Psychological predictors of weight loss after bariatric surgery: a review of the recent research

Three-Month Excessive Body Weight Loss < 37.7% as a Predictor of Mid-term Suboptimal Outcomes Postlaparoscopic Sleeve Gastrectomy: Risk Factors and the Impact of Neutrophil-to-Lymphocyte Ratio on Adipocyte Function

INTRODUCTION

This study aimed to evaluate the impact of achieving < 37.7% excess body-weight loss (EBWL) within 3 months of postlaparoscopic sleeve gastrectomy (LSG) on clinical outcomes and its correlation with adipocyte function.

METHODS

Patients (n = 176) who underwent LSG between January 2019 and January 2023 were included. Weight loss and status of health markers were monitored postoperatively. The cohort was stratified based on EBWL < 37.7% at 3 months or not. Variables including neutrophil-to-lymphocyte ratio (NLR), insulin resistance, and comorbidities were analyzed. Omental visceral and subcutaneous adipose tissue samples were used to analyze the differences in adipocyte function by western blot.

RESULTS

Patients with EBWL < 37.7% at 3 months post-LSG (suboptimal group) comprised less likelihood of achieving ≥ 50% EBWL than those who achieved ≥ 37.7% EBWL (optimal group) at 6 months (42.55% vs. 95.52% in optimal group, p < 0.001), 12 months (85.11% vs. 99.25% in optimal group, p < 0.001) and 24 months (77.14% vs. 94.74% in optimal group, p = 0.009) post-LSG. High BMI (OR = 1.222, 95% CI 1.138-1.312, p < 0.001), NLR ≥ 2.36 (OR = 2.915, 95% CI 1.257-6.670, p = 0.013), and female sex (OR = 3.243, 95% CI 1.306-8.051, p = 0.011) significantly predicted EBWL < 37.7% at 3 months post-LSG. Patients with NLR ≥ 2.36 had significantly lower adipose triglyceride lipase in omental fat (p = 0.025).

CONCLUSION

EBWL < 37.7% at 3 months post-LSG is a strong predictor of subsequent suboptimal weight loss. High BMI, NLR ≥ 2.36, and female sex are risk factors in predicting EBWL < 37.7% at 3 months post-LSG. These findings may offer a reference to apply adjuvant weight loss medications to patients who are predisposed to suboptimal outcomes.

Preoperative depression and outcomes after metabolic and bariatric surgery: A systematic narrative review

Preoperative depression is prevalent among patients undergoing metabolic and bariatric surgery (MBS) and is a potentially modifiable risk factor. However, the impact of preoperative depression on MBS outcomes has not been systematically reviewed. A search of MEDLINE, Embase, Cochrane, and PsychINFO (inception to June 2023) was conducted for studies reporting associations between preoperative depression and any clinical or patient-reported outcomes after MBS. Eighteen studies (5 prospective and 13 retrospective) reporting on 5933 participants were included. Most participants underwent gastric bypass or sleeve gastrectomy. Meta-analyses were not conducted due to heterogeneity in reported outcomes; findings were instead synthesized using a narrative and tabular approach. Across 13 studies (n = 3390) the associations between preoperative depression and weight loss outcomes at 6-72 months were mixed overall. This may be related to differences in cohort characteristics, outcome definitions, and instruments used to measure depression. A small number of studies reported that preoperative depression was associated with lower quality of life, worse acute pain, and more perioperative complications after surgery. Most of the included studies were deemed to be at high risk of bias, resulting in low or very low certainty of evidence according to the Risk of Bias In Non-randomized Studies - of Exposure (ROBINS-E) tool. While the impact of preoperative depression on weight loss after MBS remains unclear, there is early evidence that depression has negative consequences on other patient-important outcomes. Adequately powered studies using more sophisticated statistical methods are needed to accurately estimate these associations.

Influence of mental and behavioral factors on weight loss after bariatric surgery: A systematic review and meta-analysis

INTRODUCTION

Multiple factors are related to lower weight loss after bariatric surgery. This review and meta-analysis evaluates the influence of several mental and behavioral factors on weight loss.

METHOD

Six electronic databases were searched. Percentage excess weight loss (%EWL) was calculated for all moderator and non-moderator groups of the variables: symptoms of depression, anxiety and binge eating, compliance, physical activity, quality of life, and body image. All moderators, surgery types, and follow-up moments were analyzed separately.

RESULTS

In total, 75 articles were included in the review; 12 meta-analyses were conducted. Higher postoperative compliance to follow-up was associated with 6.86%-13.68% higher EWL. Preoperative binge eating was related to more weight loss at 24- and 36-month follow-up (7.97% and 11.79%EWL, respectively). Patients with postoperative binge eating symptoms had an 11.92% lower EWL. Patients with preoperative depressive symptoms lost equal weight compared to patients without symptoms.

CONCLUSION

Despite the high heterogeneity between studies, a trend emerges suggesting that the presence of postoperative binge eating symptoms and lower postoperative compliance may be associated with less weight loss after bariatric-metabolic surgery. Additionally, preoperative depressive symptoms and binge eating do not seem to significantly impact weight loss.

Pre-operative body shape concerns moderate excess weight loss trajectory in bariatric surgery patients: a 2-year longitudinal study

PURPOSE

The main research aim was to inspect whether pre-operative body shape concerns and discomfort as Body Shape Questionnaire (BSQ) scores moderate post-operative weight loss trajectory in bariatric patients.

METHODS

Two studies were conducted. Study 1 analyzed cross-sectional data and verified the structural validity of the 34-item BSQ questionnaire on a sample of 327 candidates for bariatric surgery. Study 2 examined longitudinal data, with objective Body Mass Index (BMI) recorded every 6 months, from surgery intervention on, with 5 measurement occasions, from 111 patients who initially completed BSQ as bariatric surgery candidates and then underwent periodic medical post-operative follow-ups, over 2 years.

RESULTS

In Study 1, confirmatory factor analysis of a single-dimension model yielded acceptable fit indices and high internal consistency levels. Study 2 showed that post-operative excess BMI reduction trend was not linear and pre-operative BSQ scores moderated it, with a higher risk of weight regain in patients who initially were less concerned with their body shape.

CONCLUSIONS

The present findings support the structural validity of the BSQ questionnaire in bariatric candidates and call attention on the role of pre-operative body shape concerns on post-operative weight loss trajectories over 2 years, in accordance with a pathoplasty model. They suggest the need for systematic attention on perceived body image and psychological paths aimed to help bariatric patients regain positive attitudes towards their own body. Level of evidence III, well-designed cohort.

Stress, Anxiety, and Depression Before and Twelve Months After Bariatric Surgery: Repeated Cross-sectional Study

Background

Bariatric surgery (BS) is an effective therapy for those who are excessively obese. However, the consequences of surgery on mental health are still debatable. We aimed to investigate the patients' depression, stress, and anxiety levels before and after BS at two different times: just before surgery and 12 months later.

Methods

This is a repeated cross-sectional study. The Depression Anxiety Stress Scale (DASS-21) was used to assess depression, anxiety, and stress levels.

Results

There were 288 participants in the BS groups. Changes in anxiety, stress, and depressive symptoms over time were examined using generalised estimating equations models with repeated measurements per individual. Anxiety (incidence rate ratio [IRR] = 1.2, p < .001) and stress (IRR = 0.86, p < .001) worsened, whereas depression (IRR = -1.8, p < .001) improved significantly in 288 patients one year after BS.

Conclusions

BS had significant impacts on obesity-associated mental health issues.

The role of anxiety and depression in understanding the relationship between coping and weight loss 24 months after bariatric surgery

BACKGROUND

The relationship between coping (i.e., how a person deals with stress) and weight loss after bariatric surgery is relatively inconsistent. Anxiety and depression may contribute to the lack of consistent findings in this area. It is possible that coping, including interpersonal, intrapersonal, and maladaptive coping, predicts weight loss among individuals with higher levels of anxiety or depression but not among those with lower levels of anxiety and depression.

OBJECTIVE

The aim of this study was to examine the moderating role of anxiety and depression on the association between coping and weight loss in patients 24 months after bariatric surgery.

SETTING

University Hospital, West Virginia, U.S.A.

METHODS

Participants included 841 patients who underwent bariatric surgery, 396 of whom had 24-month weight loss data (mean age, 43.21 yr [SD, ±11.40 yr]). We ran 3 moderation models to test whether the relationship between various coping styles and postoperative weight loss was moderated by anxiety and depression symptoms.

RESULTS

There was a statistically significant interaction between anxiety and depression on the association between interpersonal coping and percent excess weight loss (%EWL). Anxiety and depression also moderated the relationship between maladaptive coping and %EWL. Anxiety and depression did not moderate the association between intrapersonal coping and %EWL, but intrapersonal coping positively predicted %EWL at 24 months after bariatric surgery.

CONCLUSIONS

Maladaptive coping predicted less weight loss for patients with high levels of anxiety and/or depression. Interpersonal coping predicted more weight loss for patients with low levels of anxiety and/or depression. Clinicians should take patient levels of anxiety and depression into account when making recommendations to promote weight loss among patients pursuing bariatric surgery.

Longitudinal trajectories and psychological predictors of weight loss and quality of life until 3 years after metabolic and bariatric surgery

OBJECTIVE

This study aimed to describe longitudinal trajectories of Total Weight Loss (%TWL), and mental and physical health related quality of life (HRQOL), as well as to identify preoperative psychological predictors of these trajectories.

METHODS

A prospective observational study including Dutch patients treated with metabolic and bariatric surgery (n = 420, age 44.8 ± 10.3 years, 78.6% females) was performed. Trajectories of %TWL and HRQOL from screening to 1-, 2-, and 3-years post-surgery were described using growth mixture modelling. Multivariable and lasso regression models were used to identify predictors.

RESULTS

Three trajectories described %TWL, varying in the degree of first-year weight loss. No pre-surgical psychological factors were associated with %TWL trajectories. We identified four physical and five mental HRQOL trajectories. Approximately 25-30% of patients exhibited patterns of initial improvements followed by decline, or persistently low levels of HRQOL. Higher depressive symptoms were associated with these unfavourable physical HRQOL trajectories (OR 1.20, 95%CI 1.04-1.39), adjusted for confounders. Unfavourable mental HRQOL trajectories were predicted by depressive and anxiety symptoms, neuroticism, insecure attachment, and maladaptive coping. In contrast, self-esteem, extraversion, and conscientiousness were associated with favourable mental HRQOL trajectories.

DISCUSSION

Psychological factors did not predict weight loss, but they significantly impacted patient's HRQOL after metabolic and bariatric surgery. A subgroup with unsuccessful HRQOL after surgery was identified, who would benefit from tailored preoperative counselling to optimize surgery outcomes. Metabolic and bariatric surgery may not be universally beneficial for all patients, challenging the conventional approach to surgical interventions for severe obesity and advocating for a more nuanced, individualized assessment of potential candidates.

Psychological predictors of adherence to lifestyle changes after bariatric surgery: A systematic review

Objective

Adherence to lifestyle changes after bariatric surgery is associated with better health outcomes; however, research suggests that patients struggle to follow post-operative recommendations. This systematic review aimed to examine psychological factors associated with adherence after bariatric surgery.

Methods

PubMed, PsycInfo, and Embase were searched (from earliest searchable to August 2022) to identify studies that reported on clinically modifiable psychological factors related to adherence after bariatric surgery. Retrieved abstracts (n = 891) were screened and coded by two raters.

Results

A total of 32 studies met the inclusion criteria and were included in the narrative synthesis. Appointment attendance and dietary recommendations were the most frequently studied post-operative instructions. Higher self-efficacy was consistently predictive of better post-operative adherence to diet and physical activity, while pre-operative depressive symptoms were commonly associated with poorer adherence to appointments, diet, and physical activity. Findings were less inconsistent for anxiety and other psychiatric conditions.

Conclusions

This systematic review identified that psychological factors such as mood disorders and patients' beliefs/attitudes are associated with adherence to lifestyle changes after bariatric surgery. These factors can be addressed with psychological interventions; therefore, they are important to consider in patient care after bariatric surgery. Future research should further examine psychological predictors of adherence with the aim of informing interventions to support recommended lifestyle changes.

Finding what works-Patients' long-term experiences of weight maintenance post bariatric surgery: A systematic review and thematic synthesis of qualitative studies

Individuals with obesity can attain significant weight loss in a relatively short timeframe following bariatric surgery; however, new healthy behaviors must be sustained in perpetuity to maintain weight loss. This study investigates patients' views on the facilitators and barriers to long-term weight loss maintenance following bariatric surgery. Systematic searches of Medline, PsycINFO, and CINAHL databases identified 403 studies with 15 fitting the study inclusion criteria. Included studies were independently appraised using Critical Appraisal Skills Program (CASP). Data extraction and thematic synthesis generated three themes: changing food relationships, navigating inter- and intrapersonal influences, and caring health professionals. These appeared across six organizing sub-themes: building new food relationships, creating healthy habits, relationships with others, internalized stressors, finding and defining success, and ongoing patient education. Patients experienced a variety of barriers and facilitators to weight loss maintenance, with some facilitators diminishing over time. The findings demonstrate the importance of considering patients' perspectives and individual contexts to assist them to negotiate and overcome challenges to long-term weight loss maintenance post-bariatric surgery.

Attachment style and post-bariatric surgery health behaviours: the mediating role of self-esteem and health self-efficacy

BACKGROUND

Attachment avoidance and anxiety have been linked to overweight and poor health behaviours, yet the mechanisms that underpin the relationship between attachment and health behaviours are not fully understood. Self-esteem and self-efficacy have been found to differ between attachment styles, rendering these variables potential mediators of the relationship. This longitudinal study investigated the serial mediation between preoperative attachment and 2-year post-operative health behaviours through self-esteem and health self-efficacy.

METHODS

Participants were 263 bariatric surgery patients (75.7% females, aged 47.7 ± 10.4 years, BMI 38.9 ± 3.6 kg/m2) assessed before the operation and again one and two years after the surgery. Patients completed the Experiences for Close Relationships Brief Scale, Rosenberg Self-esteem scale, Weight Efficacy Lifestyle Questionnaire, Bariatric Surgery Self-Management Questionnaire, Exercise Self-Efficacy Scale and the Exercise Behaviour Scale.

RESULTS

Higher preoperative attachment anxiety and avoidance were associated with lower self-esteem one year after bariatric surgery and poorer health self-efficacy two years after the surgery. Self-esteem and health self-efficacy mediated the relationships between preoperative anxious and avoidant attachment and 2- year post-operative diet adherence and physical activity.

CONCLUSIONS

Helping patients to feel more worthy and reinforcing their beliefs about their own competences could lead to higher engagement with healthy lifestyle and adherence to treatment protocols, ultimately helping patients to achieve their goals for bariatric surgery.

CLINICAL TRIAL REGISTRATION

BARIA: Netherlands Trial Register: NL5837 (NTR5992) https://www.trialregister.nl/trial/5837 . Diabaria: ClinicalTrials.gov identifier (NCT number): NCT03330756.

Eating disorders and emotional dysregulation are associated with insufficient weight loss after bariatric surgery: a 1-year observational follow-up study

PURPOSE

Subjects with obesity, especially those seeking bariatric surgery, exhibit high rates of mental disorders and marked psychopathological traits. The primary objective of this prospective, non-interventional study was to investigate whether the presence of different psychiatric disorders, attention deficit/hyperactivity disorder (ADHD) symptomatology and emotional dysregulation influenced weight loss at 1-year follow-up after surgery.

METHODS

Subjects consecutively referred for pre-surgical evaluation at the Obesity Center of Pisa University Hospital were recruited. Psychiatric diagnoses were made through the Mini-International Neuropsychiatric Interview (MINI) and ADHD symptomatology was assessed with the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). Emotional dysregulation was investigated through the WRAADDS and self-report questionnaires. After surgery, weight and obesity-related comorbidities were monitored during follow-up.

RESULTS

Of the 99 participants recruited, 76 underwent surgery and 65 could be reevaluated 1 year after surgery. Subjects with insufficient weight loss (excess body mass index loss ≤ 53%, n = 15) had more frequent lifetime binge eating disorder (BED) and BED-mood disorders comorbidity than subjects with favorable post-surgical outcome. Additionally, they scored higher on both physician-administered and self-report scales assessing emotional dysregulation, which represents a nuclear symptom of ADHD in adults. At the logistic regression analysis, older age, higher preoperative excess body mass index and greater affective instability were predictors of reduced weight loss at 1-year follow-up.

CONCLUSION

Emotional dysregulation seems to be associated with a worse outcome after bariatric surgery. Further studies with larger samples and longer follow-up are needed to confirm the influence of different psychiatric disorders and psychopathological traits on post-surgical outcome.

LEVEL OF EVIDENCE

V, prospective descriptive study.

Childhood Maltreatment in Patients Undergoing Bariatric Surgery: Implications for Weight Loss, Depression and Eating Behavior

We aimed to explore the relationships between childhood maltreatment and changes in weight, depressive symptoms and eating behavior post-bariatric surgery (BS). Participants (n = 111, 85% females) were evaluated pre-surgery, and at 6 months (6 M) and 12 months (12 M) post-BS. History of maltreatment was assessed at baseline (Childhood Trauma Questionnaire), and depressive symptoms (Beck Depression Inventory-II) and eating behavior (Dutch Eating Behavior Questionnaire) were assessed at all time points. Participants' mean age and median BMI were 45.1 ± 11.7 years and 46.7 (IQR 42.4-51.9) kg/m², respectively. Histories of emotional (EA), physical (PA) and sexual abuse (SA) and emotional (EN) and physical (PN) neglect were reported by 47.7%, 25.2%, 39.6%, 51.4% and 40.5%, respectively, with 78.4% reporting at least one form of maltreatment. Changes in weight and depressive symptoms were not different between patients with vs. without a history of maltreatment. However, those with vs. without SA demonstrated limited changes in emotional eating (EE) at 12 M, while those without showed improvements. Conversely, patients with vs. without EN showed greater improvements in external eating (ExE) at 6 M, but differences were no longer observed by 12 M. Results indicate that histories of SA and EN are associated with changes in eating behaviors post-BS and have implications for assessment, monitoring and potential intervention development.

Psychiatric, psychological and addiction management in obesity surgery: Early identification for better support

Although bariatric surgery results in a significant weight reduction and an improvement in the quality of life in most people who undergo surgery, there are inter-individual differences in terms of postoperative results. Psychological, psychiatric and addictive disorders contribute substantially to these difficulties. Between 20% and 50% of bariatric surgery candidates have a current psychiatric/addictive disorder and approximately 30-75% have a history of a psychiatric/addictive disorder within their lifetime. Surgery is accompanied in the short-term by an improvement in depressive symptoms and binge eating, but these symptoms tend to increase again beyond the 3rd postoperative year. Over the long-term, only the improvement in depression remains durable, whilepostoperative anxiety and disordered eating symptoms do not differ significantly from the preoperative levels. There is a two to four fold increased risk of post-surgical suicide and suicide attempts (from the 1st postoperative year onward), as well as an increased risk of alcohol-abuse (beyond two years after surgery). Psychological support must therefore continue long-term. Several psychotherapeutic and pharmacological treatments have demonstrated their effectiveness in improving the postoperative prognosis of patients with psychological/psychiatric disorders. The early integration of psychological/psychiatric/addiction evaluation and support into multidisciplinary management makes it easier to identify these difficulties and to optimize the postoperative prognosis, both in terms of weight and quality of life. Prior to surgery, patients should be systematically evaluated by a psychologist or psychiatrist in order to identify and to manage disorders that could negatively impact the postoperative prognosis. After surgery, this assessment and support can be carried out in a programmed and systematic way for those patients who were identified preoperatively as the most vulnerable, but support can also be offered during follow-up in the event of specific symptoms (i.e., loss of control over food intake, failure in terms of weight or quality of life, suicidal ideation, loss of control over alcohol use, significant depression or anxiety symptoms).

Do reasons for undergoing bariatric surgery influence weight loss and health-related quality of life?-A Swedish mixed method study

Background

A wish for improved health or avoidance of ill health is often given as reason for wanting to undergo bariatric surgery. How such reasons relate to postoperative outcome is unclear.

Objective

The aim was to explore Swedish patients’ reasons for undergoing bariatric surgery. Also, we wanted to analyze if there were sex and age differences and associations with weight loss and health-related quality of life (HRQoL).

Settings

This was a single-center study conducted at a university hospital.

Method

Data on 688 patients (528 women and 160 men) including a free text response was analyzed inductively and deductively using predefined statements and was merged with data from the Scandinavian Obesity Surgery Registry. All data was analyzed using descriptive and analytic statistics.

Result

The most common reason for undergoing bariatric surgery was pain in different body parts. A wish for an improved medical condition was reported by most patients (59%, n = 408), followed by physical limitations making daily life difficult (42%, n = 288). Men and women reported similar reasons. Younger patients were more distressed about physical appearance (p = 0.001) and older patients wanted to improve their medical condition (p = 0.013). Health-related quality of life improved irrespective of reasons for undergoing surgery.

Conclusion

The most reported reasons for undergoing bariatric surgery were a wish for improved medical condition and to make daily life easier. Factors associated with the decision for surgery showed that there were few sex differences, but age seemed to be a factor. The HRQoL trajectory showed improvement regardless of reasons for undergoing surgery.

Early Postoperative Weight Loss Predicts Weight Loss up to 5 Years After Roux-En-Y Gastric Bypass, Banded Roux-En-Y Gastric Bypass, and Sleeve Gastrectomy

Purpose

Previous studies showed that patients with lower weight loss after bariatric surgery could be identified based on early postoperative weight loss. However, these studies had only 12–36-month follow-up. This study aimed to explore whether patients in the lowest weight loss quartile at 3 months had lower weight loss trajectories up to 5 years after Roux-en-Y gastric bypass (RYGB), banded Roux-en-Y gastric bypass (BRYGB), and sleeve gastrectomy (SG) surgery.

Methods

Weight was assessed preoperatively, and 3, 6, 9, 12, 24, 36, 48, and 60 months postoperatively. Patients were grouped into four categories based on quartiles of percentage total weight loss (%TWL) at 3-month follow-up. Results were compared between the lowest %TWL quartile group and other quartile groups.

Results

Patients underwent either RYGB (n=13,106; 72%), SG (n=3585; 20%), or BRYGB (n=1391, 8%) surgery. Weight loss trajectories of patients in the lowest %TWL quartile group remained lower than that of other quartile groups throughout a 5-year follow-up, for all three types of surgery. Patients in the lowest %TWL quartile group had higher age at surgery, higher baseline BMI, and were more likely to be male (in the SG group), and to suffer from diabetes, hypertension, dyslipidemia, and osteoarthritis.

Conclusion

This study showed a positive association between weight loss at 3 and 12 to 60 months after bariatric surgery. Weight loss at 3 months after surgery could be used to identify patients whose anticipated weight loss trajectories are below average, to potentially improve their outcomes through early behavioral or medical interventions.

Graphical Abstract

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.

The role of cognitive flexibility in weight loss after severe obesity surgery-A retrospective study

Cognitive flexibility (CF) is a fundamental skill for behavioural regulation and adaptation during the weight-loss process. Research suggests that bariatric surgery (BS) candidates underperform consistently in the Wisconsin Card Sorting Test (WCST), which is a neuropsychological instrument that measures this ability. The current study explored the predictive value of preoperative performance in WCST CF dimensions alongside relevant psychological factors on weight loss after BS. The sample comprised 100 female patients who underwent BS in a public hospital in Lisbon, Portugal. We collected data using the WCST, the Hopkins Symptom Checklist-90-Revised (SCL-90-R), and the Binge Eating Scale (BES). Multiple linear regression (MLR) analyses were performed to obtain explanatory models of total weight loss at 12- and 24-postoperative months (TWL₁ and TWL₂ , respectively). MLR identified the number of preservative responses as a highly significant predictor of TWL₁ (p < 0.01)_, and the SCL-90-R obsession-compulsion and anxiety indices as highly significant predictors of TWL₁ and TWL₂ (p < 0.01). The number of preservative responses was a relevant predictor of weight loss at 12 months. Persisting in maladaptive cognitive strategies was associated with a lesser weight loss during the important period after BS that requires the adoption new lifestyle habits.

Impact of bariatric surgery on depression, anxiety and stress symptoms among patients with morbid obesity: international multicentre study in Poland and Germany

BACKGROUND

There is a need to investigate how adopting different strategies for treating obesity in different countries in the European Union affects the psychological well-being of patients.

AIMS

The aim of this study was to perform a comparative evaluation of psychiatric symptoms (depression, anxiety and stress) in patients undergoing bariatric surgery versus patients receiving conservative treatment for morbid obesity in Poland and Germany.

METHOD

A multicentre international prospective cohort study with 155 patients who underwent bariatric surgery and 409 patients who received conservative weight reduction treatment. Evaluation of the psychiatric symptoms was carried out for each patient at baseline and after 12 months of active treatment using a standardised Depression Anxiety Stress Scale questionnaire (DASS-21) questionnaire.

RESULTS

After 12 months of active treatment, the level of psychiatric symptoms (depression, anxiety and stress) significantly decreased in both groups of patients: surgically treated versus conservatively treated patients from Poland and also from Germany. The median change in level of psychiatric symptoms among patients from both countries was significantly higher among surgically treated patients compared with conservatively treated patients (Poland P < 0.0001; Germany P < 0.0001). Improvements in the patient's mental health as a consequence of treatment were dependent on the specific strategy for treating obesity adopted in the analysed countries, the percentage of total weight loss and on gender.

CONCLUSIONS

The use of bariatric surgery in both Poland and Germany compared with non-surgical treatment for obesity resulted in more measurable benefits in the form of a decrease in psychiatric symptoms (depression, anxiety and stress) and reduction in body weight.

Psychosocial and behavioral correlates of weight loss 12 to 15 years after bariatric surgery

While significant weight loss occurs post-bariatric surgery, partial weight regain is common. Psychological and dispositional variables have been examined as predictors of weight change, but most studies have focused on the relationship of preoperative constructs to shorter-term postoperative outcomes. The goal of the current study was to examine associations between weight loss and postoperative psychosocial and behavioral factors up to an average of 13.7 years after surgery. The current study was conducted at a large bariatric center in a Midwestern U.S. city. The sample was comprised of 125 adult patients who participated in the second wave of a long-term bariatric surgery outcome study, examining weight history, physical activity, and psychological health and functioning. Correlations between percent total weight loss (%TWL) and psychosocial and behavioral variables were examined. The variables that had significant correlations with %TWL were used in stepwise linear regressions to determine their contribution to %TWL. These same variables were tested to determine differences among those in the highest and lowest weight loss quartiles. Life satisfaction, conscientiousness, positive affect, and regular exercise were positively associated with weight loss in the entire sample and were significantly higher among those in the highest versus the lowest weight-loss quartile. Experiencing a stressful event and food addiction symptoms were negatively associated with weight loss. Positive affect, fewer food addiction symptoms, and regular exercise significantly predicted weight loss, accounting for 23% of the variance in %TWL. Long-term weight loss maintenance after bariatric surgery may be related to positive affect, conscientiousness, regular physical activity, and an addictive-type relationship with food. Future studies should explore these relationships and develop approaches to deal with the interaction between dispositional tendencies and lifestyle factors.

Nutritional Assessment and Preparation for Adult Bariatric Surgery Candidates: Clinical Practice

Bariatric surgery (BS) has proven to be highly efficacious in the treatment of obesity and its comorbidities. However, careful patient selection is critical for its success. Thus, patients should undergo medical, behavioral, and nutritional assessment by a multidisciplinary team. From the nutritional point of view, BS candidates should undergo nutritional assessment, preparation, and education by a registered dietitian in the preoperative period. Currently, detailed specified and comprehensive information on these topics is lacking. The present narrative review aimed to summarize the available literature concerning both the preoperative nutritional assessment components and the preoperative nutritional preparation and education components of patients planning to undergo BS. Current literature indicates that proper management before BS should include a comprehensive nutritional assessment, in which it is advisable to perform a clinical interview to assess patients' medical background, weight management history, eating patterns and pathologies, oral health, physical activity habits, nutritional status, supplementation usage, BS knowledge, surgery expectations and anthropometric measurements. Nutritional preparation and educational strategies should include an individualized preoperative weight-loss nutrition program, improvement of glycemic control, micronutrients deficiencies correction, eating and lifestyle habits adaptation, physical activity initiation, and strengthening knowledge on obesity and BS. At this stage, more well-designed intervention and long-term cohort studies are needed in order to formulate uniform evidence-based nutritional guidelines for patients who plan to undergo BS, including populations at higher nutritional risk. Moreover, postoperative outcomes of presurgical nutritional intervention programs should be studied.

Understanding the Bariatric Patient Perspective in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study

BACKGROUND

In 2016, the Patient-Centered Outcomes Research Institute funded the National Patient Centered Clinical Research Network (PCORnet) Bariatric Study (PBS). Understanding the experience of postoperative patients was a key component of this study.

METHODS

Nine focus groups were conducted in Southern California, Louisiana, Pennsylvania, and Ohio and in a national advocacy conference for patients with obesity. Participants were identified and recruited in both clinical and community settings. Focus group transcripts were analyzed using an iterative inductive-deductive approach to identify global overarching themes.

RESULTS

There were 76 focus group participants. Participants were mostly women (81.4%), had primarily undergone gastric sleeve (47.0%), were non-Hispanic white (51.4%), had some college education (44.3%), and made $100,000 annual income or less (65.7%). Qualitative findings included negative reactions patients received from friends, family, and co-workers once they disclosed that they had bariatric surgery to lose weight; and barriers to follow-up care included insurance coverage, emotional and situational challenges, and physical pain limiting mobility.

CONCLUSIONS

These findings confirm the other qualitative findings in this area. The approach to bariatric surgery should be expanded to provide long-term comprehensive care that includes in-depth postoperative lifetime monitoring of emotional and physical health.

Negative Affect and Loss of Control Eating Among Bariatric Surgery Patients: an Ecological Momentary Assessment Pilot Investigation

BACKGROUND

Research shows that loss of control (LOC) eating impacts weight outcomes following bariatric surgery, but mechanisms explaining the development and/or maintenance of post-surgical LOC eating remain unclear. Ecological momentary assessment (EMA) research among eating disorder populations has demonstrated prospective relationships between negative affect (NA) and LOC eating; however, this momentary effect has not been examined among bariatric surgery patients. Thus, this study used EMA data to examine momentary relationships between NA and LOC eating among pre- and post-bariatric surgery patients.

METHODS

Fourteen pre- and 17 post-RYGB patients completed 2 weeks of EMA data collection. Participants responded to seven signals daily wherein they rated their mood and severity of LOC eating.

RESULTS

Higher momentary NA predicted more severe LOC eating for all participants. Group had a moderating effect, demonstrating that the association between NA and LOC eating was stronger among the post-surgery group. Percent total body weight loss (%TBWL) had a moderating effect within the post-surgery group, demonstrating that the relationship between NA and LOC eating was stronger for those who experienced less weight loss. Finally, between-subjects analyses revealed that, for individuals with lower %TBWL, lower overall NA and higher overall positive affect (PA) were related to greater LOC eating.

CONCLUSIONS

This research demonstrates that affect influences the effect of LOC eating on weight loss following bariatric surgery. While further work is needed to extend these preliminary findings, this research suggests that affective experience might become an important target in the assessment and treatment of LOC eating among bariatric patients.

Behavioral and psychological factors associated with suboptimal weight loss in post-bariatric surgery patients

PURPOSE

Bariatric surgery is the most effective long-term treatment for sustained weight loss in obesity. Studies have shown that not all patients lose the expected amount of weight. The aim of this study was to develop a better understanding of which behavioral and psychological factors are associated with suboptimal weight loss.

METHODS

The present paper describes a cross-sectional study that included 140 participants. The mean follow-up period after bariatric surgery was 3.16 years. Eating disorder pathology (Eating Disorder Examination-Questionnaire), impulsivity (Barratt Impulsiveness scale-II) and depressive symptoms (Beck Depression Inventory) were compared with successful and suboptimal participants. A weight loss of more than or equal to 50% of excess weight, was considered to be successful.

RESULTS

More than 81% of the participants met the criterion for successful weight loss. The suboptimal weight loss group reported more symptoms of eating disorder pathology (p = .001), more loss of control over eating (p = .001), and more avoidant behavior due to poor body image (p < .001). The suboptimal weight loss group scored higher on impulsivity (p = .007) and on depression (p < .001). More early weight loss was associated with better weight outcome later on (r = .491). Reporting more eating disorder pathology, a longer follow-up period and pre-operative super-obesity (body mass index ≥ 50 kg/m²) at the time of surgery were associated with poorer weight loss (p < .001).

CONCLUSION

Eating disorder pathology, loss of control over eating and avoidant behavior due to poor body image, as well as depressive symptoms and impulsivity, (as reported postoperatively) are associated with suboptimal weight loss. Level III: Case-control analytic study.

Preoperative psychological characteristics affecting mid-term outcome after bariatric surgery: a follow-up study

BACKGROUND

The purpose of this study was to investigate the relationship between preoperative psychological factors and percentage of total weight loss (%TWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB) to identify possible psychological therapy targets to improve the outcome of bariatric surgery.

METHODS

Seventy-six patients completed the Hamilton's Anxiety and Depression Scales (HAM-A, HAM-D) and Toronto Alexithymia Scale (TAS-20) the day before surgery (T0). The pre-operative body weight and the %TWL at 3 (T1), 6 (T2), and 24-30 (T3) months were collected.

RESULTS

At T3, depressed and alexithymic patients showed a lower %TWL compared to non-depressed patients (p = 0.03) and to non-alexithymic patients (p = 0.02), respectively. Finally, patients who had at least one of the three analyzed psychological factors showed less weight loss, at T2 (p = 0.02) and T3 (p = 0.0004).

CONCLUSIONS

Psychological factors may also affect long-term outcome of bariatric surgery. This study shows an association between alexithymia/depression pre-operative levels and the weight loss at 30 months'follow-up after bariatric surgery.

LEVEL OF EVIDENCE

Level III, longitudinal cohort study.

Weight Regain and Insufficient Weight Loss After Bariatric Surgery: Definitions, Prevalence, Mechanisms, Predictors, Prevention and Management Strategies, and Knowledge Gaps-a Scoping Review

Some patients experience weight regain (WR) or insufficient weight loss (IWL) after bariatric surgery (BS). We undertook a scoping review of WR and IWL after BS. We searched electronic databases for studies addressing the definitions, prevalence, mechanisms, clinical significance, preoperative predictors, and preventive and treatment approaches including behavioral, pharmacological, and surgical management strategies of WR and IWL. Many definitions exist for WR, less so for IWL, resulting in inconsistencies in the reported prevalence of these two conditions. Mechanisms and preoperative predictors contributing to WR are complex and multifactorial. A range of the current knowledge gaps are identified and questions that need to be addressed are outlined. Therefore, there is an urgent need to address these knowledge gaps for a better evidence base that would guide patient counseling, selection, and lead to improved outcomes.

"I Want to Lose Weight and it Has to Be Fair": Predictors of Satisfaction After Bariatric Surgery

PURPOSE

Bariatric surgery (BS) is the most effective technique used to help patients with obesity achieve long-term weight loss. Although many patients report high levels of postoperative satisfaction after BS, some remain unsatisfied with their outcome. Studies of factors that predict postoperative satisfaction have yielded varying results. Weight loss has been identified as a predictor of satisfaction after BS, but debate remains concerning the impact of preoperative expectations and psychological variables. Furthermore, the relevance of attribution and perception of equity to postoperative satisfaction has not been evaluated in patients undergoing BS.

MATERIALS AND METHODS

We assessed preoperative expectations and the levels of body dissatisfaction, anxiety, and depression in 80 patients undergoing BS. Satisfaction, attribution, feeling of equity, and psychological variables were evaluated 6 months, 1 year, and 2 years after BS.

RESULTS

Weight loss and equity were the two predictors of satisfaction 6 months after BS. Body dissatisfaction was the main factor predicting satisfaction 1 year after BS, with equity and anxiety having smaller influences. Weight loss and equity were the factors predicting satisfaction 2 years after BS.

CONCLUSION

Our findings support previous results concerning the influence of weight loss on satisfaction after BS. The identification of equity as a factor associated with postoperative satisfaction raises questions regarding the impact of the comparisons made by the patient with others and the consequences of the messages they receive about BS. Moreover, our results underscore the importance of considering the patient's personal experience after BS and not just their weight loss.

Executive function in individuals with clinically significant weight loss via behavioral intervention

BACKGROUND

Executive function (EF) is associated with obesity development and self-management. Individuals who demonstrate or self-report poorer EF performance tend to have poorer short-term outcomes in obesity treatment. There may be distinct behavioral self-management strategies and EF domains related to initial weight loss as compared to weight loss maintenance.

OBJECTIVE

To characterize EF in individuals who achieved clinically significant weight loss via behavioral intervention and examine potential differences in EF between those who maintained versus regained lost weight.

METHODS

Participants who previously achieved ≥5% weight loss via lifestyle intervention were included (N = 44). "Maintainers" (n = 16) maintained this minimum level of weight loss for ≥1 year. "Regainers" (n = 28) regained some or all initially lost weight. Performance-based EF, intelligence quotient, health literacy, depression, anxiety, binge eating, demographics, and medical/weight history were assessed using a cross-sectional design. Descriptive statistics and age-, gender-, education-adjusted reference ranges were used to characterize EF. Analyses of covariance were conducted to examine EF differences between maintainers and regainers.

RESULTS

The sample consisted primarily of females with obesity over age 50. Approximately half self-identified as African-American. Decision-making performance was better in maintainers than regainers (p = 0.003, partη2 = 0.19). There were no differences between maintainers and regainers in inhibitory control, verbal fluency, planning/organization, cognitive flexibility, or working memory (ps > 0.05, partη2s = 0.003-0.07). At least 75% of the sample demonstrated average-above average EF test performance, indicated by scaled scores ≥13 or t-scores > 60.

CONCLUSIONS

Most individuals with obesity who achieved clinically significant weight loss via behavioral intervention had average to above average EF. Individuals who maintained (vs. regained) their lost weight performed better on tests of decision-making.

Assessment of depressive symptoms, self-esteem, and eating psychopathology after laparoscopic sleeve gastrectomy: 1-year follow-up and comparison with healthy controls

PURPOSE

The aim of this study was to assess depressive symptoms, self-esteem, and eating psychopathology in bariatric surgery patients at the preoperative period (t0) and at the 6-month (t1) and 12-month (t2) follow-ups after laparoscopic sleeve gastrectomy (LSG). A second aim was to investigate associations between these variables and weight loss.

METHOD

The study participants were 48 bariatric surgery candidates and 50 non-obese controls. Both groups underwent assessment with the Sociodemographic Data Form, Hamilton Depression Rating Scale (HDRS), Eating Disorder Examination Questionnaire (EDE-Q), and Rosenberg Self-esteem Scale (RSES). These assessments were repeated for the patient group at t1 and t2.

RESULTS

The HDRS, RSES, and EDE-Q scores were higher in the patients before LSG (t0) than in the control group. A significant progressive improvement was identified in the patient HDRS and RSES scores as well as EDE-Q weight and shape subscale scores at t1 and t2. However, the patient EDE-Q total and dietary restraint scores improved at t1 then stabilized. The patient EDE-Q eating concern subscale improved at t1, but then worsened. The patient HDRS scores at t2 were similar to the control group, but the EDE-Q and RSES scores were still higher than the control scores at t2. Regression analyses revealed no association between the preoperative scores and percent changes in postoperative scores for any scale and patient weight loss at t2.

CONCLUSION

Depressive symptoms, self-esteem, and eating psychopathology showed an improving trend in patients after LSG. However, some aspects of eating psychopathology worsened despite an initial improvement.

LEVEL OF EVIDENCE

III, prospective cohort and case-control study.

Influence of Weight Loss on Obesity-Associated Complications After Metabolic and Bariatric Surgery in Adolescents

OBJECTIVE

Following metabolic and bariatric surgery (MBS), most adolescents experience weight loss and improvement of many obesity-associated complications (OACs). The relationship between weight loss and remission of OACs after MBS in adolescents has not been well described.

METHODS

The Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) is a multi-institutional prospective observational study of adolescents who underwent MBS between 2007 and 2012. Lower-weight-loss responders (LWLRs) were defined as having <20% total body weight loss (TBWL) and higher-weight-loss responders (HWLRs) were defined as having ≥20% TBWL at 5 years after MBS. The prevalence of OACs was compared at baseline and 5 years after MBS.

RESULTS

Both LWLRs (n = 114) and HWLRs (n = 78) lost significant weight within the first year following MBS; however, the TBWL at 5 years for the LWLRs was 8.6% ± 9.5% compared with 33.8% ± 9.2% for the HWLRs. Those in the HWLR group were more likely to experience durable remission of composite dyslipidemia at 5 years, whereas there were no differences between groups in remission rates of all other OACs.

CONCLUSIONS

Greater weight loss after MBS in adolescents was associated with greater remission of composite dyslipidemia; however, remission of other OACs was not dependent on major sustained weight loss.

Psychological predictors of poor weight loss following LSG: relevance of general psychopathology and impulsivity

PURPOSE

After bariatric surgery (BS) a significant minority of patients do not reach successful weight loss or tend to regain weight. In recent years, interest for the psychological factors that predict post-surgical weight loss has increased with the objective of developing interventions aimed to ameliorate post-surgical outcomes. In the present study, predictive models of successful or poor weight loss 12 months after BS were investigated considering pre-surgery level of psychopathological symptoms, dysfunctional eating behaviors and trait impulsivity at baseline (pre-surgery).

METHODS

Sixty-nine patients with morbid obesity canditates for laparoscopic sleeve gastrectomy were assessed regarding metabolic and psychological dimensions. Successful post-surgery weight loss was defined as losing at least 50% of excess body weight (%EWL).

RESULTS

Logistic models adjusted for patient sex, age and presence of metabolic diseases showed that the baseline presence of intense psychopathological symptoms and low attentional impulsivity predict poor %EWL (< 50%), as assessed 12-month post-surgery.

CONCLUSIONS

The present findings suggest that intensity of general psychopathology and impulsivity, among other psychological factors, might affect post-surgery %EWL. Conducting adequate psychological assessment at baseline of patients candidates for BS seems to be crucial to orient specific therapeutic interventions.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Cognitive Behavioral Therapy Versus Usual Care Before Bariatric Surgery: One-Year Follow-Up Results of a Randomized Controlled Trial

BACKGROUND

Although early results of bariatric surgery are beneficial for most patients, some patients regain weight later. Cognitive behavioral therapy (CBT) has been suggested as a way to improve patients' psychological health and maintaining weight loss in the longer term. The added value of preoperative CBT to bariatric surgery was examined. Pre- and posttreatment and 1-year follow-up data are presented.

METHODS

In a multi-center randomized controlled trial, CBT was compared to a treatment-as-usual (TAU) control group. Measurements were conducted pre- and posttreatment/pre-surgery (T0 and T1) and at 1-year post-surgery (T2). Patients in the intervention group received 10 individual, weekly sessions of preoperative CBT focused on modifying thoughts and behaviors regarding eating behavior, physical exercise, and postoperative life style. Outcome measures included weight change, eating behavior, eating disorders, depression, quality of life, and overall psychological health.

RESULTS

Though no significant differences between conditions were found per time point, in the CBT, condition scores on external eating, emotional eating, depressive symptoms, and psychological distress decreased significantly more over time between pre- (T0) and posttreatment (T1) pre-surgery compared to TAU. No significant time x condition differences were found at 1-year post-surgery (T2).

CONCLUSIONS

Compared to TAU, preoperative CBT showed beneficial effects on eating behavior and psychological symptoms only from pretreatment to posttreatment/pre-surgery, but not from pre-surgery to 1-year post-surgery. Preoperative CBT does not seem to contribute to better long-term outcomes post-surgery. Recent studies suggest that the optimal time to initiate psychological treatment may be early in the postoperative period, before significant weight regain has occurred.

TRIAL REGISTRATION

https://www.trialregister.nl Identifier: Trial NL3960.

Course of depressive symptomatology and its association with serum uric acid in one-anastomosis gastric bypass patients

The changes in depressive symptomatology during the first year following one-anastomosis gastric bypass (OAGB) were evaluated and its association with uric acid (sUA). Fifty patients were included in this analysis. Beck Depression Inventory (BDI) for measuring depressive symptomatology, blood samples, and anthropometric measurements were assessed before (T0), at 6 (T6), and 12 months (T12) after surgery. There was a significant reduction in BDI total score at T6 (− 5.6 (95% CI − 2.1, − 9.1) points; p = 0.001) and at T12 (− 4.3 (95% CI − 0.9, − 7.9) points; p = 0.011). BMI loss was unrelated to depressive symptomatology. Patients with moderate to severe depressive symptomatology presented lower sUA levels than patients with none or minimal to mild (p = 0.028). ROC analysis revealed that sUA levels below 5.0 at T6 and 4.5 mg/dl at T12 had a prognostic accuracy for depression severity. Furthermore, delta sUA was significantly associated with delta BMI (β = 0.473; p = 0.012) and delta waist circumference (β = 0.531; p = 0.003). These findings support an improvement in depressive symptomatology in the first year postoperatively, however, without relation to BMI loss. Patients with moderate to severe depressive symptomatology presented with lower sUA levels over time. Therefore, sUA could be useful to predict moderate to severe depressive symptomatology in patients undergoing OAGB in clinical practice.

Bariatric surgery in patients with psychiatric comorbidity: Significant weight loss and improvement of physical quality of life

BACKGROUND

Patients that have psychiatric comorbidity are thought to lose less weight than the general bariatric population and are therefore sometimes denied surgery. However, there is no scientific evidence for this assumption. The aim of this study is to evaluate the weight loss and health-related quality of life (HRQoL) in patients with psychiatric disorders who undergo bariatric surgery and compare these patients with a general bariatric population.

METHOD

Patients who underwent bariatric surgery in 2015 were included. Patients who received individual counselling and had a current DSM IV axis 1 or 2 diagnosis were included in the psychiatric group (n = 163), all other patients in the generic group (n = 2362).Weight and HRQoL were assessed before and 12-, 24-, 36- and 48-months after surgery. Data was analysed using regression analyses.

RESULTS

The maximum total weight loss (TWL) was 27.4% in the psychiatric group vs 31.0% in the generic group. Difference in %TWL between the psychiatric and generic group was significant from baseline to all follow-up moments (P < .001). Improvement of PHS was significantly higher in the generic group from baseline to 12-month (P = .002), 24-month (P = .0018), 36-month (P = .025) and 48-monthfollow-up (P = .003). Change in mental HRQoL was only different comparing baseline to 48-monthfollow-up (P = .014).

CONCLUSION

Although weight loss and change in physical HRQoL was lower in patients with pre-operative psychiatric disorders, results of this group were still excellent. Thus, patients with psychiatric diagnoses benefit greatly from bariatric surgery and these patients should not be denied weight loss surgery.

Check point to get adequate weight loss within 6-months after laparoscopic sleeve gastrectomy for morbid obesity in Asian population

Purpose of this study is to develope a scoring system to predict the likelihood of excess body weight loss (EBWL) ≥ 50% 6-months after laparoscopic sleeve gastrectomy (LSG). From April 2016 to September 2018, data was collected from 160 patients (BMI ≥ 32) who underwent primary LSG with at least 6-months follow-up. They were separated into score generation (operated by one surgeon, n = 122) and validation groups (operated by 3 different surgeons, n = 38). EBWL at 6-months ≥ 50% was considered adequate weight loss. Independent variables including age, gender, initial body mass index (BMI), comorbidities, life-style habits, percentage of EBWL and percentage of total body weight loss at 1-week, 1-month, and 3-months were analyzed with mutivariate logistic regression to generate the scoring system. The system was applied to internal and external validation groups to determine efficacy. As results, between the score generation and internal validation groups, the only significant difference in patient characteristics was in exercise participation. EBWL at 1-month > 19.5% (1 point) and EBWL at 3-months > 37.7% (2 points) were identified as independent factors to predict EBWL at 6-months ≥ 50%. When scores were > 1, the system had 94.03% positive predictive value (PPV) and 81.82% negative predictive value (NPV) (AUC: 0.923). Internal validation scores > 1 had a 95.83% PPV and 85.71% NPV (AUC: 0.975). External validation results showed 88.59% PPV and 72.00% NPV (AUC: 0.802). We concluded that this scoring system provides a reliable, objective prediction of EBWL at 6-months ≥ 50%. Patients requiring more aggressive clinical follow-up and intervention can be detected as early as 1- to 3-months after LSG.

Are the Results of a Combined Behavioural and Surgical Treatment of Morbid Obesity Satisfactory and Predictable?

Treatment of subjects with morbid obesity (Body Mass Index (BMI) > 40 kg/m2 or > 35 kg/m2 with obesity-related complications) often fails. This study explored the biopsychosocial predictors of dropout and weight loss during a combined behavioural and surgical weight-reduction program. Behavioural treatment for six months was followed by bariatric surgery and a visit six months after surgery. The success criterion was the loss of ≥50% of excess BMI above 25 kg/m2 (%EBMIL). Thirty-one men and 113 women with BMI 43.5 kg/m2 (SD 4.3) and 41.8 kg/m2 (SD 3.6), respectively, were included; 115 underwent bariatric surgery (Gastric sleeve: 23; Roux-en-Y gastric bypass: 92), and 98 had a follow-up visit six months after surgery. The mean %EBMIL at follow-up was 71.2% (SD 18.5). Treatment success was achieved in 86 subjects. Assuming success in 17 subjects who did not attend the follow-up visit (best possible outcome), 103 out of 144 subjects (72%) achieved successful weight reduction. Cohabitation was the only predictor of accomplishing surgery. Neither weight loss during behavioural therapy nor biopsychosocial factors were found to be clinically significant predictors of weight loss after surgery. The success rate of less than three in four subjects was unsatisfactory. There is a need to improve the regimen and to determine effective alternative interventions.

Follow-up after bariatric surgery: A review

Bariatric surgery is becoming increasingly popular in the treatment of severely obese patients who failed to lose weight with the help of non-surgical interventions. Such patients are at increased risk for premature death, type 2 diabetes, high blood pressure, gallstones, coronary heart disease, dyslipidemia, some cancers, anxiety, depression, and degenerative joint disorders. Although bariatric surgery appears to be the most effective and durable treatment option for obesity, it is associated with a number of surgical and medical complications. These include a range of conditions, of which dumping syndrome and malnutrition due to malabsorption of vitamins and minerals are the most common. To achieve better surgery outcomes, a number of postsurgical strategies must be considered. The aim of this review was to describe possible complications, ailments, and important moments in the follow-up after bariatric surgery. Adequate lifelong monitoring is crucial for the achievement of long-lasting goals and reduction of post-bariatric complications.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Personality psychopathology: Longitudinal prediction of change in body mass index and weight post-bariatric surgery

OBJECTIVE

Bariatric surgery is an effective treatment for obesity, which has been increasing worldwide. However, bariatric surgery causes dramatic physical changes that can cause significant stress. Prior research has found that psychological variables such as personality traits and levels of psychopathology can influence success after bariatric surgery (in terms of body mass index [BMI] reduction and weight loss). However, most prior studies have been limited by small sample sizes, inconsistent follow up, and categorical assessment of psychopathology.

METHOD

The present study examines the predictive utility of the Personality Assessment Inventory (PAI) scales for three bariatric surgery outcomes (BMI reduction, weight loss, and percent excess weight loss [%EWL]) across 10 follow-up points 5 years after surgery. It also examines the largest sample of bariatric surgery-completing patients (N = 2,267) on the PAI to date. Latent growth modeling was used to examine change in the outcome variables.

RESULTS

Results indicate that personality and psychopathology variables predicted less BMI reduction, weight loss, and %EWL 5 years after surgery and also affected the trajectories of change in the outcome variables across time. The PAI scales predicted more variance in the 5-year BMI outcomes than did age and gender. The most robust effects were for scales assessing phobias, traumatic stress, identity problems, and negative relationships.

CONCLUSION

The PAI may be useful to clinical health psychologists who conduct recommended psychological evaluations with potential bariatric surgery candidates. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The Symptom-Checklist-K-9 (SCL-K-9) Discriminates between Overweight/Obese Patients with and without Significant Binge Eating Pathology: Psychometric Properties of an Italian Version

A general personality and psychopathology evaluation is considered to be crucial part of the multidisciplinary assessment for weight-related problems. The Symptom Checklist-90-Revised (SCL-90-R) is commonly used to assess general psychopathology in both overweight and obese patients seeking weight-loss treatment. The main purpose of the present research was to investigate the psychometric properties of the brief form of the SCL-90-R (i.e., the SCL-K-9) in a clinical sample (N = 397) of patients seeking weight-loss treatment (i.e., bariatric surgery and a nutritional weight-loss program). The results of the confirmatory factor analysis supported a one-factor solution of the SCL-K-9, with all nine items loading significantly on the common latent factor (lambdas ≥ 0.587). The ordinal α (= 0.91), the inter-item mean indices of correlation (rii = 0.53), and the convergent validity were also satisfactory. A receiver operating characteristic curves procedure showed that both SCL-90-R and SCL-K-9 were able to classify patients with and without significant binge eating pathology according to the Binge Eating Scale (BES) total score. Overall, our results suggest that the SCL-K-9 has adequate psychometric properties and can be applied as a short screening tool to assess general psychopathology in overweight/obese individuals seeking weight-loss treatment and at follow-up interviews when time restraints preclude the use of the full-length form.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

FABP2, LEPR223, LEP656, and FTO Polymorphisms: Effect on Weight Loss 2 Years After Bariatric Surgery

PURPOSE

Differences in weight loss outcomes after bariatric surgery may be related to individual preoperative characteristics. The aim of this study was to evaluate the potential effect of fatty acid binding protein-2 (rs1799883), leptin receptor (LEP223, rs1137101 and LEP656, rs1805094), and fat mass and obesity-related (rs9939609) genotypes on weight loss 2 years after bariatric surgery in Brazilian patients.

MATERIALS AND METHODS

Prospective observational study involving 105 patients (lost to follow-up, 25.7%). In the preoperative period, patients were clinically evaluated and a fasting blood sample for genetic analysis (by real-time DNA amplification technique) was collected. From the patient's medical records, follow-up weight loss (3, 6, 12, 24 months) was obtained. Percentage of excess weight loss (%EWL) was examined by pairwise comparison across the polymorphisms.

RESULTS

At baseline, the mean weight was 127.5 (23.3) kg and age 43.1 (10.9) years old. The %EWL was significant over time (p < 0.01). Only the LEP223 genotype showed association (p < 0.01). Up to 6 months after surgery, no differences were observed. At 12 months, a significant difference (p = 0.03) between AA (n = 19) and GG (n = 34) groups was observed, with 76.5% EWL versus 52.0%, respectively. This difference remained at 24 months. Other genotypes did not present any significant association.

CONCLUSIONS

There is a different evolution of weight loss in carriers of the LEP223 after bariatric surgery. The AA genotype seems to be associated with a higher weight loss. However, this pattern was evident only at 12 months after surgery.

Emotion Self-Regulation Moderates the Association Between Symptoms of ADHD and Weight Loss After Bariatric Surgery

BACKGROUND

This study aimed to examine the combined effect of pre-surgical emotion self-regulation (ESR) and symptoms of attention deficit hyperactivity disorder (sADHD, i.e., inattention, impulsivity, and hyperactivity) on weight loss 12 months following bariatric surgery independent of psychological distress and eating pathology.

METHODS

Adults with obesity were recruited from a bariatric surgery specialty clinic in Canada. Patients completed measures of psychological distress (i.e., Beck Depression Inventory II and Beck Anxiety Inventory), eating pathology (i.e., Eating Disorder Examination Questionnaire), ESR (i.e., "Managing Own Emotions" subscale of the Schutte Emotional Intelligence Test), and sADHD (i.e., Adult ADHD Self-Report Scale) prior to surgery. Measures of height and weight were obtained and used to calculate percent excess weight loss (%EWL) of body mass index (BMI) pre- and 12 months post-surgery.

RESULTS

Thirty-seven patients were recruited. The final sample consisted of 30 patients (80% female; mean age = 48 years; mean BMI = 49.32). Patients experienced significant weight loss and reported significant improvement in anxiety, depressed mood, and eating pathology from pre- to 12 months post-surgery. A significant sADHD by ESR interaction on %EWL (F(1, 21) = 6.43, p = .019) was observed and accounted for 13% of unique variance after adjusting for relevant covariates. Probing the interaction with the Johnson-Neyman technique indicated that there was a significant inverse association between sADHD and %EWL among individuals who scored ≤ 0.15 SD below the mean on ESR.

CONCLUSIONS

ESR moderated the association between sADHD and %EWL, suggesting that sADHD may attenuate weight loss following bariatric surgery among individuals deficient in ESR. This finding has implications for bariatric surgery pre-surgical psychological assessment.

Eating expectancies before bariatric surgery: assessment and associations with weight loss trajectories

BACKGROUND

While presurgical eating behaviors have demonstrated limited prognostic value, cognitions regarding the effects of eating may serve as important predictors of weight loss outcomes after bariatric surgery. The Eating Expectancies Inventory (EEI) is a commonly used, self-report measure of expected consequences of eating; however, its psychometric and predictive properties have not yet been evaluated among bariatric surgery patients.

OBJECTIVES

This study sought to examine the factor structure and internal consistency of the EEI among bariatric surgery candidates, to examine relationships between EEI factors and measures of eating psychopathology, and to explore the effects of eating expectancies on postsurgical weight loss.

SETTING

Data originated from an interdisciplinary bariatric surgery center in the Midwest United States.

METHODS

Two hundred sixty-two women completed self-report questionnaires before bariatric surgery. Presurgical data and available postsurgical weights (at 6, 12, and 18 mo) were obtained from medical records.

RESULTS

Analyses indicated that the original 5-factor model was a good-to-excellent fit for the EEI data. All EEI factors demonstrated good reliability and were significantly associated with eating disorder symptoms and behaviors at baseline. Higher scores on EEI Factor 1 (negative affect) and Factor 5 (alleviates boredom) predicted poorer weight loss at 18 months postsurgery (n = 132).

CONCLUSIONS

Findings support the reliability and validity of the EEI among female bariatric candidates. Presurgical eating expectancies were linked to pathologic eating patterns and also predicted postsurgical weight loss trajectories, suggesting that eating expectancies may have prognostic value as predictors of bariatric surgery outcomes.