Axis I psychopathology in bariatric surgery candidates with and without binge eating disorder: results of structured clinical interviews

Prevalence and Correlates of Self-Reported ADHD Symptoms in Bariatric Patients: Focus on Mood and Anxiety Comorbidity, Disordered Eating, and Temperamental Traits

PURPOSE

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterized by inattention, hyperactivity, and impulsivity. A positive association between ADHD and obesity has been observed, especially in adult samples. In this study, prevalence and correlates of self-reported symptoms indicative of a positive screening for ADHD were examined in patients seeking bariatric treatment.

MATERIAL AND METHODS

The study sample was composed of 260 adult patients with obesity referred for bariatric surgery to the Obesity Center of the Endocrinology Unit in Pisa University Hospital between January 2006 and November 2016 (BMI ≥ 30 kg/m2; mean ± standard deviation = 46.27 ± 7.45 kg/m2). ADHD symptoms were identified using ADHD Symptom Check-List-90-R Screening Scale. Night-eating, binge-eating/purging behaviors, and temperamental and character traits were assessed in a subsample of 95 patients.

RESULTS

Thirty participants had a positive screening for ADHD (11.5%, 95% CI = 7.9-16.1%). Patients with a positive screening showed significantly higher rates of anxiety disorders (40% vs. 16.5%, χ2 = 7.97, p = 0.005) panic disorder (40% vs. 14.3%, χ2 = 10.48, p = 0.001), and a higher severity of psychopathological symptoms and sleep disturbances than those without. In subsample analyses, ADHD symptoms severity was associated with more bulimic behaviors (r = 0.31-0.46), greater harm avoidance (r = 0.45-0.66), less self-directedness (r =  - 0.44-0.63), and cooperativeness (r =  - 0.26-0.42).

CONCLUSION

ADHD symptoms may be common in patients with obesity seeking bariatric treatment and are positively associated with disordered eating, internalizing features, and maladaptive character traits.

LEVEL OF EVIDENCE

V, cross sectional descriptive study.

Psychopathology, disordered eating, and impulsivity as predictors of weight loss 24 months after metabolic and bariatric surgery

BACKGROUND

The relationship between theoretically relevant psychosocial and behavioral variables and outcomes of metabolic and bariatric surgery remains unclear. Some studies have found that the presence of psychopathology, disordered eating, and impulsivity, either before surgery or during the early postoperative period, is associated with suboptimal postoperative weight loss. Other studies have not found these relationships.

OBJECTIVE

Examine the relationship between psychopathology, disordered eating, impulsivity, and weight loss 24 months postoperatively.

SETTING

Two large, urban university health systems.

METHODS

Participant characteristics were collected using validated interviews, patient-reported outcome measures, and computerized assessment methods. Linear mixed effect models were used to test the association of the variables of interest on percent weight loss (%WL).

RESULTS

Three hundred participants were enrolled at baseline; weight data at 24 months were available for 227 participants; between 181 and 53 individuals completed other outcome measures. The mean %WL was 23.3 ± 9.9% at 24 months. Patients who underwent Roux-en-Y gastric bypass lost more weight than those who underwent sleeve gastrectomy. The presence of subjective binge episodes at baseline was related to a greater %WL at 24 months; there were no other baseline predictors. The presence of eating disorder diagnoses and disordered eating symptoms after surgery were associated with smaller weight losses over 24 months. Current and lifetime psychopathology and impulsivity were unrelated to %WL at 24 months.

CONCLUSION

Disordered eating after bariatric surgery was associated with a smaller %WL at postoperative year 2. Additional monitoring of these symptoms in the early postoperative period is recommended. Psychotherapeutic and/or dietary interventions may promote more optimal weight loss outcomes.

Depression and Anxiety as Predictors of Metabolic and Bariatric Surgery Completion Among Ethnically Diverse Patients

BACKGROUND

Mental health conditions including depression and anxiety are often prevalent among metabolic and bariatric surgery (MBS) patients, but it is not known if these conditions predict the decision to complete the procedure and if this varies by race and ethnicity. This study aimed to determine if depression and anxiety are associated with MBS completion among a race/ethnically diverse sample of patients.

METHODS

This prospective cohort study included participants who were referred to an obesity program or two MBS practices between August 2019 and October 2022. Participants completed the Mini International Neuropsychiatric Interview (MINI) instrument to determine history of anxiety and/or depression, as well as MBS completion status (Y/N). Multivariable logistic regression models determined the odds of MBS completion by depression and anxiety status adjusting for age, sex, body mass index, and race/ethnicity.

RESULTS

The sample consisted of 413 study participants (87 % women, 40% non-Hispanic White, 39% non-Hispanic Black, and 18% Hispanic). Participants with a history of anxiety were less likely to complete MBS (aOR = 0.52, 95% CI = 0.30-0.90, p = 0.020). Women had increased odds of a history of anxiety (aOR = 5.65, 95% CI = 1.64-19.49, p = 0.006) and of concurrent anxiety and depression (aOR = 3.07, 95% CI = 1.39-6.79, p = 0.005) compared to men.

CONCLUSIONS

Results showed that participants with anxiety were 48% less likely to complete MBS compared to those without anxiety. Additionally, women were more likely to report a history of anxiety with and without depression versus men. These findings can inform pre-MBS programs about risk factors for non-completion.

Psychiatric comorbidity as a prospective predictor of long-term weight and psychosocial outcomes after bariatric surgery

OBJECTIVES

Psychiatric comorbidity is common among the bariatric population although the prognostic significance of psychiatric comorbidity on outcomes is uncertain. This prospective study examined differences in weight and psychosocial functioning outcomes based on lifetime and current (post-surgical) psychiatric comorbidity.

METHODS

Participants were 140 adults in a RCT for loss-of-control (LOC)-eating approximately six months post-bariatric surgery. Two structured interviews were administered: the Eating Disorder Examination-Bariatric Surgery Version (EDE-BSV) to assess LOC-eating and eating-disorder psychopathology, and the Mini International Neuropsychiatric Interview (MINI) to assess lifetime and current (post-surgical) psychiatric disorders. The EDE-BSV and Beck Depression Inventory (BDI-II) were repeated at post-treatment and 24-month follow-ups.

RESULTS

Lifetime (75.7%) and current/post-surgical (25%) psychiatric diagnoses were common. Groups with and without psychiatric comorbidity did not differ significantly in weight loss outcomes at any timepoint but psychiatric comorbidity was associated significantly with greater LOC-eating, eating-disorder psychopathology, and depression.

CONCLUSIONS

Among participants with LOC-eating post-bariatric surgery, lifetime and post-surgical psychiatric comorbidity was not associated with acute or longer-term weight outcomes but predicted poorer psychosocial functioning. Findings challenge prevailing views that psychiatric comorbidity is related to poorer longer-term weight outcomes following bariatric surgery but highlight its clinical significance as it is associated with broad psychosocial difficulties.

Psychological considerations for the holistic management of obesity

Psychological presence in multidisciplinary obesity teams has been highlighted as an important component of such teams. Although mentioned in guidelines and recommendations, there is little information regarding the extent to which this is present currently in weight management services, and in what form. Here, we discuss important ways in which psychological aspects of obesity can impact a person living with obesity and how psychology can be incorporated to provide holistic support in weight management services. Recommendations are also made to create clearer guidelines to provide a more robust reference for the inclusion of psychology in multidisciplinary teams.

Treatment characteristics among patients with binge-eating disorder: an electronic health records analysis

OBJECTIVES

Treatment for adults diagnosed with binge-eating disorder (BED) includes psychotherapy and/or pharmacotherapy and aims to reduce the frequency of binge-eating episodes and disordered eating, improve metabolic-related issues and reduce weight, and address mood symptoms. Data describing real-world treatment patterns are lacking; therefore, this study aims to characterize real-world treatment patterns among patients with BED.

METHODS

This retrospective study identified adult patients with BED using natural language processing of clinical notes from the Optum electronic health record database from 2009 to 2015. Treatment patterns were examined during the 12 months preceding the BED recognition date and during a follow-up period after BED recognition (1-3 years for most patients).

RESULTS

Among 1042 patients, 384 were categorized as the BED cohort and 658, who met less stringent criteria, were categorized as probable BED. In the BED cohort, mean ± SD age was 45.2 ± 13.4 years and 81.8% were women (probable BED, 45.9 ± 12.8 years, 80.2%). A greater percentage of patients in the BED cohort were prescribed pharmacotherapy (70.6% [probable BED, 66.9%]) than received/discussed psychotherapy (53.1% [probable BED, 39.2%]) at baseline. In the BED cohort, 54.4% of patients were prescribed antidepressants (probable BED, 52.4%), 25.3% stimulants (probable BED, 20.1%), and 34.4% nonspecific psychotherapy (probable BED, 24.6%) at baseline, with no substantive differences observed during follow-up. Low percentages of patients in the BED cohort received/discussed cognitive behavioral therapy at baseline (12.5% [probable BED, 9.0%) or during follow-up (13.0% [probable BED, 8.8%). Among patients with ≥1 psychotherapy visit, the mean ± SD number of visits in the BED cohort was 1.2 ± 5.9 at baseline (probable BED, 1.7 ± 7.3) and 2.2 ± 7.7 during follow-up (probable BED, 2.6 ± 7.7).

CONCLUSION

This cohort of patients with BED was treated more frequently with pharmacotherapy than psychotherapy. These data may help inform strategies for reducing differences between real-world treatment patterns and evidence-based recommendations.

Impact of COVID-19 on the Postoperative Bariatric Surgery Patient Experience

OBJECTIVE

To characterize patient and provider perceptions of the impact of coronavirus disease 2019 (COVID-19) on weight loss following bariatric surgery.

BACKGROUND

COVID-19 has disrupted routines and healthcare throughout the United States, but its impact on bariatric surgery patients' postoperative experience is unknown.

METHODS

Semistructured interviews with bariatric surgery patients, primary care providers, and health psychologists were conducted from April to November 2020. As part of a secondary analysis, patients and providers described how the COVID-19 pandemic affected the postoperative experience within 3 domains: dietary habits, physical activity, and follow-up care. Interview guides were created from 2 conceptual models: Torain's Surgical Disparities Model and Andersen's Behavioral Model of Health Services Use. Study team members derived codes, which were grouped into themes using conventional content analysis.

RESULTS

Thirty-four participants were interviewed: 24 patients (12 Roux-en-Y gastric bypass and 12 sleeve gastrectomy), 6 primary care providers, and 4 health psychologists. Patients were predominately female (83%) and White (79%). Providers were predominately female (90%) and White (100%). COVID-19 affected the postoperative bariatric surgery patient experience via 3 mechanisms: (1) it disrupted dietary and physical activity routines due to facility closures and fear of COVID-19 exposure; (2) it required patients to transition their follow-up care to telemedicine delivery; and (3) it increased stress due to financial and psychosocial challenges.

CONCLUSIONS

COVID-19 has exacerbated patient vulnerability. The pandemic is not over, thus bariatric surgery patients need ongoing support to access mental health professionals, develop new physical activity routines, and counteract increased food insecurity.

Clinical aspects of binge eating disorder: A cross-sectional mixed-methods study of binge eating disorder experts' perspectives

Introduction

Research on binge eating disorder continues to evolve and advance our understanding of recurrent binge eating.

Methods

This mixed-methods, cross-sectional survey aimed to collect information from experts in the field about clinical aspects of adult binge eating disorder pathology. Fourteen experts in binge eating disorder research and clinical care were identified based on receipt of relevant federal funding, PubMed-indexed publications, active practice in the field, leadership in relevant societies, and/or clinical and popular press distinction. Anonymously recorded semi-structured interviews were analyzed by ≥2 investigators using reflexive thematic analysis and quantification.

Results

Identified themes included: (1) obesity (100%); (2) intentional/voluntary or unintentional/involuntary food/eating restriction (100%); (3) negative affect, emotional dysregulation, and negative urgency (100%); (4) diagnostic heterogeneity and validity (71%); (5) paradigm shifts in understanding binge eating disorder (29%); and (6) research gaps/future directives (29%).

Discussion

Overall, experts call for a better understanding of the relationship between binge eating disorder and obesity, including a need for clarification around the extent to which the two health issues are separate vs. related/overlapping. Experts also commonly endorse food/eating restriction and emotion dysregulation as important components of binge eating disorder pathology, which aligns with two common models of binge eating disorder conceptualization (e.g., dietary restraint theory and emotion/affect regulation theory). A few experts spontaneously identified several paradigm shifts in our understanding of who can have an eating disorder (beyond the anorexi-centric "thin, White, affluent, cis-gendered neurotypical female" stereotype), and the various factors that can drive binge eating. Experts also identified several areas where classification issues may warrant future research. Overall, these results highlight the continual advancement of the field to better understand adult binge eating disorder as an autonomous eating disorder diagnosis.

Depressive symptoms and multi-joint pain partially mediate the relationship between obesity and opioid use in people with knee osteoarthritis

OBJECTIVES

To assess the relation of obesity to opioid use in people with or at risk of knee osteoarthritis (OA), and the extent to which this association is mediated by number of painful joints or depressive symptoms.

METHODS

We used data from the Multicenter Osteoarthritis Study, a longitudinal cohort of older adults with or at risk of knee OA. Opioid use was identified by prescription medications and self-report. Obesity was defined as BMI ≥ 30 kg/m2. Multi-joint pain was assessed using a standardized body homunculus, and depressive symptoms using the Center for Epidemiological Studies Depression scale. We quantified the direct and indirect effect of obesity on opioid use through the number of painful joints or depressive symptoms using causal mediation analysis by natural-effects models.

RESULTS

We studied 2,335 participants (mean age: 68; mean BMI 31 kg/m2; 60% women). Persons with obesity had ∼50% higher odds of opioid use than those without. Estimates of indirect (mediated) effect by the number of painful joints and depressive symptoms suggested an increased odds of opioid use by 34% (odds ratio [OR] = 1.34, 95% CI: 1.04, 1.70) and 35% (OR 1.35, 95% CI: 1.05, 1.71), respectively, in obese vs non-obese individuals. The total effect of obesity on opioid use was higher in women than in men.

CONCLUSIONS

Multi-joint pain and depressive symptoms partially explained greater opioid use among obese persons with knee OA, demonstrating that the negative impact of obesity on knee OA extends beyond its influence on knee pain and structural progression.

Binge eating disorder and eating self-efficacy in adults seeking bariatric surgery

This study assessed the relationships between binge eating disorder (BED) and eating self-efficacy in a sample of patients prior to bariatric surgery. The study also examined the extent that BED status accounted for variance in self-efficacy after controlling for demographic factors (age, sex and race), physical variables (comorbidities and body mass index [BMI]) and depressive symptoms. This was a cross-sectional study of pre-surgical data from patients seeking bariatric surgery at a university-based healthcare system (N = 98; mean ± SD age of 46.2 ± 12.5 years; BMI of 45.4 ± 7.2 kg/m² ; 86.7% female; and 60.2% of patients self-identified as White). Patients completed the Weight and Lifestyle Inventory (WALI), Beck Depression Inventory-II (BDI-II) and Weight Efficacy Lifestyle Questionnaire. Of the total sample, 15.3% met criteria for BED, 33.7% had subthreshold BED and 51.0% were free of this disorder. In adjusted analyses, total self-efficacy was significantly lower in patients with subthreshold BED (B ± SE = -15.88 ± 7.23, p = .03) and individuals with BED (B ± SE = -35.07 ± 10.23, p = .001) than in those without BED. Patients with BED, compared to those without, had significantly worse scores (in adjusted analyses) on the self-efficacy subscales of negative emotions (p = .003), availability of food (p < .001), social pressure (p = .004) and positive activities (p = .03). In patients seeking bariatric surgery, total self-efficacy scores were significantly lower in patients with BED and subthreshold BED than those without BED. The results suggest that eating self-efficacy may be an important factor to target in patients with BED who seek bariatric surgery.

Comparison of eating disorders and eating behaviors in adults with and without type 2 diabetes prior to bariatric surgery

BACKGROUND

Eating disorders (ED) are group of psychological disorders that significantly impair physical health and psychosocial function. ED consists wide range of morbidity such as loss of eating control, binge eating disorder (BED), night eating syndrome, and bulimia nervosa. Eating behavior is a wide range term that includes food choices, eating patterns, eating problems. In this study, we compared eating disorders and eating behaviors in adults with and without type 2 diabetes prior to bariatric surgery.

METHODS

284 participants with class III obesity were included in the single center study. Each case (patients with type 2 diabetes) and control (patients without type 2 diabetes) groups consists 142 patients. Loss of eating control, BED and Bulimia nervosa, Night eating syndrome and eating behaviors and psychosocial factors were screened with standard questionnaires. SPSS version 20 was used for statistical analysis. A P-value of < 0.05 was considered significant.

RESULTS

There was a significant difference between participants with and without type 2 diabetes in case of BED (76.3% vs. 47.3%, P = 0.001). The logistic regression model has shown that participants without type 2 diabetes had lower odds of exhibiting BED (OR = 0.28, 95% CI 0.142-0.552). Among participants without type 2 diabetes, men had 65% high odds of BED (OR = 1.65, 95% CI 1.13-2.53) in compare with women. Participants with and without type 2 diabetes with high school degree (OR = 5.54, 95% CI 2.46-9.45, P = 0.0001 and OR = 6.52, 95% CI 3.15-10.56, respectively) and moderate depression level (OR = 2.03, 95% CI 0.98-3.95 and OR = 3.12, 95% CI 2.12-4.56, P = 0.0001) had higher odds of BED.

CONCLUSION

These results probably indicate that people with Class III obesity are more cautious about their diet for blood glucose control if they have type 2 diabetes. Future studies are recommended to follow up these patients after surgery to compare weight loss and blood sugar control in patients with and without type 2 diabetes.

Prevalence of mood, panic and eating disorders in obese patients referred to bariatric surgery: patterns of comorbidity and relationship with body mass index

PURPOSE

We aimed at investigating the lifetime prevalence of mood, eating and panic disorders in a large sample of obese patients referred to bariatric surgery. We also explored the patterns of psychiatric comorbidity and their relationship with Body Mass Index (BMI).

METHODS

The sample was composed of patients consecutively referred for pre-surgical evaluation to the Obesity Center of Pisa University Hospital between January 2004 and November 2016. Clinical charts were retrieved and examined to obtain sociodemographic information, anthropometric variables and lifetime psychiatric diagnoses according to DSM-IV criteria.

RESULTS

A total of 871 patients were included in the study; 72% were females, and most patients had BMI ≥ 40 kg/m² (81%). Overall, 55% of the patients were diagnosed with at least one lifetime psychiatric disorder. Binge eating disorder (27.6%), major depressive disorder (16%), bipolar disorder type 2 (15.5%), and panic disorder (16%) were the most common psychiatric diagnoses. Mood disorders showed associations with panic disorder (OR = 2.75, 95% CI = 1.90-3.99, χ² = 41.85, p = 0.000) and eating disorders (OR = 2.17, 95% CI 1.64-2.88, χ² = 55.54, p = 0.000). BMI was lower in patients with major depressive disorder (44.9 ± 7.89) than in subjects without mood disorders (46.75 ± 7.99, p_adj = 0.017).

CONCLUSION

Bariatric patients show high rates of psychiatric disorders, especially binge eating and mood disorders. Longitudinal studies are needed to explore the possible influence of such comorbidities on the long-term outcome after bariatric surgery.

LEVEL OF EVIDENCE

V, cross sectional descriptive study.

Suicidality risk among adults with binge-eating disorder

OBJECTIVE

To estimate relative suicidality risk associated with binge-eating disorder (BED).

METHODS

Retrospective study of patients identified as having BED (N = 1042) and a matched general population cohort (N = 10,420) from the Optum electronic health record database between January 2009 and September 2015. Patients had ≥1 outpatient encounter with a provider who recognized BED during the 12-month baseline preceding entry date. Incidence and relative risk of suicidality were assessed.

RESULTS

Incidence per 1000 person-years (95% CI) of suicidal ideation and suicide attempts, respectively, was 31.1 (23.1, 41.0) and 12.7 (7.9, 19.4) in the BED cohort and 5.8 (4.7, 7.1) and 1.4 (0.9, 2.2) in the comparator cohort. Risk of suicidal ideation and suicide attempts was greater in the BED cohort (HR [95% CIs], 6.43 [4.42, 9.37]) than in the comparator cohort (HR [95% CI], 9.47 [4.99, 17.98]) during follow-up. After adjusting for psychiatric comorbidities, associations of suicidal ideation and suicide attempts with BED remained elevated in patients with BED having histories of suicidality.

CONCLUSIONS

Findings suggest that history of suicidality may result in an increased risk of suicidal ideation and suicide attempts in patients with BED relative to the general population. Psychiatric comorbidity burden may explain the elevated risk of these conditions in BED.

The impact of impulsivity on weight loss after bariatric surgery: a systematic review

BACKGROUND

Impulsivity has been shown to be associated with obesity through links to pathological eating behavior such as binge eating. The recent literature suggests that impulsivity is linked to poorer outcomes post-bariatric surgery. Impulsivity can be measured in various ways and comprises of three broad domains: impulsive choice, impulsive action, and impulsive personality traits. The aim of this systematic review is to synthesize the current evidence on the impact of impulsivity on post-bariatric surgery weight loss.

METHODS

A literature review was performed in February 2020. Original studies investigating the relationship between impulsivity and weight loss post-bariatric surgery were evaluated.

RESULTS

Ten studies with a total of 1246 patients were analyzed. There were four case-control, four prospective observational and two retrospective observational studies. The postoperative follow-up ranged from 0.5 to 12 years. Eight studies measuring trait impulsivity did not show any association with weight loss post-bariatric surgery, although two studies reported an indirect effect of impulsivity on weight loss mediated via pathological eating behavior. Assessment of impulsive action by two studies showed that post-bariatric surgery weight loss is affected by impulsive action.

CONCLUSION

Impulsivity may adversely affect postoperative outcomes after bariatric surgery. However, this may be specific to state impulsivity or impulsive action rather than trait impulsivity. Patients with a higher state impulsivity may benefit from closer follow-up post-bariatric surgery, as well as cognitive behavioral therapies targeting cognitive control over food.

LEVEL OF EVIDENCE

Level I, systematic review.

Psychopathology, disordered eating, and impulsivity in patients seeking bariatric surgery

BACKGROUND

Most patients who undergo bariatric surgery experience significant weight loss and improvements in obesity-related co-morbidities in the first 6-18 months after surgery. However, 20%-30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. Psychosocial functioning may contribute to suboptimal weight loss and/or postoperative psychosocial distress.

OBJECTIVE

Assess psychosocial functioning, eating behavior, and impulsivity in patients seeking bariatric surgery.

SETTING

Two university hospitals.

METHODS

Validated interviews and questionnaires. Impulsivity assessed via computer program.

RESULTS

The present study included a larger (n = 300) and more racially diverse (70% non-White) sample than previous studies of these relationships. Forty-eight percent of participants had a current psychiatric diagnosis and 78% had at least 1 lifetime diagnosis. Anxiety disorders were the most common current diagnosis (25%); major depressive disorder was the most common lifetime diagnosis (44%). Approximately 6% of participants had a current alcohol or substance use disorder; 7% had a positive drug screen before surgery. A current psychiatric diagnosis was associated with greater symptoms of food addiction and night eating. Current diagnosis of alcohol use disorder or a lifetime diagnosis of anxiety disorders was associated with higher delay discounting.

CONCLUSION

The study identified high rates of psychopathology and related symptoms among a large, diverse sample of bariatric surgery candidates. Psychopathology was associated with symptoms of disordered eating and higher rates of delay discounting, suggesting impulse control issues.

DSM 5 Lifetime Psychiatric Diagnoses in Two Bariatric Surgery Programs

Patients presenting for bariatric surgery have been shown to have high rates of psychiatric disorders. These studies have utilized structured interviews using older versions of the DSM. This study examined whether similar lifetime frequencies would be similar using the recent DSM-5. Participants (N = 131) were evaluated as part of a longitudinal study examining post-operative weight loss at two sites. Participants were administered the Structured Clinical Interview for DSM-5 (SCID5) pre-surgically. Lifetime estimates using the SCID5 were compared to the range and mean of 3 prior US studies and 2 international studies using the DSM-IV. Overall, frequency of psychiatric disorders was similar or lower than prior studies. Changes to diagnostic criteria may explain differences although future studies are needed to better characterize this population.

A review of the psychosocial aspects of clinically severe obesity and bariatric surgery

For the past 2 decades, clinically severe obesity (operationalized as a body mass index ≥40 kg/m2) has increased at a more pronounced rate that less severe obesity. As a result, the surgical treatment of obesity (bariatric surgery) has become a more widely accepted, yet still underutilized, treatment for persons with severe obesity and significant weight-related health problems. Psychologists play a central role on the multidisciplinary team involved in the preoperative assessment and postoperative management of patients. They also have played a central role in clinical research which has enhanced understanding of the psychosocial and behavioral factors that contribute to the development of severe obesity as well as how those factors and others contribute to postoperative outcomes. This article, written specifically for psychologists and other mental health professionals who currently work with these patients or are considering the opportunity to do so in the future, reviews these contributions over the past 20 years. The article highlights how this work has become a fundamental part of international clinical care guidelines, which primarily focus on preoperative psychosocial screening. The article also outlines avenues for future research in the field, with a specific focus on the need for additional behavioral and psychosocial interventions to promote lifelong success after bariatric surgery. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Depression and Perceived Stress, but Not Anxiety, are Associated with Elevated Inflammation in an Obese Adult Population

BACKGROUND

Anxiety, depression and perceived stress are risk factors for adverse health problems. Inflammation participates in the development of chronic diseases such as psychiatric disorders. This study explored the relationships between inflammatory biomarkers and depression, anxiety and perceived stress in an obese adult population.

METHODS

The relationships between psychological scores and inflammatory markers were analyzed.

RESULTS

A higher BMI was not correlated with a higher anxiety score (P=0.152); however, BMI was positively associated with a higher depression score (P<0.001) and a higher perceived stress score (P<0.001). Multivariate linear regression analysis revealed that in participants with BMI≥30 and 25≤BMI<30, depression and perceived stress were significantly and independently associated with ICAM-1, E-selectin and CRP, but these associations were not observed in participants with BMI<25. The anxiety score was not associated with any inflammatory marker in any group of subjects, as determined by multivariate analysis.

CONCLUSION

Depression and perceived stress were strongly associated with increased serum levels of pro-inflammatory markers, including ICAM-1, E-selectin and CRP, among a general obese population from the United States. These results further suggest that depression and perceived stress might also be chronic systemic inflammatory diseases.

Endorsement of Binge Eating Symptoms in a Sample of Predominantly Non-Hispanic Black Adolescents

Binge eating disorder (BED) as well as individual subthreshold binge eating symptoms are related to deleterious physical and socioemotional outcomes among adolescents. The present study examined the prevalence of specific binge eating behaviors among a sample of primarily non-Hispanic Black outpatients presenting to weight management and endocrinology clinics. Analyses are based on 103 adolescents (69.9% female, 66.9% non-Hispanic Black) who endorsed one or more binge eating symptoms on a nonstandardized clinical assessment patterned after Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. The most commonly endorsed symptom was eating in excess of what is considered normal (71.8%), while least commonly endorsed symptoms included guilt, distress, and embarrassment due to overeating (17.5% to 26.2%). More than half of the participants endorsed multiple specific binge eating symptoms. The level of subthreshold symptomatology reported underscores the importance of developmental and cultural tailoring of prevention and intervention efforts to address these behaviors as a means of curbing clinical-level onset of BED.

A review of binge eating disorder and obesity

Binge eating disorder (BED) is a mental illness characterised by recurrent binge eating episodes in the absence of appropriate compensatory behaviours. Consequently, BED is strongly associated with obesity. The current review aims to provide an update of the most relevant aspects of BED (e.g., clinical profile, aetiology and treatment approaches), in order not only to facilitate a better understanding of the disorder and its clinical consequences, but also to identify potential targets of prevention and intervention. Patients with BED often present high comorbidity with other medical conditions and psychiatric disorders. Numerous risk factors have been associated with the development and maintenance of the disorder. Moreover, although some treatments for BED have proven to be effective in addressing different key aspects of the disorder, the rates of patients that have ever received specific treatment for BED are very low. The factors involved and how to implement effective treatments will be discussed for the purpose of addressing the eating symptomatology and comorbid obesity.

No association between binge eating disorder and severity of non-alcoholic fatty liver disease in severely obese patients

Background and Aim

The main aim of this study was to evaluate if the binge eating disorders (BEDs) related to obesity were associated with the severity of non‐alcoholic fatty liver disease (NAFLD).

Methods

Severely obese patients who had been referred for bariatric surgery were included in this study at the Nice University Hospital. All patients underwent a liver biopsy at the time of surgery. Between 2008 and 2015, 388 patients had an assessable Bulimia Test (BULIT) self‐questionnaire at the time of surgery. A subgroup (n = 183), between 2011 and 2015, also responded to a Beck Depression Inventory, Hospital Anxiety and Depression Scale, and a Fatigue Impact Scale autoquestionnaire. A control group of 29 healthy people matched by age and gender was included.

Results

Among the 388 obese patients (median age 40 years, body mass index 41.7 kg/m², 81% women), 14 patients had a “probable diagnosis” of BED, and 47 patients had a “high risk” of developing a BED according to the BULIT. Obese patients had significantly more severe BED, depression, anxiety, and fatigue compared to controls. Steatosis, non‐alcoholic steatohepatitis, or fibrosis was not associated with BED. Similarly, the severity of NAFLD was not associated with depression, anxiety, or fatigue.

Conclusions

Severely obese patients had more severe BED, depression, anxiety, and fatigue than lean subjects independent of the severity of NAFLD.

The Real Happy Study: Protocol for a Prospective Assessment of the Real-World Effectiveness of the HAPIFED Program-a Healthy APproach to weIght management and Food in Eating Disorders

The prevalence of obesity with comorbid binge eating behaviour is growing at a faster rate than that seen for either obesity or eating disorders as separate conditions. Approximately 6% of the population are affected and they potentially face a lifetime of poor physical and mental health outcomes and an inability to sustain long-term weight loss. Current treatment options are inadequate in that they typically address either obesity or eating disorders exclusively, not the combination of both conditions. By treating one condition without treating the other, relapse is common, and patients are often left disappointed with their lack of weight loss. An integrated approach to treating these individuals is needed to prevent a worsening of the comorbidities associated with excess body weight and eating disorders. A new therapy has recently been developed, named HAPIFED, which addresses both overweight/obesity and comorbid binge eating behaviour with the combination of behavioural weight loss therapy and cognitive behaviour therapy-enhanced (CBT-E). The aim of this paper is to document the protocol for the Real Happy Study, which will evaluate the effectiveness of the HAPIFED program in treating overweight or obesity with comorbid binge-eating behaviour in a real-world setting.

Binge Eating Disorder and Related Features in Bariatric Surgery Candidates

OBJECTIVE

The present study sought to: 1) assess the prevalence of Binge Eating Disorder (BED) and abnormal eating behaviors in bariatric surgery candidates; 2) compare patients with and without BED as regards to eating disturbances, psychological characteristics, and health status; 3) individuate which factors were significantly related to binge eating severity.

METHODS

Sixty-three preoperative patients (17 males and 46 females) were screened by means of an ad hoc socio-demographic schedule, the Rosenberg Self-Esteem Scale, the Eating Disorders Inventory-3, the Binge Eating Scale, and the General Health Questionnaire-28. BED diagnosis was performed through a clinical interview.

RESULTS

BED and disordered eating, such as episodes of binge eating, sense of lack of control over eating and inappropriate compensatory behaviors, appear common in patients undergoing weight loss surgery. Significant differences between BED and non-BED subjects in relation to eating disturbances and psychological characteristics emerged. Multiple regression analysis revealed that only emotional dys-regulation significantly predicted binge eating vulnerability.

CONCLUSION

The recognition of factors involved in the development and maintenance of disordered eating in bariatric patients may support the choice of particular therapeutic strategies and improve bariatric surgery outcome. Further studies on this issue would be useful.

Problematic Eating Behaviors and Eating Disorders Associated with Bariatric Surgery

Bariatric surgery candidates often report problematic and/or eating disordered behaviors. For most patients, these eating behaviors improve after surgery. A subset, however, experience a recurrence or new onset of problematic eating behaviors as early as 2 months to 18 months after surgery, which can result in compromised weight loss/excessive weight regain. Those most at risk are individuals with comorbid psychopathology (ie, loss-of-control eating or depression) after surgery. For some, such problems are present before surgery. Therefore, it is critical to monitor patients closely after surgery so that appropriate psychiatric treatments can be provided if indicated.

Psychometric properties of NIH PROMIS® instruments in bariatric surgery candidates

OBJECTIVE

Ascertain the psychometric properties of the Patient-Reported Outcomes Measurement Information System® (PROMIS®) Depression (PROMIS-D®) and Anxiety (PROMIS-A®) Short Forms in a sample of presurgical bariatric patients.

METHOD

This retrospective chart review included 259 patients who completed a presurgical psychological evaluation comprising a semistructured interview and self-report measures. Other data used included demographics, psychiatric diagnoses, and initial psychological clearance for surgery (yes/no). Reliability of the PROMIS-D® and PROMIS-A® instruments was assessed using Cronbach's alpha, interitem correlations, and item-total correlations. Convergent, predictive, and concurrent validity were assessed using various methods (correlations, logistic regressions, and generalized linear models) to determine whether PROMIS® instruments were correlated with similar measures, predicted surgical clearance and psychiatric diagnosis, and whether psychiatric diagnosis status was associated with significantly different PROMIS® scores. Categorical confirmatory factor analyses assessed the factor structure, and multiple-indicator multiple cause models assessed invariance.

RESULTS

Patients were predominantly female (78%), white (97%) and middle-aged (M = 43.49, SD = 11.26). Rates of diagnosed anxiety and depression-related disorders were high (17% and 23%). At least 65% of respondents reported "never" or "rarely" experiencing symptoms across both measures, and the mean T scores for the PROMIS-A® and PROMIS-D® were 48.31 (SD = 8.99) and 48.64 (SD = 9.49), respectively. Both measures demonstrated good psychometric properties and were essentially unidimensional.

CONCLUSIONS

Analyses supported using both PROMIS® measures. Additionally, two subgroups were identified: those who reported virtually no symptoms of anxiety or depression, likely because they want surgical approval, and those not receiving initial psychological clearance for surgery based on PROMIS® self-reported scores indicating distress and clinician-diagnosed psychopathology. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Identity statuses in prebariatric patients with obesity: Associations with eating disorder symptoms, psychological complaints, and coping behaviour?

OBJECTIVE

In the present study, we focused on the associations between identity processes/statuses and eating and general psychopathology and coping in prebariatric patients suffering from morbid obesity.

METHOD

Our sample consisted of 369 prebariatric patients (68.8% female) who filled out self-report questionnaires to assess identity processes, eating and general psychopathology, and coping.

RESULTS

Concerning identity processes, ruminative exploration was positively related to eating-related and general psychopathology and maladaptive coping, whereas commitment processes were protective against psychopathology and maladaptive coping. Based on cluster analyses, we identified five identity statuses, being achievement, foreclosure, moratorium, diffusion, and an undifferentiated status, showing some heterogeneity within the prebariatric patient group. Patients in the diffused and moratorium statuses reported more eating and general psychopathology and more maladaptive coping compared with prebariatric patients of the other statuses.

CONCLUSIONS

Given the clinical vulnerability to psychopathology of patients in the moratorium and diffused statuses, it would be advisable to increase the psychological help in their prebariatric and postbariatric trajectories.

Validation of the Arabic version of the binge eating scale and correlates of binge eating disorder among a sample of the Lebanese population

OBJECTIVES

To test the psychometric properties of the Arabic version of the Binge Eating Scale (BES), a self-questionnaire assessing binge eating, in a sample of the Lebanese population. The secondary objective was to evaluate factors associated with binge eating.

METHODS

This cross-sectional study, conducted between January and May 2018, enrolled 811 adult participants from all districts of Lebanon. The BES was administered to study its psychometric properties. The sample was divided into two separate samples (405 for sample 1 and 406 for sample 2). An exploratory factor analysis was executed on Sample 1, followed by a confirmatory factor analysis on Sample 2 using the structure obtained in Sample 1. Three hierarchical stepwise linear regressions were conducted to assess factors associated with binge eating.

RESULTS

The factor analysis suggested a two-factor structure for the BES explaining a total of 41.4% of the variance. All items could be extracted from the list. The internal consistency of the measurement was adequate (Cronbach's alpha = 0.86). The confirmatory factor analysis revealed an adequate fit to the model with satisfactory Maximum Likelihood Chi-Square/Degrees of Freedom (χ²/df), Steiger-Lind RMSEA, Joreskog GFI, and AGFI. Higher BMI, depression, anxiety, emotional eating, greater body dissatisfaction, and more pressure from media to lose weight were associated with higher binge eating. Higher expressive suppression facet score was associated with lower binge eating.

CONCLUSION

The Arabic version of BES could be a useful tool for screening and assessing the binge eating behaviors in clinical practice and research. Also, being dissatisfied with one's body size, having a history of sexual abuse, family history of binge eating, increased depressive/anxiety symptoms, and lower self-esteem seem to be associated with higher BES scores.

Obesity with Comorbid Eating Disorders: Associated Health Risks and Treatment Approaches

Obesity and eating disorders are each associated with severe physical and mental health consequences, and individuals with obesity as well as comorbid eating disorders are at higher risk of these than individuals with either condition alone. Moreover, obesity can contribute to eating disorder behaviors and vice-versa. Here, we comment on the health complications and treatment options for individuals with obesity and comorbid eating disorder behaviors. It appears that in order to improve the healthcare provided to these individuals, there is a need for greater exchange of experiences and specialized knowledge between healthcare professionals working in the obesity field with those working in the field of eating disorders, and vice-versa. Additionally, nutritional and/or behavioral interventions simultaneously addressing weight management and reduction of eating disorder behaviors in individuals with obesity and comorbid eating disorders may be required. Future research investigating the effects of integrated medical, psychological and nutritional treatment programs addressing weight management and eating disorder psychopathology in individuals with obesity and comorbid eating disorder behaviors—such as binge eating—is necessary.

Agreement of screening tools with established questionnaires used in psychological assessment of bariatric patients

Background:

Depression and binge eating contributes to less weight loss after bariatric surgery. The lack of standardized assessment of depression and binge eating in bariatric patients makes it hard to identify and provide treatment to relevant patients. This study aimed to enhance the accuracy of identifying binge eating and depression in bariatric patients before surgery. We determined the agreement of brief screening tools for depression, binge eating and quality of life with established questionnaires used in psychological assessment of bariatric patients.

Methods:

In total, 120 patients completed both screening tools and established questionnaires before surgery during their psychological assessment sessions. Cohen’s kappa was conducted to determine whether Patient Health Questionnaire-2 agreed with the Beck Depression Inventory II in identifying depression; and if Patient Health Questionnaire-Binge agreed with the Binge Eating Scale in identifying binge eating. To investigate the degree of agreeableness between the RAND 36-Item Health Survey and Moorehead–Ardelt Quality of Life Questionnaire II on quality of life, Bland Altman analysis was performed.

Results:

Our results show that agreement between Patient Health Questionnaire-2 and Beck Depression Inventory II ( k=0.35) was fair. We found that agreement between Patient Health Questionnaire-Binge and Binge Eating Scale ( k=0.41) was moderate.

Conclusions:

These results indicate that the respective brief instruments’ identification of depression and binge eating is comparable to established questionnaires. Our results play a role in offering brief screening tools to be included at different points of assessment, together with established questionnaires and clinical interviews for a more accurate and comprehensive assessment.

Does Laparoscopic Sleeve Gastrectomy Improve Depression, Stress and Eating Behaviour? A 4-Year Follow-up Study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a restrictive bariatric surgery procedure and currently the second most performed technique worldwide. Follow-up data on depression, stress and eating behaviour are scarce. The aim of this longitudinal study was to investigate the medium-term effects of LSG on mental health and eating behaviour and their influence on weight loss by using a comprehensive interview-based assessment.

METHODS

Seventy-five individuals, who had undergone LSG at a university hospital, were included in the study. Symptoms of disordered eating were assessed using a structured clinical interview (eating disorder examination) and the Three-Factor Eating Questionnaire with depressive symptoms and stress assessed via the Patient Health Questionnaire.

RESULTS

Mean interval from LSG to follow-up (FU) examination was 48 ± 13.3 months. The total body weight loss was 24.2 ± 12.0 %. Depressive symptom scores improved from pre-operative to FU (9 [IQR 5-14] vs. 6 [IQR 2-10], p = 0.002) as did stress scores (8.7 ± 4.6 vs. 6.3 ± 4.7, p = 0.001). At FU, 11 % of patients reported loss-of-control eating and 39 % grazing, paralleled by increased body mass index, stress and depressive symptoms. Prior to LSG, nine patients fulfilled the diagnostic criteria of binge eating disorder but only one at FU.

CONCLUSIONS

Post-surgical mental health appears to be highly relevant in terms of weight loss maintenance. It is likely that the surgical outcome could be positively influenced if patients at risk of developing mental health issues or eating disorders were identified and monitored in order to offer targeted interventions.

Mental Health Support Provided Throughout the Bariatric Surgery Clinical Pathway in French Specialized Care Centers for Obesity

OBJECTIVE

Pre-operative psychological assessment is recommended by international guidelines for bariatric surgery candidates. Thereby, service teams caring for bariatric patients should include at least one mental health provider (e.g., a psychologist or psychiatrist). The objective of this study was to evaluate the psychology and psychiatry resources and practices in the 37 specialized obesity centers (CSOs) created by the French Ministry of Health.

MATERIALS AND METHODS

CSO coordinators were contacted by e-mail to collect general information on the centers (e.g., number of bariatric operations). Secondly, psychologists and psychiatrists of each center completed an anonymous questionnaire assessing their professional practices and their organization of care pathways.

RESULTS

The vast majority of CSO coordinators (81%, n = 26/32) answered our survey. These results show significant differences and shortages in terms of the psychology/psychiatry resources available. Most of the psychologists (n = 26/31) and psychiatrists (n = 10/10) stated that they systematically meet new patients only before surgery (56%) or both before and after the operation (30%); however, some psychologists and psychiatrists (14%) do not systematically meet all the patients (before and/or after surgery). Nevertheless, all the professionals provide psychology assessments, and about 75% of them offer a psychological follow-up, indicating a similarity regarding the practices of psychologists and psychiatrists.

CONCLUSION

Our results highlight the place of psychological/psychiatric evaluations in French CSOs and emphasize the absence of mental health providers in several of these services. Post-operative psychological follow-up is not usually provided. It would be appropriate to create clear recommendations for post-operative psychological or psychiatric long-term follow-up.

Treatment of Obesity: Weight Loss and Bariatric Surgery

This review focuses on the mechanisms underlying, and indications for, bariatric surgery in the reduction of cardiovascular disease (CVD), as well as other expected benefits of this intervention. The fundamental basis for bariatric surgery for the purpose of accomplishing weight loss is the determination that severe obesity is a disease associated with multiple adverse effects on health, which can be reversed or improved by successful weight loss in patients who have been unable to sustain weight loss by nonsurgical means. An explanation of possible indications for weight loss surgery as well as specific bariatric surgical procedures is presented, along with review of the safety literature of such procedures. Procedures that are less invasive or those that involve less gastrointestinal rearrangement accomplish considerably less weight loss but have substantially lower perioperative and longer-term risk. The ultimate benefit of weight reduction relates to the reduction of the comorbidities, quality of life, and all-cause mortality. With weight loss being the underlying justification for bariatric surgery in ameliorating CVD risk, current evidence-based research is discussed concerning body fat distribution, dyslipidemia, hypertension, diabetes mellitus, inflammation, obstructive sleep apnea, and others. The rationale for bariatric surgery reducing CVD events is discussed and juxtaposed with impacts on all-cause mortalities. Given the improvement of established obesity-related CVD risk factors after weight loss, it is reasonable to expect a reduction of CVD events and related mortality after weight loss in populations with obesity. The quality of the current evidence is reviewed, and future research opportunities and summaries are stated.

Anxiety independently contributes to elevated inflammation in humans with obesity

OBJECTIVE

Anxious and depressive states are associated with increased cardiovascular disease (CVD) risk and a proinflammatory phenotype, although the latter appears to be at least partially explained by adiposity. It was hypothesized that depression and anxiety would be associated with elevated inflammation independent of adiposity in persons with obesity at high risk of CVD.

METHODS

This study explored the relation between baseline anxiety as measured by the Beck Anxiety Inventory and depression as measured by the Beck Depression Inventory-II and baseline serum c-reactive protein (CRP) in a cross-sectional sample of 100 participants [mean (SD) age 57.8 (7.7) years; 64% female] with obesity [mean (SD) body mass index, BMI 37.3 (5.5) kg/m² ] enrolled in a clinical trial for pharmacological weight loss.

RESULTS

Beck Anxiety Inventory, but not Beck Depression Inventory-II, scores were significantly correlated with CRP (ρ = 0.28, P = 0.005). BMI was also highly correlated with CRP (ρ = 0.42, P < 0.0001). In multivariate models, the relation between anxiety and CRP remained significant (P = 0.038), independent of BMI, age, and sex.

CONCLUSIONS

Anxiety, but not depression, was associated with elevated inflammation in persons with obesity beyond that attributable to higher BMI. Further study is warranted to assess whether anxiety represents a potential therapeutic target to mitigate corresponding CVD risk associated with elevated inflammation in persons with obesity.

Body mass index, depression, and suicidality: The role of self-esteem in bariatric surgery candidates

BACKGROUND

Previous research suggests a relationship between weight and depression/suicidality, although few studies have examined the mechanisms underlying this association. This study examined the mediating role of self-esteem in the relationship between BMI and depression/suicidality, as well as the moderating role of gender in the mediated pathways.

METHODS

As part of a screening process in consideration for bariatric surgery, 3,101 adults (81.4% female, 18.6% male) were assessed one time. Five univariate mediation and five univariate moderated-mediation models were hypothesized and analyzed. For the mediation models, we entered five outcome variables separately: 1) severity of depressed mood, 2) diagnosis of Major Depressive Disorder, 3) lifetime history of suicide attempts, 4) suicidal ideation at the time of evaluation, and 5) severity of suicidality, BMI as the independent variable, and self-esteem as the mediator. For the moderated-mediated models, gender was examined as a moderator to examine whether self-esteem was a stronger mediator for one gender, compared to the other.

RESULTS

Findings supported the mediating role of self-esteem across all five outcomes. Further, the mediated effect was moderated by gender, such that the mediation effect was stronger for males, compared to females.

LIMITATIONS

The majority of the sample consisted of White females, limiting broad applicability of findings. All variables were assessed simultaneously, at baseline, limiting the ability to make causal attributions.

CONCLUSIONS

Study findings suggest that self-esteem may help explain the relationship between BMI and depression/suicidality, particularly for men. Thus, interventions targeting self-esteem may be useful for improving psychological outcomes among those presenting for bariatric surgery.

The Psychosocial Burden of Obesity

Obesity is associated with several comorbidities, including cardiovascular disease, type 2 diabetes, sleep apnea, osteoarthritis, and several forms of cancer. Obesity and its comorbidities also come with a significant psychosocial burden, impacting numerous areas of psychosocial functioning. The evaluation of psychosocial functioning is an important part of the assessment and treatment planning for the patient with obesity. This article provides an overview of the psychosocial burden of obesity. The article also describes the psychological changes typically seen with weight loss. A particular focus is on the psychosocial functioning of individuals with extreme obesity who present for and undergo bariatric surgery.

Cirurgia bariátrica e transtornos alimentares: uma revisão integrativa

RESUMO Objetivo Realizar revisão sobre transtornos alimentares e comportamentos alimentares transtornados relacionados à cirurgia bariátrica. Métodos Revisão integrativa da literatura nas bases de dados PubMed, Lilacs, Bireme, portal SciELO com descritores indexados com critérios de inclusão: oferecer dado sobre a presença ou frequência de transtorno alimentar e/ou comportamentos alimentares disfuncionais previamente e/ou após a cirurgia. Resultados Foram selecionados 150 estudos (14 nacionais e 136 internacionais): 80,6% eram com avaliação de pacientes pré-/pós-cirúrgicos; 12% eram estudos de caso e 7,3% eram estudos de revisão. Diferentes instrumentos foram usados para avaliação, principalmente o Questionnaire on Eating and Weight Patterns, a Binge Eating Scale e Eating Disorders Examination Questionnaire. A compulsão alimentar foi o comportamento mais avaliado, com frequências/prevalências variando de 2% a 94%; no caso do transtorno da compulsão alimentar as frequências/prevalências variaram de 3% a 61%. Houve também a descrição de anorexia e bulimia nervosa, síndrome da alimentação noturna e comportamento beliscador. Alguns estudos apontam melhora dos sintomas no pós-cirúrgico e/ou seguimento enquanto outros apontam surgimento ou piora dos problemas. Conclusão Apesar da variabilidade entre métodos e achados, comportamentos alimentares disfuncionais são muito frequentes em candidatos à cirurgia bariátrica e podem ainda surgir ou piorar após a intervenção cirúrgica. Profissionais de saúde devem considerar de maneira mais cuidadosa tais problemas neste público, dadas às consequências para o resultado cirúrgico e qualidade de vida.

Decreased Escitalopram Concentrations Post-Roux-en-Y Gastric Bypass Surgery

BACKGROUND

There is a high coincidence between obesity and psychiatric disorders including depression. Depressive disorders are commonly treated with antidepressants, including the selective serotonin reuptake inhibitor Lexapro (escitalopram). Although candidates for elective Roux-en-Y gastric bypass (RYGB) surgery may be treated with escitalopram, drug dosing strategies are typically not adjusted postoperatively. Therefore, studies are needed to better characterize escitalopram drug concentrations in a postsurgical setting.

METHODS

Turbulent flow-liquid chromatographic-tandem mass spectrometric methods were used to quantify escitalopram concentrations in serum in study participants approved for RYGB. Blood was collected from study subjects 2 weeks before surgery, and 2 and 6 weeks postoperatively, to assess the impact of RYGB on systemic drug concentrations.

RESULTS

Twelve samples from 4 study participants were collected and analyzed for serum escitalopram concentrations. Two weeks post-RYGB, although there were minimal changes in each participant's body mass index (<5%), drug concentrations were 33% (4%-71%) decreased as compared with presurgical serum concentrations. There were further decreases in drug concentrations 6 weeks postsurgery. All clinical laboratory values were within normal reference intervals.

CONCLUSIONS

RYGB significantly alters the gastrointestinal tract and impacts escitalopram drug concentrations, even shortly after surgery.

Recognizing Binge-Eating Disorder in the Clinical Setting: A Review of the Literature

OBJECTIVE

Review the clinical skills needed to recognize, diagnose, and manage binge-eating disorder (BED) in a primary care setting.

DATA SOURCES

A PubMed search of English-language publications (January 1, 2008-December 11, 2014) was conducted using the term binge-eating disorder. Relevant articles known to the authors were also included.

STUDY SELECTION/DATA EXTRACTION

Publications focusing on preclinical topics (eg, characterization of receptors and neurotransmitter systems) without discussing clinical relevance were excluded. A total of 101 publications were included in this review.

RESULTS

Although BED is the most prevalent eating disorder, it is underdiagnosed and undertreated. BED can be associated with medical (eg, type 2 diabetes and metabolic syndrome) and psychiatric (eg, depression and anxiety) comorbidities that, if left untreated, can impair quality of life and functionality. Primary care physicians may find diagnosing and treating BED challenging because of insufficient knowledge of its new diagnostic criteria and available treatment options. Furthermore, individuals with BED may be reluctant to seek treatment because of shame, embarrassment, and a lack of awareness of the disorder. Several short assessment tools are available to screen for BED in primary care settings. Pharmacotherapy and psychotherapy should focus on reducing binge-eating behavior, thereby reducing medical and psychiatric complications.

CONCLUSIONS

Overcoming primary care physician- and patient-related barriers is critical to accurately diagnose and appropriately treat BED. Primary care physicians should take an active role in the initial recognition and assessment of suspected BED based on case-finding indicators (eg, eating habits and being overweight), the initial treatment selection, and the long-term follow-up of patients who meet DSM-5 BED diagnostic criteria.

The DSM-5 effect: psychological characteristics of new patients affected by Binge Eating Disorder following the criteria of the DSM-5 in a sample of severe obese patients

PURPOSE

The current study evaluated whether or not there were significant differences in psychopathological traits between three groups of individuals. The first was a group of patients seeking bariatric surgery diagnosed as being affected by Binge Eating Disorder (BED), according to the new criteria of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This group (NEW BED group) did not meet BED diagnosis following the previous criteria listed in the DSM-IV-TR. The second group of individuals was composed of severely obese patients seeking bariatric surgery not affected by an eating disorder, according to the diagnostic criteria of the DSM-5 (OB group). The third group was composed of individuals within a healthy weight range (Control group).

METHODS

94 severely obese patients (33 in the NEW BED group and 61 in the OB group) were compared to the Control group including 41 participants on depression, anxiety and eating habits.

RESULTS

The NEW BED scored significantly higher than the OB group on the Beck Depression Inventory, both the subscales of the State Trait Anxiety Inventory, on disinhibition and hunger subscales of the Three-Factor Eating Questionnaire and on many subscales of the Eating Disorders Inventory.

CONCLUSIONS

The new, less restrictive diagnostic criteria for BED of the DSM-5 are useful in identifying obese patients affected by severe psychopathology and dysfunctional eating habits.

Psychiatric disorders among obese patients seeking bariatric surgery: results of structured clinical interviews

BACKGROUND

Obesity and psychiatric disorders are burdensome health problems commonly observed in general population and clinical samples. However, non-standardized assessment and small size of the sample might hamper conclusions of the investigations. The objective of this study is to replicate previous findings on frequency of psychiatric disorders and associated factors among obese patients seeking bariatric surgery, assessed through standardized interview.

MATERIAL AND METHOD

The sample was comprised of 393 treatment-seeking obese patients (79.1% women; mean age 43.0 years, mean BMI 47.8 kg/m(2)) recruited from a university-based bariatric center. Trained clinicians ascertained the psychiatric diagnosis of the participants through structured clinical interview for DSM-IV Axis I diagnosis (SCID-I).

RESULTS

The current rate of any psychiatric disorders was 57.8% (58.5% men vs. 57.6% women). The current anxiety disorders were the most frequent diagnosis (46.3%) among those participants with current disorder. Age and educational level were associated with the likelihood of presenting current psychiatric disorders. The lifetime rate of any psychiatric disorders was 80.9% (81.7 men vs. 80.7% women). Lifetime affective disorders were the most frequent diagnosis (total 64.9%; bipolar disorders 35.6% and depressive disorders 29.3%). About half of the sample presented 3 or more concurrent disorders among those respondents presenting any lifetime psychiatric disorders.

CONCLUSIONS

Psychiatric disorders are frequent conditions among obese patients before bariatric surgery. Systematic assessment of patients in the pre-surgical phase is recommended. Prognostic implications of psychiatric disorders on surgery outcome should be demonstrated in follow-up study.

Axis I disorders in adjustable gastric band patients: the relationship between psychopathology and weight loss

BACKGROUND

Bariatric surgery candidates have higher rates of co-morbid psychological illnesses than those in the general population. The effect of weight loss on these illnesses is unclear.

METHODS

This prospective observational study explored psychiatric co-morbidities and weight loss outcomes in 204 gastric banding surgery candidates. Psychiatric co-morbidities were assessed prior to surgery and 2 years post-surgery. One hundred and fifty patients (74%) completed assessments at both time points.

RESULTS

At baseline, 39.7% of the patients met the criteria for a current axis I disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). Mood disorders were the most frequent (26.5%), followed by anxiety disorders (15.2%) and binge eating disorder (13.2%). Preoperative psychopathology predicted clinical psychopathology at 2 years. No preoperative or post-operative axis I disorder was significantly related to weight loss at 2 years. The frequency of current axis I disorders decreased significantly from 39.7% preoperatively to 20% 2 years post-surgery.

CONCLUSIONS

The point prevalence of psychopathology in this sample of Australian bariatric candidates is high. Psychopathology, preoperatively and at 2 years of follow-up, was not associated with weight loss at 2 years.

The eating-related behaviours, disorders and expectations of candidates for bariatric surgery

It is important that clinicians and researchers understand the possible eating-related difficulties experienced by pre-bariatric surgery candidates, as well as their expectations of how their eating and hunger will change after surgery. This review examines English-language publications related to the eating-related behaviours, disorders and expectations of bariatric candidates. Seventy-five articles related to binge eating disorder, grazing, night eating syndrome, emotional eating, food cravings and addiction, and pre-surgical expectations of post-surgical eating in this population were critically reviewed. A variety of often problematic eating behaviours appear more common in bariatric candidates than in non-obese populations. The literature suggests that 4-45% of candidates may have binge eating disorder, 20-60% may graze, 2-42% may have night eating syndrome, 38-59% may engage in emotional eating and 17-54% may fit criteria for food addiction. Binge eating may also be more prevalent in bariatric candidates than in similarly obese non-surgical individuals. Expectations of surgery are high, with pre-surgical candidates believing their bariatric procedure will virtually guarantee significantly improved eating behaviours. Study replications are needed, and further investigation into prevalence, impacts and candidate characteristics related to disordered eating behaviours, as well as candidates' expectations of eating after surgery, will be important. Further comparisons of bariatric candidates to similarly obese non-bariatric populations will be important to understand eating-related characteristics of candidates beyond those related to their weight. Future research may be improved by the use of validated measures, replicable methodologies, minimization of data collected in circumstances where respondents may been motivated to 'fake good', use of prospective data and consistent definitions of key terminology.

Binge eating prevalence according to obesity degrees and associated factors in women

Objective Investigate binge eating (BE) prevalence in women according to the obesity degree and assess the associated factors. Methods Cross-sectional study with female adults presenting body mass index (BMI) ≥ 35 kg/m2. The analyzed variables were: sociodemographics, health status, obesity history, lifestyle, eating behavior and obesity degree. In order to analyse BE it was used the Binge Eating Scale (BES), which is considered positive when BES ≥ 18 points. Prevalence and prevalence ratios (PR) were calculated with confidence intervals (CI) of 95%. Multivariate analysis was carried out using Poisson regression. Results BE prevalence was 53.2%, and the prevalence in super superobese women (BMI ≥ 60 kg/m2) was 75%. After multivariate analysis, associations were observed between the age group 40-49 years old (PR = 2.0; 95% CI = 1.2-3.4) and the “snacking habit” (PR = 1.9; 95% CI = 1.2-2.9). Conclusion The prevalence of BE in severe obese women was high. Association with the “snacking habit” can be a BE marker that should be monitored in the severely obese individuals that fit this profile.