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Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach
Surgery for Obesity and Related Diseases 2 (2006) 171–179
Article in co-publication
Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach Thomas A. Waddena,*, David B. Sarwera,b a
Department of Psychiatry, Weight and Eating Disorders Program, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania b Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
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. © 2006 NAASO. All rights reserved.
Keywords:
Bariatric surgery; Psychosocial status; Assessment; Weight and Lifestyle Inventory; Mood
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 “wellinformed 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
This article will also appear in the March 2006 supplement of Obesity Research. *Address correspondence to Thomas A. Wadden, Weight and Eating Disorders Program, University of Pennsylvania School of Medicine, 3535 Market Street, Suite 3029, Philadelphia, PA 19104. E-mail: [email protected] 1550-7289/06/$ – see front matter © 2006 NAASO. All rights reserved. doi:10.1016/j.soard.2006.03.011
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 welldefined 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]. 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
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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, found that persons with a BMI ⬎ 40 kg/m2 were 5 times more likely to have experienced an episode of major depression in the past year than were individuals of average weight [8]. Among persons seeking bariatric surgery, ⬃50% reported a lifetime history of depression or other affective disturbance [4,5,7]. In five separate studies, 23% to 47% of patients reported using psychotropic medication at the time of their presurgical behavioral assessment [9 –13].
Prejudice and discrimination Even quality of life scales, however, cannot adequately capture the adverse emotional consequences of the prejudice and discrimination to which extremely obese individuals are daily subjected [24]. Disparagement of obese individuals has been described as the “last socially acceptable form of prejudice” [25]. Overweight individuals are routinely labeled, even by health care professionals, as “lazy, ugly, awkward, and sloppy” [26]. Such ridicule likely engenders negative body image and feelings of inferiority in many obese individuals [4,7]. Studies also have documented that obesity is associated with adverse economic and social consequences, particularly in women [27,28]. Extreme obesity, for some, carries a substantial emotional toll that exceeds the burden imposed by its physical complications.
Eating disorders Factors responsible for the increased rate of depression in persons with extreme obesity are not clear but may include the co-occurrence of eating disorders. Approximately 10% to 25% of candidates for bariatric surgery appear to suffer from binge eating disorder (BED),1 which is characterized by the consumption of an objectively large amount of food in a brief period (⬍2 hours), during which the individual experiences subjective loss of control [14 – 17]. Binge episodes are followed by remorse and distress. They are not followed, however, by purging (e.g., vomiting), which distinguishes BED from bulimia nervosa [14]. A minority of bariatric surgery candidates also suffer from the night eating syndrome, in which ⬎35% of daily food intake is consumed after dinner, and sleep is disrupted by episodes of nocturnal eating [18]. Estimates of the prevalence of this syndrome in surgery candidates vary markedly, depending on the criteria used, as discussed by Allison et al. [19] in this supplement.
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 treatment response; identifying variables that reliably predicted suboptimal outcome; and demonstrating that preoperative intervention, to ameliorate behavioral or psychosocial complications, improved postoperative outcome. In cases in which alternative therapies were recommended, their benefit, relative to bariatric surgery, would need to be evaluated. Predictors of outcome
Health-related quality of life The risk of depression also is probably increased in persons with extreme obesity because of impaired healthrelated quality of life. This term refers to the burden of suffering and the limitations in vocational and social functioning associated with illness [20]. Numerous population and clinical studies have shown that, as compared with average weight individuals, persons with extreme obesity report significantly greater bodily pain and impairments in physical functioning, work, and social interactions [21–23]. These are likely to be long-standing impairments, given the chronicity of obesity, and could increase vulnerability of patients to depression and other affective disturbance.
1
Nonstandard abbreviations: BED, binge eating disorder; GBP, gastric bypass; WALI, Weight and Lifestyle Inventory.
To date, there has been limited success in identifying consistent behavioral predictors of outcome after bariatric surgery [4,30]. The majority of studies found that baseline psychiatric status, particularly depression, did not predict postoperative weight loss [13,30 –33]. One study, in fact, found that greater baseline symptoms of depression were associated with greater (not smaller) weight loss [33]. Some studies have suggested that BED is associated with smaller weight loss after bariatric surgery [34 –37]. Dymek et al. [34], for example, found that patients with BED who underwent gastric bypass (GBP) lost significantly less weight at 6 months than individuals who were free of this disorder (38.5% reduction in excess weight vs. 53.9%). Kalarchian et al. [36] examined patients 2 to 7 years after GBP and found that reports of current binge eating were associated with weight gain (from the point of maximum weight loss). BED status, however, was not determined before surgery in this study, which also was a limitation of
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two other studies [35,37]. In contrast to these reports, Powers et al. [38] found no relationship between preoperative binge eating status and weight loss as assessed in clinic 2 years postoperatively and by self-report at an average of 5.5 years. Malone and Alger-Mayer [39] obtained a similar negative finding. Clinical significance of predictors Thus, at present, there are not adequate data to determine whether the presence of BED, before surgery, is associated with smaller weight loss or other undesirable outcomes. Even if BED were consistently associated with diminished weight loss, it is not clear how this finding would alter treatment recommendations. For example, patients with binge eating in the study by Dymek et al. [34] still lost nearly 40% of their excess weight, which is substantially more than they would lose with behavioral or pharmacological treatments for obesity [40]. Although it is possible that cognitive behavioral treatment for binge eating [41], provided before surgery, might improve weight loss in patients with BED, there have been no studies of this issue. Prediction of outcome and, thus, screening are likely to improve as investigators study larger numbers of patients, whose behavior is well-characterized before surgery, and who are carefully followed for 2 or more years postoperatively. The Bariatric Surgery Consortium, which will assess patients at six sites, using a common protocol, should greatly facilitate this effort. Research also is needed to identify postoperative behaviors that are associated with suboptimal outcome. Binge eating, for example, observed after GBP, is likely to be associated with poor adherence to dietary recommendations [17,36]. Even if binge eating does not limit weight loss, patients with this complication would seem to be at increased risk of plugging, vomiting, and dumping, all of which can adversely affect physical and emotional health [4,17,36,42]. These individuals should receive dietary or behavioral counseling to address these complications, although there have been no systematic studies of the benefits of such intervention. 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 conducted as a semistructured interview that is organized, in part, around patients’ responses to the Weight and Lifestyle Inventory
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(WALI) [43]. The WALI assesses patients’ weight and dieting histories, eating and activity habits, social and psychological status, and current life stressors. Surgery candidates complete both the WALI and the Beck Depression Inventory [44] before the interview. Clinicians can review both questionnaires before the interview, grasp the patients’ history, and identify areas of potential concern. The Beck Depression Inventory has excellent reliability and validity. The WALI has generally acceptable reliability, as described in several papers in this supplement. The instrument’s predictive validity, however, has not been demonstrated, and the WALI is best viewed, at present, as a method of eliciting and organizing clinical information. The goals and methods of the WALI have been described in detail by Wadden and Phelan [45]. 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 usually addresses the following five areas, although not necessarily in the following order. Knowledge of bariatric surgery Throughout the interview, we seek to determine how well informed candidates are of the nature of the operation they plan to have, of its potential risks and benefits, and of the changes they must make in their eating and lifestyle habits, both short- and long-term. A majority of candidates seem well informed, having researched the operation by talking with their surgeon, attending support groups offered by our program, or, increasingly, by using the Internet. They also are aware of the likelihood of experiencing vomiting, dumping, and related complications as they adjust to the operation and their new eating plan. A small minority of candidates seem to have only marginal knowledge of the operation they seek and its requirements. They decide on surgery after having heard about it in a media report and speak in the vaguest of terms about risks, expected outcomes, and postsurgical dietary requirements. We use the interview to educate such individuals but typically recommend that they meet again with their surgeon or the program’s dietitian and attend several meetings of the program’s support group. They also may be provided with web sites and recommended readings. These practices are intended to ensure that candidates are fully informed about the surgery, its risks, and its behavioral consequences. We rarely encounter persons who are not mentally competent to
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make a decision concerning surgery [10], although this is an obvious consideration. Weight and dieting histories We devote a substantial portion of the interview to reviewing patients’ weight and dieting histories, as assessed by the WALI. This includes assessing the age of onset of obesity and the history of the condition in parents and other family members. As discussed by Crerand et al. [46] in this supplement, persons with extreme obesity (BMI ⬎ 40 kg/ m2) typically have an earlier age of onset of obesity and stronger family history of the disorder than do persons with class I-II obesity. Such characteristics may well be associated with a greater genetic (or biological) predisposition to the disorder [45]. Whitaker et al., for example, found that the strongest predictor of obesity as an adult was child or adolescent onset of this disorder, in combination with a parental history; 70% to 75% of children with these two risk factors were obese as adults [47]. With such individuals, we indicate that they may well have a genetic predisposition to obesity that has made it difficult to control their weight, despite lifelong efforts to do so. We often describe a study by Bouchard et al. [48] that found that some persons gained more weight than others, when overfed by the same number of calories; genetics contributed to the differences observed. This finding resonates with the experience of many patients, who are perplexed by their body weight when they compare their eating and activity habits with their less obese peers. The message for such patients is that they should not needlessly blame themselves for their obesity. Repeat dieters. Most expert panels have recommended bariatric surgery as the final treatment option after diet, exercise, lifestyle modification, and pharmacotherapy have been exhausted [2,49,50]. We agree with this recommendation and have found that the great majority of our surgery candidates have made multiple, significant efforts to lose weight, as reported by Gibbons et al. [51] in this supplement. Patients often are ashamed of their failed attempts at weight control. We express our admiration for their determination and resolve to control their weight, which have frequently gone unrecognized by health care professionals. Novice dieters. As bariatric surgery has increased in popularity in the last few years, our clinicians have encountered a growing number of patients (⬃10%) who have not participated in any organized weight loss programs before seeking surgery [51]. They, for example, have not enrolled in Weight Watchers or a lifestyle modification class at the YMCA or been prescribed a weight loss medication. With many of these patients, we recommend that they attend the program’s support group and follow a modified version of the postoperative diet for several months to best prepare them for the dietary changes required after surgery. In other cases, particularly with individuals with a rela-
tively low BMI (⬍45 kg/m2) and no major health complications, we recommend that they try Weight Watchers or another conservative approach. Some patients have agreed to, but others have responded, somewhat paradoxically, that they cannot afford these treatments. By contrast, their insurance will cover the surgery. Such cases underscore the need for insurers to pay for non-surgical therapies, particularly in these special circumstances [52]. Expectations of surgery. We conclude this portion of the interview by discussing candidates expected weight losses after surgery. We inform them that most persons lose ⬃30% of their initial weight after GBP and compare this amount with their expectations [53]. The effects of unrealistic expectations on weight loss and other outcomes after surgery are not known. Instead of focusing on weight loss per se, we ask candidates to describe improvements in health or activities of daily living that they seek, such as being able to play with their children or to sit comfortably on an airplane. These events are far better measures of success than is weight loss alone. Eating and activity habits The WALI seeks to obtain an overview of the candidate’s dietary intake, focusing on the number of meals and snacks consumed daily and whether the individual has a structured eating plan. It also inquires about foods typically eaten and favorite foods. The goal is to identify changes in food intake that will be required after surgery, particularly a reduction in sweets (associated with the dumping syndrome). The need to consume multiple small meals throughout the day is also discussed and how such an eating pattern will fit the candidate’s work and social schedule. These issues are discussed in greater detail with the program’s dietitian who provides an overview of the postoperative diet, as prescribed short and long term. Clinicians who wish to assess dietary intake more thoroughly can use the Block Food Frequency Questionnaire [54] or a 24-hour food recall. Alcohol intake. Alcohol consumption is routinely assessed as part of dietary intake. We rarely encounter patients with current alcohol dependence or abuse, although some studies have suggested that a significant minority of surgery candidates have a history of substance abuse [4,7]. Active substance abuse or dependence is considered a contraindication to surgery [55]. Eating disorders. The WALI also includes the Questionnaire on Eating and Weight Patterns [56], used to diagnose BED and bulimia nervosa, and the Night Eating Questionnaire [57], which assesses this latter syndrome. As noted previously, we do not routinely defer patients from surgery on the basis of BED or the night eating syndrome, given the absence of data to warrant this practice. We do, however, determine how concerned they are about the potential effect
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of their eating disorder on their adherence to the postoperative diet. Persons with significant concern are provided a referral for cognitive behavioral therapy, which they may pursue either before or concurrent with surgery. Current evidence suggests that binge eating, in those affected, is most likely to reoccur 18 to 24 months after surgery [4,36]. In contrast to BED and NES, we believe that bulimia nervosa is a contraindication to bariatric surgery. Patients with this disorder would seem at high risk of excessive vomiting after surgery with its attendant effects on oral health, electrolyte balance, and cardiac function [58]. We have encountered only a handful of patients with bulimia nervosa in the ⬎2000 candidates evaluated. We refer these individuals to an eating disorders specialist and their family physician to resolve the condition before surgery. Physical activity. Physical activity is briefly assessed to determine the patient’s pattern of lifestyle and programmed activity and any physical conditions that limit mobility. Not surprisingly, most bariatric surgery candidates report low levels of activity that they are eager to increase with weight loss. Social/psychological status We assess psychological status in several ways, including by attending to patients’ appearance, speech, thought, mood, and appropriateness of affect in describing themselves and in responding to questions. This global assessment is complemented by reviewing the patient’s history of psychiatric illness and any treatment received, including pharmacotherapy. We also examine responses to the Beck Depression Inventory [44], a 21-item self-report questionnaire, with scores of 0 to 63, that yields ratings of minimal (0 to 13), mild (14 to 19), moderate (20 to 28), and severe (⬎29) symptoms of depression. As reported by Wadden et al. [59], in this supplement, ⬃70% to 75% of surgery candidates report minimal to mild symptoms of depression that generally are not of clinical concern, unless patients have suicidal ideation. These latter individuals, and those who score in the moderate to severe range of depression, require further examination, not only of potential suicidal ideation, but also of their sleep, concentration, cognition (including self-critical thoughts), and vocational and social function. With individuals who have a history of depression, or other conditions, we ask how they are functioning now, as compared with their best and worst times. We also inquire who is treating them and typically ask permission to contact practitioners to obtain their assessment of the patient’s psychiatric status (and whether they support the individual’s decision to have surgery). Such consultation is invaluable, given that these practitioners have far better appreciation for patients’ functioning than we can achieve in a one-time interview. Untreated conditions. A small minority of surgery candidates score in the moderate to severe range of depression
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but report no history of depression or other emotional complications. They often deny that they feel depressed or believe that their dysphoria and related symptoms are attributable to their obesity. With such individuals, we devote greater attention to assessing how obesity affects their quality of life, in the areas of physical health, mobility, sleep, work, social interactions, body image, and self-esteem. Practitioners may wish to administer additional questionnaires, including the Medical Outcomes Scale-Short Form [60] or the Impact of Weight on Quality of Life scale [61]. With persons who seem to have significant symptoms of depression, even after accounting for conditions associated with their weight, we suggest that medication, psychotherapy, or their combination could help them (e.g., decrease feelings of hopelessness, worthlessness, or marked fatigue). Patients are encouraged to speak with their primary care physician or are provided with a mental health referral. The goal of such referral is to alleviate patients’ current emotional suffering. Most candidates are receptive to recommendations that they seek assistance for their mood (or other complications) and are scheduled for a follow-up visit in our clinic 8 to 12 weeks later to assess their progress. A small number of individuals disagree with our recommendations. Ultimately, we respect their right to refuse our advice, except in cases of suicidal ideation, active psychosis, or other contraindications previously described. In the absence of data to show a clear relation between psychiatric status and unfavorable outcome of bariatric surgery, stipulating that patients cannot have surgery until they have received psychiatric care presents significant ethical concerns. Such practice potentially could prevent some patients from obtaining the surgery, needed to improve their weight and associated health complications. We inform the surgeon of our concerns but leave the final decision to the surgeon and patient. Family members. The decision to seek bariatric surgery is a significant one, not only for the patient, but for his or her family members. This section of the interview, thus, inquires about patients’ living arrangements, their satisfaction with their spouse (partner) and other intimate relationships, and whether family members and friends support the decision to undertake surgery. In cases in which family members are opposed, we attempt to clarify their perceived concerns (e.g., risk of health complications) and offer to speak with relatives to provide an objective view of the surgery and its risks and benefits. We also address patients’ occasional concerns that family members may try to sabotage their weight loss efforts. Candidates who report they are dissatisfied with their marriages (or other intimate relationships) are informed that surgery and weight loss are unlikely to resolve these problems [62]. We also ensure that patients have identified relatives or friends who will assist in their care in the initial days and weeks after the operation.
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Planning for surgery and postoperative care A separate section of the WALI inquires about stressors or major life events expected in the next several months. The purpose of this assessment is to ensure that the candidate has chosen a propitious time to undergo surgery, relatively free of stressors such as starting a new job, changing homes, or getting a divorce. Ideally, the patient should have 3 to 4 weeks of protected time to undergo the operation, recover from it physically, and begin to adopt new lifestyle habits, the most important of which is adhering to the postoperative diet. As noted previously, we always ask candidates to identify family members or friends who will assist them with postoperative needs that may include transportation, caring for children, or assisting with meal preparation and other activities of daily living. We also inquire whether patients have any questions about what to tell their employer, coworkers, or friends about the operation and its effects on their functioning and availability. In cases in which candidates report extremely stressful life events, we discuss whether they might delay surgery until the stressors have resolved (if they seem short term). At a minimum, we discuss how they can cope optimally with the challenges they face. Postoperative care. This part of the interview concludes by reviewing the patients’ plans for postoperative care. We reiterate the importance of regular postoperative visits with the surgeon, dietitian, and other medical staff and strongly encourage all candidates to attend our program’s monthly patient support group meetings. We also ask them to identify their biggest concerns about adhering to the postoperative diet or adjusting to life after surgery (and weight loss). We examine the concerns and identify potential resources for handling them. We always encourage patients to contact us with any difficulties, whether 3 days or 3 years after surgery. Summarizing the findings We conclude the interview by providing patients a brief summary of our findings concerning their weight and dieting histories, eating and activity habits, social/psychological status, and readiness for bariatric surgery. As described elsewhere [45], the summary follows the acronym BEST Treatment, in which B represents biological factors that may contribute to the patient’s obesity (i.e., genetic predisposition), E stands for environmental factors (i.e., eating and activity habits and the effects of the obesegenic environment), S represents social/psychological factors, and T captures the timing of the planned weight loss effort. After discussing these components, we examine which treatment appears to be the best option. In the overwhelming majority of cases, we confirm that bariatric surgery appears to be the best choice for the individual. We also repeat here any recommendations that the individual seek treatment for a mood disorder or other behavioral complications. We
schedule a follow-up visit to reevaluate the patient’s progress. A recent review of 90 candidates we had assessed revealed that 33% were encouraged to seek adjunctive counseling of some kind, whereas 3% were judged to have absolute contraindications to surgery at the time of the evaluation [10]. The remaining 64% of candidates were approved unconditionally for surgery (from a psychosocial standpoint). We inform patients that we will send their surgeon a letter “that describes what we discussed today.” (Appendix A and B provide examples of two typical letters written to surgeons.) We wish patients success with the surgery, whether they pursue it immediately or in a few months, and encourage them to contact us for any needed assistance. 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 invaluable opportunity to discuss their often life-long struggle with their weight and the distress it has caused them. We want to ensure that these individuals, so many of who have been stigmatized because of their weight, receive any psychosocial care they need and the opportunity to make a fully informed decision concerning the surgery they seek. Appendix A August 3, 2005 Dear Dr. Smith: We met today with Ms. Betty Green whom you referred for a behavioral assessment of her appropriateness for bariatric surgery. Ms. Green is a 47 year-old, African-American female. She is 5=7⬙ with a weight of 272.4 lbs. and body mass index (BMI) of 43 kg/m2. She is single and lives with her two daughters. She has been employed with the post office for the past 25 years. Biological factors Ms. Green reported that she has been overweight since early adulthood. She is currently below her highest adult weight of 297 lbs. reached several months ago. She reported losing approximately 25 lbs. since that time secondary to following a low-carbohydrate diet and by reducing her portion sizes. Ms. Green reported her mother is and father was obese. Her two siblings are of average weight. Her medical history and current medications are known to you. Of note, she reported a history of heart disease and hypertension.
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Ms. Green’s family history suggests a significant biological predisposition to obesity. Environmental factors Ms. Green reported eating two to three meals and several snacks each day. She reported eating large portion sizes of calorically dense foods at many of her meals. She often works during the evening and overnight hours, which alters her eating schedule and often increases her reliance on takeout food and fast food. Currently, Ms. Green is on a lowcarbohydrate diet. She denied any behaviors consistent with binge eating disorder. She denied any compensatory or purging behaviors. Ms. Green has made several previous weight loss attempts, including self-directed diets, commercial programs, and FDA-approved weight-loss medications. These approaches have been moderately successful, typically resulting in a 5–10% weight loss. Unfortunately, she has been unable to maintain these losses over long periods of time. She reported no experience with very-low-calorie diets, nutritional counseling, or hospital-based programs. She reported a moderate level of physical activity at present, walking several times each week. In summary, Ms. Green’s reported eating calorically dense foods and large portions sizes, both of which are likely contributors to her obesity. Social/psychological factors Ms. Green denied any psychiatric treatment history. Her Beck Depression Inventory-II score was 7, suggestive of an average number of depressive symptoms. She described her mood as “good” and her affect was appropriate. She denied any symptoms of depression upon questioning. She revealed that her father was an alcoholic but denied any alcohol problems herself. She also revealed a history of physical abuse from past boyfriends. Upon questioning, she denied involvement in a physically abusive relationship at present. She reported no suicidal ideation. No evidence of a thought disorder was found. Timing Ms. Green reported no significant life stressors at this time. This appears to be an excellent time to have surgery. Summary Ms. Green appears to be an appropriate candidate for bariatric surgery. Her BMI is above 40, she has heart disease, hypertension, and she has tried several more conservative weight loss approaches without long-term success. Weight loss following surgery will likely decrease her risk of weight related health problems in the future and improve her quality of life. Please call me if you have any questions regarding this patient.
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Appendix B August 31, 2005 Dear Dr. Jones: I met today with Ms. Alice Smith whom you referred for a behavioral assessment of her appropriateness for bariatric surgery. Ms. Smith is a 54 year-old, Caucasian female. She is 5=1⬙ with a weight of 270 lbs. and body mass index (BMI) of 51 kg/m2. She is married and lives with her husband and three of her four adult children. She has been employed as a telephone operator for the past 24 years. Biological factors Ms. Smith reported that she first recognized being overweight during childhood. She is currently at her highest adult weight of 270 lbs. reached this year. She reported a weight increase of 40 lbs. in the past two years as a result of eating “the wrong foods.” Ms. Smith reported her mother and father were average weight. Her two half-sibling are average weight. Her medical history and current medications are known to you. Of note, she reported a history of hypertension and sleep apnea. In summary, Ms. Smith’s early onset of overweight provides evidence for a moderate biological predisposition to obesity. Environmental factors Ms. Smith reported eating two meals and several snacks each day. She reported that she typically skips breakfast and eats a very large lunch. For example, she will often eat two large fast food hamburgers, a large order of French fries, a large regular soda, and serving of ice cream. She reported eating similarly large portion sizes for dinner. Approximately twice per week, she reported that she will “lose control” during her evening snack and eat a large bag of potato chips while watching television. During these episodes, she reported eating without hunger and past the feeling of fullness. She also reported feelings of dysphoria and guilt. Thus, she appears to meet diagnostic criteria for binge eating disorder. She denied any compensatory or purging behaviors following these episodes. Ms. Smith has made several previous weight loss attempts, including self-directed diets, commercial programs, and over-the-counter as well as FDA-approved weight-loss medications, and behaviorally-based programs. These approaches have been moderately successful, typically resulting in a 5–15% weight loss. Unfortunately, she has been unable to maintain these losses over long periods of time. She reported no experience with very-low-calorie diets or nutritional counseling. She stated that she has not tried to lose weight in the past several years and that she became interested in bariatric surgery after seeing it on television. Ms. Smith reported that she is not physically active at this time secondary to degenerative disc arthritis in her back.
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In summary, Ms. Smith’s binge eating, regular consumption of calorically dense foods and beverages, and lack of physical activity are likely contributors to her obesity. Social/psychological factors For the past 5 years, Ms. Smith has been taking Prozac 40mg/d for depression, as prescribed by her primary care physician. She indicated that she has experienced a number of significant life stressors over the past few years, including issues related to her oldest son’s and her husband’s use of alcohol. Her Beck Depression Inventory-II score was 32, suggestive of a major depressive episode. She described her mood as “irritable” and her affect was flat. She became tearful several times during the assessment. Upon further questioning, she reported difficulty sleeping, decreased appetite, and trouble concentrating. She also reported significant loss of interest in pleasurable activity. She reported no suicidal ideation. No evidence of a thought disorder was found. Timing Ms. Smith reported a number of life stressors at this time. They appear to be impairing her function, as noted above. Summary While Ms. Smith has a BMI above 40, hypertension and sleep apnea, I have concerns about her appropriateness for surgery at this time. First, her symptoms of depression do not appear to be well-controlled at this time. As a result, they may interfere with her ability to make the necessary behavioral and dietary changes to ensure a successful postoperative result. Second, her current diet is quite poor and Ms. Smith reported binge eating several times per week. Third, as compared to our typical surgery candidate, she reported little knowledge of the postoperative behavioral and dietary changes. I made several recommendations to Ms. Smith. First, I referred her to our outpatient psychiatry unit for additional assessment and treatment of her depressive symptoms. Second, I encouraged her to attend the Bariatric Surgery Program’s monthly support group for the next several months. This will provide her with additional information on the postoperative behavioral and dietary requirements. I shared these concerns with Ms. Smith and she reported to be in agreement with them. If she is able to address these concerns in the next 3 months, she will likely be a more appropriate candidate for surgery. We have scheduled a tentative follow-up visit at the end of November to reassess her status. Please call me if you have any questions regarding this patient.
Acknowledgments This work was supported, in part, by Grants K23DK60023, K24-DK65018, and R01-DK069652 from the National Institute of Diabetes, Digestive, and Kidney Disease.
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T.A. Wadden and D.B. Sarwer / Surgery for Obesity and Related Diseases 2 (2006) 171–179 [22] Larsson U, Karlsson J, Sullivan M. Impact of overweight and obesity on health-related quality of life-a Swedish population study. Int J Obes Relat Metab Disord 2002;26:417–24. [23] Fabricatore AN, Wadden TA, Sarwer DB, et al. Health-related quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery. Obes Surg 2005;15:304 –9. [24] Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res 2001;9:788 – 805. [25] Sobal J, Stunkard AJ. Socioeconomic status and obesity: a review of the literature. Psychol Bull 1989;105:260 –75. [26] Foster GD, Wadden TA, Makris AP, et al. Primary care physicians’ attitudes about obesity and its treatment. Obes Res 2003;11:1168 –77. [27] Roehling MV. Weight-based discrimination in employment: psychological and legal aspects. Personnel Psychol 1999;52:969 –1016. [28] Gortmaker SL, Must A, Perrin JM, et al. Social and economic consequences of overweight in adolescence and young adulthood. N Engl J Med 1993;329:1008 –12. [29] Wadden TA, Lelizia KA. Predictors of attrition and weight loss in patients treated by moderate and severe calorie restriction. In: Wadden TA, Van Itallie TB, eds. Treatment of the Seriously Obese Patient. New York: Guilford Press; 1992, pp. 383– 410. [30] Hsu LK, Benotti PN, Dwyer J, et al. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med 1998;60:338 – 46. [31] Powers PS, Rosemurgy A, Boyd F, et al. Outcome of gastric restriction procedures: weight, psychiatric diagnoses, and satisfaction. Obes Surg 1997;7:471–7. [32] Davidson T, Rohde P, Wastell C. Psychological profile and outcome in patient undergoing gastroplasty for morbid obesity. Obes Surg 1991;1:177– 80. [33] Averbukh Y, Heshka S, El-Shoreya H, et al. Depression score predicts weight loss following Roux-en-Y gastric bypass. Obes Surg 2003;13:833– 6. [34] Dymek MP, le Grange D, Neven K, et al. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg 2001;11:32–9. [35] Hsu LKG, Betancourt S, Sullivan SP. Eating disturbances before and after vertical banded gastroplasty: a pilot study. Int J Eat Disord 1996;19:23–34. [36] Kalarchian MA, Marcus MD, Wilson GT, et al. Binge eating among gastric bypass patients at long-term follow-up. Obes Surg 2002;12: 270 –5. [37] Hsu LKG, Betancourt S, Sullivan SP. Eating disturbances and outcome of gastric bypass surgery: a pilot study. Int J Eat Disord 1997;21:385–90. [38] Powers PS, Perez A, Boyd F, et al. Eating pathology before and after bariatric surgery: a prospective study. Int J Eat Disord 1999;25:293– 300. [39] Malone M, Alger-Mayer S. Binge status and quality of life after gastric bypass surgery: a one-year study. Obes Res 2004;12:473– 81. [40] Wadden TA, Butryn ML. Behavioral treatment of obesity. Endocrinol Metab Clin North Am 2003;32:981–1003. [41] Wilfley DE, Welch RR, Stein RI, et al. A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Arch Gen Psychiatry 2002;59:713–21.
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[42] de Zwaan M, Lancaster KL, Mitchell JE, et al. Health-related quality of life in morbidly obese patients: effects of gastric bypass surgery. Obes Surg 2002;12:73– 80. [43] Wadden TA, Foster GD. Weight and Lifestyle Inventory. Philadelphia, PA: University of Pennsylvania; 2003. [44] Beck AT, Steer RA, Brown GK. Beck Depression Inventory II (BDIII) Manual. San Antonio, TX: Harcourt Brace & Company; 1993. [45] Wadden TA, Phelan S. Behavioral assessment of the obese patient. In: Wadden TA, Stunkard AJ, eds. Handbook of Obesity Treatment. New York, NY: Guilford; 2002, pp. 186 –208. [46] Crerand CE, Wadden TA, Sarwer DB, et al. A comparison of weight histories in women with class III versus class I-II obesity. Obesity 2006;14(Suppl 2):63S–9S. [47] Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997; 337:869 –73. [48] Bouchard C, Tremblay A, Despres JP, et al. The response to longterm overfeeding in identical twins. N Engl J Med 1990;322:1477– 82. [49] National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Obes Res 1998;6(Suppl):51–210S. [50] World Health Organization. Obesity: Preventing and Managing the Global Epidemic (Publication No. WHO/NUT/NCD). Geneva, Switzerland: World Health Organization; 1998. [51] Gibbons LM, Sarwer DB, Crerand CE, et al. Previous weight loss experiences of bariatric surgery candidates: how much have patients dieted prior to surgery? Obesity 2006;14(Suppl 2):70S–5S. [52] Tsai AG, Asch DA, Wadden TA. Insurance reimbursement for obesity treatment. J Am Diet Assoc 2005 (in press). [53] Brolin RE. Bariatric surgery and long-term control of morbid obesity. JAMA 2002;288:2793– 6. [54] Block G, Hartman AM, Dresser CM, et al. A data-based approach to diet questionnaire design and testing. Am J Epidemiol 1986;124:453– 69. [55] Sugerman HJ. Preface to obesity surgery. Surg Clin North Am 2001; 81:iv. [56] Yanovski SZ. The Questionnaire on Eating and Weight PatternsRevised. Obes Res 1993;1:306 –24. [57] Allison KC, Stunkard AJ, Thier SL. Overcoming Night Eating Syndrome: A Step-By-Step Guide to Breaking the Cycle. Oakland, CA: New Harbinger; 2004. [58] Pomeroy C, Mitchell JE. Medical complications of anorexia nervosa and bulimia nervosa. In: Eating Disorders and Obesity: A Comprehensive Handbook. 2nd ed. New York: Guilford Press; 2002, pp. 278 – 85. [59] Wadden TA, Butryn ML, Sarwer DB, et al. Comparison of psychosocial status in treatment-seeking women with class III vs. class I-II obesity. Obesity 2006;14(Suppl 2):89S–97S. [60] Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care 1992;30:473– 83. [61] Kolotkin RL, Crosby RD. Psychometric evaluation of the impact of weight on quality of life-lite questionnaire (IWQOL-lite) in a community sample. Qual Life Res 2002;11:157–71. [62] Rand CSW, Juldau JM, Robbins L. Surgery for obesity and marriage quality. JAMA 1982;247:1419 –22.
Article in co-publication
Behavioral assessment of candidates for bariatric surgery: a patient-oriented approach Thomas A. Waddena,*, David B. Sarwera,b a
Department of Psychiatry, Weight and Eating Disorders Program, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania b Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
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. © 2006 NAASO. All rights reserved.
Keywords:
Bariatric surgery; Psychosocial status; Assessment; Weight and Lifestyle Inventory; Mood
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 “wellinformed 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
This article will also appear in the March 2006 supplement of Obesity Research. *Address correspondence to Thomas A. Wadden, Weight and Eating Disorders Program, University of Pennsylvania School of Medicine, 3535 Market Street, Suite 3029, Philadelphia, PA 19104. E-mail: [email protected] 1550-7289/06/$ – see front matter © 2006 NAASO. All rights reserved. doi:10.1016/j.soard.2006.03.011
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 welldefined 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]. 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
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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, found that persons with a BMI ⬎ 40 kg/m2 were 5 times more likely to have experienced an episode of major depression in the past year than were individuals of average weight [8]. Among persons seeking bariatric surgery, ⬃50% reported a lifetime history of depression or other affective disturbance [4,5,7]. In five separate studies, 23% to 47% of patients reported using psychotropic medication at the time of their presurgical behavioral assessment [9 –13].
Prejudice and discrimination Even quality of life scales, however, cannot adequately capture the adverse emotional consequences of the prejudice and discrimination to which extremely obese individuals are daily subjected [24]. Disparagement of obese individuals has been described as the “last socially acceptable form of prejudice” [25]. Overweight individuals are routinely labeled, even by health care professionals, as “lazy, ugly, awkward, and sloppy” [26]. Such ridicule likely engenders negative body image and feelings of inferiority in many obese individuals [4,7]. Studies also have documented that obesity is associated with adverse economic and social consequences, particularly in women [27,28]. Extreme obesity, for some, carries a substantial emotional toll that exceeds the burden imposed by its physical complications.
Eating disorders Factors responsible for the increased rate of depression in persons with extreme obesity are not clear but may include the co-occurrence of eating disorders. Approximately 10% to 25% of candidates for bariatric surgery appear to suffer from binge eating disorder (BED),1 which is characterized by the consumption of an objectively large amount of food in a brief period (⬍2 hours), during which the individual experiences subjective loss of control [14 – 17]. Binge episodes are followed by remorse and distress. They are not followed, however, by purging (e.g., vomiting), which distinguishes BED from bulimia nervosa [14]. A minority of bariatric surgery candidates also suffer from the night eating syndrome, in which ⬎35% of daily food intake is consumed after dinner, and sleep is disrupted by episodes of nocturnal eating [18]. Estimates of the prevalence of this syndrome in surgery candidates vary markedly, depending on the criteria used, as discussed by Allison et al. [19] in this supplement.
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 treatment response; identifying variables that reliably predicted suboptimal outcome; and demonstrating that preoperative intervention, to ameliorate behavioral or psychosocial complications, improved postoperative outcome. In cases in which alternative therapies were recommended, their benefit, relative to bariatric surgery, would need to be evaluated. Predictors of outcome
Health-related quality of life The risk of depression also is probably increased in persons with extreme obesity because of impaired healthrelated quality of life. This term refers to the burden of suffering and the limitations in vocational and social functioning associated with illness [20]. Numerous population and clinical studies have shown that, as compared with average weight individuals, persons with extreme obesity report significantly greater bodily pain and impairments in physical functioning, work, and social interactions [21–23]. These are likely to be long-standing impairments, given the chronicity of obesity, and could increase vulnerability of patients to depression and other affective disturbance.
1
Nonstandard abbreviations: BED, binge eating disorder; GBP, gastric bypass; WALI, Weight and Lifestyle Inventory.
To date, there has been limited success in identifying consistent behavioral predictors of outcome after bariatric surgery [4,30]. The majority of studies found that baseline psychiatric status, particularly depression, did not predict postoperative weight loss [13,30 –33]. One study, in fact, found that greater baseline symptoms of depression were associated with greater (not smaller) weight loss [33]. Some studies have suggested that BED is associated with smaller weight loss after bariatric surgery [34 –37]. Dymek et al. [34], for example, found that patients with BED who underwent gastric bypass (GBP) lost significantly less weight at 6 months than individuals who were free of this disorder (38.5% reduction in excess weight vs. 53.9%). Kalarchian et al. [36] examined patients 2 to 7 years after GBP and found that reports of current binge eating were associated with weight gain (from the point of maximum weight loss). BED status, however, was not determined before surgery in this study, which also was a limitation of
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two other studies [35,37]. In contrast to these reports, Powers et al. [38] found no relationship between preoperative binge eating status and weight loss as assessed in clinic 2 years postoperatively and by self-report at an average of 5.5 years. Malone and Alger-Mayer [39] obtained a similar negative finding. Clinical significance of predictors Thus, at present, there are not adequate data to determine whether the presence of BED, before surgery, is associated with smaller weight loss or other undesirable outcomes. Even if BED were consistently associated with diminished weight loss, it is not clear how this finding would alter treatment recommendations. For example, patients with binge eating in the study by Dymek et al. [34] still lost nearly 40% of their excess weight, which is substantially more than they would lose with behavioral or pharmacological treatments for obesity [40]. Although it is possible that cognitive behavioral treatment for binge eating [41], provided before surgery, might improve weight loss in patients with BED, there have been no studies of this issue. Prediction of outcome and, thus, screening are likely to improve as investigators study larger numbers of patients, whose behavior is well-characterized before surgery, and who are carefully followed for 2 or more years postoperatively. The Bariatric Surgery Consortium, which will assess patients at six sites, using a common protocol, should greatly facilitate this effort. Research also is needed to identify postoperative behaviors that are associated with suboptimal outcome. Binge eating, for example, observed after GBP, is likely to be associated with poor adherence to dietary recommendations [17,36]. Even if binge eating does not limit weight loss, patients with this complication would seem to be at increased risk of plugging, vomiting, and dumping, all of which can adversely affect physical and emotional health [4,17,36,42]. These individuals should receive dietary or behavioral counseling to address these complications, although there have been no systematic studies of the benefits of such intervention. 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 conducted as a semistructured interview that is organized, in part, around patients’ responses to the Weight and Lifestyle Inventory
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(WALI) [43]. The WALI assesses patients’ weight and dieting histories, eating and activity habits, social and psychological status, and current life stressors. Surgery candidates complete both the WALI and the Beck Depression Inventory [44] before the interview. Clinicians can review both questionnaires before the interview, grasp the patients’ history, and identify areas of potential concern. The Beck Depression Inventory has excellent reliability and validity. The WALI has generally acceptable reliability, as described in several papers in this supplement. The instrument’s predictive validity, however, has not been demonstrated, and the WALI is best viewed, at present, as a method of eliciting and organizing clinical information. The goals and methods of the WALI have been described in detail by Wadden and Phelan [45]. 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 usually addresses the following five areas, although not necessarily in the following order. Knowledge of bariatric surgery Throughout the interview, we seek to determine how well informed candidates are of the nature of the operation they plan to have, of its potential risks and benefits, and of the changes they must make in their eating and lifestyle habits, both short- and long-term. A majority of candidates seem well informed, having researched the operation by talking with their surgeon, attending support groups offered by our program, or, increasingly, by using the Internet. They also are aware of the likelihood of experiencing vomiting, dumping, and related complications as they adjust to the operation and their new eating plan. A small minority of candidates seem to have only marginal knowledge of the operation they seek and its requirements. They decide on surgery after having heard about it in a media report and speak in the vaguest of terms about risks, expected outcomes, and postsurgical dietary requirements. We use the interview to educate such individuals but typically recommend that they meet again with their surgeon or the program’s dietitian and attend several meetings of the program’s support group. They also may be provided with web sites and recommended readings. These practices are intended to ensure that candidates are fully informed about the surgery, its risks, and its behavioral consequences. We rarely encounter persons who are not mentally competent to
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make a decision concerning surgery [10], although this is an obvious consideration. Weight and dieting histories We devote a substantial portion of the interview to reviewing patients’ weight and dieting histories, as assessed by the WALI. This includes assessing the age of onset of obesity and the history of the condition in parents and other family members. As discussed by Crerand et al. [46] in this supplement, persons with extreme obesity (BMI ⬎ 40 kg/ m2) typically have an earlier age of onset of obesity and stronger family history of the disorder than do persons with class I-II obesity. Such characteristics may well be associated with a greater genetic (or biological) predisposition to the disorder [45]. Whitaker et al., for example, found that the strongest predictor of obesity as an adult was child or adolescent onset of this disorder, in combination with a parental history; 70% to 75% of children with these two risk factors were obese as adults [47]. With such individuals, we indicate that they may well have a genetic predisposition to obesity that has made it difficult to control their weight, despite lifelong efforts to do so. We often describe a study by Bouchard et al. [48] that found that some persons gained more weight than others, when overfed by the same number of calories; genetics contributed to the differences observed. This finding resonates with the experience of many patients, who are perplexed by their body weight when they compare their eating and activity habits with their less obese peers. The message for such patients is that they should not needlessly blame themselves for their obesity. Repeat dieters. Most expert panels have recommended bariatric surgery as the final treatment option after diet, exercise, lifestyle modification, and pharmacotherapy have been exhausted [2,49,50]. We agree with this recommendation and have found that the great majority of our surgery candidates have made multiple, significant efforts to lose weight, as reported by Gibbons et al. [51] in this supplement. Patients often are ashamed of their failed attempts at weight control. We express our admiration for their determination and resolve to control their weight, which have frequently gone unrecognized by health care professionals. Novice dieters. As bariatric surgery has increased in popularity in the last few years, our clinicians have encountered a growing number of patients (⬃10%) who have not participated in any organized weight loss programs before seeking surgery [51]. They, for example, have not enrolled in Weight Watchers or a lifestyle modification class at the YMCA or been prescribed a weight loss medication. With many of these patients, we recommend that they attend the program’s support group and follow a modified version of the postoperative diet for several months to best prepare them for the dietary changes required after surgery. In other cases, particularly with individuals with a rela-
tively low BMI (⬍45 kg/m2) and no major health complications, we recommend that they try Weight Watchers or another conservative approach. Some patients have agreed to, but others have responded, somewhat paradoxically, that they cannot afford these treatments. By contrast, their insurance will cover the surgery. Such cases underscore the need for insurers to pay for non-surgical therapies, particularly in these special circumstances [52]. Expectations of surgery. We conclude this portion of the interview by discussing candidates expected weight losses after surgery. We inform them that most persons lose ⬃30% of their initial weight after GBP and compare this amount with their expectations [53]. The effects of unrealistic expectations on weight loss and other outcomes after surgery are not known. Instead of focusing on weight loss per se, we ask candidates to describe improvements in health or activities of daily living that they seek, such as being able to play with their children or to sit comfortably on an airplane. These events are far better measures of success than is weight loss alone. Eating and activity habits The WALI seeks to obtain an overview of the candidate’s dietary intake, focusing on the number of meals and snacks consumed daily and whether the individual has a structured eating plan. It also inquires about foods typically eaten and favorite foods. The goal is to identify changes in food intake that will be required after surgery, particularly a reduction in sweets (associated with the dumping syndrome). The need to consume multiple small meals throughout the day is also discussed and how such an eating pattern will fit the candidate’s work and social schedule. These issues are discussed in greater detail with the program’s dietitian who provides an overview of the postoperative diet, as prescribed short and long term. Clinicians who wish to assess dietary intake more thoroughly can use the Block Food Frequency Questionnaire [54] or a 24-hour food recall. Alcohol intake. Alcohol consumption is routinely assessed as part of dietary intake. We rarely encounter patients with current alcohol dependence or abuse, although some studies have suggested that a significant minority of surgery candidates have a history of substance abuse [4,7]. Active substance abuse or dependence is considered a contraindication to surgery [55]. Eating disorders. The WALI also includes the Questionnaire on Eating and Weight Patterns [56], used to diagnose BED and bulimia nervosa, and the Night Eating Questionnaire [57], which assesses this latter syndrome. As noted previously, we do not routinely defer patients from surgery on the basis of BED or the night eating syndrome, given the absence of data to warrant this practice. We do, however, determine how concerned they are about the potential effect
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of their eating disorder on their adherence to the postoperative diet. Persons with significant concern are provided a referral for cognitive behavioral therapy, which they may pursue either before or concurrent with surgery. Current evidence suggests that binge eating, in those affected, is most likely to reoccur 18 to 24 months after surgery [4,36]. In contrast to BED and NES, we believe that bulimia nervosa is a contraindication to bariatric surgery. Patients with this disorder would seem at high risk of excessive vomiting after surgery with its attendant effects on oral health, electrolyte balance, and cardiac function [58]. We have encountered only a handful of patients with bulimia nervosa in the ⬎2000 candidates evaluated. We refer these individuals to an eating disorders specialist and their family physician to resolve the condition before surgery. Physical activity. Physical activity is briefly assessed to determine the patient’s pattern of lifestyle and programmed activity and any physical conditions that limit mobility. Not surprisingly, most bariatric surgery candidates report low levels of activity that they are eager to increase with weight loss. Social/psychological status We assess psychological status in several ways, including by attending to patients’ appearance, speech, thought, mood, and appropriateness of affect in describing themselves and in responding to questions. This global assessment is complemented by reviewing the patient’s history of psychiatric illness and any treatment received, including pharmacotherapy. We also examine responses to the Beck Depression Inventory [44], a 21-item self-report questionnaire, with scores of 0 to 63, that yields ratings of minimal (0 to 13), mild (14 to 19), moderate (20 to 28), and severe (⬎29) symptoms of depression. As reported by Wadden et al. [59], in this supplement, ⬃70% to 75% of surgery candidates report minimal to mild symptoms of depression that generally are not of clinical concern, unless patients have suicidal ideation. These latter individuals, and those who score in the moderate to severe range of depression, require further examination, not only of potential suicidal ideation, but also of their sleep, concentration, cognition (including self-critical thoughts), and vocational and social function. With individuals who have a history of depression, or other conditions, we ask how they are functioning now, as compared with their best and worst times. We also inquire who is treating them and typically ask permission to contact practitioners to obtain their assessment of the patient’s psychiatric status (and whether they support the individual’s decision to have surgery). Such consultation is invaluable, given that these practitioners have far better appreciation for patients’ functioning than we can achieve in a one-time interview. Untreated conditions. A small minority of surgery candidates score in the moderate to severe range of depression
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but report no history of depression or other emotional complications. They often deny that they feel depressed or believe that their dysphoria and related symptoms are attributable to their obesity. With such individuals, we devote greater attention to assessing how obesity affects their quality of life, in the areas of physical health, mobility, sleep, work, social interactions, body image, and self-esteem. Practitioners may wish to administer additional questionnaires, including the Medical Outcomes Scale-Short Form [60] or the Impact of Weight on Quality of Life scale [61]. With persons who seem to have significant symptoms of depression, even after accounting for conditions associated with their weight, we suggest that medication, psychotherapy, or their combination could help them (e.g., decrease feelings of hopelessness, worthlessness, or marked fatigue). Patients are encouraged to speak with their primary care physician or are provided with a mental health referral. The goal of such referral is to alleviate patients’ current emotional suffering. Most candidates are receptive to recommendations that they seek assistance for their mood (or other complications) and are scheduled for a follow-up visit in our clinic 8 to 12 weeks later to assess their progress. A small number of individuals disagree with our recommendations. Ultimately, we respect their right to refuse our advice, except in cases of suicidal ideation, active psychosis, or other contraindications previously described. In the absence of data to show a clear relation between psychiatric status and unfavorable outcome of bariatric surgery, stipulating that patients cannot have surgery until they have received psychiatric care presents significant ethical concerns. Such practice potentially could prevent some patients from obtaining the surgery, needed to improve their weight and associated health complications. We inform the surgeon of our concerns but leave the final decision to the surgeon and patient. Family members. The decision to seek bariatric surgery is a significant one, not only for the patient, but for his or her family members. This section of the interview, thus, inquires about patients’ living arrangements, their satisfaction with their spouse (partner) and other intimate relationships, and whether family members and friends support the decision to undertake surgery. In cases in which family members are opposed, we attempt to clarify their perceived concerns (e.g., risk of health complications) and offer to speak with relatives to provide an objective view of the surgery and its risks and benefits. We also address patients’ occasional concerns that family members may try to sabotage their weight loss efforts. Candidates who report they are dissatisfied with their marriages (or other intimate relationships) are informed that surgery and weight loss are unlikely to resolve these problems [62]. We also ensure that patients have identified relatives or friends who will assist in their care in the initial days and weeks after the operation.
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Planning for surgery and postoperative care A separate section of the WALI inquires about stressors or major life events expected in the next several months. The purpose of this assessment is to ensure that the candidate has chosen a propitious time to undergo surgery, relatively free of stressors such as starting a new job, changing homes, or getting a divorce. Ideally, the patient should have 3 to 4 weeks of protected time to undergo the operation, recover from it physically, and begin to adopt new lifestyle habits, the most important of which is adhering to the postoperative diet. As noted previously, we always ask candidates to identify family members or friends who will assist them with postoperative needs that may include transportation, caring for children, or assisting with meal preparation and other activities of daily living. We also inquire whether patients have any questions about what to tell their employer, coworkers, or friends about the operation and its effects on their functioning and availability. In cases in which candidates report extremely stressful life events, we discuss whether they might delay surgery until the stressors have resolved (if they seem short term). At a minimum, we discuss how they can cope optimally with the challenges they face. Postoperative care. This part of the interview concludes by reviewing the patients’ plans for postoperative care. We reiterate the importance of regular postoperative visits with the surgeon, dietitian, and other medical staff and strongly encourage all candidates to attend our program’s monthly patient support group meetings. We also ask them to identify their biggest concerns about adhering to the postoperative diet or adjusting to life after surgery (and weight loss). We examine the concerns and identify potential resources for handling them. We always encourage patients to contact us with any difficulties, whether 3 days or 3 years after surgery. Summarizing the findings We conclude the interview by providing patients a brief summary of our findings concerning their weight and dieting histories, eating and activity habits, social/psychological status, and readiness for bariatric surgery. As described elsewhere [45], the summary follows the acronym BEST Treatment, in which B represents biological factors that may contribute to the patient’s obesity (i.e., genetic predisposition), E stands for environmental factors (i.e., eating and activity habits and the effects of the obesegenic environment), S represents social/psychological factors, and T captures the timing of the planned weight loss effort. After discussing these components, we examine which treatment appears to be the best option. In the overwhelming majority of cases, we confirm that bariatric surgery appears to be the best choice for the individual. We also repeat here any recommendations that the individual seek treatment for a mood disorder or other behavioral complications. We
schedule a follow-up visit to reevaluate the patient’s progress. A recent review of 90 candidates we had assessed revealed that 33% were encouraged to seek adjunctive counseling of some kind, whereas 3% were judged to have absolute contraindications to surgery at the time of the evaluation [10]. The remaining 64% of candidates were approved unconditionally for surgery (from a psychosocial standpoint). We inform patients that we will send their surgeon a letter “that describes what we discussed today.” (Appendix A and B provide examples of two typical letters written to surgeons.) We wish patients success with the surgery, whether they pursue it immediately or in a few months, and encourage them to contact us for any needed assistance. 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 invaluable opportunity to discuss their often life-long struggle with their weight and the distress it has caused them. We want to ensure that these individuals, so many of who have been stigmatized because of their weight, receive any psychosocial care they need and the opportunity to make a fully informed decision concerning the surgery they seek. Appendix A August 3, 2005 Dear Dr. Smith: We met today with Ms. Betty Green whom you referred for a behavioral assessment of her appropriateness for bariatric surgery. Ms. Green is a 47 year-old, African-American female. She is 5=7⬙ with a weight of 272.4 lbs. and body mass index (BMI) of 43 kg/m2. She is single and lives with her two daughters. She has been employed with the post office for the past 25 years. Biological factors Ms. Green reported that she has been overweight since early adulthood. She is currently below her highest adult weight of 297 lbs. reached several months ago. She reported losing approximately 25 lbs. since that time secondary to following a low-carbohydrate diet and by reducing her portion sizes. Ms. Green reported her mother is and father was obese. Her two siblings are of average weight. Her medical history and current medications are known to you. Of note, she reported a history of heart disease and hypertension.
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Ms. Green’s family history suggests a significant biological predisposition to obesity. Environmental factors Ms. Green reported eating two to three meals and several snacks each day. She reported eating large portion sizes of calorically dense foods at many of her meals. She often works during the evening and overnight hours, which alters her eating schedule and often increases her reliance on takeout food and fast food. Currently, Ms. Green is on a lowcarbohydrate diet. She denied any behaviors consistent with binge eating disorder. She denied any compensatory or purging behaviors. Ms. Green has made several previous weight loss attempts, including self-directed diets, commercial programs, and FDA-approved weight-loss medications. These approaches have been moderately successful, typically resulting in a 5–10% weight loss. Unfortunately, she has been unable to maintain these losses over long periods of time. She reported no experience with very-low-calorie diets, nutritional counseling, or hospital-based programs. She reported a moderate level of physical activity at present, walking several times each week. In summary, Ms. Green’s reported eating calorically dense foods and large portions sizes, both of which are likely contributors to her obesity. Social/psychological factors Ms. Green denied any psychiatric treatment history. Her Beck Depression Inventory-II score was 7, suggestive of an average number of depressive symptoms. She described her mood as “good” and her affect was appropriate. She denied any symptoms of depression upon questioning. She revealed that her father was an alcoholic but denied any alcohol problems herself. She also revealed a history of physical abuse from past boyfriends. Upon questioning, she denied involvement in a physically abusive relationship at present. She reported no suicidal ideation. No evidence of a thought disorder was found. Timing Ms. Green reported no significant life stressors at this time. This appears to be an excellent time to have surgery. Summary Ms. Green appears to be an appropriate candidate for bariatric surgery. Her BMI is above 40, she has heart disease, hypertension, and she has tried several more conservative weight loss approaches without long-term success. Weight loss following surgery will likely decrease her risk of weight related health problems in the future and improve her quality of life. Please call me if you have any questions regarding this patient.
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Appendix B August 31, 2005 Dear Dr. Jones: I met today with Ms. Alice Smith whom you referred for a behavioral assessment of her appropriateness for bariatric surgery. Ms. Smith is a 54 year-old, Caucasian female. She is 5=1⬙ with a weight of 270 lbs. and body mass index (BMI) of 51 kg/m2. She is married and lives with her husband and three of her four adult children. She has been employed as a telephone operator for the past 24 years. Biological factors Ms. Smith reported that she first recognized being overweight during childhood. She is currently at her highest adult weight of 270 lbs. reached this year. She reported a weight increase of 40 lbs. in the past two years as a result of eating “the wrong foods.” Ms. Smith reported her mother and father were average weight. Her two half-sibling are average weight. Her medical history and current medications are known to you. Of note, she reported a history of hypertension and sleep apnea. In summary, Ms. Smith’s early onset of overweight provides evidence for a moderate biological predisposition to obesity. Environmental factors Ms. Smith reported eating two meals and several snacks each day. She reported that she typically skips breakfast and eats a very large lunch. For example, she will often eat two large fast food hamburgers, a large order of French fries, a large regular soda, and serving of ice cream. She reported eating similarly large portion sizes for dinner. Approximately twice per week, she reported that she will “lose control” during her evening snack and eat a large bag of potato chips while watching television. During these episodes, she reported eating without hunger and past the feeling of fullness. She also reported feelings of dysphoria and guilt. Thus, she appears to meet diagnostic criteria for binge eating disorder. She denied any compensatory or purging behaviors following these episodes. Ms. Smith has made several previous weight loss attempts, including self-directed diets, commercial programs, and over-the-counter as well as FDA-approved weight-loss medications, and behaviorally-based programs. These approaches have been moderately successful, typically resulting in a 5–15% weight loss. Unfortunately, she has been unable to maintain these losses over long periods of time. She reported no experience with very-low-calorie diets or nutritional counseling. She stated that she has not tried to lose weight in the past several years and that she became interested in bariatric surgery after seeing it on television. Ms. Smith reported that she is not physically active at this time secondary to degenerative disc arthritis in her back.
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In summary, Ms. Smith’s binge eating, regular consumption of calorically dense foods and beverages, and lack of physical activity are likely contributors to her obesity. Social/psychological factors For the past 5 years, Ms. Smith has been taking Prozac 40mg/d for depression, as prescribed by her primary care physician. She indicated that she has experienced a number of significant life stressors over the past few years, including issues related to her oldest son’s and her husband’s use of alcohol. Her Beck Depression Inventory-II score was 32, suggestive of a major depressive episode. She described her mood as “irritable” and her affect was flat. She became tearful several times during the assessment. Upon further questioning, she reported difficulty sleeping, decreased appetite, and trouble concentrating. She also reported significant loss of interest in pleasurable activity. She reported no suicidal ideation. No evidence of a thought disorder was found. Timing Ms. Smith reported a number of life stressors at this time. They appear to be impairing her function, as noted above. Summary While Ms. Smith has a BMI above 40, hypertension and sleep apnea, I have concerns about her appropriateness for surgery at this time. First, her symptoms of depression do not appear to be well-controlled at this time. As a result, they may interfere with her ability to make the necessary behavioral and dietary changes to ensure a successful postoperative result. Second, her current diet is quite poor and Ms. Smith reported binge eating several times per week. Third, as compared to our typical surgery candidate, she reported little knowledge of the postoperative behavioral and dietary changes. I made several recommendations to Ms. Smith. First, I referred her to our outpatient psychiatry unit for additional assessment and treatment of her depressive symptoms. Second, I encouraged her to attend the Bariatric Surgery Program’s monthly support group for the next several months. This will provide her with additional information on the postoperative behavioral and dietary requirements. I shared these concerns with Ms. Smith and she reported to be in agreement with them. If she is able to address these concerns in the next 3 months, she will likely be a more appropriate candidate for surgery. We have scheduled a tentative follow-up visit at the end of November to reassess her status. Please call me if you have any questions regarding this patient.
Acknowledgments This work was supported, in part, by Grants K23DK60023, K24-DK65018, and R01-DK069652 from the National Institute of Diabetes, Digestive, and Kidney Disease.
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