Person-First Treatment Strategies: Weight Bias and Impact on Mental Health of People Living with Obesity.

Stigma and bias surrounding body weight is both explicit and implicit, but the most concerning impact on individuals is internalized stigma which is correlated with poor physical and mental health. Strategies to combat this public health concern include increasing awareness, education around the complex disease of obesity, proper use of communication and language surrounding weight, health, and treatment approaches, addressing equipment and practices in the clinical environment, and larger, systemic approaches to policy. Addressing stigma for a condition impacting the majority of our population is critical for the best health and well-being of our patients and ourselves.

Weight Loss Prior to Bariatric Surgery and 30-Day Mortality, Readmission, Reoperation, and Intervention: an MBSAQIP Analysis of 349,016 Cases.

INTRODUCTION: Despite preoperative weight loss being a common prerequisite to metabolic and bariatric surgery, its relationship to 30-day postoperative outcomes is unclear. The aim of this study was to assess whether preoperative weight loss is associated with 30-day postoperative quality outcomes in adults undergoing metabolic and bariatric surgery. METHODS: Retrospective cohort study assessing adults who underwent Roux-en-Y gastric bypass or sleeve gastrectomy in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use File, years 2015-2017. The relationship between preoperative weight loss and 30-day readmission, reoperation, mortality, intervention, and morbidity was assessed using multivariable logistic regression. RESULTS: Preoperative weight loss, body mass index loss, and percent weight loss were not associated with 30-day postoperative overall readmission, reoperation, mortality, or intervention (p > 0.01). Preoperative percent weight loss was associated with increased incidence of superficial surgical site infections (OR = 1.023, 95% CI 1.009-1.036; p = 0.001) and urinary tract infections (OR = 1.044, 95% CI 1.030-1.059; p < 0.001). CONCLUSION: Weight loss prior to metabolic and bariatric surgery may not be necessary or safe for all patients. Unsafe weight loss prior to surgery may compromise nutrition status and lead to increased infection rates.

Nutrition Care in Bariatric Surgery: An Academy Evidence Analysis Center Systematic Review.

Obesity continues to be a major public health crisis, both nationally and globally. Metabolic and bariatric surgery has been proven to be a safe and effective treatment for this multifactorial chronic disease. However, inconsistent and varied results in bariatric nutrition literature have prevented the implementation of standardized guidelines. The purpose of this Evidence Analysis Library systematic review is to provide an evidence-based summary of nutrition-related practices in bariatric surgery. The systematic review methodology of the Academy of Nutrition and Dietetics was applied. A total of 27 research studies were included, analyzed, and assessed for risk of bias by trained evidence analysts. The literature included in the systematic review was published from 2003 to 2015. Evaluation of the literature resulted in the development of five graded conclusion statements. Limited research demonstrates that registered dietitian nutritionists play a role in improving weight loss outcomes after bariatric surgery; further research is needed to understand the role of registered dietitian nutritionists in changing behaviors after bariatric surgery. Bariatric surgery results in significant reductions in resting metabolic rate and postoperative energy intake. There is no significant relationship between macronutrient distribution and postoperative weight loss. The graded conclusion statements provide registered dietitian nutritionists who practice in the field of bariatric nutrition with more insight and evidence that can guide and support their recommendations.

Can Hypocaloric, High-Protein Nutrition Support Be Used in Complicated Bariatric Patients to Promote Weight Loss?

Bariatric surgery, an effective treatment for morbid obesity, may result in complications that require nutrition support. Common goals for nutrition support in post-bariatric surgery patients include nutrition repletion, avoiding overfeeding, preserving lean body mass, and promoting wound healing. It is often questioned if continued weight loss can be part of the nutrition goals and if weight loss is safe for patients who become critically ill following bariatric surgery. Recent clinical practice guidelines from both the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and Society of Critical Care Medicine (SCCM) have recommended the use of hypocaloric, high-protein nutrition support in both critically and non-critically ill obese patients. Hypocaloric feedings of 50%-70% of estimated energy requirements based on predictive equations or <14 kcal/kg actual body weight, as well as high-protein feedings of 1.2 g/kg actual weight or 2-2.5 g/kg ideal body weight, are suggested by A.S.P.E.N. in the 2013 clinical guidelines for nutrition support of hospitalized adult patients with obesity. Two small studies in complicated post-bariatric surgery patients requiring nutrition support have shown that the strategy of hypocaloric, high-protein feedings can result in positive outcomes, including positive nitrogen balance, wound healing, weight loss, and successful transition to oral diets. Additional research, including large, randomized studies, is still needed to validate these findings. However, based on a review of available clinical practice guidelines, predictive equations, indirect calorimetry, case studies, and systematic reviews, hypocaloric, high-protein nutrition support appears to at least be equal to eucaloric feedings and may be a useful tool for clinicians to achieve continued weight loss in complicated bariatric surgery patients requiring nutrition support.

Emotional eating, marital status and history of physical abuse predict 2-year weight loss in weight loss surgery patients.

BACKGROUND: Weight loss surgery (WLS) is an effective weight loss treatment for individuals with severe obesity. Psychosocial factors can affect short-term WLS outcomes. This study sought to identify psychosocial predictors of medium-term outcomes. METHODS: In this prospective study, 250 consecutive WLS candidates were evaluated between January 1, 2010 and December 31, 2010. Each completed baseline medical, surgical, and psychological evaluations as part of standard of care. Two hundred and four patients had surgery (81.6%). Successful surgical outcome was defined as ≥50% excess weight loss two years post-surgery. RESULTS: Comparison of study sample (n=80) and those lost to follow-up (n=124) revealed negligible differences across baseline characteristics. At follow-up, 60% (n=48) of the sample was classified as a success with an average of 72.58% (std dev=13.01%) excess weight lost. The remaining 40% (n=32) was classified as a failure with an average of 33.98% (std dev=13.19%) excess weight lost. Logistic regression revealed that pre-surgical marital status, emotional eating, and history of physical abuse were independently associated with outcome variables, p<0.05. CONCLUSIONS: Being married, perhaps as a proxy for social support, is associated with 6.9 times increased odds of medium-term WLS success and emotionally driven disordered eating patterns are associated with 7.4 times increased odds of medium-term WLS success. A history of physical abuse is associated with an 84% decreased odds of successful medium-term outcomes. Further research that studies both the quality and impact of spousal support on weight loss as well as longer-term effects of emotional eating on outcomes is needed. Addressing longer-standing consequence of abuse may improve WLS outcomes.

A closer look at the nature of anxiety in weight loss surgery candidates.

OBJECTIVE: Depression among weight loss surgery (WLS) candidates is common. Anxiety in this population is less studied. Untreated anxiety persists post-surgery and is associated with poor surgical outcomes. The current study sought to explore the nature of anxiety in WLS candidates. Given shared symptoms of anxiety and obesity, we hypothesized that physiological symptoms of anxiety would be most common. METHODS: In this retrospective study, the medical records of 174 pre-WLS candidates at a large medical center were reviewed. Each completed a comprehensive medical, surgical, and psychological evaluation as part of standard of care. Data from these evaluations were abstracted. One hundred forty-three candidates completed the Beck Anxiety Inventory (BAI). A Principal Components Analysis (PCA) with varimax rotation was used to identify the factor structure of the BAI. RESULTS: The sample consisted of primarily middle-aged (46.0 ± 13.24 years), married (60.8%), Caucasian (65.7%), females (79%) with Class III obesity (Body Mass Index = 50.1 ± 10.68) and mild anxiety (8.86 ± 8.70). Forty-four percent of the sample endorsed clinically significant anxiety. PCA revealed a four-factor structure that explained 56.28% of the variance in the BAI. The four factors were: 1) cognitive-emotional distress, 2) autonomic hyperarousal, 3) neurophysiologic concerns, and 4) body temperature. CONCLUSIONS: Clinically significant anxiety is common among WLS candidates. Cognitive-emotional clustering of anxiety symptoms was more common than hypothesized. This is notable given the overlap of physiological symptoms of anxiety and obesity. Findings lend support for the utility of psychotherapeutic approaches tailored to address maladaptive thoughts to address anxiety and potentially improve WLS outcomes.

Food cravings among bariatric surgery candidates.

PURPOSE: Food cravings are common, more prevalent in the obese, and may differ in those who pursue surgical treatment for obesity. Food craving tools are most often validated in non-clinical, non-obese samples. METHODS: In this retrospective study, 227 bariatric surgery candidates at a large medical center completed the Food Cravings Questionnaire-Trait (FCQ-T). The aim was to explore the factor structure of the FCQ-T. RESULTS: Principal components analysis with varimax rotation revealed a seven-factor structure that explained 70.89 % of the variance. The seven factors were: (1) preoccupation with food, (2) emotional triggers, (3) environmental cues, (4) loss of control, (5) relief from negative emotions, (6) guilt, and (7) physiological response. The preoccupation with food factor accounted for 49.46 % of the variance in responses. CONCLUSIONS: Unlike other populations, food cravings in bariatric surgery candidates appear to be related most to preoccupations with food.

Presurgical Weight Is Associated with Pain, Functional Impairment, and Anxiety among Gastric Bypass Surgery Patients.

Chronic pain and obesity are significant public health concerns in the United States associated with significant levels of health-care expenses and lost productivity. Previous research suggests that obesity is a risk factor for chronic pain, mainly due to excessive weight placed on the joints. However, the obesity-pain relationship appears to be complex and reciprocal. Little work to date has focused on the relationship between weight and pain among patients undergoing gastric bypass surgery for weight loss. Patients scheduled to undergo bariatric surgery for weight loss at a large southeastern academic medical center (N = 115) completed the Brief Pain Inventory (BPI), the Center for Epidemiological Studies 10-item Depression scale (CESD-10), and the Beck Anxiety Inventory (BAI). Higher presurgical weight was associated with higher pain-on-average ratings, higher functional impairment due to pain across the domains of physical activity, mood, walking ability, relationships, and enjoyment of life. Higher presurgical weight was associated with higher BAI scores, but weight was not related to depression. Findings suggest that bariatric surgery candidates report a moderate amount of pain prior to surgery and that presurgical weight is associated with higher pain, increased functional impairment due to pain, and increased anxiety. Anxiety was found to mediate the relationship between increased weight and pain.

The Food Craving Questionnaire-Trait in a bariatric surgery seeking population and ability to predict post-surgery weight loss at six months.

Food cravings have been understudied in bariatric surgery patients and the Food Craving Questionnaire-Trait has not been validated in this population. Reliability and validity of the FCQ-T were examined and a regression analysis was run to determine whether or not preoperative scores on individual subscales of the instrument could predict weight loss at 6 months. The FCQ-T demonstrated excellent internal consistency in bariatric surgery-seeking patients, and individual subscales measuring emotion and mood were correlated with other measures of depression and anxiety. Endorsement of binge eating or emotional eating behaviors during a clinical interview was correlated with similar subscales on the FCQ-T. Higher scores on the subscale 'cues that may trigger food cravings' were associated with greater weight loss at 6 months post-surgery and higher scores on the subscale 'guilt from cravings and/or giving into them' was associated with less weight loss. Management of external cues may predict successful outcomes while emotional impact of cravings may indicate the need for further intervention to help manage specific food craving traits.

Patients who endorse more binge eating triggers before gastric bypass lose less weight at 6 months.

BACKGROUND: Patients presenting for gastric bypass surgery often demonstrate binge eating behaviors. The present study sought to determine whether binge eating triggers are predictive of weight loss outcomes in bariatric surgery patients at 6 months postoperatively in the setting of a university hospital. METHODS: A total of 48 patients presenting for gastric bypass surgery at an academic medical center in the Southeastern United States and who had returned for the 6-month follow-up visit were included in the present study. The patients were mostly women (85%), white (71%), and middle-aged (mean age 47 years), with an average weight of 100.9 kg. The patients completed the Inventory of Binge Eating Situations at baseline, and weight loss outcomes were assessed at 6 months. Weight loss success was indexed using 2 methods: the percentage of excess weight lost (continuous variable) and whether the patient was on track with their weight loss as defined by a ≥ 50% excess weight loss (dichotomous variable). RESULTS: A significant negative correlation (r = -.31, P = .03) was found between the preoperative Inventory of Binge Eating Situations scores and the percentage of excess weight loss at 6 months after gastric bypass surgery. Logistic regression analysis showed that "on track" status at 6 months was predicted by the Inventory of Binge Eating Situations score at baseline (Wald chi-square = 3.97, df = 1, P = .046). CONCLUSION: Careful assessment of binge eating situations could serve as a potential predictor of poor weight loss outcomes in patients seeking gastric bypass surgery. These findings support the baseline assessment of binge eating triggers and future research to examine the effectiveness of interventions for coping with binge eating triggers for gastric bypass surgery patients.