Evaluating preoperative weight loss, binge eating disorder, and sexual abuse history on Roux-en-Y gastric bypass outcome

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.

Is binge eating associated with poor weight loss outcomes in people with a high body weight? A systematic review with meta-analyses

OBJECTIVES

This systematic review aimed to compare the weight change in people with or without binge eating who underwent various weight loss treatments.

METHODS

We searched for studies in PubMed, American Psychological Association, and Embase from inception to January 2022. The studies selected included assessment of binge eating and body weight before and after weight loss treatment in people of any age. The meta-analyses were conducted using Comprehensive Meta-Analysis (CMA). We used Egger's regression test, the funnel plot, and the Trim and Fill test to assess the risk of publication bias.

RESULTS

Thirty-four studies were included in the systematic review, with a total of 10.184 participants. The included studies were divided into three categories according to types of weight loss treatments, namely, (1) bariatric surgery; (2) pharmacotherapy isolated or combined with behavioral interventions; and (3) behavioral and/or nutritional interventions. The meta-analyses showed no significant difference in weight loss between people with or without binge eating engaged in weight loss treatments, with an overall effect size of - 0.117 (95% CI - 0.405 to 0.171; P = 0.426).

CONCLUSIONS

Our findings showed no difference in weight loss in people with or without pre-treatment binge eating who received various weight loss treatments. Weight loss treatments should not be withheld on the basis that they will not be effective in people with pre-treatment binge eating, albeit their safety and longer term impacts are unclear.

LEVEL OF EVIDENCE

Level I, at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies.

History of abuse and bariatric surgery outcomes: a systematic review

BACKGROUND

Although there is evidence to support the relationship between abuse history and obesity, the association between abuse history and outcomes after bariatric surgery is not well-established. We aimed to summarize the current literature examining this relationship, as well as provide clinical recommendations to optimize postoperative outcomes.

METHODS

PubMed and SCOPUS databases were queried to identify relevant published studies.

RESULTS

Overall, 20 studies were included. Rates of the various types of abuse reported in the bariatric surgery population varied widely across studies, as did the methodology used to assess it. The majority of studies found no significant associations between abuse history and postoperative weight loss outcomes. The literature examining the relationship between abuse history and postoperative psychiatric outcomes was less conclusive.

CONCLUSIONS

Most current evidence demonstrates that abuse history is not associated with weight loss outcomes after bariatric surgery. Literature on postoperative psychiatric outcomes is mixed, and more robust studies are needed to further investigate the relationship between abuse history and postoperative psychiatric outcomes. Importantly, abuse history should not preclude patients from undergoing bariatric surgery. Of note, patients may benefit from careful monitoring for emotional distress and worsening of psychiatric comorbidities after surgery and psychiatric counseling and treatment when indicated.

Preoperative Binge Eating and Weight Loss After Bariatric Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Several studies have investigated if bariatric surgery candidates with binge eating disorder (BED) are at risk for suboptimal postoperative weight loss. The aim of this systematic review with meta-analysis was to evaluate the association between binge eating diagnosed preoperatively and weight loss after bariatric surgery.

METHODS

MEDLINE, EMBASE, CENTRAL, LILACS, and other specialized databases were searched on August 2020. Clinical trials and observational studies including individuals who had undergone any type of bariatric surgical treatment with preoperative evaluation of BED and at least one postoperative measure of weight were initially selected. Four reviewers independently screened for eligibility. The mean difference was calculated using the random-effects model.

RESULTS

Nineteen studies, comprising 3223 participants (80.25% women; median age 41 years), met the inclusion criteria for meta-analysis. At 6 months postoperative, the percentage of total weight loss (%TWL) was not significantly different between BED and non-BED groups [6 studies, 914 participants: - 0.75% (95% CI, - 2.79 to 1.29; I² = 0%)], even when analyzing only those three studies that included gold standard assessment tools. No significant differences were found at 12, 24, 36, or 60 months.

CONCLUSIONS

Pre-bariatric BED seems to have little or no influence on weight loss after surgery. However, many questions remain unanswered because of the use of different measures across studies. The heterogeneity among studies emphasizes the importance of investigators using the same assessment measures.

Weight loss in adults following bariatric surgery, a systematic review of preoperative behavioural predictors

Bariatric surgery is effective in treating obesity in many cases, yet as many as 50% of patients may not achieve the desired weight reduction. Preoperative modifiable behavioural factors could help patient selection and intervention design to improve outcomes. Medline, EMBASE, Cochrane Library and PsychINFO were searched to identify studies published between 1 January 2008 and 14 February 2019 reporting on preoperative modifiable behavioural factors associated with postoperative weight loss, with minimum 2 years follow-up. A total of 6888 articles were screened, 34 met the inclusion criteria. Maladaptive eating behaviours (MEB), preoperative weight loss (PWL), and tobacco use were reported 21, 18, and 3 times respectively. Physical activity and substance abuse were each reported once. Most articles on PWL (72.2%) and MEB (52.4%) reported no association. Positive associations were reported in 22.2% and 14.3% of articles for PWL and MEB respectively. Negative associations were reported in 5.6% and 33.3% of articles for PWL and MEB, respectively. Marked heterogeneity in outcome reporting hindered quantitative synthesis. The current paucity of evidence amenable to synthesis leads to ongoing uncertainty regarding the size and direction of association between PWL and MEB with outcomes following bariatric surgery. Long-term studies with common reporting of outcomes are needed.

Influence of Preoperative Weight Loss on Outcomes of Bariatric Surgery for Patients Under the Enhanced Recovery After Surgery Protocol

INTRODUCTION

The enhanced recovery after surgery (ERAS) protocol, which emphasizes preoperative interventions, is safely implemented in patients undergoing bariatric surgery. Patients are additionally encouraged to achieve weight loss preoperatively. We aimed to identify factors contributing to preoperative weight loss and assess their influence on outcomes of bariatric surgery among patients under the ERAS protocol.

MATERIALS AND METHODS

We reviewed a prospectively created database in two bariatric centers with 909 bariatric patients treated in accordance with ERAS principles. The database included demographic characteristics, factors related to the surgery or perioperative period, and short-term outcomes. Our endpoints included analyses of (1) factors potentially contributing to preoperative weight loss and (2) the influence of preoperative weight loss on short-term outcomes of bariatric treatment.

RESULTS

Diabetes mellitus (p = 0.007), obstructive sleep apnea (p < 0.001), and previous surgery (p = 0.012) were identified as predictors of preoperative weight loss. Steatohepatitis (p < 0.001) and respiratory disorder (p = 0.004) decreased the chance of achieving satisfactory preoperative body mass reduction. Except for operative time, early outcomes of bariatric surgery were not influenced by preoperative weight loss. Patients who achieved preoperative weight loss were less likely to be lost to follow-up (p = 0.023). Postoperative weight loss was better in patients who could lose ≥ 5% total weight preoperatively (p = 0.009).

CONCLUSION

Unsatisfactory preoperative weight loss among patients treated under ERAS principles is not associated with increased risk of complications. Satisfactory preoperative weight loss predicts superior postoperative weight loss and follow-up participation.

Relationships Between a History of Abuse, Changes in Body Mass Index, Physical Health, and Self-Reported Depression in Female Bariatric Surgery Patients

Background/Objectives: A history of physical and sexual abuse has been implicated in weight gain. Although bariatric surgery is effective for weight loss in severely obese individuals, we investigated whether bariatric surgery patients who self-report a history of physical and/or sexual abuse have differential outcomes regarding weight loss, body mass index (BMI), quality of life (SF-36), and depressive symptoms (Center for Epidemiologic Studies Depression [CESD]) compared with nonabused patients. Materials and Methods: Standardized assessments at baseline and follow-up visits were performed on 103 obese (BMI >35) female bariatric surgery patients (mean age: 44.11 years, standard deviation: 11.67 years). Results: In total 49.5% of participants reported abuse. Abused group had significantly higher BMI (p < 0.01) and depression scores (p < 0.01). After surgery, the BMI between the two groups was no longer significantly different, although the abused group remained significantly more depressed. Mixed models showed that abuse was associated with CESD scores (p < 0.01) and SF-36 mental composite scores (p = 0.03) after adjusting for smoking history. Conclusion: Bariatric surgery leads to a better weight loss in abused patients. Abuse history might be an additional factor for clinicians to consider when advising bariatric surgery, as our study suggests that women with history of abuse may have a higher weight loss benefit but less mental health improvement from the intervention.

Interpersonal Abuse and Long-term Outcomes Following Bariatric Surgery

BACKGROUND

History of abuse may impact weight loss (WL) following bariatric surgery. Some investigations have indicated slower WL rates among patients reporting abuse; however, among studies with multiple assessments, significant differences in WL are not evidenced at later measurement. Few investigations have extended follow-up beyond 18 months, limiting understanding of the impact of abuse on weight trajectory over time. Furthermore, existing research has insufficiently accounted for forms of interpersonal trauma beyond sexual abuse (i.e., emotional, physical) that may impact WL and other health outcomes.

OBJECTIVES

To determine whether post-surgical percent total WL (%TWL) and specific clinical outcomes are differentially impacted by history of interpersonal abuse.

SETTING

Large, comprehensive medical center.

METHODS

Retrospective data was collected from patients who underwent bariatric surgery at a single center (N = 433). Based on pre-surgical interview, patients were grouped according to reported history of interpersonal abuse (Y/N). Nonlinear repeated measures regression examined impact of abuse history on %TWL, and clinical selequae.

RESULTS

Differences in %TWL at 6, 12, 18, 24, and 36 months post-surgically did not differ significantly. Further, %TWL did not differ across time, according to group. A significantly greater number of those with history of interpersonal abuse had a clinical diagnosis of depression as compared with those not reporting interpersonal abuse (38% vs. 22% respectively), p < .001.

CONCLUSIONS

Interpersonal abuse history does not negatively impact %TWL post-surgically but is associated with diagnosis of depression, indicating depressive symptoms may be a viable clinical intervention target for surgery patients with interpersonal trauma history.

Meta-analysis of the influence of lifestyle changes for preoperative weight loss on surgical outcomes

Background

The aim was to investigate whether preoperative weight loss results in improved clinical outcomes in surgical patients with clinically significant obesity.

Methods

This was a systematic review and aggregate data meta-analysis of RCTs and cohort studies. PubMed, MEDLINE, Embase and CINAHL Plus databases were searched from inception to February 2018. Eligibility criteria were: studies assessing the effect of weight loss interventions (low-energy diets with or without an exercise component) on clinical outcomes in patients undergoing any surgical procedure. Data on 30-day or all-cause in-hospital mortality were extracted and synthesized in meta-analyses. Postoperative thromboembolic complications, duration of surgery, infection and duration of hospital stay were also assessed.

Results

A total of 6060 patients in four RCTs and 12 cohort studies, all from European and North American centres, were identified. Most were in the field of bariatric surgery and all had some methodological limitations. The pooled effect estimate suggested that preoperative weight loss programmes were effective, leading to significant weight reduction compared with controls: mean difference –7·42 (95 per cent c.i. –10·09 to –4·74) kg (P &lt; 0·001). Preoperative weight loss interventions were not associated with a reduction in perioperative mortality (odds ratio 1·41, 95 per cent c.i. 0·24 to 8·40; I2 = 0 per cent, P = 0·66) but the event rate was low. The weight loss groups had shorter hospital stay (by 27 per cent). No differences were found for morbidity.

Conclusion

This limited preoperative weight loss has advantages but may not alter the postoperative morbidity or mortality risk.

Weight Loss and Timing of J Tube Removal in Biliopancreatic Diversion with Duodenal Switch Patients Who Report Physical or Sexual Abuse

BACKGROUND

Bariatric surgery patients who report physical or sexual abuse form a sizeable cohort that stands out due to psychological comorbidity. Their possible vulnerability to suboptimal weight loss remains of interest. Their risk for malnutrition due to inadequate oral intake following surgery is underexplored.

OBJECTIVES

Study aims were to determine the effect of self-reported physical or sexual abuse in patients undergoing open biliopancreatic diversion with duodenal switch (BPD/DS) on (a) 3-year weight loss trajectories and (b) timing of feeding jejunostomy tube (J tube) removal. Delayed J tube removal served as an indicator for inadequate oral intake.

METHODS

In this retrospective cohort study, the sample (N = 189) consisted of all patients who underwent primary BPD/DS by the same surgeon during 2009 and 2010 at a Midwestern health system. All patients had a J tube placed during surgery. Longitudinal mixed models were used for testing differences in weight loss trajectories by abuse status.

RESULTS

There were no significant differences in weight loss trajectories by abuse status. The abused group had the J tube in place a mean of 61.9 days (SD = 39.5) compared to 44.8 days (SD = 32.8) for the not abused group, a significant difference.

CONCLUSIONS

Our use of the best available statistical methods lends validity to previous findings that suggest physical or sexual abuse does not affect weight loss after bariatric surgery. Increased likelihood of persistent inadequate oral intake in the abused group suggests the need for early multidisciplinary interventions that include mental health and nutrition experts.

Binge-eating disorder and the outcome of bariatric surgery in a prospective, observational study: Two-year results

OBJECTIVE

A previous study reported that preoperative binge-eating disorder (BED) did not attenuate weight loss at 12 months after bariatric surgery. This report extends the authors' prior study by examining weight loss at 24 months.

METHODS

A modified intention-to-treat population was used to compare 24-month changes in weight among 59 participants treated with bariatric surgery, determined preoperatively to be free of a current eating disorder, with changes in 33 surgically treated participants with BED. Changes were also compared with 49 individuals with obesity and BED who sought lifestyle modification for weight loss. Analyses included all available data points and were adjusted for covariates.

RESULTS

At month 24, surgically treated patients with BED preoperatively lost 18.6% of initial weight, compared with 23.9% for those without BED (P = 0.049). (Mean losses at month 12 had been 21.5% and 24.2%, respectively; P = 0.23.) Participants with BED who received lifestyle modification lost 5.6% at 24 months, significantly less than both groups of surgically treated patients (P < 0.001).

CONCLUSIONS

These results suggest that preoperative BED attenuates long-term weight loss after bariatric surgery. We recommend that patients with this condition, as well as other eating disturbances, receive adjunctive behavioral support, the timing of which remains to be determined.

Eating behavior and eating disorders in adults before bariatric surgery

OBJECTIVE

To describe eating patterns, prevalence of problematic eating behaviors, and determine factors associated with binge eating disorder (BED), before bariatric surgery.

METHOD

Before surgery, 2,266 participants (median age 46 years; 78.6% female; 86.9% white; median body mass index 45.9 kg/m(2) ) of the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study completed eating behavior survey items in the self-administered LABS-2 Behavior form. Other measures included the Alcohol Use Disorder Identification Test, the LABS-2 Psychiatric and Emotional Test Survey, the Beck Depression Inventory, the Interpersonal Support Evaluation List-12, the Short Form-36 Health Survey, and Impact of Weight Quality of Life-Lite Survey.

RESULTS

The majority (92.1%) of participants reported eating dinner regularly, whereas just over half (54.0%) reported eating breakfast regularly. Half of the participants reported eating at least four meals/week at restaurants; two meals/week were fast food. Loss of control eating was reported by 43.4%, night eating syndrome by 17.7%; 15.7% satisfied criteria for binge eating disorder (BED), 2% for bulimia nervosa. Factors that independently increased the odds of BED were being a college graduate, eating more times per day, taking medication for psychiatric or emotional problems, and having symptoms of alcohol use disorder, lower self-esteem and greater depressive symptoms.

DISCUSSION

Before undergoing bariatric surgery a substantial proportion of patients report problematic eating behaviors. Several factors associated with BED were identified, most suggesting other mental health problems, including higher levels of depressive symptomotology. The strengths of this study include the large sample size, the multi-center design and use of standardized assessment practices.

Depression and Disordered Eating in the Obese Person

Three mental health problems commonly associated with obesity are major depression, binge eating disorder (BED), and Night Eating Syndrome (NES). Evidence from both cross-sectional and longitudinal studies support independent relationships between obesity and depression, and between obesity and binge eating. These problems are most prevalent in severely obese individuals (Class III obesity; a body mass index (BMI) of >40kgm(2)), many of whom seek bariatric surgery, and we briefly review whether the presence of pre-operative depression, BED or NES affects post-operative outcomes. Historically depressed individuals have been screened out of weight loss trials due to concerns of worsening mood with weight loss. Such practices have precluded the development of effective treatments for depressed, obese individuals, leaving large numbers of people without appropriate care. We present recent advances in this area, and attempt to answer whether depressed individuals can lose clinically significant amounts of weight, show improvements in mood, and adhere to the demands of a weight loss intervention.

Roux-en-Y gastric bypass for morbid obesity: what are the preoperative predictors of weight loss?

Obesity has become an increasingly important health problem over the past 30 years. Presently around a quarter of the UK adult population are obese and this figure is set to increase further in the coming decades. The health consequences of obesity on multiple body systems have been well established as has the financial cost of the condition to both the individuals affected as well as to society as a whole. Bariatric surgery has been shown to be the only long term effective solution in terms of sustained weight loss and comorbidity resolution. The commonest bariatric procedure in the UK is the Roux-en-y gastric bypass which consistently results in the loss of 70%-80% of excess bodyweight. Results however are variable and in order to optimise resource allocation and avoid exposing patients unlikely to benefit from surgery to its inherent risks, much research has been done to try to identify those patients most likely to obtain a good result. The only factor which has been subjected to meta-analysis is that of preoperative weight loss which shows a positive association with postoperative weight loss following bypass surgery. Although the remaining data are not based on level 1 evidence those other preoperatively identifiable factors which are associated with an improved outcome include Caucasian or Hispanic ethnicity, higher educational status, non-shift-work working patterns, female gender and divorced or single marital status. Similarly increased levels of preoperative physical activity and an absence of binge eating behaviour are consistent with a favourable result whereas increased age, smoking and other socioeconomic factors have not been shown to have a significant impact. Conversely diabetes mellitus seems to have a slight negative correlation with postoperative weight loss; however, a history of sexual abuse or psychiatric illness has not been shown to have a lasting influence.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Development and validation of a new questionnaire measuring eating disordered behaviours post bariatric surgery

Contextualization of post-surgery circumstances in terms of key behaviours and emotions related to eating is crucial for reliable screening. Disordered eating post surgery is characterized by frequent snacking and a sense of loss of control over food intake. The purpose of this study was to evaluate the psychometric properties of a short self-report questionnaire entitled Disordered Eating after Bariatric Surgery (DEBS). Results indicate that the DEBS possesses satisfactory psychometric properties in terms of reliability, validity, internal consistency and test-retest reliability. The DEBS may facilitate both systematic clinical evaluation and future research within the area of bariatric surgery.

Sexual abuse in bariatric surgery candidates: impact on weight loss after surgery: a systematic review

Bariatric surgery is becoming more and more influential as efficient weight loss therapy for the morbidly obese. As many studies propose a relationship between sexual abuse and obesity in general, but especially with regard to weight regain after successful weight loss, sexual abuse might also have a crucial impact on the outcome of the surgical procedures. This review examines the literature comparing weight loss after bariatric surgery in sexually abused and non-abused individuals. We conducted a systematic electronic literature search covering PubMed/Medline, ScienceDirect, PsychInfo and Web of Science. While 13 studies examined prevalence rates of sexual abuse among bariatric patients, eight studies explicitly investigated the effect of sexual abuse on surgery outcome. We hypothesized that individuals with a history of sexual abuse lose less weight compared to individuals with no such abuse history. At first glance, only three out of eight studies demonstrated significantly reduced weight loss in the sexually abused patients. However, a closer investigation of all studies revealed that patients with abuse experiences may indeed tend to lose less weight initially. Still, this sub-population apparently benefits from the surgical procedure, as revealed by increased weight loss over time. Reasons for these mixed results are discussed, as well as the clinical implications that can be drawn from these studies.

Clinical considerations for the management of residual diabetes following bariatric surgery

Residual diabetes following bariatric surgery is increasingly recognized despite initial weight loss. It occurs more commonly following banding and sleeve gastrectomy procedures than with gastric bypass, is associated with long duration and advanced stages of diabetes and is exacerbated by weight regain. Long-term diabetes management following various gastric restrictive surgery (i.e. lap banding) requires targeting weight loss, insulin resistance and insulin secretion defects with antidiabetic agents that have weight negative or neutral effects. In contrast, re-emergence of hyperglycaemia following gastric bypass may require targeting β-cell failure with insulin analogues. Revisional bariatric surgery is also a consideration. On the basis of our experience, we propose a clinical approach for long-term management of diabetes following various bariatric procedures in the presence and absence of weight regain that is based on recognized pathophysiological effects of these procedures on diabetes remission.

Preoperative predictors of weight loss following bariatric surgery: systematic review

BACKGROUND

Obesity affects 32% of adults in the USA. Surgery generates substantial weight loss, but 20-30% fails to achieve successful weight loss. Our objective was to identify preoperative psychosocial factors associated with weight loss following bariatric surgery.

METHODS

We performed a literature search of PubMed® and the Cochrane Database of Reviews of Effectiveness between 1988 and April 2010. Articles were screened for bariatric surgery and weight loss if they included a preoperative predictor of weight loss: body mass index (BMI), preoperative weight loss, eating disorders, or psychiatric disorder/substance abuse. One thousand seven titles were reviewed, 534 articles screened, and 115 included in the review.

RESULTS

Factors that may be positively associated with weight loss after surgery include mandatory preoperative weight loss (7 of 14 studies with positive association). Factors that may be negatively associated with weight loss include preoperative BMI (37 out of 62 studies with negative association), super-obesity (24 out of 33 studies), and personality disorders (7 out of 14 studies). Meta-analysis revealed a decrease of 10.1% excess weight loss (EWL) for super-obese patients (95% confidence interval (CI) [3.7-16.5%]), though there was significant heterogeneity in the meta-analysis, and an increase of 5.9% EWL for patients with binge eating at 12 months after surgery (95% CI [1.9-9.8%]).

CONCLUSIONS

Further studies are necessary to investigate whether preoperative factors can predict a clinically meaningful difference in weight loss after bariatric surgery. The identification of predictive factors may improve patient selection and help develop interventions targeting specific needs of patients.

Pre-bariatric surgery weight loss requirements and the effect of preoperative weight loss on postoperative outcome

Pre-bariatric surgery requirements vary between surgeons and surgical centers, with standards of practice not yet established. The goal of this systematic review was to summarize and evaluate the available literature on pre-bariatric surgery weight loss requirements and the relation between preoperative weight loss and postoperative outcome. Major databases, including Medline, PubMed and PsychINFO were searched for relevant articles. Case studies, studies>20 years old and studies that utilized self-reported body weight data were excluded. Data on the effect of the following was summarized: (1) preoperative requirements on preoperative weight loss; (2) insurance-mandated preoperative requirements; (3) the contingency of receipt of surgery; (4) preoperative weight loss on postoperative weight loss and (5) preoperative weight loss on perioperative and postoperative complication and comorbidity rates. The majority of studies suggest that: (1) current preoperative requirements held by the majority of third party payer organizations in the United States are ineffective in fostering preoperative weight loss; (2) making receipt of surgery contingent upon achieving preoperative weight loss, and meal-replacement diets, may be particularly effective in fostering preoperative weight loss and (3) preoperative weight loss may lead to improvements in at least some relevant postoperative outcomes. However, a preoperative weight loss mandate may lead to the denial of surgery and subsequent health benefits to individuals who are unable to achieve a prespecified amount of weight. Overall, the limited number and quality of prospective studies in this area prohibits the much-needed establishment of standards of practice for pre-bariatric requirements.

[Preoperative weight loss in bariatric surgery candidate patients. evidence-based recommendations]

INTRODUCTION

Bariatric surgery is becoming increasingly more common in the treatment of morbid obesity in our hospitals. One of the measures being used to optimise the results of this surgery seems to be the standardising the preoperative weight loss. As there are no universal recommendations for carrying out this weight loss, a review of this topic is presented.

OBJECTIVES

To analyse whether sufficient scientific evidence exists to recommend preoperative weight loss in candidate patients for bariatric surgery. What would be the best options to carry out this weight loss is also analysed, as well as making some recommendations based on the scientific evidence.

RESULTS

There is great heterogeneity in the designs of the different studies, with different guidelines for weight loss and various surgical techniques. However, preoperative weight loss leads to a decrease in the size of the liver and intra-abdominal fat, which improves the surgical field and intra-operative view, which in turn helps during the surgical act, both in open as well as laparoscopic surgery. There is no consensus on the effect of preoperative weight loss has in predicting the medium or long term results after bariatric surgery.

CONCLUSION

The current scientific evidence makes preoperative weight loss recommendable in candidate patients for bariatric surgery. However, there is no consensus on what is the best procedure to achieve this preoperative weight loss.

The Effect of Preoperative Weight Loss before Gastric Bypass: A Systematic Review

Background. Many insurance companies require obese patients to lose weight prior to gastric bypass. From a previous study by the same authors, preoperative weight at surgery is strongly predictive of weight loss up to one year after surgery. This review aims to determine whether preoperative weight loss is also correlated with weight loss up to one year after surgery. Methods. Of the 186 results screened using PubMed, 12 studies were identified. A meta-analysis was performed to further classify studies (A class, B class, regression, and rejected). Results. Of all 12 studies, one met the criteria for A class, six were B class, four were regression, and one was rejected. Six studies supported our hypothesis, five were inconclusive, and no study refuted. Conclusions. Preoperative weight loss is additive to postsurgery weight loss as predicted from the weight at the time of surgery.

Effect of preoperative weight loss in bariatric surgical patients: a systematic review

BACKGROUND

The potential benefit of preoperative weight loss in patients undergoing bariatric surgery has led many bariatric surgeons to recommend an aggressive weight reduction regimen to their patients. Some surgeons might withhold bariatric procedures if a certain threshold of preoperative weight loss is not achieved. It is unclear whether this practice has any scientific evidence supporting it. Our study aimed to examine the current evidence surrounding this issue in a systematic review. The setting was a university hospital.

METHODS

A systematic search of multiple databases, including MEDLINE, Google Scholar, EMBASE, the Cochrane Library, and conference proceedings were reviewed, yielding a final total of 27 studies. Of the 27 studies, 7 were prospective studies (2 randomized controlled trials from the same patient population), 14 were retrospective studies (2 chart reviews from the same patient population), 1 was an editorial, and a number were conference presentations.

RESULTS

A total of 17 trials, including approximately 4611 patients, deemed preoperative weight loss beneficial, and 10 studies, including 2075 patients, deemed preoperative weight loss to be of no benefit. The operative time was 12.5 minutes shorter for the preoperative weight loss patients undergoing laparoscopic Roux-en-Y gastric bypass. With regard to the effects of preoperative weight loss on postoperative weight loss, 9 studies (39%) reported a positive correlation, and 15 (62.5%) reported no benefit. Nine studies reporting perioperative complications (852 patients) revealed no difference in the complication rates, and 2 studies (1234 patients) suggested a significant decrease was associated with preoperative weight loss.

CONCLUSION

This systematic review suggests little evidence is available to support or refute the routine use of preoperative weight reduction in bariatric surgery. Clearly, a large-scale, multicenter, randomized, controlled trial with sufficient power is necessary to clarify this significant aspect of preoperative care.

Binge eating disorder and the outcome of bariatric surgery at one year: a prospective, observational study

Previous studies have suggested that binge eating disorder (BED) impairs weight loss following bariatric surgery, leading some investigators to recommend that patients receive behavioral treatment for this condition before surgery. However, many of these investigations had significant methodological limitations. The present observational study used a modified intention-to-treat (ITT) population to compare 1-year changes in weight in 59 surgically treated participants, determined preoperatively to be free of a current eating disorder, with changes in 36 individuals judged to have BED. Changes in weight and binge eating in the latter group were compared with those in 49 obese individuals with BED who sought lifestyle modification for weight loss. BED was assessed using criteria proposed for the Diagnostic and Statistical Manual (DSM) 5. At 1 year, surgically treated participants without BED lost 24.2% of initial weight, compared with 22.1% for those with BED (P > 0.309). Both groups achieved clinically significant improvements in several cardiovascular disease (CVD) risk factors. Participants with BED who received lifestyle modification lost 10.3% at 1 year, significantly (P < 0.001) less than surgically treated BED participants. The mean number of binge eating days (in the prior 28 days) fell sharply in both BED groups at 1 year. These two groups did not differ significantly in BED remission rates or in improvements in CVD risk factors. The present results, obtained in carefully studied participants, indicate that the preoperative presence of BED does not attenuate weight loss or improvements in CVD risk factors at 1 year in surgically treated patients. Longer follow-up of participants is required.

Positive response to binge eating intervention enhances postoperative weight loss

BACKGROUND

Binge eating disorder has been suggested as a predictor of negative outcomes, including weight regain and poorer weight loss, particularly if the symptoms (e.g., loss of control eating) remain after surgery. Binge eating disorder has been viewed by some as a contraindication for weight loss surgery, and preoperative treatment has been recommended to help reduce binge eating behaviors. The objective of the present study was to evaluate whether the response to a preoperative binge eating intervention related to differential postoperative weight loss at an academic medical center.

METHODS

A total of 128 bariatric surgery candidates completed a brief cognitive behavioral group treatment for binge eating behaviors. The patients were categorized as positive responders or nonresponders according to the postintervention outcomes, including binge eating symptoms and episodes. The percentage of excess body weight loss (%EBWL) was measured at 6 and 12 months after surgery.

RESULTS

Across all bariatric procedures, the positive responders to the brief binge eating intervention had lost significantly more weight at 6 months (46% EBWL versus 38% EBWL) and 12 months (59% EBWL versus 50% EBWL) postoperatively. The results for a subsample of Roux-en-Y gastric bypass patients (n = 89) were also significant, with 53% EBWL for the responders and 42% EBWL for the nonresponders at 6 months and 68% EBWL versus 54% EBWL at 12 months postoperatively, respectively.

CONCLUSION

The response to binge eating treatment could be an important predictor of postoperative weight loss. The results from the present study provide support for patients who respond to preoperative binge eating treatment having enhanced surgical outcomes.

Weight loss prior to bariatric surgery is not a pre-requisite of excess weight loss outcomes in obese patients

BACKGROUND

Although weight loss before bariatric surgery may carry advantages during the surgical procedure (decreased liver volume, operation duration, and blood loss), it is still debated whether it induces a greater long-term weight loss.

METHODS

We conducted a retrospective analysis over 539 patients operated by the same surgeon until September 2008. Five hundred seven primary bariatric surgical procedures were performed: gastric bypass in 381, gastric banding in 97, and sleeve gastrectomy in 29. Preoperative multidisciplinary care was similar for all the patients over a period of 12 months. Relationship between weight changes during this period and the percentage of excess weight loss (%EWL) over the 48 month after surgery was analyzed by logistic regression.

RESULTS

No relationship could be evidenced between pre- and postoperative weight loss, regardless of the surgical technique performed. Whether patients were male or female, and whether they had an initial BMI greater or lower than 50 kg/m(2), did not make a difference in the relationship between EWL at any point and weight loss prior to surgery. Despite a large range of weight changes before surgery, there was no trend for a relationship.

CONCLUSIONS

This study suggests that weight loss before surgery should not be considered a pre-requisite. Although it can reduce the difficulties of the surgical procedure, advantages for long-term weight loss are not validated.

Effectiveness of a prebariatric surgery insurance-required weight loss regimen and relation to postsurgical weight loss

Most US insurance companies require patients to participate in a medically supervised weight loss regimen prior to bariatric surgery. However, the utility of this requirement has not been documented. Data was collected from 94 bariatric surgery patients who were required, and 59 patients who were not required, by their insurance company to participate in a presurgical weight loss regimen. Weight change in the required group, as well as group differences in weight change, was examined from 3 and 6 months presurgery to 1 week presurgery, and from 1 week presurgery to 3 months postsurgery. Weight change presurgery was then used to predict weight loss postsurgery. In the 6 months prior to surgery, required patients gained 3.7 kg +/- 5.9 (s.d.) (P < 0.0005), which did not differ from nonrequired patients. From surgery to 3 months postsurgery, required patients lost 23.6 +/- 8 kg (P < 0.0005), also without differing from nonrequired patients. Patients who gained more weight prior to surgery, lost more weight postsurgery (P = 0.001), while controlling for initial weight. Findings suggest that the common weight loss regimen requirements of US insurance carriers were ineffective in producing presurgical weight loss in this sample. Most patients (>70%) in this sample gained weight prior to surgery, potentially taking advantage of final opportunities to overindulge in preferred foods. Required patients fared no better in terms of weight change postsurgically and, surprisingly, presurgical weight gain predicted better postsurgical weight loss outcome. Several potential explanations for this finding are offered.

Does weight loss immediately before bariatric surgery improve outcomes: a systematic review

BACKGROUND

Preoperative weight loss before bariatric surgery has been proposed as a predictive factor for improved patient compliance and the degree of excess weight loss achieved after surgery. In the present study, we sought to determine the effect of preoperative weight loss on postoperative outcomes.

METHODS

A search of MEDLINE was completed to identify the patient factors associated with weight loss after bariatric surgery. Of the 909 screened reports, 15 had reported on preoperative weight loss and the degree of postoperative weight loss achieved. A meta-analysis was performed that compared the postoperative weight loss and perioperative outcomes in patients who had lost weight preoperatively compared to those who had not.

RESULTS

Of the 15 articles (n = 3404 patients) identified, 5 found a positive effect of preoperative weight loss on postoperative weight loss, 2 found a positive short-term effect that was not sustained long term, 5 did not find an effect difference, and 1 found a negative effect. A meta-analysis revealed a significant increase in the 1-year postoperative weight loss (mean difference of 5% EWL, 95% confidence interval 2.68-7.32) for patients who had lost weight preoperatively. A meta-analysis of other outcomes revealed a decreased operative time for patients who had lost weight preoperatively (mean difference 23.3 minutes, 95% confidence interval 13.8-32.8).

CONCLUSION

Preoperative weight loss before bariatric surgery appears to be associated with greater weight loss postoperatively and might help to identify patients who would have better compliance after surgery.

Comprehensive interview assessment of eating behavior 18-35 months after gastric bypass surgery for morbid obesity

BACKGROUND

Weight loss surgery induces a marked change in eating behavior. However, not much work has been done characterizing the eating behavior after weight loss surgery. We conducted a detailed analysis of patients' eating behavior 18-35 months after Roux-en-Y gastric bypass surgery, determined whether preoperative eating disorders might be associated with non-normative postoperative eating, and examined the association of such eating behaviors with weight loss and psychopathology.

METHODS

A sample of 59 patients who had undergone Roux-en-Y gastric bypass was interviewed in person after surgery about a range of eating behaviors, including binge eating, chewing and spitting out food, picking at and nibbling food, and nocturnal eating and compensatory behaviors such as vomiting and laxative and diuretic misuse. An established semistructured interview was used. The prevalence of preoperative eating disorders was assessed retrospectively. The eating-related and general psychopathology and quality of life were assessed using self-report questionnaires before and after surgery.

RESULTS

Subjective bulimic episodes were reported by 25% and vomiting for weight and shape reasons by 12% of the participants, on average, 2 years after surgery. Subjective bulimic episodes were significantly associated with a preoperative binge eating disorder, with more eating-related and general psychopathology after surgery, and with less weight loss.

CONCLUSION

A substantial subgroup of patients with a preoperative eating disorder will develop binge eating after surgery that might be associated with less weight loss. A subsample will start vomiting for weight and shape reasons after bariatric surgery. Clinicians must probe carefully for these behaviors postoperatively to identify patients in need of treatment of pathological eating behaviors.

Psychosocial evaluation for bariatric surgery: the Boston interview and opportunities for intervention

The process of psychosocial evaluation for weight loss surgery (WLS) is one that goes beyond serving the function of information-gathering (Bauchowitz et al. in Surg Obes Relat Dis 3:554-558, 2007; Friedman et al. in Surg Obes Relat Dis 3:376-382, 2007; Lanyon and Maxwell in Obes Surg 17:321-328, 2007; Sogg and Mori in Obes Surg 14:370-380, 2004; Sogg and Mori in Surg Obes Relat Dis 4:455-463, 2008). This process offers myriad opportunities for delivering significant and powerful interventions that can enhance the patient's success in the WLS process. A discussion of the unique opportunities for psychosocial intervention afforded by the pre-surgical evaluation process is presented, using The Boston Interview for Bariatric Surgery (Sogg and Mori in Surg Obes Relat Dis 4:455-463, 2008) as the organizing framework.