Jacqueline C. Spitzer

A review of the relationships between extreme obesity, quality of life, and sexual function.

Extreme obesity is associated with significant health issues as well as substantial psychosocial burden for many individuals. Numerous studies have documented the impairments in quality of life associated with extreme obesity. Sexual behavior and functioning is an important aspect of quality of life but is frequently overlooked in research studies as well as clinical care. This paper focuses on the quality of life and sexual functioning of obese individuals with specific focus on the changes in these domains following the substantial weight losses seen after bariatric surgery.

A pilot study investigating the efficacy of postoperative dietary counseling to improve outcomes after bariatric surgery.

BACKGROUND Bariatric surgery is a powerful treatment of severe obesity. During the past several years, a greater appreciation for the need for multidisciplinary care to optimize outcomes has developed, and a number of studies have been started to examine the role of postoperative interventions used in combination with surgery. The purpose of the present study was to investigate the hypothesis that the provision of postoperative dietary counseling, delivered by a registered dietitian, would lead to greater weight loss and more positive improvements in dietary intake and eating behavior compared with standard postoperative care. The study was performed at an academic medical center. METHODS Eighty-four individuals who underwent bariatric surgery were randomly assigned to receive either dietary counseling or standard postoperative care for the first 4 months after surgery. The participants completed measures of macronutrient intake and eating behavior at baseline and 2, 4, 6, 12, 18, and 24 months after surgery. RESULTS The patients who received dietary counseling achieved greater weight loss than those who received standard postoperative care that did not involve this counseling, although this difference did not reach statistical significance. Patients in the dietary counseling arm did report significant changes in several eating behaviors believed to be important to successful long-term weight maintenance. CONCLUSION The results of our pilot study provide some support for the efficacy of early postoperative dietary counseling to improve outcomes after bariatric surgery.

Body image dysmorphic disorder in persons who undergo aesthetic medical treatments.

This article reviews the literature on body dysmorphic disorder (BDD) in patients who seek aesthetic surgery and other appearance-enhancing medical treatments such as dermatologic treatment. It begins with a discussion of the growing popularity of aesthetic medical treatments. The literature investigating the psychological characteristics of individuals interested in these treatments is highlighted. Studies suggest that 5% to 15% of individuals who seek these aesthetic medical treatments suffer from BDD. Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms following these treatments, leading some to suggest that BDD is a contraindication to treatment. The article ends with a discussion of the clinical management of patients with BDD who present for an aesthetic change in their appearance.

Sexual functioning and sex hormones in persons with extreme obesity and seeking surgical and nonsurgical weight loss

BACKGROUND Many individuals with obesity are motivated to lose weight to improve weight-related co-morbidities or psychosocial functioning, including sexual functioning. Few studies have documented rates of sexual dysfunction in persons with obesity. This study investigated sexual functioning, sex hormones, and relevant psychosocial constructs in individuals with obesity who sought surgical and nonsurgical weight loss. METHODS One hundred forty-one bariatric surgery patients (median BMI [25th percentile, 75th percentile] 44.6 [41.4, 50.1]) and 109 individuals (BMI = 40.0 [38.0, 44.0]) who sought nonsurgical weight loss participated. Sexual functioning was assessed by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF). Hormones were assessed by blood assay. Quality of life, body image, depressive symptoms, and marital adjustment were assessed by validated questionnaires. RESULTS Fifty-one percent of women presenting for bariatric surgery reported a sexual dysfunction; 36% of men presenting for bariatric surgery reported erectile dysfunction (ED). This is in contrast to 41% of women who sought nonsurgical weight loss and reported a sexual dysfunction and 20% of men who sought nonsurgical weight loss and reported ED. These differences were not statistically significant. Sexual dysfunction was strongly associated with psychosocial distress in women; these relationships were less strong and less consistent among men. Sexual dysfunction was unrelated to sex hormones, except for sex hormone binding globulin (SHGB) in women. CONCLUSION Women and men who present for bariatric surgery, compared with individuals who sought nonsurgical weight loss, were not significantly more likely to experience a sexual dysfunction. There were few differences in reproductive hormones and psychosocial constructs between candidates for bariatric surgery and individuals interested in nonsurgical weight loss.

Sexual functioning and sex hormones in men who underwent bariatric surgery

BACKGROUND The relationship between obesity and impairments in male sexual functioning is well documented. Relatively few studies have investigated changes in sexual functioning and sex hormones in men who achieve significant weight loss with bariatric surgery. The objective of this study was to assess changes in sexual functioning, sex hormones, and relevant psychosocial constructs in men who underwent bariatric surgery. METHODS A prospective cohort study of 32 men from the Longitudinal Assessment of Bariatric Surgery-2 (LABS) investigation who underwent a Roux-en-Y gastric bypass (median body mass index [25th percentile, 75th percentile] 45.1 [42.0, 52.2]) and completed assessments between 2006 and 2012. Bariatric surgery was performed by a LABS-certified surgeon. Sexual functioning was assessed by the International Index of Erectile Functioning (IIEF). Hormones were assessed by blood assay. Quality of life (QoL), body image, depressive symptoms and marital adjustment were assessed by questionnaire. RESULTS Men lost, on average, (95% confidence interval) 33.3% (36.1%, 30.5%) of initial weight at postoperative year 1, 33.6% (36.8%, 30.5%) at year 2, 31.0% (34.1%, 27.9%) at year 3, and 29.4% (32.7%, 26.2%) at year 4. Participants experienced significant increases in total testosterone (P<.001) and sex hormone binding globulin (SHBG) (P<.001) through postoperative year 4. Although men reported improvements in sexual functioning after surgery, these changes did not significantly differ from baseline, with the exception of overall satisfaction at postoperative year 3 (P = .008). Participants reported significant improvements in physical domains of health-related quality of life (HRQoL), all domains of weight-related QOL, and body image, but not in the mental health domains of HRQoL or relationship satisfaction. CONCLUSIONS Men who lost approximately one third of their weight after Roux-en-Y gastric bypass experienced significant increases in total testosterone and SHBG. They did not, however, report significant improvements in sexual functioning, relationship satisfaction, or mental health domains of HRQoL. This pattern of results differs from that of women who have undergone bariatric surgery, who reported almost uniform improvements in sexual functioning and psychosocial status.

The use of novel technology-based weight loss interventions for obese women with endometrial hyperplasia and cancer

OBJECTIVE Obesity significantly increases the risk of the development of both endometrial hyperplasia and cancer. Our objective was to assess the feasibility of two technology-based weight loss interventions in this patient population. METHODS Women with obesity (BMI≥30kg/m(2)) and endometrial hyperplasia or Type I endometrial cancer were randomized 1:1 to a technology-based 6month lifestyle intervention via either telemedicine or text messaging. The telemedicine arm received weekly phone calls, with weights tracked online using Withings© Wi-Fi scales. The text arm received 3-5 personalized messages daily via Text4Diet™. Participants maintained a 1200-1800calorie/day diet, self-monitored food intake and received exercise goals. Biomarkers (IGFBP-1, adiponectin, VEGF, IL1-beta, IL2, IL6, and IL7) were assessed pre- and post-treatment. RESULTS Twenty women were randomized (Telemedicine: n=10, Text4Diet: n=10), and 90% lost weight. Many were early stage (70%) and grade (43.8%) disease with a median age of 60.5years. We observed a statistically greater weight loss in the Telemedicine arm [median loss: 9.7kg (range: 1.6-22.9kg)] versus 3.9kg (range: 0.3-11.4kg) in the Text4Diet arm (p=0.0231). Similarly, percent weight loss was greater in the Telemedicine (7.6%) as compared to the Text4Diet arm (4.1%, p=0.014). Mean serum levels of IL-2 were significantly (27.15pg/mL vs. 5.18pg/mL, p=0.0495) lower at intervention end as compared to baseline. CONCLUSIONS A technology-based weight loss intervention is feasible in women with Type I endometrial cancer/hyperplasia. Both interventions produced weight loss, although more person-to-person contact produced more significant outcomes. Reductions in expression of IL-2 were related to weight loss.

Attitudes Toward Vascularized Composite Allotransplantation of the Hands and Face in an Urban Population

Background: Almost 100 hand and face transplants have been performed worldwide. Their success has generated enthusiasm within the medical community, however, little is known about public attitudes toward vascularized composite allotransplantation (VCA) of the hands and face as compared to solid organ transplantation. The objective of this survey study was to assess these attitudes and the acceptability and potential barriers to the further growth of these procedures. Methods: Cooper University Hospital Emergency Department (Camden, New Jersey) patients, accompanying family members and friends ≥18 years of age were surveyed about knowledge of and attitudes toward organ, hand, and face transplants as well as preferences as a potential VCA donor or recipient. The socioeconomic aspects of VCA also were assessed. Results: A total of 1,027 individuals participated. Approximately 70% (69.7%) of respondents indicated that they would want to be organ donors, although only 37.1% reported donor registrations on their drivers license. Respondents demonstrated greatest willingness to donate solid organs upon death: kidneys (77.5%), liver (77.1%), and heart (76.4%). Willingness to donate was less for hands (54.6%) and face (44.0%). Similarly, respondents were more willing to receive a kidney (85.2%) than a hand (60.0%) or face (49.4%). Conclusions: Respondents were more willing to be donors or recipients of solid organs than of hands or face. However, substantial percentages of individuals indicated a willingness to donate or receive hands or a face. As VCA continues to evolve, knowledge of public attitudes toward VCA will be critical for organ procurement organizations, health system engagement, and funding for relevant research.

Discussion: The psychological burden of idiopathic adolescent gynecomasatia.

T physical changes associated with adolescence have the potential to dramatically influence an individual’s psychosocial development. The normal physical changes seen with puberty can threaten the body image development and self-esteem of the individual. Although these occurrences were once seen as a somewhat innocuous “rite of passage” for most individuals, research over the past several decades has shown that teenagers can develop a negative body image that can echo throughout adulthood.1 This is most commonly seen in the development of weight and shape concerns and potentially eating disorders in female adolescents. In the plastic surgery literature, the impact of physical appearance on psychosocial development has been most frequently discussed in the context of cleft lip and palate patients, as well as in children and adolescents who undergo craniofacial procedures.2 The study by Kinsella and colleagues highlights the psychosocial challenges in a previously understudied group of patients—adolescent boys with idiopathic gynecomastia.3 The 24 adolescents studied were assessed by a clinical interview (performed by a psychologist), as well as conceptually relevant and psychometrically validated paperand-pencil measures of symptoms of anxiety and depression, as well as daily behavior. All 24 patients received a formal psychiatric diagnosis (primarily adjustment disorders) and displayed greater symptoms of anxiety, depression, and social phobia compared with the general population. These results, and the authors’ thoughtful interpretation of them, underscore the significant degree of psychosocial distress experienced by boys with idiopathic gynecomastia. At the risk of minimizing these important results, the study is curtailed by some methodological limitations. Given the paucity of research on this patient population, a retrospective study such as this is informative. Future studies in this area, however, should be prospective in nature. The use of reliable and valid psychometric assessments is a strength. Unfortunately, the reliance on comparisons with the norms of these measures, rather than a contemporaneously assessed comparison group, is another methodological limitation that can be improved on in subsequent studies. A particularly relevant construct that was not assessed was body image. Body image disturbances likely contribute to the psychosocial problems reported by adolescents with gynecomastia and should be investigated in future studies. Studies also should explore the social impact of gynecomastia, given that affected adolescents often report significant problems with teasing and stigmatization. Finally, as the authors indicate, the psychological issues seen in breast reduction and mastectomy patients are well-documented in adult women. It is important for future studies to investigate the psychosocial changes experienced by adolescent girls with breast conditions, including macromastia, as well as other, less common, breast anomalies that can affect psychosocial functioning. Even with these limitations, this well-written article underscores the emotional suffering experienced by these adolescents. Unfortunately, it appears that third-party payers are still slow to acknowledge that the psychosocial impact of a visible difference in physical appearance, such as gynecomastia, can profoundly affect the psychosocial functioning of the individual. There has been From the Departments of Psychiatry and Surgery, The Edwin and Fannie Gray Hall Center for Human Appearance, Perelman School of Medicine at the University of Pennsylvania; and Division of Plastic Surgery, Children’s Hospital of Philadelphia. Received for publication August 26, 2011; accepted August 26, 2011. Copyright ©2011 by the American Society of Plastic Surgeons

Lessons Learned from a Randomized Controlled Trial of Bariatric Surgery versus Intensive Lifestyle Modification for Individuals with Type 2 Diabetes

Objective: Relatively few Randomized Controlled Trials (RCTs) have compared bariatric surgery to lifestyle modification for weight loss and improvements in type 2 diabetes. The Surgery or Lifestyle Intervention for Diabetes (SOLID) RCT was designed to address this insufficiency by comparing (1) Roux-en-Y Gastric Bypass surgery (RYGB), (2) Adjustable Gastric Banding surgery (AGB), and (3) A non-surgical Intensive Lifestyle Modification (ILM) for weight loss on changes in weight and diabetes status. Methods: SOLID was a RCT for the first 24 months, but due to low enrollment, was modified to a prospective observational study for the last 12 months. Results: In total, 1,290 individuals inquired about the study and completed initial screening. Of these, 209 were eligible, however only 18 were enrolled in the trial (3 RYGB, 3 AGB, 12 ILM). Multiple barriers to patient enrollment were identified, including issues related to the eligibility criteria, reluctance to accept random assignment to the three interventions, and lack of insurance coverage or availability of funds to pay for the bariatric procedures. Conclusion: These issues warrant thoughtful attention from investigators who are planning future RCTs in this area.