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.
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.
This morning, I presented a keynote address at the 31st Scientific Meeting of the Deutsche Adipositas Gesellschaft (German Obesity Society) on the issue of risk stratification beyond BMI.
As regular readers will be well aware, I have long stated that our current definition of obesity based on BMI is problematic when applied to individuals presenting with excess weight.
We have therefore proposed the use of the Edmonton Obesity Staging System as a simple clinical tool for risk stratification that can guide clinical decision making.
Judging by the response from the audience, this concept met overwhelming approval, especially from the clinicians in the audience.
If, how, and when this concept will find its way into German obesity management guidelines remains to be seen.
As a clinician often dealing with patients presenting with binge-eating disorder (BED), I am quite aware of the often pathological cognitive and emotional relationship to food, eating, and body image presented by patients with this syndrome.
Whether or not this impairment in thinking and feeling also extends to other behavioural or emotional domains is the topic of a systematic review by Kittel and colleagues from the University of Leipzig, published in the International Journal of Eating Disorders.
The paper is based on the review of almost 60 studies and shows that, individuals with BED consistently demonstrate higher information processing biases compared to obese and normal-weight controls in the context of disorder-related stimuli (i.e., food and body cues) – in contrast, cognitive functioning in the context of neutral stimuli appear to be less affected.
With regard to emotional functioning, individuals with BED also report greater emotional deficits when compared to obese and normal-weight controls.
Thus, these findings confirm the clinical observation that patients with BED tend to have specific difficulties in cognitive and emotional functioning when it comes to food, eating or body image, however, appear to function adequately in other domains.
For clinicians these finding are relevant as they show that while people with BED may benefit from help in changing their cognitive and emotional response to food cues, such problems are indeed more often encountered in people with BED rather than in everyone living with obesity.
Screening for BED should be an essential element of workup in anyone presenting with excess weight gain.
According to a study conducted by a team of researchers from the US, Canada, Australia and Iceland, published in Pediatric Obesity, weight-based bullying in children and youth is the most prevalent form of youth bullying in these countries, exceeding by a substantial margin other forms of bullying including race/ethnicity, sexual orientation or religion.
According to the almost 3000 participants in this study, parents, teachers and health professionals were seen as those with the greatest potential of reducing weight-based bullying.
In addition, the majority of participants (65-87%) supported government augmentation of anti-bullying laws to include prohibiting weight-based bullying.
While these findings may not strike anyone living with obesity as surprising, they should be a reminder to the rest of us that weight-based bullying, with all of its negative consequences for mental, physical and social health, is something to be taken very seriously and needs to be opposed as much as we would oppose any other forms of bullying.