Psychosocial predictors of quality of life and weight loss two years after bariatric surgery: Results from the Toronto Bari-PSYCH study

Baseline Psychosocial, Environmental, Health, and Behavioral Correlates of 1- and 3-Year Weight Loss After Bariatric Surgery

PURPOSE

Weight loss surgery is an effective, long-term treatment for severe obesity but individual response to surgery varies widely. The purpose of this study was to test a comprehensive theoretical model of factors that may be correlated with the greatest surgical weight loss at 1-3 years following surgery. Such a model would help determine what predictive factors to measure when patients are preparing for surgery that may ensure the best weight outcomes.

MATERIALS AND METHODS

The Bariatric Experience Long Term (BELONG) study collected self-reported and medical record-based baseline information as correlates of 1- and 3-year % total weight loss (TWL) in n = 1341 patients. Multiple linear regression was used to determine the associations between 120 baseline variables and %TWL.

RESULTS

Participants were 43.4 ± 11.3 years old, Hispanic or Black (52%; n = 699), women (86%; n = 1149), and partnered (72%; n = 965) and had annual incomes of ≥ $51,000 (60%; n = 803). A total of 1006 (75%) had 3-year follow-up weight. Regression models accounted for 10.1% of the variance in %TWL at 1-year and 13.6% at 3 years. Only bariatric operation accounted for a clinically meaningful difference (~ 5%) in %TWL at 1-year. At 3 years after surgery, only bariatric operation, Black race, and BMI ≥ 50 kg/m2 were associated with clinically meaningful differences in %TWL.

CONCLUSIONS

Our findings combined with many others support a move away from extensive screening and selection of patients at the time of surgery to a focus on improving access to this treatment.

Predictors of improved psychological function after bariatric surgery

BACKGROUND

Negative psychological sequelae have been reported after bariatric surgery. It is unclear which factors affect psychological function in the first postoperative years.

OBJECTIVE

Evaluation of significant predictors of improved psychological function following bariatric surgery by analyzing data from the BODY-Q questionnaire.

SETTING

Multicenter prospective cohort in 3 centers located in The Netherlands and Denmark.

METHODS

The BODY-Q questionnaire was used to assess 6 domains of health-related quality of life. The domain of interest, psychological function, consists of 10 questions from which a converted score of 0 (low) to 100 (high) can be calculated. Linear mixed models were used to analyze which patient characteristics were most predictive of the psychological function score. Secondary outcomes of interest were cross-sectional scores of psychological function and the impact of weight loss, and the effect of major short-term complications on psychological function.

RESULTS

Data were analyzed from 836 patients who underwent bariatric surgery from 2015 to 2020. Patients with lower expectations concerning weight loss (<40% desired total weight loss), higher educational level, no history of psychiatric illness, and employment before bariatric surgery demonstrated the highest psychological function scores after bariatric surgery. At 1 and 2 years after bariatric surgery, more weight loss was associated with significantly higher psychological function scores. Experiencing a major short-term complication did not significantly impact psychological function.

CONCLUSIONS

Several relevant predictors of improved postoperative psychological function have been identified. This knowledge can be used to enhance patient education preoperatively and identify patients at risk for poor psychological functioning postoperatively.

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.

Evolution of depressive symptoms from before to 24 months after bariatric surgery: A systematic review and meta-analysis

AIMS

Depression after bariatric surgery can lead to suboptimal health outcomes. However, it is unclear how depressive symptoms evolve over the 24 months after surgery. We determined the extent depressive symptoms changed up to 24 months after bariatric surgery and how this was impacted by measurement tool and surgical procedure.

METHODS

We conducted a systematic review and meta-analysis, searching five databases from database inception to June 2021 for studies that prospectively measured depressive symptoms before and up to 24 months after bariatric surgery. Change scores were converted to Hedge's g, and analyses were performed using mixed-effects models. Subgroup analyses examined differences across time of follow-up, measurement tool, and surgical procedure.

FINDINGS

Forty-six studies met inclusion criteria (32,342 patients). Meta-analysis indicated a postsurgical reduction in depressive symptom scores that were significant (large effect, g = 0.804; 95% CI: 0.73-0.88, I²  = 95.7%). Subgroup analyses found that symptom reductions did not differ between the timing of follow-up periods, measurement tool, and surgical procedure.

CONCLUSIONS

Depressive symptom scores reduced substantially following surgery; comparable decreases occurred 6 through 24 months after surgery. These findings can help inform practitioners of the typical evolution of depressive symptoms following surgery and where deviations from this may require additional intervention.

Judgment towards emotions as a mediator of the relationship between emotional eating and depression symptoms in bariatric surgery candidates

PURPOSE

Emotional eating is common in bariatric surgery candidates, and often is associated with depression and poorer weight loss outcomes following surgery. However, less is known about other modifiable risk factors that may link depression and emotional eating. The aim of the current study was to examine facets of mindfulness as potential mediators of the relationship between emotional eating and depression severity in bariatric surgery candidates.

METHODS

Bariatric surgery candidates (n = 743) were referred by their surgeons for a comprehensive psychiatric pre-surgical evaluation that included self-report questionnaires assessing depression severity, emotional overeating, and facets of mindfulness. Mediation effects were examined for each mindfulness facet based on prior research.

RESULTS

Only the nonjudging mindfulness facet significantly mediated the relationship between emotional eating and depression, suggesting that greater emotional eating may be associated with greater depression severity through higher levels of judgement towards thoughts and emotions. A reverse mediation analysis showed that depression severity was not a significant mediator of the relationship between nonjudging and emotional eating.

CONCLUSION

Fostering a nonjudgmental stance towards thoughts and feelings may be helpful in improving eating habits that would support greater post-surgical success. Other clinical and research implications are discussed.

LEVEL OF EVIDENCE

Level V, descriptive study.

Examination of the Reliability and Validity of the Minnesota Multiphasic Personality Inventory-3 (MMPI-3) in a Preoperative Bariatric Surgery Sample

Presurgical psychological assessment of bariatric surgery candidates aims to identify psychosocial risk factors and provide treatment recommendations to facilitate optimal outcomes. Such assessment typically includes psychometric testing and a clinical interview. The Minnesota Multiphasic Personality Inventory (MMPI) has been commonly used as a broadband measure to assess a number of psychosocial domains in bariatric clinics. The newest version of the MMPI, the MMPI-3, was recently released. This study sought to (1) establish whether the MMPI-3 is comparable to the MMPI-2-RF in a sample of patients seeking bariatric surgery, (2) report reliability data for all MMPI-3 scale scores in this sample, and (3) explore associations between commonly used self-report symptom measures and substantive scales of the MMPI-3 to ascertain convergent and discriminant validity patterns. Six hundred and thirty-five presurgical patients completed the MMPI-3 in addition to the Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 (GAD-7), Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), and Eating Disorder Examination-Questionnaire (EDE-Q). The majority (79.1%) of the sample was female, 65.5% was white, and 26.6% was Black. Scores on most of the MMPI-3 Emotional/Internalizing Dysfunction scales were meaningfully associated with the PHQ-9, GAD-7, and most EDE-Q subscales (except for Restraint). Meaningful discriminant patterns were observed as well. We conclude that the substantive scales of the MMPI-3 are reliable, comparable to their MMPI-2-RF counterparts, and evidence good convergent validity with extra-test measures assessing depression, anxiety, alcohol use, and eating disorder psychopathology in a preoperative bariatric sample.

Patient-Level Factors Associated with Health-Related Quality of Life and Satisfaction with Body After Bariatric Surgery: a Multicenter, Cross-Sectional Study

BACKGROUND

Health-Related Quality of Life (HRQL) is a key outcome of success after bariatric surgery. Not all patients report improved HRQL scores postoperatively, which may be due to patient-level factors. It is unknown which factors influence HRQL after surgery. Our objective was to assess patient-level factors associated with HRQL after surgery.

METHODS

This international cross-sectional study included 730 patients who had bariatric surgery. Participants completed BODY-Q scales pertaining to HRQL and satisfaction with body, and demographic characteristics were obtained. The sample was divided into three groups based on time since surgery: 0 - 1 year, 1 - 3 years and more than 3 years. Uni- and multivariable linear regression analyses were conducted to identify variables associated with the BODY-Q scales per group.

RESULTS

The 0 - 1 year postoperative group included 377 patients (50.9%), the 1 - 3 years postoperative group 218 (29.4%) and the more than 3 years postoperative group 135 patients (18.2%). Lower current body-mass index (BMI), more weight loss (%TWL), being employed, having no comorbidities, higher age and shorter time since surgery were significantly associated with improved HRQL outcomes postoperatively. None of these factors influenced all BODY-Q scales. The effect of current BMI increased with longer time since surgery.

CONCLUSION

Factors including current BMI, %TWL, employment status, presence of comorbidities, age and time since surgery were associated with HRQL postoperatively. This information may be used to optimize patient-tailored care, improve patient education and underline the importance of long-term follow-up with special attention to weight regain to ensure lasting improvement in HRQL.

Correlation between Anxiety Symptoms and Perception of Quality of Life in Women with More Than 24 Months after Undergoing Bariatric Surgery

Purpose: To analyze the correlation between anxiety symptoms and perceived quality of life in women more than 24 months after undergoing bariatric surgery. Methods: Cross-sectional, descriptive and analytical study, carried out with women who underwent bariatric surgery after at least 24 months. To assess the level of anxiety symptoms, the Beck Inventory was used and to assess the perception of quality of life, the Item Short Form Healthy Survey was applied. Results: Of the 50 participants, 36.0% had reports indicative of moderate symptoms and 64.0% had severe symptoms of anxiety. The domains of quality of life that correlated with better perception were pain (p < 0.001), functional capacity (p = 0.013), general health status (p = 0.018), social aspects (p < 0.001), and mental health (p < 0.001). In linear regression, a significant inverse correlation was found between the general emotional component of quality of life and anxiety score (β = −0.546; CI −1.419; −0.559; p < 0.001) and between the general physical component of quality of life and anxiety score (β = −0.339; CI −0.899; −0.131; p = 0.010), both independent of weight regain and surgery time. Conclusions: It was observed that moderate to severe anxiety symptoms seem to interfere with the perception of quality of life, regardless of weight regain and surgery time.

Cohort profile: The Bariatric Experience Long Term (BELONG): a long-term prospective study to understand the psychosocial, environmental, health and behavioural predictors of weight loss and regain in patients who have bariatric surgery

PURPOSE

The Bariatric Experience Long Term (BELONG) prospective study cohort was created to address limitations in the literature regarding the relationship between surgical weight loss and psychosocial, health, behaviour and environmental factors. The BELONG cohort is unique because it contains 70% gastric sleeve and 64% patients with non-white race/ethnicity and was developed with strong stakeholder engagement including patients and providers.

PARTICIPANTS

The BELONG cohort study included 1975 patients preparing to have bariatric surgery who completed a baseline survey in a large integrated health system in Southern California. Patients were primarily women (84%), either black or Hispanic (59%), with a body mass index (BMI) of 45.1±7.4 kg/m², age 43.3±11.5 years old, and 32% had at least one comorbidity.

FINDINGS TO DATE

A total of 5552 patients were approached before surgery between February 2016 and May 2017, and 1975 (42%) completed a baseline survey. A total of 1203 (73%) patients completed the year 1 and 1033 (74%) patients completed the year 3 postoperative survey. Of these survey respondents, 1341 at baseline, 999 at year 1, and 951 at year 3 were included in the analyses of all survey and weight outcome data. A total of 803 (60% of eligible patients) had survey data for all time points. Data collected were self-reported constructs to support the proposed theoretical model. Height, weight and BMI were abstracted from the electronic medical record to obtain the main outcomes of the study: weight loss and regain.

FUTURE PLANS

We will collect self-reported constructs and obtain height, weight and BMI from the electronic medical record 5 years after bariatric surgery between April 2022 and January 2023. We will also collect patient experiences using focus groups of 8-12 patients each throughout 2022.

The Impact of Telephone-Based Cognitive Behavioral Therapy on Mental Health Distress and Disordered Eating Among Bariatric Surgery Patients During COVID-19: Preliminary Results from a Multisite Randomized Controlled Trial

Background

Patients undergoing bariatric surgery have high rates of psychiatric comorbidity, which may increase their vulnerability to COVID-19-related mental health distress. Exacerbation of mental health distress and disordered eating could have significant negative effects on long-term weight management and quality of life for these patients if untreated.

Objective

To determine the efficacy of a telephone-based cognitive behavioral therapy (Tele-CBT) intervention in improving depressive, anxiety, and disordered eating symptoms during COVID-19.

Methods

Participants were recruited as part of a larger randomized controlled trial study (clinicaltrials.gov ID: NCT03315247) between March 2020 and March 2021 and randomized 1:1 to receive Tele-CBT or standard bariatric care. Outcomes of Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Emotional Eating Scale (EES), and Binge Eating Scale (BES) were measured at baseline, immediately post-intervention, and 3 months post-intervention. Linear mixed models were used to test the effect of intervention group, time, and group-by-time interaction for each outcome.

Results

Eighty-one patients were included in the intention-to-treat analysis. Mean (SD) age of participants was 47.68 (9.36) years and 80.2% were female. There were significant group-by-time interactions for all outcomes and significant differences between groups across time. There were significant decreases in mean GAD-7 (p = 0.001), PHQ-9 (p < 0.001), EES-Total (p = 0.001), EES-Anger (p = 0.003), EES-Anxiety (p < 0.001), EES-Depression (p < 0.001), and BES (p = 0.002) scores for the Tele-CBT group at post-intervention and follow-up when compared to baseline and the control group.

Conclusion

Tele-CBT is a feasible and effective treatment for improving psychological distress and disordered eating among post-operative bariatric surgery patients during the COVID-19 pandemic.

Graphical abstract

Seven-year trajectories of body weight, quality of life and comorbidities following Roux-en-Y gastric bypass and sleeve gastrectomy

BACKGROUND/OBJECTIVES

There is limited long-term data comparing the outcomes of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for severe obesity, both with respect to body weight, quality of life (QOL) and comorbidities. We aimed to determine 7-year trajectories of body mass index (BMI), QOL, obesity-related comorbidities, biomarkers of glucose and lipid metabolism, and early major complications after SG and RYGB.

SUBJECTS/METHODS

Patients scheduled for bariatric surgery at two Norwegian hospitals, preferentially performing either SG or RYGB, were included consecutively from September 2011 to February 2015. Data was collected prospectively before and up to 7 years after surgery. Obesity-specific, generic and overall QOL were measured by the Impact of Weight on Quality of Life-Lite, Short-Form 36 and Cantril's ladder, respectively. Comorbidities were assessed by clinical examination, registration of medication and analysis of glucose and lipid biomarkers. Outcomes were examined with linear mixed effect models and relative risk estimates.

RESULTS

Of 580 included patients, 543 (75% women, mean age 42.3 years, mean baseline BMI 43.0 kg/m²) were operated (376 SG and 167 RYGB). With 84.2% of participants evaluable after 5-7 years, model-based percent total weight-loss (%TWL) at 7 years was 23.4 after SG versus 27.3 after RYGB (difference 3.9%, p = 0.001). All levels of QOL improved similarly after the two surgical procedures but remained below reference data from the general population at all timepoints. Remission rates for type 2 diabetes, dyslipidemia, obstructive sleep-apnea and gastroesophageal reflux disease (GERD) as well as the rate of de novo GERD significantly favored RYGB. SG had fewer major early complications, but more minor and major late complications combined over follow-up.

CONCLUSION

In routine health care, both SG and RYGB are safe procedures with significant long-term weight-loss, improvement of QOL and amelioration of comorbidities. Long-term weight-loss and remission rates of main obesity-related comorbidities were higher after RYGB.

The Impact of Psychiatric History and Peri-operative Psychological Distress on Weight Loss Outcomes 1 Year After Bariatric Surgery

BACKGROUND

To determine if self-reported baseline psychological distress moderates the association between lifetime psychiatric diagnosis and weight loss 1 year after bariatric surgery. An exploratory analysis assessed change in psychological distress from baseline on weight loss at 1 year.

METHODS

A retrospective cohort study using data from the Ontario Bariatric Registry for all individuals undergoing surgery between January 1, 2012, and December 31, 2018, with a complete baseline psychological assessment and 1-year post-operative weight recorded (N = 11,159). Multiple linear regressions assessed the relationship between psychiatric diagnosis and percentage of excess body mass index loss (%EBMIL) at 1-year post-surgery, controlling for baseline body mass index, socio-demographics, medical co-morbidities, and surgical complications. Baseline psychological distress, measured with the EQ-5D-5L anxiety/depression rating, was examined as a moderator of this relationship. %EBMIL was separately regressed on change in psychological distress from baseline to 1 year, controlling for psychiatric diagnosis.

RESULTS

In the adjusted model, psychiatric diagnosis was associated with lower %EBMIL at 1 year (B =  - 1.00, P = .008). Baseline psychological distress was not a moderator, but had a significant main effect on %EBMIL (B =  - .84, P = .001). Those who experienced a decrease in psychological distress at 1 year, or remained low throughout, fared better than those who increased or had persistently high symptoms.

CONCLUSIONS

These findings support use of a self-report assessment for psychological distress prior to bariatric surgery. Addressing active psychological distress prior to and/or following surgery may increase the likelihood of successful outcomes.

Understanding bariatric patients' experiences of self-management post-surgery: A qualitative study

Although most bariatric patients achieve significant weight loss and improvements in both physical and mental health-related quality of life (HRQoL) in the short-term, there is wide variability in weight and long-term HRQoL outcomes. The role of bariatric patients' self-management style in explaining variability in long-term outcomes is unclear. This qualitative study examined bariatric patients' self-management experiences after bariatric surgery in relation to long-term outcomes. A qualitative study was conducted using semi-structured individual interviews with post-surgery patients (n = 23) at a Canadian bariatric surgery program. A constant comparative approach was used to systematically analyse the data and identify overarching themes. Variation in patients' experiences and follow-up time were the two primary units of analysis. Patients were predominantly female (n = 19; 82.6%) and had a mean age of 50 ± 8.49 years. The median time post-surgery was 2 years (range: 6 months-7 years). Three distinct phases described the process of self-management post-bariatric surgery: (1) rediscovering self-esteem and confidence in one's ability to self-manage (1-month to 1.5-years post-surgery), (2) achieving weight maintenance and addressing emotion dysregulation (1.5-3-years post-surgery) and (3) embracing a flexible balanced lifestyle (beyond 3-years). Bariatric surgery patients experience distinct challenges relative to their post-surgery time course. Facilitating access to interprofessional bariatric care after surgery allowed patients to acquire the self-management knowledge and skills necessary to address challenges to following the bariatric guidelines in the long-term.

Quality of life and psychopathology in candidates to bariatric surgery: relationship with BMI class

PURPOSE

This cross-sectional study aimed at comparing the quality of life (Qol), the prevalence of psychiatric diagnosis and pharmacological treatment in 104 candidates to bariatric surgery according to the degree of obesity (class 2 vs. class ≥ 3 obesity).

METHODS

All surgical candidates underwent a detailed psychiatric interview based on DSM-5 criteria, including sociodemographic, clinical, psychological and psychiatric data. Participants completed the Binge Eating Scale (BES) and the 12-Item Short Form Health Survey (SF-12).

RESULTS

Overall, bariatric candidates reported a significant impairment in the physical (PCS 38.8 [95% CI 36.2-41.5]) and mental (MCS 42.2 [95% CI 40.4-43.9]) components of Qol compared to population norms (p < 0.001 for both). Subjects with class 2 obesity scored significantly lower in the MCS compared to those with class 3 (38.7 (8.1) vs. 43.6 (8.4), p = 0.008). No other statistically significant differences were found between the two groups in terms of sociodemographic and clinical variables.

CONCLUSION

These data support the usefulness of Qol assessment in bariatric candidates as a sensible screening parameter, especially in patients with lower BMI, in whom MCS could identify the need for early psychosocial intervention.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

The impact of COVID-19 pandemic on bariatric patients' self-management post-surgery

Background

The coronavirus disease 2019 (COVID-19) pandemic has had far reaching consequences on the health and well-being of the general public. Evidence from previous pandemics suggest that bariatric patients may experience increased emotional distress and difficulty adhering to healthy lifestyle changes post-surgery.

Objective

We aimed to examine the impact of the novel COVID-19 public health crisis on bariatric patients’ self-management post-surgery.

Method

In a nested-qualitative study, semi-structured telephone interviews were conducted with 23 post-operative bariatric patients who had undergone Roux-en-Y gastric bypass (RYGB) at a Canadian Bariatric Surgery Program between 2014 and 2020. A constant comparative approach was used to systematically analyze the data and identify the overarching themes.

Results

Participants (n = 23) had a mean age of (48.82 ± 10.03) years and most were female (n = 19). The median time post-surgery was 2 years (range: 6 months–7 years). Themes describing the impact of COVID-19 pandemic on patients’ post-bariatric surgery self-management included: coping with COVID-19; vulnerability factors and physical isolation; resiliency factors during pandemic; and valuing access to support by virtual care. The need for patients to access post-operative bariatric care during COVID-19 differed based on gender and socioeconomic status.

Conclusion

This study showed that the COVID-19 pandemic has impacted patients’ ability to self-manage obesity and their mental health in a variety of ways. These findings suggest that patients may experience unique psychological distress and challenges requiring personalized care strategies to improve obesity self-care and overall well-being.

Food Addiction Is Associated with Binge Eating and Psychiatric Distress among Post-Operative Bariatric Surgery Patients and May Improve in Response to Cognitive Behavioural Therapy

The current study examined clinical correlates of food addiction among post-operative bariatric surgery patients, compared the clinical characteristics of patients with versus without food addiction, and examined whether a brief telephone-based cognitive behavioural therapy (Tele-CBT) intervention improves food addiction symptomatology among those with food addiction. Participants (N = 100) completed measures of food addiction, binge eating, depression, and anxiety 1 year following bariatric surgery, were randomized to receive either Tele-CBT or standard bariatric post-operative care, and then, repeated the measure of food addiction at 1.25 and 1.5 years following surgery. Thirteen percent of patients exceeded the cut-off for food addiction at 1 year post-surgery, and this subgroup of patients reported greater binge eating characteristics and psychiatric distress compared to patients without food addiction. Among those with food addiction, Tele-CBT was found to improve food addiction symptomatology immediately following the intervention. These preliminary findings suggest that Tele-CBT may be helpful, at least in the short term, in improving food addiction symptomatology among some patients who do not experience remission of food addiction following bariatric surgery; however, these findings require replication in a larger sample.

"Caring About Me": a pilot framework to understand patient-centered care experience in integrated care - a qualitative study

OBJECTIVE

The aim of this study is to examine patients' experiences in integrated care (IC) settings.

DESIGN

Qualitative study using semistructured interviews.

SETTINGS

Two IC sites in Toronto, Canada: (1) a community-based primary healthcare centre, supporting patients with hepatitis C and comorbid mental health and substance use issues; and (2) an integrated bariatric surgery programme, an academic tertiary care centre.

PARTICIPANTS

The study included patients (n=12) with co-occurring mental and physical health conditions. Seven participants (58%) were female and five (42%) were male.

METHODS

Twelve indepth semistructured interviews were conducted with a purposeful sample of patients (n=12) with comorbid mental and physical conditions at two IC sites in Toronto between 2017 and 2018. Data were collected and analysed using grounded theory approach.

RESULTS

Four themes emerged in our analysis reflecting patients' perspectives on patient-centred care experience in IC: (1) caring about me; (2) collaborating with me; (3) helping me understand and self-manage my care; and (4) personalising care to address my needs. Patients' experiences of care were primarily shaped by quality of relational interactions with IC team members. Positive interactions with IC team members led to enhanced patient access to care and fostered personalising care plans to address unique needs.

CONCLUSION

This study adds to the literature on creating patient-centredness in IC settings by highlighting the importance of recognising patients' unique needs and the context of care for the specific patient population.

Psychiatric Management of Bariatric Surgery Patients: A Review of Psychopharmacological and Psychological Treatments and Their Impact on Postoperative Mental Health and Weight Outcomes

BACKGROUND

Bariatric surgery is an effective treatment for severe obesity; however, high rates of psychiatric comorbidity complicate bariatric surgery care. As a result, importance has been placed on the need for ongoing psychiatric support in patients undergoing bariatric surgery. Given the lack of conclusive presurgery psychosocial predictors of postoperative mental health outcomes, studies have now shifted their focus to understand the long-term psychosocial sequalae that arise after surgery. Increasing evidence has demonstrated the potential for psychiatric care to stabilize psychiatric symptoms and minimize patient distress.

OBJECTIVE

To review psychopharmacological and psychological interventions for patients undergoing bariatric surgery and their impact on mental health and weight outcomes after surgery.

METHODS

We performed a comprehensive literature search in Ovid MEDLINE for studies examining the impact of psychopharmacological and psychological treatments on bariatric patients' postoperative mental health and weight outcomes.

RESULTS

Overall, 37 studies were included in the review. Preliminary evidence suggests that psychiatric medications do not negatively impact weight loss or health-related quality of life in the short term; however, more rigorous research designs are needed. There are insufficient data on specific psychiatric medications and long-term impact on weight loss and psychosocial outcomes. Postoperative psychological interventions have evidence for improving eating psychopathology, anxiety, and depressive symptoms; however, effects on weight loss remain unclear.

CONCLUSION

Evidence for psychopharmacological and psychological treatments remains preliminary. Consideration should be given to integrated, stepped-care models to provide personalized psychiatric interventions after surgery. Future research on expanding current psychiatric interventions, timing of delivery, and predictors of response is needed.

Exploring the Effects of Telemedicine on Bariatric Surgery Follow-up: a Matched Case Control Study

Telemedicine offers a potential solution for bariatric surgery (BS) aftercare for patients living in rural areas with limited access to healthcare services. This study aimed to compare post-BS appointment adherence, psychosocial, and body mass index (BMI) outcomes in patients that did or did not use telemedicine. In total, 192 (96 telemedicine and 96 non-telemedicine) patients were matched on gender, age, time since surgery, BMI, and travel distance from program. Additional psychosocial and demographic variables including rurality index (RIO) were collected. Telemedicine users had a significantly higher RIO (p < 0.001) than non-telemedicine users. Appointment attendance, BMI, and psychosocial outcomes were not significantly different between the two groups. Therefore, our results suggest that telemedicine could help overcome geographical barriers to provide comparable quality healthcare services to more remote regions.

Predictors of suicidal ideation one-year post-bariatric surgery: Results from the Toronto Bari-Psych Cohort Study

OBJECTIVE

Previous studies have shown higher rates of death by suicide, suicide attempts, suicidal ideation and non-suicidal self-directed violence (NS-SDV) in bariatric surgery patients.

METHODS

Data came from the Toronto Bari-Psych Cohort study of adult patients who underwent bariatric surgery between 2010 and 2016. The MINI International Neuropsychiatric Interview was used to obtain lifetime psychodiagnostic data. Information about lifetime suicidal ideation, suicide attempts, NS-SDV and hospitalizations related to any of these phenomena was collected during clinical interview. Pre-surgery sociodemographic data, lifetime psychiatric disorders, mental health symptoms, mental health treatment, suicidal ideation and surgical complications were covariates. Logistic regression analyses were used to examine the relationship between these variables and suicidal ideation one-year post-surgery.

RESULTS

Among a total of 284 participants, 4.2% reported a past suicide attempt and 15.1% reported past suicidal ideation. One-year post-surgery, no suicide attempts were reported. In the multivariate regression model, a history of suicidal ideation was the strongest predictor of suicidal ideation one-year post-surgery (p < 0.01), followed by younger age (p = 0.05). Mental health symptoms decreased from pre to post-surgery.

CONCLUSION

One-year post-surgery, a history of suicidal ideation was the strongest predictor of post-surgery suicidal ideation. Results should be interpreted with caution given the short duration of follow-up.

Psychiatric Medication Use and Weight Outcomes One Year After Bariatric Surgery

BACKGROUND

Given the high rates of psychiatric comorbidity in bariatric surgery patients, pharmacotherapy is common and could potentially influence weight loss outcomes.

OBJECTIVE

We aimed to identify the impact of psychotropic medication use on percent total weight loss (%TWL) 1 year after bariatric surgery.

METHODS

In this prospective cohort study, 190 patients were compared based on demographic variables (age, sex, relationship status, employment status), body mass index, %TWL, and psychotropic medication use before and 1 year after bariatric surgery. An analysis of variance test was used as a global test of significance for psychotropic medication comparisons related to %TWL. Significance of post hoc comparisons was calculated with the Tukey's Honestly Significance Difference test.

RESULTS

Sixty-one of 190 (32.1%) patients were taking psychiatric medications before surgery; of those, 82% (50/61) continued to take psychiatric medications 1-year after surgery. %TWL did not significantly differ between patients taking no psychiatric medications, one medication, or more than one medication 1 year after surgery (31.4% vs. 29.9% vs. 34.4%, respectively). Among patients taking antidepressants, those taking serotonin-norepinephrine reuptake inhibitors had a significantly higher %TWL than those taking selective serotonin reuptake inhibitors (36.4% vs. 27.8%; P = 0.032).

CONCLUSION

This longitudinal study suggests that psychiatric medication use was not associated with poorer %TWL at 1 year after bariatric surgery. Within class, antidepressant use may have differential effects on weight loss after bariatric surgery and warrants further investigation.

The Impact of Massive Weight Loss on Psychological Comorbidities: A Large, Retrospective Database Review

BACKGROUND

The obese population has a higher incidence of mood disorders compared to individuals with normal body mass index (BMI). A better understanding of the unique psychosocial challenges faced by this patient population will allow physicians to better optimize patient psychosocial support systems perioperatively, as well as help the patient to maintain appropriate expectations.

METHODS

A large, retrospective database of 1135 patients with greater than 50 pounds of weight loss was reviewed. Data were analyzed using a multinomial regression model to determine the influence of psychosocial factors on the incidence of depression and anxiety.

RESULTS

Prior to massive weight loss, patients reported an overall incidence of depression and anxiety of 42.5% and 26.3%, respectively. Following massive weight loss, the incidence of depression decreased to 32.3% and the incidence of anxiety decreased to 22.0%. Patients with spousal support and with positive self-image were more likely to experience resolution of depression. Patients with positive self-image were likely to experience resolution of anxiety. Resolution of medical comorbidities correlated with a decrease in the rate of depression.

CONCLUSION

Depression and anxiety are prevalent in the massive weight loss patient population undergoing body contouring surgery. Support systems are a vital resource for patients with psychological comorbidities undergoing massive weight loss. Patients who have a positive self-image of themselves are more likely to experience resolution of psychological comorbidities. Physicians should consider recommending support groups and/or counseling in patients who have poor support and negative self-image.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Telephone-based cognitive behavioural therapy for female patients 1-year post-bariatric surgery: A pilot study

OBJECTIVE

Although bariatric surgery is a durable treatment for patients with severe obesity, it does not directly address behavioural and psychological factors that potentially contribute to weight regain post-surgery. Psychological interventions, such as cognitive behavioural therapy (CBT), can be challenging to access due to physical limitations and practical barriers. Telephone-based CBT (Tele-CBT) can improve eating psychopathology and psychological distress before and after surgery. Given the frequent occurrence/recurrence of problematic eating-related and psychological issues many patients face 1-year post-surgery, this open-trial pilot study aimed to evaluate the effectiveness of Tele-CBT delivered 1-year post-surgery as an adjunctive treatment to the usual standard of bariatric care.

METHODS

Patients (n=43) received six 1-h Tele-CBT sessions delivered weekly beginning at 1-year post-surgery. Patients completed questionnaire packages before and after the intervention to assess changes in binge eating (BES), emotional eating (EES), depression (PHQ-9), and anxiety (GAD-7).

RESULTS

Thirty-two patients completed Tele-CBT yielding a 74.4% completion rate. Participants reported significant improvements on the Binge Eating Scale (t(31)=3.794, p=0.001), Emotional Eating Scale (t(31)=3.508, p=0.001), Patient Health Questionnaire-9 Item Scale (z=-2.371, p=0.018), and Generalised Anxiety Disorder-7 Item Scale (z=-3.546, p<0.001) immediately following Tele-CBT.

DISCUSSION

The results demonstrate that Tele-CBT delivered 1-year post-surgery may improve binge eating, emotional eating, depression, and anxiety. Additional research is warranted to examine whether these changes translate into long-term improvements in bariatric surgery outcomes.

Prospective Study of Attachment as a Predictor of Binge Eating, Emotional Eating and Weight Loss Two Years after Bariatric Surgery

Bariatric surgery remains the most effective treatment for severe obesity, though post-surgical outcomes are variable with respect to long-term weight loss and eating-related psychopathology. Attachment style is an important variable affecting eating psychopathology among individuals with obesity. To date, studies examining eating psychopathology and attachment style in bariatric surgery populations have been limited to pre-surgery samples and cross-sectional study design. The current prospective study sought to determine whether attachment insecurity is associated with binge eating, emotional eating, and weight loss outcomes at 2-years post-surgery. Patients (n = 108) completed questionnaires on attachment style (ECR-16), binge eating (BES), emotional eating (EES), depression (PHQ-9), and anxiety (GAD-7). Multivariate linear regression analyses were conducted to examine the association between attachment insecurity and 2-years post-surgery disordered eating and percent total weight loss. Female gender was found to be a significant predictor of binge eating (p = 0.007) and emotional eating (p = 0.023) at 2-years post-surgery. Avoidant attachment (p = 0.009) was also found to be a significant predictor of binge eating at 2-years post-surgery. To our knowledge, this study is the first to explore attachment style as a predictor of long-term post-operative eating pathology and weight outcomes in bariatric surgery patients.

Prevalence and Factors Associated With Psychiatric Medication Use in Bariatric Surgery Candidates

OBJECTIVE

We aimed to describe the rates of psychiatric medication use in bariatric surgery candidates and factors associated with psychiatric medication use.

METHODS

Patients from the Toronto Western Hospital Bariatric Surgery Program were recruited from 2011 to 2014. Data extracted included demographics, clinical factors (e.g., mood disorder, anxiety disorder, eating disorder, Patient Health Questionnaire-9, Generalized Anxiety Disorder 7), and psychiatric medication use. Logistic regression analyses were used to examine the relationship between demographic variables, clinical factors, and psychiatric medication use. Multiple logistic regression was conducted to determine the predictors of clinical factors from demographic variables with psychiatric medication use.

RESULTS

A total of 262 (35.1%) patients were taking at least 1 psychiatric medication and 105 patients (14.1%) were taking more than 1 psychiatric medication. Antidepressants were the most common psychiatric medication reported. The majority of patients taking a psychiatric medication had a psychiatric illness, with 16.0% not having a lifetime diagnosis of a mental illness. Being male and being employed significantly predicted lower odds of being on a psychiatric medication. Older age significantly predicted higher odds of being on a psychiatric medication. Psychiatric disorders were significantly associated with psychiatric medication use independent of demographic variables.

CONCLUSION

Our study provides insights into clinical and demographic factors related to psychiatric medication use in bariatric surgery patients. The findings support careful screening and clarification of psychiatric medications, especially in patients without a formal psychiatric diagnosis.

Eating Behaviour Predicts Weight Loss Six Months after Bariatric Surgery: A Longitudinal Study

Bariatric surgery is currently the most durable weight loss solution for patients with morbid obesity. The extent of weight loss achieved, however, is subject to variation due to various factors, including patients' behaviour. In this study, we aimed to identify pre- and post-surgical predictors of weight loss following bariatric surgery. This prospective study included 57 participants who went through bariatric surgery (laparoscopic Roux-en-Y gastric bypass: n = 30; laparoscopic sleeve gastrectomy: n = 23; one anastomosis gastric bypass-mini gastric bypass: n = 4) in two tertiary referral hospitals. Consenting participants were assessed prior to surgery (T₀), and three months (T₁) and six months (T₂) after surgery. The assessment included interview and anthropometric measurements. The interview was done with the aid of instruments, including the Hospital Anxiety and Depression Scale (HADS) for anxiety and depression screening and the Dutch Eating Behaviour Questionnaire (DEBQ) for eating behaviour assessment. Baseline comorbidity status was obtained from medical records. A Generalised Estimating Equation (GEE) was developed to determine predictors of weight loss. Participants in the study were mostly women (n = 37, 65%) with a mean age of 39.4 (SD = 10.01) years. The mean excess BMI loss (EBMIL) and total weight loss (TWL) at the sixth month was 63.31% and 23.83%, respectively. Anxiety, depression, and external eating scores reduced over time. Advancing age, high BMI, and higher scores for emotional and external eating emerged as significant negative predictors for TWL%. It can be concluded that the patients experienced substantial weight loss after surgery. Continuous monitoring of psychological well-being and eating behaviour are essential for optimal weight loss.