Eat Weight Disord (2014) 19:217–224 DOI 10.1007/s40519-014-0123-6
ORIGINAL ARTICLE
Psychological effects and outcome predictors of three bariatric surgery interventions: a 1-year follow-up study Giovanni Castellini • Lucia Godini • Silvia Gorini Amedei • Carlo Faravelli Marcello Lucchese • Valdo Ricca
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Received: 21 December 2013 / Accepted: 1 April 2014 / Published online: 16 April 2014 Ó Springer International Publishing Switzerland 2014
Abstract Purpose Weight loss surgery efficacy has been demonstrated for morbid obesity. Different outcomes have been hypothesized, according to specific bariatric surgery interventions and psychological characteristics of obese patients. The present study compared three different surgery procedures, namely laparoscopic adjustable gastric band (LAGB), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD), in terms of weight loss efficacy and psychological outcomes. Methods Eighty-three subjects seeking bariatric surgery have been evaluated before and 12 months after surgery intervention, by means of a clinical interview and different self-reported questionnaires, including Eating Disorder Examination Questionnaire, Emotional Eating Scale, Binge Eating Scale, Beck Depression Inventory, Symptom Checklist and State-Trait Anxiety Inventory.
G. Castellini L. Godini S. G. Amedei V. Ricca Psychiatric Unit, Department of Neuropsychiatric Sciences, Florence University School of Medicine, Viale Morgagni 85, 50134 Florence, Italy L. Godini S. G. Amedei M. Lucchese Bariatric Surgery Unit, Careggi Hospital, Viale Morgagni 85, 50134 Florence, Italy C. Faravelli Department of Psychology, University of Florence, Via di San Salvi 12, Complesso di San Salvi, Padiglione 26, 50135 Florence, Italy V. Ricca (&) Psychiatric Unit, Department of Neuropsychiatric Sciences, Florence University School of Medicine, Largo Brambilla 3, 50134 Florence, Italy e-mail: [email protected]
Results BPD group (26 subjects) showed the greatest weight loss, followed by RYGB (30 subjects), and LAGB group (27 subjects). All the treatments were associated with a significant improvement of anxiety, depression, and general psychopathology, and a similar pattern of reduction of binge eating symptomatology. BPD group reported a greater reduction of eating disorder psychopathology, compared to the other groups. Pre-treatment emotional eating severity was found to be a significant outcome modifier for the three treatment interventions. Conclusions These results suggest that all the three types of bariatric surgery significantly improved psychopathology and eating disordered behaviors. They also support the importance of a pre-treatment careful psychological assessment in order to supervise the post-surgical outcome. Keywords Bariatric surgery Eating psychopathology General psychopathology Morbid obesity Weight loss
Introduction Morbid obesity is a severe medical condition characterized by a poor outcome for dietary, pharmacological or psychotherapeutic treatments [1]. Over the past 10 years different studies have supported a good efficacy of weight loss surgery, as gastroplasty, gastric bypass or biliopancreatic diversion seems to have an important impact on weight loss outcome with high percentages of excess weight loss [2]. Furthermore, the efficacy of bariatric surgery has been demonstrated also in the improvement of frequent obesity comorbidities such as diabetes, hyperlipidemia, hypertension and obstructive sleep apnea, which were improved or completely resolved after surgery in most of the patients [3].
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Obese subjects referring to bariatric surgery facilities show high rates of current and lifetime Axis I mental disorders [4], in particular affective, anxiety and binge eating disorders [5]. Several evidences suggest that weight loss surgery is associated with an improvement in psychological condition; however, high psychiatric comorbidity seems to last after the surgery interventions [5]. Furthermore, psychiatric comorbidities have been proposed as significant outcome modifiers of bariatric surgery [5, 6]. In particular, considering eating disorders symptoms, preoperative binge eating behavior seems to be associated with more eating-related and general psychopathology and low weight loss after surgery, whereas post-operative binge eating behavior significantly predicts poorer post-surgical weight loss and psychosocial outcomes [7]. Therefore, patients reporting loss of control over eating, above all after surgery, have been identified as a distinctive subgroup with a less favorable outcome, including weight regain [8]. To date, few studies have compared the clinical and psychopathological outcomes of different types of bariatric surgery interventions [5], and in most of the cases the comparison included only patients treated with the vertical banded gastroplasty or gastric bypass [8, 9]. Moreover, some studies were conducted on relatively small samples [10], with high drop-out rates at the post-operative assessment points [9, 10], and without an adequate eating psychopathology assessment at different time points [1]. The aim of the present study was to compare different surgical interventions, in terms of weight loss, psychopathological outcomes, and outcome predictors. In particular, we evaluated the effect of restrictive [laparoscopic adjustable gastric banding (LAGB)], malabsorptive [biliopancreatic diversion (BPD)], restrictive and malabsorptive [Roux-en-Y gastric bypass (RYGB)] bariatric surgery procedures.
Materials and methods Participants The present study was designed as a follow-up survey, and was performed by the Psychiatric Unit of the University of Florence (Italy) and the Bariatric Surgery Unit. All the diagnostic procedures and the psychometric tests were part of the routine clinical assessment for obese patients performed at our clinics. Before the collection of data, during the first routine visit, the procedures of the study were fully explained; after that, the patients were asked to provide their written informed consent to the participation in the present study. The protocol was approved by the Ethics Committee of the Institution.
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The patients were recruited among a consecutive series of overweight and obese subjects referring for the first time to the Obesity Surgery Clinic of the University of Florence (Italy) and candidates for bariatric surgery. Patients were enrolled from September 2010 to December 2011. The inclusion criteria were age between 18 and 65 years, body mass index (BMI) [40 kg/m2 or BMI [35 kg/m2 with severe obesity-related disease, over 5 years of obesity and failure in previous weight reduction therapies, absence of previous bariatric intervention, and the patient’s complete understanding of the surgical procedure and its risks. The exclusion criteria were illiteracy, mental retardation, high surgical risk, current comorbid severe mental disorders, such as bulimia nervosa and vomiting behaviors, schizophrenia, bipolar disorder, severe major depression, suicide ideation and psychoactive substance dependence, assessed by means of the structured clinical interview for diagnostic and statistical manual of mental disorders (DSM-IV) [11]. Design of the study Psychopathological, behavioral and sociodemographic data were collected through a face-to-face interview on the first day of admission (baseline T0; 21.2 ± 14.8 week before surgery), and 1 year after the surgery treatment (T1) by two expert psychiatrists who were unaware of the kind of surgical procedure (LG, SGA) and had not therapeutic relationship with any of the participants they assessed. During the visits, BMI was calculated and the psychopathological evaluation was performed. Furthermore, during the first visit, the patients were evaluated by a dietitian and a surgeon. As already reported in a previous study by our group [12], patients choose by their own initiative to address to the Bariatric Surgery Unit of Florence. Patients were assessed at their first contact with the clinic, before the evaluation of the inclusion/exclusion criteria for starting a surgical or medical intervention. The bariatric surgical procedure is determined after completing all the assessments, composed by a psychiatric visit (a clinical interview and specific psychopathological questionnaires), a dietitian visit and a surgical visit. If the patient was evaluated as eligible to the surgery, he/she received detailed information about the treatment. At T1, the patients were evaluated by the same psychiatrists during a specialist control visit, and those subjects who were not attending the clinic for control visits were contacted by telephone and invited to the clinic for a follow-up visit. The three bariatric surgery procedures (LAGB, BPD, RYGB) took place in exclusion.
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Assessment Anthropometric measurements were made using standard calibrated instruments. Height (m) was measured using a wall-mounted stadiometer and weight (kg) using electronic scales with an upper weight limit of 300 kg. BMI was calculated as weight in kilograms divided by the square of height in meters. Diagnosis of obesity (BMI [30 kg/m2) was performed according to a single clinical criterion suggested by recent clinical guidelines developed by the National Heart, Lung and Blood Institute [13]. The results of bariatric surgery on body weight were evaluated through the use of the percentage of the excess BMI loss (%EBMIL = 100 9 [(initial BMI - final BMI)/ (initial BMI-25)] [14]. In order to assess the current and lifetime prevalence of mental disorders, patients were interviewed by two expert clinicians (LG, SGA) by means of the structured clinical interview for DSM-IV [11]. Current eating attitudes and behaviors were specifically investigated by means of the Eating Disorder Examination Questionnaire (EDE-Q). The self-reported EDE-Q consists of 38 items, assessing the core psychopathological features of eating disorders, and contains four subscales: dietary restraint, eating concern, weight concern, and shape concern. The dietary restraint subscale is an admixture of cognitions and behaviors pertaining to dietary restriction. The three other subscales evaluate the dysfunctional attitudes regarding eating and overvalued thoughts regarding weight and shape. The global score represents the mean of the four subscale scores [15]. The EDE-Q has been reported to show a good validity also in bariatric surgery candidates [16]. In order to investigate the severity of binge eating, the Binge Eating Scale (BES) was applied [17]. The BES has been proposed as a rapid screening instrument for BED in obese patients, and it examines both behavioral signs (eating large amounts of food) and feeling or cognition during a binge episode (loss of control, guilt, fear of being unable to stop eating) through 16 items. The BES was already used in bariatric surgery populations showing good psychometric properties [18, 19]. Emotional eating was assessed by means of the Emotional Eating Scale (EES) [20], a 25-item self-report questionnaire that indicates the extent to which specific feelings lead a subject to feel an urge to eat. Each item consists of an emotion term (e.g., jittery, angry, helpless), and the 5-point scale used was anchored on ‘‘no desire to eat’’ and ‘‘an overwhelming urge to eat,’’ with ‘‘a small desire to eat,’’ ‘‘a moderate desire to eat,’’ and ‘‘a strong desire to eat’’. The 25 items form 3 subscales, reflecting eating in response to anger (anger/frustration), anxiety
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(anxiety), and depressed mood (depression). For a further characterization of the psychopathological features of the patients, the Beck Depression Inventory (BDI) [21], Symptom Checklist (SCL-90-R) [22] and State-Trait Anxiety Inventory (STAI) [23] were also applied. Treatment At Bariatric and Metabolic Surgery Unit of University of Florence (Italy), three main surgical options are performed: LAGB as ‘‘restrictive’’ procedure, BPD as ‘‘malabsorptive’’ procedure, and RYGB as ‘‘restrictive and malabsorptive’’ procedure. LAGB is one of the most important types of bariatric restrictive procedures. LAGB is a restrictive procedure and consists on the limitation of the luminal diameter of the stomach, without the exclusion of some segments of the gastrointestinal tract. This procedure involves a foreign material (the ‘‘band’’) that is an adjustable plastic and silicone ring, placed around the proximal stomach just beneath the gastroesophageal junction. An access present in the subcutaneous area links to the band and it allows to adjust the constriction level by the injection or withdrawal of saline [24]. The BPD is a primarily malabsorptive procedure with some restrictions. It consists of a partial gastrectomy where a 200–500 mL proximal gastric pouch, a distal Roux and proximal biliary limb are created by division of the small bowel 250 cm proximal to the terminal ileum. The gastric pouch is attached to the end of the Roux limb, and the biliary limb is connected 50 cm proximal to the ileocecal valve, thereby obtaining a very short common [24]. The RYGB consists of a malabsorbitive and restrictive procedure. It determines the creation of a small, vertically oriented gastric pouch (*30 mL) that is attached to a Roux limb formed by division of the jejunum about 40–60 cm from the ligament of Trietz. The biliary limb is anastomosed to the Roux limb 150 cm from the gastrojejunostomy [24]. The patients have been allocated to a specific surgical option in relation to the BMI ([50 kg/m2) or metabolic criteria. Subjects with BMI \45 kg/m2 underwent LAGB, patients with BMI between 45 and 50 kg/m2 underwent RYGB, and patients with BMI[50 kg/m2 underwent BPD. Furthermore, if diabetes mellitus, blood lipid disorders, impaired glucose tolerance or low resting metabolic rate was present, RYGB or BPD was the procedure of choice. Statistical analyses Continuous variables were reported as mean ± standard deviation (SD), whereas categorical variables were reported as percentages. Univariate analysis of variance
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(ANOVA, with Bonferroni post hoc test) and Chi square (v2) were used for continuous and categorical variables, respectively. Linear mixed models (ANOVA mixed model with random intercept) were adopted for longitudinal data. Linear mixed models are a proper method to analyze repeated measures data because they take into account the dependencies within the data. They are more flexible in handling missing data than other methods, such as regression and ANOVA, and they are able to model within subjects’ random effects, thereby allowing for individual variation in intercepts and/or regression slopes. Linear mixed models were used to study the variation (time effect) of BMI and psychological variables from baseline to 1-year follow-up. BMI and psychological variables were the dependent variables for each model, and time was entered as independent variable, together with age and BMI before surgery as covariates. At first, we tested the between treatment group effect (time by treatment interaction), and subsequently we evaluated the time effect within each treatment group (LAGB, BPD, RYGB). For each model, we considered: random subject level effects, and time, age, BMI before surgery as fixed effects. Linear regression analyses were performed to evaluate associations between psychological variables percentage variation and excess of BMI loss, and between psychological variables at baseline and excess of BMI loss, in order to identify moderators of weight loss outcome. All analyses were performed using SPSS for windows 15.0 (Chicago Inc., USA).
Results From the 133 consecutive patients initially included in the follow-up study, 42 were excluded and 37 did not meet inclusion criteria because of illiteracy (2), mental retardation (1), severe mental disorders (28) and medical contraindication (6), while 5 patients refused the surgical treatment. Ninety-one patients were enrolled in the study: 30 were allocated to LAGB; 31 were allocated to RYGB and 30 were treated with BPD, as reported in the consort flow diagram of the study. Patients who were not available at follow-up (three in the LAGB group, one in the RYGB group and four in the BPD) were excluded from the analyses. The final sample consisted of 83 Caucasian outpatients (75 women; 90.4 %) with a mean ± standard deviation age of 45.3 ± 10.1 years. Twenty-seven subjects underwent LAGB, 30 underwent RYGB and 26 BPD. The main DSM-IV diagnoses observed at baseline were: unipolar depression (20 subjects, 24.1 %), obsessive compulsive disorder (5 subjects, 6.0 %), panic disorder (11 subjects, 13.3 %), and binge eating disorder (22 subjects,
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26.5 %). No significant difference was found between groups in terms of rates of the mentioned diagnoses. No significant differences were found among the three groups of patients in terms of sociodemographic, clinical and psychopathologic variables at baseline (Table 1), with the exception of BMI which was higher in RYGB and BPD when compared with LAGB group. At 1-year follow-up (Table 1), BMI was no longer different between the groups. Other comparisons at follow-up were not significant. As far as the excess of BMI loss is concerned (Fig. 1), a different effect of treatment was found (F = 5.16; p = 0.008), with RYGB and BPD groups reporting greater weight loss compared with LAGB. The different pattern of treatment effects on psychological variables was evaluated (Table 2). A slight effect of group was found in terms of general psychopathology change, and all the three groups showed a significant reduction of SCL-90, BDI and STAI scores. LAGB group showed a higher BDI reduction, as compared with the other groups. Considering eating disorder specific psychopathology, all the groups showed a significant reduction in most of the psychological measures taken into account, with the exception of EDE-Q restraint. However, a different pattern of response was found between groups (time by treatment effect). BPD group reported a higher reduction of EDE-Q total score, compared with the other groups, while RYGB group reported an intermediate effect. Only BPD was associated with a reduction in all EDE-Q subscales scores. All the treatments showed a significant reduction in BES scores with a lower reduction in BPD subjects, while a reduction in EES total score was found in RYGB and BPD, but not in LAGB group. EDE-Q total score variation rate [calculated as (EDE-Q at baseline - EDE-Q at follow-up)/EDE-Q at baseline] was found to be positively associated with excess of BMI loss only in the RYGB group (R2 = 0.65; b = 0.80; p = 0.015). This means that the higher rate of variation of EDE-Q was associated with the higher BMI loss. Other correlations were not significant Finally, the effect of baseline psychological variables on excess of BMI loss was calculated. Within all the psychological variables only emotional eating at baseline was found to be associated with the excess of BMI loss (R2 = 0.08; b = -0.24; p = 0.03). In particular, the higher baseline EES values were reported at baseline and the lower was found to be the excess of BMI loss. The analyses were performed for the whole sample and the results were confirmed for each group of treatment separately.
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Table 1 BMI and psychopathological variables at baseline (T0) and 1 year after surgery (T1) Baseline LAGB (n: 27)
1 year after surgery RYGB (n: 30)
BPD (n: 26)
ANOVA, v2 2.28
LAGB (n: 27)
RYGB (n: 30)
BPD (n: 26)
34.91 ± 6.22 0.65 ± 0.60
34.39 ± 7.14 0.80 ± 0.52
32.5 ± 5.55 0.92 ± 0.54
0.97 0.77 0.80
Age (years)
43.85 ± 11.36
43.63 ± 9.83
48.84 ± 8.36
Gender (women)
23 (83.2 %)
28 (93.3 %)
24 (92.3 %)
1.24
BMI (kg/m2) SCL-90 GSI
44.79 ± 5.3 0.96 ± 0.58
49.49 ± 6.76 1.28 ± 0.69
50.57 ± 6.55 1.14 ± 0.5
6.26*** 1.88
BDI
16 ± 11.07
18.34 ± 11.31
17.76 ± 12.06
0.28
6.66 ± 6.46
8.53 ± 6.45
9.88 ± 6.64
ANOVA
STAI
45.12 ± 9.18
44.68 ± 10.21
44.5 ± 11.32
0.01
36.14 ± 10.5
40.72 ± 6.49
38.00 ± 13.67
0.59
EES
46.25 ± 9.88
43.14 ± 12.43
46.76 ± 10.01
0.52
1.30 ± 1.03
0.75 ± 0.73
0.79 ± 0.51
1.69
EDE-Q total score
1.40 ± 0.93
1.64 ± 0.89
1.67 ± 0.91
0.50
1.80 ± 1.28
2.20 ± 1.18
1.2 ± 0.89
1.97
EDE-Q restraint
1.78 ± 1.4
1.96 ± 1.39
2.01 ± 1.49
0.17
1.61 ± 1.31
1.78 ± 1.59
0.88 ± 1.01
1.30
EDE-Q eating concern
1.61 ± 1.52
2.09 ± 1.08
1.94 ± 1.85
0.53
1.18 ± 1.53
1.08 ± 1.49
0.25 ± 0.27
1.51
EDE-Q weight concern
3.27 ± 1.2
3.43 ± 1.33
3.06 ± 1.45
0.54
1.87 ± 1.36
2.37 ± 1.22
1.42 ± 1.40
1.50
EDE-Q shape concern
4.09 ± 1.4
4.42 ± 1.22
4.05 ± 1.57
0.59
2.53 ± 1.82
2.55 ± 1.13
2.29 ± 1.69
2.44
BES
15.5 ± 9.6
20.11 ± 9.51
16.11 ± 8.53
1.92
6.00 ± 6.43
6.13 ± 4.15
11.22 ± 9.93
2.10
Statistics—continuous variables are reported as mean ± standard deviation BDI Beck Depression Inventory, BES Binge Eating Scale, BPD biliopancreatic diversion, BMI body mass index, EDE-Q Eating Disorder Examination Questionnaire, EES Emotional Eating Scale Total Score, LAGB laparoscopic adjustable gastric band, RYGB Roux-en-Y gastric bypass, STAI State-Trait Anxiety Inventory, SCL-90 GSI Symptom Checklist (SCL 90-R) global severity index *** p \ 0.001
disorder specific psychopathology is of relevance, considering the increasing evidences of their role as potential predictors of sustained weight loss in the long term after surgery interventions [25]. According to our main results: –
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Fig. 1 Excess body mass index (BMI) loss: 100 9 [(initial BMI final BMI)/(initial BMI-25)]. LAGB laparoscopic adjustable gastric band, BPD biliopancreatic diversion, RYGB Roux-en-Y gastric bypass
Discussion To our knowledge, this is one of the few studies which compared different bariatric surgery procedures, in terms of weight loss and psychopathological outcomes. The evaluation of bariatric surgery effects on general and eating
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The three types of bariatric surgical procedures showed a different pattern of efficacy on weight loss, with BPD group reporting the greatest weight loss; ‘‘Malabsorptive’’ and ‘‘restrictive and malabsorptive’’ procedures showed a higher reduction of eating disorder psychopathology as compared with the restrictive intervention; however, all the treatments showed a significant improvement in terms of binge eating behaviors; A high emotional eating at baseline resulted to be associated with a lower weight loss after surgery interventions.
The different efficacy of surgical interventions in terms of weight loss seems to support previous researches which reported that weight loss outcomes strongly favor RYGB over LAGB [26] and that RYGB is associated to a lower %EWL (percentage of excess of weight loss) than BPD [2]. The mechanisms whereby RYGB and BPD produce weight loss may be represented by malabsorption of nutrients, decreased intake, food aversion, altered
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Table 2 Treatment effects on BMI and psychopathological variables
BMI
Treatment by time effect (F)
Treatment effect of gastric banding Time effect (b)
Treatment effect of gastric bypass Time effect (b)
Treatment effect of biliopancreatic diversion Time effect (b)
62.2***
0.65***
0.73***
0.82***
SCL-90 GSI STAI
2.86*
0.26*
0.36*
0.23*
2.70
0.48**
0.24*
0.27*
BDI
7.46***
0.44**
0.46**
0.38*
BES
11.6***
0.49**
0.68***
0.34*
EDE-Q total score
7.08**
0.31*
0.38**
0.62***
EDE-Q restraint
1.08
0.01
0.04
0.36*
EDE-Q eating concern
3.59*
0.09
0.31*
0.44*
EDE-Q weight concern
9.64***
0.41*
0.47**
0.61**
EDE-Q shape concern EES
7.52***
0.32*
0.39**
0.58**
4.43**
0.03
0.46**
0.48**
Statistical analyses—data reported in the table represent the F and b values for linear mixed models assessing the variation (time effect) of BMI and psychological variables from baseline to 1-year follow-up. The first column reports the F values for differences in treatment effects (time by treatment interaction), and the other columns report the b values for the time effects within different treatment groups. Data are age and baseline BMI adjusted BDI Beck Depression Inventory, BES Binge Eating Scale, BMI body mass index, SCL-90 GSI Symptom Checklist (SCL 90-R) global severity index, STAI State-Trait Anxiety Inventory, EDE-Q Eating Disorder Examination Questionnaire, EES Emotional Eating Scale Total Score * p \ 0.05; ** p \ 0.01; *** p \ 0.001
metabolism, or a combination of them [27]. Cummings et al. showed that gastric bypass disrupts ghrelin secretion by isolating ghrelin producing cells from direct contact with ingested nutrients which normally regulate ghrelin levels. This effect, associated to an adaptation in the levels of other gut hormones (increase of peptide YY, glucagonlike peptide 1, oxyntomodulin and reduction of leptin and insulin) that promote satiety, may contribute to the efficacy of the bariatric procedures in reducing weight [28, 29]. The greatest %EBMI loss in BPD group confirmed results of previous studies [2], and it can be interpreted also as the subjects who underwent BPD had a lower weight regain during the first post-operative year, as compared with other treatments.
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Furthermore, a significant effect of treatment on general psychopathology was found independently from bariatric procedure, according to the previous researches demonstrating a reduction of Axis I comorbidity after bariatric surgery [30]. The significant decrease of depressive symptoms after surgery [5] confirmed the existence of a complex relationship between obesity and depression [31]. Biological mechanisms have been implicated, such as HPA-axis dysregulation, as well as diabetes mellitus and insulin resistance which have been found to increase the risk of depression [31]. Furthermore, weight-related stigmatization [32], increased body dissatisfaction and decreased selfesteem might increase the risk of depression [31]. In general, a significant reduction in weight has been frequently associated with a post-operative improvement in all patients’ psychopathologic parameters, given the reduced perception of criticism and self-blame associated with relevant weight loss after bariatric surgery [9]. As far as pathological eating behaviors are concerned, we found that eating disorder specific psychopathology was similarly present in the treatments groups, according to the previous studies reporting that a substantial percentage of bariatric surgery patients suffered from binge eating symptoms [33]. All the considered surgical interventions demonstrated to be efficacious in reducing pathological eating behaviors, and eating disorder specific psychopathology. Sa`nchez Zaldvar et al. [34] showed that after bariatric surgery the impulse to thinness and corporal dissatisfaction improved in patients with morbid obesity. Moreover, we found that bariatric surgery was effective in reducing the severity of binge eating (BES scores), according to the previous studies [34] which suggested that the gastric restrictive procedures make physiologically very difficult to binge eat. However, it is of note that RYGB and BPD were associated with a higher reduction in EDE-Q scores and emotional eating. A possible explanation could be that in RYGB patients obtained a higher weight loss after surgery, and a more relevant weight loss outcome determined a better outcome in terms of eating disorder specific psychopathology. The positive correlation between EDE-Q reduction and excess of BMI loss seems to support such hypothesis. Alternatively, we may hypothesize that a higher reduction of eating pathology in RYGB and BPD group may be one of the mechanisms favoring the weight loss [8]. Finally, our data showed that emotional eating prior to undergo bariatric surgery was associated with different pattern of weight loss after intervention, since higher pretreatment emotional eating levels predicted lower excess of BMI loss, for all the three treatment groups. Previous studies demonstrated that emotional eating was a maintaining factor of binge eating [35], and an important
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outcome modifier in psychological treatments [36]. Our findings support the importance of this psychopathological dimension, which seems to play a relevant role even in obese patients who underwent bariatric surgery, and stress the importance of a careful assessment of different psychological variables in obese subjects attending different bariatric surgery interventions, in order to identify potential outcome predictors for weight loss. However, it is important to note that even if emotional eating was associated with %EBML, it accounts for a limited proportion of its variance in the model. Therefore, it is possible that in sever obese subjects, weight loss depends on several other clinical variables than psychopathology. One limitation of the current data set is that it included a limited number of patients. Therefore, the results of the present study should be confirmed by larger studies. However, it is important to note that, despite the relatively small sample size, significant differences were found between treatment groups. A second limitation is that some important psychological data of this study were obtained by means of self-reported questionnaires, thus possibly determining potential subjective bias. Errors or memory biases could have affected the retrospectively collected data. Finally, the follow-up length of this study is very short (only 12 months); indeed, considering that the weight loss curves observed after LAGB, RYGB and DBP (with the LAGB having a slower a more prolonged weight loss phase) show different slopes and duration, at the end of 1 year only a part of the long-term effects of these different procedures can be captured. Therefore, further studies with longer follow-up period are needed.
Conclusion In conclusion, our results support the importance of a careful assessment of different psychological variables in obese subjects attending different bariatric surgery interventions, in order to supervise the post-surgical outcome. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Pull CB (2010) Current psychological assessment practices in obesity surgery programs: what to assess and why. Curr Opin Psychiatry 23:30–36. doi:10.1097/YCO.0b013e328334c817 2. Topart P, Becouarn G, Ritz P (2013) Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients. Surg Obes Relat Dis 9:526–530. doi:10.1016/j.soard.2012.02.006
223 3. MacLean LD, Rhode BM, Sampalis J, Forse RA (1993) Results of the surgical treatment of obesity. Am J Surg 165:155–160 4. American Psychiatric Association (2000). The diagnostic and statistical manual of mental disorders, 4th edn (text rev). doi:10. 1176/appi.books.9780890423349 5. de Zwaan M, Enderle J, Wagner S et al (2011) Anxiety and depression in bariatric surgery patients: a prospective, follow-up study using structured clinical interviews. J Affect Disord 133:61–68. doi:10.1016/j.jad.2011.03.025 6. Karlsson J, Taft C, Ryde´n A, Sjo¨stro¨m L, Sullivan M (2007) Tenyear trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obesity 31:1248–1261 7. de Zwaan M, Hilbert A, Swan-Kremeier L et al (2010) Comprehensive interview assessment of eating behavior 18–35 months after gastric bypass surgery for morbid obesity. Surg Obes Relat Dis 6:79–85. doi:10.1016/j.soard.2009.08.011 8. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB (2002) Binge eating among gastric bypass patients at long-term follow-up. Obes Surg 12:270–275 9. Papageorgiou GM, Papakonstantinou A, Mamplekou E, Terzis I, Melissas J (2002) Pre- and postoperative psychological characteristics in morbidly obese patients. Obes Surg 12:534–539 10. Rosik C (2005) Psychiatric symptoms among prospective bariatric surgery patients: rates of prevalence and their relation to social desirability, pursuit of surgery, and follow-up attendance. Obes Surg 15:677–683 11. First MB, Spitzer RL, Gibbon M, Williams JBW (1995) Structured clinical interview for DSM-IV axis I disorders. Patient edition (SCID-P, version 2). Biometrics Research, New York State Psychiatric Institute, New York 12. Castellini G, Godini L, Amedei SG, Galli V, Alpigiano G, Mugnaini E, Veltri M, Rellini AH, Rotella CM, Faravelli C, Lucchese M, Ricca V (2013) Psychopathological similarities and differences between obese patients seeking surgical and nonsurgical overweight treatments. Eat Weight Disord 19:95–102 13. National Institutes of Health (1998) Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. Obes Res 6(Suppl 2):51–209 14. Deitel M, Gawdat K, Melissas J (2007) Reporting weight loss. Obes Surg 17:565–568 15. Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJ (2004) Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples. Behav Res Ther 42:551–567 16. Grilo CM, Henderson KE, Bell RL, Crosby RD (2013) Eating disorder examination-questionnaire factor structure and construct validity in bariatric surgery candidates. Obes Surg 23:657–662. doi:10.1007/s11695-012-0840-8 17. Gormally J, Block S, Daston S, Rardin D (1982) The assessment of binge eating severity among obese persons. Addict Behav 7:47–55 18. Grupski AE, Hood MM, Hall BJ, Azarbad L, Fitzpatrick SL, Corsica JA (2013) Examining the Binge Eating Scale in screening for binge eating disorder in bariatric surgery candidates. Obes Surg 23:1–6. doi:10.1007/s11695-011-0537-4 19. Hood MM, Grupski AE, Hall BJ, Ivan I, Corsica J (2012) Factor structure and predictive utility of the Binge Eating Scale in bariatric surgery candidates. Surg Obes Relat Dis 9:942–948 20. Arnow B, Kenardy J, Agras WS (1995) The Emotional Eating Scale. The development of a measure to assess coping with negative affect by eating. Int J Eat Disord 18:79–90 21. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4:561–571
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224 22. Derogatis LR, Lipman RS, Covi L (1973) SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmacol Bull 9:13–28 23. Spielberg CD, Gorsuch RL, Lushene RE (1970) Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Consulting Psychologists Press, Palo Alto 24. Noria SF, Grantcharov T (2013) Biological effects of bariatric surgery on obesity-related comorbidities. Can J Surg 56:47–57. doi:10.1503/cjs.036111 25. Walfish S (2010) Psychological correlates of laparoscopic adjustable gastric band and gastric bypass patients. Obes Surg 20:423–425. doi:10.1007/s11695-008-9666-9 26. Angrisani L, Lorenzo M, Borrelli V (2007) Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial. Surg Obes Relat Dis 3:127–132 27. Beckman LM, Beckman TR, Earthman CP (2010) Changes in gastrointestinal hormones and leptin after Roux-en-Y gastric bypass procedure: a review. J Am Diet Assoc 110:571–584. doi:10.1016/j.jada.2009.12.023 28. Cummings DE, Weigle DS, Frayo RS et al (2002) Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med 346:1623–1630 29. Ionut V, Burch M, Youdim A, Bergman RN (2013) Gastrointestinal hormones and bariatric surgery induced weight loss. Obesity 21:1093–1103. doi:10.1002/oby.20364
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Eat Weight Disord (2014) 19:217–224 30. Gertler R, Ramsey-Stewart G (1986) Pre-operative psychiatric assessment of patients presenting for gastric bariatric surgery (surgical control of morbid obesity). Aust N Z J Surg 56:157–161 31. Luppino FS, de Wit LM, Bouvy PF et al (2010) Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry 67:220–229. doi:10. 1001/archgenpsychiatry.2010.2 32. Chen EY, Bocchieri-Ricciardi LE, Munoz D et al (2007) Depressed mood in class III obesity predicted by weight-related stigma. Obes Surg 17:669–671 33. Kalarchian MA, Wilson GT, Brolin RE, Bradley L (1998) Binge eating in bariatric surgery patients. Int J Eat Disord 23:89–92 34. Sa`nchez Zaldvar S, Arias Horcajadas F, Gorgojo Martıˆnez JJ, Sa`nchez Romero S (2009) Evolution of psychopathological alterations in patients with morbid obesity after bariatric surgery. Med Clin (Barc) 133:206–212. doi:10.1016/j.medcli.2008.11.045 35. Chesler BE (2012) Emotional eating: a virtually untreated risk factor for outcome following bariatric surgery. Sci World J 2012:365961. doi:10.1100/2012/365961 36. Castellini G, Mannucci E, Lo Sauro C et al (2012) Different moderators of cognitive-behavioral therapy on subjective and objective binge eating in bulimia nervosa and binge eating disorder: a three-year follow-up study. Psychother Psychosom 81:11–20. doi:10.1159/000329358
ORIGINAL ARTICLE
Psychological effects and outcome predictors of three bariatric surgery interventions: a 1-year follow-up study Giovanni Castellini • Lucia Godini • Silvia Gorini Amedei • Carlo Faravelli Marcello Lucchese • Valdo Ricca
•
Received: 21 December 2013 / Accepted: 1 April 2014 / Published online: 16 April 2014 Ó Springer International Publishing Switzerland 2014
Abstract Purpose Weight loss surgery efficacy has been demonstrated for morbid obesity. Different outcomes have been hypothesized, according to specific bariatric surgery interventions and psychological characteristics of obese patients. The present study compared three different surgery procedures, namely laparoscopic adjustable gastric band (LAGB), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD), in terms of weight loss efficacy and psychological outcomes. Methods Eighty-three subjects seeking bariatric surgery have been evaluated before and 12 months after surgery intervention, by means of a clinical interview and different self-reported questionnaires, including Eating Disorder Examination Questionnaire, Emotional Eating Scale, Binge Eating Scale, Beck Depression Inventory, Symptom Checklist and State-Trait Anxiety Inventory.
G. Castellini L. Godini S. G. Amedei V. Ricca Psychiatric Unit, Department of Neuropsychiatric Sciences, Florence University School of Medicine, Viale Morgagni 85, 50134 Florence, Italy L. Godini S. G. Amedei M. Lucchese Bariatric Surgery Unit, Careggi Hospital, Viale Morgagni 85, 50134 Florence, Italy C. Faravelli Department of Psychology, University of Florence, Via di San Salvi 12, Complesso di San Salvi, Padiglione 26, 50135 Florence, Italy V. Ricca (&) Psychiatric Unit, Department of Neuropsychiatric Sciences, Florence University School of Medicine, Largo Brambilla 3, 50134 Florence, Italy e-mail: [email protected]
Results BPD group (26 subjects) showed the greatest weight loss, followed by RYGB (30 subjects), and LAGB group (27 subjects). All the treatments were associated with a significant improvement of anxiety, depression, and general psychopathology, and a similar pattern of reduction of binge eating symptomatology. BPD group reported a greater reduction of eating disorder psychopathology, compared to the other groups. Pre-treatment emotional eating severity was found to be a significant outcome modifier for the three treatment interventions. Conclusions These results suggest that all the three types of bariatric surgery significantly improved psychopathology and eating disordered behaviors. They also support the importance of a pre-treatment careful psychological assessment in order to supervise the post-surgical outcome. Keywords Bariatric surgery Eating psychopathology General psychopathology Morbid obesity Weight loss
Introduction Morbid obesity is a severe medical condition characterized by a poor outcome for dietary, pharmacological or psychotherapeutic treatments [1]. Over the past 10 years different studies have supported a good efficacy of weight loss surgery, as gastroplasty, gastric bypass or biliopancreatic diversion seems to have an important impact on weight loss outcome with high percentages of excess weight loss [2]. Furthermore, the efficacy of bariatric surgery has been demonstrated also in the improvement of frequent obesity comorbidities such as diabetes, hyperlipidemia, hypertension and obstructive sleep apnea, which were improved or completely resolved after surgery in most of the patients [3].
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Obese subjects referring to bariatric surgery facilities show high rates of current and lifetime Axis I mental disorders [4], in particular affective, anxiety and binge eating disorders [5]. Several evidences suggest that weight loss surgery is associated with an improvement in psychological condition; however, high psychiatric comorbidity seems to last after the surgery interventions [5]. Furthermore, psychiatric comorbidities have been proposed as significant outcome modifiers of bariatric surgery [5, 6]. In particular, considering eating disorders symptoms, preoperative binge eating behavior seems to be associated with more eating-related and general psychopathology and low weight loss after surgery, whereas post-operative binge eating behavior significantly predicts poorer post-surgical weight loss and psychosocial outcomes [7]. Therefore, patients reporting loss of control over eating, above all after surgery, have been identified as a distinctive subgroup with a less favorable outcome, including weight regain [8]. To date, few studies have compared the clinical and psychopathological outcomes of different types of bariatric surgery interventions [5], and in most of the cases the comparison included only patients treated with the vertical banded gastroplasty or gastric bypass [8, 9]. Moreover, some studies were conducted on relatively small samples [10], with high drop-out rates at the post-operative assessment points [9, 10], and without an adequate eating psychopathology assessment at different time points [1]. The aim of the present study was to compare different surgical interventions, in terms of weight loss, psychopathological outcomes, and outcome predictors. In particular, we evaluated the effect of restrictive [laparoscopic adjustable gastric banding (LAGB)], malabsorptive [biliopancreatic diversion (BPD)], restrictive and malabsorptive [Roux-en-Y gastric bypass (RYGB)] bariatric surgery procedures.
Materials and methods Participants The present study was designed as a follow-up survey, and was performed by the Psychiatric Unit of the University of Florence (Italy) and the Bariatric Surgery Unit. All the diagnostic procedures and the psychometric tests were part of the routine clinical assessment for obese patients performed at our clinics. Before the collection of data, during the first routine visit, the procedures of the study were fully explained; after that, the patients were asked to provide their written informed consent to the participation in the present study. The protocol was approved by the Ethics Committee of the Institution.
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The patients were recruited among a consecutive series of overweight and obese subjects referring for the first time to the Obesity Surgery Clinic of the University of Florence (Italy) and candidates for bariatric surgery. Patients were enrolled from September 2010 to December 2011. The inclusion criteria were age between 18 and 65 years, body mass index (BMI) [40 kg/m2 or BMI [35 kg/m2 with severe obesity-related disease, over 5 years of obesity and failure in previous weight reduction therapies, absence of previous bariatric intervention, and the patient’s complete understanding of the surgical procedure and its risks. The exclusion criteria were illiteracy, mental retardation, high surgical risk, current comorbid severe mental disorders, such as bulimia nervosa and vomiting behaviors, schizophrenia, bipolar disorder, severe major depression, suicide ideation and psychoactive substance dependence, assessed by means of the structured clinical interview for diagnostic and statistical manual of mental disorders (DSM-IV) [11]. Design of the study Psychopathological, behavioral and sociodemographic data were collected through a face-to-face interview on the first day of admission (baseline T0; 21.2 ± 14.8 week before surgery), and 1 year after the surgery treatment (T1) by two expert psychiatrists who were unaware of the kind of surgical procedure (LG, SGA) and had not therapeutic relationship with any of the participants they assessed. During the visits, BMI was calculated and the psychopathological evaluation was performed. Furthermore, during the first visit, the patients were evaluated by a dietitian and a surgeon. As already reported in a previous study by our group [12], patients choose by their own initiative to address to the Bariatric Surgery Unit of Florence. Patients were assessed at their first contact with the clinic, before the evaluation of the inclusion/exclusion criteria for starting a surgical or medical intervention. The bariatric surgical procedure is determined after completing all the assessments, composed by a psychiatric visit (a clinical interview and specific psychopathological questionnaires), a dietitian visit and a surgical visit. If the patient was evaluated as eligible to the surgery, he/she received detailed information about the treatment. At T1, the patients were evaluated by the same psychiatrists during a specialist control visit, and those subjects who were not attending the clinic for control visits were contacted by telephone and invited to the clinic for a follow-up visit. The three bariatric surgery procedures (LAGB, BPD, RYGB) took place in exclusion.
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Assessment Anthropometric measurements were made using standard calibrated instruments. Height (m) was measured using a wall-mounted stadiometer and weight (kg) using electronic scales with an upper weight limit of 300 kg. BMI was calculated as weight in kilograms divided by the square of height in meters. Diagnosis of obesity (BMI [30 kg/m2) was performed according to a single clinical criterion suggested by recent clinical guidelines developed by the National Heart, Lung and Blood Institute [13]. The results of bariatric surgery on body weight were evaluated through the use of the percentage of the excess BMI loss (%EBMIL = 100 9 [(initial BMI - final BMI)/ (initial BMI-25)] [14]. In order to assess the current and lifetime prevalence of mental disorders, patients were interviewed by two expert clinicians (LG, SGA) by means of the structured clinical interview for DSM-IV [11]. Current eating attitudes and behaviors were specifically investigated by means of the Eating Disorder Examination Questionnaire (EDE-Q). The self-reported EDE-Q consists of 38 items, assessing the core psychopathological features of eating disorders, and contains four subscales: dietary restraint, eating concern, weight concern, and shape concern. The dietary restraint subscale is an admixture of cognitions and behaviors pertaining to dietary restriction. The three other subscales evaluate the dysfunctional attitudes regarding eating and overvalued thoughts regarding weight and shape. The global score represents the mean of the four subscale scores [15]. The EDE-Q has been reported to show a good validity also in bariatric surgery candidates [16]. In order to investigate the severity of binge eating, the Binge Eating Scale (BES) was applied [17]. The BES has been proposed as a rapid screening instrument for BED in obese patients, and it examines both behavioral signs (eating large amounts of food) and feeling or cognition during a binge episode (loss of control, guilt, fear of being unable to stop eating) through 16 items. The BES was already used in bariatric surgery populations showing good psychometric properties [18, 19]. Emotional eating was assessed by means of the Emotional Eating Scale (EES) [20], a 25-item self-report questionnaire that indicates the extent to which specific feelings lead a subject to feel an urge to eat. Each item consists of an emotion term (e.g., jittery, angry, helpless), and the 5-point scale used was anchored on ‘‘no desire to eat’’ and ‘‘an overwhelming urge to eat,’’ with ‘‘a small desire to eat,’’ ‘‘a moderate desire to eat,’’ and ‘‘a strong desire to eat’’. The 25 items form 3 subscales, reflecting eating in response to anger (anger/frustration), anxiety
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(anxiety), and depressed mood (depression). For a further characterization of the psychopathological features of the patients, the Beck Depression Inventory (BDI) [21], Symptom Checklist (SCL-90-R) [22] and State-Trait Anxiety Inventory (STAI) [23] were also applied. Treatment At Bariatric and Metabolic Surgery Unit of University of Florence (Italy), three main surgical options are performed: LAGB as ‘‘restrictive’’ procedure, BPD as ‘‘malabsorptive’’ procedure, and RYGB as ‘‘restrictive and malabsorptive’’ procedure. LAGB is one of the most important types of bariatric restrictive procedures. LAGB is a restrictive procedure and consists on the limitation of the luminal diameter of the stomach, without the exclusion of some segments of the gastrointestinal tract. This procedure involves a foreign material (the ‘‘band’’) that is an adjustable plastic and silicone ring, placed around the proximal stomach just beneath the gastroesophageal junction. An access present in the subcutaneous area links to the band and it allows to adjust the constriction level by the injection or withdrawal of saline [24]. The BPD is a primarily malabsorptive procedure with some restrictions. It consists of a partial gastrectomy where a 200–500 mL proximal gastric pouch, a distal Roux and proximal biliary limb are created by division of the small bowel 250 cm proximal to the terminal ileum. The gastric pouch is attached to the end of the Roux limb, and the biliary limb is connected 50 cm proximal to the ileocecal valve, thereby obtaining a very short common [24]. The RYGB consists of a malabsorbitive and restrictive procedure. It determines the creation of a small, vertically oriented gastric pouch (*30 mL) that is attached to a Roux limb formed by division of the jejunum about 40–60 cm from the ligament of Trietz. The biliary limb is anastomosed to the Roux limb 150 cm from the gastrojejunostomy [24]. The patients have been allocated to a specific surgical option in relation to the BMI ([50 kg/m2) or metabolic criteria. Subjects with BMI \45 kg/m2 underwent LAGB, patients with BMI between 45 and 50 kg/m2 underwent RYGB, and patients with BMI[50 kg/m2 underwent BPD. Furthermore, if diabetes mellitus, blood lipid disorders, impaired glucose tolerance or low resting metabolic rate was present, RYGB or BPD was the procedure of choice. Statistical analyses Continuous variables were reported as mean ± standard deviation (SD), whereas categorical variables were reported as percentages. Univariate analysis of variance
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(ANOVA, with Bonferroni post hoc test) and Chi square (v2) were used for continuous and categorical variables, respectively. Linear mixed models (ANOVA mixed model with random intercept) were adopted for longitudinal data. Linear mixed models are a proper method to analyze repeated measures data because they take into account the dependencies within the data. They are more flexible in handling missing data than other methods, such as regression and ANOVA, and they are able to model within subjects’ random effects, thereby allowing for individual variation in intercepts and/or regression slopes. Linear mixed models were used to study the variation (time effect) of BMI and psychological variables from baseline to 1-year follow-up. BMI and psychological variables were the dependent variables for each model, and time was entered as independent variable, together with age and BMI before surgery as covariates. At first, we tested the between treatment group effect (time by treatment interaction), and subsequently we evaluated the time effect within each treatment group (LAGB, BPD, RYGB). For each model, we considered: random subject level effects, and time, age, BMI before surgery as fixed effects. Linear regression analyses were performed to evaluate associations between psychological variables percentage variation and excess of BMI loss, and between psychological variables at baseline and excess of BMI loss, in order to identify moderators of weight loss outcome. All analyses were performed using SPSS for windows 15.0 (Chicago Inc., USA).
Results From the 133 consecutive patients initially included in the follow-up study, 42 were excluded and 37 did not meet inclusion criteria because of illiteracy (2), mental retardation (1), severe mental disorders (28) and medical contraindication (6), while 5 patients refused the surgical treatment. Ninety-one patients were enrolled in the study: 30 were allocated to LAGB; 31 were allocated to RYGB and 30 were treated with BPD, as reported in the consort flow diagram of the study. Patients who were not available at follow-up (three in the LAGB group, one in the RYGB group and four in the BPD) were excluded from the analyses. The final sample consisted of 83 Caucasian outpatients (75 women; 90.4 %) with a mean ± standard deviation age of 45.3 ± 10.1 years. Twenty-seven subjects underwent LAGB, 30 underwent RYGB and 26 BPD. The main DSM-IV diagnoses observed at baseline were: unipolar depression (20 subjects, 24.1 %), obsessive compulsive disorder (5 subjects, 6.0 %), panic disorder (11 subjects, 13.3 %), and binge eating disorder (22 subjects,
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26.5 %). No significant difference was found between groups in terms of rates of the mentioned diagnoses. No significant differences were found among the three groups of patients in terms of sociodemographic, clinical and psychopathologic variables at baseline (Table 1), with the exception of BMI which was higher in RYGB and BPD when compared with LAGB group. At 1-year follow-up (Table 1), BMI was no longer different between the groups. Other comparisons at follow-up were not significant. As far as the excess of BMI loss is concerned (Fig. 1), a different effect of treatment was found (F = 5.16; p = 0.008), with RYGB and BPD groups reporting greater weight loss compared with LAGB. The different pattern of treatment effects on psychological variables was evaluated (Table 2). A slight effect of group was found in terms of general psychopathology change, and all the three groups showed a significant reduction of SCL-90, BDI and STAI scores. LAGB group showed a higher BDI reduction, as compared with the other groups. Considering eating disorder specific psychopathology, all the groups showed a significant reduction in most of the psychological measures taken into account, with the exception of EDE-Q restraint. However, a different pattern of response was found between groups (time by treatment effect). BPD group reported a higher reduction of EDE-Q total score, compared with the other groups, while RYGB group reported an intermediate effect. Only BPD was associated with a reduction in all EDE-Q subscales scores. All the treatments showed a significant reduction in BES scores with a lower reduction in BPD subjects, while a reduction in EES total score was found in RYGB and BPD, but not in LAGB group. EDE-Q total score variation rate [calculated as (EDE-Q at baseline - EDE-Q at follow-up)/EDE-Q at baseline] was found to be positively associated with excess of BMI loss only in the RYGB group (R2 = 0.65; b = 0.80; p = 0.015). This means that the higher rate of variation of EDE-Q was associated with the higher BMI loss. Other correlations were not significant Finally, the effect of baseline psychological variables on excess of BMI loss was calculated. Within all the psychological variables only emotional eating at baseline was found to be associated with the excess of BMI loss (R2 = 0.08; b = -0.24; p = 0.03). In particular, the higher baseline EES values were reported at baseline and the lower was found to be the excess of BMI loss. The analyses were performed for the whole sample and the results were confirmed for each group of treatment separately.
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Table 1 BMI and psychopathological variables at baseline (T0) and 1 year after surgery (T1) Baseline LAGB (n: 27)
1 year after surgery RYGB (n: 30)
BPD (n: 26)
ANOVA, v2 2.28
LAGB (n: 27)
RYGB (n: 30)
BPD (n: 26)
34.91 ± 6.22 0.65 ± 0.60
34.39 ± 7.14 0.80 ± 0.52
32.5 ± 5.55 0.92 ± 0.54
0.97 0.77 0.80
Age (years)
43.85 ± 11.36
43.63 ± 9.83
48.84 ± 8.36
Gender (women)
23 (83.2 %)
28 (93.3 %)
24 (92.3 %)
1.24
BMI (kg/m2) SCL-90 GSI
44.79 ± 5.3 0.96 ± 0.58
49.49 ± 6.76 1.28 ± 0.69
50.57 ± 6.55 1.14 ± 0.5
6.26*** 1.88
BDI
16 ± 11.07
18.34 ± 11.31
17.76 ± 12.06
0.28
6.66 ± 6.46
8.53 ± 6.45
9.88 ± 6.64
ANOVA
STAI
45.12 ± 9.18
44.68 ± 10.21
44.5 ± 11.32
0.01
36.14 ± 10.5
40.72 ± 6.49
38.00 ± 13.67
0.59
EES
46.25 ± 9.88
43.14 ± 12.43
46.76 ± 10.01
0.52
1.30 ± 1.03
0.75 ± 0.73
0.79 ± 0.51
1.69
EDE-Q total score
1.40 ± 0.93
1.64 ± 0.89
1.67 ± 0.91
0.50
1.80 ± 1.28
2.20 ± 1.18
1.2 ± 0.89
1.97
EDE-Q restraint
1.78 ± 1.4
1.96 ± 1.39
2.01 ± 1.49
0.17
1.61 ± 1.31
1.78 ± 1.59
0.88 ± 1.01
1.30
EDE-Q eating concern
1.61 ± 1.52
2.09 ± 1.08
1.94 ± 1.85
0.53
1.18 ± 1.53
1.08 ± 1.49
0.25 ± 0.27
1.51
EDE-Q weight concern
3.27 ± 1.2
3.43 ± 1.33
3.06 ± 1.45
0.54
1.87 ± 1.36
2.37 ± 1.22
1.42 ± 1.40
1.50
EDE-Q shape concern
4.09 ± 1.4
4.42 ± 1.22
4.05 ± 1.57
0.59
2.53 ± 1.82
2.55 ± 1.13
2.29 ± 1.69
2.44
BES
15.5 ± 9.6
20.11 ± 9.51
16.11 ± 8.53
1.92
6.00 ± 6.43
6.13 ± 4.15
11.22 ± 9.93
2.10
Statistics—continuous variables are reported as mean ± standard deviation BDI Beck Depression Inventory, BES Binge Eating Scale, BPD biliopancreatic diversion, BMI body mass index, EDE-Q Eating Disorder Examination Questionnaire, EES Emotional Eating Scale Total Score, LAGB laparoscopic adjustable gastric band, RYGB Roux-en-Y gastric bypass, STAI State-Trait Anxiety Inventory, SCL-90 GSI Symptom Checklist (SCL 90-R) global severity index *** p \ 0.001
disorder specific psychopathology is of relevance, considering the increasing evidences of their role as potential predictors of sustained weight loss in the long term after surgery interventions [25]. According to our main results: –
–
Fig. 1 Excess body mass index (BMI) loss: 100 9 [(initial BMI final BMI)/(initial BMI-25)]. LAGB laparoscopic adjustable gastric band, BPD biliopancreatic diversion, RYGB Roux-en-Y gastric bypass
Discussion To our knowledge, this is one of the few studies which compared different bariatric surgery procedures, in terms of weight loss and psychopathological outcomes. The evaluation of bariatric surgery effects on general and eating
–
The three types of bariatric surgical procedures showed a different pattern of efficacy on weight loss, with BPD group reporting the greatest weight loss; ‘‘Malabsorptive’’ and ‘‘restrictive and malabsorptive’’ procedures showed a higher reduction of eating disorder psychopathology as compared with the restrictive intervention; however, all the treatments showed a significant improvement in terms of binge eating behaviors; A high emotional eating at baseline resulted to be associated with a lower weight loss after surgery interventions.
The different efficacy of surgical interventions in terms of weight loss seems to support previous researches which reported that weight loss outcomes strongly favor RYGB over LAGB [26] and that RYGB is associated to a lower %EWL (percentage of excess of weight loss) than BPD [2]. The mechanisms whereby RYGB and BPD produce weight loss may be represented by malabsorption of nutrients, decreased intake, food aversion, altered
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Table 2 Treatment effects on BMI and psychopathological variables
BMI
Treatment by time effect (F)
Treatment effect of gastric banding Time effect (b)
Treatment effect of gastric bypass Time effect (b)
Treatment effect of biliopancreatic diversion Time effect (b)
62.2***
0.65***
0.73***
0.82***
SCL-90 GSI STAI
2.86*
0.26*
0.36*
0.23*
2.70
0.48**
0.24*
0.27*
BDI
7.46***
0.44**
0.46**
0.38*
BES
11.6***
0.49**
0.68***
0.34*
EDE-Q total score
7.08**
0.31*
0.38**
0.62***
EDE-Q restraint
1.08
0.01
0.04
0.36*
EDE-Q eating concern
3.59*
0.09
0.31*
0.44*
EDE-Q weight concern
9.64***
0.41*
0.47**
0.61**
EDE-Q shape concern EES
7.52***
0.32*
0.39**
0.58**
4.43**
0.03
0.46**
0.48**
Statistical analyses—data reported in the table represent the F and b values for linear mixed models assessing the variation (time effect) of BMI and psychological variables from baseline to 1-year follow-up. The first column reports the F values for differences in treatment effects (time by treatment interaction), and the other columns report the b values for the time effects within different treatment groups. Data are age and baseline BMI adjusted BDI Beck Depression Inventory, BES Binge Eating Scale, BMI body mass index, SCL-90 GSI Symptom Checklist (SCL 90-R) global severity index, STAI State-Trait Anxiety Inventory, EDE-Q Eating Disorder Examination Questionnaire, EES Emotional Eating Scale Total Score * p \ 0.05; ** p \ 0.01; *** p \ 0.001
metabolism, or a combination of them [27]. Cummings et al. showed that gastric bypass disrupts ghrelin secretion by isolating ghrelin producing cells from direct contact with ingested nutrients which normally regulate ghrelin levels. This effect, associated to an adaptation in the levels of other gut hormones (increase of peptide YY, glucagonlike peptide 1, oxyntomodulin and reduction of leptin and insulin) that promote satiety, may contribute to the efficacy of the bariatric procedures in reducing weight [28, 29]. The greatest %EBMI loss in BPD group confirmed results of previous studies [2], and it can be interpreted also as the subjects who underwent BPD had a lower weight regain during the first post-operative year, as compared with other treatments.
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Furthermore, a significant effect of treatment on general psychopathology was found independently from bariatric procedure, according to the previous researches demonstrating a reduction of Axis I comorbidity after bariatric surgery [30]. The significant decrease of depressive symptoms after surgery [5] confirmed the existence of a complex relationship between obesity and depression [31]. Biological mechanisms have been implicated, such as HPA-axis dysregulation, as well as diabetes mellitus and insulin resistance which have been found to increase the risk of depression [31]. Furthermore, weight-related stigmatization [32], increased body dissatisfaction and decreased selfesteem might increase the risk of depression [31]. In general, a significant reduction in weight has been frequently associated with a post-operative improvement in all patients’ psychopathologic parameters, given the reduced perception of criticism and self-blame associated with relevant weight loss after bariatric surgery [9]. As far as pathological eating behaviors are concerned, we found that eating disorder specific psychopathology was similarly present in the treatments groups, according to the previous studies reporting that a substantial percentage of bariatric surgery patients suffered from binge eating symptoms [33]. All the considered surgical interventions demonstrated to be efficacious in reducing pathological eating behaviors, and eating disorder specific psychopathology. Sa`nchez Zaldvar et al. [34] showed that after bariatric surgery the impulse to thinness and corporal dissatisfaction improved in patients with morbid obesity. Moreover, we found that bariatric surgery was effective in reducing the severity of binge eating (BES scores), according to the previous studies [34] which suggested that the gastric restrictive procedures make physiologically very difficult to binge eat. However, it is of note that RYGB and BPD were associated with a higher reduction in EDE-Q scores and emotional eating. A possible explanation could be that in RYGB patients obtained a higher weight loss after surgery, and a more relevant weight loss outcome determined a better outcome in terms of eating disorder specific psychopathology. The positive correlation between EDE-Q reduction and excess of BMI loss seems to support such hypothesis. Alternatively, we may hypothesize that a higher reduction of eating pathology in RYGB and BPD group may be one of the mechanisms favoring the weight loss [8]. Finally, our data showed that emotional eating prior to undergo bariatric surgery was associated with different pattern of weight loss after intervention, since higher pretreatment emotional eating levels predicted lower excess of BMI loss, for all the three treatment groups. Previous studies demonstrated that emotional eating was a maintaining factor of binge eating [35], and an important
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outcome modifier in psychological treatments [36]. Our findings support the importance of this psychopathological dimension, which seems to play a relevant role even in obese patients who underwent bariatric surgery, and stress the importance of a careful assessment of different psychological variables in obese subjects attending different bariatric surgery interventions, in order to identify potential outcome predictors for weight loss. However, it is important to note that even if emotional eating was associated with %EBML, it accounts for a limited proportion of its variance in the model. Therefore, it is possible that in sever obese subjects, weight loss depends on several other clinical variables than psychopathology. One limitation of the current data set is that it included a limited number of patients. Therefore, the results of the present study should be confirmed by larger studies. However, it is important to note that, despite the relatively small sample size, significant differences were found between treatment groups. A second limitation is that some important psychological data of this study were obtained by means of self-reported questionnaires, thus possibly determining potential subjective bias. Errors or memory biases could have affected the retrospectively collected data. Finally, the follow-up length of this study is very short (only 12 months); indeed, considering that the weight loss curves observed after LAGB, RYGB and DBP (with the LAGB having a slower a more prolonged weight loss phase) show different slopes and duration, at the end of 1 year only a part of the long-term effects of these different procedures can be captured. Therefore, further studies with longer follow-up period are needed.
Conclusion In conclusion, our results support the importance of a careful assessment of different psychological variables in obese subjects attending different bariatric surgery interventions, in order to supervise the post-surgical outcome. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Pull CB (2010) Current psychological assessment practices in obesity surgery programs: what to assess and why. Curr Opin Psychiatry 23:30–36. doi:10.1097/YCO.0b013e328334c817 2. Topart P, Becouarn G, Ritz P (2013) Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients. Surg Obes Relat Dis 9:526–530. doi:10.1016/j.soard.2012.02.006
223 3. MacLean LD, Rhode BM, Sampalis J, Forse RA (1993) Results of the surgical treatment of obesity. Am J Surg 165:155–160 4. American Psychiatric Association (2000). The diagnostic and statistical manual of mental disorders, 4th edn (text rev). doi:10. 1176/appi.books.9780890423349 5. de Zwaan M, Enderle J, Wagner S et al (2011) Anxiety and depression in bariatric surgery patients: a prospective, follow-up study using structured clinical interviews. J Affect Disord 133:61–68. doi:10.1016/j.jad.2011.03.025 6. Karlsson J, Taft C, Ryde´n A, Sjo¨stro¨m L, Sullivan M (2007) Tenyear trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obesity 31:1248–1261 7. de Zwaan M, Hilbert A, Swan-Kremeier L et al (2010) Comprehensive interview assessment of eating behavior 18–35 months after gastric bypass surgery for morbid obesity. Surg Obes Relat Dis 6:79–85. doi:10.1016/j.soard.2009.08.011 8. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB (2002) Binge eating among gastric bypass patients at long-term follow-up. Obes Surg 12:270–275 9. Papageorgiou GM, Papakonstantinou A, Mamplekou E, Terzis I, Melissas J (2002) Pre- and postoperative psychological characteristics in morbidly obese patients. Obes Surg 12:534–539 10. Rosik C (2005) Psychiatric symptoms among prospective bariatric surgery patients: rates of prevalence and their relation to social desirability, pursuit of surgery, and follow-up attendance. Obes Surg 15:677–683 11. First MB, Spitzer RL, Gibbon M, Williams JBW (1995) Structured clinical interview for DSM-IV axis I disorders. Patient edition (SCID-P, version 2). Biometrics Research, New York State Psychiatric Institute, New York 12. Castellini G, Godini L, Amedei SG, Galli V, Alpigiano G, Mugnaini E, Veltri M, Rellini AH, Rotella CM, Faravelli C, Lucchese M, Ricca V (2013) Psychopathological similarities and differences between obese patients seeking surgical and nonsurgical overweight treatments. Eat Weight Disord 19:95–102 13. National Institutes of Health (1998) Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. Obes Res 6(Suppl 2):51–209 14. Deitel M, Gawdat K, Melissas J (2007) Reporting weight loss. Obes Surg 17:565–568 15. Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJ (2004) Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples. Behav Res Ther 42:551–567 16. Grilo CM, Henderson KE, Bell RL, Crosby RD (2013) Eating disorder examination-questionnaire factor structure and construct validity in bariatric surgery candidates. Obes Surg 23:657–662. doi:10.1007/s11695-012-0840-8 17. Gormally J, Block S, Daston S, Rardin D (1982) The assessment of binge eating severity among obese persons. Addict Behav 7:47–55 18. Grupski AE, Hood MM, Hall BJ, Azarbad L, Fitzpatrick SL, Corsica JA (2013) Examining the Binge Eating Scale in screening for binge eating disorder in bariatric surgery candidates. Obes Surg 23:1–6. doi:10.1007/s11695-011-0537-4 19. Hood MM, Grupski AE, Hall BJ, Ivan I, Corsica J (2012) Factor structure and predictive utility of the Binge Eating Scale in bariatric surgery candidates. Surg Obes Relat Dis 9:942–948 20. Arnow B, Kenardy J, Agras WS (1995) The Emotional Eating Scale. The development of a measure to assess coping with negative affect by eating. Int J Eat Disord 18:79–90 21. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4:561–571
123
224 22. Derogatis LR, Lipman RS, Covi L (1973) SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmacol Bull 9:13–28 23. Spielberg CD, Gorsuch RL, Lushene RE (1970) Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Consulting Psychologists Press, Palo Alto 24. Noria SF, Grantcharov T (2013) Biological effects of bariatric surgery on obesity-related comorbidities. Can J Surg 56:47–57. doi:10.1503/cjs.036111 25. Walfish S (2010) Psychological correlates of laparoscopic adjustable gastric band and gastric bypass patients. Obes Surg 20:423–425. doi:10.1007/s11695-008-9666-9 26. Angrisani L, Lorenzo M, Borrelli V (2007) Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial. Surg Obes Relat Dis 3:127–132 27. Beckman LM, Beckman TR, Earthman CP (2010) Changes in gastrointestinal hormones and leptin after Roux-en-Y gastric bypass procedure: a review. J Am Diet Assoc 110:571–584. doi:10.1016/j.jada.2009.12.023 28. Cummings DE, Weigle DS, Frayo RS et al (2002) Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med 346:1623–1630 29. Ionut V, Burch M, Youdim A, Bergman RN (2013) Gastrointestinal hormones and bariatric surgery induced weight loss. Obesity 21:1093–1103. doi:10.1002/oby.20364
123
Eat Weight Disord (2014) 19:217–224 30. Gertler R, Ramsey-Stewart G (1986) Pre-operative psychiatric assessment of patients presenting for gastric bariatric surgery (surgical control of morbid obesity). Aust N Z J Surg 56:157–161 31. Luppino FS, de Wit LM, Bouvy PF et al (2010) Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry 67:220–229. doi:10. 1001/archgenpsychiatry.2010.2 32. Chen EY, Bocchieri-Ricciardi LE, Munoz D et al (2007) Depressed mood in class III obesity predicted by weight-related stigma. Obes Surg 17:669–671 33. Kalarchian MA, Wilson GT, Brolin RE, Bradley L (1998) Binge eating in bariatric surgery patients. Int J Eat Disord 23:89–92 34. Sa`nchez Zaldvar S, Arias Horcajadas F, Gorgojo Martıˆnez JJ, Sa`nchez Romero S (2009) Evolution of psychopathological alterations in patients with morbid obesity after bariatric surgery. Med Clin (Barc) 133:206–212. doi:10.1016/j.medcli.2008.11.045 35. Chesler BE (2012) Emotional eating: a virtually untreated risk factor for outcome following bariatric surgery. Sci World J 2012:365961. doi:10.1100/2012/365961 36. Castellini G, Mannucci E, Lo Sauro C et al (2012) Different moderators of cognitive-behavioral therapy on subjective and objective binge eating in bulimia nervosa and binge eating disorder: a three-year follow-up study. Psychother Psychosom 81:11–20. doi:10.1159/000329358
