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Surgical patients may have different psychological profiles

The researchers from the Charité—Universitätsmedizin Berlin, Berlin, Germany, published in PlosOne, have concluded that psychological factors are independent of somatic conditions in surgical patients compared to obese patients who prefer conservative treatment.

The authors claim that identifying predictors that could then be addressed prior to surgery could improve pre-surgical screening and the selection process, resulting in maintained weight loss after surgery. They claim that this treatment pathway may result in a more personalised medicine course, although longitudinal studies are required to assess the effectiveness of identifying psychological factors.

The authors stated that although psychological factors could influence the choice of treatment, to date, very few studies have been reported. The aim of this study was to analyse whether surgical patients differ from those who require a conservative treatment in regard to psychological and socio-demographic factors, regardless of their somatic conditions, such as personal and social resources, physical discomfort and mood.

In total, 244 patients (189 women), with a mean BMI 45.1, underwent a weight reduction treatment, with 126 patients undergoing bariatric surgery and 118 patients conservative treatment. In Germany, health insurance companies demand that patients who want to undergo surgery must be evaluated by a psychiatrist, clinical psychologist or a physician who specialises in psychosomatic medicine to determine their mental condition. All surgically treated patients has psychosomatic evaluation after the consultation by the surgeon, but prior to the operation.

Overall, 122 out of the 126 surgical patients underwent bariatric surgery and 4 patients received a gastric balloon. Restrictive surgery was performed in 110 patients (10 received laparoscopic adjustable gastric banding, 100 received laparoscopic Sleeve Gastrectomy). Twelve patients underwent a laparoscopic Roux-en-Y Gastric Bypass.

The one-year multimodal, conservative outpatient weight reduction programme was divided into four areas of intervention and application: advice on diet and training, movement therapy and training, psycho-education and behavioural therapy interventions, as well as Jacobson’s progressive muscle relaxation.

The outcomes revealed that surgically and conservatively treated obese patients differ in socio-demographic and somatic factors. Surgical patients were younger and more often male, had a lower educational level and were more likely to be unemployed.

Surgical patients also weighed significantly more, had higher BMIs and consulted more physicians due to their current complaints than the conservatively treated patients did. They also suffered significantly more often from type 2 diabetes mellitus, hypertension and coronary heart disease and less often from dyslipidaemia

Surgical patients also had less favourable scores on almost all of the psychological variables including having:

  • more “perceived feelings of hunger”
  • more “drive for thinness”
  • more “ineffectiveness”
  • more “perceived stress”
  • less “joy”
  • higher scores for “complaints” overall
  • more negative and less positive “mood”
  • more psychopathology
  • higher sub-scores for “anxiety syndrome” or “somatoform syndrome”.
  • more “depression”
  • less “mental health” and “physical health” (SF-8)
  • less “sense of coherence”
  • more “pessimism”; and
  • more “avoidant coping” and “delegated active coping”

After controlling for the confounding factors of BMI and type 2 diabetes mellitus, hypertension and coronary heart disease, the psychological differences persisted between the groups, which indicates that the differences are independent of these somatic conditions.

As shown in Table 2, the likelihood of having surgery increase by a factor of 54.34 if coupled with type 2 diabetes mellitus, apathy 47.2 times, degree of complaints by a factor of 1.15, sense of coherence by a factor of 8.35, delegated active coping increase the odds by 28.52 times, although age decreases the factor by 0.9 for each year the age increased.

The researchers report that psychological and somatic factors that equally predicted the choice of surgery were:

  • apathy
  • delegated active coping
  • a sense of coherence
  • complaints
  • type 2 diabetes mellitus
  • BMI; and
  • age

“In the present study, we found a great number of differences between surgically and conservatively treated obese patients regarding the psychological, somatic and socio-demographic factors,” the researchers note. “We demonstrated that psychological differences between the two groups persisted, even after controlling for BMI and obesity-related co-morbidities.”

They reported that surgical patients had significantly worse physical conditions before the intervention and that patients may expect surgery to result in rapid weight loss and pain relief. They also add that these patients may “tend to more strongly act out conflicts and the related negative emotions on a somatic level”. Nevertheless, they add that “it remains doubtful that bariatric surgery alone is a sufficient intervention strategy.”

There were no differences between the groups with regards to the prevalence of hyperphagic eating disorder, binge eating disorder, or other specific eating behaviours.

“The current study identified that psychological factors are independent of somatic conditions in obese patients who seek a surgical, rather than a conservative, weight reduction treatment.…The identification of predictors that can be therapeutically addressed before surgery to secure sufficient and sustained weight loss after the bariatric surgery is essential when determining treatment pathways for patients and may result in a more personalised medicine course,” the authors conclude.

Surgery can benefit some obese pediatric patients

As a last resort when conservative interventions have failed, bariatric surgery can improve liver disease and other obesity-related health problems in severely obese children and adolescents, according to a position paper in the Journal of Pediatric Gastroenterology and Nutrition, official journal of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

Due to the potential for serious complications, an expert panel recommends that bariatric surgery be reserved for carefully selected subgroups of young children with severe or morbid obesity and associated medical conditions. The recommendations appear in a new position paper authored by the ESPGHAN Hepatology Committee, under the leadership of Prof Valerio Nobili of Bambino Gesù Children’s Hospital, Rome.

The Committee, made up of 12 European specialists in paediatric liver disease, was tasked with reviewing and analyzing the available evidence on bariatric surgery for obese children and adolescents. The epidemic of childhood obesity has brought an increase in obesity-related diseases, including type 2 diabetes and nonalcoholic fatty liver disease (NAFLD).

“Recent evidence suggests that in carefully selected patients an early intervention by bariatric surgery can strongly reduce the risk of adulthood obesity and obesity-related diseases, including NAFLD,” Nobili and colleagues write.

Yet the appropriate use of bariatric surgery in paediatric patients remains unclear, mainly because of limited research data and the known risks of the procedure. Based on the available evidence and expert opinion, the position paper outlines a standardised approach to considering bariatric surgery in children and adolescents.