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Bariatric surgery and alcohol

Bariatric surgery patients at high-risk of alcohol problems

The ASMBS currently recommends that patients be screened for alcohol use disorder before surgery and be made aware of the risk of developing the disorder after surgery
Overall, 3.5 percent of RYGB patients reported getting substance use disorder treatment, far less than the 21 percent of patients reporting alcohol problems

One in five patients who undergo Roux-en-Y gastric bypass (RYGB) is likely to develop problems with alcohol, with symptoms sometimes not appearing until years after their surgery, according to one of the largest, longest-running studies of adults who underwent bariatric surgery.  The findings were reported in a paper, ‘Alcohol and other substance use after bariatric surgery: prospective evidence from a U.S. multicenter cohort study’, in Surgery for Obesity and Related Diseases, the journal of the American Society for Metabolic and Bariatric Surgery. The authors said their findings indicate that bariatric surgery patients should receive long-term clinical follow-up to monitor for and treat alcohol use disorder, which includes alcohol abuse and dependence.

Wendy C King

"We knew there was an increase in the number of people experiencing problems with alcohol within the first two years of surgery, but we didn't expect the number of affected patients to continue to grow throughout seven years of follow-up," said lead author, Dr Wendy C King, associate professor of epidemiology at the University of Pittsburgh Graduate School of Public Health.

The American Society for Metabolic and Bariatric Surgery currently recommends that patients be screened for alcohol use disorder before surgery and be made aware of the risk of developing the disorder after surgery. Additionally, the society recommends that high-risk groups be advised to eliminate alcohol consumption following RYGB. However, given the data, King suggests that those who undergo RYGB are a high-risk group, due to the surgery alone.

Starting in 2006, King and her colleagues followed more than 2,000 patients participating in the National Institutes of Health-funded Longitudinal Assessment of Bariatric Surgery-2 (LABS-2), a prospective observational study of patients undergoing weight-loss surgery at one of ten hospitals across the US.

A total of 1,481 patients underwent a RYGB, with 522 patients receiving a laparoscopic adjustable gastric banding.

Both groups of patients increased their alcohol consumption over the seven years of the study; however, there was only an increase in the prevalence of alcohol use disorder symptoms, as measured by the Alcohol Use Disorders Identification Test, following RYGB. Among patients without alcohol problems in the year prior to surgery, RYGB patients had more than double the risk of developing alcohol problems over seven years compared to those who had gastric banding.

"Because alcohol problems may not appear for several years, it is important that doctors routinely ask patients with a history of bariatric surgery about their alcohol consumption and whether they are experiencing symptoms of alcohol use disorder, and are prepared to refer them to treatment," said King.

The LABS-2 study was not designed to determine the reason for the difference in risk of alcohol use disorder between surgical procedures, but previous studies indicate that, compared with banding, RYGB is associated with higher and quicker elevation of alcohol in the blood. Additionally, some animal studies suggest that RYGB may increases alcohol reward sensitivity via changes in genetic expression and the hormone system affecting the areas of the brain associated with reward.

In addition to RYGB, the LABS-2 study identified several personal characteristics that put patients at increased risk for developing problems with alcohol, including being male and younger, and having less of a social support system. Getting divorced, a worsening in mental health post-surgery and increasing alcohol consumption to at least twice a week also were associated with a higher risk of alcohol use disorder symptoms.

King and her team found that although RYGB patients were nearly four times as likely to report having received substance use disorder treatment compared with banding patients, relatively few study participants reported such treatment.

The year-five cumulative incidence of post-RYGB onset alcohol use disorder (AUD) symptoms were 20.8% (95% CI: 18.5–23.3), illicit drug use 7.5% (95% CI: 6.1–9.1) and substance use disorders (SUD) treatment 3.5% (95% CI: 2.6–4.8). For post-LAGB patients, AUD rates were 11.3% (95% CI: 8.5–14.9), illicit drug use 4.9% (95% CI: 3.1–7.6) and SUD 0.9% (95% CI: .4–2.5). Therefore, undergoing RYGB versus LAGB was associated with higher risk of incident AUD symptoms (adjusted hazard ratio or AHR = 2.08 [95% CI: 1.51–2.85]), illicit drug use (AHR = 1.76 [95% CI: 1.07–2.90]) and SUD treatment (AHR = 3.56 [95% CI: 1.26–10.07]).

Overall, 3.5 percent of RYGB patients reported getting substance use disorder treatment, far less than the 21 percent of patients reporting alcohol problems.

"This indicates that treatment programs are underutilized by bariatric surgery patients with alcohol problems," said King. "That's particularly troubling given the availability of effective treatments."

The authors conclude that one-fifth of participants reported incident AUD symptoms within five years post-RYGB. Patient education, screening, evaluation and treatment referral should be incorporated in pre- and postoperative care for AUD.

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