Distress Tolerance and Psychological Comorbidity in Patients Seeking Bariatric Surgery

INTRODUCTION/PURPOSE

Distress intolerance is characterized by a low threshold for negative emotional experiences and lack of emotion regulation and has been shown to predict various health outcomes. As such, the primary aim of this study was to determine the association between distress tolerance and psychological variables (eating behaviors, mood, substance use, trauma history), completion of bariatric surgery, and post-bariatric surgery weight loss outcomes and follow up with a provider.

MATERIALS AND METHODS

Two hundred forty-eight patients (75 % female, 89 % Caucasian) underwent a multidisciplinary evaluation for bariatric surgery and were assessed for psychiatric disorders via semi-structured clinical interview and psychometric questionnaires.

RESULTS

Low distress tolerance was associated with symptoms of depression (p ≤ 0.001), anxiety (p ≤ 0.001), disordered eating behaviors (p ≤ 0.001), substance abuse (p ≤ 0.001), a history of being the victim of childhood sexual abuse (p ≤ 0.001), and with high BMI (p < .05). Patients endorsing higher levels of distress tolerance were more likely to undergo bariatric surgery (p < .01). Distress tolerance was not related to 2-year post-surgical weight loss outcomes or follow up with a provider.

CONCLUSION

The ability to tolerate negative affect may be a variable that differentiates which patients undergo bariatric surgery rather than early postoperative outcomes.

Change in Use of Sleep Medications After Gastric Bypass Surgery or Intensive Lifestyle Treatment in Adults with Obesity

OBJECTIVE

To examine the change in use of hypnotics and/or sedatives after gastric bypass surgery or intensive lifestyle modification in adults with obesity.

METHODS

Adults with obesity who underwent gastric bypass surgery or initiated intensive lifestyle modification between 2007 and 2012 were identified through the Scandinavian Obesity Surgery Registry and a Swedish commercial weight loss database. The two cohorts were matched on BMI, age, sex, education, history of hypnotics and/or sedatives use, and treatment year (surgery n = 20,626; lifestyle n = 11,973; 77% women, mean age 41 years, mean BMI 41 kg/m² ). The proportion of participants with filled hypnotics and/or sedatives prescriptions was compared yearly for 3 years.

RESULTS

In the matched treatment cohorts, 4% had filled prescriptions for hypnotics and/or sedatives during the year before treatment. At 1 year follow-up, following an average weight loss of 37 kg and 18 kg in the surgery and intensive lifestyle cohorts, respectively, this proportion had increased to 7% in the surgery cohort but remained at 4% in the intensive lifestyle cohort (risk ratio 1.7; 95% CI: 1.4-2.1); at 2 years, the proportion had increased to 11% versus 5% (risk ratio 2.0; 95% CI: 1.7-2.4); and at 3 years, it had increased to 14% versus 6% (risk ratio 2.2; 95% CI: 1.9-2.6).

CONCLUSIONS

Gastric bypass surgery was associated with increased use of hypnotics and/or sedatives compared with intensive lifestyle modification.

Obesity and addiction: can a complication of surgery help us understand the connection?

Obesity is a multifactorial, chronic disease that has proven difficult to treat. An increased understanding of aetiological mechanisms is critical to the development of more effective obesity prevention and treatment strategies. A growing body of empirical evidence has demonstrated parallels between obesity, overeating and substance abuse, including shared behavioural, psychological and neurophysiological factors implicated in the excessive intake of both food and substances of abuse. Several different lines of research have recently emerged that hold the potential to shed light on the connection between obesity, food reward and addiction, with studies examining changes in alcohol use/misuse after weight loss surgery providing a particularly interesting perspective on these interrelationships. However, these lines of investigation have proceeded in relative isolation, and relevant research findings have yet to be integrated in a synthesized, comprehensive manner. To provide an opportunity to achieve such a synthesis, a scientific symposium was convened at the Radcliffe Institute in Cambridge, Massachusetts. Invited participants were researchers working in diverse domains related to the intersection between obesity and addiction. Extensive discussion was generated suggesting novel research directions. In this article, we summarize and synthesize the symposium participants' ongoing research in this area, incorporating additional relevant research holding potential clues regarding the connections between obesity, weight loss surgery and addiction.

Impact of Roux-en-Y gastric bypass surgery on appetite, alcohol intake behaviors, and midbrain ghrelin signaling in the rat

OBJECTIVE

Roux-en-Y gastric bypass (RYGB) surgery reduces appetite and stimulates new onset alcohol misuse; however, the genesis of these behavioral changes is unclear. This study is hypothesized that new onset alcohol intake is a behavioral adaptation that occurs secondary to reduced appetite and correlates with altered central ghrelin signaling.

METHODS

Hedonic high-fat diet (HFD) intake was evaluated prior to the assessment of alcohol intake behaviors in RYGB and control rats. Measurements were also taken of circulating ghrelin and ghrelin receptor (GHSR) regulation of neuronal firing in ventral tegmental area (VTA) dopamine (DA) neurons.

RESULTS

RYGB rats displayed reduced HFD intake relative to controls. Sham and RYGB rats consumed more alcohol and preferred lower concentrations of alcohol, whereas only RYGB rats escalated alcohol intake during acute withdrawal. Remarkably, GHSR activity, independent of peripheral ghrelin release, set the tonic firing of VTA DA neurons, a response selectively diminished in RYGB rats.

CONCLUSIONS

This study indicates that gut manipulations lead to increased alcohol intake, whereas RYGB promotes behaviors that may maintain alcohol misuse. Reductions in hedonic feeding and diminished GHSR control of VTA firing further distinguish gut manipulation from complete bypass and present a potential mechanism linking reduced appetite with alcohol misuse after RYGB surgery.

Overlapping Neural Endophenotypes in Addiction and Obesity

Impulsivity refers to a tendency to act rapidly without full consideration of consequences. The trait is thought to result from the interaction between high arousal responses to potential rewards and poor self-control. Studies have suggested that impulsivity confers vulnerability to both addiction and obesity. However, results in this area are unclear, perhaps due to the high phenotypic complexity of addictions and obesity. Focusing on impulsivity, the aim of this review is to tackle the putative overlaps between addiction and obesity in four domains: (1) personality research, (2) neurocognitive tasks, (3) brain imaging, and (4) clinical evidence. We suggest that three impulsivity-related domains are particularly relevant for our understanding of similarities between addiction and obesity: lower self-control (high Disinhibition/low Conscientiousness), reward sensitivity (high Extraversion/Positive Emotionality), and negative affect (high Neuroticism/Negative Emotionality). Neurocognitive studies have shown that obesity and addiction are both associated with increased impulsive decision-making and attention bias in response to drug or food cues, respectively. Mirroring this, obesity and different forms of addiction seem to exhibit similar alterations in functional MRI brain activity in response to reward processing and during self-control tasks. Overall, our review provides an integrative approach to understand those facets of obesity that present similarities to addictive behaviors. In addition, we suggest that therapeutic interventions targeting inhibitory control may represent a promising approach for the prevention and/or treatment of obesity.

Risk of psychiatric disorders, self-harm behaviour and service use associated with bariatric surgery

OBJECTIVE

To investigate psychiatric outcomes after bariatric surgery, including suicide, self-harm, psychiatric service use and substance misuse.

METHOD

Retrospective study on a Danish nationwide register-based cohort of 22 451 patients followed for 1 029 736 person-years. Data were analysed utilizing single- and multi-event Cox regression with non-operated controls with obesity and mirror-image analyses with the operated patient serving as their own controls.

RESULTS

We showed an increased ratio of self-harm (hazard ratio [HR] 3.23, P < 0.001; incidence rate ratio [IRR] 1.71, P < 0.001), psychiatric service use (admissions IRR 1.52, P < 0.001; emergency room visits IRR 1.70, P < 0.001), psychiatric diagnosis (organic psychiatric disorders HR 1.78, P < 0.001; substance use HR 2.06, P < 0.001; mood disorders HR 2.66, P < 0.001; neurotic, stress-related and somatoform disorders HR 2.48, P < 0.001; behavioural syndromes HR 3.15, P < 0.001; disorders of personality HR 2.68, P < 0.001; behavioural and emotional disorders HR 6.43, P < 0.001), as well as substance misuse utilizing Cox regression as well as mirror-image analyses, as compared to non-operated. We did not find an increased suicide rate (HR 1.35, P = 0.658) among operated as compared to non-operated.

CONCLUSION

Our study shows that undergoing bariatric surgery is associated with increases in self-harm, psychiatric service use and occurrence of mental disorders.

Sexual life after weight loss surgery

BACKGROUND

Previous research revealed a relationship between higher body mass index (BMI) and lower sexual functioning. However, the role of psychosocial variables, such as body image, in this relationship has been understudied.

OBJECTIVE

To assess sexual life before and after weight loss surgery (WLS) and examine the role of body image and BMI in these changes.

SETTING

WLS center at a major urban community hospital.

METHODS

327 participants (275 women and 52 men) who underwent either laparoscopic Roux-en-Y gastric bypass surgery (n = 225) or laparoscopic adjustable gastric band (n = 102) were assessed on measures of sexual life preoperatively and at 1, 3, 6, 12, and 24 months after surgery. The number of completers were n = 126 at 1-month follow-up, n = 84 at 3 months, n = 86 at 6 months, n = 84 at 12 months, and n = 55 at 24 months.

RESULTS

There was a significant increase in quality of sexual life over time, F(5,479.5) = 24.3, P<.001. Greater body image dissatisfaction predicted lower quality of sexual life when controlling for BMI, F(1,580.3) = 36.9, P<.001, but BMI did not predict quality of sexual life when controlling for body dissatisfaction, F(1,566.6)<.01, P = .94. A mediation analysis revealed that the relationship BMI had with sexual life was through its influence on body dissatisfaction.

CONCLUSION

Participants experienced improvements in quality of sexual life over time after WLS, and decrease in body image dissatisfaction was the strongest predictor of these improvements. These results underscore the importance of body image, independent of weight loss, in postsurgical sexual life.

Preoperative Evaluation of the Patient with Substance Use Disorder and Perioperative Considerations

The patient with a current or former history of substance use disorder can be challenging to adequately care for in the perioperative period. A thorough preoperative evaluation is essential. In addition to drug abuse screening, the evaluation should include an assessment of the effects of the substance abuse, associated diseases, end-organ damage, and an awareness of the potential perioperative risks so appropriate plans are developed to minimize the risks. Intraoperatively, anesthetic management needs to be appropriately modified. Signs and symptoms of withdrawal should be monitored for postoperatively. Pain management is particularly challenging. After discharge, this patient population is vulnerable and requires close follow-up and early referral to appropriate specialists when needed.

[Metabolic surgery or conservative measures as therapy of obese type 2 diabetics?]

After bariatric surgery there are some favourable effects on comorbidities of obesity as glucose and lipid metabolism besides weight loss. Therefore surgical measures targeting at improvement of such metabolic disorders especially diabetes type 2 has been called "metabolic surgery". The complexity of its underlying metabolic mechanisms is not yet clear, but restriction of energy and weight loss (maintenance) seem to be the cornerstones.Risks of these procedures which are drawn of the established methods of bariatric surgery are reported to be relatively low in qualified centers. Being an elective operation special focus has to be set on mortality and morbidity, numbers of therapeutic failure and redo-surgery. Multiple irreversible and not seldom severe, potentially life-threatening consequences of bariatric surgery require consequent interdisciplinary postsurgery care and therapy throughout the whole life, especially substitution therapy of deficiencies due to post-operative malassimilation, if necessary. Little is known about long term consequences of modified anatomy and function of digestive system caused by surgery, and there may be a delay of (many) years until manifestation of clinical problems.Obese diabetics (BMI ≥ 35 kg/m²) should primarily be treated conservatively in an "individualized" way. Metabolic surgery should not be considered earlier than failure of the conservative approach has to be stated (in this case as an "ultima ratio" in well defined trials). A broader use of metabolic surgery beyond this narrow frame is not yet supported by long-term evidence-based data showing its value and safety.

THE ALCOHOL CONSUMPTION IS AMENDED AFTER BARIATRIC SURGERY? AN INTEGRATIVE REVIEW

Background

Bariatric surgery has been an alternative when conservative methods of weight loss fail. Patients undergoing bariatric surgery have an increased risk of up to 6.5% of problems related to alcohol

Objective:

Integrative review out to analyze the change of alcohol consumption in this public

Method:

Database was accessed from June of 2015 to January of 2016 by searching "bariatric surgery" AND "alcoholism", and their Portuguese equivalents. ScienceDirect, PubMed, Lilacs and Medline, besides manual search, were searched. To be included, the paper should have been published between 2005-2016 and related to bariatric surgery and alcoholism. Theses, dissertations, unpublished papers, case reports and theoretical studies were excluded, and a database was subsequently composed

Results:

In 2005 there was only a review of change in alcohol metabolism in patients undergoing bariatric surgery. There were no publications in 2006. In 2007, only one study was published, and it did not meet the inclusion criteria. In 2010, there was an increase of 13% in publications and of 20% in 2012, reaching 40% in 2013

Conclusion:

The prevalence and incidence of alcohol consumption in relation to the postoperative time was six months to three years with higher incidence for follow-up treatment by men. Roux-en-Y gastric bypass showed greater association with increased consumption of alcohol during the postoperative period. Alcohol consumption proved to be essential to be faced in bariatric surgery.

Evaluation of eating habits and lifestyle in patients with obesity before and after bariatric surgery: a single Italian center experience

BACKGROUND

The study evaluated and compared the eating habits and lifestyle of patients with moderate to severe obesity who have undergone Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG).

METHODS

Food frequency (FF), food habits (FH), physical activity and life style (PA) as well as smoking habits (SH) were analyzed in 50 RYGB (25 M; aged: 24-64) and 50 SG patients (25 M; aged: 22-63) by means of a validated questionnaire, before (T0) and 6 months (T1) post bariatric surgery. A score for each section (FF, FH, PA, SH) was calculated.

RESULTS

ANOVA analysis (age/sex adjusted): FF and FH scores improved at T1 (RYGB and SG: p < 0.001); PA score improved but not significantly; SH score did not change at T1 neither in RYGB nor in SG. Mixed models: FF and PA scores did not correlate with age, gender, weight, BMI, neither in RYGB nor in SG; FH score was negatively correlated both with weight (RYGB: p = 0.002) and BMI (SG: p = 0.003); SH score was positively correlated with age, in SG (p = 0.002); the correlation was stronger in females than in males (p = 0.004).

CONCLUSIONS

Although dietary habits improved, patients did not change their physical activity level or their smoking habits. Patients should receive adequate lifestyle counseling to ensure the maximal benefit from bariatric surgery.

Alcohol and substance abuse, depression and suicide attempts after Roux-en-Y gastric bypass surgery

BACKGROUND

Small studies suggest that subjects who have undergone bariatric surgery are at increased risk of suicide, alcohol and substance use disorders. This population-based cohort study aimed to assess the incidence of treatment for alcohol and substance use disorders, depression and attempted suicide after primary Roux-en-Y gastric bypass (RYGB).

METHODS

All patients who underwent primary RYGB in Sweden between 2001 and 2010 were included. Incidence of hospital admission for alcohol and substance use disorders, depression and suicide attempt was measured, along with the number of drugs prescribed. This cohort was compared with a large age-matched, non-obese reference cohort based on the Swedish population. Inpatient care and prescribed drugs registers were used.

RESULTS

Before RYGB surgery, women, but not men, were at higher risk of being diagnosed with alcohol and substance use disorder compared with the reference cohort. After surgery, this was the case for both sexes. The risk of being diagnosed and treated for depression remained raised after surgery. Suicide attempts were significantly increased after RYGB. The adjusted hazard ratio for attempted suicide in the RYGB cohort after surgery compared with the general non-obese population was 2·85 (95 per cent c.i. 2·40 to 3·39).

CONCLUSION

Patients who have undergone RYGB are at an increased risk of being diagnosed with alcohol and substance use, with an increased rate of attempted suicide compared with a non-obese general population cohort.

Guidelines for the follow-up of patients undergoing bariatric surgery

Bariatric surgery can facilitate weight loss and improvement in medical comorbidities. It has a profound impact on nutrition, and patients need access to follow-up and aftercare. NICE CG189 Obesity emphasized the importance of a minimum of 2 years follow-up in the bariatric surgical service and recommended that following discharge from the surgical service, there should be annual monitoring as part of a shared care model of chronic disease management. NHS England Obesity Clinical Reference Group commissioned a multi-professional subgroup, which included patient representatives, to develop bariatric surgery follow-up guidelines. Terms of reference and scope were agreed upon. The group members took responsibility for different sections of the guidelines depending on their areas of expertise and experience. The quality of the evidence was rated and strength graded. Four different shared care models were proposed, taking into account the variation in access to bariatric surgical services and specialist teams across the country. The common features include annual review, ability for a GP to refer back to specialist centre, submission of follow-up data to the national data base to NBSR. Clinical commissioning groups need to ensure that a shared care model is implemented as patient safety and long-term follow-up are important.

Substance use after bariatric surgery: A review

BACKGROUND

Prevalence of obesity has increased dramatically. Obese individuals may undergo bariatric surgery to lose excessive body fat and mitigate obesity-related comorbidities. However, bariatric patients are particularly vulnerable to substance use problems. We conducted a review to examine the prevalence change and factors associated with substance use and determine the association between substance use and health status after weight loss among bariatric patients.

METHODS

We searched peer-reviewed articles published between January 1990 and January 2015 in several databases (PubMed, PsycINFO, Cochrane Library, Google Scholar) using different keywords combinations. Studies that focused on pre-surgery substance use only or without reported effect measurements were excluded.

RESULTS

Overall, 40 studies were included in the review. Preoperative history of substance use was a reliable correlate of postoperative substance use. The prevalence of postoperative alcohol use was higher among patients with preoperative history of alcohol use than those without. Postoperative prevalence of alcohol use ranged from 7.6% to 11.8%. No significant prevalence change in cigarette smoking from pre-to postoperative period was observed. Time effect was not observed on smoking or drug use prevalence, while an increase in alcohol consumption was inconsistent across studies. The proportion of new-onset substance users among bariatric patients after surgery ranged from 34.3% to 89.5%.

CONCLUSION

Substance use is associated with poor health among bariatric patients. Preoperative assessment and postoperative follow-up should include interventions to reduce relapse among users and prevent substance use initiation.

[The psychiatric, psychological and addiction evaluation in bariatric surgery candidates: What should we assess, why and how?]

Bariatric surgery is indicated in obese patients with a BMI ≥ 40 kg/m(2) or ≥ 35 kg/m(2) with serious comorbidities, in second intention in patients who failed to achieve significant weight loss after a well-managed medical, nutritional and psychotherapeutic treatment for 6 to 12 months, and in patients who are aware of the consequences of bariatric surgery and who agree with a long term medical and surgical follow-up. Such a treatment requires a preoperative multidisciplinary assessment and management, which includes a mandatory consultation with a psychiatrist or a psychologist that should be member of the multidisciplinary staff and participate in these staffs. Although one of this consultation's aim is to screen for the few patients who for which surgery is contra-indicated, in most cases, the main aim of this assessment is to screen for and manage psychiatric and psychopathologic disorders that could be temporary contra-indication, because these disorders could lead to poorer postoperative outcome when untreated. By explaining to the patient how these disorders could affect postoperative outcome and which benefits he could retrieve from their management, the patient will increase his motivation for change and he will be more likely to seek professional help for these disorders. In all cases, a systematic examination of the patient's personality and his/her ability to understand the postoperative instructions is essential before surgery because clinicians should check that the patient is able to be adherent to postoperative instructions. In addition to clinical interview, use of self-administered questionnaires before the consultation might help to determine which psychiatric or psychopathologic factors should be more closely screened during the consultation. Psychiatric disorders and addictions are highly prevalent in this population (e.g., mood and anxiety disorders, binge eating disorder, attention deficit hyperactivity disorder, addictions, personality disorders, pathological personality traits and dimensions), and when untreated, they can lead to poorer postoperative outcome (postoperative occurrence of psychiatric disorders, poorer quality of life, and sometimes to poorer weight loss or excessive weight rebound when the disorder is present during the postoperative period). A complementary training in addiction medicine is helpful given the higher risk for addictions in this population. Given that this evaluation is often the first meeting with a psychiatrist, an empathic and motivational approach is helpful to improve the patient's ability to request for a future psychiatric consultation during the follow-up. Some conditions are required for a high quality assessment: the objectives and expectations of the consultation should be systematically explained to the patient prior to the consultation by the physician who enquires for the assessment; it needs time; the psychiatrist should systematically be member of the multidisciplinary staff and should take part in regular multisciplinary staff meetings; patients should be seen alone to assess his/her readiness to change. After the consultation, a contact with the physician who enquires for the assessment should be systematic (e.g., use of a medical letter that sum up the main conclusions of the consultation; participation in regular multisciplinary staff meetings).

Alcohol and Drug Use Among Postoperative Bariatric Patients: A Systematic Review of the Emerging Research and Its Implications

BACKGROUND

Emerging research suggests that some bariatric surgery patients are at a heightened risk for developing substance use problems, especially alcohol use problems.

METHODS

An exhaustive literature review was conducted in January 2015 to investigate all articles published that included data on postoperative alcohol use, alcohol use disorders, and illicit drug use among bariatric surgery patients.

RESULTS

Twenty-three studies reported on alcohol and/or substance use among bariatric patients. Six studies longitudinally assessed alcohol use behaviors; 3 of these studies found an increase in alcohol use following surgery. Six studies were cross-sectional, and 2 studies assessed medical records. Five studies investigated the prevalence of admissions to substance abuse treatment, and 3 studies combined alcohol and drug use data in a single index. Six studies reported on illicit drug use and reported low-postoperative use. The studies' samples were primarily non-Hispanic white females in their upper 40s, and only 11 of the 23 studies utilized validated assessment instruments.

CONCLUSIONS

Studies employing longitudinal designs and large sample sizes indicate that bariatric patients who had the gastric bypass procedure are at an elevated risk for alcohol use problems postoperatively. Research also indicates that bariatric surgery patients might be overrepresented in substance abuse treatment facilities. Risk factors for problematic postoperative alcohol use include regular or problematic alcohol use presurgery, male gender, younger age, tobacco use, and symptoms of attention deficient and hyperactivity disorder. As a whole, however, studies indicate bariatric surgery patients demonstrate a low prevalence of problematic alcohol use, and studies about gastric bypass patients are not entirely conclusive. Prospective, longitudinal studies are needed, utilizing standardized and validated alcohol assessment instruments that follow postoperative bariatric patients well beyond 2 years, and account for types of bariatric procedure. Finally, study samples with greater racial/ethnic diversity and wider age ranges are needed.

Increased intravenous morphine self-administration following Roux-en-Y gastric bypass in dietary obese rats

Roux-en-Y gastric bypass (RYGB) surgery is a commonly performed and very effective method to achieve significant, long-term weight loss. Opioid analgesics are primarily used to manage postoperative pain as fewer alternative medication options are available for bariatric surgery patients than for the general population. Recent clinical studies support a greater risk for substance use following bariatric surgery, including an increased use of opioid medications. The present study is the first to study morphine self-administration in a rat model of RYGB. High fat diet-induced obese (HFD-DIO) rats underwent RYGB (n=14) or sham-surgery with ad libitum HFD (SHAM, n=14) or a restricted amount that resulted in weight matched to the RYGB cohort (SHAM-WM, n=8). An additional normal-diet (ND, n=7), intact (no surgery) group of rats was included. Two months after the surgeries, rats were fitted with jugular catheters and trained on a fixed ratio-2 lick task to obtain morphine intravenously. Both morphine-seeking (number of licks on an empty spout to obtain morphine infusion) and consumption (number of infusion) were significantly greater in RYGB than any control group beginning on day 3 and reached a two-fold increase over a period of two weeks. These findings demonstrate that RYGB increases motivation for taking morphine and that this effect is independent of weight loss. Further research is warranted to reveal the underlying mechanisms and to determine whether increased morphine use represents a risk for opioid addiction following RYGB. Identifying risk factors preoperatively could help with personalized postoperative care to prevent opioid abuse and addiction.

Smoking Habit in Severe Obese after bariatric procedures

BACKGROUND

Bariatric procedures provide an effective means of short term weight loss and sustained weight control for the morbidly obese. The effect of bariatric procedures on smoking habit in obese subjects is not well known. Therefore, we examined the short term effect of bariatric surgery on smoking habit of severe obese patients up to 12 months from the intervention.

PATIENTS AND METHODS

Smoking habit was assessed in a cohort of 78 morbid smoking obese patients followed at our clinic for bariatric procedures. They underwent non surgical intra-gastric balloon (IB) or surgical procedures such as lap-band laparoscopic surgery (LAGB) or sleeve gastrectomy/gastric by-pass (SPG). Subjects were administered a written questionnaire about their smoking habit before and 3, 6 and 12 months after the procedures.

RESULTS

No differences were found among the three groups at 6 and 12 months after the procedures (IB 21 %, LAGB 6 %, SPG 5 %; and IB 14 %, LAGB 3 %, SPG 5 %). Only after 3 months, the rate of quitting of the IB group was higher than LAGB and SPG groups (36 %, 6 % and 5 %, respectively; p = 0.02).

CONCLUSIONS

Bariatric procedures have no effects on smoking habit of moderate-to-heavy smoker severe obese patients. The use of other traditional smoking cessation methods in patients undergone to bariatric procedures should be implemented.

Deterioration of mental health in bariatric surgery after 10 years despite successful weight loss

BACKGROUND/OBJECTIVE

The present study evaluated the mental health and psychological functioning of bariatric patients before surgery, and after 1 year and 10 year follow-ups, and compared them with participants in a dietary program. Such long follow-up is rare, but strongly recommended by the American Association of Bariatric Surgeons.

SUBJECTS/METHODS

Thirty-six bariatric surgery patients and 34 participants of a weight loss program were weighed and assessed at all 3 points in time. Participants were administered the mental health inventory, neuroticism, sense of control and fear of intimacy scales. Along with these mental and psychological measurements, the medical outcome short form (SF-36) was used.

RESULTS

The surgery group achieved successful weight loss outcomes (27% reduction of pre-operative weight) after 10 years and better than baseline health-related quality-of-life scores. However, their general mental health, neuroticism, sense of control and fear of intimacy scores showed significant deterioration in comparison to pre-operative levels after 10 years. The dietary group participants remained psychologically stable among all three points in time.

CONCLUSIONS

This study highlights the importance of identifying a risk group among bariatric patients for which the dietary and psychological follow-up may be of special significance.

Postoperative marijuana use and disordered eating among bariatric surgery patients

BACKGROUND

Current literature is scarce in documenting marijuana use after bariatric weight loss surgery (WLS).

OBJECTIVES

The objective of this study was to explore the association among marijuana use patterns, disordered eating, and food addiction behaviors in patients 2 years after WLS.

SETTING

A university hospital in the United States.

METHODS

Participants (N = 50, mean age 28 y, standard deviation = 5.8) were administered a structured assessment that included the Addiction Severity Index, Yale Food Addiction Scale, Eating Disorder Examination Questionnaire, and Disordered Eating Questionnaire. Marijuana use was defined based on the Addiction Severity Index as current use (within 30 d), recent use (use in last year), and increased use (increased use since surgery). Data were analyzed using Fisher's exact tests and linear regression methods adjusting for age, gender, race/ethnicity, time since surgery, and change in body mass index.

RESULTS

The majority of the sample was female (76%) and underwent Roux-en-Y gastric bypass (62%). Eighteen percent (18%) of the sample reported current marijuana use; 38% reported recent use; and 21.4% reported increased use post-WLS. A loss of controlled food intake was associated with current (P = .02) and increased post-WLS use (P = .01). Increased use and/or regular marijuana use predicted higher scores on eating disorder subscales compared with respective counterparts (P<.05). Current use did not significantly predict higher scores on the Yale Food Addiction Scale.

CONCLUSIONS

Findings indicated marijuana use in post-WLS patients despite recommendations against use. A subgroup of WLS patients may be at risk for disordered eating post-WLS, particularly those who used marijuana before surgery, and should be closely monitored for several years post-WLS.

Roux-en-Y Gastric Bypass Alters Brain Activity in Regions that Underlie Reward and Taste Perception

BACKGROUND

Roux-en-Y gastric bypass (RYGB) surgery is a very effective bariatric procedure to achieve significant and sustained weight loss, yet little is known about the procedure's impact on the brain. This study examined the effects of RYGB on the brain's response to the anticipation of highly palatable versus regular food.

METHODS

High fat diet-induced obese rats underwent RYGB or sham operation and were then tested for conditioned place preference (CPP) for the bacon-paired chamber, relative to the chow-paired chamber. After CPP, animals were placed in either chamber without the food stimulus, and brain-glucose metabolism (BGluM) was measured using positron emission tomography (μPET).

RESULTS

Bacon CPP was only observed in RYGB rats that had stable weight loss following surgery. BGluM assessment revealed that RYGB selectively activated regions of the right and midline cerebellum (Lob 8) involved in subjective processes related to reward or expectation. Also, bacon anticipation led to significant activation in the medial parabrachial nuclei (important in gustatory processing) and dorsomedial tegmental area (key to reward, motivation, cognition and addiction) in RYGB rats; and activation in the retrosplenial cortex (default mode network), and the primary visual cortex in control rats.

CONCLUSIONS

RYGB alters brain activity in areas involved in reward expectation and sensory (taste) processing when anticipating a palatable fatty food. Thus, RYGB may lead to changes in brain activity in regions that process reward and taste-related behaviors. Specific cerebellar regions with altered metabolism following RYGB may help identify novel therapeutic targets for treatment of obesity.

Change in consumption patterns for treatment-seeking patients with alcohol use disorder post-bariatric surgery

OBJECTIVE

The aim of this study is to describe the clinical phenotype of alcohol use disorder (AUD) treatment-seeking patients with Roux-en-Y Gastric Bypass Surgery (RYGB) history; and to compare it to AUD obese non-RYGB controls.

METHODS

Retrospective study of electronic medical records for all patients 30-60years treated at the Mayo Clinic Addiction Treatment Program, between June, 2004 and July, 2012. Comparisons were performed with consumption patterns pre-RYGB and at time of treatment; excluding patients with AUD treatments pre-RYGB.

RESULTS

Forty-one out of 823 patients had a RYGB history (4.9%); 122 controls were selected. Compared to controls, the RYGB group had significantly more females [n=29 (70.7%) vs. n=35 (28.7%) p<0.0001]; and met AUD criteria at a significantly earlier age (19.1±0.4 vs. 25.0±1years old, p=0.002). On average, RYGB patients reported resuming alcohol consumption 1.4±0.2years post-surgery, meeting criteria for AUD at 3.1±0.5years and seeking treatment at 5.4±0.3years postoperatively. Pre-surgical drinks per day were significantly fewer compared to post-surgical consumption [2.5±0.4 vs. 8.1±1.3, p=0.009]. Prior to admission, RYGB patients reported fewer drinking days per week vs. controls (4.7±0.3 vs. 5.5±1.8days, p=0.02). Neither RYGB, gender, age nor BMI was associated with differential drinking patterns.

CONCLUSION

The results of this study suggest that some patients develop progressive AUD several years following RYGB. This observation has important clinical implications, calling for AUD-preventive measures following RYGB. Further large-scale longitudinal studies are needed to clarify the association between RYGB and AUD onset.

Preoperative factors and 3-year weight change in the Longitudinal Assessment of Bariatric Surgery (LABS) consortium

BACKGROUND

Limited data guide the prediction of weight loss success or failure after bariatric surgery according to presurgery factors. There is significant variation in weight change after bariatric surgery and much interest in identifying preoperative factors that may contribute to these differences. This report evaluates the associations of a comprehensive set of baseline factors and 3-year weight change.

SETTING

Ten hospitals in 6 geographically diverse clinical centers in the United States.

METHODS

Adults undergoing a first bariatric surgical procedure as part of clinical care by participating surgeons were recruited between 2006 and 2009. Participants completed research assessments utilizing standardized and detailed data collection on over 100 preoperative and operative parameters for individuals undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB). Weight was measured 3 years after surgery. Percent weight change for RYGB or LAGB from baseline to 3 years was analyzed as both a continuous and dichotomous outcome with cut points at 25% for RYGB and 10% for LAGB. Multivariable linear and logistic regression models were used to identify independent baseline predictors of the continuous and categorical outcomes, respectively.

RESULTS

The median weight loss 3 years after surgery for RYGB (n = 1513) participants was 31.5% (IQR: 24.6%-38.4%; range, 59.2% loss to .9% gain) of baseline weight and 16.0% (IQR: 8.1%-23.1%; range, 56.1% loss to 12.5% gain) for LAGB (n = 509) participants. The median age was 46 years for RYGB and 48 years for LAGB; 80% of RYGB participants and 75% of LAGB participants were female; and the median baseline body mass index (BMI) was 46 kg/m(2) for RYGB and 44 kg/m(2) for LAGB. For RYGB, black participants lost 2.7% less weight compared with whites and participants with diabetes at baseline had 3.7% less weight loss at year 3 than those without diabetes at baseline. There were small but statistically significant differences in weight change for RYGB in those with abnormal kidney function and current or recent smoking. For LAGB participants, those with a large band circumference had 75% greater odds of experiencing less than 10% weight loss after adjusting for BMI and sex.

CONCLUSIONS

Few baseline variables were associated with 3-year weight change and the effects were small. These results indicate that baseline variables have limited predictive value for an individual's chance of a successful weight loss outcome after bariatric surgery.

TRIAL REGISTRATION

NCT00465829, ClinicalTrials.gov.

Interventions to improve long-term weight loss in patients following bariatric surgery: challenges and solutions

Bariatric surgery aims to provide long-term weight loss and improvement in weight-related comorbidities. Unfortunately, some patients do not achieve predicted weight loss targets and many regain a portion of their lost weight within 2-10 years postsurgery. A review of the literature found that behavioral, dietary, psychological, physical, and medical considerations can all play a role in suboptimal long-term weight loss. Recommendations to optimize long-term weight loss include ensuring that the patient understands how the procedure works, preoperative and postoperative education sessions, tailored nutritional supplements, restraint with liquid kilojoules, pureed foods, grazing and eating out of the home, an average of 60 minutes of physical activity per day, and lifelong annual medical, psychological, and dietary assessments.

Is age a better predictor of weight loss one year after gastric bypass than symptoms of disordered eating, depression, adult ADHD and alcohol consumption?

INTRODUCTION

Findings regarding psychological risk factors for low weight loss after bariatric surgery have been inconsistent. The association between gender and weight outcome is unclear while younger age has been consistently shown to be associated with better weight outcome. The aim of this study was to analyze the interactions between gender and age on the one hand and symptoms of disordered eating, depression, adult ADHD and alcohol consumption on the other hand in regard to weight loss after gastric bypass.

METHODS

Bariatric surgery patients were recruited and asked to fill out self-report questionnaires regarding behavioral risk factors before and twelve months after surgery. Data from one hundred and twenty-nine patients were analyzed.

RESULTS

After controlling for age, no psychological variable measured prior to surgery could predict weight loss after twelve months. After surgery, there was an interaction effect between age, gender and specific eating disorder symptoms. Specifically, loss of control over eating was a risk factor for low weight loss among older, but not among younger, female participants. Symptoms of adult ADHD were associated with elevated alcohol consumption after surgery.

DISCUSSION

These results indicate that age and gender may moderate the effects of potential risk factors for inferior weight outcome. This interaction could potentially be one of the reasons behind the mixed findings in this field. Thus, there are important gender differences in the bariatric population that should be considered. The present study is the first to show that symptoms of adult ADHD may not be a risk factor for inferior weight loss but for alcohol risk consumption after gastric bypass.

Roux-en-Y gastric bypass does not affect daily water intake or the drinking response to dipsogenic stimuli in rats

Bariatric surgery is currently the most effective treatment for severe obesity, and Roux-en-Y gastric bypass (RYGB) is the most common approach in the United States and worldwide. Many studies have documented the changes in body weight, food intake, and glycemic control associated with the procedure. Although dehydration is commonly listed as a postoperative complication, little focus has been directed to testing the response to dipsogenic treatments after RYGB. Accordingly, we used a rat model of RYGB to test for procedure-induced changes in daily water intake and in the response to three dipsogenic treatments: central administration of ANG II, peripheral injection of hypertonic saline, and overnight water deprivation. We did not find any systematic differences in daily water intake of sham-operated and RYGB rats, nor did we find any differences in the response to the dipsogenic treatments. The results of these experiments suggest that RYGB does not impair thirst responses and does not enhance any satiating effect of water intake. Furthermore, these data support the current view that feedback from the stomach is unnecessary for the termination of drinking behavior and are consistent with a role of orosensory or postgastric feedback.

Bariatric psychology in the UK National Health Service: input across the patient pathway

BACKGROUND

Providers of bariatric surgery within the National Health Service (NHS) are required to provide psychological assessment and intervention, yet operational definitions regarding the purpose and scope of this input are lacking. This has led to significant variation in the provision of psychology, with some providing an assessment-only service and others providing a more comprehensive package of intervention throughout the patient pathway. The aims of this paper are to document the current psychology provision and service models of National Health Service (NHS) bariatric surgery services in the UK. Psychologists belonging to a bariatric psychology forum completed a survey. This focused on provision of psychological assessment and intervention throughout the bariatric pathway as well as the ratio between psychology resources and number of bariatric procedures per year. We obtained information from 22 NHS services which provide 3691 procedures per year.

RESULTS

There is significant variation in the ratio between psychology resources and number of bariatric procedures undertaken per service. Whilst all services offer pre-surgery psychology assessments, less than one-third routinely assess all potential bariatric surgery candidates. Over 90% of services offer pre-surgery individual interventions and 41% offer pre-surgery groups. None of the services routinely offer post-surgery assessments but 68% offer post-surgery assessment and intervention following referral. None offered post-operative structured psychological group interventions.

CONCLUSION

There are significant disparities and inconsistencies in the provision of psychology resources in relation to surgery volume in the NHS. Most of these resources are directed at pre-surgery assessment and this raises issues regarding the function of these assessments. Rather than focusing on assessing psychological (un)suitability for surgery, an evidence-based approach involves psychologists offering pre-operative interventions to improve readiness for surgery and post-operative interventions to address recurring or emerging difficulties which impact on outcomes.

Alcohol metabolism is not affected by sleeve gastrectomy

INTRODUCTION

It has been published that patients who underwent gastric bypass surgery have impaired alcohol metabolism, predisposing them to higher rates of intoxication and DUI arrests. Yet the impact of laparoscopic sleeve gastrectomy (LSG) on alcohol metabolism and in particular the long-term effects are still unclear. We hypothesized that LSG does not alter alcohol metabolism.

METHODS

A prospective cohort study of patients undergoing LSG was evaluated. Blood alcohol concentration (BAC) was extrapolated using a Breathalyzer(®). Alcohol metabolism was evaluated by determining BAC every 5 min after a single dose of alcohol (5 oz. glass of 14% v/v Malbec wine), until BAC was equal to zero. Subjects were queried about alcohol intoxication symptoms. All parameters were obtained and analyzed preoperatively and at 3 and 12 months postoperatively.

RESULTS

Our study consisted of 10 patients (9 female) with a mean age of 46.6 ± 2.2 years and BMI of 43.5 ± 2.2 kg/m(2). The mean percentage excess weight loss was 39.5 ± 3.3 at 3 months and 55.6 ± 4.4 at 12 months. Peak BAC at 20 min was not different at 3 months (0.068 ± 0.007, p = 0.77) or at 12 months (0.047 ± 0.008, p = 0.19) when compared to the preoperative assessment (0.059 ± 0.014). In addition, the time to BAC equal to zero was not significantly different between baseline and the follow-up values (preoperative: 70 ± 9 min, 3 months: 95 ± 18 min, and 12 months: 57 ± 8 min, (p > 0.05). Symptoms of intoxication were not significantly different in patients before and after surgery.

CONCLUSIONS

Our study suggests that LSG does not alter alcohol metabolism. Patients who undergo LSG do not have higher levels of intoxication following alcohol consumption and are therefore not prone to higher rates of DUI charges than the general public, in contrast to that previously reported following in patients who undergo gastric bypass surgery.

Involvement of nucleus accumbens AMPA receptor trafficking in augmentation of D- amphetamine reward in food-restricted rats

RATIONALE

Chronic food restriction (FR) increases behavioral responsiveness to drugs of abuse and associated environments. Pre- and postsynaptic neuroadaptations have been identified in the mesoaccumbens dopamine pathway of FR subjects but the mechanistic basis of increased drug reward magnitude remains unclear.

OBJECTIVES

Effects of FR on basal and D-amphetamine-induced trafficking of AMPA receptor subunits to the nucleus accumbens (NAc) postsynaptic density (PSD) were examined, and AMPA receptor involvement in augmentation of D-amphetamine reward was tested.

MATERIALS AND METHODS

FR and ad libitum fed (AL) rats were injected with D-amphetamine (2.5 mg/kg, i.p.) or vehicle. Brains were harvested and subcellular fractionation and Western analyses were used to assess AMPA receptor abundance in NAc homogenate and PSD fractions. A follow-up experiment used a curve-shift protocol of intracranial self-stimulation to assess the effect of 1-naphthylacetyl spermine (1-NASPM), a blocker of Ca(2+)-permeable AMPA receptors, on rewarding effects of D-amphetamine microinjected in NAc shell.

RESULTS

FR increased GluA1 in the PSD, and D-amphetamine increased p-Ser845-GluA1, GluA1, GluA2, but not GluA3, with a greater effect in FR than AL rats. D-amphetamine lowered reward thresholds, with greater effects in FR than AL rats, and 1-NASPM selectively reversed the enhancing effect of FR.

CONCLUSIONS

Results suggest that FR leads to increased synaptic incorporation of GluA1 homomers to potentiate rewarding effects of appetitive stimuli and, as a maladaptive byproduct, D-amphetamine. The D-amphetamine-induced increase in synaptic p-Ser845-GluA1, GluA1, and GluA2 may contribute to the rewarding effect of D-amphetamine, but may also be a mechanism of synaptic strengthening and behavior modification.

Smoking and alcohol use in gastric bypass patients

Bariatric surgery may increase the risk of substance use. The purpose of this study was to prospectively assess smoking and alcohol use before and after bariatric surgery, identify characteristics associated with alcohol use and smoking, and examine substance use and weight loss. Participants (N = 155, mean = 50.1 ± 11.3 y and 45.7 ± 7.0 kg/m(2)) were Roux-en-Y gastric bypass (RYGB) patients that completed surveys on substance use preoperatively and postoperatively. Alcohol use decreased significantly from the preoperative (72.3%) to the postoperative (63.2%) period. As preoperative alcohol quantity rose, the odds of consuming any alcohol postoperatively increased six-fold. Higher BMI increased the odds of high alcohol consumption. Older age decreased the odds of alcohol use and smoking. Smoking status did not differ pre- (19.4%) to post- (14.8%) surgery. Alcohol use and smoking were not associated with weight loss. After weight-loss surgery, alcohol use declined but smoking rates did not significantly change. Younger patients were more likely to use alcohol and smoke postoperatively. Patients with a higher BMI or a history of substance use may be more likely to use alcohol postoperatively.

Effectively addressing addiction requires changing the language of addiction

Public knowledge and attitudes about addiction are largely inconsistent with scientific evidence. The gap between the facts and public and professional perceptions is due in part to the language used to describe the disease and those who have it. A key step in modifying public attitudes and improving how health professionals and policymakers address addiction is to better align the language of addiction with the scientific evidence. Unless we clarify the language, those with the disease will continue to experience the stigma associated with it and attempts to deliver comprehensive and effective evidence-based prevention, treatment, and disease management will be profoundly compromised.

Psychiatric aspects of bariatric surgery

While most conventional treatments for individuals with severe obesity have a modest and short lived impact bariatric surgery has been consistently shown to result in long-term marked weight loss and significant improvement in medical comorbidities. Empirical data suggest a high prevalence of mental disorders among bariatric surgery candidates. This article reviews specific areas of psychopathology, problems in using psychopharmacological medications post-surgery, body contouring, and recommendations for pre and post-surgery care. Available research indicates a decrease in psychiatric symptoms post-surgery. However, in some patients the improvement appears to erode over time. Therefore, bariatric surgery patients should be monitored not only before surgery but also following surgery and referred for mental health treatment if problems develop.

Roux-en-Y gastric bypass patients hospitalized for substance use disorders achieve successful weight loss despite poor psychosocial outcomes

An emerging body of literature indicates that Roux-en-Y gastric bypass (RYGB) patients may be at a heightened risk for substance use disorders (SUDs) after surgery. Little is known about how weight loss and psychosocial outcomes of RYGB patients who develop SUD differ from those who do not. The present study compared weight loss and psychosocial outcomes of 26 post-RYGB patients in inpatient SUD treatment with those of 26 RYGB patients who did not evidence problematic substance use in the post-operative period. SUD and control cases were matched on age, sex and time lapse since surgery. No significant differences in % total weight loss or % excess weight loss (EWL) were found between groups. Those in SUD treatment were significantly less likely to meet the surgical failure criteria of <50% EWL but evidenced greater symptoms of depression, higher rates of probable major depressive disorder and poorer quality of life. Our findings indicate that RYGB patients hospitalized for SUDs achieve successful weight loss despite having poor psychosocial outcomes.

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.