Kathleen Ashton

Alcohol and bariatric surgery: review and suggested recommendations for assessment and management

BACKGROUND Established clinical guidelines identify current alcohol abuse and dependence as contraindications for weight loss surgery. However, guidance on how to best assess alcohol use in bariatric patients has not been elucidated. Furthermore, concerns with postoperative alcohol use/abuse and increased sensitivity warrant the development of recommendations on appropriate interventions for patients pursuing weight loss surgery. Our objective was to review the current data on bariatric surgery and substance abuse/addiction, with an emphasis on alcohol use, offer guidance on how to assess the risk of such problems, and provide preliminary recommendations on treating high-risk patients. METHODS The relevant published data on alcohol use, abuse, and dependence in pre- and postoperative bariatric patients was reviewed. Also, the putative mechanisms of increased alcohol sensitivity after weight loss surgery were examined. RESULTS Although current alcohol abuse/dependence is less than that in population-base rates, bariatric surgery candidates have a greater history of alcohol use disorders. Physiologic changes after surgery can also change vulnerability to problematic alcohol use, and many patients continue to consume alcohol after surgery. Assessment techniques and strategies to provide informed consent and education on alcohol were included from the Bariatric and Metabolic Institute at the Cleveland Clinic. CONCLUSION Weight loss surgery candidates might have a greater lifetime risk of alcohol use disorders and greater sensitivity to the intoxicating effects of alcohol after surgery. Adequate screening, assessment, and preoperative preparation could help mitigate this risk. Future research should examine the efficacy of such risk management strategies.

History of substance abuse relates to improved postbariatric body mass index outcomes

BACKGROUND Recent clinical guidelines have identified current alcohol or substance abuse as contraindications for weight loss surgery. Past research has indicated that a lifetime history of any substance use disorder is significantly greater in those seeking weight loss surgery than the population base rate. However, current substance abuse has been reported to be remarkably low (<1%). The objective was to examine whether a history of substance abuse/dependence is associated with differing weight loss outcomes after bariatric surgery. METHODS A total of 413 patients who had undergone weight loss surgery (75.8% women, 77.7% white, mean age 47.72 years, mean body mass index 50.27 kg/m(2)) at the Cleveland Clinic Bariatric and Metabolic Institute completed a psychological evaluation before surgery, and a history of substance abuse and/or dependence was determined. RESULTS A series of analyses of covariance examining group differences in the percentage of excess weight loss (%EWL) at 1, 3, 6 , 9, and 12 months after surgery were conducted comparing a history of substance abuse/dependence (SA+; n = 45) with the absence of a substance abuse/dependence history (SA-; n = 368), controlling for the baseline body mass index. The groups did not differ in the type of surgery or %EWL at 1 and 3 months of follow-up. However, after adjusting for the baseline body mass index, the patients with a substance abuse history had a significantly greater %EWL at 6 and 9 months postoperatively, with a trend toward significance at the 12-month follow-up visit. CONCLUSION Patients with a substance abuse/dependence history had a greater %EWL from 6 months postoperatively onward. Future research should examine longer term outcomes among SA+ patients and the possible explanations for their short-term improved outcomes compared with SA- patients.

Impact of using DSM-5 criteria for diagnosing binge eating disorder in bariatric surgery candidates: Change in prevalence rate, demographic characteristics, and scores on the minnesota multiphasic personality inventory – 2 restructured form (MMPI-2-RF)

OBJECTIVE Binge eating disorder (BED) was recently included in the DSM-5. The prevalence rate for BED using the DSM-IV-TR research criteria tends to be higher in bariatric surgery candidates than the normative population; however, no studies have examined how many more bariatric surgery candidates will meet the new, less conservative criteria of DSM-5. We explore the current BED prevalence rate change in a sample of bariatric surgery candidates. METHOD Data were obtained for 1,283 bariatric surgery candidates. 84 men and 213 women were diagnosed with current BED using DSM-IV-TR research criteria. A semi-structured interview, the binge eating scale (BES), and a Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) were given to every patient as part of standard procedures mandated by the facility. RESULTS AND DISCUSSION An additional 3.43% (p < .001) of bariatric surgery candidates met the diagnostic threshold for BED when using DSM-5 criteria. These individuals were demographical similar and produced similar MMPI-2-RF and BES scores when compared with patients who met DSM-IV-TR criteria for BED. Thus, the current investigation indicates that individuals meeting BED criteria based on DSM-5 are similar to those meeting the more conservative diagnostic threshold outlined in DSM-IV-TR in a sample of bariatric surgery candidates.

Predicting One and Three Month Postoperative Somatic Concerns, Psychological Distress, and Maladaptive Eating Behaviors in Bariatric Surgery Candidates with the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF)

BackgroundPresurgical psychological screening of bariatric surgery candidates includes some form of standardized psychological assessment. However, associations between presurgical psychological screening and postoperative outcome have not been extensively studied. Here, we explore associations between presurgical Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) scores and early postoperative Somatic Concerns, Psychological Distress, and Maladaptive Eating Behaviors.MethodsThe sample consisted of male (n = 238) and female (n = 621) patients who were administered the MMPI-2-RF at their presurgical psychological evaluation and received bariatric surgery. Patients were evaluated at their 1- and 3-month postoperative appointments.ResultsConfirmatory factor analysis indicated that three latent constructs—somatic concerns, psychological distress, and maladaptive eating behaviors—were represented by responses to a postoperative assessment and that these constructs could be measured consistently over time. Presurgical scores on MMPI-2-RF scales measuring internalizing dysfunction were associated with more psychological distress at postoperative follow-ups, scores on scales measuring somatization were associated with more postoperative somatic concerns, and scores on scales assessing emotional/internalizing, behavioral/externalizing, cognitive complaints, and thought dysfunction prior to surgery were associated with maladaptive eating behaviors after surgery.ConclusionsIn conjunction with a presurgical psychological interview, the MMPI-2-RF provides information that can assist in anticipating postoperative outcomes and inform efforts to prevent them.

Using presurgical psychological testing to predict 1-year appointment adherence and weight loss in bariatric surgery patients: predictive validity and methodological considerations

BACKGROUND Previous studies suggest that presurgical psychopathology accounts for some of the variance in suboptimal weight loss outcomes among Roux-en-Y gastric bypass (RYGB) patients, but research has been equivocal. OBJECTIVES The present study seeks to extend the past literature by examining associations between presurgical scale scores on the broadband Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and suboptimal weight loss and poor adherence to follow-up 1 year postoperatively after accounting for several methodologic considerations. SETTING Cleveland Clinic Bariatric and Metabolic Institute, Cleveland, Ohio, USA. METHODS The sample consisted of 498 RYGB patients, who produced a valid presurgical MMPI-2-RF protocol at program intake. The sample was primarily female (72.9%), Caucasian (64.9%), and middle-aged (mean = 46.4 years old; standard deviation [SD] = 11.6). The mean presurgical body mass index (BMI) was 47.4 kg/m(2) (SD = 8.2) and mean percent weight loss (%WL) at 1 year postoperatively was 31.18 %WL (SD = 8.44). RESULTS As expected, scales from the Behavioral/Externalizing Dysfunction (BXD) domain of the MMPI-2-RF were associated with worse weight loss outcomes and poor adherence to follow-up, particularly after accounting for range restriction due to underreporting. Individuals producing elevated scores on these scales were at greater risk for achieving suboptimal weight loss (<50% excess weight loss) and not following up with their appointment compared with those who scored below cut-offs. CONCLUSIONS Patients who are more likely to engage in undercontrolled behavior (e.g., poor impulse control), as indicated by presurgical MMPI-2-RF findings, are at greater risk for suboptimal weight loss and poor adherence to follow-up following RYGB. Objective psychological assessments should also be conducted postoperatively to ensure that intervention is administered in a timely manner. Future research in the area of presurgical psychological screening should consider the impact of underreporting and other discussed methodologic issues in predictive analyses.

Minnesota multiphasic personality inventory‐2 restructured form (MMPI‐2‐RF) scale score differences in bariatric surgery candidates diagnosed with binge eating disorder versus BMI‐matched controls

OBJECTIVE Binge Eating Disorder (BED) is among the most common psychiatric disorders in bariatric surgery candidates. The Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) is a broadband, psychological test that includes measures of emotional and behavioral dysfunction, which have been associated with BED behaviors in bariatric surgery candidates; however these studies have lacked appropriate controls. In the current study, we compared MMPI-2-RF scale scores of bariatric surgery patients diagnosed with BED (BED+) with BMI-matched controls without BED (BED-). METHOD Three-hundred and seven BED+ participants (72.64% female and 67.87% Caucasian; mean BMI of 51.36 kg/m(2) [SD = 11.94]) were drawn from a large, database (N = 1304). Three-hundred and seven BED- participants were matched on BMI and demographics (72.64% female, 68.63% Caucasian, and mean BMI of 51.30 kg/m(2) [SD = 11.70]). RESULTS The BED+ group scored significantly higher on measures of Demoralization, Low Positive Emotions, and Dysfunctional Negative Emotions and scored lower on measures of Antisocial Behaviors, reflecting behavioral constraint. Optimal T-Score cutoffs were below the traditional 65 T score for several MMPI-2-RF scales. MMPI-2-RF externalizing measures also added incrementally to differentiating between the groups beyond the Binge Eating Scale (BES). DISCUSSION BED+ individuals produced greater elevations on a number of MMPI-2-RF internalizing scales and externalizing scales. Use of the test in conjunction with a clinical interview and other self-report data can further aid the clinician in guiding patients to appropriate treatment to optimize outcome.

Use of the MMPI-2-RF Suicidal/Death Ideation and Substance Abuse Scales in Screening Bariatric Surgery Candidates

Bariatric surgery patients are at increased risk for suicide and lifetime substance abuse problems, and these risks are surgical contraindications. The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) has scales to screen for these risks factors, among others. We seek to evaluate the classification accuracy of the MMPI-2-RF Suicidal/Death Ideation (SUI) and Substance Abuse (SUB) scales to optimize their use in bariatric surgery settings. Data were collected from 1,311 (72.1% female; 65.5% Caucasian) bariatric surgery candidates from the Cleveland Clinic as well as 295 (94.1% female; 85.9% Caucasian) bariatric surgery candidates from a private practice in St. Paul, Minnesota. Classification accuracies were calculated at original and revised SUI and SUB interpretative cutoffs in the Cleveland Clinic sample and replicated in the St. Paul sample. Significant and meaningful classification accuracy gains were demonstrated by excluding a death ideation item from the SUI scale and lowering the interpretive cutoff on the SUB scale. Practical implications and study limitations are discussed.

Replication and evaluation of a proposed two-factor Binge Eating Scale (BES) structure in a sample of bariatric surgery candidates

BACKGROUND The Binge Eating Scale (BES) is a widely-used self-report measure of binge eating severity. Hood et al. reported a 2-factor structure for the BES in a sample of bariatric surgery candidates, with factors labeled feelings/cognitions and behavioral manifestations. The present study aims to replicate and extend the factor structure obtained by Hood et al. by testing the utility of a bifactor model that removes binge eating severity variance, which the total BES score purports to assess, in another sample of bariatric surgery candidates. METHODS Bariatric surgery candidates (n = 517; 71.2% women; mean body mass index = 49.50 kg/m(2); SD = 10.17) were sampled. Twenty-four percent met DSM-IV-TR diagnostic criteria for binge eating disorder. RESULTS Consistent with previous research, a 2-factor structure for the BES was supported; however, the 2 factors were substantially correlated (r = .89). A bifactor model significantly improved model fit, supporting the presence of a higher-order severity factor accounting for a significant amount of variance. This factor was primarily marked by binge eating severity as demonstrated by associations with number of objective binge eating episodes and DSM-IV-TR diagnosis. In the bifactor model, the feelings/cognitions factor was modestly associated with self-reported mood psychopathology. However, contrary to expectations, the behavioral manifestation factor was not associated with empirically derived behavioral problems. CONCLUSIONS The current findings partially converge with those of Hood et al. However, the use of the BES as a 2-factor measure is not recommended at this point because of lack of incremental validity demonstrated by the behavioral manifestation factor. Continued use of the BES as a unidimensional measure of binge eating severity, in conjunction with a comprehensive clinical interview, can provide useful guidance for presurgical treatment recommendations.