There is no doubt that bariatric surgery is currently the most effective long-term treatment for severe obesity, however, there is also some evidence to suggest that patients seeking bariatric surgery (or for that matter any kind of weight loss) are more likely to have accompanying mental issues that individuals with obesity who don’t and that such issues may affect the outcomes of surgery.
Now, a paper by Aaron Dawes and colleagues from Los Angeles, CA, published in JAMA presents a meta-analysis of mental health conditions among patients seeking and undergoing bariatric surgery.
They identified 68 publications meeting inclusion criteria: 59 reporting the prevalence of preoperative mental health conditions (65,363 patients) and 27 reporting associations between preoperative mental health conditions and postoperative outcomes (50,182 patients).
Among patients seeking and undergoing bariatric surgery, the most common mental health conditions, each affecting about one-in-five patients were depression and binge eating disorder.
However, neither condition was consistently associated with differences in post-surgical weight outcomes. Nor was there a consistent relationship between other mental health conditions including PTSD or bipolar disease and post-surgical outcomes.
Interestingly, bariatric surgery was consistently associated with a significant decrease in the prevalence and/or severity of depressive symptoms.
So what do these findings mean for clinical practice?
As the authors note,
“Guidelines from the American Society for Metabolic and Bariatric Surgery and the Department of Veterans Affairs/Department of Defense recommend routine preoperative health assessments, including a review of patients’ mental health conditions. Other groups advocate for a more comprehensive, preoperative mental health examination in addition to the general evaluation currently performed by medical and surgical teams. The results of our study do not defend or rebut such a recommendation.”
So why are these data not clearer than they should be? Here is what the authors have to offer:
“Much of the difficulty in determining the effectiveness of preoperative mental health screening is due to the limitations of current screening strategies, which use a variety of scales and focus on mental health diagnoses rather than psychosocial factors. Previous reviews have suggested that self-esteem, mental image, cognitive function, temperament, support networks, and socioeconomic stability play major roles in determining outcomes after bariatric surgery. Future studies would benefit from including these characteristics as well as having clear eligibility criteria, standardized instruments, regular measurement intervals, and transparency with respect to time-specific follow-up rates. By addressing these methodological issues, future work can help to identify the optimal strategy for evaluating patients’ mental health prior to bariatric surgery.”
At this time, perhaps to err on the side of caution, our centre (like many others) continues to screen for and address any relevant mental health issues in patients wishing to undergo bariatric surgery.
Obesity, like most other chronic diseases, requires interdisciplinary approaches that involves a wide range of clinicians from different disciplines (e.g. physician, nurse, psychologist, dietitian, exercise physiologist, social worker, physiotherapist, occupational therapist, etc.).
But exactly how to get these teams to function efficiently and deliver timely and ongoing obesity management remains largely understudied.
In a paper by Jodi Asselin and colleagues, published in Clinical Obesity, we explore the challenges faced by members of multidisciplinary teams working in the setting of a large primary care network.
Participants (n = 29) included in this analysis are healthcare providers supporting chronic disease management in 12 family practice clinics randomized to the intervention arm of the 5As Team trial including mental healthcare workers (n = 7), registered dietitians (n = 7), registered nurses or nurse practitioners (n = 15). Participants were part of a 6-month intervention consisting of 12 biweekly learning sessions aimed at increasing provider knowledge and confidence in addressing patient weight management.
Qualitative methods included interviews, structured field notes and logs.
Four common themes of importance in the ability of healthcare providers to address weight with patients within an interdisciplinary care team emerged, (i) Availability; (ii) Referrals; (iii) Role perception and (iv) Messaging.
Availability (i) refers to the ability of two or more people to meet and communicate as needed within a reasonable amount of time. This included the interdisciplinary team members knowing and meeting each other, being able to consistently communicate during the work-day, or deliberately asynchronously, and having work schedules that allowed collaboration.
Availability was often affected by scheduling that limited face-to-face time between providers and subsequently limited the potential for collaboration or discussion. Another issue was lack of in-clinic time to speak to providers who were physically present but otherwise unavailable.
Referrals (ii) points to the need for weight management referrals to take place, for those referrals to be appropriate to provider ability and for the patient to be knowledgeable about, or in agreement with the reason for referral. Many practitioners felt they were not receiving the weight management referrals they could, or that the referrals often left the patient and provider unclear as to where to begin the conversation.
Role perception (iii) concerns the way a provider’s role is understood by other interdisciplinary team members. Issues pertaining to role perception were fairly consistent and strongly linked to concerns with referrals. Common examples included concern that they were not receiving the type of referrals they could, that other providers did not understand their role in weight management, or that they as providers did not understand the role of others.
Messaging (iv) refers to the overall approach to weight management that providers within the same clinic were using, as well as the key information being shared between providers and patients. Inconsistent messaging among providers within clinics, as well as with specialists seen by the patient, was a common concern raised during interviews. In such cases there was feeling that advice was not patient-centred, that efforts had not been taken to consider patient history and that as a consequence, the patient might suffer a setback, reduced interest, or reduced personal confidence. In these cases the message a patient had received from another provider was counter to the message or approach the interviewee was giving.
However, we find that what was key to our participants was not that these issues be uniformly agreed upon by all team members, but rather that communication and clinic relationships support their continued negotiation.
Our study shows that firm clinic relationships and deliberate communication strategies are the foundation of interdisciplinary care in weight management.
Furthermore, there is a clear need for shared messaging concerning obesity and its treatment between members of interdisciplinary teams.
From the project it is evident that broad training in the various contributors to obesity enables providers to not only see their own role in treatment, but to better understand the role of others and therefore begin addressing problems in referrals, messaging and role perception.
One factor accounting for this may well be the lack of timely access to sleep testing.
Now, a study by Hirsch Allen and colleagues from the University of British Columbia Hospital Sleep Clinic, published in the Annals of the American Thoracic Society, examined the relationship between severity of sleep apnea and travel times to the clinic in 1275 patients referred for suspected sleep apnea.
After controlling for a number of confounders including gender, age, obesity and education, travel time was a significant predictor of OSA severity with each 10 minute increase in travel time associated with an apnea-hypopnea-index increase of 1.4 events per hour.
The most likely explanation for these findings is probably related to the fact that the more severe the symptoms, the more likely patients are to travel longer distances to undergo a sleep study.
Thus, travel distance may well be a significant barrier for many patients accounting for a large proportion of undiagnosed sleep apnea – at least for milder forms.
Given the often vast distances in Canada one can only wonder about just how much sleep apnea goes under diagnosed because of this issue.
Although bariatric surgery is by far the most effective treatment for severe obesity, most health professionals will have learnt little about it during their training. For those who did, much of what they learnt is probably obsolete, given the remarkable advances both in surgical technique as well as patient management.
Given that the family doctor may often be the key person to suggest or counsel patients about the pros and cons of bariatric surgery, refer appropriate patients for surgery and manage them long-term in the years following surgery, it is essential that they have a sound understanding of the indications, risk and benefits of surgery.
Now, a survey of Ontario family docs, published in Obesity Surgery by Mark Auspitz and colleagues from the University of Toronto, reveals important knowledge gaps and misconceptions about bariatric surgery.
The 28-item questionnaire, sent to 1328 physicians in Ontario resulted in 165 responses.
Overall experience was limited: around 70% of responding family physicians had less than five surgical patients in their practice, almost 10% had none.
The vast majority of responders (70 %) stated that they at best referred about 5 % of their patients with severe obesity for surgery.
Not surprisingly, compared to physicians who had previously referred patients for surgery, physicians who had never referred a patient for surgery were less likely to discuss bariatric surgery with their patients (30 vs. 79 %), less likely to feel comfortable explaining procedure options (6 vs. 34 %) or providing postoperative care (27 vs. 64 %).
Virtually all (92%) of family physicians stated that they would like to receive more education about bariatric surgery.
To the question as to whether or not they would consider referring a family member for surgery, only 56% of docs who had never referred a patient would consider it, compared to 85% of physicians with previous referrals.
As a side note, only 30% of responders felt that they had the appropriate equipment and resources to manage patients with obesity.
Unless one assumes that the docs who responded to this survey are somehow very different from the docs who didn’t, one must conclude that there are indeed considerable knowledge gaps about bariatric surgery among family docs in Ontario (and I have no reason to believe that this situation would be much better anywhere else in Canada).
On a positive note, it appears that the vast majority of docs are keenly aware of this deficit and would appreciate more education on bariatric surgery.
How much does your doctor know about it?
Yesterday’s guest post on the issue of food addiction (as expected) garnered a lively response from readers who come down on either side of the discussion – those, who vehemently oppose the idea and those, who report success.
Fact is, that we can discuss the pros and cons of this till the cows come home, because the simple truth is that the whole notion lacks what my evidence-based colleagues would consider “strong evidence”.
Indeed, I did try to find at least one high-quality randomized controlled study on using an addictions approach to obesity vs. “usual” care (or for that matter anything else) and must admit that I came up short. The best evidence I could find comes from a few case series – no controls, one observer, nothing that would compel anyone to believe that this approach has more than anecdotal merit.
Yet, the biology (and perhaps even the psychology) of the idea is appealing. Self-proclaimed “food addicts” that I have spoken to readily identify with the addiction model and describe their relationship to “trigger foods” as an uncontrollable factor in their lives that calls for complete abstinence. Animal studies confirm that foods do indeed stimulate the same parts of the brain that are sensitive to other hedonic pleasures and substances.
So why the lack of good data? After all, the idea is hardly new – intervention programs for “food addicts” using the 12 steps or other approaches have been around for decades.
Can it be simply the lack of academic interest in this issue? I find that hard to imagine – but nothing would surprise me.
Is it perhaps because addiction researchers do not take obesity seriously and obesity researchers don’t like the addiction model?
I certainly don’t buy the argument that there is no commercial interest in such an approach – if there were strong and irrefutable evidence, I’m sure someone would figure out how to monetize it.
So again, I wonder, why the lack of good data?
Honestly, I don’t know.
I’m open to any views on this (especially if substantiated by actual evidence).