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

BACKGROUND: The relationship between theoretically relevant psychosocial and behavioral variables and outcomes of metabolic and bariatric surgery remains unclear. Some studies have found that the presence of psychopathology, disordered eating, and impulsivity, either before surgery or during the early postoperative period, is associated with suboptimal postoperative weight loss. Other studies have not found these relationships. OBJECTIVE: Examine the relationship between psychopathology, disordered eating, impulsivity, and weight loss 24 months postoperatively. SETTING: Two large, urban university health systems. METHODS: Participant characteristics were collected using validated interviews, patient-reported outcome measures, and computerized assessment methods. Linear mixed effect models were used to test the association of the variables of interest on percent weight loss (%WL). RESULTS: Three hundred participants were enrolled at baseline; weight data at 24 months were available for 227 participants; between 181 and 53 individuals completed other outcome measures. The mean %WL was 23.3 ± 9.9% at 24 months. Patients who underwent Roux-en-Y gastric bypass lost more weight than those who underwent sleeve gastrectomy. The presence of subjective binge episodes at baseline was related to a greater %WL at 24 months; there were no other baseline predictors. The presence of eating disorder diagnoses and disordered eating symptoms after surgery were associated with smaller weight losses over 24 months. Current and lifetime psychopathology and impulsivity were unrelated to %WL at 24 months. CONCLUSION: Disordered eating after bariatric surgery was associated with a smaller %WL at postoperative year 2. Additional monitoring of these symptoms in the early postoperative period is recommended. Psychotherapeutic and/or dietary interventions may promote more optimal weight loss outcomes.

Changes in Eating Behaviors and Their Relation to Weight Change 6 and 12 Months After Bariatric Surgery.

INTRODUCTION: Identifying eating behaviors associated with suboptimal weight loss following bariatric surgery remains important. This study assessed the relationship between eating behaviors and weight loss following bariatric surgery in a racially diverse sample. METHODS: Participants were assessed before surgery and 6 and 12 months postoperatively, with the Structured Clinical Interview for DSM-5, the Eating Disorder Examination-Bariatric Surgery Version, and validated measures assessing a range of eating behaviors. Linear mixed effect models were used to test the impact of eating behaviors on percent weight loss (%WL) at 6 and 12 months. RESULTS: We enrolled 300 participants (mean age 40.1 years; BMI 45.9 kg/m2; 87% women; 62% Black and 30% White). The majority (82%) underwent sleeve gastrectomy (SG). Mean %WL was 23.0 ± 5.1% at 6 months and 26.2 ± 7.6% at 12 months. Subjective binge episodes prior to surgery predicted greater %WL over the first 12 postoperative months (p = 0.028). Postoperative disinhibition, hunger, night eating symptoms, objective binge episodes, global disordered eating attitudes and behaviors, and snacks per day were associated with smaller %WL over 12 months (all p's < 0.01). The presence of picking/nibbling and addictive-like eating behaviors was not associated with %WL at the end of the first postoperative year. CONCLUSION: Among a diverse participant sample, problematic eating behaviors following surgery were associated with smaller %WL over 12 months. Postoperative assessment and treatment of eating behaviors are needed to address these issues as they arise and to prevent attenuation of early weight loss in some patients.

The psychosocial burden of visible disfigurement following traumatic injury.

Hundreds of thousands of individuals experience traumatic injuries each year. Some are mild to moderate in nature and patients experience full functional recovery and little change to their physical appearance. Others result in enduring, if not permanent, changes in physical functioning and appearance. Reconstructive plastic surgical procedures are viable treatments options for many patients who have experienced the spectrum of traumatic injuries. The goal of these procedures is to restore physical functioning and reduce the psychosocial burden of living with an appearance that may be viewed negatively by the patient or by others. Even after receipt of reconstructive procedures, many patients are left with residual disfigurement. In some, disability and disfigurement may be so profound that individuals are candidates for vascularized composite allotransplantation (VCA) procedures, i.e., the transplantation of a vascularized human body part containing multiple tissue types (skin, muscle, bone, nerves, and blood vessels) as an anatomical and/or structural unit. This narrative review paper summarizes the literature on the psychosocial burden experienced by those who have visible disfigurement. While many of these individuals experience stigma and discrimination, relatively few studies have employed a stigma framework to understand the psychosocial sequelea. This paper briefly addresses this framework. Last, particular focus is given to the psychosocial issues of individuals with particularly severe injuries who are potential candidates for VCA procedures.

Role of weight bias and patient-physician communication in the underutilization of bariatric surgery.

A growing body of evidence supports the efficacy and safety of bariatric surgery for clinically severe obesity. Despite this empirical support, bariatric surgery remains profoundly underutilized. The reasons for underutilization are likely multifactorial, including health insurance coverage and benefits design, lack of awareness about bariatric surgery by patients, and anecdotal concerns about safety. We believe that there are two other factors-the occurrence of weight stigma and bias and suboptimal communication between patients and providers-that also serve as barriers to greater utilization. The article reviews the existing literature related to these two factors. The review also highlights the science of shared medical decision-making as a potential strategy to promote appropriate conversations between patients and providers, both surgical and nonsurgical, about the efficacy and safety of bariatric surgery. Shared medical decision-making is used in other areas where complex medical decisions are required. We believe that it has great potential to contribute to the increased utilization for the millions of individuals who could benefit from bariatric surgery.

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

BACKGROUND: Most patients who undergo bariatric surgery experience significant weight loss and improvements in obesity-related co-morbidities in the first 6-18 months after surgery. However, 20%-30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. Psychosocial functioning may contribute to suboptimal weight loss and/or postoperative psychosocial distress. OBJECTIVE: Assess psychosocial functioning, eating behavior, and impulsivity in patients seeking bariatric surgery. SETTING: Two university hospitals. METHODS: Validated interviews and questionnaires. Impulsivity assessed via computer program. RESULTS: The present study included a larger (n = 300) and more racially diverse (70% non-White) sample than previous studies of these relationships. Forty-eight percent of participants had a current psychiatric diagnosis and 78% had at least 1 lifetime diagnosis. Anxiety disorders were the most common current diagnosis (25%); major depressive disorder was the most common lifetime diagnosis (44%). Approximately 6% of participants had a current alcohol or substance use disorder; 7% had a positive drug screen before surgery. A current psychiatric diagnosis was associated with greater symptoms of food addiction and night eating. Current diagnosis of alcohol use disorder or a lifetime diagnosis of anxiety disorders was associated with higher delay discounting. CONCLUSION: The study identified high rates of psychopathology and related symptoms among a large, diverse sample of bariatric surgery candidates. Psychopathology was associated with symptoms of disordered eating and higher rates of delay discounting, suggesting impulse control issues.

Psychopathology, disordered eating, and impulsivity as predictors of outcomes of bariatric surgery.

Outcomes of bariatric surgery, while frequently impressive, are not universal and vary between patients and across surgical procedures. Between 20% and 30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. The reasons for this are not fully understood, but likely involve both physiologic processes, behavioral factors, and psychological characteristics. Evidence suggests that preoperative psychosocial status and functioning can contribute to suboptimal weight losses and/or postoperative psychosocial distress. Much of this work has focused on the presence of recognized psychiatric diagnoses and with particular emphasis on mood disorders as well as binge eating disorder. Several studies have suggested that the presence of preoperative psychopathology is associated with suboptimal weight losses, postoperative complications, and less positive psychosocial outcomes. Contemporary psychological theory suggests that it may be shared features across diagnoses, rather than a discrete diagnosis, that better characterizes psychopathology. Mood and substance use disorders as well as binge eating disorder, share common features of impulsivity, although clinicians and researchers often use complementary, yet different terms, such as emotional dysregulation or disinhibition (i.e., loss of control over eating, as applied to food intake), to describe the phenomenon. Impulse control is a central factor in eating behavior and extreme obesity. It also may contribute to the experience of suboptimal outcomes after bariatric surgery, including smaller than expected weight loss and psychosocial distress. This paper reviews the literature in these areas of research and articulates a direction for future studies of these complex relationships among persons with extreme obesity.

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.

Changes in Dietary Intake and Eating Behavior in Adolescents After Bariatric Surgery: an Ancillary Study to the Teen-LABS Consortium.

BACKGROUND: A growing number of studies suggest that bariatric surgery is safe and effective for adolescents with severe obesity. However, surprisingly little is known about changes in dietary intake and eating behavior of adolescents who undergo bariatric surgery. OBJECTIVE: Investigate changes in dietary intake and eating behavior of adolescents with obesity who underwent bariatric surgery (n = 119) or lifestyle modification (LM) (n = 169). SETTING: University-based health systems METHODS: A prospective investigation of 288 participants (219 female and 69 male) prior to bariatric surgery or LM and again 6, 12, and 24 months (surgery patients only) after treatment. Measures included changes in weight, macronutrient intake, eating behavior, and relevant demographic and physiological variables. RESULTS: Adolescents who underwent bariatric surgery experienced significantly greater weight loss than those who received LM. The two groups differed in self-reported intake of a number of macronutrients at 6 and 12 months from baseline, but not total caloric intake. Patients treated with surgery, compared to those treated with LM, also reported significantly greater reductions in a number of disordered eating symptoms. After bariatric surgery, greater weight loss from postoperative month 6 to 12 was associated with self-reported weight consciousness, craving for sweets, and consumption of zinc. CONCLUSIONS: Adolescents who underwent bariatric surgery, compared to those who received LM, reported significantly greater reductions in weight after 1 year. They also reported greater reductions in disordered eating symptoms. These findings provide new information on changes in dietary intake and eating behavior among adolescents who undergo bariatric surgery.

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.

Identification and management of mental health issues by dermatologic surgeons: a survey of American Society for Dermatologic Surgery members.

BACKGROUND: Dermatologists have long been interested in mental health issues of their patients. Some psychosocial distress likely motivates the pursuit of cosmetic dermatologic treatments. However, a percentage of patients seeking treatment suffer from significant psychopathology, such as body dysmorphic disorder (BDD), which may contraindicate treatment. OBJECTIVE: To assess dermatologic surgeons' strategies for identification and management of mental health issues among patients seeking cosmetic procedures. MATERIALS AND METHODS: A survey was sent to 2,855 practicing members of the American Society for Dermatologic Surgery by e-mail. RESULTS: Two hundred sixty members completed the survey (9.1%). Approximately, 60% of respondents indicated that they ask new patients about psychiatric treatment history, and 92% reported that they have declined to provide a cosmetic treatment because of concerns about mental health status. Most (94%) indicated that they were aware of BDD, and 62% indicated that they refused to treat a patient believed to have BDD. Respondents estimated that 13% of new patients had BDD and 63% considered BDD to be a contraindication to treatment. CONCLUSION: Approximately 60% of dermatologic surgeons inquire about the mental health issues of their cosmetic patients. Most are aware of BDD, but less than two-thirds consider it a contraindication to treatment.

Changes in sexual functioning and sex hormone levels in women following bariatric surgery.

IMPORTANCE: Obesity has been associated with impairments in sexual function and untoward changes in reproductive hormones in women. Relatively few studies have investigated changes in these domains following bariatric surgery. OBJECTIVE: To investigate changes in sexual functioning, sex hormone levels, and relevant psychosocial constructs in women who underwent bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study of 106 women from phase 2 of the Longitudinal Assessment of Bariatric Surgery who underwent bariatric surgery (median [interquartile range] body mass index, 44.5 [41.4-49.7]). Assessments were completed between 2006 and 2012. INTERVENTIONS: Bariatric surgery was performed by a surgeon certified by the Longitudinal Assessment of Bariatric Surgery (85 women underwent a Roux-en-Y gastric bypass, and 21 women underwent laparoscopic adjustable gastric banding). MAIN OUTCOMES AND MEASURES: Sexual functioning was assessed by use of the Female Sexual Function Index. Hormones were assessed by use of a blood assay. Quality of life, body image, depressive symptoms, and marital adjustment were assessed by use of validated questionnaires. RESULTS: Women lost a mean 32.7% (95% CI, 30.7%-34.7%) of initial body weight at postoperative year 1 and a mean 33.5% (95% CI, 31.5%-35.6%) at postoperative year 2. Two years following surgery, women reported significant improvements in overall sexual functioning and specific domains of sexual functioning: arousal, lubrication, desires, and satisfaction. They also experienced significant changes at 2 years in all hormones of interest. Women reported significant improvements in most domains of quality of life, as well as body image and depressive symptoms, within the first year after surgery, with these improvements being maintained through the second postoperative year. CONCLUSIONS AND RELEVANCE: Women who underwent bariatric surgery had significant improvements in overall sexual functioning, in most reproductive hormones of interest, and in psychosocial status. Improvements in sexual health can be added to the list of health benefits associated with bariatric surgery. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00670098.

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.

Attitudes about the safety and efficacy of bariatric surgery among patients with type 2 diabetes and a body mass index of 30-40 kg/m2.

BACKGROUND: Despite increasing awareness within the medical community about the benefits of bariatric surgery for type 2 diabetes mellitus (T2DM), little is known about patients' attitudes toward bariatric surgery as a treatment for T2DM. The objective of this study was to investigate the attitudes of individuals with T2DM and a body mass index of 30 to 40 kg/m(2) concerning bariatric surgery for the treatment of T2DM. METHODS: Patients identified from the Pennsylvania Integrated Clinical and Administrative Research Database (PICARD) were surveyed about perceptions of the safety profile and efficacy of bariatric surgery as a treatment for obesity and T2DM and their willingness to be randomly assigned to receive a surgical procedure. RESULTS: A total of 130 individuals of 513 (25.3%) responded. Respondents had a median (interquartile range) age of 58.0 (range 51.0-63.0) years and self-reported body mass index of 32.9 (range 30.9-35.2) kg/m(2). Roughly half (66 of 130) were female. Overall, only 20.3% of respondents had positive views of bariatric surgery, with few reporting that it is a safe (14.3%) and effective (28.5%) treatment for T2DM. Less than 20% of respondents were willing to be randomly assigned to undergo a surgical procedure for the treatment of diabetes (16.1%) or obesity (17.5%). CONCLUSIONS: Few obese individuals with T2DM who responded to the survey had positive views about bariatric surgery. Patients' concerns about the procedure's safety profile and efficacy must be addressed to improve the acceptability of bariatric surgery as well as the feasibility of randomized, controlled trials of bariatric surgery for these individuals.

Body image dysmorphic disorder in persons who undergo aesthetic medical treatments.

This article reviews the literature on body dysmorphic disorder (BDD) in patients who seek aesthetic surgery and other appearance-enhancing medical treatments such as dermatologic treatment. It begins with a discussion of the growing popularity of aesthetic medical treatments. The literature investigating the psychological characteristics of individuals interested in these treatments is highlighted. Studies suggest that 5% to 15% of individuals who seek these aesthetic medical treatments suffer from BDD. Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms following these treatments, leading some to suggest that BDD is a contraindication to treatment. The article ends with a discussion of the clinical management of patients with BDD who present for an aesthetic change in their appearance.

A pilot study investigating the efficacy of postoperative dietary counseling to improve outcomes after bariatric surgery.

BACKGROUND: Bariatric surgery is a powerful treatment of severe obesity. During the past several years, a greater appreciation for the need for multidisciplinary care to optimize outcomes has developed, and a number of studies have been started to examine the role of postoperative interventions used in combination with surgery. The purpose of the present study was to investigate the hypothesis that the provision of postoperative dietary counseling, delivered by a registered dietitian, would lead to greater weight loss and more positive improvements in dietary intake and eating behavior compared with standard postoperative care. The study was performed at an academic medical center. METHODS: Eighty-four individuals who underwent bariatric surgery were randomly assigned to receive either dietary counseling or standard postoperative care for the first 4 months after surgery. The participants completed measures of macronutrient intake and eating behavior at baseline and 2, 4, 6, 12, 18, and 24 months after surgery. RESULTS: The patients who received dietary counseling achieved greater weight loss than those who received standard postoperative care that did not involve this counseling, although this difference did not reach statistical significance. Patients in the dietary counseling arm did report significant changes in several eating behaviors believed to be important to successful long-term weight maintenance. CONCLUSION: The results of our pilot study provide some support for the efficacy of early postoperative dietary counseling to improve outcomes after bariatric surgery.

Physicians' attitudes about referring their type 2 diabetes patients for bariatric surgery.

BACKGROUND: Despite increasing evidence about the beneficial effects of bariatric surgery, little is known about physicians' attitudes toward it as a treatment of type 2 diabetes. Our objective was to investigate physicians' attitudes about referring patients with type 2 diabetes for bariatric surgery. METHODS: Physicians were identified from the Pennsylvania Integrated Clinical and Administrative Research Database and other databases. Physicians at an academic medical center (n = 142) and community-based physicians (n = 197) in the Philadelphia area in specialties likely to treat type 2 diabetes were sent a survey about their perceptions of the safety and efficacy of bariatric surgery as a treatment for obesity and type 2 diabetes. RESULTS: Of the physicians, 93 returned the survey, for a combined response rate of 27.4%. Respondents reported having positive impressions of bariatric surgery as a treatment for obesity and type 2 diabetes (79.6% and 67.4%, respectively). Only 20.8% of respondents indicated that they would be likely to refer their patients with type 2 diabetes with a body mass index of 30-34.9 kg/m(2) to a randomized research trial of bariatric surgery. CONCLUSION: In general, physicians who treat patients with type 2 diabetes had favorable impressions about bariatric surgery as a treatment for obesity and type 2 diabetes. However, only a few were willing to refer their patients with type 2 diabetes and a body mass index of 30-34.9 kg/m(2) to randomized research trials of bariatric surgery. This reluctance to refer patients represents an important barrier to the successful completion of studies of the efficacy of bariatric surgery for those with type 2 diabetes and a body mass index <35 kg/m(2).

A review of the relationships between extreme obesity, quality of life, and sexual function.

Extreme obesity is associated with significant health issues as well as substantial psychosocial burden for many individuals. Numerous studies have documented the impairments in quality of life associated with extreme obesity. Sexual behavior and functioning is an important aspect of quality of life but is frequently overlooked in research studies as well as clinical care. This paper focuses on the quality of life and sexual functioning of obese individuals with specific focus on the changes in these domains following the substantial weight losses seen after bariatric surgery.