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Psychological assessment and surgery

Mental health assessment and weight loss post LSG

Credit:Flickr/Airman 1st Class Devin N. Boyer
Study assesses the role of psychological burden, coping style and motivation to undergo surgery

Researchers from Charité-Universitätsmedizin Berlin, Berlin, Germany, have reported that an ‘active coping’ style could be used to predict more favourable postoperative weight loss outcomes for patients undergoing laparoscopic sleeve gastrectomy (LSG). Nevertheless, they state that biomedical markers or an extensive set of other psychological constructs assessed before surgery resulted in a clinically relevant prediction of the weight-related treatment success of LSG. The study, ‘Determinants of Weight Loss following Laparoscopic Sleeve Gastrectomy: The Role of Psychological Burden, Coping Style, and Motivation to Undergo Surgery’, was published in the Journal of Obesity.

Despite the success bariatric surgery has in achieving weight loss, the authors state that little is known about the factors that promote or hinder weight loss and although an assessment of psychosocial factors prior to surgery has become more widespread there is very little empirical evidence about the impact of psychosocial factors on postoperative weight loss, they report.

For example, preoperative depression and anxiety disorders, mental disorders and depression are all thought to impact the relative success of bariatric surgery. Furthermore, they state that there is some evidence to suggest that “the severity rather than the types of mental disorders appears to be more relevant for weight loss outcomes”, and therefore a greater overall psychological burden is associated with less weight loss after bariatric surgery.

Therefore, the researchers decided to investigate the relationship between postoperative %EWL and preoperative psychological burden (as a broader construct comprising perceived stress, depression, anxiety and mental impairment), coping style, and the motivation to undergo surgery in LSG patients. Primarily, they sought to characterise patients with low, moderate, and high postoperative %EWL retrospectively.

They used between-group comparisons to assess whether LSG patients with different %EWL levels after surgery differed preoperatively in:

  • Psychological burden
  • Coping style
  • Motivation to lose weight

In total 96 patients who planned to undergo bariatric surgery were assessed by an experienced clinical psychologist or physician specialised in psychosomatic medicine, 71% of the patients participated in the follow-up. Only patients who underwent LSG were included in the study, therefore 64 morbidly obese patients (46 women and 18 men) were included in the analysis.


The mean postoperative %EWL was 53% (range: 14–115%). In relation to the observed %EWL distribution in the study, patients were classified into three %EWL groups of nearly equal size based on tertiles: low (n=21, EWL range: 14–39%), moderate (n=22, EWL range: 40–59%), and high (n=21, EWL range: 60–115%). Postoperative %EWL differed significantly between the three %EWL groups (p,0.001). The results showed no significant group difference in the follow-up time interval (p>0.05).

Within all three %EWL groups, the patients’ mean weight, excess weight, and BMI decreased significantly after surgery (p<0.001). Significant preoperative group differences between patients of moderate and high %EWL were detected: patients with high %EWL had a lower preoperative weight (p=0.018), excess weight (p=0.012), and BMI (p=0.015). Preoperative weight and BMI differences between the low-%EWL and moderate-%EWL groups and between the low-%EWL and high-%EWL groups did not reach statistical significance (p>0.05). In the high-%EWL group, 38% (n=8) of the patients attained a postoperative non-obese BMI<30. There were no significant differences in age, sex, partnership, or employment status before surgery (p>0.005).

With regard to physical comorbidities, all three %EWL groups had high rates of pre-surgically diagnosed metabolic syndrome symptoms; approximately half of the patients in each group suffered from type 2 diabetes mellitus. No group differences in diabetes prevalence were found (p>0.05). With regard to mental comorbidities, the groups with low and high %EWL presented with particularly high rates of pre-surgically diagnosed mental disorders (i.e., depression); however, the results showed no statistically significant group differences in the prevalence of mental disorders (p>0.05).

All three %EWL groups presented with high rates of disordered eating behaviours such as hyperphagia. The results showed a statistically significant group difference in the use of psychotherapy: slightly more patients in the low-%EWL group underwent psychotherapeutic treatment before LSG surgery compared with those in the moderate-%EWL group (p=0.013). For the high-%EWL group, no statistically significant difference in the use of psychotherapy could be identified (p>0.05).

The low-%EWL and moderate-%EWL groups did not differ (p>0.05) and the positive relationship between preoperative ‘active coping’ and postoperative %EWL was confirmed (Figure 1) by a statistically significant correlation analysis (p=0.004).

Figure 1: Preoperative coping style according to postoperative %EWL groups. Brief COPE scores before LSG for the groups with low, moderate, and high postoperative %EWL. Bars represent the standard deviation. The asterisk indicates statistically significant group differences between the high-%EWL and low-%EWL groups and the high-%EWL and moderate-%EWL groups

With regards to ‘active coping’, they note that it might be predictive of higher postoperative weight loss outcomes, although these results provided “no clear evidence of a clinically important role of pre-operative mental health and the motivation to lose weight in the weight-related treatment success of LSG.”

“Our results demonstrate the difficulty of preoperatively identifying patients who are at risk for more unfavourable postoperative weight-related outcomes,” they write. “However, our results might also indicate that more active coping behaviour is a marker of higher postoperative weight loss. This behaviour may in turn contribute to patients developing a more informed and educated perspective on the possibilities and limitations of LSG surgery and the necessary lifestyle modifications (e.g., following dietary advice and physical activity recommendations) to achieve higher and sustained weight loss after surgery.”

However, they add that as bariatric surgery leads to a profound change in patients’ gastrointestinal and whole-body physiology, it is important to also consider potential physiological mechanisms, and such considerations might be complex, and psychological and physiological factors might actually combine and interact in influencing outcomes.

“Our study highlights the need for further research on the psychological correlates of post-bariatric health outcomes,” the authors conclude. “Nevertheless, despite our finding of a considerably large degree of variation in postoperative weight loss in our sample of LSG patients, all three %EWL groups showed significant weight loss and decreases in body weight and BMI, including the low-%EWL group. Therefore, the bariatric intervention proved to be highly beneficial for the vast majority of patients, thus promoting positive health outcomes.”

To access this paper, please click here

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