Michael J. Devlin

Psychopathology before surgery in the Longitudinal Assessment of Bariatric Surgery-3 (LABS-3) Psychosocial Study

BACKGROUND Current and previous psychopathology in bariatric surgery candidates is believed to be common. Accurate prevalence estimates, however, are difficult to obtain given that bariatric surgery candidates often wish to appear psychiatrically healthy when undergoing psychiatric evaluation for approval for surgery. Also, structured diagnostic assessments have been infrequently used. METHODS The present report concerned 199 patients enrolled in the longitudinal assessment of bariatric surgery study, who also participated in the longitudinal assessment of bariatric surgery-3 psychopathology substudy. The setting was 3 university hospitals, 1 private not-for-profit research institute, and 1 community hospital. All the patients were interviewed independently of the usual preoperative psychosocial evaluation process. The patients were explicitly informed that the data would not be shared with the surgical team unless certain high-risk behaviors, such as suicidality, that could lead to adverse perioperative outcomes were reported. RESULTS Most of the patients were women (82.9%) and white (nonwhite 7.6%, Hispanic 5.0%). The median age was 46.0 years, and the median body mass index was 44.9 kg/m2. Of the 199 patients, 33.7% had ≥1 current Axis I disorder, and 68.8% had ≥1 lifetime Axis I disorder. Also, 38.7% had a lifetime history of a major depressive disorder, and 33.2% had a lifetime diagnosis of alcohol abuse or dependence. All these rates were much greater than the population-based prevalence rates obtained for this age group in the National Comorbidity Survey-Replication Study. Also, 13.1% had a lifetime diagnosis and 10.1% had a current diagnosis of a binge eating disorder. CONCLUSION The current and lifetime rates of psychopathology are high in bariatric surgery candidates, and the lifetime rates of affective disorder and alcohol use disorders are particularly prominent. Finally, binge eating disorder is present in approximately 1 in 10 bariatric surgery candidates.

Improved memory function 12 weeks after bariatric surgery

BACKGROUND Growing evidence has shown that obesity is associated with poor neurocognitive outcomes. Bariatric surgery has been shown to be an effective intervention for morbid obesity and can result in improvement of many co-morbid medical conditions that are associated with cognitive dysfunction. The effects of bariatric surgery on cognition are unknown. METHODS We performed a prospective study total of 150 subjects (109 bariatric surgery patients enrolled in the Longitudinal Assessment of Bariatric Surgery project and 41 obese control subjects who had not undergone bariatric surgery). These 150 subjects completed a cognitive evaluation at baseline and at 12 weeks of follow-up. The demographic, medical, and psychosocial information was also collected to elucidate the possible mechanisms of change. RESULTS Many bariatric surgery patients exhibited impaired performance on cognitive testing at baseline (range 4.6-23.9%). However, the surgery patients were no more likely to exhibit a decline on ≥2 cognitive tests at 12 weeks of follow-up than were the obese controls [12.84% versus 23.26%; chi-square (1) = 2.51, P = .11]. Group comparisons using repeated measures multivariate analysis of variance showed that the surgery patients had improved memory performance at 12 weeks of follow-up [λ = .86, F(4, 147) = 5.88, P <.001]; however, the memory performance of the obese controls had actually declined. Regression analyses showed that the surgery patients without hypertension had better short delay recall at 12 weeks than those with hypertension [β = .31, P = .005], although the other demographic and medical variables were largely unrelated to the test performance. CONCLUSION The present results suggest that cognitive impairment is common in bariatric surgery patients, although these deficits might be at least partly reversible. Future studies are needed to clarify the underlying mechanisms, in particular, longitudinal studies using neuroimaging and blood markers.

The slippery slope: prediction of successful weight maintenance in anorexia nervosa

BACKGROUND Previous research has found that many patients with anorexia nervosa (AN) are unable to maintain normal weight after weight restoration. The objective of this study was to identify variables that predicted successful weight maintenance among weight-restored AN patients. METHOD Ninety-three patients with AN treated at two sites (Toronto and New York) through in-patient or partial hospitalization achieved a minimally normal weight and were then randomly assigned to receive fluoxetine or placebo along with cognitive behavioral therapy (CBT) for 1 year. Clinical, demographic and psychometric variables were assessed after weight restoration prior to randomization and putative predictors of successful weight maintenance at 6 and 12 months were examined. RESULTS The most powerful predictors of weight maintenance at 6 and 12 months following weight restoration were pre-randomization body mass index (BMI) and the rate of weight loss in the first 28 days following randomization. Higher BMI and lower rate of weight loss were associated with greater likelihood of maintaining a normal BMI at 6 and 12 months. An additional predictor of weight maintenance was site; patients in Toronto fared better than those in New York. CONCLUSIONS This study found that the best predictors of weight maintenance in weight-restored AN patients over 6 and 12 months were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. These results suggest that outcome might be improved by achieving a higher BMI during structured treatment programs and on preventing weight loss immediately following discharge from such programs.

Course of depressive symptoms and treatment in the longitudinal assessment of bariatric surgery (LABS-2) study.

To examine changes in depressive symptoms and treatment in the first 3 years following bariatric surgery.

Improved Memory Function Two Years After Bariatric Surgery

Obesity is as an independent risk factor for poor neurocognitive outcomes, including Alzheimers disease. Bariatric surgery has recently been shown to result in improved memory at 12‐weeks postoperatively. However, the long‐term effects of bariatric surgery on cognitive function remain unclear.

Racial/ethnic differences in adults in randomized clinical trials of binge eating disorder.

OBJECTIVE Recent studies suggest that binge eating disorder (BED) is as prevalent among African American and Hispanic Americans as among Caucasian Americans; however, data regarding the characteristics of treatment-seeking individuals from racial and ethnic minority groups are scarce. The purpose of this study was to investigate racial/ethnic differences in demographic characteristics and eating disorder symptoms in participants enrolled in treatment trials for BED. METHOD Data from 11 completed randomized, controlled trials were aggregated in a single database, the Clinical Trials of Binge Eating Disorder (CT-BED) database, which included 1,204 Caucasian, 120 African American, and 64 Hispanic participants assessed at baseline. Age, gender, race/ethnicity, education, body mass index (BMI), binge eating frequency, and Eating Disorder Examination (EDE) Restraint, Shape, Weight, and Eating Concern subscale scores were examined. RESULTS Mixed model analyses indicated that African American participants in BED treatment trials had higher mean BMI than Caucasian participants, and Hispanic participants had significantly greater EDE shape, weight, and eating concerns than Caucasian participants. No racial or ethnic group differences were found on the frequency of binge eating episodes. Observed racial/ethnic differences in BED symptoms were not substantially reduced after adjusting for BMI and education. Comparisons between the CT-BED database and epidemiological data suggest limitations to the generalizability of data from treatment-seeking samples to the BED community population, particularly regarding the population with lower levels of education. CONCLUSIONS Further research is needed to assess alternative demographic, psychological, and culturally specific variables to better understand the diversity of treatment-seeking individuals with BED.

Behavioral assessment of satiety in bulimia nervosa

The abnormalities in eating behavior associated with bulimia nervosa suggest that patients with this illness may have a disturbance in satiety. The present study employed a six-meal protocol to assess satiety in both binge and non-binge eating episodes in women with bulimia nervosa and normal controls by examining whether an increase in the size of a soup preload led to a decrease in the amount of food consumed in a subsequent test meal. In control subjects, the increase in preload size was associated with an increase in fullness and a reduction in consumption of the non-binge test meal. Patients did not report consistent changes in ratings of hunger and fullness in response to the change in preload size, and few patients were able to complete the non-binge meals and refrain from vomiting afterwards. When instructed to binge eat, patients ate considerably more than control subjects, but patients did significantly reduce their intake of the test meal after the large compared to the small preload. These findings demonstrate that, although patients with bulimia nervosa exhibit abnormalities in the development of satiety, some mechanisms responsible for the control of food intake are functional during binge eating episodes.

Cognitive function predicts weight loss after bariatric surgery.

BACKGROUND Clinically significant cognitive impairment is found in a subset of patients undergoing bariatric surgery. These difficulties could contribute to a reduced adherence to postoperative lifestyle changes and decreased weight loss. The present study is the first to prospectively examine the independent contribution of cognitive function to weight loss after bariatric surgery. Executive function/attention and verbal memory at baseline were expected to negatively predict the percentage of excess weight loss (%EWL) and body mass index (BMI) at follow-up. Three sites of the Longitudinal Assessment of Bariatric Surgery parent project were used: Columbia (New York, NY), Cornell (Princeton, NJ), and the Neuropsychiatric Research Institute (Fargo, ND). METHODS A total of 84 individuals enrolled in the Longitudinal Assessment of Bariatric Surgery project undergoing bariatric surgery completed a cognitive evaluation at baseline. The BMI and %EWL were calculated at the 12-week and 12-month postoperative follow-up visits. RESULTS Clinical impairment in task performance was most prominent in tasks associated with verbal recall and recognition (14.3-15.5% of the sample) and perseverative errors (15.5%). After accounting for demographic and medical variables, the baseline test results of attention/executive function and memory predicted the BMI and %EWL at 12 months but not at 12 weeks. CONCLUSIONS These results have demonstrated that baseline cognition predicts for greater %EWL and lower BMI 12 months after bariatric surgery. Additional work is needed to clarify the degree to which cognition contributes to adherence and the potential mediation of cognition on the relationship between adherence and weight loss in this group.

Aspectos psiquiátricos da obesidade

Pesquisas recentes mostram que a obesidade e, em grande parte, o produto da vulnerabilidade genetica mediada por um ambiente promotor da doenca, o que sugere que os modelos biologicos podem ser mais uteis que os psicologicos para entender seu inicio e manutencao. No entanto, entre os pacientes que procuram tratamento, a obesidade tem sido associada a outros transtornos psiquiatricos, especialmente a depressao, o que sugere que a comorbidade psiquiatrica deve ser considerada na avaliacao e no manejo clinicos. Alem disso, embora a obesidade nao seja em si mesma um transtorno alimentar, um subgrupo de individuos obesos, incluidos aqueles com o transtorno de compulsao alimentar periodica (TCAP) e com a sindrome do comer noturno - SCN (night eating syndrome - NES) sofrem de transtornos alimentares. Os psiquiatras podem e devem ter um papel ativo no tratamento da comorbidade ou de patologias relacionadas a alimentacao e no auxilio aos pacientes obesos para que facam escolhas de estilos de vida saudaveis que levem a um maior bem-estar em termos fisicos e psicologicos.

Cognitive Behavioral Therapy and Fluoxetine for Binge Eating Disorder: Two-year Follow-up

Objective: This study assessed the long‐term effects of group behavioral treatment plus individual cognitive behavioral therapy (CBT) and/or fluoxetine in binge eating disorder (BED) patients.