Mental health, loss of control eating, and cognitive functioning in adolescents undergoing bariatric surgery

Mental health, loss of control eating, and cognitive functioning in adolescents undergoing bariatric surgery

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Mental health, loss of control eating, and cognitive functioning in adolescents undergoing bariatric surgery Sheethal D. Reddy PhD , Robyn Sysko PhD , Eleanor Race Mackey PhD PII: DOI: Reference:

S1055-8586(20)30012-3 https://doi.org/10.1016/j.sempedsurg.2020.150892 YSPSU 150892

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Seminars in Pediatric Surgery

Please cite this article as: Sheethal D. Reddy PhD , Robyn Sysko PhD , Eleanor Race Mackey PhD , Mental health, loss of control eating, and cognitive functioning in adolescents undergoing bariatric surgery, Seminars in Pediatric Surgery (2020), doi: https://doi.org/10.1016/j.sempedsurg.2020.150892

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MENTAL HEALTH EATING PATHOLOGY IN BARIATRIC SURGERY

Mental health, loss of control eating, and cognitive functioning in adolescents undergoing bariatric surgery Sheethal D. Reddy, PhD Emory University School of Medicine Robyn Sysko, PhD Icahn School of Medicine at Mount Sinai Eleanor Race Mackey, PhD Children’s National Health System

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Abstract Bariatric surgery is an effective treatment for severe obesity in adolescence. Nevertheless, much remains to be understood regarding the impact of surgery on mental health, eating behaviors, and cognition. We review the findings related to mental health both before and after surgery as well as long-term changes in psychopathology, including suicide risk. Overall, adolescents with and without a history of psychopathology lose weight at similar rates. At the same time, there is an increased risk for suicide that requires further study. Regarding alcohol and substance use, this population reports lower rates of consumption than age related non-obese cohorts. Nevertheless the impact of altered anatomy and metabolism on alcohol ingestion in a population at risk for substance use is concerning. Eating behaviors, specifically loss of control eating, are discussed. Finally, we include discussion of the cognitive changes occurring perioperatively and considerations for adolescents with cognitive impairments. Clinical recommendations and suggestions for future research are discussed.

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Mental health, loss of control eating, and cognitive functioning in adolescents undergoing bariatric surgery

In the last several years, research on adolescent bariatric surgery has yielded a trove of information regarding preoperative preparation and considerations, the various bariatric procedures, and post-operative medical and psychosocial outcomes.1-5 A search of the literature for “bariatric surgery” and “adolescents” since 2014 produced 772 search results. For these reasons, a synopsis of recent findings is necessary to draw a cohesive picture of mental health considerations and outcomes of adolescent bariatric surgery. The following sections summarize the most recent information in 4 key areas: 1) affective disorders including suicide risk, 2) substance use, 3) eating pathology including loss of control eating behaviors and 4) considerations and outcomes of bariatric surgery for adolescents with cognitive impairment/developmental delays. Mental Health and Suicide Risk Affective Disorders. Affective disorders, including major depressive disorder, anxiety disorders and bipolar disorder, are estimated to affect between one third and half of adolescents seeking bariatric surgery. 6-8 Adolescents with obesity are more likely to have a mental health diagnosis and report a higher incidence of bullying and victimization compared to normal weight teens.9 Surgical weight loss outcomes appear to unaffected by the presence of psychiatric disorders, provided that they are being effectively managed.6,10 While there is improvement in depressive symptoms shortly after surgery, these gains tend to dissipate over time.7 In a review of the literature, Herget and colleagues (2014) found a reported range of 15% - 66% of adolescents

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seeking surgery to be diagnosed with a depressive disorder, with more than half described as moderate to severe depressive symptoms. Notably, patients reporting depressive and anxiety symptoms frequently present with comorbid eating pathology. 6,7 Postoperative adherence may be impacted by psychopathology, although this relationship has not been thoroughly examined. Litz et al. (2018), in a state-wide cost analysis of readmission rates following adult bariatric surgery, found that individuals with a psychiatric disorder represented a disproportionate number of those readmitted within 30 days (34% of readmissions, 6.5% of all bariatric patients were readmitted). Nevertheless, among adolescents in one study, those with a diagnosis of depression did not require any additional perioperative pain management compared to their nondepressed counterparts.11 There is an absence of literature on bipolar disorder and how this condition may impact bariatric surgery outcomes in adolescents. Hence, the information that follows is based on data from adult samples. Pharmacological treatment of bipolar disorder often results in unintentional weight gain. Nevertheless, rates of surgery among individuals with bipolar disorder tend to be lower, with higher denial rates, compared to those with diagnoses of major depressive disorder or anxiety disorders.12, 13 For those who do undergo surgery, short-term weight loss outcomes appear to be similar to the general bariatric population.14 Attrition from surgical programs two or more years postoperatively appears to be higher among this group.12 In summary, the reasons for higher denial rates and attrition have yet to be thoroughly examined. This is an area that warrants further attention given the challenges of maintaining a healthy weight while treating bipolar disorder.

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Suicide Risk. Surgical weight loss outcomes appear to be similar for those with and without a history of suicidal ideation or behaviors, however there is an increased risk for suicide among those who undergo bariatric surgery. 15 Among 15-19 year olds, suicide is the second leading cause of death in the United States.16 Risk for suicide among teens seeking bariatric surgery may be higher given their reporting of bullying, weight discrimination/stigmatization and greater likelihood of affective disorders.9 In summary, the presence of a psychiatric disorder is not a contraindication for surgery nor in the data reported to date is it a predictor of postoperative weight loss. At the same time, the lack of resolution of psychiatric symptoms and the increased risk for suicide warrant closer follow-up for patients who may be at high risk, especially those with a past history of affective disorders and suicidal ideation or behaviors. Alcohol and Substance Use Experimentation with alcohol and illicit substances is common at this developmental stage, with almost half of high school students reporting having tried an illicit substance at least once by 12th grade and nearly 1 in 5 teens ages 12-20 having consumed alcohol within the last month. Binge drinking – having 4 or more drinks on one occasion for female (5 drinks for males) – is the most common method of alcohol consumption at this age.17 Adolescents seeking surgery tend to report lower rates of substance and alcohol use than the general adolescent population.3 It is likely that these rates are partially artificially suppressed due to impression management associated with the presurgical psychological evaluation. However, long-term follow-up of these individuals suggests that they continue to have lower rates of consumption as they transition into adulthood.

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While these findings are positive, altered metabolism associated with bariatric procedures results in a rapid and heightened peak blood alcohol concentration (BAC). A 2018 study found breathalyzer results underestimated BAC by 27% among individuals post vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB), well above the typical standard deviation of 13%, while peak BACs were missed entirely. 18 We recommend counseling adolescents both before and after weight loss surgery on their increased sensitivity to alcohol and risks associated with consumption. Eating Disorders and Loss of Control Eating Notable rates of eating pathology and eating disorders have been observed among adults19 and adolescents20 presenting for bariatric surgery, but prevalence estimates for binge eating, or eating a large amount of food and experiencing a sense of loss of control (objective binge episode; OBE) are wide 2%-64%.21 Binge eating disorder (BED), the eating disorder characterized by the regular experience of these episodes over a three month period with other markers (e.g., eating rapidly, eating when not hungry, eating until uncomfortably full, distress about the episodes, a lack of compensatory markers) has been identified as the second most common psychiatric diagnosis after depression in bariatric samples (17%)22. Understanding the binge eating symptoms that continue, return, or initiate post-surgery therefore appears particularly important for the clinical management of adolescents. Regardless of age, anatomical changes make the consumption of large amounts of food difficult or impossible following VSG and RYGB procedures. Thus, the presence of BED or OBEs are reduced in the months following surgery by virtue of the procedures themselves. However, soon after surgery it is still possible to feel a sense of

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loss of control over eating episodes, as the perception of a lack of control can occur regardless of the amount of food consumed. In adults, loss of control over eating was identified as a risk factor for more limited long-term weight loss and increased weight regain using prospective data over 7 years from the LABS cohort. 19 Further, although rare soon after surgery, eating large amounts of food can recur over time.23 24 There are no published studies focused on the frequency of eating disorder diagnoses among adolescents post-surgery. It is possible this gap in the literature relates to the limited number of self-report measures that can formally assign a BED diagnosis as most studies of post-operative symptoms use questionnaire data, or the low rates of a full threshold BED in adolescents in the years following a bariatric procedure. However, several studies offer information about loss of control or binge eating behaviors. The Teen-LABS study evaluated eating behavior among adolescents, with rates of binge eating episodes observed to decrease significantly from baseline over the four years of follow-up, with some increase between 6 months and 4 years post-surgery.5 Loss of control over eating appears significant with younger individuals, as a prospective relationship between adolescents reporting loss of control eating at the 1, 2, or 3 year follow-up and subsequent weight regain was also reported. Significant reductions in more broadly defined eating disordered symptoms were also noted 6 and 12 months after adolescents received bariatric surgery in a subset of this Teen-LABS cohort.25 In a sample of Swedish adolescents,20 substantial reductions in self-reported binge eating, uncontrolled eating, and emotional eating were found in the two years after gastric bypass, which parallels the pattern of other psychopathological symptoms and studies in adults.19, 25 Järvholm and colleagues (2018) also observed the onset of

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new cases of self-reported binge eating after surgery, which was not described in the publications from Teen-LABS. The extant studies suggest similarities to data from the adult literature, but a number of outstanding questions about eating behavior remain for adolescents. Are the self-report measures used with younger populations developmentally appropriate? Do the low rates of binge eating after surgery stem from a response bias? Should researchers assess other potential problematic eating behaviors more consistently (e.g., loss of control eating with smaller amounts of food)? These unresolved issues will best be addressed by additional research on a range of feeding behaviors with larger samples of adolescents. Executive and Cognitive Function A robust literature links poor executive and cognitive function with severe obesity, both in terms of increasing risk for obesity as well as suffering as a result of obesity. 26-30 The role that executive and cognitive function play in weight loss and maintenance following surgery, as well as changes to these functions as a result of weight loss are currently being studied, with a growing body of literature that examines these associations. Executive Function. Studies examining rates of attention deficit hyperactivity disorder (ADHD) and attention deficit disorder (ADD) in surgical populations find around 21% of adolescents qualify for a diagnosis.6 This is in contrast to approximately 10% of the general child population.31 With regard to surgical preparation, disorganization, concentration difficulties, and impulsivity associated with ADD/ADHD may affect adherence.32 For example, one recent study found that poorer working memory, as

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measured by computerized assessment prior to surgery, was associated with less weight loss at 6 months following surgery.33 These results are consistent with findings among adults pursuing surgery.34, 35 With regards specifically to a diagnosis of ADHD, however, it appears that a diagnosis of ADHD is not associated with weight loss outcomes following surgery,6 which is also consistent with findings in adults.36 Existing evidence thus suggests that aspects of executive functioning, with working memory appearing to be particularly important, may be especially relevant to post-surgical weight loss, but a general diagnosis of ADHD is not. There is also evidence that significant weight loss following surgery is associated with improvements in cognitive function. Recent studies replicate findings in adults that cognition, which includes both executive function and memory, improves following surgery37-39 and have demonstrated evidence of similar improvements in adolescents. Specifically, one study using fMRI, found that although task performance on executive function and memory tasks was similar across adolescents with severe obesity and healthy weight, there was increased neural activation in those with obesity, suggesting that their brains had to work harder to achieve the same level of task performance. However, those with severe obesity who had surgery demonstrated a normalization of neural functioning 3 months after surgery.40 This small study requires replication in a larger sample and a closer examination of mechanisms, but demonstrates that weight loss following surgery may ameliorate some of the negative impact that obesity has on the brain and cognitive function. Cognitive Impairment and Developmental Disability. Youth with cognitive impairment or developmental disability are at particular risk for the development of severe obesity, and

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are in fact two to four times more likely to have severe obesity than their typically developing peers.41-43 These higher rates of obesity are associated with greater comorbidities for weight-related complications,44 making the successful treatment of their obesity a high priority. As with typically developing youth, bariatric surgery is an essential treatment option for severe obesity in youth with cognitive impairment and developmental disability. Indeed, recent existing research has examined weight loss following surgery in this population, allowing for a better understanding of the effectiveness of surgery for youth with cognitive impairment or developmental delay. For example, a recent review of bariatric surgery literature regarding all individuals with cognitive impairment and developmental disability included studies conducted on adolescents, which showed evidence of significant weight loss following surgery.45 Only two larger-scale studies exist which compared weight loss trajectories of adolescents and young adults diagnosed with cognitive impairment or developmental delay with typically developing peers. These studies found no differences in weight loss outcomes between the two groups, and even noted a trend towards better weight loss in the group with cognitive impairment than typically developing peers.46 These studies indicate that bariatric surgery is an effective treatment for severe obesity in youth with cognitive impairment and developmental delay. Despite the effectiveness of surgery in youth with disabilities, it is important to note that there are additional considerations to be made when evaluating whether bariatric surgery is an option for youth with cognitive impairment or developmental delay.47 For example, medical teams must assess the child’s ability to provide assent or a guardian to provide consent, social and structural support available to the individual,

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clear articulation of risks and benefits of the surgery, and considerations for any additional support (e.g., inpatient stay) to ensure adherence to pre- and post-operative requirements. Medical teams must also provide information about the surgery in developmentally appropriate ways. Additionally, as with any other adolescent pursuing surgery, careful attention must be paid to the mental health and psychosocial situation of the adolescent and family in order to refer for treatment any comorbid psychological concerns. In summary, the extant literature supports use of bariatric surgery as an effective tool for weight loss among adolescents with psychopathology and/or cognitive impairments. The amount of weight lost, postoperative complications, and potential for weight regain are similar, with caveats, to outcomes among teens without psychopathology or impairment. Nevertheless, clinical management of adolescents patients with a positive history for either would do well to include more tailored education and psychological interventions both pre- and postoperatively to maximize gains and minimize complications. Given the delayed but increased risk for suicide after surgery for some patients, we recommend closer follow-up for high risk patients that have had a history of moderate to severe depression and/or past history of suicidal behaviors. Despite the proliferation of research in this area, there remain gaps in the literature regarding anxiety disorders and bipolar disorder that require further investigation. A better understanding of the presentation of binge eating disorder following surgery is necessary as well. Finally, while the relationship between cognitive functioning and obesity, has been acknowledged, the mechanisms of these connections

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are not well understood. Given that only 1% of teenagers who qualify for bariatric surgery go on to receive the procedure, these lines of research may help clinicians reach more adolescents who would benefit from bariatric surgery.

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