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Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach

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Abstract

This paper discusses the behavioral evaluation of patients who seek bariatric surgery and the psychosocial complications most frequently observed in these individuals. The effects of such complications on surgical outcome are briefly examined, as is the challenge of predicting therapeutic response on the basis of preoperative variables. The paper concludes with a description of the goals and methods of a behavioral assessment used at the University of Pennsylvania. This evaluation includes the use of the Weight and Lifestyle Inventory, a questionnaire that guides our interview with patients.

Introduction

Patients who seek bariatric surgery typically are required to complete a behavioral (i.e., psychiatric) examination with a mental health provider to determine their appropriateness for surgery [1]. This practice resulted from recommendations of a consensus development conference in 1991 sponsored by the NIH [2]. The consensus panel concluded that patients “… should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise.” The panel, however, did not identify any specific behaviors or psychiatric disorders that it believed contraindicated surgery. Instead, it discussed broader issues that included the goal of selecting “well-informed and motivated patients” who should have an opportunity to discuss weight loss approaches other than surgery and the advantages and disadvantages of each. The panel also noted the need to consider changes in mood and quality of life that may occur with surgery and weight loss. It concluded that, “There must be full discussion with the patient of the probable outcome of the surgery, of the probable extent to which it will eliminate the patient’s problems, of the compliance that will be needed in the postoperative regimen, and of the possible complications from surgery, both short- and long-term” [2].

Mental health professionals vary in the methods and criteria they use to evaluate candidates for bariatric surgery [1], [3]. Most conduct an interview to identify psychosocial factors believed to contraindicate or compromise surgery. Many administer symptom inventories to screen for depression, and some include formal testing of psychopathology, personality, or cognitive function [1], [3]. The lack of a uniform approach is not surprising given the lack of well-defined contraindications to surgery [1]. In addition, there has been limited study of presurgical, behavioral factors that predict an unfavorable outcome, as judged by suboptimal weight loss or complications that include excessive vomiting, bingeing, or dumping [4], [5]. The lack of data has led some surgeons to conclude (we believe prematurely) that candidates need not routinely undergo a preoperative behavioral evaluation [6].

Section snippets

Psychosocial status of patients with extreme obesity

Perhaps the principal reason mental health professionals have been included in the preoperative assessment of surgery candidates is the high prevalence of psychiatric and behavioral complications observed in this population. The literature on this topic has been reviewed recently by several authors (to whom the reader is referred) and is only highlighted here [4], [5], [7]. The reviews found that depression is common among persons with extreme obesity. A recent population study, for example,

Predicting surgical outcome based on psychosocial and behavioral status

Practitioners have long desired to identify baseline predictors of weight loss and related outcomes [29]. Such predictors would allow them to effectively target patients at risk of a poor response. These individuals could be provided alternative therapies or assistance, before treatment, in addressing problems (e.g., depression, low self-efficacy) thought to result in a suboptimal outcome. As applied to bariatric surgery, this strategy would include: defining a priori what constituted a poor

Behavioral evaluation conducted at the University of Pennsylvania

All candidates for bariatric surgery at the Hospital of the University of Pennsylvania complete a behavioral evaluation with a mental health professional, all of whom also have expertise in obesity (which we believe is critical to conducting a thorough evaluation). The assessment is designed to meet the broad objectives proposed by the 1991 NIH consensus panel [2], while also identifying psychopathology that, if uncontrolled, could contraindicate or compromise surgery. The evaluation is

A patient-oriented behavioral evaluation

We generally begin the behavioral assessment by thanking patients for completing the questionnaires and explaining that we want to review their responses with them to learn more about their weight and dieting histories, eating and activity habits, and related information to understand what has led them to seek bariatric surgery. We often indicate that “we are not going to try to psychoanalyze you” but instead “want to help you decide if surgery is the right choice for you.” The interview

Conclusion

We trust that future research will reveal reliable behavioral predictors of improvements in weight and health after bariatric surgery. Such findings could guide surgeons in selecting the most appropriate operation for a candidate or allow dietitians and mental health professionals to provide pre- or postoperative counseling to improve long-term outcome. Until such data are obtained, however, we believe that a patient-oriented behavioral evaluation, as described here, provides candidates an

Acknowledgments

This work was supported, in part, by Grants K23-DK60023, K24-DK65018, and R01-DK069652 from the National Institute of Diabetes, Digestive, and Kidney Disease.

References (62)

  • C.U. Onyike et al.

    Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey

    Am J Epidemiol

    (2003)
  • L.A. Pawlow et al.

    Findings and outcomes of psychological evaluations of gastric bypass applications

    Surg Obes Relat Dis

    (2005)
  • D.B. Sarwer et al.

    Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates

    Obes Surg

    (2004)
  • J.D. Latner et al.

    Gastric bypass in a low-income, inner-city populationeating disturbances and weight loss

    Obes Res

    (2004)
  • J. Glinski et al.

    The psychology of gastric bypass surgery

    Obes Surg

    (2001)
  • J.B. Dixon et al.

    Pre-operative predictors of weight loss at 1-year after the Lap-Band surgery

    Obes Surg

    (2001)
  • R.L. Spitzer et al.

    Binge eating disordera multisite field trial of the diagnostic criteria

    Int J Eat Disord

    (1992)
  • M.A. Kalarchian et al.

    Binge eating in bariatric surgery patients

    Int J Eat Disord

    (1998)
  • L.K.G. Hsu et al.

    Binge eating disorder in extreme obesity

    Int J Obes

    (2002)
  • K.C. Allison et al.

    Night eating syndrome and binge eating disorder among persons seeking bariatric surgeryprevalence and related figures

    Obesity

    (2006)
  • T.A. Wadden et al.

    Assessment of quality of life in obese individuals

    Obes Res

    (2002)
  • K.B. Fontaine et al.

    Health-related quality of life in obese persons seeking treatment

    J Fam Pract

    (1996)
  • U. Larsson et al.

    Impact of overweight and obesity on health-related quality of life-a Swedish population study

    Int J Obes Relat Metab Disord

    (2002)
  • A.N. Fabricatore et al.

    Health-related quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery

    Obes Surg

    (2005)
  • R. Puhl et al.

    Bias, discrimination, and obesity

    Obes Res

    (2001)
  • J. Sobal et al.

    Socioeconomic status and obesitya review of the literature

    Psychol Bull

    (1989)
  • G.D. Foster et al.

    Primary care physicians’ attitudes about obesity and its treatment

    Obes Res

    (2003)
  • M.V. Roehling

    Weight-based discrimination in employmentpsychological and legal aspects

    Personnel Psychol

    (1999)
  • S.L. Gortmaker et al.

    Social and economic consequences of overweight in adolescence and young adulthood

    N Engl J Med

    (1993)
  • T.A. Wadden et al.

    Predictors of attrition and weight loss in patients treated by moderate and severe calorie restriction

  • L.K. Hsu et al.

    Nonsurgical factors that influence the outcome of bariatric surgerya review

    Psychosom Med

    (1998)
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    This article will also appear in the March 2006 supplement of Obesity Research.

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