Clinical Practice Guidelines for the Support of Bariatric Surgery Patients: The Impact of the 2013 Update on the Role of Psychology

| December 10, 2014

This column is dedicated to covering a variety of topics relevant to the multidisciplinary care of the bariatric surgical patient.

Column Editor: Christine Bauer, MSN, RN, CBN
University of Maryland Harford Memorial Hospital, Havre de Grace, Maryland; President, American Society for Metabolic and Bariatric Surgery Integrated Health

This month: Clinical Practice Guidelines for the Support of Bariatric Surgery Patients: The Impact of the 2013 Update on the Role of Psychology

by Dene Berman, PhD, ABP

Dr. Berman is a Board Certified Clinical Psychologist. He is the Clinical Director of Lifespan Counseling Associates in Beavercreek, Ohio and Clinical Professor in the School of Professional Psychology, Wright State University, Dayton, Ohio.

Funding: No funding was provided.

Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2014;10(12):21–23.

ABSTRACT

The American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery jointly published updated Clinical Practice Guidelines in 2013. Fifteen of these guidelines have implications for the role of the psychologist on the bariatric team. The current article considers the potential impact of these 15 clinical practice guidelines as they inform the practice of psychologists as members of the bariatric healthcare team. In this article, the clinical practice guidelines are heuristically organized into categories of appropriate candidates, psychological evaluations, and postoperative intervention.

Introduction

In 2013, the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and the American Society for Metabolic and Bariatric Surgery (ASMBS) jointly published updated clinical practice guidelines (CPGs) “on the nonsurgical aspects of perioperative management of the bariatric surgery patient, with special emphasis on nutritional and metabolic support.”[1] In the original guidelines, there were 165 CPGs.[2] With this update, that number was reduced to 74, with two new and 54 revised guidelines.

Many of the updated guidelines are related to the appropriate types of medical patients for surgery, the role of specific surgeries, and nutritional considerations. Other recommendations concern matters such as informed consent.

This article focuses on the psychological recommendations of the CPGs for bariatric patients. A review of the updated CPGs may lead bariatric teams, and psychologists within them, to reconsider how and what psychologists do as part of the team. This article reviews 15 of the guidelines that appear most relevant to the psychologist, and are organized and presented in three broad categories: appropriate candidates, preoperative evaluation, and postoperative intervention. Within each category, reference will be made to the recommendation number, following the updated CPG. For example, the first recommended CPG is denoted as R1.

This analysis is the author’s own attempt to incorporate the updated CPGs into his own practice of psychology on a bariatric surgery team. It is intended to stimulate thought and practice of the psychologist’s role for other bariatric teams as they implement the revised CPGs.

 

Appropriate Candidates

Quality of life.

  1. Patients with a BMI of 35kg/m2 and one or more severe obesity-related co-morbidities, including […] considerably impaired quality of life may also be offered a bariatric surgery (R2).

Quality of life (QOL) is a multidimensional concept that has been the focus of many researchers over the past 40 years. Early attempts to quantify QOL identified 15 components into five broad dimensions: physical and material well-being; relationships with other people; social, community, and civic activities; personal development and fulfillment; and recreation.[3] More recently, the World Health Organization (WHO) attempted to develop a valid measure of QOL, the WHOQOL-100, which was field-tested in 15 countries worldwide.[4] Twenty-four facets of QOL were identified (e.g., activities of daily living, mobility, social support), yielding a four-factor model that consisted of physical, psychological, social, and environmental domains.

Fayers et al[5] argued that while some measures of QOL consist of items related to medical symptoms of disease states (causal items), others reflect the level of quality (effect items). Some scales attempt to measure causal factors, while others measure the level of QOL (effect items), although most scales combine the two. As psychologists, we are more concerned with the level of QOL (effects) than the symptoms of disease states that may cause them. Such a distinction is not always possible to make, as Fayers et al pointed out. The authors concluded, “Effect indicators may lead to homogeneous summary scales with high reliability coefficients, whilst causal indicators should be treated with greater caution.”[5] Thus, scales emphasizing effects may constitute the best measures for psychologists to use.

The Centers for Disease Control and Prevention (CDC) focused on health-related quality of life (HRQOL) as a national standard to measure public health.[6] The CDC cites three measures of HRQOL that have been widely used and validated, although lengthy and perhaps impractical: 1) Medical Outcomes Study Short Forms (SF-12 and SF-36), 2) the Sickness Impact Profile, and 3) the Quality of Well-Being Scale (http://www.cdc.gov/hrqol/concept.htm). The CDC also has its own 14-item measure of HRQOL, the CDC HRQOL-14 Measure, that reflects activity limitations, symptoms, and general health (http://www.cdc.gov/hrqol/hrqol14_measure.htm ).

There is even a journal devoted to the topic titled Quality of Life Research. With so many choices, the decision of which instrument to use in determining QOL is a complex one. Some psychologists may opt for Flanagan’s original QOL scale,[7] widely used, reliable, valid, and in the public domain. Another instrument, specifically designed to measure the effects of obesity on QOL is the Impact of Weight on Quality of Life questionnaire (IWQOL).[8] This brief, self-report measure consists of 31 items compiled into a total score and five domains (physical function, self-esteem, sexual life, public distress, and work). Kolotkin et al[9] at Duke University have published extensively using this measure.

Whichever measure used, psychologists can help identify that subset of appropriate patients whose QOL has been significantly affected by their weight. In using a measure of QOL, it is also possible to highlight specific areas of the patient’s QOL affected by his or her weight (e.g., social withdrawal and isolation).

 

Psychological Evaluations

Preoperative psychological evaluation.

The following CPGs can easily be incorporated into preoperative psychological examination:

  1. All patients should undergo preoperative evaluation for obesity-related co-morbidities and causes of obesity, with special attention directed to those factors that could affect a recommendation for bariatric surgery…includes Psychosocial-behavioral evaluation (R5).
  2. The preoperative evaluation must include a comprehensive … psychosocial history (R6).
  3. Informed consent for bariatric surgery is a dynamic process of education and comprehension in addition to the disclosure of risks and benefits. Educational objectives, active teaching and learning processes, and assessments are recommended and should be communicated at a 6th-8th grade reading level. (R8)
  4. A psychosocial-behavioral evaluation, which assesses environmental, familial, and behavioral factors, should be required for all patients before bariatric surgery. Any patient considered for bariatric surgery with a known or suspected psychiatric illness, or substance abuse or dependence, should undergo a formal mental health evaluation before performance of the surgical procedure. More comprehensive evaluations assess the bariatric surgery knowledge, weight history, eating and physical activity habits, potential obstacles, and resources that may influence postoperative outcomes.(R27).
  5. Tobacco use should be avoided at all times by all patients. In particular, patients who smoke cigarettes should stop, preferably at least 6 weeks before bariatric surgery. Also, tobacco use should be avoided after bariatric surgery given the increased risk for poor wound healing, anastomotic ulcer, and overall impaired health. (R20)
  6. All patients should undergo evaluation of their ability to incorporate nutritional and behavioral changes before and after bariatric surgery. (R28)
  7. Many bariatric surgery patients have negative beliefs and cognitions regarding physical activity. (R44)

These CPGs reference both psychosocial and behavioral evaluation. Evaluations of this sort, distinguished from purely medical examinations, can be traced back to Engels,[10] whose concept of psychosocial evaluations proposed a systems theory approach to evaluating the person, not only at a biomedical level, but also on personal, family, and social levels. The decision of exactly which factors to include within the evaluation is open to interpretation and, to some extent, left to the discretion of the psychologist.[11]

My interpretation of the revised CPGs leads to the conclusion that a thorough assessment should include the following:

  • Psychosocial history that considers the patient’s environment and family
  • Relevant behaviors
  • Knowledge of bariatric surgery, weight history, eating and physical activity habits, potential obstacles, and resources that may influence postoperative outcomes
  • Psychiatric history and mental health status
  • Substance use, including tobacco
  • Understanding of the risks and benefits of the procedure
  • Ability of making lifestyle changes before and after surgery

 

In conducting a psychological assessment, there is the need to gather important, relevant information and, at the same time, avoid being over-inclusive in what one gathers.[12] Thus, one needs to be selective in both the type of information sought and the depth of detail, with a degree of latitude left to the discretion of the psychologist.

Consider the patient’s environment and family. Relevant factors selected by a psychologist might include the patient’s living situation, such as marital status, number of children, and others in the home, as well as complicating factors that may cause undue stress. Work or disability status is also seen as relevant, including education, career, and retirement. For example, a patient who has a 90-minute commute to work, along with an hour for lunch and eight hours of work, may be gone from the home for 12 hours. Other factors to be considered in the category of environment and family can include the patient’s support system and the availability of bariatric support groups.

Another assessment topic, and the second on the above list, is relevant behaviors. The guidelines do not specify which behaviors to include, thus determining relevant behaviors to include in the assessment may be up to the psychologist and the team. For example, the patient’s lifestyle can include relevant factors such as exercise, not only at this time, but any previous patterns. These can be key to the patient’s determination of the kind of activities to plan for or even initiate pre-surgery.

Another key behavior to include is the pattern of how a patient copes with stress. This may be important because surgery, dietary, and lifestyle changes can increase stress. The American Psychological Association[13] has conducted surveys that include 10 major factors contributing to stress and 24 ways in which people deal with stress. While some coping strategies may be healthy and protective (e.g., yoga, spending time with loved ones, playing with pets), others (e.g., eating, drinking, smoking) are important to note because of the risks they pose to successful outcomes of bariatric surgery.

Surgery knowledge, as mentioned in R27, can be assessed by asking patients to identify key points to the surgery they elect, perhaps even identifying parts of an illustration of surgery, and knowledge of advantages and disadvantages, which are available on the ASMBS website (http://asmbs.org/obesity-and-surgery-learning-center/bariatric-surgery-procedures/).

Another category of the psychological assessment relates to the patient’s psychiatric status. R27 specifically refers to contraindications for surgery as substance abuse or poorly controlled psychiatric illness. Other contraindications are cessation of smoking (R20) and loss-of-control eating and grazing (R28). One might make a determination of mental health status during the verbal interview by asking about any mental health history, including treatment. Psychological tests can also aid in making this determination, which may also address the CPG concerning the identification of resources that may influence postoperative outcomes (R27).

Two of the CPGs (R28, R44) relate to the patient’s thoughts, beliefs, and ability to make changes in diet and behavior, including physical activity, before and after surgery. One way that a psychologist can assess these factors is to ask patients about their plans to transition from their present patterns to those consistent with postoperative success. Patient responses to these questions can reveal obstacles to success. For example, some patients anticipate a major change in their motivation to exercise after surgery. That is, they expect to feel a desire to work out, even if this has never historically been the case. Such thinking is unlikely to lead to a positive outcome and can be targeted for education/counseling. Similarly, some people have jobs that make proper nutrition difficult, such as truckers who eat most of their meals at truck stops. Without proper planning, they are likely to find themselves hungry and without healthy alternatives to past habits.

Psychologists can also assess the patient’s comprehension (R8). This CPG entails the patient’s understanding of surgical information and instructions, informed consent, and the assessment process itself, all of which must be at a 6th to 8th grade reading level. A survey conducted by Bauchowitz et al[14] found that the majority of bariatric surgery candidates are required to undergo psychological evaluation and most of those evaluations utilize psychological tests. They reported the two most common tests administered were the Beck Depression Inventory and the Minnesota Multiphasic Personality Inventory. Both of these tests have a required reading level of the fifth grade.[15],[16]

The outcome of this evaluation is for the psychologist to make recommendations to the team about both inclusionary and exclusionary factors. An example of an inclusionary element would include the patient’s understanding of the surgery, its risks and benefits, and pre- and post-surgical requirements. Exclusionary criteria contained in the above CPGs would obviously include the absence of such knowledge as well as the finding of substance abuse (including tobacco), poorly controlled psychiatric disorders, eating disorders, compromises to the ability to make necessary changes required for successful weight loss, and the lack of resources, such as a positive support system for postoperative success.

Postoperative Intervention

Postoperative follow up.

  1. Significant weight regain or failure to lose weight should prompt evaluation for (a) decreased patient adherence with lifestyle modification, (b) evaluation of medications associated with weight gain or impairment of weight loss, (c) development of maladaptive eating behaviors, (d) psychological complications,… Interventions should first include a multidisciplinary approach, including dietary change, physical activity, behavioral modification with frequent follow up…. (R42)
  2. All patients should be encouraged to participate in ongoing support groups after discharge from the hospital. (R45)

As psychologists consider these CPGs, the need for postoperative follow up on two levels may be evident. First, when postoperative medical visits reveal that a patient has regained a significant amount of weight or has not lost a targeted amount of weight, an evaluation is indicated. Psychologists are well equipped to determine the patient’s lifestyle, eating behaviors, and psychological complications. Some healthcare psychologists may even be able to note medications that lead to weight gain. Thus, psychologists are in a unique position to perform postoperative evaluations for patients whose weight loss is less than optimal.

Second, along with other members of the bariatric team, psychologists, during pre- or post-surgery evaluations, may be in a position to recommend support group participation. Patients can be directed to support groups at area health facilities and online. Many patients’ concerns about surgery involve psychological matters,[17] putting psychologists in a valuable role participating in or facilitating support groups.

For those patients who have been evaluated and are struggling due to lifestyle, eating behavior, or mental health instability, individual and group therapies[18],[19] offer an avenue for patients to make the changes necessary for a more successful surgical outcome.

Discussion

The 2013 updated CPGs for bariatric surgery can lead to a revision of the role of psychologists on the bariatric team. This can result in teams further defining and even expanding the role of psychologists. For example, quality of life, readily measured as part of a psychological assessment, when considerably impaired, along with a BMI of 35kg/m2, can now constitute legitimate criteria for bariatric surgery, even in the absence of other medical problems.

The updated CPGs have added clarity for my psychology practice with regard to the scope of pre-surgical psychological evaluations. In this way, evaluations can include topics, such as a psychosocial history, psychiatric history, and status that includes substance use, behaviors related to eating and activity, and resources that influence the patient’s success (e.g., support system, ability to make lifestyle changes before and after surgery, and understanding of the procedure).

Pre-surgical psychological evaluations have the ability to reveal the extent to which the patient has any characteristics that would preclude surgery, such as tobacco or substance abuse, uncontrolled psychiatric symptoms, or the inability to understand the procedure. To be of greatest help to the patient, psychological evaluations can make recommendations about support for the patient that will predict a more successful outcome. For example, recommendations aimed at increasing the patient’s support system might lead to a family member attending preoperative meetings with the patient. This could lead to such outcomes as an increase in the patient’s greater understanding of the procedure, increased adherence with postoperative expectations, or even securing rides to support group meetings. In a similar vein, patients with unstable psychiatric symptoms can be referred for mental health services. Other recommendations can be made to modify eating behavior or patterns of inactivity.

I also see another role for the psychologist that is implied but not explicitly stated in the CPGs—psychotherapy. For those patients with unstable psychiatric symptoms; substance abuse; eating disorders; or feelings, beliefs, or behaviors that are inconsistent with postoperative success, psychotherapy can help them make changes that would otherwise lead to less than optimal outcomes. Psychologists will want to ensure that there is no conflict of interest when both conducting an evaluation and being a psychotherapist.20

After surgery, psychologists can have a role in facilitating support groups. For patients who have failed to lose a significant amount of weight or who have regained weight, psychologists may have a role in conducting a post-surgical evaluation or in offering treatment. The CPGs specify the scope of post-surgical evaluations as including assessing patient struggles with lifestyle modification, determining maladaptive eating patterns, and assessing psychological complications. Once such impediments to weight loss have been identified, psychologists may have a role in providing appropriate treatments to help patients become more successful with weight loss and lifestyle changes.

References

  1. Mechanick JI, Youdim A, Jones DB, et al. Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient—2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity. 2013:21;S1–S27.
  2. Mechanick JI, Sugerman HJ, Kushner RF, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient. Surg Obes Relat Dis. 2008;4:S109–S184.
  3. JC Flanagan. A research approach to improving our quality of life. Am Psychol. 1978;33(2):138–147.
  4. The WHOQOL Group. The World Health Organization Quality of Life Assessment (WHOQOL). Development and psychometric properties. Soc Sci Med. 1998;46 (12):1569–1585.
  5. Fayers PM, Hand DJ , Bjordal K, Groenvold M. Causal indicators in quality of life research. Qual Life Res. 1997;6(5):393–406.
  6. Centers for Disease Control and Prevention. Measuring healthy days: Population assessment of health-related quality of life. Atlanta: Centers for Disease Control and Prevention, 2000.
  7. Burckhardt CS, KL Anderson. The Quality of Life Scale (QOLS): Reliability, validity, and utilization. Health and Quality of Life Outcomes. 2003;1:60
  8. Kolotkin RL, Crosby RD, Kosloski KD, Williams GR. Development of a brief measure to assess quality of life in obesity. Obes Res. 2001;9:102–111.
  9. Boan J, Kolotkin RL, Westman EC, McMahon RL, Grant JP. Binge eating, quality of life and physical activity improve after Roux-en-Y gastric bypass (RYGB) for morbid obesity. Obes Surg. 2004;14:341–348.
  10. Engels GL. The biopsychosocial model and the education of health professionals. Gen Hosp Psychiatry. 1979; 1(2):156–165.
  11. Berman D. A primer on bariatric surgery assessments. Independent Practitioner: Bulletin of Psychologists in Independent Practice. 2007;27(2):70–74.
  12. Lilienfeld SO. Conceptual problems in the assessment of psychopathy. Clinical Psychology Review. 1994;14(1):17–38.
  13. American Psychological Association. Stress in America. Washington, DC: APA, 2008. http://www.apa.org/news/press/releases/2008/10/stress-in-america.pdf. Accessed September 18, 2014.
  14. Bauchowitz AU, Gonder-Frederick LA, Olbrisch ME, et al. Psychosocial evaluation of bariatric surgery candidates: a survey of present practices. Psychosom Med. 2005:67(5);825–832.
  15. Beck AT, Brown G, Steer RA. Beck Depression Inventory II manual. San Antonio, TX: The Psychological Corporation, 1996.
  16. Hathaway SR, JC McKinley. MMPI-2: Minnesota Multiphasic Personality Inventory- 2: Manual for Administration and Scoring. Minneapolis: University of Minnesota Press, 1987
  17. Davis-Berman J, Berman D. Concerns about bariatric surgery: Internet postings of patients. Internet Journal of Health. 2009;9 (1). http://ispub.com/IJH/9/1/6005. Accessed September 18, 2014.
  18. Berman D. A case of clinical anxiety following successful bariatric surgery: A cognitive behavior therapy approach. Bariatric Times;10(8):10–13.
  19. McVay MA, Friedman KE. The benefits of cognitive behavioral groups for bariatric surgery patients. Bariatric Times. 2012;9(9):22–28.
  20. American Psychological Association. Ethical Principles of Psychologists and Code of Conduct. Washington DC: 2010. http://www.apa.org/ethics/code/principles.pdf. Accessed September 18, 2014.

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