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Psychological factors

Psychological factors impact on post-surgical weight loss

The pre-operative level of anxiety, depression and impulsivity and their effect on weight loss following surgery are not fully understood
There is limited evidence as to the efficacy of surgery on depression

Depression is common among individuals selected to undergo bariatric surgery and psychological assessment can be valuable in recognising patients who may not benefit optimally from bariatric surgery, according to two papers presented at the 6th Annual Meeting of the British Obesity and Metabolic Surgical Society 21-23 January, in Newcastle, UK.

Ahmed Salman Bodla from the University Hospital of Coventry and Warwickshire, Coventry, UK, said that although bariatric surgery is an effective treatment for morbid obesity its success can be affected by many factors. Psychological factors can play a significant role in this regard and patients who are obese have an increased risk of anxiety and depression which in turn, may reinforce unhealthy eating behaviours.

Ahmed Salman Bodla

As the pre-operative level of anxiety, depression and impulsivity and their effect on weight loss following surgery are not fully understood, the researchers assessed the effect of pre-operative psychological factors on weight loss post-surgery.

Between 2009 and 2014, 610 patients from a single centre underwent comprehensive pre-op psychological assessment using validated Hospital Anxiety and Depression (HADS) and Impulsivity scales along with information about their eating behaviours (EB). Pre- and post-op weight loss data were obtained at various time points and compared against psychological scores.

Anxiety and depression often co-existed in morbidly obese patients and led to more impulsive behaviour. High HADS and Impulsivity scores promoted uncontrolled and emotional eating (p<0.0001) but pre-op BMI was not significantly affected by these (p=0.06–0.35). However, scoring high on Impulsivity or having an uncontrolled or emotional EB had a strong negative correlation with post-op weight loss (p=0.01) in gastric sleeve and bypass patients.

Weight loss was quite variable in gastric band patients and did not correlate with any of the psychological parameters. On the other hand, a favourable diet-controlled pre-op weight loss (using 800-1000Kcal/d diet) was a strong indicator of success of all bariatric procedures including gastric bands, highlighting the importance of individual metabolic variations.

“We show that pre-op impulsivity and emotional/uncontrolled eating behaviours are strong indicators of poor outcomes of bariatric surgery, even in restrictive and malabsorptive procedures,” concluded Bodla. “Therefore, a thorough psychological assessment is valuable in recognising patients who may not benefit optimally from bariatric surgery. Combining this with appropriate psychological interventions may promote better outcomes and quality of life which is an area of further investigation.”          

Co-authors of this study were Victoria Gibbs, Jenny Abraham, David Kendrick and Vinod Menon.

Depression

Mr Omar Khan from the Whittington Hospital, Department of Surgery, London, UK, said that there is limited evidence as to the efficacy of surgery on depression and subsequently the research team decided to evaluate the impact of bariatric surgery on the long-term incidence of clinical depression using data from a large-scale prospectively collated primary care database.

An interrupted time series design, with matched controls, was conducted from three years before, to a maximum of seven years after surgery. Obese adults who received bariatric surgery from 2002 to 2014 were sampled from the UK Clinical Practice Research Datalink. Controls were matched for BMI, age, gender and year of procedure. Clinical depression was evaluated from medical diagnoses and antidepressant prescriptions in primary care electronic health records. Analyses were adjusted for comorbidity and co-prescribing.

Omar Khan

There were 3,045 participants who received surgery, including laparoscopic gastric banding in 1,297 (43%), gastric bypass in 1,265 (42%), sleeve gastrectomy in 477 (16%) and six undefined. The mean age was 45.9 years and mean BMI 44.0. In the year before surgery, 36% of BS patients, and 21% of controls, had clinical depression, (p<0.001).

Following bariatric surgery, the proportion with clinical depression declined to 32% in the second post-operative year (p<0.001). By the seventh post-operative year, the prevalence of clinical depression increased to 37% (p=0.959).

“Depression is common among individuals selected to undergo bariatric surgery,” said Khan. “Bariatric surgery may be associated with a modest reduction in clinical depression over the first two to three postoperative years but this is not maintained.”

Co-authors of this study were Helen Booth1, Marcus Reddy4, Toby Prevost1, Martin Gulliford1 (1King’s College London, Department of Primary Care and Public Health Sciences, London, UK, 2NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust, London, UK, 4St George’s Hospital, Department of Surgery, London, UK).

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