Does obesity surgery improve psychosocial functioning? A systematic review

IMPACT ON QUALITY OF LIFE, WEIGHT LOSS AND COMORBIDITIES: a study comparing the biliopancreatic diversion with duodenal switch and the banded Roux-en-Y gastric bypass

Context Few studies have evaluated the results of different types of bariatric surgery using the Medical Outcome Study 36 - Health Survey Short-Form (SF-36) quality of life questionnaire, the Bariatric and Reporting Outcome System (BAROS) and the reviewed Moorehead-Ardelt Quality of Life II Questionnaire (M-A QoLQ II) that is part of BAROS. The Roux-en-Y gastric bypass (RYGB) is the most common morbid obesity surgery worldwide. However, there is evidence indicating that a biliopancreatic diversion with duodenal switch (DS) is more effective than RYGB in weight loss terms. Objectives To evaluate the impact of different types of bariatric surgery on quality of life, comorbidities and weight loss. Methods Two groups of patients who underwent bariatric surgery conventional Banded Roux-en-Y gastric bypass (BRYGB) or DS were evaluated through monitoring at 12 to 36 months after surgery, as well as a control group of obese patients who had not undergone surgery. The tools used for this were SF-36, BAROS and M-A QoLQ II. The DS group consisted of 17 patients and the BRYGB group consisted of 20. The control group comprised 20 independent, morbidly obese individuals. Results The mean age of the patients in the groups was 45.18 in the DS group, 49.75 in the BRYGB group and 44.25 in the control group, with no significant difference. There was no difference in the ratio of men to women in the groups. The patients that had surgery showed a significant improvement in all domains of quality of life vs the control group. Comparing the two groups that underwent surgery, the DS group achieved better quality of life results in terms of “general state of health” and “pain”, according to responses to the SF-36 tool, and in terms of “sexual interest”, according to responses to the M-A QoLQ II tool. There was no significant difference among the three groups regarding the ratio of occurrence of comorbidities. In the groups that had surgery, the resolution of comorbidities was similar. The final classification according to the BAROS Protocol was excellent for the DS group and very good for the BRYGB group, with a statistical difference in favor of the DS group (P = 0.044*). There was no difference in the percentages of excess weight loss between the DS group (82.1%) and the BRYGB group (89.4%) (P = 0.376). Conclusions A comparison of the performance of the groups, which were monitored from 12 to 36 months after surgery, showed that the two types of surgery are effective to improve quality of life, comorbidities and weight loss. The DS surgery produced better results in the quality of life evaluations regarding 2 of 8 domains according to the SF-36, and “sexual interest” according to the M-A QoLQ II. In the groups that had surgery, the patients showed high rates of comorbidity resolution. Weight loss was similar for the two surgical groups.

Obesity and co-morbid psychiatric disorders as contraindications for bariatric surgery?-A case study

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Current or past psychiatric disorders are not uncommon in patients undergoing bariatric surgery.

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Bariatric surgery contributes to weight loss, improvement of physical disorders and well-being but psychiatric disorders may remain.

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Adequate post-operative support is inevitable.

INTRODUCTION

Many patients undergoing bariatric surgery report current or past psychiatric disorders and controversy exists regarding their outcome after bariatric surgery.

PRESENTATION OF CASE

We present a case of an obese patient with a borderline personality disorder, a recurrent depressive disorder, post-traumatic stress symptoms and binge eating episodes who underwent bariatric surgery.

DISCUSSION

Although the psychiatric disorders remained, the procedure contributed to an improvement of the health status and well-being of the patient. Adequate psychological care after the surgical procedure is necessary to enable a long-term stabilization of patients with mental co-morbidities.

CONCLUSION

Patients with psychiatric co-morbidities should not be excluded from the procedure if adequate post-operative support is provided.

Mental and physical health-related quality of life in obese patients before and after bariatric surgery: a meta-analysis

In this meta-analysis, we review studies that compare mental and physical health-related quality of life measured with the Short-Form 36 of obese patients before and after bariatric surgery with a follow-up measure until one year. Twenty-one studies were selected to conduct the meta-analysis about the relationship between quality of life in obesity before (2680 subjects) and after (2251 subjects) bariatric surgery. Results reveal that obese patients scored less in the mental health component of the Short-Form 36 before bariatric surgery than after (d = -9.00). The same pattern could be observed in the case of the physical health component of the Short-Form 36 (d = -22.84). The results show the strong improvement that obese patients experience in both mental and physical components of the Short-Form 36 after receiving bariatric surgery.

"That's who I am: a fat person in a thin body": weight loss, negative self-evaluation, and mitigating strategies following weight loss surgery

OBJECTIVE

To explore negative self-evaluation following weight loss surgery (WLS).

METHODS

In-depth interviews were conducted with 11 women who had WLS. Thematic analysis was conducted through an iterative process, allowing categories and themes to emerge. To ensure rigor, two coders analyzed the data. Data were collected until thematic saturation was achieved.

RESULTS

All participants reported health as the motivation for WLS. Overall sentiment regarding WLS was positive. However, negative self-evaluation was reported and includes the following: (a) body-image distortion; (b) body-image dissatisfaction, including excessive skin; and (c) perceived stigma. Mitigating strategies include the following: (a) utilizing markers of progress to increase assimilation of a new identity as a thinner person, and (b) reflecting on the former self as a time of decreased quality of life.

IMPLICATIONS FOR PRACTICE

Nurse practitioners and other clinicians treat and counsel patients on obesity and obesity-related morbidity, and may need to discuss WLS with patients who are either contemplating it or have already undergone it. The findings from the present study can provide clinicians insight into the possible psychological effects of WLS-associated weight loss. Bringing possible negative self-evaluative effects into open discussion can help optimize patient care and healthcare results.

Understanding disposition after referral for bariatric surgery: when and why patients referred do not undergo surgery

BACKGROUND

Bariatric surgery is an effective long-term solution for weight loss in the severely obese. Prevalence of bariatric surgery has increased over the recent years; however, the attrition rate of those referred who actually undergo surgery is high. The purpose of this study was to examine patients' attrition rates after referral for bariatric surgery at an academic tertiary care institution. When and why patients who were referred for bariatric surgery did not ultimately undergo surgical treatment was examined.

METHODS

Charts of 1,237 patients referred to the Toronto Western Hospital Bariatric Program from program inception to February 2011 were retrospectively reviewed. Patient demographics, appointment dates, no shows and cancellations, and when and why patients did not undergo surgery were summarized.

RESULTS

Patients' mean age was 47. Most patients were female, and the mean body mass index was 47. Half (50.6 %) of the total persons referred left the program prior to being seen by a health-care professional, and only 36.2 % underwent surgical treatment. Only 2.75 % of persons were ineligible for surgery. A total of 60.6 % of persons self-removed from our program. Reasons for self-removal varied, with the most common reason for leaving the program recorded as "unknown."

CONCLUSIONS

Our multidisciplinary program with in-hospital psychosocial resources resulted in very few persons being excluded from receiving surgical treatment. However, less than half of those referred underwent surgery as most persons self-removed from our program for unknown reasons. Further investigation is required to determine which patient, administrative, and system factors play a role in the patients' decision to not undergo bariatric surgical treatment.

Dionne M, E. Cassin S, Wnuk S, Taube-Schiff M, Sockalingam S. Psychopathology in severely obese women from a Canadian bariatric setting

Purpose

– Evidence suggests high rates of psychiatric disorders in bariatric surgery candidates (e.g. Mitchell et al., 2012), although no rigorous studies have examined the prevalence in a Canadian sample. Improved understanding of the prevalence of psychopathology among female patients is an important area of study, as females comprise approximately 80 percent of surgical candidates (Martin et al., 2010; Padwal, 2005). The purpose of this paper is to assess the prevalence of Axis I disorders and associations with quality of life in a Canadian sample of female bariatric surgery candidates.

Design/methodology/approach

– Female patients (n=257) were assessed using a structured psychodiagnostic interview and completed a health-related quality of life questionnaire.

Findings

– Results indicated that 57.2 percent of patients met DSM-IV-TR criteria for a lifetime psychiatric disorder and 18.3 percent met criteria for a current psychiatric disorder. Major depressive disorder was the most common lifetime psychiatric disorder (35.0 percent) and binge eating disorder was the most prevalent current psychiatric disorder (6.6 percent). Patients scored significantly lower than Canadian population norms on all domains of the SF-36 (all p's<0.001). Patients with a current Axis I disorder also reported significantly worse functioning on four mental health domains and one physical health domain (p's<0.01) compared to patients without a current Axis I disorder.

Originality/value

– Results confirm high rates of psychiatric disorders in Canadian female bariatric surgery candidates and provide evidence for associated functional health impairment. Further study is needed to elucidate how pre-operative psychopathology may impact female patients’ post-operative outcomes.

Efficacy and safety of the adjustable gastric band - pooled interim analysis of the APEX and HERO studies at 48 weeks

OBJECTIVE

This 48 week combined analysis reports safety and clinical effectiveness of the LAP-BAND AP * laparoscopic adjustable gastric band (LAGB) in severely obese patients enrolled in the 5 year, prospective, observational, open-label APEX (NCT00501085) and HERO (NCT00953173) studies.

METHODS

The studies enrolled 1620 patients (APEX: N = 514; HERO: N = 1106), 1140 patients in the US (including all APEX patients), and 480 patients in the European Union (EU), Canada or Australia. APEX and HERO are non-randomized, non-comparator, open-label studies with differences in study management practices and follow-up. Notably, laboratory data were not collected during the APEX study.

RESULTS

After 48 weeks, mean (SD) percentage weight loss (%WL) was for APEX: 18.7% (7.9); HERO-US: 17.9% (8.5); HERO-EU: 16.5% (10.3); HERO-Canada: 13.4% (8.9); and HERO-Australia: 12.3% (6.9). After 48 weeks, there were no significant differences in %WL for APEX vs. HERO-US. After 48 weeks in the combined analysis (APEX + HERO): (1) patients without vs. with type 2 diabetes at baseline had greater %WL (18% [8.7] vs. 16% [8.5], p = 0.002); (2) female patients had greater %WL vs. male patients (17.9% [8.5] vs. 15.9% [9.3], p = 0.003); (3) younger patients had greater %WL vs. older patients (<50 years: 17.8% [8.7] vs. ≥50 years: 16.7% [8.6], p = 0.035); (4) baseline BMI did not affect %WL (≤35 to ≤45 kg/m(2): 17.7% [8.4] vs. >45 kg/m(2): 17.1% [9.1], p = 0.272). Device-related serious adverse events and adverse events were reported in 1.9% and 17.7% of patients, respectively. Revision and explantation surgeries were carried out on 3.4% and 2.3% of patients, respectively during the 48 weeks of follow-up.

CONCLUSIONS

This analysis demonstrates the effective weight loss and safety profile of the current LAGB system, with US patients achieving better weight loss than patients from outside the US.

Roux en Y gastric bypass increases ethanol intake in the rat

Roux en Y gastric bypass (RYGB) surgery is currently the most effective therapy employed to treat obesity and its associated complications. In addition to weight loss and resolution of metabolic syndromes, such as diabetes, the RYGB procedure has been reported to increase alcohol consumption in humans. Using an outbred rodent model, we demonstrate that RYGB increases postsurgical ethanol consumption, that this effect cannot be explained solely by postsurgical weight loss and that it is independent of presurgical body weight or dietary composition. Altered ethanol metabolism and postsurgical shifts in release of ghrelin were also unable to account for changes in alcohol intake. Further investigation of the potential physiological factors underlying this behavioral effect identified altered patterns of gene expression in brain regions associated with reward following RYGB surgery. These findings have important clinical implications as they demonstrate that RYGB surgery leads directly to increased alcohol intake in otherwise alcohol nonpreferring rat and induces neurobiological changes in brain circuits that mediate a variety of appetitive behaviors.

The multi-disciplinary approach to adolescent bariatric surgery

The multi-disciplinary team is essential for the success of an adolescent bariatric surgical program. This article will describe the components of the team and their roles. Essential members include a pediatrician or pediatric subspecialist with an interest and expertise in adolescent obesity, a pediatric surgeon with bariatric expertise, or an adult bariatric surgeon with adolescent experience, adolescent/child psychologist, pediatric nutritionist, exercise physiologist or physical therapist, nursing support, and a patient coordinator. Some programs have found a social worker to be helpful as well. The function of the team members is more important than the title. A physical therapist may develop an activity program or a social worker may function as the coordinator. The whole team, led by the pediatric bariatrician, makes decisions concerning the selection of candidates for bariatric surgery. During team rounds, each patient is discussed and treatment decisions are made.

Psychological predictors of mental health and health-related quality of life after bariatric surgery: a review of the recent research

BACKGROUND

Improvement of mental health and health-related quality of life (HRQOL) is an important success criterion for bariatric surgery. In general, mental health and HRQOL improve after surgery, but some patients experience negative psychological reactions postoperatively and the influence of pre-surgical psychological factors on mental wellbeing after surgery is unclear. The aim of the current article therefore is to review recent research investigating psychological predictors of mental health and HRQOL outcome.

METHODS

We searched PubMed, PsycInfo and Web of Science for studies investigating psychological predictors of either mental health or HRQOL after bariatric surgery. Original prospective studies published between 2003 and 2012 with a sample size >30 and a minimum of 1 year follow-up were included.

RESULTS

Only 10 eligible studies were identified. The findings suggest that preoperative psychological factors including psychiatric symptoms, body image and self-esteem may be important for mental health postoperatively. Predictors of postoperative HRQOL seem to include personality, severe psychiatric disorder at baseline and improvement of depressive symptoms. In addition, psychiatric symptoms that persist after surgery and inappropriate eating behaviour postoperatively are likely to contribute to poor health-related quality of life outcome.

CONCLUSION

Certain psychological factors appear to be important for mental health and HRQOL after bariatric surgery. However, the literature is extremely sparse and further research is highly needed.

Identity transformation and a changed lifestyle following dramatic weight loss and body-contouring surgery: An exploratory study

This article reports on two major quality-of-life perception changes for patients who had undergone plastic surgery following dramatic weight loss. The exploratory, qualitative study was undertaken with 20 patients from one teaching hospital. In-depth interviews were conducted, and a thematic analysis of the data was undertaken. The results provide unique glimpses of surgical consumption empowering and facilitating ‘identity transformation’, embracing improved physical function and enhanced self-esteem, confidence and quality of life, and a ‘changed lifestyle’. For a minority, identity transformation was sometimes interrupted by ‘identity lag’, posing the need for additional health-care support throughout the adjustment process. The study provides additional insight into existing quantitative studies, adding to the body of knowledge in this area.

Weighty dynamics: exploring couples' perceptions of post-weight-loss interaction

Although romantic couples can use communication to help one another lose weight and maintain weight loss, the effect of weight loss on partner interaction is less understood. However, an examination of the interpersonal context in which partners manage their weight is important to help partners negotiate their weight, their relationship, and the U.S. obesity epidemic. Guided by systems theory, this study explored partners' perceptions of post-weight-loss interaction in relationships in which one partner lost weight and the other did not. Through qualitative questionnaires of 42 adults (21 romantic couples), the dyadic investigation revealed that while losing weight resulted in positive interaction for many partners (e.g., engaging in a shared healthy lifestyle), shedding weight also yielded some negative consequences (e.g., non-weight-loss partner criticism). The extent to which partners embraced new weight management rules and patterns largely influenced post-weight-loss communication and behavior.

Safety and effectiveness of LAP-BAND AP System: results of Helping Evaluate Reduction in Obesity (HERO) prospective registry study at 1 year

BACKGROUND

Laparoscopic adjustable gastric banding has several distinctive features, including band adjustability, easy reversibility, and lack of malabsorption, which contribute to its widespread use. The LAP-BAND AP System (LBAP; Allergan, Inc.), a redesigned and improved version of the original device, was approved by the US Food and Drug Administration in 2006. Because of limited information on LBAP, this study prospectively assesses the efficacy and safety of LBAP in real-world settings at clinical centers located in North America, Europe, and Australia.

STUDY DESIGN

This interim report of the ongoing 5-year prospective, observational, international, multicenter registry, Helping Evaluate Reduction in Obesity (HERO) Study (NCT00953173), describes clinical efficacy and safety of LBAP in real-world settings at 1 year.

RESULTS

One thousand one hundred and six patients were implanted with LBAP and 1-year data were available from 834 patients for efficacy analysis. At 1 year, the mean (SD) percentage of excess weight loss was 39.8% (22.3%), of weight loss was 16.9% (9.0%), and the mean (SD) body mass index decreased to 37.7 (7.0) kg/m(2) from 45.1 (6.9) kg/m(2) at baseline. Patients with type 2 diabetes mellitus or hypertension showed significant improvements at 1 year post LBAP (both p < 0.005). The most common device-related complications were port displacement (n = 20 [1.8%]), pouch dilation (n = 12 [1.1%]), band slippage (n = 7 [0.6%]), and band erosion (n = 5 [0.5%]). Eighteen (1.6%) patients had the device explanted.

CONCLUSIONS

At 1 year post LBAP, progressive weight loss was associated with improvement and/or resolution of comorbid conditions and was safe and well tolerated. Patient follow-up continues.

Totally changed, yet still the same: patients' lived experiences 5 years beyond bariatric surgery

Bariatric surgery provides sustainable weight loss and increased quality of life for most, but not all patients. To increase the knowledge of this complex patient group and their needs during follow-up, we aimed to describe the essential meaning of bariatric surgery patients' long-term experiences by using a phenomenological lifeworld approach. Eight patients were interviewed between 5 and 7 years after bariatric surgery. Life after bariatric surgery was described as living with tension, ambivalence, and reinforced attention toward one's own body. The tension was related to embodied change and altered relations to the social world. The patients express an ongoing demand for control of health-related habits and practices, and to not lose control over the body again. Surgical weight loss and improved physical function do not necessarily mean changed health-related habits and practices in the long term. Experiencing weight regain is connected with emotional stress, shame, and self-contempt.

Two-year changes in generic and obesity-specific quality of life after gastric bypass

The study objectives were to assess 2-year changes in health-related quality of life (HRQL) after gastric bypass in patients with severe obesity and to analyze HRQL improvements in relation to weight loss after bariatric surgery. This was a prospective intervention study with consecutive patients referred to two bariatric surgical units in the Basque Country. We used both generic (Short Form Health Survey, SF-36 and EuroQol, EQ-5D), and specific questionnaires (Moorehead-Ardelt, MA II and Obesity-related Problems Scale, OP). Effect sizes and receiver operating characteristic (ROC) curves were calculated to assess the change in quality of life. Spearman's correlation coefficient was calculated to assess whether there was an association between changes in body mass index (BMI) and HRQL. Of 82 patients who underwent surgery, 79 were followed-up for 2 years. Mean weight loss was 37% of body weight (49 kg) and BMI fell from 50.6 to 31.8. The initial problems and final improvements were greater in the physical dimensions. Considerable benefits were observed in assessments with all the instruments used. However, the changes in weight/BMI and HRQL were not linear. The comparison with general population showed a similar profile in SF-36 dimensions after surgery. Severely obese patients have lower perceived health across all dimensions of quality of life. Moreover, the impact on functioning is so important that severe obesity can be described as a cause of disability that disappears 2 years after surgical treatment. ROC curves indicate that most of the HRQL measures are poor predictors of change in terms of reduction in body weight or BMI.

Medical and psychosocial implications of adolescent extreme obesity - acceptance and effects of structured care, short: Youth with Extreme Obesity Study (YES)

Background

Prevalence rates of overweight and obesity have increased in German children and adolescents in the last three decades. Adolescents with extreme obesity represent a distinct risk group. On the basis of data obtained by the German Child and Youth Survey (KiGGS) and the German district military offices we estimate that the group of extremely obese adolescents (BMI ≥ 35 kg/m²) currently encompasses approximately 200.000 adolescents aged 14 to 21 yrs. Conventional approaches focusing on weight reduction have largely proven futile for them. In addition, only a small percentage of adolescents with extreme obesity seek actively treatment for obesity while contributing disproportionately strong to health care costs. Because of somatic and psychiatric co-morbidities and social problems adolescents with extreme obesity require special attention within the medical care system.

We have initiated the project “Medical and psychosocial implications of adolescents with extreme obesity - acceptance and effects of structured care, short: ‘Youths with Extreme Obesity Study (YES)’”, which aims at improving the medical care and social support structures for youths with extreme obesity in Germany.

Methods/Design

We focus on identification of these subjects (baseline examination) and their acceptance of diagnostic and subsequent treatment procedures. In a randomized controlled trial (RCT) we will investigate the effectiveness of a low key group intervention not focusing on weight loss but aimed at the provision of obesity related information, alleviation of social isolation, school and vocational integration and improvement of self-esteem in comparison to a control group treated in a conventional way with focus on weight loss. Interested individuals who fulfill current recommended criteria for weight loss surgery will be provided with a structured preparation and follow-up programs. All subjects will be monitored within a long-term observational study to elucidate medical and psychosocial outcomes. Our aim is to evaluate realistic treatment options. Therefore inclusion and exclusion criteria are minimized.

We will recruit adolescents (age range 14–21 years) with extreme obesity (BMI ≥ 35 kg/m²) (extreme group) within 24 months (120 per centre, 5 centres) as well as obese adolescents being at risk for developing extreme obesity (BMI ≥ 30 – 34.9 kg/m²) (at risk group). Follow-up evalutations will be performed biannually after inclusion for several years depending on additional funding. In sum, we aim at establishing evaluated health care structures for extremely obese adolescents.

Discussion

The results of YES will be of importance for a frequently neglected group of individuals, for whom current medicine has little to offer in terms of structured access to empirically evaluated therapeutic programs. Thus, the results will be both a help for the adolescents within the study and for others in the future given that the trial will lead to a positive finding. Moreover, it will help practitioners and therapists to deal with this neglected group of individuals.

Trial registration

Project registration numbers for each subproject: 1.) ClinicalTrials.gov: NCT01625325, NCT01703273, NCT01662271, NCT01632098; 2.) Germanctr.de: DRKS00004172, DRKS00004195, DRKS00004198, DRKS00004197.

Risk of completed suicide after bariatric surgery: a systematic review

Bariatric surgery is one of the most effective treatments for morbid obesity, and a large body of research indicates significant long-term weight loss. While overall mortality decreases in patients who received bariatric surgery, a number of studies have shown that suicide rates are higher in bariatric patients than in control groups. The objective of this study was to present a systematic review of suicide mortality after bariatric surgery and calculate an estimate for the suicide rate. Literature researches of the databases PubMed, Web of Knowledge, PsychInfo, ScienceDirect and Google Scholar were conducted. Thirty studies concerning bariatric surgery and completed suicides met the inclusion criteria. We included 28 studies in the estimation of a suicide rate for the bariatric population. Only one study (Tindle et al.) put a main focus on suicide after bariatric surgery; this was therefore chosen as an adequate reference figure for comparison. The other 27 chosen studies were compared with World Health Organization data and the suicide rate reported by Tindle et al. Twenty-three thousand eight hundred eighty-five people were included in the analysis. In the literature, we found a total of 95 suicides when examining 190,000 person-years of post-bariatric surgery data. Little information was provided describing the reasons for suicide and the time-point of these events after surgery. We estimated a suicide rate of 4.1/10,000 person-years (95% confidence interval [3.2, 5.1]/10,000 person-years). A comparison with Tindle et al. demonstrates that their rate is significantly higher than our estimate (P = 0.03). Bariatric surgery patients show higher suicide rates than the general population. Therefore, there is a great need to identify persons at risk and post-operative psychological monitoring is recommended.

Five-year changes in psychiatric treatment status and weight-related comorbidities following bariatric surgery in a veteran population

BACKGROUND

Although bariatric surgery is an established treatment for obesity, less is known regarding the long-term effects of surgery on psychiatric function. This paper reports changes in psychiatric treatment status, weight, and weight-related comorbidities over 5 years of follow-up among a population of veterans completing bariatric surgery.

METHODS

We assessed 55 veterans undergoing bariatric surgery at a single Veteran Affairs medical center for 5 years post-surgery. Patients completed a pre-surgery clinical interview with a licensed psychologist. Using computerized medical records, we tracked pre- to post-surgery involvement with antidepressants, anxiolytics, psychotherapies, and overall psychiatric treatment visits along with changes in weight and metabolic function.

RESULTS

Rates of antidepressant use and/or involvement with psychotherapy for depression declined from 56.4 % at pre-surgery to 34.6 % at 5 years post-surgery, p = 0.01. Anxiolytic use and/or involvement with psychotherapy for anxiety, however, increased from 23.6 to 32.7 % pre- to 5 years post-surgery. Average psychiatric treatment volume remained similar to pre-surgery status across follow-up. These mixed indicators of psychiatric improvement occurred despite marked metabolic improvements from surgery. Mean percent excess weight loss = 51.7 and 41.3 (1 and 5 years post-surgery, respectively), systolic blood pressure (-6.8 mmHg (14.3)/-6.1 mmHg (12.8), respectively), glucose levels (-18.6 mg/dL (30.2)/-10.0 mg/dL (25.9), respectively), triglycerides (-78.2 mg/dL (96.7)/-69.1 mg/dL (102.2), respectively) and high-density lipoproteins (+7.1 (9.9)/+11.3 (11.3), respectively) levels each improved.

CONCLUSIONS

We report evidence of decreased antidepressant use and depression therapies following bariatric surgery, but no improvements on rates of anxiolytic use and anxiety therapies or on overall psychiatric treatment involvement. Despite metabolic improvements, bariatric patients with psychiatric histories may warrant ongoing attention to mental health.

The improvement of quality of life in patients treated with bariatric surgery in Korea

PURPOSE

Bariatric surgery is considered an efficient treatment for severe obesity, but postoperative complications and psychosocial problems may impact quality of life (QoL). Although QoL is an important aspect of bariatric surgery, few studies have evaluated the changes in QoL. We examined whether severely obese patients who had undergone bariatric surgery had better QoL compared with severely obese adults who had not undergone bariatric surgery in Korea.

METHODS

Data were obtained from 78 participants in two groups; bariatric surgery group (n = 53) and nonsurgery group (n = 25). EuroQoL-5D (EQ-5D), the impact of weight on quality of life-lite (IWQoL-lite) and the obesity-related psychosocial problem scale (OP-scale) were used to assess the improvement of QoL.

RESULTS

A total of 78 patients completed the QoL forms as part of their surgical consultation. In the EQ-5D, the changes of EQ-5D 3 level and EQ-5D visual analogue scale in the surgery group was 0.174 and 24.6 versus 0.017 and 17.8 in the nonsurgery group (P = 0.197 and P = 0.179). The changes of IWQoL-lite and OP-scale were significantly improved after bariatric surgery. In the IWQoL-lite, the mean changes in the surgery group was 33.4 versus 14.3 points in the nonsurgery group (P = 0.000). In the OP-scale, the mean changes in the surgery group patients scored 39.3 versus 9.0 points in the nonsurgery group (P = 0.000).

CONCLUSION

We demonstrated significant improvement of QoL observed after bariatric surgery compared to nonsurgical procedure. The results of this comparative study favor bariatric surgery for the treatment of severe obesity.

Health related quality of life after gastric bypass or intensive lifestyle intervention: a controlled clinical study

Background

There is little robust evidence relating to changes in health related quality of life (HRQL) in morbidly obese patients following a multidisciplinary non-surgical weight loss program or laparoscopic Roux-en-Y Gastric Bypass (RYGB). The aim of the present study was to describe and compare changes in five dimensions of HRQL in morbidly obese subjects. In addition, we wanted to assess the clinical relevance of the changes in HRQL between and within these two groups after one year. We hypothesized that RYGB would be associated with larger improvements in HRQL than a part residential intensive lifestyle-intervention program (ILI) with morbidly obese subjects.

Methods

A total of 139 morbidly obese patients chose treatment with RYGB (n=76) or ILI (n=63). The ILI comprised four stays (seven weeks) at a specialized rehabilitation center over one year. The daily schedule was divided between physical activity, psychosocially-oriented interventions, and motivational approaches. No special diet or weight-loss drugs were prescribed. The participants completed three HRQL-questionnaires before treatment and 1 year thereafter. Both linear regression and ANCOVA were used to analyze differences between weight loss and treatment for five dimensions of HRQL (physical, mental, emotional, symptoms and symptom distress) controlling for baseline HRQL, age, age of onset of obesity, BMI, and physical activity. Clinical relevance was assessed by effect size (ES) where ES<.49 was considered small, between .50-.79 as moderate, and ES>.80 as large.

Results

The adjusted between group mean difference (95% CI) was 8.6 (4.6,12.6) points (ES=.83) for the physical dimension, 5.4 (1.5–9.3) points (ES=.50) for the mental dimension, 25.2 (15.0–35.4) points (ES=1.06) for the emotional dimension, 8.7 (1.8–15.4) points (ES=.37) for the measured symptom distress, and 2.5 for (.6,4.5) fewer symptoms (ES=.56), all in favor of RYGB. Within-group changes in HRQOL in the RYGB group were large for all dimensions of HRQL. Within the ILI group, changes in the emotional dimension, symptom reduction and symptom distress were moderate. Linear regression analyses of weight loss on HRQL change showed a standardized beta-coefficient of –.430 (p<.001) on the physical dimension, –.288 (p=.004) on the mental dimension, –.432 (p<.001) on the emotional dimension, .287 (p=.008) on number of symptoms, and .274 (p=.009) on reduction of symptom pressure.

Conclusions

Morbidly obese participants undergoing RYGB and ILI had improved HRQL after 1 year. The weaker response of ILI on HRQL, compared to RYGB, may be explained by the difference in weight loss following the two treatments.

Trial registration

Clinical Trials.gov number NCT00273104

Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes

Obesity is recognized as a global health crisis. Bariatric surgery offers a treatment that can reduce weight, induce remission of obesity-related diseases, and improve the quality of life. In this article, we outline the different options in bariatric surgery and summarize the recommendations for selecting and assessing potential candidates before proceeding to surgery. We present current data on post-surgical outcomes and evaluate the psychosocial and economic effects of bariatric surgery. Finally, we evaluate the complication rates and present recommendations for post-operative care.

Effectiveness of a low-calorie weight loss program in moderately and severely obese patients

AIMS

To compare effectiveness of a 1-year weight loss program in moderately and severely obese patients.

METHODS

The study sample included 311 obese patients participating in a weight loss program, which comprised a 12-week weight reduction phase (low-calorie formula diet) and a 40-week weight maintenance phase. Body weight and glucose and lipid values were determined at the beginning of the program as well as after the weight reduction and the weight maintenance phase. Participants were analyzed according to their BMI class at baseline (30-34.9 kg/m²; 35-39.9 kg/m²; 40-44.9 kg/m²; 45-49.9 kg/m²; ≥50 kg/m²). Furthermore, moderately obese patients (BMI < 40 kg/m²) were compared to severely obese participants (BMI ≥ 40 kg/m²).

RESULTS

Out of 311 participants, 217 individuals completed the program. Their mean baseline BMI was 41.8 ± 0.5 kg/m². Average weight loss was 17.9 ± 0.6%, resulting in a BMI of 34.3 ± 0.4 kg/m² after 1 year (p < 0.001). Overall weight loss was not significantly different in moderately and severely obese participants. Yet, severely obese participants achieved greater weight loss during the weight maintenance phase than moderately obese participants (-3.1 ± 0.7% vs. -1.2 ± 0.6%; p = 0.04). Improvements in lipid profiles and glucose metabolism were found throughout all BMI classes.

CONCLUSION

1-year weight loss intervention improves body weight as well as lipid and glucose metabolism not only in moderately, but also in severely obese individuals.

The impact of bariatric surgery on psychological health

Obesity is associated with a relatively high prevalence of psychopathological conditions, which may have a significant negative impact on the quality of life. Bariatric surgery is an effective intervention in the morbidly obese to achieve marked weight loss and improve physical comorbidities, yet its impact on psychological health has yet to be determined. A review of the literature identified a trend suggesting improvements in psychological health after bariatric surgery. Majority of mental health gain is likely attributed to weight loss and resultant gains in body image, self-esteem, and self-concept; however, other important factors contributing to postoperative mental health include a patient's sense of taking control of his/her life and support from health care staff. Preoperative psychological health also plays an important role. In addition, the literature suggests similar benefit in the obese pediatric population. However, not all patients report psychological benefits after bariatric surgery. Some patients continue to struggle with weight loss, maintenance and regain, and resulting body image dissatisfaction. Severe preoperative psychopathology and patient expectation that life will dramatically change after surgery can also negatively impact psychological health after surgery. The health care team must address these issues in the perioperative period to maximize mental health gains after surgery.

Bariatric surgery: a best practice article

Bariatric surgery can effectively reduce body weight and treat obesity associated metabolic diseases such as diabetes mellitus. There are also benefits for an individual's functional status and psychological health. A multi-disciplinary evaluation should be offered to the individual as the first essential step in considering bariatric surgery as a treatment. This evaluation should include a thorough medical assessment, as well as psychological and dietetic assessments. In this best practice article, we outline the current recommendations for referral for bariatric surgery. We also present the data for pre-operative assessment before bariatric surgery, with particular reference to cardiovascular disease and obstructive sleep apnoea. We describe the literature on outcomes after bariatric surgery, including the results for mortality, weight loss, remission of diabetes and associated endocrine disorders such as hypogonadism. Within this review, we will illustrate the impact of bariatric surgery on self-image, psychological health and perceived health and functional status. Finally, we briefly detail the potential complications of bariatric surgery, and offer advice on post-operative care and surveillance.

Safety and efficacy of the LAP-BAND AP® adjustable gastric band in the treatment of obesity: results at 2 years

BACKGROUND

The objective of this analysis is to report interim, 2-year results for morbidly obese patients who have undergone laparoscopic adjustable gastric banding in the LAP-BAND AP® EXperience (APEX) trial.

METHODS

The APEX trial is an ongoing, multicenter, prospective, open-label, 5-year study of the LAP-BAND AP® System (LBAP) in 517 morbidly obese patients at 50 clinical centers in the United States. Last observation carried forward was used in the analyses of change in body weight and comorbid conditions, and observed data were analyzed for the Obesity and Weight-Loss Quality of Life (OWLQOL) questionnaire. Changes in body weight, percent weight loss, percent excess weight loss, body mass index (BMI), OWLQOL score, remission or improvement in obesity-related comorbid conditions, and adverse events were reported.

RESULTS

At baseline, 81.5% of patients were female, and 85.8% were white. The mean age was 42.5 years, and the mean BMI was 44.0 kg/m(2). More than 85% of patients had ≥ 1 obesity-related comorbidity. At 2 years, the mean BMI change was -8.5 kg/m(2), and the mean percent weight loss was -19.3%. Responses to all questions on the OWLQOL questionnaire had a mean improvement of 54% (range, 26%-67%) at 2 years. Obesity-related comorbid conditions were remitted or improved in the majority of patients at 2 years, including type 2 diabetes mellitus (96%), hypertension (91%), gastroesophageal reflux disease (91%), hyperlipidemia (77%), obstructive sleep apnea (86%), depression (75%), and osteoarthritis (93%). The LBAP and its implantation were well tolerated, with 19.1% and 6.0% of patients reporting device-related adverse events or serious device-related adverse events, respectively.

CONCLUSION

The LBAP safely and effectively facilitated weight loss in morbidly obese patients, with clinically meaningful improvements in quality of life and obesity-related comorbidities. The durability of these results will be further described with additional follow-up through 5 years.

TRIAL REGISTRATION

www.ClinicalTrials.gov identifier NCT00501085.

"I didn't see this coming.": why are postbariatric patients in substance abuse treatment? Patients' perceptions of etiology and future recommendations

BACKGROUND

Recent evidence suggests that bariatric patients may be overrepresented in inpatient substance abuse treatment, but the reasons for this are unclear. Patients' perceptions of this problem may be of heuristic value. Using a qualitative approach, the present study evaluated bariatric patients' impressions of how their postsurgical substance use disorders emerged and their future recommendations for those working with bariatric patients.

METHODS

Semi-structured interviews were conducted with 24 bariatric patients in an inpatient substance abuse treatment program. Seven prominent themes emerged, four referring to etiology of substance use (unresolved psychological problems, addiction transfer/substitution, faster onset or stronger effects from substances, and increased availability of pain medications) and three pertaining to future recommendations (counseling pre- and/or postsurgery, increased knowledge of the associated risks of substance use postsurgery, and greater "honesty"). Blind coders rated the presence or absence of each theme in each interview.

RESULTS

Of the four etiology themes, 75 % of patients acknowledged unresolved psychological problems, 83.33 % identified addiction transfer/substitution, 58.33 % noticed faster onset or stronger effects from substances, and 45.83 % identified increased availability of pain medications. For future recommendations, 41.67 % suggested counseling pre- and/or postsurgery, 70.83 % suggested increased education about the associated risks of substance use postsurgery, and 41.67 % identified a need for greater "honesty."

CONCLUSIONS

Patient perceptions suggest that several common themes may be related to risk for the development of postsurgical substance use disorders.

A review of unmet needs in obesity management

The prevalence of obesity continues to escalate in the USA; however, there is no consensus regarding the optimal therapy for obesity. For the vast majority of severely obese patients, conventional medical therapies (i.e., diet, exercise, behavioral counseling) often fail over the long term. Existing pharmacotherapy adjunctive to behavioral therapy has limited effectiveness and an imperfect safety record. In contrast, bariatric surgery has a high degree of weight loss efficacy, yet only a small fraction of the qualifying obese population undergoes these procedures because of the associated perioperative risks and potential late complications. In addition, the role of bariatric surgery is unclear in certain patient populations, such as patients with lower body mass index (BMI, 30-35 kg/m(2)), the high-risk super-super obese patients (BMI > 60), the morbidly obese adolescent, and obese patients requiring weight reduction in preparation for other procedures, such as orthopedic, transplant, or vascular surgeries. In these circumstances, there is a need for an effective but less invasive treatment to bridge the gap between medical and surgical therapy. This review examines current treatment outcomes, identifies prominent areas of unmet clinical needs, and provides an overview of two minimally invasive "temporary procedures for weight loss" that may eventually address some of the unmet needs in obesity management.

Impact of eating disorders and psychological distress on the quality of life of obese people

OBJECTIVE

Quality of life (QoL) is impaired in obesity, but the roles of eating behavior and psychological distress need to be more documented.

METHODS

One hundred thirty consecutive obese patients seeking medical care filled out questionnaires evaluating QoL, the presence of an eating disorder (ED), levels of anxiety and depression, and perception of body image.

RESULTS

Global QoL was poor in 16.4% and intermediate in 61.8% of the patients. EDs were present in 58% of patients who were more (P = 0.05) overweight; 24.2% of patients had binging. EDs impaired significantly the global and specific dimensions of QoL; binging impaired physical and sexual QoLs (both P < 0.02). Anxiety and depression were found in 73.6% and 50.4% of patients, respectively; depression was more frequent in women (P = 0.007) and in patients with EDs. Anxiety and/or depression impaired global (P < 0.001) and specific dimensions of QoL. Body shape concern was marked in 86.4% of women and associated with poor global (P < 0.001) and specific QoL, and with anxiety and depression.

CONCLUSION

The impairment of QoL in obese patients is increased by the presence of an ED, anxiety, and/or depression and marked body shape concern. These psychological factors should be assessed more carefully and taken into account in global strategies aiming to improve the well-being of obese patients.

High preoperative depression, phobic anxiety, and binge eating scores and low medium-term weight loss in sleeve gastrectomy obese patients: a preliminary cohort study

OBJECTIVE

Although depression, anxiety, and binge eating are prevalent in candidates for bariatric surgery, their impact on weight loss is unknown following sleeve gastrectomy. This study assesses the associations between weight loss and preoperative depression, anxiety, and binge eating scores in patients undergoing sleeve gastrectomy for morbid obesity.

METHOD

This cohort study included 34 patients who underwent sleeve gastrectomy for morbid obesity between May 2006 and February 2010 in a French tertiary referral center. We assessed preoperative depression (using the Beck depression inventory and the SCL-90-R depression subscale), anxiety (using the Hamilton anxiety rating scale and the SCL-90-R anxiety subscales), and binge eating (using the bulimic investigatory test, Edinburgh). The primary outcome was the percentage of excess weight loss at 12 months (PEWL).

RESULTS

The preoperative mean body mass index (BMI) was 55.3 kg/m2 ± 10.2 kg/m2 and 41.7 kg/m2 ± 8.7 kg/m2 at the 12-month follow-up visit. The mean PEWL was 46.8% ± 15.8%. After adjusting for the preoperative BMI, the PEWL was negatively associated with preoperative scores for depression (β= -0.357; P < 0.05), phobic anxiety (β = -0.340; P < 0.05), interpersonal sensitivity (β = -0.328; P < 0.05), and binge eating (β = -0.315; P = 0.05). Other forms of anxiety were not correlated with the PEWL.

CONCLUSIONS

Higher preoperative depression, phobic anxiety, interpersonal sensitivity, and binge eating scores are associated with low postoperative weight loss in patients undergoing sleeve gastrectomy. Future studies should assess the preoperative prevalence of syndromal or subsyndromal atypical depression and its relationship to postoperative weight loss in bariatric surgery candidates.

Short-term psychological outcomes in severely obese adolescents after bariatric surgery

Bariatric surgery is suggested as a treatment option for severely obese adolescents. Because adolescence is characterized by intense psychosocial adjustment and development, it is important to study the effect of this procedure on adolescents' psychological health. This study examined baseline status and short-term changes in anxiety, depression, anger, disruptive behavior, and self-concept in 37 adolescents (mean age 16.6 ± 1.3). Participants completed the Beck Youth Inventories (BYI) at inclusion and (on average) 4 months after undergoing Roux-en-Y gastric bypass (RYGB). Internalizing (anxiety and depression) and externalizing (anger and disruptive behavior) symptoms were higher at baseline than gender-specific norms. One fifth had a very low self-concept. Four months after surgery, the adolescents showed significantly fewer symptoms of anxiety and depression and significantly improved self-concept from baseline. Anger and disruptive behavior showed no significant changes. An analysis of clinically meaningful changes was conducted, and besides the overall positive outcome, 16% (n = 6) of the adolescents had deteriorated on two or more inventories in BYI shortly after surgery. This impaired group did not show any specific features at inclusion. The results indicate the importance of psychological monitoring immediately after bariatric surgery and the need for additional psychosocial support to be available for vulnerable sub-groups of adolescents. Further studies with larger samples are necessary to identify characteristics predictive of short-term adverse psychological outcomes in adolescents after bariatric surgery.

Psychological flexibility and the gains of acceptance-based treatment for post-bariatric surgery: six-month follow-up and a test of the underlying model

Research highlights •  Bariatric surgery is associated with dramatic weight loss. •  Follow-up studies show that many surgery patients continue to struggle with self-stigma, body dissatisfaction and emotional eating. •  To date we are aware of only three published randomized controlled trials evaluating psychological interventions in combination with bariatric surgery. •  Acceptance and Commitment Therapy (ACT) targets psychological flexibility: acceptance to have difficult feelings and thoughts, while at the same time engaging in vital healthy activities. •  The present study shows significant improvements in the ACT group as compared with (TAU) after treatment as usual at a 6-month follow-up and shows that the mechanism of change may be psychological flexibility. •  Results from this study indicate the possibility of optimizing bariatric surgery outcomes by adding interventions targeting psychological flexibility.

SUMMARY

The current article presents and evaluates an Acceptance and Commitment Therapy (ACT) approach for obesity-related psychological struggles post-bariatric surgery. Some patients who have undergone bariatric surgery report loss of control over eating and distress concerning body figure and shape, which can affect other outcomes such as weight loss and quality of life post surgery. A recent randomized trial (n = 39) evaluating a 6-week treatment package of ACT following bariatric surgery found large and significant effects as compared with treatment as usual (TAU) on eating disordered behaviours, body dissatisfaction, psychological flexibility and quality of life. Though effects were found, questions remain regarding maintenance of outcomes and the process changes related to outcomes. The present study examines both the maintenance of behavioural change at a 6-month follow-up for the original study and the processes that may be involved in the outcomes. ACT led to gains in quality of life (es = 0.88) and body dissatisfaction (es = 0.77), as compared with TAU at follow-up. Both groups improved in eating disordered behaviours (ACT; es = 0.86 and TAU; es = 0.55). A series of multiple mediator tests supported the role of enhanced psychological flexibility in the changes seen in body dissatisfaction, eating disordered behaviour and quality of life. This study provides preliminary support for the ACT treatment model in terms of optimizing bariatric surgery outcomes.

Advances in the etiology and management of hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass

INTRODUCTION

Hyperinsulinemic hypoglycemia with severe neuroglycopenia has been identified as a late complication of Roux-en-Y gastric bypass (RYGB) in a small number of patients.

DISCUSSION

The rapid resolution of type 2 diabetes mellitus after RYGB is probably related to increased secretion of the incretin hormones glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1), and patients with post-RYGB hypoglycemia demonstrate prolonged elevations of GIP and GLP-1 compared to non-hypoglycemic post-RYGB patients. Nesidioblastosis has been identified in some patients with post-RYGB hypoglycemia and is likely due to the trophic effects of GIP and GLP-1 on pancreatic islets.

CONCLUSIONS

Treatment of hypoglycemia after RYGB should begin with strict dietary (low carbohydrate) alteration and may require a trial of diazoxide, octreotide, or calcium-channel antagonists, among other drugs. Surgical therapy should include consideration of a restrictive form of bariatric procedure, with or without reconstitution of gastrointestinal continuity. Partial or total pancreatic resection should be avoided.

Determining factors required for a holistic approach to weight management of those with obesity

A prospective 6-month longitudinal survey was carried out to ascertain the extent of relationships between weight beliefs, expectations of weight loss; physical, social, emotional, and well-being; and weight management from the perspective of obese individuals who did not have an identified eating disorder. Physical, social, and emotional factors in weight management show interrelationship and are associated with weight change. Therefore, understanding the relationships between physical, social, and emotional factors of obese individuals would facilitate a holistic, person-centered approach and, it is suggested, have an impact on achieving weight loss and thereby reduce considerable detrimental health effects.

Changes in eating behavior after laparoscopic adjustable gastric banding: a systematic review of the literature

This systematic review evaluates the current evidence base for eating behavior changes after laparoscopic adjustable gastric banding (LAGB). A literature search from 1990 to February 2010 was conducted to identify original studies that assessed eating behavior in adults who have undergone LAGB. Sixteen articles (14 separate studies) met inclusion criteria. Although strength of the evidence base was limited by observational study designs and methodological weaknesses, results suggest that positive changes in eating behavior occur after surgery, including reduced over-eating in response to emotional and situational cues. There is some evidence to suggest that uncontrolled eating behaviors persist in some individuals, and that this may be problematic for weight loss after surgery. Few studies examined the relationship between changes in eating behavior and weight loss; thus, optimal behavioral strategies for promoting positive weight outcomes remain unclear. Further interventional research addressing the inherent limitations of the current-evidence base is required to guide development of evidence-based management guidelines for LAGB in future.

Psychiatric factors and weight loss patterns following gastric bypass surgery in a veteran population

BACKGROUND

Although pre-surgical psychological evaluations are commonly administered to patients considered for weight loss surgeries, the value of these evaluations for predicting weight loss success has been questioned. In this study, we addressed this issue by examining patient's total number of psychiatric indicators rather than individual psychological factors as predictors of weight loss/weight regain.

METHODS

Sixty adult veterans completed gastric bypass surgery or laparoscopic gastric banding after completing a multidisciplinary evaluation for surgical clearance, including a psychological assessment. Patients were subsequently followed for 24 month to examine changes in weight, body mass index, and risk of weight regain.

RESULTS

Nearly three fourths of the sample carried either a single (40.0%) or multiple psychiatric diagnoses (33.4%). Nearly half (47.5%) of the sample ceased losing weight after 1 year, with 29.5% regaining weight after this point. Neither psychiatric nor biomedical factors effectively predicted 1-year weight loss totals; however, we observed a significant linear relationship between the number of psychiatric factors and post-1-year weight changes (r = 0.33, p = 0.01). After adjusting for demographic and biomedical factors, patients with two or more psychiatric diagnoses were found to be significantly more likely to experience weight loss cessation or weight regain after 1-year (OR = 6.4, 95% CI = 1.3-12.4) relative to those with zero or one psychiatric diagnosis.

CONCLUSIONS

Assessing mental health factors in terms of the total number of psychiatric conditions improved the prediction of weight loss surgery outcomes in this veteran sample. An expanded model for understanding how psychological factors may affect weight loss surgery may improve the utility of pre-bariatric psychological assessments.

Changes in quality of life and body image after gastric bypass surgery

BACKGROUND

Improvements in psychosocial status are an important aspect of successful outcomes after bariatric surgery. Relatively few studies have investigated the changes in psychosocial functioning at a number of points in the first few postoperative years. The present study was undertaken to assess the changes in quality of life and body image after gastric bypass surgery. The present study was performed at an academic medical center.

METHODS

A total of 200 men and women were enrolled in the study and completed psychometric measures of quality of life and body image before surgery and again 20, 40, and 92 weeks postoperatively.

RESULTS

The participants reported significant improvements in several domains of health- and weight-related quality of life, as well as changes in body image, after surgery. These changes were correlated with the percentage of weight loss.

CONCLUSION

Those who undergo gastric bypass surgery experienced significant improvements in quality of life and body image within the first few months after surgery. These changes were, with few exceptions, maintained into the second postoperative year.

The Alberta population-based prospective evaluation of the quality of life outcomes and economic impact of bariatric surgery (APPLES) study: background, design and rationale

Background

Extreme obesity affects nearly 8% of Canadians, and is debilitating, costly and ultimately lethal. Bariatric surgery is currently the most effective treatment available; is associated with reductions in morbidity/mortality, improvements in quality of life; and appears cost-effective. However, current demand for surgery in Canada outstrips capacity by at least 1000-fold, causing exponential increases in already protracted, multi-year wait-times. The objectives and hypotheses of this study were as follows: 1. To serially assess the clinical, economic and humanistic outcomes in patients wait-listed for bariatric care over a 2-year period. We hypothesize deterioration in these outcomes over time; 2. To determine the clinical effectiveness and changes in quality of life associated with modern bariatric procedures compared with medically treated and wait-listed controls over 2 years. We hypothesize that surgery will markedly reduce weight, decrease the need for unplanned medical care, and increase quality of life; 3. To conduct a 3-year (1 year retrospective and 2 year prospective) economic assessment of bariatric surgery compared to medical and wait-listed controls from the societal, public payor, and health-care payor perspectives. We hypothesize that lower indirect, out of pocket and productivity costs will offset increased direct health-care costs resulting in lower total costs for bariatric surgery.

Methods/design

Population-based prospective cohort study of 500 consecutive, consenting adults, including 150 surgically treated patients, 200 medically treated patients and 150 wait-listed patients. Subjects will be enrolled from the Edmonton Weight Wise Regional Obesity Program (Edmonton, Alberta, Canada), with prospective bi-annual follow-up for 2 years. Mixed methods data collection, linking primary data to provincial administrative databases will be employed. Major outcomes include generic, obesity-specific and preference-based quality of life assessment, patient satisfaction, patient utilities, anthropometric indices, cardiovascular risk factors, health care utilization and direct and indirect costs.

Discussion

The results will identify the spectrum of potential risks associated with protracted wait times for bariatric care and will quantify the economic, humanistic and clinical impact of surgery from the Canadian perspective. Such information is urgently needed by health-service providers and policy makers to better allocate use of finite resources. Furthermore, our findings should be widely-applicable to other publically-funded jurisdictions providing similar care to the extremely obese.

Trial Registration

Clinicaltrials.gov NCT00850356

Bariatric surgery: a primer for eating disorder professionals

Obesity is a public health epidemic with medical, psychological and economic consequences. It continues to increase globally in prevalence and severity. Despite numerous behaviourally, medically or pharmacologically guided treatments, an effective non-surgical long-term treatment approach has not been identified. Bariatric surgery has surfaced as a viable option for a subset of individuals with medically complicated obesity who have failed non-surgical approaches. Pre-operative evaluation followed by post-operative, longitudinal follow-up by a multidisciplinary team specializing in surgery, medicine, psychiatry/psychology, exercise science and nutrition constitutes recognized and necessary standard of care for these complex patients. More information is needed regarding factors that interfere with successful outcomes and mechanisms of optimal follow-up for bariatric surgery patients to prevent and detect post-operative medical, psychological and social difficulties. We will review these issues with a focus on issues relevant to eating disorders professionals.

Clinical and psychological correlates of health-related quality of life in obese patients

Background

Health-related quality of life (HRQL) is poor in obese subjects and is a relevant outcome in intervention studies. We aimed to determine factors associated with poor HRQL in obese patients seeking weight loss in medical units, outside specific research projects.

Methods

HRQL, together with a number of demographic and clinical parameters, was studied with generic (SF-36, PGWB) and disease-specific (ORWELL-97) questionnaires in an unselected sample of 1,886 (1,494 women; 392 men) obese (BMI > 30 kg/m²) patients aged 20-65 years attending 25 medical units scattered throughout Italy. The clinics provide weight loss treatment using different programs. General psychopathology (SCL-90 questionnaire), the presence of binge eating (Binge Eating scale), previous weight cycling and somatic comorbidity (Charlson's index) were also determined. Scores on SF-36 and PGWB were compared with Italian population norms, and their association with putative determinants of HRQL after adjustment for confounders was assessed through logistic regression analysis.

Results

HRQL scores were significantly lower in women than in men. A greater impairment of quality of life was observed in relation to increasing BMI class, concurrent psychopathology, associated somatic diseases, binge eating, and weight cycling. In multivariate analysis, psychopathology (presence of previously-diagnosed mental disorders and/or elevated scores on SCL-90) was associated with lower HRQL scores on both psychosocial and somatic domains; somatic diseases and higher BMI, after adjustment for confounders, were associated with impairment of physical domains, while binge eating and weight cycling appeared to affect psychosocial domains only.

Conclusions

Psychopathological disturbances are the most relevant factors associated with poor HRQL in obese patients, affecting not only psychosocial, but also physical domains, largely independent of the severity of obesity. Psychological/psychiatric interventions are essential for a comprehensive treatment of obesity, and to improve treatment outcome and to reduce the burden of disease.