Article in co-publicationBehavioral assessment of candidates for bariatric surgery: a patient-oriented approach
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)
Bariatric surgery for morbid obesityhealth implications for patients, health professionals, and third-party payers
J Am Coll Surg
(2005)- et al.
Psychosocial aspects of obesity and obesity surgery
Surg Clin North Am
(2001) - et al.
Characteristics of morbidly obese patients before gastric bypass surgery
Compr Psychiatry
(2003) - et al.
Obesity and eating disorders
Psychiatr Clin North Am
(2005) - et al.
Behavioral treatment of obesity
Endocrinol Metab Clin North Am
(2003) - et al.
Surgical management of obese patients with eating disordersa survey of current practice
Obes Surg
(2004) Gastrointestinal surgery for severe obesityConsensus Development Conference Panel
Ann Intern Med
(1991)- et al.
Common practices in preoperative psychological evaluations of bariatric surgery candidates
Obes Res
(2005) - et al.
Psychosocial and behavioral aspects of bariatric surgery
Obes Res
(2005) - et al.
Does obesity surgery improve psychosocial functioning? A systematic review
Int J Obes
(2003)
Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey
Am J Epidemiol
Findings and outcomes of psychological evaluations of gastric bypass applications
Surg Obes Relat Dis
Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates
Obes Surg
Gastric bypass in a low-income, inner-city populationeating disturbances and weight loss
Obes Res
The psychology of gastric bypass surgery
Obes Surg
Pre-operative predictors of weight loss at 1-year after the Lap-Band surgery
Obes Surg
Binge eating disordera multisite field trial of the diagnostic criteria
Int J Eat Disord
Binge eating in bariatric surgery patients
Int J Eat Disord
Binge eating disorder in extreme obesity
Int J Obes
Night eating syndrome and binge eating disorder among persons seeking bariatric surgeryprevalence and related figures
Obesity
Assessment of quality of life in obese individuals
Obes Res
Health-related quality of life in obese persons seeking treatment
J Fam Pract
Impact of overweight and obesity on health-related quality of life-a Swedish population study
Int J Obes Relat Metab Disord
Health-related quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery
Obes Surg
Bias, discrimination, and obesity
Obes Res
Socioeconomic status and obesitya review of the literature
Psychol Bull
Primary care physicians’ attitudes about obesity and its treatment
Obes Res
Weight-based discrimination in employmentpsychological and legal aspects
Personnel Psychol
Social and economic consequences of overweight in adolescence and young adulthood
N Engl J Med
Predictors of attrition and weight loss in patients treated by moderate and severe calorie restriction
Nonsurgical factors that influence the outcome of bariatric surgerya review
Psychosom Med
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2018, Contemporary Clinical Trials CommunicationsCitation Excerpt :This information-rich data [68] opens up for a more targeted analysis, which allows for a deeper and fuller understanding of factors which have been identified as important for sustained weight loss. These are: Social resources, and support [65,66], patients' body perceptions, and aspirations for and concerns about weight loss after surgery [69,70], patients' different eating strategies, i.e. how they perceive and handle eating behavior, meal timing and food choice post-surgery [67,68]. In-depth knowledge of how patients evaluated their body and monitored weight changes in their daily practices [69,70] made investigations of the causes of such practices possible and thus how they contributed to e.g. eating behavior and food choice post-surgery.
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This article will also appear in the March 2006 supplement of Obesity Research.