Overview of the Psychological and Behavioral Aspects of Bariatric Surgery

| February 11, 2011

by David B. Sarwer, PhD, and Rebecca J. Dilks, RD

Dr. Sarwer and Ms. Dilks are from the Center for Weight and Eating Disorders, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Financial Disclosure: Dr. Sarwer has consulting relationships with Allergan, BAROnova, Enteromedics, and Ethicon Endo-Surgery. He has received grant funding from the NIH, ASMBS, and Ethicon Endo-Surgery. He also serves on the Board of Directors for the Surgical Review Corporation.

Abstract
Approximately five percent of the American population currently suffers from extreme obesity, defined as a body mass index greater than 40kg/m[2]. Extreme obesity is associated with increased risk of morbidity and mortality as well as several untoward psychosocial issues. Bariatric surgery is the most effective treatment for extreme obesity and is associated with significant improvements in morbidity and mortality. The psychological and behavioral aspects of the patient, both before and after surgery, play a significant role in successful outcomes. Mental health professionals play a central role in the preoperative evaluation of patients who are interested in bariatric surgery. Postoperative mental healthcare, by comparison, has been neglected. The anticipated growth of bariatric surgery in the coming years will provide ample opportunity to further consider the role of the mental health professional in postoperative care.

Bariatric Times. 2011;8(2):18–24

Introduction
Over the past several decades, obesity has become one of our nation’s most significant public health issues. Approximately one-third of American adults have obesity, a disease defined by a body mass index (BMI) greater than 30kg/m[2].[1] Furthermore, 6.9 percent of women and 2.8 percent of men have extreme obesity, defined by a BMI greater than 40kg/m[2]. Extreme obesity is associated with major health complications, including coronary heart disease, hypertension, noninsulin dependent diabetes mellitus, and osteoarthritis.[2–5] At present, surgical intervention appears to be the most effective treatment for extreme obesity. The weight lost with bariatric surgery greatly exceeds and is far more durable than what is typically seen with lifestyle modification (diet and exercise) and/or pharmacotherapy.[5]

Unfortunately, the impressive outcomes of bariatric surgery often lead patients (as well as some providers) to mistakenly think success following bariatric surgery is primarily a product of the surgical intervention. All of the current surgical procedures are powerful tools that can lead to significant weight loss and improvements in health; however, like any tool, they need to be used properly in order to increase the likelihood of desirable outcomes. In this regard, the psychological and behavioral aspects of the patient, both before and after surgery, play a significant role in successful outcomes.

Preoperative Psychosocial Status
Comprehensive reviews of the literature on the psychosocial and behavioral aspects of bariatric surgery have been published.[6–13] Collectively, these reviews have found a high rate of psychopathology among candidates for bariatric surgery. Between 20 and 60 percent of patients have been characterized as suffering from an Axis I psychiatric disorder, the most common of which were mood and anxiety disorders.[14,15] Smaller percentages of patients have been diagnosed with substance abuse problems and personality disorders, both of which may impact preoperative management and postoperative outcomes.

Candidates for bariatric surgery typically report significant impairments in both health and weight-related quality of life as well as (and not surprisingly) greater body image dissatisfaction.[16–18] Less than 70 percent of patients are married at the time of surgery and approximately two-thirds report problems with their sexual functioning.[19,20] Individuals with extreme obesity often report weight-related prejudice if not outright discrimination in social, educational, occupational, and even healthcare settings.[21,22]

Psychosocial Evaluation Prior to Bariatric Surgery
For the previously mentioned reasons, almost all bariatric surgery programs in the United States require a mental health consultation as part of the preoperative evaluation process.23 Such evaluations were initially recommended in a 1991 National Institutes of Health (NIH) consensus development panel statement and on an as-needed basis in a more recent statement by the American Society of Metabolic and Bariatric Surgery (ASMBS).[24,25] Mental health consultations are also required by the Surgical Review Corporation (SRC) Centers of Excellence (COE) program as well as many third-party payers. Although there is a great deal of variability in the way preoperative mental health evaluations are conducted, most psychologists and other professionals who perform these assessments agree that significant psychiatric issues contraindicate bariatric surgery.[23,26] Typical contraindications include active substance abuse, active psychosis, bulimia nervosa, and severe, uncontrolled depression.[25,27] These features are thought to limit capacity for informed consent and may increase the likelihood of postoperative behavioral issues.

Almost all mental health professionals who conduct mental health evaluations complete a clinical interview of the surgery candidate.[26] Many augment the interview with paper-and-pencil symptom inventories or personality assessments. While the focus of these evaluations is often on screening for psychopathology, the evaluation also should include an assessment of the behavioral factors that may have contributed to the development of extreme obesity as well as the potential impact of these factors on the patient’s ability to make the necessary dietary and behavioral changes to experience an optimal postoperative outcome.[28]

In our program at the Center for Weight and Eating Disorders at the University of Pennsylvania, Philadelphia, Penssylvania, we organize our information into the following four areas: biological, environmental, social/psychological, and timing. We use this framework to communicate our impressions and recommendations about the appropriateness for bariatric surgery to both the patient and the bariatric surgeon. The resulting written report is also forwarded on to the patient’s insurance company.

Four Areas of the Mental Health Evaluation
Biological factors. This part of the evaluation typically confirms that the patient meets the BMI criteria for surgery and provides a summary of any obesity-related comorbidies. While both patients and referring surgeons typically have this information already, patients often find it useful to hear from another professional that they are physically appropriate for surgery (and perhaps not a more conservative weight loss treatment). In this part of the evaluation, we also will obtain information about both the age of onset of obesity as well as the history of obesity in the extended family. Patients with a childhood onset of obesity and a history of obesity throughout the generations of their family likely have a biological predisposition to obesity. Patients often find this information comforting, as it allows them to view their obesity from the perspective of other diseases with a genetic component, something that many patients have not considered.

Environmental factors. In this part of the evaluation, environmental factors and eating behaviors are assessed. Patients’ previous weight loss efforts are reviewed. Patients are asked about their experience with self-directed diets, commercial weight loss programs, dietary counseling, portion-controlled or meal replacement programs, and over-the-counter and prescription weight loss medications. Many patients are “dieting veterans” who have tried numerous weight loss programs in advance of surgery.[29] We also review patients’ eating habits. Portion sizes, snacking, and beverage intake are evaluated. This information provides a sense of overall nutritional knowledge and can also be used to target specific problematic behaviors that need to be changed prior to surgery. While the registered dietitian in the bariatric surgery program also assesses much of this, we believe a review of this information by the mental health professional is useful as well. At a minimum, the repetition underscores to patients the importance of changing these behaviors to optimize long-term success.

The average daily caloric intake of patients prior to surgery often ranges greatly. On average, patients typically report consuming approximately 2,400kcal per day, or approximately 400kcal per day more than the 2,000kcal recommended by the United States Department of Agriculture and other government agencies.[22,30] Some patients will report eating upwards of 4,000kcal per day with many meals from fast food or take-out restaurants, and including sweetened beverages. In contrast, some candidates for bariatric surgery, often those working diligently to control their type 2 diabetes, will report quite healthy eating habits. Nevertheless, many patients who present for bariatric surgery report difficulties controlling their ability to limit their eating behavior in response to emotional or social cues.[26] Physical activity also is evaluated. Not surprisingly, most patients are quite sedentary prior to surgery.
The possible presence of disordered eating is also assessed. One disorder that receives particular attention is binge eating disorder (BED), which is characterized by the consumption of an objectively large amount of food in a brief period of time (i.e., two hours) with the patient’s report of subjective loss of control during the overeating episode.[31,32] It is important to note that patients with BED do not engage in a compensatory behavior, such as vomiting, laxative abuse, or excessive exercise, which distinguishes BED from bulimia nervosa. Night eating is also assessed and is defined as a circadian delay in the pattern of eating, characterized by evening hyperphagia (i.e., the consumption of ≥25% of total daily caloric intake after the evening meal) and/or three or more nocturnal ingestions (i.e., waking during the sleep period to eat).[33,34] Early reports in the bariatric surgery literature suggested that up to 50 percent of candidates for surgery had some form of BED.35 More recent reports, however, suggest that BED and night eating occur in approximately 5 to 10 percent of patients.[36,37] These smaller rates are more consistent with the clinical experience of many providers. The smaller rates may also be the result of more rigorous application of the formal diagnostic criteria for BED and night eating, and also reflect a greater understanding of the eating behavior of individuals with extreme obesity, some of whom eat very large amounts of food (as a result of their metabolic demands) but do not experience the sensation of a loss of control while eating.
Psychological factors. Most of the mental health evaluation focuses on the social and psychological factors. This includes an assessment of patients’ psychiatric status and history, as done routinely in mental health assessment. Particular attention is paid to the presence of the disorders that contraindicate surgery, as noted previously. Mood and anxiety are assessed, as is the presence of thought disorders, such as schizophrenia and dissociative identity disorder, both of which occur, albeit rarely, among candidates for surgery.

Up to 40 percent of patients who present for bariatric surgery are engaged in some form of mental health treatment and approximately 50 percent report a history of mental health treatment.[38,39] The most common form of treatment appears to be the use of a psychiatric medication (typically low dosages of the selective serotonin reuptake inhibitors [SSRIs] for depression and anxiety) being prescribed by a primary care physician (rather than a psychiatrist). In many cases, these medications or other forms of treatment are appropriately controlling the patient’s symptoms. However, the bariatric team should not assume that engagement in mental health treatment, in any form, means that patients are stable and appropriate for bariatric surgery. The treating or prescribing professional should be contacted to confirm that patients are stable and appropriate for surgery.
Timing factors. The final part of the assessment focuses on the timing of surgery. Ideally, patients are electing to undergo surgery at a time that is relatively free of major stressors. Thus, the presence of these stressors is assessed. Patients are also asked about their knowledge of the dietary and behavioral changes required of surgery and their readiness to change their previous maladaptive behaviors to increase their likelihood of a successful outcome.

Candidates for bariatric surgery often believe that the preoperative mental health evaluation is designed to “rule-out” patients for surgery. Studies have suggested that between 70 to 90 percent of patients are unconditionally recommended for surgery by the mental health professional.[26,38–41] The remaining patients are typically asked to enter into some additional mental health and/or dietary treatment for a period of time to help them better prepare for surgery. These patients are typically re-evaluated after a period of time (often 3–6 months); the majority who follow the recommendations of the mental health professional and return for further assessment are typically recommended for surgery.

Nutritional Evaluation Prior to Bariatric Surgery
A commitment to life-long dietary changes is required of patients undergoing any of the bariatric surgical procedures. For patients to be successful in the long term, it is essential to undergo dietary changes consistent with surgery. It is the role of the registered dietitian (RD) to provide critical instructions to help patients change their eating/lifestyle habits in preparation for surgery.[41]

At the presurgical nutrition evaluation, RDs collect patient information, such as weight history and previous weight-loss attempts. Other data, such as dietary patterns, alcohol intake, vitamin supplementation, and physical activity, are also assessed. Specific attention should be given to BED, when and where the patient eats, who shops and cooks for the patient, snacking habits, portion sizes, caloric beverage intake (e.g., soda and/or juice), and overall nutrition knowledge.[28] Readiness and motivation to make long-term dietary and lifestyle changes are major factors when determining if a candidate is appropriate for bariatric surgery.

The RD and the patient work together to set dietary goals that will set a foundation for postoperative meal and snack patterns.[42] Dietary changes commonly recommended include using meal replacement products to appropriate control portion sizes, reducing fat and sugar intake, reducing alcohol consumption, increasing consumption of fruits and vegetables, consuming meals consistently throughout the day, and preparing meals at home instead of eating out. Patients are also instructed to start or continue on a dietary supplement schedule based on their laboratory findings.

If the patient is struggling to commit to dietary changes at the time of the assessment, it is often recommended that they enter a presurgical medical weight-management program, or seek individual treatment from an RD to help them better prepare for surgery. Patients who lose 10 percent of their excess body weight in the weeks prior to surgery are less likely to suffer from surgical complications.[43] In addition, these patients who lose weight before surgery have been shown to experience better weight loss results in the long term.[43,44]

Postoperative Psychological and Behavioral Outcomes
As noted previously, the typical weight loss following bariatric surgery is far greater than seen with more conservative weight loss treatments.[5] Surgically induced weight loss also appears to be more durable for most patients.[5] Surgically induced weight loss is associated with significant improvements in obesity-related comorbidities as well as decreased mortality.[4]

Numerous studies have found that patients similarly experience improvements in psychosocial status postoperatively.[7,9] Most psychosocial characteristics, including self esteem, depressive symptoms, and health-related quality of life and body image, improve dramatically in the first year after surgery.[6–12] These psychosocial benefits, however, may be limited to the first few postoperative years. The impact of bariatric surgery on longer-term psychological functioning is largely unknown.

Psychological Complications Following Bariatric Surgery
Despite the impressive physical and psychological improvements seen in the majority of bariatric surgery patients, there appears to be a small, yet significant, minority of patients who experience behavioral or psychological complications following bariatric surgery. These complications include depression and suicide, disordered eating, body image dissatisfaction, sexual dysfunction and/or marital discord, and substance abuse. In addition, there is the issue of suboptimal weight loss and weight regain.

Depression and suicide. Several studies have found that depressive symptoms typically improve following bariatric surgery.[45,38] However, there is some concern that these symptoms can return, particularly in individuals with a history of mood disorders. While some of this dysphoria can be treated with psychotherapy and/or pharmacotherapy, large epidemiological studies have documented an increased rate of suicide in individuals who have undergone bariatric surgery.[46] Several of these studies also found an elevated risk of accidental deaths, such as deaths in car accidents or following overdoses, which actually may have been “masked” suicides. These findings warrant further study and highlight the important role of the preoperative psychological screening of patients as well as the availability of mental health professionals postoperatively.
Disordered eating. Several studies have investigated the relationship between disordered eating prior to surgery and postoperative outcomes. Studies have found that a significant minority of patients reported feelings of loss of control consistent with BED, even though the surgery makes it impossible for them to eat excessively large amounts of food.[47–50] In some studies, it appears that binge eating is related to smaller weight losses or weight regain within the first two postoperative years.[47,48,50,51] This may be somewhat attributable to stretching of the gastric pouch, which would allow for increased energy intake over time.[52] Individuals who engage in night eating before surgery have been found to continue the behavior postoperatively.53,54 At least one study has found that more frequent nocturnal eating following bariatric surgery was associated with greater BMI and lower satisfaction with surgery.[55]
Body image dissatisfaction. Massive weight loss following bariatric surgery is associated with significant improvements in body image.[9,16,56–59] Unfortunately, some patients who lose large amounts of weight report residual body image dissatisfaction associated with loose, sagging skin of the breasts, abdomen, thighs, and arms.[59,60] More than two-thirds of postbariatric surgery patients considered the development of excess skin to be a negative consequence of surgery.[61] This dissatisfaction likely motivates some individuals to seek plastic surgery to address these concerns.

According to the American Society of Plastic Surgeons, in 2009, approximately 50,000 patients underwent body contouring procedures after the massive weight loss from bariatric surgery.[62] The most common procedures were breast reduction procedures, which were performed on 29,712 women; and extended abdominoplasty/lower body lift procedures, which are designed to eliminate the excessive skin around the abdomen and lower torso, were performed on 19,043 individuals. There is a rapidly growing body of knowledge related to the surgical aspects of these procedures. Far less, however, is known about the psychological aspects of them.[63,13]
Sexual functioning and sexual abuse. Patients with and without a history of sexual abuse often present for bariatric surgery with the expectation that weight loss will improve their marital and sexual relationships. Others fear that the weight loss may destabilize these relationships. In general, the few studies of this issue that exist suggest that romantic relationship quality improves following bariatric surgery.[64,65] The impact, however, seems to be a function of the quality of the existing relationship.[64]

Little is known about the effects of surgically induced weight loss on sexual functioning. Individuals with extreme obesity report greater impairments in sexual quality of life than individuals without obesity.[66] Given our society’s emphasis on thinness as a sign of physical beauty and sexuality, it is not surprising that women with obesity are often stigmatized in regard to being potential sexual partners.[67] Obesity-related metabolic abnormalities, and the medications often used to treat them, also are associated with problems in sexual functioning.[68,69] Intuitive thought suggests that the physical and psychological benefits associated with bariatric surgery will lead to improvements in sexual functioning; however, these issues have received little study to date.
There appears to be a modest association between sexual abuse and obesity.[70] Recent studies have suggested that between 16 and 32 percent of bariatric surgery candidates reported a history of sexual abuse.[71,72] At least two studies have suggested that a history of previous sexual abuse is unrelated to weight loss following bariatric surgery.[73,74] Nevertheless, anecdotal reports suggest that patients with a history of sexual abuse often struggle with a range of psychological issues, including body image, sexual, and romantic relationship issues, following bariatric surgery. While it may be difficult to predict which patients may have these issues postoperatively, the preoperative psychological evaluation presents an opportunity to discuss these issues and inform patients that they may experience some psychological distress during the postoperative period.
Substance abuse and “addiction transfer.” As noted previously, there appears to be an elevated rate of a history of substance abuse in individuals who seek bariatric surgery. In the past several years, there has been some concern, particularly expressed by the mass media, that bariatric surgery patients can experience “addiction transfer,” transferring their “addiction to food” to another addiction, such as drugs, alcohol, shopping, or sex. Sogg75 has offered criticisms of the idea of addiction transfer. As she notes, not only is “addiction transfer” not an accepted clinical diagnosis, there is also no scientific consensus at present that food is an addictive substance or eating food is an addictive behavior. Furthermore, there is little support for the notion that addictive behaviors can “switch” in the absence of resolution of the initial problem.

Nevertheless, it is possible that some patients, particularly those with a history of addiction, could be at increased risk for substance abuse postoperatively. Thus, during the preoperative psychological evaluation, it is important to assess for the history of substance abuse and inform these patients that the stress of surgery and the required behavioral changes may represent some threat to their sobriety.

Suboptimal weight loss and weight regain. Approximately 20 percent of persons who undergo bariatric surgery fail to reach the typical postoperative weight loss or begin to regain large amounts of weight within the first few postoperative years.[76,78] Suboptimal results, regardless of the type of procedure, are typically attributed to poor adherence to the postoperative diet or a return of maladaptive eating behaviors, rather than to surgical reasons.[79–81]

A number of studies have also suggested that adherence to the postoperative diet is poor.30,82–84 Caloric intake often increases significantly during the postoperative period.[30,82–87] This increased caloric intake likely contributes to weight regain, which often begins during the second postoperative year.[77] Despite the increase in caloric intake, a subset of bariatric surgery patients suffers from malnutrition. The most common and severe problems appear to be vitamin B12, iron, and folic acid deficiency.[88–95] Protein, calcium, vitamin D, and other vitamin deficiencies appear to be less common. Most cases of malnutrition among bariatric surgery patients appear to be responsive to improved dietary adherence or vitamin supplementation.[96,97]

Poor adherence to the postoperative diet may contribute to nausea and/or “plugging.” Plugging is an uncomfortable feeling that patients describe as tightness in the chest when food has become stuck. Some patients avoid foods that may trigger these events, which can contribute to malnutrition. Plugging may also lead to reflexive or self-induced vomiting in an effort to dislodge the food. One- to two-thirds of patients report postoperative vomiting.[99–101] Vomiting is thought to occur most frequently during the first few postoperative months.102 Frequent vomiting can occur several years postoperatively and may be associated with malnutrition.[99,103]

Gastric dumping is believed to be triggered by foods high in sugar and/or fat. Studies suggest that dumping occurs in approximately 50 to 70 percent of RYGB patients.[104,105] The frequency of this behavior, however, is not well documented. In addition to serving as a trigger for gastric dumping, increased consumption of sugar has been associated with smaller weight losses following RYGB.[87]
Bariatric surgery requires regular, if not lifelong, follow up. Patients who undergo RYGB are recommended to return to the bariatric surgery program at least every six months in the first two postoperative years and annually thereafter.[96] Adjustments of a gastric band can require follow-up appointments as regularly as every 4 to 6 weeks in the first postoperative year and quarterly through the first three postoperative years.[106] Clinical reports have suggested that postoperative follow up with the bariatric surgery program is frequently suboptimal and can negatively impact weight loss, in some cases within the first postoperative year.[98,107–110] In recent reports, only 40 percent patients returned for each of their annual follow-up visits with the surgeon within the first four years of surgery.[82,111] Those who returned for all of their annual follow-up visits lost significantly more weight than those patients who did not return.

These postoperative visits can be used to not only monitor patients’ weight loss, but also counsel patients on issues related to dietary adherence and eating behavior.[107,111] This provides an opportunity for the bariatric team to help the patient with behavioral weight control strategies. Consistent encouragement of self monitoring and dietary adherence and increasing physical activity are believed to be critical skills for successful long-term maintenance.

Conclusions
Bariatric surgery is presently the most powerful tool to treat obesity. For the majority of patients, the surgical procedures produce sizable weight loss that is well maintained and associated with significant improvements in mortality as well as physical and psychological comorbidities. Unfortunately, these impressive outcomes are not experienced by all bariatric surgery patients. A small, yet sizable minority of patients experience suboptimal outcomes, which are most often attributed to behavioral and psychological reasons rather than surgical ones.

Mental health professionals often play a central role in the evaluation of patients who are interested in bariatric surgery. Postoperative mental healthcare, by comparison, has been neglected. Many mental health professionals participate in the care of patients after surgery. Some run support groups for bariatric patients that may have a specific focus. Others see patients in individual psychotherapy. Unfortunately, there has been little discussion or study of psychological and behavioral interventions for patients who have undergone bariatric surgery. While postoperative support groups are important in providing social support, RDs and mental health professionals could also develop behaviorally based interventions designed to promote long-term dietary adherence, address maladaptive eating behaviors, and help patients who are suffering from body image dissatisfaction related to their weight. Many of these interventions have been developed and demonstrated to be effective in helping persons with less severity. The refinement, application, and testing of these interventions on patients who have undergone bariatric surgery is an important next step in the evolution of postoperative care in the bariatric patient.

Acknowledgment: This article is based on a presentation from the “2010 Update on the Comprehensive Management of Obesity,” held at Westchester Medical Center on October 1, 2010 in Valhalla, New York

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