Previous weight loss experiences of bariatric surgery candidates: how much have patients dieted prior to surgery?

OBJECTIVE: To describe the dieting histories of bariatric surgery candidates. RESEARCH METHODS AND PROCEDURES: One hundred seventy-seven individuals with extreme obesity who sought bariatric surgery completed the Weight and Lifestyle Inventory, a self-report instrument that assesses several variables, including weight and dieting history. Patients' dieting histories were further explored with an aided recall during a preoperative behavioral/psychological evaluation performed by a mental health professional. RESULTS: Participants who completed the Weight and Lifestyle Inventory reported an average of 4.7 +/- 2.9 successful dieting attempts, defined as those that resulted in a loss of 10 lbs (4.5 kg) or more. These individuals reported a mean total lifetime weight loss of 61.1 +/- 41.3 kg. Despite these efforts, their weight increased from 89.4 +/- 27.4 kg at the time of their first diet (age 21.2 +/- 10.1 years) to 144.5 +/- 30.8 kg at the time they underwent their behavioral/psychological evaluation (age 43.0 +/- 11.0 years). Results of the aided recall revealed that participants had made numerous other efforts to lose weight that were unsuccessful. Self-directed diets and commercial programs were used more frequently. DISCUSSION: Individuals who sought bariatric surgery reported an extensive history of dieting, beginning in adolescence, that was not successful in halting progressive weight gain. Thus, the recommendation often made by insurance companies that patients delay surgery to attempt more conservative treatment options may be unwarranted, particularly in the presence of significant obesity-related comorbidities. Weight loss histories should be routinely examined during a behavioral evaluation to determine whether additional attempts at non-surgical weight loss are advisable. Future studies also are needed to explore the potential relationship between dieting history and postoperative outcome.     

Psychosocial Predictors of Success following Bariatric Surgery

Background: Bariatric surgery is the treatment of choice for morbid obesity, but it does not lead to equal results in every patient. In addition to surgery, a number of non-surgical and psychological factors may influence patients' ability to adjust to the postoperative condition. Understanding the relationship between potential predictive variables and success after bariatric surgery will enable better patient selection, and the development of interventions to improve outcome. Methods: A systematic literature search identified relevant variables, such as demography, preoperative weight, motivation, expectations, eating behavior, psychological functioning, personality, and psychiatric disorders, which may have predictive value for success after bariatric surgery. Results: Greater success following bariatric surgery appears to occur in patients who are young and female, and have a high self-esteem, good mental health, a satisfactory marriage, and high socio-economic status, who are self-critical and cope in a direct and active way, are not too obese, were obese before the age of 18, suffer from and are concerned about their obesity, have realistic expectations and undisturbed eating behaviors. Occasionally, these variables may have poor or no predictive value. Although reliable predictors are lacking, most treatment teams propose their own exclusion criteria. Conclusion: The existing literature about potential predictors of success after bariatric surgery is far from conclusive; it is still uncertain which factors can predict success. Even where psychosocial functioning does not predict outcome, it is important to identify patients' characteristics which may be linked to their prognosis and to provide necessary pre- and postoperative psychosocial interventions.     

Impression management or real change? Reports of depressive symptoms before and after the preoperative psychological evaluation for bariatric surgery

Background Many bariatric surgery programs require that candidates undergo a preoperative mental health evaluation. Candidates may be motivated to suppress or exaggerate psychiatric symptoms (i.e., engage in impression management), if they believe doing so will enhance their chances of receiving a recommendation to proceed with surgery. Method 237 candidates for bariatric surgery completed the Beck Depression Inventory-II (BDI-II) as part of their preoperative psychological evaluation (Time 1). They also completed the BDI-II approximately 2–4 weeks later, for research purposes, after they had received the mental health professional’s unconditional recommendation to proceed with surgery (Time 2). Results There was a small but statistically significant increase in mean BDI-II scores from Time 1 to Time 2 (11.4 vs 12.7, P < .001). Clinically significant changes, defined as a change from one range of symptom severity to another, were observed in 31.2% of participants, with significant increases in symptoms occurring nearly twice as often as reductions (20.7% vs 10.5%, P < .008). Demographic variables were largely unrelated to changes in BDI-II scores from Time 1 to Time 2. Conclusion Approximately one-third of bariatric surgery candidates reported a clinically significant change in depressive symptoms after receiving psychological “clearance” for surgery. Possible explanations for these findings include measurement error, impression management, and true changes in psychiatric status.     

Psychosocial Status in Adolescents Undergoing Bariatric Surgery

Background Little is known about the psychosocial status of adolescents who undergo bariatric surgery. Our objective was to describe the psychological and behavioral characteristics of patients in this age group who underwent bariatric surgery at our institution. Methods A review of clinical charts of patients aged 14–21 years who had bariatric surgery at our institution between 2000 and 2005 was conducted. Abstracted data included clinical information and the results of a psychosocial evaluation consisting of a clinical interview with a psychologist and self-reported data from the Weight and Lifestyle Inventory and the Beck Depression Inventory-II. Results Twenty-five patient records were reviewed. Nineteen patients (76%) were female. The mean (±SD) age was 18.7 ± 1.6 years, and mean body mass index was 50.6 ± 7.9 kg/m². Depression was the most common psychiatric comorbidity (68%). Abnormal eating behaviors were frequent and included binge eating (48%), rapid eating (44%), having guilt associated with eating (36%), eating until uncomfortably full (36%), loss of control (24%), eating without hunger (24%), and eating alone (20%). Sixteen patients were judged to be appropriate for surgery by the bariatric surgery team; surgery was delayed for nine patients primarily because of concerns about ability to adhere to the postoperative diet. These patients were recommended for additional dietary counseling and/or psychotherapeutic treatment prior to surgery. Conclusions Among adolescent bariatric surgery candidates, depression and aberrant eating behaviors were very common. Early identification and management of these conditions may enable most of these patients to undergo bariatric surgery and optimize the likelihood for a successful outcome.     

Socially desirable responding by bariatric surgery candidates during psychological assessment

BackgroundMost bariatric surgery programs in the United States require preoperative psychological evaluations for candidates for surgery. Among those who perform these evaluations is concern that many patients engage in “impression management” or minimizing the symptoms of distress to receive a recommendation to proceed with surgery from the mental health professional. We sought to assess the prevalence of socially desirable responding and its associations with measures of psychological functioning among bariatric surgery candidates at 2 academic medical centers in the United States.MethodsThe participants were male (n = 66) and female (n = 293) bariatric surgery candidates who presented for psychological evaluation. The participants completed 2 measures of socially desirable response styles (Marlowe-Crowne Social Desirability Scale and Personality Assessment Inventory Positive Impression Management scale) and standardized measures of anxiety, depression, and alcohol-related problems.ResultsThe participants exhibited elevated scores on the social desirability indicators, with 33.3–39.8% scoring above the recommended cut-score on the Personality Assessment Inventory Positive Impression Management scale and 62.3–67% scoring 1 standard deviation above the standardization mean on the Marlowe-Crowne Social Desirability Scale. Scores on the Marlowe-Crowne Social Desirability Scale and Personality Assessment Inventory Positive Impression Management scale correlated inversely with the clinical measures of anxiety and depression, and the high/low scorers on the social desirability indices exhibited significant differences in anxiety and depression. Thus, elevated scores on the social desirability indices were associated with underreporting of certain clinical symptoms.ConclusionA substantial proportion of bariatric surgery candidates appear to present themselves in an overly favorable light during the psychological evaluation. This response style is associated with less reporting of psychological problems and might interfere with the accurate assessment of patient functioning.     

A focus on surgical preoperative evaluation of the bariatric patient – The Cleveland Clinic protocol and review of the literature

Bariatric surgery is well established as a safe and effective treatment for morbid obesity and related metabolic diseases. As an elective procedure, it is critical that individuals considering bariatric surgery should be carefully selected, extensively evaluated, and optimized in order to achieve optimal outcomes. This patient population has unique and challenging issues, including an extensive range of potential medical, psychiatric, and psychological comorbidities, and often patients have unrealistic expectations of the surgery. Therefore, a multidisciplinary, comprehensive and timely assessment preoperatively is of great importance. Individual bariatric units utilise different preoperative patient evaluation protocols. There is at present no uniformly accepted or recommended practice. In this article we describe what we believe are the essential components of a preoperative bariatric surgery evaluation, with supporting evidence for each recommendation. We also present a protocol currently in practice at a high volume bariatric center of excellence; the Bariatric and Metabolic Institute in the Cleveland Clinic, Ohio.     

Psychological Profile of Candidates for Vertical Banded Gastroplasty

Background: Because bariatric surgery is a forced behavior modification and the operation represents only one element in it, behavioral and psychological factors play an important role in its results. Consequently, better understanding of candidates for bariatric surgery may improve selection for and success with this intervention. Methods: In this study, the psychological profile of candidates for vertical banded gastroplasty (VBG) was investigated. In the context of preoperative psychological evaluation, 153 patients were interviewed by a psychologist and completed a battery of psychological tests. Results: Compared to varying samples of the general population, candidates for VBG, especially females, experienced more psychological difficulties, more disturbed eating patterns, poor body attitude, and poor quality of life (QoL). In addition, 3 subgroups could be identified, ranging from relatively good to relatively poor psychological functioning. Conclusion: Preoperatively, candidates for VBG struggle with a diversity of problems; however, some patients are less negatively affected by their obesity than others.     

How Do Mental Health Professionals Evaluate Candidates for Bariatric Surgery? Survey Results

Background: The prevalence of extreme obesity and the popularity of bariatric surgery have increased dramatically in recent years. Many surgery programs require that candidates undergo a preoperative psychological evaluation, but no consensus exists for guiding mental health professionals in the conduct of these evaluations. Method: A survey was sent to bariatric surgeons, who were asked to distribute the surveys to the mental health professionals to whom they refer surgery candidates for preoperative evaluations. 194 respondents provided information on the assessment methods they use, which psychosocial domains are the focus of their evaluations, and what they consider to be contraindications to surgery. Responses to open-ended questions were coded for content. Results: Most respondents reported using clinical interviews (98.5%), symptom inventories (68.6%), and objective personality/psychopathology tests (63.4%). A minority used tests of cognitive function (38.1%) and projective personality tests (3.6%). Over 90% of respondents listed mental health issues among the most important areas to assess. Similarly, 92.3% listed psychiatric issues as "clear contraindications" to surgery, but no specific disorder was listed by a majority of respondents. Issues related to informed consent and treatment adherence were the non-psychiatric domains most frequently listed as important areas to assess and as contraindications to surgery. Conclusion: The assessment practices of mental health professionals who evaluate bariatric surgery candidates vary widely. No consensus is likely to emerge until large long-term studies identify consistent psychosocial predictors of poor postoperative outcomes.     

Outcome of Gastric Restriction Procedures: Weight, Psychiatric Diagnoses, and Satisfaction

Background: Weight losses following bariatric surgery have varied widely, depending on length of follow-up and various pre-surgical characteristics of patients undergoing surgery. Methods: One hundred thirty one patients had a detailed presurgical psychiatric evaluation. Patients were assessed clinically for 2 years after surgery and at follow-up a mean of 5.7 years after surgery. Results: Mean presurgical body mass index (BMI) was 52.9 kg/m²; therefore, many patients had ‘super obesity’. Two-thirds of the patients were located a mean of 5.7 years after surgery. The mean change in BMI at follow-up was 25% and the mean weight loss was 27%. One-third had excellent or good weight outcomes using the Griffen criteria. Five patients had died by follow-up. There was no relationship between age, gender, or fat content presurgically and weight loss at follow-up, although presurgical weight was associated with greater weight loss at follow-up. Weight regain began 2 years after surgery. There was no relationship between the presence or absence of a presurgical psychiatric diagnosis and weight loss at follow-up. There was also no relationship between the presence of a presurgical psychiatric diagnosis and various mental health parameters at follow-up. Satisfaction with the surgery was marginally associated with weight loss but significantly associated with improved mental and physical health. Conclusions: Mean weight losses were less than have been previously reported with gastric restriction procedures but the follow-up was longer than usually reported and many patients had ‘super obesity’ prior to surgery. The implications of ‘super obesity’ for weight loss are discussed.