Psychological and psychiatric assessment prior to bariatric surgery is an essential part of our current management model and is recommended by all current obesity guidelines. Indeed, there is little doubt that psychiatric diagnoses are relatively common in weight loss-seeking obese individuals. Specifically, the prevalence of binge eating disorder (BED) has been reported to be in the range of 25-40% of all individuals seeking bariatric surgery.

The general notion is that patients with significant BED should undergo cognitive behavioural intervention prior to surgery and that severe BED may be a contraindication to proceeding with any form of weight-loss.

However, contrary to this widely held notion, hard data confirming that the presence of BED is indeed a predictor of poor surgical outcomes is sparse. In fact, most published studies, suggest that weight loss results in BED patients may be as good (or in some cases even better) than in patients without BED!

Nevertheless, there appear to be some important caveats. Thus, in a new study by Sharon Alger-Mayer and colleagues from Albany Medical College, NY, published in this months edition of Obesity Surgery, weight loss outcomes in patients with severe BED (37 out of 157 patients), who managed to lose 10% of body weight prior to surgery and attended all follow-up consultations during the first 12 months following surgery, were similar to the outcomes in patients without BED over 6 years of follow-up.

Note: the two caveats are:

1) losing 10% of their weight prior to surgery and

2) attending all follow-up appointments.

The study of course did not include patients with BED, who did not lose 10% body weight prior to surgery or who failed to attend their follow-up appointments.

Incidentally, depression (Beck’s Depression Inventory) and poor quality of life (SF-36) likewise did not predict weight loss outcomes.

Overall, this study is consistent with previous shorter-term studies that did not find BED to be a negative predictor of surgical outcomes. Nevertheless, the authors still regard psychological and psychiatric assessment an essential part of patient work-up prior to surgery.

Thus, BED should not generally be seen as a contraindication to proceeding with gastric bypass surgery. Does the same apply to other types of surgery such as the gastric sleeve or gastric banding? We’ll have to wait for the appropriate studies.

In the meantime, at our centre, we continue to insist on regular attendance and demonstration of significant lifestyle changes that include diligent food journaling, regular planned exercise, strict attendance of all clinic appointments, and a minimum of 5-10% weight loss in all pateints prior to consideration for surgery (in addition, we insist on smoking cessation, elimination of all pop, juices and carbonated beverages, elimination of all junk foods and high-caloric snacks, and a sound understanding of the risks and benefits of the planned procedure) .

I guess it may be time for a randomized trial to determine if assessment and treatment for BED will help improve surgical outcomes or prove a waste of resources and an unwarranted barrier to sugery.

Till then, I believe it is advisable to err on the side of caution.

AMS
Edmonton, Alberta

Yesterday, I hosted another of my Bariatric Lunch Forums that can be viewed via the TeleHealth Network in Alberta.

My guest on the forum was Geoff Ball, Director of the Pediatric Centre for Weight and Health (PCWH) here in Edmonton. While the program focuses on family interventions, Geoff emphasized the importance of psychological issues (both in the kids and their parents) that often prove important promoters of weight gain and/or barriers to weight management.

Indeed, I have previously blogged about studies showing that mental health issues are common in overweight and obese kids and can be important predictors of obesity in adulthood.

Now a new obesity study by Rhonda BeLue and colleagues from Penn State University, PA, published in the latest issue of Pediatrics, examines the relationship between mental health problems and overweight in a nationally representative sample of US youth aged 12 to 17 years.

The study specifically focuses on whether the association between mental health problems and weight is moderated by race and ethnicity in the 2003 National Survey on Children’s Health data.

Compared with their nonoverweight counterparts, both white and Hispanic youth who were overweight were significantly more likely to report depression or anxiety, feelings of worthlessness or inferiority, behavior problems, and bullying of others. In black subjects, only the physician diagnosis of depression was more frequent in overweight kids.

The results of this study not only emphasizes the important need for assessing mental health problems when addressing overweight and obesity in kids, but also that this relationship may differ between ethnic groups.

As in the adult population, it appears more and more evident that the obesity epidemic is not just a matter of individuals and families making poor choices and not moving enough - clearly, the obesity epidemic is part of a much bigger mental health issue that is affecting vast proportions of society.

If I had to bet on what comes first (the chicken or egg question), I’d be placing my money on mental health issues.

I believe it is safe to predict that any approach to solving the obesity crisis without due attention to the much broader mental health problem is doomed to failure.

While clearly not all overweight and obese kids or adults have mental health problems; but for the ones that do, addressing these issues is key to managing their weight.

AMS
Edmonton, Alberta

Yes, we all know someone, who has lost a significant amount of weight and is keeping it off - all without drugs or surgery.

While these people definitely exist, they are rare indeed and always interesting people to study. This is exactly what the National Weight Control Registry (NWCR) has been doing for years - anyone, who has maintained at least a 30 pound weight loss for one year or longer can join the study. Currently over 5000 individuals are being followed, many of whom have lost considerable amounts of weight and are continuing to keep it off.

Although this registry is good evidence that long-term weight loss maintenance is indeed possible with lifestyle change alone, in reality, the vast majority of patients attempting lifestyle change will rarely keep the weight off. This is why, an increasing number of patients with severe obesity turn to surgery for help. Despite its risks and limitations, the likelihood for the average patient to substantially reduce their weight and keep it off with surgery is substantially higher than the success rate of lifestyle interventions alone.

So how are patients who manage to lose weight and keep it off different from those who need surgery to do the same?

This question was now studied by Bond and colleagues from Brown University, Providence, RI, USA, in a study just published in the International Journal of Obesity.

This study compared the amount of weight regain, behaviors and psychological characteristics in NWCR participants who were equally successful in losing and maintaining large amounts of weight through either bariatric surgery or non-surgical methods.

A total of 105 surgical participants were matched with two non-surgical participants (n=210) for gender, entry weight, maximum weight loss and weight-maintenance duration, and compared prospectively over 1 year.

Both the surgical participants and the matched non-surgical participants reported having initially lost around 56 kg and hving keept off at least 13.5 Kg over the last 5.5 years.

Over the year of the study, both groups (re-)gained a similar amount of weight (1.8 vs. 1.7 Kg). However, surgical participants reported less physical activity, more fast food and fat consumption, less dietary restraint, and higher depression and stress at entry and 1 year than the non-surgical group. In both groups, higher weight regain was observed in individuals with higher levels of disinhibition.

These findings suggest that weight-loss maintenance comparable with that after bariatric surgery can be accomplished through non-surgical methods with more intensive behavioral efforts.

In other words, obesity surgery appears to be more “forgiving” than lifestyle management alone, when it comes to weight maintenance. Thus, although the surgical participants exercised less, ate more fat and fast food, showed less dietary restraint and were more depressed and stressed, they were still able to maintain the same degree of weight loss as the succesful non-surgical NWCR group. I have little doubt that these same surgical patients would likely have done a lot worse had they relied on lifestyle change alone. This does not deny the fact that success with surgery also requires substantial and consistent changes in lifestyle.

My conclusion from this study is: Yes, some people can indeed lose significant amounts of weight and keep it off, but they need to exercise more, avoid fast food, display high dietary restraint and better not be depressed or stressed out (even then, there is some weight regain). For others, surgery may very well be a more realistic option.

AMS
Edmonton, Alberta

Mental health assessment should be part of every assessment for adult obesity.

But how well does a history of mental problems as a kid or teenager predict adult obesity?

This question was recently addressed by Eryn Liem and colleagues from the University of Groningen, Groningen, the Netherlands, published in last month’s issue of the Archives of Pediatrics and Adolescent Medicine.

Liem and colleagues reviewed the recent literature regarding the association between depressive symptoms in childhood and adolescence and overweight in later life. In total, 32 articles were reviewed including 21 cross-sectional and 11 longitudinal reports. Of these, four cross-sectional studies that satisfied their quality criteria revealed an association between depressive symptoms and overweight in girls aged 8 to 15 years. Four longitudinal studies that met their quality criteria suggest that depressive symptoms in childhood or adolescence are associated with a 1.90- to 3.50-fold increased risk of subsequent overweight.

Thus, these results suggest that having depressive symptoms at age 6 to 19 years may lead to overweight and obesity in later life.

Obviously, the study does not address the issue of whether or not recognizing and managing depression in kids and adolescents will actually help prevent adult obesity.

Whatever the case, I do believe that mental health aspects of weight management are likely as important in kids as they are in adults and that early detection of mental health issues, that can lead to obesity later in life, need to be addressed in high-risk kids and adolescents.

AMS
Alberta, Canada

This week, Orexigen, a biopharmaceutical company in La Jolla, CA, announced that it won a patent covering its obesity drug Contrave.

Contrave actually consists of a sustained-release version of two older drugs: bupropion, which is currently used as an antidepressant and smoking cessation aid, and naltrexone, which is used for opioid addiction and alcoholism. Contrave is currently undergoing Phase III trials for obesity and the company hopes to file for FDA approval in late 2009.

Why is Contrave, a combination of two drugs that have been around for a while, novel?

Firstly, there is no doubt that depression is a common problem in treatment-seeking obese individuals, many of whom are “self-medicating” with food - i.e. eating highly palatable foods that increase serotonin levels in the brain to improve their mood (albeit temporarily). There is indeed evidence that buproprion may help some people lose weight.

Secondly, many patients with obesity will be the first to admit that for them eating is akin to an addiction - a statement that is not surprising given that opioid-mediated reward mechanisms may play an important role in the hedonic aspects of ingestive behaviour and that this behaviour may well involve exactly the same neurocircuitary that plays a role in other addictions.

So the idea of combining two drugs that address depression and addiction, respectively, is certainly one with merit and may well prove to be highly effective in obese patients in whom depression and hedonic eating are significantly contributing to hyperphagia.

I have not seen data from these trials and have no relationship with Orexigen. I do however, like the concept of this drug and can’t wait to try it on some of my patients, who I can well imagine would benefit.

Obviously, we need to await the results of the Phase III program and certainly need to very carefully look at the side effect profile of the two drugs used in combination.

But I do think that this could indeed be a useful drug for some patients battling obesity - although it is unlikely to be the “magic bullet” for everyone.

Remember, obesity is a highly complex and heterogeneous disorder and there is absolutely no reason why any one treatment should work for all.

AMS
Edmonton, Alberta