Preoperative and post‐operative psychosocial interventions for bariatric surgery patients: A systematic review

Psychosocial interventions are increasingly being utilized to help patients prepare for, and adjust to changes following, bariatric surgery in order to optimize psychosocial adjustment and weight loss. The current systematic review examined the impact of preoperative and post‐operative psychosocial interventions with a behavioural and/or cognitive focus on weight, dietary behaviours, eating pathology, lifestyle behaviours, and psychological functioning. A PsycINFO and Medline search of publications was conducted in March 2019. Two authors assessed retrieved titles and abstracts to determine topic relevance and rated the quality of included studies using a validated checklist. Forty‐four articles (representing 36 studies) met the study inclusion criteria. The current evidence is strongest for the impact of psychosocial interventions, particularly cognitive behavioural therapy, on eating behaviours (eg, binge eating and emotional eating) and psychological functioning (eg, quality of life, depression, and anxiety). The evidence for the impact of psychosocial interventions on weight loss, dietary behaviours (eg, dietary intake), and lifestyle behaviours (eg, physical activity) is relatively weak and mixed. Psychosocial interventions can improve eating pathology and psychosocial functioning among bariatric patients, and the optimal time to initiate treatment appears to be early in the post‐operative period before significant problematic eating behaviours and weight regain occur.     

Comparative Effectiveness of Treatments for Binge‐Eating Disorder: Systematic Review and Network Meta‐Analysis

Psychological and pharmacological interventions for binge‐eating disorder have previously demonstrated efficacy (compared with placebo or waitlist control); thus, we aimed to expand that literature with a review of comparative effectiveness. We searched MEDLINE,® EMBASE,® Cochrane Library, Academic OneFile, CINAHL® for binge‐eating disorder treatment articles and selected studies using predetermined inclusion and exclusion criteria. Data were sufficient for network meta‐analysis comparing two pharmacological interventions; psychological interventions were analysed qualitatively. In all, 28 treatment comparisons were included in this review: one pharmacological comparison (second‐generation antidepressants versus lisdexamfetamine) and 26 psychological comparisons. Only three statistically significant differences emerged: lisdexamfetamine was better at increasing binge abstinence than second‐generation antidepressants; therapist‐led cognitive behavioural therapy was better at reducing binge‐eating frequency than behavioural weight loss, but behavioural weight loss was better at reducing weight. The majority of other treatment comparisons revealed few significant differences between groups. Thus, patients and clinicians can choose from several effective treatment options. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.     

Eating behaviour: social influences in open community nuns

This article analysed the eating behaviour and the psychological discomfort in a sample of 44 religious women living in open communities. The Eating Attitudes Test‐40 items, the Interview for the Diagnosis of Eating Disorders, the Bulimic Investigatory Test, and the revised Symptom Checklist‐90 were used in order to assess the sample, and a factor analysis was performed. Three basic dimensions in the mental state were obtained: (1) Psychological discomfort, (2) Anorexic behaviour, and (3) Bulimic behaviour. Our results support the idea that people living in open communities share the social values regarding weight and body size, and show elevated levels of psychological discomfort strongly associated with symptoms of eating disturbances. Copyright © 2002 John Wiley & Sons, Ltd and Eating Disorders Association.     

Behavioural weight management for the primary careprovider

Primary care providers (PCPs) provide the majority of weight management care in clinical settings; however, they often lack the time or resources to apply strategies recommended in treatment guidelines. This review surveyed randomized clinical trials and prospective weight management studies from 1990 to present to identify evidence‐based behavioural strategies for weight management applicable to the PCP treatment environment. Data supported, time‐limited weight management strategies included self‐monitoring, portion control, sleep hygiene, restaurant eating and television viewing. The current review suggests that a number of behavioural strategies are available to enhance the effectiveness of PCPs weight management interventions. Increasing PCP awareness of these evidence‐based strategies may increase their attention to overweight and obesity concerns in clinical encounters and encourage more collaborative efforts with patients towards weight management goals.     

Cognitive‐behavioural,fluoxetine and combined treatment for bulimia nervosa: short‐ and long‐term results

This study examined the short‐ and long‐term effectiveness of cognitive‐behavioural group treatment (CBT), pharmacological treatment with fluoxetine and combined treatment in patients with DSM‐III‐R bulimia nervosa. Fifty‐three patients were randomly assigned to the three conditions. Outcome measures were frequency of bingeing and purging, attitudes toward weight and shape, depression and self‐concept. Patients were followed for 1 year post‐treatment. Thirty‐five patients completed treatment. Drop‐out rates were 42 per cent for CBT, 25 per cent for the fluoxetine and 33 per cent for the combined condition. All treatments led to significant improvements in eating disorder symptoms and in other psychological disturbances between pre‐ and post‐treatment, which could be maintained at 1‐year follow‐up. Abstinence rates for completers were highest for CBT at both post‐treatment and follow‐up. The short‐ and long‐term results of this study do not favour the combined treatment in comparison to CBT alone. Cultural differences in health systems as well as in the acceptance of treatments offered in a treatment trial are discussed. Copyright © 2002 John Wiley & Sons, Ltd and Eating Disorders Association.     

Who will lose weight on sibutramine and orlistat? Psychological correlates for treatment success

Aim:  To study the associations between weight loss with sibutramine and orlistat with psychological aspects that may interact with patients' response to these drugs.
Methods:  A total of 478 obese patients with a mean body mass index of 42 ± 12 kg/m² gave self-reported, retrospective data on different types of previous weight loss treatments (sibutramine and orlistat, and Weight Watchers used as a control condition) including the amount of weight lost with these treatments, eating behaviour (Dutch Eating Behaviour Questionnaire) and personality (NEO Personality Inventory – Revised).
Results:  Greater weight loss with sibutramine was associated with lower levels of restrained eating and higher levels of 'neuroticism', in particular 'anxiety' and 'depression'. Greater weight loss with orlistat was associated with aspects of the personality dimension 'conscientiousness' (e.g. 'order' and 'deliberation').
Conclusion:  Sibutramine may exert its greatest effect in patients whose eating is a 'natural' response to hunger rather than regulated by cognitions and conscious controls. Patients with low levels of restraint could be more sensitive to the satiety-enhancing effect of sibutramine. They may be able to reduce their food intake without cognitive interference and/or start to control their eating most radically in response to enhanced satiety. Enhanced satiety may also help patients withstand a wish to eat triggered by psychological distress. Possible central nervous system effects on mood could also have reduced eating, which was related to distress. The administration regimen of orlistat is more demanding, requiring greater adherence. This can account for the finding that personality attributes such as conscientiousness are important for success.     

Relationship between dietary restraint, binge eating, and leptin in obese women

OBJECTIVE: To describe some biological, behavioural and psychological correlates of the Three-Factor Eating Questionnaire, and to determine the relationship between dietary restraint, binge eating, and leptin among obese women seeking treatment. DESIGN: Consecutive series of obese women enrolled in a clinical program for weight reduction treatment. SUBJECTS: Forty-two obese women. Eight participants met the criteria for 'severe binge eating' as measured by the Binge Eating Scale. MEASUREMENTS: Energy intake, resting energy expenditure, body composition, leptin, restraint, disinhibition, hunger and binge eating were assessed before starting the treatment. RESULTS: In this sample both higher disinhibition and hunger scores were associated with greater binge eating severity. Obese women with severe binge eating had lower restraint, higher disinhibition and hunger scores, as well as higher daily fat intake, when compared with obese non-binge-eaters. Interestingly, restraint scores were negatively associated with leptin levels among subjects with severe binge eating. CONCLUSION: In obese women with severe binge eating, the negative relationship between dietary restraint and serum leptin concentrations seems mediated by a greater fat intake. These findings need to be verified in further human studies.     

Psychometric Evaluation of the Eating Disorder Examination Adapted for Children

The Eating Disorder Examination adapted for children (ChEDE) is the child version of the semi‐structured gold standard eating disorder interview for adults. This study was a comprehensive test statistic evaluation of the German ChEDE in a large sample of children and adolescents with anorexia nervosa, binge eating disorder, loss of control eating, overweight and obesity, as well as non‐eating‐disordered and chronically ill control probands (n = 352). Excellent inter‐rater reliability, adequate internal consistency and satisfactory stability of ChEDE indicators were demonstrated. ChEDE indicators discriminated between diverse forms of eating and weight disturbances and normative eating and were significantly correlated with conceptually related measures. Factorial validity was not convincing; a brief eight‐item scale showed the best fit. Item statistics were mostly acceptable. Overall, the ChEDE's German translation reliably and validly assesses psychopathology across the eating and weight disorder spectrum and facilitates international comparison of eating disorder research. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.     

Understanding and effectively addressing disparities in obesity: A systematic review of the psychological determinants of emotional eating behaviours among Black women

Emotional eating may be a particularly important contributor to differences in body weight and weight loss response to behavioural interventions among non‐Hispanic Black women. We performed a systematic review on the impact of psychological factors (stress, anxiety, depression, and discrimination) upon emotional eating and weight among non‐Hispanic Black women, applying the Preferred Reporting Items for Systematic Reviews and Meta‐analysis for relevant studies. The initial search yielded 4593 articles with 15 accepted for review. Based on this review, there is a suggestion that negative emotions, in particular, perceived stress, may be predictive of emotional eating among non‐Hispanic Black women. Results from the only two longitudinal studies identified by the review indicate that stress influences emotional eating, and emotional eating predicts weight gain over time. Findings from this review highlight the need for more studies that examine various negative emotions that may lead to emotional eating and weight gain among non‐Hispanic Black women. Findings from this review also highlight the need for more rigorous studies to differentiate the effects of emotional eating from that of the physiologic (ie, activation of the hypothalamic‐pituitary axis) responses to stress and its impact on high‐risk groups.     

Long-term health and psychosocial outcomes from surgically induced weight loss: results obtained in patients not attending protocolled follow-up visits

OBJECTIVE: Obesity management is focused at weight loss to obtain health, psychological and social benefits. Outcomes from controlled trials, however, do not reflect the everyday routine practice. Therefore, we aimed to investigate the results from surgically induced weight loss in patients devoid of a protocol-wise follow-up, who were visited at home. PATIENTS AND METHODS: Patients who underwent a vertical banded gastroplasty or a gastric bypass between 1980 and 1997 were eligible. Body weight and height were measured. Patients filled out questionnaires on health status (Nottingham Health Profile (NHP)), psychological symptoms (Symptom Check List (SCL-90-R)), personality traits (Dutch Personality Questionnaire (DPQ)) and eating behaviour (Dutch Eating Behaviour Questionnaire (DEBQ)). RESULTS: Out of 451 operated patients the addresses of 313 subjects could be traced and 236 (75%) agreed to participate. They maintained a mean (s.d.) loss of 32.1 (22.6) kg and 45.2 (29.3) % of excess weight, 8.2 (4.5) years after the operation, about two-third of the largest weight loss they achieved after 17 months postoperatively. The NHP and SCL-90-R conformed to norm values in males except for energy, sleep and emotional reactions. Females differed from norm values in every aspect and even women achieving a BMI<30 kg/m(2) did not catch up to norm values. Weight loss was inversely related to physical immobility and pain. Personality traits (DPQ) showed a higher grievance and dominance and a lower rigidity and self-esteem compared to norm values. Females scored higher in inadequacy and lower in social inadequacy. Eating patterns (DEBQ) showed mainly emotional eating and restrained eating. Effect sizes of >/=0.8 s.d. were chosen to reflect the clinical relevance of statistically significant findings. Pain, disturbances in sleep, energy and mobility and emotional and restrained eating proved to be clinically relevant. In subjects operated >5 years ago, a higher sensitivity, a higher inadequacy and a lower social inadequacy were observed compared to more recently operated subjects. A more restrained eating pattern was related to an operation of recent date. CONCLUSIONS: Surgically induced weight losses are satisfactory in the long-term, even in patients not attending a strict follow-up protocol. Health, psychological symptoms, personality traits and eating behaviour were related to weight loss and time lapse since the operation and did not return to reference normal-weight subject values.     

Behavioural correlates of successful weight reduction over 3 y. Results from the Lean Habits Study

OBJECTIVE: To examine behavioural characteristics of subjects with successful long-term weight reduction. DESIGN: Prospective cohort study with 3 y follow-up. SETTING: Multicentre study of participants of a commercial weight-reduction programme (BCM-Programme). SUBJECTS: Until February 2000, 6857 voluntary study participants were included. Analyses are based on 1247 subjects with complete 3 y data. INTERVENTIONS: Open-group dietary and behavioural counselling with initial meal substitutions. RESULTS: Subjects show a number of significant behavioural improvements, for example, choice of low-fat food, flexible control of eating behaviour and coping with stress. Subjects who maintain these changes by the end of the first year have a higher probability of successful weight reduction after 3 y. CONCLUSIONS: Successful weight maintenance is associated with more pronounced improvements of health behaviours after 1 y. The likelihood of success increases with the number of behavioural patterns which are involved in the process of change.     

Binge status as a predictor of weight loss treatment outcome.

OBJECTIVE: A widely held clinical belief is that individuals with binge eating problems fare poorly in weight loss programs. The empirical evidence regarding the prognostic significance of binge eating, however, is mixed. The goals of this study were to examine psychological and behavioral characteristics associated with binge eating and the prognostic significance of binge eating for short- and long-term weight loss in a large sample of women treated for obesity. DESIGN: The dataset used in the current study was a combined sample of women (n = 444) who participated in one of three behavioral weight loss research studies. MATERIALS AND METHOD: Measures of dieting and weight history were obtained at baseline. Body weight, the Binge Eating Scale (BES), a measure of perceived barriers to weight loss, the Beck Depression Inventory, the Block Food Frequency Questionnaire, and the Paffenbarger Physical Activity Questionnaire were assessed at baseline, 6 months and 18 months. Regression analyses examined cross-sectional associations between the BES and the other variables at baseline, prospective associations between baseline BES and changes in weight and the psychological and behavioral variables over time, and temporal covariations between BES and the other variables over time. RESULTS: Cross-sectional analyses showed baseline binge eating status to be strongly associated with dieting history, weight cycling, depressive symptomatology and perceived barriers to weight loss. Women with binge eating problems were also more likely to drop out of treatment. Baseline binge status was not associated with 6-month weight loss, but was weakly predictive of less weight loss success at 18 months. Binge status at baseline did not predict changes in dietary intake, physical activity, perceived barriers to weight loss or depressive symptomatology at either 6 months or 18 months. In time-dependent covariance analyses, changes in BES scores were significantly associated with changes in body weight, independent of changes in dietary intake and physical activity. However, when depression scores are included in the analysis, the association between binge score and body weight was no longer statistically significant. CONCLUSION: These findings suggest that baseline binge status was a weak prognostic indicator of success in women who are moderately obese and are seeking treatment for weight loss. Although assessments of binge status covary with weight loss and regain, the relationship appears to be mediated by psychological dysphoria.     

Personality Subtypes in Female Pre‐Bariatric Obese Patients: Do They Differ in Eating Disorder Symptoms,Psychological Complaints and Coping Behaviour?

In the pre‐bariatric psychological assessment of 102 morbidly obese women, two personality subtypes emerged: a resilient/high functioning subtype with a ‘normal’ personality profile and an emotional dysregulated/undercontrolled subtype, characterized by high neuroticism and low extraversion/conscientiousness. Emotional dysregulated/undercontrolled patients showed more concerns about eating/weight/shape, more binge eating driven by emotions and external triggers, more psychological complaints (such as depression and anxiety) and more avoidance and depressive coping reactions than resilient/high functioning patients. Further research should clarify whether these clearly different psychological profiles are related to different outcomes (weight loss or well‐being) of bariatric surgery. Copyright © 2012 John Wiley & Sons, Ltd and Eating Disorders Association.     

Psychological outcomes following surgical and endoscopic bariatric procedures: A systematic review

Obesity is a leading global epidemic. Bariatric surgery is the only treatment demonstrating substantial long‐term weight loss and medical benefits. However, there is limited research on the psychological outcomes following surgery. Therefore, the primary aim of this study was to systematically review depression, anxiety, and binge eating outcomes at different time points following bariatric surgery and identify whether bariatric surgery significantly reduces psychological symptoms over time. These outcomes were also examined among endoscopic bariatric procedures as a secondary aim. Forty‐eight studies met inclusion criteria. Findings suggested that most patients experience a short‐term reduction in anxiety and depression symptoms from pre‐surgery. Over time, however, these symptoms increase and may even return to pre‐surgery levels. Furthermore, while binge eating was uncommon after surgery, other disordered eating patterns may emerge. Binge eating may also restart over time as the stomach enlarges again. Overall, the complex psychological difficulties faced by individuals with obesity continue after surgery and may contribute to longer‐term weight recidivism. More comprehensive and standardised psychological assessment procedures, including clinical interviews and longer‐term follow‐up, may provide insight into the psychological mechanisms maintaining weight management issues, and may serve as a starting point for improving the long‐term success of patients with obesity.     

Dieting and the development of eating disorders in overweight and obese adults

We reviewed articles evaluating the relations among dieting, weight loss treatment, weight cycling, eating disorders, and psychological functioning in overweight and obese adults. Moderate caloric (energy) restriction, in combination with behavioral weight loss treatment, does not seem to cause clinically significant binge eating in overweight adults without preexisting binge eating problems and might ameliorate binge eating, at least in the short term, in those reporting recurrent binge eating before treatment. Most studies of behavioral weight loss interventions report improvements in psychological status during weight loss. However, these improvements might return to baseline with weight regain. Weight cycling does not seem to be associated with clinically significant psychopathologic conditions, although results of cross-sectional studies show an association between weight cycling and binge eating, as well as poorer perceived health status. "Nondieting" approaches seem to lead to improvements in mood and self-esteem; however, weight loss is generally minimal. Concerns that dieting induces eating disorders or other psychological dysfunction in overweight and obese adults are generally not supported by empirical studies. Such concerns should not preclude attempts to reduce caloric intake and increase physical activity to achieve modest weight loss or prevent additional weight gain.     

Migraine and obesity: epidemiology,possible mechanisms and the potential role of weight loss treatment

Migraine and obesity are two public health problems of enormous scope that are responsible for significant quality of life impairment and financial cost. Recent research suggests that these disorders may be directly related with obesity exacerbating migraine in the form of greater headache frequency and severity, or possibly increasing the risk for having migraine. The relationship b e tween migraine and obesity may be explained through a variety of physiological, psychological and behavioural mechanisms, many of which are affected by weight loss. Given that weight loss might be a viable approach for alleviating migraine in obese individuals, randomized controlled trials are needed to test the effect of weight loss interventions in obese migraineurs. Large‐scale weight loss trials have shown that behavioural interventions, in particular, can produce sustained weight losses and related cardiovascular improvements in patients who are diverse in body weight, age and ethnicity. Consequently, these interventions may provide a useful treatment model for showing whether weight loss reduces headache frequency and severity in obese migraineurs, and offering further insight into pathways through which weight loss might exert an effect.     

Eating behavior in obese patients with and without type 2 diabetes mellitus

OBJECTIVE: Aim of this study was the assessment of the prevalence of eating disorders, and of eating disorder symptoms, in obese patients with type 2 diabetes, compared to non-diabetic subjects. DESIGN: Three samples of individuals were studied: a series of 156 (76 male, 80 female) overweight and obese type 2 diabetic patients, aged 30-65 y, with a body mass index (BMI)>28 kg/m(2) (DM); a series of 192 (20 male, 172 female) obese (BMI>30 kg/m(2)) non-diabetic patients aged 30-65 y seeking treatment for weight loss (OC); and a non-clinical sample of 48 (22 male, 26 female) obese (BMI>30 kg/m(2)) subjects aged 30-65 y selected from the lists of two general practices (OP). Eating behavior was assessed using the Eating Disorder Examination (EDE 12.0D). RESULTS: The prevalence of Binge Eating Disorder was lower than 5% in all the three samples. Median EDE scores in females were significantly higher in OC (3.0) and OP (3.4) than in DM (1.7), while diabetic patients showed higher scores on Restraint than both non-diabetic samples. Among diabetic patients, a significant correlation of EDE scores with HbA(1)c was observed. CONCLUSIONS: Type 2 diabetes is unlikely to induce relevant eating disturbances in obese patients, apart from an increase in restraint. Abnormalities of eating attitudes and behavior are associated with an impairment of metabolic control.     

Psychological counselling in problematic diabetes: does it help?

BACKGROUND: In past decades clinicians have increasingly recognized the importance of psychological support for people with diabetes and their families, and many have recommended integrating psychological counselling into routine diabetes care. It is therefore important to consider whether psychological interventions in diabetes are effective in improving clinical outcomes. METHODS: This review was limited to the literature reporting on the treatment of five common psychological problems known to complicate diabetes management: depression, eating disorders, anxiety/stress, self-destructive behaviour and interpersonal/family conflicts. A literature search was undertaken using MedLine and PsychInfo, including studies published in English peer-reviewed journals between 1990 and 2001, reporting on the effects of psychological interventions in the areas mentioned. Case studies were excluded from the review. RESULTS: In line with earlier reviews, relatively little empirical research was found to substantiate the effect of psychological counselling in complicated diabetes. Most studies are uncontrolled, and involve small samples. In total only 11 randomized controlled trials were identified. Results indicate that cognitive behaviour therapy (CBT) is effective in the treatment of depression in Type 2 diabetes patients, both in reducing depressive symptoms and HbA1c. Favourable effects have been observed in pilot studies applying CBT in the field of stress management, eating disorders and self-destructive behaviour, but future research should substantiate these preliminary findings. Behaviour family therapy proved beneficial in terms of resolving family conflicts, but did not impact glycaemic control. CONCLUSIONS: Evidence to support the effect of psychological treatment in problematic diabetes is still scarce, due to limited research in this area. Suggestions are made to further develop psychotherapeutic research in diabetes care. We conclude that future research should gain from a behavioural medicine approach to diabetes, with close collaboration between diabetologists and psychologists.     

Risk and protective factors for disturbed eating in adolescent girls – aspects of perfectionism and attitudes to eating and weight

The aim of this study was to longitudinally examine the role of personal standards, self‐evaluation, perceived benefits of thinness and attitudes to eating and weight in the development of healthy versus disturbed eating in adolescent girls. In a longitudinal study, girls who participated in two assessments, four to five years apart, were divided into three groups according to the attitudes to eating that they manifested at the second evaluation: those with disturbed eating patterns (DE‐group, n = 49), those with intermediate concerns about eating (IE‐group, n = 260) and those with healthy eating attitudes (HE‐group, n = 120). Variables concerning attitudes to eating and weight and physical self‐evaluation emerged as risk factors, whereas personal standards or self‐evaluation in general did not. Protective factors were a low BMI, healthy eating attitudes, an accepting attitude towards body size and a positive self‐evaluation, particularly with regard to physical and psychological characteristics. The results of this study contribute to the understanding of early risk and protective factors for eating disturbances in girls. Copyright © 2009 John Wiley & Sons, Ltd and Eating Disorders Association.     

Correlates of Binge Eating Disorder in French Women

In the present study, patients seeking help for weight control with and without “Binge eating disorder” were compared to community non patients in terms of functional impairment and psychological problems. Subjects with BED self reported psychological difficulties, history of depression, treatment for emotional problems and alcohol abuse significantly more frequently than subjects without BED or subjects from the community. © 1997 John Wiley & Sons, Ltd and Eating Disorders Association.