others may be upset or angry that people who treated them as if they were “invisible” before, now are friendly and sociable. Patients are encouraged to consider these issues prior to surgery and often may want to discuss them in psychotherapy.

Similarly, men and women interested in bariatric surgery should consider the potential impact of their weight loss on their marital and sexual relationships. Intuitively, most people would think that these relationships would improve with weight loss. However body weight can play a much more complex role in some relationships. Some partners may feel threatened or jealous witnessing a partner’s weight loss. Some patients may be uncomfortable with additional romantic or sexual attention, particularly those with a history of sexual abuse. Similarly, little is known about the relationship between excess body weight and sexual function, although studies have suggested that excess body weight can negatively impact sexual functioning. Couples are encouraged to discuss these issues prior to undergoing surgery.

Self-esteem

For some individuals, the degree of obesity can dramatically impact their self-esteem, such that it is difficult for them to recognize and appreciate their other talents and abilities because of their struggles with their weight. For others, obesity has relatively little impact. These individuals may be quite comfortable with their work and home life, but their weight has been the one area where they have not been successful. Obesity may be more likely to impact the self-esteem of women, likely given our society’s overemphasis on thinness as a criteria for physical beauty.

Quality of life

Obesity also negatively impacts health related quality of life. Numerous studies have shown a relationship between excess body weight and decreases in quality of life.  Individuals often report significant difficulties with physical functioning (walking, climbing stairs) and often difficulties with occupational functioning. These impairments likely motivate many individuals to seek bariatric surgery.

Obesity and extreme obesity in particular, can contribute to the experience of discrimination. Obese individuals are less likely to complete high school, are less likely to marry, and earn less money compared to average weight persons. Obese persons are frequently subjected to discrimination in a number of settings, including educational, employment and even health care settings. These experiences may be even more common among those suffering from severe obesity.

Body Image Dissatisfaction

Body image is an important aspect of quality of life for many individuals. Body image dissatisfaction is common in overweight and obese individuals, as it is for women and girls of average weight. The degree of dissatisfaction seems to be directly related to the amount of excess weight a person has, although persons can report dissatisfaction with their entire bodies or with specific features.  Body image dissatisfaction is believed to motivate many appearance-enhancing behaviors, including weight loss, health club memberships and cosmetic surgery (Sarwer & Magee, 2006). It also is believed to play an influential role in the decision to seek bariatric surgery, even in the presence of significant weight related health problems.

 

Postoperative Psychosocial Outcomes

In general, bariatric surgery is also associated with significant improvements in psychosocial status. Most psychosocial characteristics --  including symptoms of depression and anxiety, health-related quality of life, self-esteem, and body image—improve dramatically in the first year after surgery (Bocchieri et al, 2002; Herpertz et al, 2003; van Hout et al, 2003; Sarwer & Wadden, 2005; Herpertz et al, 2004; Mitchell & de Zwaan, 2005; van Hout et al, 2006). Many of these benefits appear to endure through the first four postoperative years.  Longer-term psychosocial outcomes are largely unknown.

Similarly, the impact of bariatric surgery on formal psychopathology is unclear. In their review of the psychosocial literature, Herpertz and colleagues drew a thought-provoking conclusion (Herpertz et al, 2004). They suggested that psychosocial distress that is secondary to obesity—such as significant body image dissatisfaction or distress about weight-related limitations on functioning -- may facilitate weight loss following surgery. In contrast, the presence of significant psychopathology that is independent from the degree of obesity—such as major depression—may inhibit patients’ ability to make the necessary dietary and behavioral changes to have the most successful postoperative outcome possible.

Psychological Complications Following Bariatric Surgery

While the majority of studies suggest that the psychosocial outcomes of bariatric surgery are largely positive, we note that these experiences are not universal. Just as some patients experience medical complications, some also will experience poor behavioral or psychological outcomes.  Among the greatest causes for concern are recent findings that suggest that postoperative bariatric surgery patients have higher-than-expected rates of suicide.  This and other potential negative outcomes are reviewed below.

 

Depression and Suicide    

A number of studies have identified a relationship between depression, suicidality, and obesity. A large epidemiological study found that obese women were significantly more likely to experience suicidal ideation and to make suicide attempts than their normal-weight counterparts (Carpenter, Hasin, Allison, & Faith, 2000).  Persons with extreme obesity have been found to be more likely to attempt suicide than persons in the general population.

Adams and colleagues (2007) examined mortality and causes of death over a mean of 7 years in 7925 postoperative bariatric surgery patients and 7925 non-patient controls who were matched for age, gender, and BMI. All-cause mortality was significantly reduced in surgery patients compared to controls.  However, nearly twice as many surgery patients (n = 43) as controls (n = 24) died by suicide.  

Given the relationship between extreme obesity and suicide, and the generally salutary effects of bariatric surgery on psychological distress, reports of suicide after bariatric surgery are largely counterintuitive.  In the absence of additional information on the relationship between bariatric surgery and suicide, these findings underscore the importance of ensuring that patients who have psychiatric disorders receive appropriate mental health care before and after bariatric surgery. 

   

Suboptimal Weight Loss

As noted above, 20-30% of persons who undergo bariatric surgery fail to reach the typical postoperative weight loss or begin to regain large amounts of weight within the first few postoperative years. Suboptimal results are typically attributed to poor adherence to the postoperative diet or a return of maladaptive eating behaviors, rather than to surgical factors. A number of studies have found that adherence to the postoperative diet is poor.  Caloric intake often increases significantly during the postoperative period.

Bariatric surgery requires regular, if not lifelong, follow-up. Patients who undergo surgery are recommended to return to the bariatric surgery program at least every 6 months in the first two postoperative years and annually thereafter. Adjustments of a gastric band can require follow-up appointments as regularly as every 4-6 weeks in the first postoperative year and quarterly through the first three postoperative years. These postoperative visits can be used not only to monitor patients’ weight loss (and overall psychosocial status), but also to counsel patients on issues related to dietary adherence and eating behavior. Clinical reports have suggested that postoperative follow-up with the bariatric surgery program is frequently suboptimal and can negatively impact weight loss, in some cases within the first postoperative year.

The following case illustrates the history of a woman who has struggled postoperatively.

Case Example: Post-Operative Difficulties

Ms. A is a 34 year old, European-American female. She is 5’4” with a weight of 245 lbs and a body mass index (BMI) of 42 kg/m2.  She reported a college degree. She reported that she is married and lives with her husband and two young children. She reported that she used to work in marketing for a pharmaceutical company but has not worked since the birth of her first child four years ago.  She reported that she is primarily interested in a laparoscopic adjustable gastric banding procedure, in part as the family is thinking about having a third child in the near future.

Ms. A reported that she first recognized being overweight at the age of 14, following puberty. She reported that she is currently below her highest adult weight of 260 lbs reached approximately 2 years ago near the end of her second pregnancy. Since that time, she reported that she has been able to lose some weight, but has struggled to return to the weight she was at before her first pregnancy, which was 170 lbs.  She attributed her struggles with her weight to eating more in response to the stress of motherhood.

Ms. A reported that her mother and father were overweight in middle adulthood. She reported that three sisters are of average weight. Ms. A reported that she was diagnosed with gestational diabetes during her second pregnancy and that her primary care physician reported that she is pre-diabetic at present. Ms. A reported that her maternal grandmother suffered from type 2 diabetes and she is “afraid” of becoming diabetic at such an early stage in her life. Her primary care physician is supportive of her efforts to lose weight and her interest in bariatric surgery.  

Ms. A reported typically eating 3 meals and several snacks each day. She reported that she starts out each day “good” but that her eating behavior deteriorates throughout the day. She reported that she eats appropriate meals for breakfast and lunch, but will find herself snacking throughout the afternoon, particularly when her two children are napping. She also reported that she will snacking on high calorie, high fat foods such as cookies and chips when she is relaxing at the end of the day and after her daughters have gone to bed for the night. She acknowledged being an “emotional eater” and reported that she sometimes has difficulty stopping herself from snacking at night. In this regard, she appears to suffer from binge eating disorder. She denied any features of the night eating syndrome. She denied any history of purging or other compensatory behaviors after overeating at present, but reported that she did engage in some infrequent self-induced vomiting in college.  

Ms. A has made several previous weight loss attempts, including self-directed diets, commercial weight loss programs, nutritional counseling, portion controlled diets and over the counter weight loss medications. Her previous weight loss efforts have typically resulted in a 10-20% weight loss, the largest weight loss coming after she was engaged in a highly structured portion-controlled weight loss program. Unfortunately, she has been unable to maintain these losses over long periods of time. She reported no experience with hospital based weight loss programs or prescription weight loss medications. Ms. A reported no physical activity at present, secondary to a lack of time. She reported that she would like to find time to exercise in the evenings, but as her husband is often traveling for work, she is reluctant to go down into her basement to exercise and leave her children upstairs sleeping and out of earshot.

       

Ms. A reported that she is currently taking Celexa 10 mg/d for symptoms of depression and anxiety and as prescribed by her primary care physician. She reported that she started taking the medication after the birth of her first daughter. She denied a history of psychotherapy. She denied a history of psychiatric hospitalizations.

Her Beck Depression Inventory-II score at today’s visit was 14, suggestive of an average number of depressive symptoms. She described her mood as “ok”. Her affect was appropriate. She reported some difficulties with her sleep, which she noticed is worse when her husband is away overnight for work. She also reported some social isolation, feeling like she has only limited “adult contact” at present. She denied any additional symptoms of depression, anxiety or excessive stress upon questioning. She denied any suicidal ideation. No evidence of a thought disorder was found.

Overview: Ms. A appears to be an appropriate candidate for bariatric surgery. She is obese and is pre-diabetic. Her early onset of being overweight, provides evidence for a biological predisposition to obesity.  Her regular eating habits, history of binge eating, and lack of physical activity are likely contributors to her obesity. 

From a psychosocial perspective, however, Ms. A raises some concerns. She presented with some symptoms of both depression and anxiety. However, she is receiving treatment and does not appear to be in significant distress. In this regard, she is like many candidates for bariatric surgery. Yet, clinical thought and experience may suggest that she might benefit from a re-evaluation of her anti-depressant medication and/or a possible referral for psychotherapy. 

In this case, however, Ms. A is presenting for bariatric surgery and has not presented to the psychologist specifically for psychotherapy. In the present example, her symptoms were not judged to be severe enough to warrant additional mental health treatment prior to surgery. Thus, the result of the psychological evaluation was an unconditional recommendation for surgery.

Ms. A underwent a laparoscopic adjustable gastric banding procedure. In the first month, she lost approximately 10 lbs. She then returned 3 months after surgery and had lost 25 lbs. Ms. A was then lost to follow-up. She returned to the bariatric surgery program approximately 15 months after surgery. She has lost approximately 30 lbs since surgery (a weight loss of approximately 15%). She reported that she is disappointed in her weight loss, is struggling to follow the recommended postoperative diet, and is vomiting several times a week. She stated that she is interested in undergoing a gastric bypass procedure, as she has a neighbor who had a laparoscopic gastric band and was subsequently converted to a bypass procedure.

As noted above, a patient being lost to follow-up after bariatric surgery is common and is associated with suboptimal postoperative outcomes. Unfortunately, patients and surgeons often see that the solution to the problem is an additional surgical procedure. However, those health care providers who work in the trenches with patients (the nurses, the dietitians, the psychologists) often recognize that patients would likely benefit from additional behaviorally based treatment prior to undergoing more surgery. In Ms. A’s case, she has struggled to follow the postoperative diet. Furthermore, and in retrospect, it appears that her mood disorder may have been more significant than initially recognized. To address these issues, Ms. A was recommended to work with the dietitian from the bariatric surgery program to help improve her adherence to the postoperative diet. In addition, she was recommended to see a psychologist to address her depressive symptoms and emotional eating.  

Malnutrition

Poor adherence to the postoperative diet is a behavioral and psychosocial issue that can have significant physical and potentially medical implications postoperatively. While total caloric intake typically increases during the postoperative period, a subset of bariatric surgery patients suffers from malnutrition. The most common and severe problems appear to be vitamin B12, iron, and folic acid deficiency. Most cases of malnutrition among bariatric surgery patients appear to be responsive to improved dietary adherence or vitamin supplementation (Fujioka, 2005).

 

Gastrointestinal Symptoms

Poor adherence to the postoperative diet also may result in gastrointestinal discomfort, including nausea, “plugging,” vomiting, and gastric dumping.  “Plugging” has been described as the subjective experience of ingested food becoming lodged in the gastric pouch, which leads to pressure and/or pain in the chest. These symptoms typically follow over-consumption of pasta, bread, or dry meats, and can endure for years after surgery. Some patients avoid foods that may trigger these events, which can contribute to malnutrition.

One- to two-thirds of patients report postoperative vomiting. Although vomiting occurs most frequently during the first few postoperative months, it also may continue for several years postoperatively and may be associated with malnutrition. Patients may vomit reflexively, due to food intolerance, or may self-induce vomiting to relieve the discomfort associated with “plugging”.  This self-induced vomiting to dislodge food that feels “stuck” is problematic if done repeatedly.  It should not, however, be considered a sign of bulimia if it is not motivated by the desire to compensate for excessive calorie intake or by an excessive fear of weight gain.

Gastric dumping, which occurs with RYGB but not LAGB procedures, is a constellation of symptoms that can include nausea, flushing, bloating, faintness, fatigue, and severe diarrhea.  It typically occurs following the consumption of foods high in sugar and/or fat. Dumping is believed to occur in the majority of patients, but its prevalence is not well documented. The aversiveness of dumping was believed to be one factor that contributes to the weight loss superiority of RYGB as compared to LAGB.  However, clinical reports suggest that gastric dumping is not universal nor does it appear to be the lifelong problem it was once believed to be.  Thus, it is no longer seen as the major factor that contributes to weight loss after RYGB surgery. Rather, changes in gastric hormones and peptides, along with gastric restriction, are believed to be the major mechanisms for weight loss. 

 

Disordered Eating

As detailed above, disordered eating, specifically binge eating and night eating, are thought to be relatively common among candidates for bariatric surgery. Several studies have investigated the relationship between disordered eating prior to surgery and postoperative outcomes. Two studies found that while patients did not report any objective binge episodes postoperatively, a significant minority reported feelings of loss of control consistent with BED (Hsu, Betancourt & Sullivan, 1996; Hsu, Betancourt, & Sullivan, 1997).  Kalarchian and colleagues (Kalarchian, Wilson, Brolin, & Bradley, 1999) observed no binge episodes in the 4 months following surgery.  However, 46% of patients reported either objective or subjective binge eating at longer follow-up (Kalarchian et al., 2002).

Thus, preoperative binge eating may be related to smaller weight losses or weight regain within the first two years after surgery. Individuals who engage in night eating before surgery also have been found to continue the behavior postoperatively. At least one study has found that more frequent nocturnal eating following bariatric surgery was associated with greater BMI and lower satisfaction with surgery.

 

Body Image Dissatisfaction

The massive weight loss seen with bariatric surgery is associated with significant improvements in body image. Unfortunately some patients who lose large amounts of weight report residual body image dissatisfaction associated with loose, sagging skin of the breasts, abdomen, thighs and arms. Most post-bariatric surgery patients considered the development of excess skin to be a negative consequence of surgery. This dissatisfaction likely motivates some individuals to seek plastic surgery to address these concerns.

According to the American Society of Plastic Surgeons, in 2008  approximately 55,000 patients underwent body contouring procedures after weight loss. The most common procedures were breast reduction procedures, which were performed on nearly 30,000 women. Extended abdominoplasty/lower body lift procedures, which are designed to eliminate the excessive skin around the abdomen and lower torso, also are common. There is a rapidly growing body of knowledge related to the surgical aspects of these procedures. Far less, however, is known about the psychological aspects of these procedures. Studies of other cosmetic surgical procedures, such as breast augmentation, suggest that body image improves postoperatively (Sarwer, Brown, & Evans, 2007). There is concern, however, that some patients who present for body contouring following bariatric surgery may be suffering from body dysmorphic disorder, which is seen in 5% to 15% of cosmetic surgery patients (Sarwer et al., 2007; Sarwer & Crerand, 2008). Thus, patients seeking body contouring should be assessed for body dysmorphic disorder, as well as other psychopathology, prior to undergoing plastic surgery.

 

Sexual Abuse, Romantic Relationships, and Sexual Functioning

There appears to be a modest association between sexual abuse and obesity (Gustafson & Sarwer, 2004). Studies have suggested that between 16% and 32% of bariatric surgery candidates reported a history of sexual abuse, which appears to be higher than seen in the general population (e.g., Grilo et al., 2005; Gustafson et al., 2006). Interestingly, several studies have suggested that a history of previous sexual abuse is unrelated to weight loss following bariatric surgery. Nevertheless, patients with a history of sexual abuse often struggle with a range of psychological issues, including body image, sexual, and romantic relationship issues, following bariatric surgery.  While it may be impossible to predict which patients will struggle with these issues, the preoperative psychological evaluation presents an opportunity to discuss these issues with patients and inform them that they may experience some psychological distress related to this during the postoperative period.

Patients seeking bariatric surgery (regardless of sexual abuse history) often present with the expectation that weight loss will improve their sexual functioning and romantic relationships. Others fear that the weight loss may destabilize these relationships. In general, the few studies of this issue suggest that romantic relationship quality improves following bariatric surgery. The impact, however, seems to be a function of the quality of the existing relationship.  That is, stable, functional relationships may improve, while unstable, dysfunctional ones appear to be the ones at risk of deteriorating.

Little is known about the effects of surgically induced weight loss on sexual functioning. Persons with extreme obesity report greater impairments in sexual quality of life than less obese individuals. Given our society’s emphasis on thinness as a sign of physical beauty and sexuality, it is not surprising that obese women often are stigmatized as potential sexual partners. Obesity related metabolic abnormalities, and the medications often used to treat them, also are associated with problems in sexual functioning. Intuitive thought suggests that the physical and psychological benefits associated with bariatric surgery will lead to improvements in sexual functioning; however, these issues have received little study to date. 

 

Substance Abuse

Most studies that have examined the relationship between BMI and substance use disorders found lower rates of these disorders among obese individuals.  In a sample of bariatric surgery candidates, less than 2% met criteria for a current substance use disorder (Kalarchian et al., 2007).  By contrast, the DSM-IV-TR (2004) estimates the point prevalence of just one such disorder, alcohol dependence, at approximately 5%.

Two concerns regarding postoperative substance use are prominent in the media, if not in the scientific literature: changes in alcohol metabolism and “addiction transfer.”  “Addiction transfer” is a popular, mass media created term that refers to the idea that patients who undergo bariatric surgery may develop addictions to substances, gambling, sex, etc. to replace their preoperative “addiction” to food.  “Addiction transfer” is not an accepted clinical or scientific term. The term and construct have several shortcomings, as detailed by Sogg (2007).  Chief among these is that the view of food as an addictive substance, or eating as an addictive behavior, is by no means supported by scientific consensus.  Additionally, there is little support for the notion that a treated symptom (e.g., compulsive eating) will resurface in a different form (e.g., compulsive drinking or shopping) unless the psychological basis for the original problem is resolved.

Currently, there is no empirical evidence that bariatric surgery increases the risk of substance use or other addictive behaviors.  Thus, “addiction transfer” cannot be considered a common outcome of bariatric surgery.  It is, however, possible, that bariatric surgery candidates are at increased risk of problematic substance use.  Studies that have found an increased risk of death by suicide following bariatric surgery also have found an elevated risk of accidental death (Adams et al., 2007).  It is not known how many of those accidental deaths were substance related.  Clearly, the effect of bariatric surgery on the risk of substance use disorders is an area in need of further research.

 

ADOLESCENT BARIATRIC SURGERY

Over the past several decades, the prevalence of obesity among children and adolescents has steadily increased. Approximately 4% of American children and adolescents are extremely obese, defined as having a BMI ≥ 99th percentile for their age. Obese children and adolescents are likely to become obese adults and, as a result, be at risk for premature morbidity and mortality.

While dietary, behavioral, and pharmacological interventions may help some overweight and obese adolescents, they are most likely of little help for those suffering from extreme obesity. For this group, there is a need for more aggressive intervention, such as bariatric surgery, that produces a larger and more sustainable weight loss. Studies examining bariatric surgery performed on adolescents have shown dramatically positive short-term results in terms of weight loss, resolution of comorbidities, and increased quality of life. Complications generally have been few. However, more research is needed on the long term outcomes after surgery, both medical and behavioral.

In general, adolescents presenting for bariatric surgery must meet the same general BMI and comorbidity criteria for surgery as adults. Additionally, the adolescent must have attained or nearly attained physical maturity and have a history of organized attempts at weight management without success. He or she should demonstrate reasonable decision making abilities and be willing to commit to the comprehensive medical and psychological assessment process prior to surgery. During the psychological evaluation, consideration of the family support system is of specific concern. A certain level of maturity, and family support, is required for the adolescent to be able to adhere to the rigorous dietary and behavioral changes required of bariatric surgery.

The following case illustrates some unique and challenging psychosocial issues in an adolescent who presented for bariatric surgery.

Case Example: Bariatric Surgery in Adolescence

Ms. Z is a 15-year old female of Mexican descent who presented for bariatric surgery. She was 5’0” with a weight of 325 lbs and BMI = 63 kg/m 2. At the time of her initial evaluation with the bariatric surgery program, she had the following diagnoses: hypertension, asthma, pseudotumor cerebri, severe scoliosis, obstructive sleep apnea (requiring BiPAP treatment), narcolepsy, and previous gallstone disease (treated by cholecystectomy).

Ms. Z was born and raised in Mexico in what can best be described as chaotic conditions. Her parents both had substance abuse problems. Her father left the family and her mother suffered from hypertension, diabetes type II, and obesity. She also was diagnosed with schizophrenia and, when Ms. Z was 10 years old, was considered legally incompetent to care for Ms Z or her siblings.  Soon after, Ms. Z moved to the United States to live with her aunt, who became her legal guardian.

Ms. Z reported that her excessive weight gain started at the age of 6. Ms. Z reported poor dietary habits and general lack of physical activity throughout her life. When she arrived in the United States, she indicated that she frequently consumed large portion sizes of calorically dense foods, such as ice cream, candy, cookies and fast food. She would also binge eat and engage in purging behaviors several times per week. Two years prior to presenting for surgery, her aunt had her treated for bulimia in an intensive day treatment program with good result. Subsequently, she was in an inpatient weight management program for approximately two months which produced a 15 lbs weight loss. At this time, she reported typically eating two to three meals, as well as several snacks, each day.  She denied any binge eating or purging in the past few years.

Ms Z is currently finishing her sophomore year of high school. She reported receiving B’s and C’s on her last report card. Since being in the United States, she also has been engaged in mental health treatment, not only for her bulimia, but also for depression, post traumatic stress disorder (related to her childhood abuse and neglect) and generalized anxiety disorder. Her outpatient mental health professional reported that Ms. Z was making good progress in treatment but would likely benefit from additional and ongoing psychotherapy.

Following her initial evaluation by the consultants with the bariatric surgery program, the initial recommendations from the multidisciplinary team were:

(1) to continue mental health treatment and remain psychiatrically stable for a period of 2-3 months

(2) to engage in some additional nutritional counseling with the dietitians from the bariatric surgery program in order to teach Ms. Z more about the postoperative diet

Ms. Z returned for further evaluation 3 months later. She had lost approximately 4 lbs with help from a dietician, and had initiated a fitness program as well as continued in psychotherapy. Her outpatient therapist stated that she believed the patient to be psychiatrically stable and had made good progress in managing her mood and anxiety level. At this time, she was deemed an appropriate candidate for bariatric surgery. 

Ms. Z underwent laparoscopic gastric bypass. At the time of surgery, she weighed 302 lbs and had a BMI = 59 kg/m2. Over the course of the first postoperative year, Ms. Z struggled with the transition back to a regular diet of solid foods. At several of her postoperative visits with the surgeon and program dietitian, she reported stomach pain as well as dizziness, sweating and shaking soon after a meal. She also reported several episodes of diarrhea each week. These episodes were attributed to her continued reliance on high sugar and high fat foods. It took close to a year for the patient to get back to solid foods without these untoward gastrointestinal events.

Approximately 13 months after surgery, Ms. Z was hospitalized for approximately 5 weeks secondary to a return of her eating disorder symptoms. The patient’s aunt reported that Ms. Z was starving herself and sometimes purging in an effort to expedite weight loss. Following the hospitalization period, Ms. Z improved and maintained healthy eating habits, which allowed for slow and steady weight loss. Her sleep apnea improved and no longer required treatment. However she continued to suffer with insomnia. She was scared of nightmares after trauma she suffered while living with her biological parents, and also feared that she might choke or die in her sleep. The patient was referred to cognitive behavior therapy to help her manage her sleeping problems.

As of her last follow-up visit, approximately 18 months after surgery, Ms. Z’s weight was 219 lbs (BMI = 43 kg/m2), representing a weight loss of approximately one-third of her initial body weight. She reported feeling “Great!” and added, “You guys changed my life.” She was making healthy food choices, eating every 3-4 hours, and could tolerate a regular diet without nausea or vomiting. Her blood pressure was normal without anti-hypertensive medication. She continued to be engaged in outpatient psychotherapy and attends a support group for bariatric surgery patients on a regular basis.

Overview: Ms Z illustrates some of the challenges in bariatric surgery for adolescents. From a physical perspective, Ms. Z was clearly an appropriate surgery candidate – not only was her BMI well above 40, but she also suffered from several significant obesity-related co-morbidities. Without surgery, Ms Z’s weight would have likely continued to increase and her health would have deteriorated as she got older. Surgery resulted in resolution of her hypertension and obstructive sleep apnea.

However, the team had a number of concerns about her psychosocial appropriateness for surgery. Ms. Z suffered from various, severe psychiatric conditions (bulimia, PTSD, generalized anxiety disorder) that might interfere with her ability to follow the dietary and behavioral requirements of surgery. As detailed above, despite the overall success of bariatric surgery, approximately 20-30% of patients either fail to reach the typical postoperative weight loss or begin to regain large amounts of weight within the first few postoperative years. Many of these suboptimal results can be attributed to poor adherence to the postoperative diet or a return of maladaptive eating behaviors.

In fact, even with delaying surgery for additional psychological and dietary counseling to prepare Ms. Z for surgery, she struggled with these issues postoperatively, as evidenced by her delayed transition to solid foods and frequent vomiting in the first postoperative year. These issues also likely contributed to the relapse of her eating disorder early in the second postoperative year, which was successfully treated with an inpatient hospitalization.

Since that time, Ms Z’s eating habits and psychosocial status appear to have stabilized. While she can be considered a successful outcome at this point, she will likely continue to need ongoing psychological support to help her deal with her traumatic childhood as she transitions to adulthood. Nevertheless, her case underscores some valuable lessons about the need for a multidisciplinary-team approach to adolescent bariatric surgery—both with respect to the preoperative evaluation process but also with regard to postoperative care.

At present, the National Institute of Health is conducting a nationwide, multi-center investigation of the safety and efficacy of bariatric surgery for adolescents. The results from the studies supported by this research consortium will address a number of very important issues related to the physical, behavioral and psychosocial issues related to bariatric surgery for adolescents and likely will have a great deal of influence on the continued use of bariatric surgery to treat teens who are suffering from extreme obesity.

Summary

This course has provided an overview for the mental health professional of the psychosocial and behavioral aspects of obesity. The scope of the obesity problem in the United States has been detailed and the likely genetic and environmental contributions to the problem have been outlined. The psychosocial consequences of excess body weight were detailed. The range of potential weight loss treatments have been noted, several of which involve a behavioral component and can involve the mental health professional. Much of the course has focused on the role of the mental health professional in the assessment and treatment of the person with extreme obesity who is presenting for bariatric surgery. Mental health professionals are considered valuable members of the multidisciplinary treatment team in bariatric surgery and play a crucial role in the preoperative assessment process. A number of case examples illustrated the structure of these evaluations and the interplay of the mental heath professional with the treatment team. The postoperative and behavioral challenges faced by individuals who undergo bariatric surgery also were detailed. The course concluded with a discussion of bariatric surgery for adolescents.

As obesity remains a significant public health issue in the United States, it provides a challenge and opportunity for almost all medical and mental health professionals. However, like any medical condition, individuals who suffer from obesity often do so with unique behavioral and psychosocial issues. These issues warrant the acquisition of new knowledge by the mental health professional specifically working in the area of obesity and weight loss or treating patients with obesity in a more general practice. At the same time, the scope of obesity provides an opportunity for professional growth as well as an opportunity to help fight back against one of the biggest threats to the health and well being of millions of American adults and children.

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