4-Year Changes in Sex Hormones, Sexual Functioning, and Psychosocial Status in Women Who Underwent Bariatric Surgery.

BACKGROUND: Initial weight loss after bariatric surgery has been associated with improvements in reproductive hormones and sexual functioning in women. Few studies have investigated the durability of these changes. OBJECTIVES: The objective of this paper is to investigate changes in sex hormones, sexual functioning, and relevant psychosocial constructs over 4 years in women who underwent bariatric surgery. SETTING: The setting is a prospective cohort of 106 women from the Longitudinal Assessment of Bariatric Surgery consortium. METHODS: Changes in sex hormones were assessed by blood assay. Sexual functioning, quality of life (QOL), body image, depressive symptoms, and marital adjustment were assessed by psychometric measures. RESULTS: Women lost on average (95% confidence interval) 32.3% (30.4%, 34.3%) at postoperative year 3 and 30.6% (28.5%, 32.8%) at postoperative year 4. Compared to baseline, women experienced significant changes at 4 years in all hormones assessed, except estradiol. Women reported significant improvements in sexual functioning (i.e., arousal, desire, and satisfaction) through year 3, but these changes were not maintained through year 4. Changes in relationship quality followed a similar pattern. Improvements in physical aspects of QOL, body image, and depressive symptoms were maintained through 4 years. CONCLUSIONS: Improvements in reproductive hormones and physical aspects of QOL, body image, and depressive symptoms were maintained 4 years after bariatric surgery. Improvements in sexual functioning, relationship satisfaction, and mental components of QOL eroded over time.

Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study.

BACKGROUND: We established Safeguard the Family (STF) to support Ministry of Health (MoH) scale-up of universal antiretroviral therapy (ART) for HIV-infected pregnant and breastfeeding women (Option B+) and to strengthen the prevention of mother-to-child transmission (PMTCT) cascade from HIV testing and counseling (HTC) through maternal ART provision and post-delivery early infant HIV diagnosis (EID). To these ends, we implemented the following interventions in 5 districts: 1) health worker training and mentorship; 2) couples' HTC and male partner involvement; 3) women's psychosocial support groups; and 4) health and laboratory system strengthening for EID. METHODS: We conducted a serial cross-sectional study using facility-level quarterly (Q) program data and individual-level infant HIV-1 DNA PCR data to evaluate STF performance on PMTCT indicators for project years (Y) 1 (April-December 2011) through 3 (January-December 2013), and compared these results to national averages. RESULTS: Facility-level uptake of HTC, ART, infant nevirapine prophylaxis, and infant DNA PCR testing increased significantly from quarterly baselines of 66 % (n/N = 32,433/48,804), 23 % (n/N = 442/1,958), 1 % (n/N = 10/1,958), and 52 % (n/N = 1,385/2,644) to 87 % (n/N = 39,458/45,324), 96 % (n/N = 2,046/2,121), 100 % (n/N = 2,121/2,121), and 62 % (n/N = 1,462/2,340), respectively, by project end (all p < 0.001). Quarterly HTC, ART, and infant nevirapine prophylaxis uptake outperformed national averages over years 2-3. While transitioning EID laboratory services to MoH, STF provided first-time HIV-1 DNA PCR testing for 2,226 of 11,261 HIV-exposed infants (20 %) tested in the MoH EID program in STF districts from program inception (Y2) through Y3. Of these, 78 (3.5 %) tested HIV-positive. Among infants with complete documentation (n = 608), median age at first testing decreased from 112 days (interquartile range, IQR: 57-198) in Y2 to 76 days (IQR: 46-152) in Y3 (p < 0.001). During Y3 (only year with national data for comparison), non-significantly fewer exposed infants tested HIV-positive (3.6 %) at first testing in STF districts than nationally (4.1 %) (p = 0.4). CONCLUSIONS: STF interventions, integrated within the MoH Option B+ program, achieved favorable HTC, maternal ART, infant prophylaxis, and EID services uptake, and a low proportion of infants found HIV-infected at first DNA PCR testing. Continued investments are needed to strengthen the PMTCT cascade, particularly around EID.

Sexual functioning and sex hormones in men who underwent bariatric surgery.

BACKGROUND: The relationship between obesity and impairments in male sexual functioning is well documented. Relatively few studies have investigated changes in sexual functioning and sex hormones in men who achieve significant weight loss with bariatric surgery. The objective of this study was to assess changes in sexual functioning, sex hormones, and relevant psychosocial constructs in men who underwent bariatric surgery. METHODS: A prospective cohort study of 32 men from the Longitudinal Assessment of Bariatric Surgery-2 (LABS) investigation who underwent a Roux-en-Y gastric bypass (median body mass index [25th percentile, 75th percentile] 45.1 [42.0, 52.2]) and completed assessments between 2006 and 2012. Bariatric surgery was performed by a LABS-certified surgeon. Sexual functioning was assessed by the International Index of Erectile Functioning (IIEF). Hormones were assessed by blood assay. Quality of life (QoL), body image, depressive symptoms and marital adjustment were assessed by questionnaire. RESULTS: Men lost, on average, (95% confidence interval) 33.3% (36.1%, 30.5%) of initial weight at postoperative year 1, 33.6% (36.8%, 30.5%) at year 2, 31.0% (34.1%, 27.9%) at year 3, and 29.4% (32.7%, 26.2%) at year 4. Participants experienced significant increases in total testosterone (P<.001) and sex hormone binding globulin (SHBG) (P<.001) through postoperative year 4. Although men reported improvements in sexual functioning after surgery, these changes did not significantly differ from baseline, with the exception of overall satisfaction at postoperative year 3 (P = .008). Participants reported significant improvements in physical domains of health-related quality of life (HRQoL), all domains of weight-related QOL, and body image, but not in the mental health domains of HRQoL or relationship satisfaction. CONCLUSIONS: Men who lost approximately one third of their weight after Roux-en-Y gastric bypass experienced significant increases in total testosterone and SHBG. They did not, however, report significant improvements in sexual functioning, relationship satisfaction, or mental health domains of HRQoL. This pattern of results differs from that of women who have undergone bariatric surgery, who reported almost uniform improvements in sexual functioning and psychosocial status.

Sexual functioning and sex hormones in persons with extreme obesity and seeking surgical and nonsurgical weight loss.

BACKGROUND: Many individuals with obesity are motivated to lose weight to improve weight-related co-morbidities or psychosocial functioning, including sexual functioning. Few studies have documented rates of sexual dysfunction in persons with obesity. This study investigated sexual functioning, sex hormones, and relevant psychosocial constructs in individuals with obesity who sought surgical and nonsurgical weight loss. METHODS: One hundred forty-one bariatric surgery patients (median BMI [25th percentile, 75th percentile] 44.6 [41.4, 50.1]) and 109 individuals (BMI = 40.0 [38.0, 44.0]) who sought nonsurgical weight loss participated. Sexual functioning was assessed by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF). Hormones were assessed by blood assay. Quality of life, body image, depressive symptoms, and marital adjustment were assessed by validated questionnaires. RESULTS: Fifty-one percent of women presenting for bariatric surgery reported a sexual dysfunction; 36% of men presenting for bariatric surgery reported erectile dysfunction (ED). This is in contrast to 41% of women who sought nonsurgical weight loss and reported a sexual dysfunction and 20% of men who sought nonsurgical weight loss and reported ED. These differences were not statistically significant. Sexual dysfunction was strongly associated with psychosocial distress in women; these relationships were less strong and less consistent among men. Sexual dysfunction was unrelated to sex hormones, except for sex hormone binding globulin (SHGB) in women. CONCLUSION: Women and men who present for bariatric surgery, compared with individuals who sought nonsurgical weight loss, were not significantly more likely to experience a sexual dysfunction. There were few differences in reproductive hormones and psychosocial constructs between candidates for bariatric surgery and individuals interested in nonsurgical weight loss.

Longitudinal Assessment of Bariatric Surgery (LABS): retention strategy and results at 24 months.

BACKGROUND: Retaining participants in observational longitudinal studies after bariatric surgery is difficult yet critical because the retention rate affects interpretation and generalizability of results. Strategies for keeping participants involved in such studies are not commonly published. The objective of this study was to review LABS retention strategies and present the 24-month retention data. METHODS: The LABS Consortium monitors an observational cohort study of 2458 adults enrolled before bariatric surgery at 10 centers within the United States (LABS-2). To maximize data completeness, the investigators developed retention strategies, including flexible scheduling, a call protocol, reminder letters, abbreviated visit options, honoraria, travel reimbursement, providing research progress reports, laboratory results, newsletters, study website, and retention surveys. Strategies for locating participants included frequent updates of contact information, sending registered letters, and searching medical and public records. RESULTS: At 12 and 24 months, 2426 and 2405 participants remained active, with vital status known for 98.7% and 97.3% and weight obtained for 95.2% and 92.2%, respectively. There were 148 missed visits (6.2%) at 24 months primarily because of inability to contact the participant. Only 15 (0.6%) active participants at 24 months missed all follow-up visits. Although 42 participants could not be located or contacted at 6 months, data were obtained for 23 (54.7%) of them at 12 months, and of the 52 participants who could not be located or contacted at 12 months, data were obtained for 18 (34.6%) at 24 months. CONCLUSION: Longitudinal studies provide the ability to evaluate long-term effects of bariatric surgical procedures. The retention achieved in LABS is superior to that of many published reports but requires extensive effort and resources. This report identifies useful retention strategies. Further research is needed to identify the efficacy and cost-effectiveness of specific retention strategies.

The emergence of eating pathology after bariatric surgery: a rare outcome with important clinical implications.

OBJECTIVE: The present review examines the extant literature regarding the post-operative development of eating disorders (e.g., EDNOS) in bariatric surgery patients. METHOD: Internet, PsycINFO, Pubmed, and reference lists were examined to aggregate and compare literature from January 1985 to May 2010. RESULTS: Several case studies and case series have investigated the emergence of eating disorders after bariatric surgery. Clinical considerations are outlined. DISCUSSION: The development of classical eating disorders after bariatric surgery appears to be a rare occurrence; however, eating problems are far more common. Unfortunately no typology exists to classify such eating problems. Future research should examine the incidence, risk factors, symptomatology, course, and outcome of such eating disorders and eating problems. It is highly likely that such problems are underreported.

Therapeutic factors affecting the cognitive behavioral treatment of bulimia nervosa via telemedicine versus face-to-face delivery.

OBJECTIVE: Recently, Mitchell et al. (Behav Res Ther, 46, 581-592, 2008) conducted a randomized controlled trial of an empirically supported treatment for bulimia nervosa (BN) delivered face-to-face (FTF-CBT) or via telemedicine (TV-CBT). Results suggested that the TV-CBT and FTF-CBT were generally equivalent in effectiveness. The objective of the current study was to examine ratings of therapeutic alliance factors in TV-CBT and FTF-CBT. METHOD: Data obtained from 116 adults who met criteria for BN or eating disorder-not otherwise specified with binge eating or purging weekly and six doctoral-level psychologists who delivered the therapy were used in the analyses. RESULTS: Therapists generally endorsed greater differences between the treatment delivery methods than patients. Patients tended to make significantly higher ratings of therapeutic factors than therapists. DISCUSSION: TV-CBT is an acceptable method for the delivery of BN treatment compared to FTF-CBT, and TV-CBT is more easily accepted as a treatment delivery method by patients than therapists.

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.

Caffeine, artificial sweetener, and fluid intake in anorexia nervosa.

OBJECTIVE: This article provides an analysis of the use of artificial sweeteners, caffeine, and excess fluids in patients diagnosed with anorexia nervosa (AN). METHOD: Seventy participants with AN were recruited to participate in an ecologic momentary assessment study which included nutritional analysis using the Nutrition Data Systems for Research, a computer based dietary recall system. RESULTS: When subtypes were compared, participants with AN-restricting subtype (AN-R) and participants with AN-Binge-Purge (AN-B/P) did not differ in quantity of aspartame, caffeine, or water consumed. Daily water consumption was related to daily vomiting frequency in AN-B/P but not to daily exercise frequency in either participants with AN-R or AN-B/P. DISCUSSION: Caffeine, water, and aspartame consumption can be variable in patients with AN and the consumption of these substances seems to be only modestly related to purging behavior.

A randomized trial comparing the efficacy of cognitive-behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face.

OBJECTIVE: A major problem in the delivery of mental health services is the lack of availability of empirically supported treatment, particularly in rural areas. To date no studies have evaluated the administration of an empirically supported manual-based psychotherapy for a psychiatric condition via telemedicine. The aim of this study was to compare the relative efficacy and acceptability of a manual-based cognitive-behavioral therapy (CBT) for bulimia nervosa (BN) delivered in person to a comparable therapy delivered via telemedicine. METHOD: One hundred twenty-eight adults meeting DSM-IV criteria for BN or eating disorder-not otherwise specified with binge eating or purging at least once per week were recruited through referrals from clinicians and media advertisements in the targeted geographical areas. Participants were randomly assigned to receive 20 sessions of manual-based, CBT for BN over 16 weeks delivered either face-to-face (FTF-CBT) or via telemedicine (TV-CBT) by trained therapists. The primary outcome measures were binge eating and purging frequency as assessed by interview at the end of treatment, and again at 3- and 12-month follow-ups. Secondary outcome measures included other bulimic symptoms and changes in mood. RESULTS: Retention in treatment was comparable for TV-CBT and FTF-CBT. Abstinence rates at end-of-treatment were generally slightly higher for FTF-CBT compared with TV-CBT, but differences were not statistically significant. FTF-CBT patients also experienced significantly greater reductions in eating disordered cognitions and interview-assessed depression. However, the differences overall were few in number and of marginal clinical significance. CONCLUSIONS: CBT for BN delivered via telemedicine was both acceptable to participants and roughly equivalent in outcome to therapy delivered in person.

Travel distance and attrition in outpatient eating disorders treatment.

OBJECTIVE: The purpose of this study was to investigate the impact of the distance patients had to travel for treatment on attendance patterns and treatment attrition. METHOD: Contact information, clinical records, and/or appointment records of 209 adult patients presenting to an outpatient eating disorder treatment center over a specific period of time were reviewed. Information was obtained on demographics, diagnosis, number of appointments attended, cancelled, and failed, and termination status. Patients were classified as treatment completers or dropouts and compared on demographic, diagnostic, attendance, and distance to treatment site variables. RESULTS: Treatment completer and dropout groups did not differ significantly on demographic variables, with the exception of employed patients being more likely to drop out of treatment. Although not statistically significant, patients diagnosed with bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) were more likely to drop out of treatment prematurely. Surprisingly, distance traveled to the treatment site was not significantly different between groups and did not appear to significantly impact attendance patterns. CONCLUSION: Results of this archival investigation were unexpected and likely limited by the design. Results can be useful in understanding motivational factors inherent in noncompliance and premature termination of treatment. A prospective study including fine-grained analysis of variables associated with eating disorder treatment attrition is indicated.

The use of alternative delivery systems and new technologies in the treatment of patients with eating disorders.

OBJECTIVE: The purpose of the current article is to review the literature regarding the use of alternative delivery systems, such as telemedicine, and new technologies, such as the use of hand-held computers, in the treatment of patients with eating disorders. METHOD: The literature is reviewed in the following areas: self-help (supervised and unsupervised), telemedicine, telephone therapy, e-mail, internet, computer software, CD-ROMs, portable computers, and virtual reality techniques. RESULTS: A growing literature suggests a number of alternative delivery systems hold promise, in particular permitting patients to access services who otherwise would not be able to receive treatment. Although most of these areas are early in their development, a growing literature supports the utility of several of these approaches. DISCUSSION: Although the literature in this area is limited, and the research base is small, a number of these technologies appear to hold substantial promise for the treatment of patients with eating disorders.

The relationship between compulsive buying and eating disorders.

OBJECTIVE: Compulsive buying has received increased research attention in the last decade. The disorder has high rates of comorbidity for other disorders, including eating disorders. This study explored the possible relationship between compulsive buying and eating disorders. METHOD: Twenty women who scored in the pathological range on a measure of compulsive buying and 20 controls were recruited via the media. Various measures of psychopathology and eating disorder symptoms were administered to both groups. RESULT: Compulsive buyers were significantly more likely to have a higher lifetime history of substance abuse or dependence. No differences existed between normal controls and compulsive buyers in prevalence of current or lifetime eating disorders, nor were there differences in scores of eating-related psychopathology. DISCUSSION: This work failed to demonstrate an increased risk for eating disorder in compulsive buyers, although a higher rate of substance dependence or abuse and higher scores on pathological personality dimension scales were seen.