Influence of mental and behavioral factors on weight loss after bariatric surgery: A systematic review and meta-analysis.

INTRODUCTION: Multiple factors are related to lower weight loss after bariatric surgery. This review and meta-analysis evaluates the influence of several mental and behavioral factors on weight loss. METHOD: Six electronic databases were searched. Percentage excess weight loss (%EWL) was calculated for all moderator and non-moderator groups of the variables: symptoms of depression, anxiety and binge eating, compliance, physical activity, quality of life, and body image. All moderators, surgery types, and follow-up moments were analyzed separately. RESULTS: In total, 75 articles were included in the review; 12 meta-analyses were conducted. Higher postoperative compliance to follow-up was associated with 6.86%-13.68% higher EWL. Preoperative binge eating was related to more weight loss at 24- and 36-month follow-up (7.97% and 11.79%EWL, respectively). Patients with postoperative binge eating symptoms had an 11.92% lower EWL. Patients with preoperative depressive symptoms lost equal weight compared to patients without symptoms. CONCLUSION: Despite the high heterogeneity between studies, a trend emerges suggesting that the presence of postoperative binge eating symptoms and lower postoperative compliance may be associated with less weight loss after bariatric-metabolic surgery. Additionally, preoperative depressive symptoms and binge eating do not seem to significantly impact weight loss.

The effect of suppressing negative emotions on eating behavior in binge eating disorder.

Overeating may be a consequence of the suppression of negative emotions, by depleting self-control resources. This experiment investigated whether (a) there is a causal relationship between the suppression of negative emotions, negative mood, and overeating in people with binge eating disorder (BED) and whether (b) this relationship is increased in depressed people with BED. Sixty-six women with (full and sub-threshold) BED were shown an upsetting movie and then asked either to suppress their emotions or to react naturally. Subsequently, everyone participated in a taste task. After a decline, initial mood before watching the movie was restored after eating. Depressive symptomatology was positively correlated with caloric intake. Within the clinically depressed (Beck Depression Inventory-score>19) BED group, those who were most affected by the negative mood induction consumed the most calories. No differences were found between the two conditions with regard to caloric intake. No interaction effect was found between depressive symptoms and mood suppression. The hypothesis that suppression of negative emotion leads to overeating in (depressed) binge eaters was not born out. Overeating may serve as a means to (temporary) repair negative mood.

Expectations, mood, and eating behavior in binge eating disorder. Beware of the bright side.

Sad people may indulge in fattening snacks because they believe that eating will repair their mood. To test whether (1) changes in expectations and mood had an effect on caloric intake and (2) depressive symptoms moderated caloric intake, 73 women with binge eating disorder were randomly assigned to a condition in which expectations about food and emotion were either confirmed or disconfirmed. Subsequently they were shown either an upsetting or an amusing movie clip followed by a taste task. Contrary to our expectations, there were no differences in the four conditions: participants in all four conditions ate comparable amounts of calories. Manipulation of expectations or mood had no effect on caloric intake. However, higher baseline expectations that food is pleasurable and useful as a reward resulted in a higher caloric intake after positive mood induction. Non-depressed individuals ate less after a negative mood induction than did depressed individuals. Interestingly, they also ate less than the group of individuals, depressed and not, whose mood was positively induced. Non-depressed individuals seem to use healthier coping strategies: negative affect signals that the environment poses a problem. Positive affect on the other hand signals that the environment is benign, and thus makes people less vigilant about food intake.

Weight Change After Roux-en Y Gastric Bypass, Physical Activity and Eating Style: Is There a Relationship?

BACKGROUND: Insufficient weight loss and weight regain is seen in 20-30% of the post-bariatric population. More knowledge about the effect of physical activity and eating style on weight change after Roux-en-Y gastric bypass is essential since behaviour can be modified and thereby results improved. The goal of this study is to determine the relationship between weight change, self-reported physical activity and eating style. METHODS: Weight, physical activity (PA) and eating style (ES) were assessed before surgery and 15, 24, 36 and 48 months after surgery. A linear mixed model was performed to assess the association between the change in PA and ES and percentage total weight loss (% TWL). RESULTS: There were 4569 patients included. Preoperative PA and ES were not related to weight change. Change in PA was positively associated with % TWL at 15, 36 and 48 months follow-up. Change in emotional eating was negatively related to % TWL at all follow-up moments. Change in external eating was only negatively related to weight loss at 24 months follow-up. Change in restrained eating was negatively associated with weight loss up to 36 months follow-up. More restrained eating at 36 months follow-up was related to higher weight regain, and more emotional eating at 48 months to 48-month weight regain. CONCLUSION: Preoperative self-reported PA and ES did not predict weight change after RYGB. Being are more physically active and showing less emotional and restrained eating was related to a higher weight loss. Emotional and restrained eating were related to higher weight regain.

Body Contouring Surgery after Massive Weight Loss: Excess Skin, Body Satisfaction, and Qualification for Reimbursement in a Dutch Post-Bariatric Surgery Population.

BACKGROUND: Body contouring surgery improves quality of life, weight loss, and body image after bariatric surgery. It is unclear why only a minority of the post-bariatric surgery population undergoes body contouring surgery. This study assesses overhanging skin, body satisfaction, and qualification for reimbursement of body contouring surgery in a Dutch post-bariatric surgery population. METHODS: Post-bariatric patients were selected from a prospective database. Electronic questionnaires evaluated demographics, desire for body contouring surgery, excess skin, and satisfaction with their body. RESULTS: A total of 590 patients were included: 368 patients (62.4 percent) desired body contouring surgery, 157 (26.6 percent) did not and 65 (11.0 percent) had undergone body contouring surgery. There were no significant differences between the groups regarding the percentage of patients who met the qualifications for reimbursement. Patients who desired body contouring surgery had more body parts affected by overhanging skin and more often rated the overhanging skin with a Pittsburgh Rating Scale grade 3 compared with patients without a desire to undergo body contouring surgery. The plastic surgeon was never consulted by 39.1 percent of the "desire" population; 44.1 percent of these patients met the weight criteria. CONCLUSIONS: Post-bariatric patients who desired body contouring surgery had more excess skin than patients without a desire and were less satisfied with their body. Almost half of these patients never consulted a plastic surgeon, partly because of incorrect assumptions regarding reimbursement. Plastic surgeons (together with bariatric teams) should better inform these patients about body contouring surgery possibilities.

Body image dissatisfaction and depression in postbariatric patients is associated with less weight loss and a desire for body contouring surgery.

BACKGROUND: Overhanging skin in postbariatric patients leads to a negative body image. In patients with obesity, negative body image is related to more depressive symptoms and a higher weight. This relationship might also be important in postbariatric patients, because improvement of body image via body contouring surgery (BCS) could lead to better weight loss results. OBJECTIVES: To evaluate the relationship between body image, depressive symptoms, and weight loss in a postbariatric population, focusing on desire for BCS. SETTING: Outpatient clinic. METHODS: One thousand twenty-four primary bariatric surgery patients were contacted, and 590 patients agreed to participate and filled in online questionnaires regarding body image (Body Shape Questionnaire and Multidimensional Body-Self Relations Questionnaire-Appearance Scales) and depression (Beck Depression Inventory-II). Differences between patients who had BCS, patients who desired BCS, and patients who did not desire BCS were studied. The mediating role of body image in the association between percentage total weight loss and depressive symptoms was assessed via a 2-mediator model. RESULTS: There was a desire for BCS in 368 patients (62.4%); these patients had significantly lower scores on appearance evaluation and body image satisfaction scales and showed more depressive symptoms. Patients without a desire (n = 157, 26.6%) had lowest rates of depressive symptoms and a more positive body image. Sixty-five patients (11.0%) had undergone BCS. In the patients who desired BCS, percentage total weight loss was negatively affected by depressive symptoms via appearance evaluation and body-area satisfaction. CONCLUSIONS: There are striking differences regarding body image satisfaction and depressive symptoms when comparing postbariatric patients and without desire for BCS. Body image satisfaction is associated with less depressive symptoms in all postbariatric patients. In patients who desired BCS, body image is one of the mediators of the relationship between percentage total weight loss and depressive symptoms. Therefore, body image should be taken seriously and be part of outcome assessment in postbariatric patients.

Attentional re-training decreases attentional bias in heavy drinkers without generalization.

AIMS: To examine whether alcohol-related attentional bias (AB) can be reduced by training heavy drinkers to attend to soft drinks as an alternative to alcohol. Diminishing AB is important because AB has been suggested to be a significant factor in the development, maintenance and relapse of addictive behaviours. AB was trained in a clinically relevant design, and we studied the generalization of this training. DESIGN, PARTICIPANTS AND INTERVENTION: We assigned randomly 106 heavy drinking male college and university students to the attentional re-training (AR; modified visual-probe task) or control condition (standard visual-probe task). SETTING: Laboratory at Maastricht University. MEASUREMENTS: We measured the effects of AR on the visual-probe task with stimuli that were presented in the AR and with new stimuli, and on an alternative measure of AB, the flicker paradigm. We further measured effects on craving and preference for either an alcohol beverage or a soft drink. FINDINGS: After AR, participants had learned to avoid alcohol stimuli and had developed an AB for soft drinks. This effect was restricted to stimuli used in the AR. The flicker task, where AB for alcohol was found in both the AR and control groups, was not affected by the AR. No effect was found on craving and the preference task. CONCLUSIONS: Although heavy drinkers can learn to attend selectively to an alternative category for alcohol, a single AR is not sufficient to decrease symptoms of problem drinking.

Improvement of Health-Related Quality of Life After Roux-en-Y Gastric Bypass Related to Weight Loss.

INTRODUCTION: Effect of bariatric surgery on health-related quality of life (HRQOL) varies greatly. This might be caused by the diversity in questionnaires used to assess HRQOL and the weight loss of the studied population. This study assesses the relationship between weight loss and HRQOL in primary Roux-en-Y gastric bypass (RYGB) patients by using an obesity-specific (impact of weight on quality of life-lite, IWQOL-lite) and a generic (RAND-36) questionnaire. METHODS: HRQOL and weight parameters were assessed before and 15 and 24 months after RYGB surgery. HRQOL was assessed by using IWQOL-lite (an obesity-specific questionnaire consisting of one total score and five domains) and RAND-36 (a generic questionnaire consisting of two subtotal scores, the physical health summary (PHS) and mental health summary (MHS), and nine scales). RESULTS: Two thousand one hundred thirty-seven patients were included. HRQOL improved significantly after RYGB. Preoperative BMI was negatively related to baseline PHS (p < 0.001) and IWQOL-lite total (p < 0.001). Percentage total weight loss (%TWL) was positively related to HRQOL score at both follow-up moments. Change in HRQOL from baseline to 24 months was related to %TWL at 24 months in both subtotals of RAND-36 and IWQOL-lite total score (p ≤ 0.001 in all). CONCLUSION: HRQOL improves after RYGB. Higher %TWL is related to greater improvement in HRQOL and better HRQOL 15 and 24 months after RYGB. The variance in the effect of RYGB surgery on HRQOL can be explained by the questionnaire used and weight loss of the population.

Effect of cue exposure, urge to smoke, and nicotine deprivation on cognitive performance in smokers.

The primary aim of this investigation was to test the hypothesis that the urge to smoke interferes directly with cognitive performance. Fifty-four smokers were randomly assigned to 1 of 3 groups: (a). ad lib, (b). deprived, or (c). nicotine patch. Participants rated their urge to smoke on continuous visual analogue scales. Cognitive performance was determined by measuring reaction times (RTs) on a Sternberg task. The deprived group reported a higher urge and had longer RTs than the ad lib group when exposed to smoking-related cues. However, the nicotine patch group reported a higher urge in the absence of longer RTs. The results indicated that nicotine deprivation affects cognitive performance and that the urge to smoke only partially mediated RTs.

Increasing the efficacy of cue exposure treatment in preventing relapse of addictive behavior.

Theoretically, cue exposure treatment should be able to prevent relapse by extinguishing conditioned drug responding (e.g. cue-elicited craving). According to contemporary learning theory, though, extinction does not eliminate conditioned responding. Analogous cue exposure with response prevention (CERP) as a treatment of addictive behavior might not eliminate the learned relation between drug-related cues and drug use. This does not necessarily mean that cue exposure cannot successfully prevent relapse. Various suggestions for increasing the efficacy of cue exposure treatment are being discussed from a contemporary learning theory perspective. It is suggested that cue exposure treatment incorporating retrieval cues can be a beneficial treatment in preventing relapse of addictive behavior.

Implicit measures of association in psychopathology research.

Studies obtaining implicit measures of associations in Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision; American Psychiatric Association, 2000) Axis I psychopathology are organized into three categories: (a) studies comparing groups having a disorder with controls, (b) experimental validity studies, and (c) incremental and predictive validity studies. In the first category, implicit measures of disorder-relevant associations were consistent with explicit beliefs for some disorders (e.g., specific phobia), but for other disorders evidence was either mixed (e.g., panic disorder) or inconsistent with explicit beliefs (e.g., pain disorder). For substance use disorders and overeating, expected positive and unexpected negative associations with craved substances were found consistently. Contrary to expectation, implicit measures of self-esteem were consistently positive for patients with depressive disorder, social phobia, and body dysmorphic disorder. In the second category, short-term manipulations of disorder-relevant states generally affected implicit measures as expected. Therapeutic interventions affected implicit measures for one type of specific phobia, social phobia, and panic disorder, but not for alcohol use disorders or obesity. In the third category, implicit measures had predictive value for certain psychopathological behaviors, sometimes moderated by the availability of cognitive resources (e.g., for alcohol and food, only when cognitive resources were limited). The strengths of implicit measures include (a) converging evidence for dysfunctional beliefs regarding certain disorders and consistent new insights for other disorders and (b) prediction of some psychopathological behaviors that explicit measures cannot explain. Weaknesses include (a) that findings were inconsistent for some disorders, raising doubts about the validity of the measures, and (b) that understanding of the concept "implicit" is incomplete.