Transforming the landscape of obesity education - The Canadian obesity education competencies.

Background: With ongoing gaps in obesity education delivery for health professions in Canada and around the world, a transformative shift is needed to address and mitigate weight bias and stigma, and foster evidence-based approaches to obesity assessment and care in the clinical setting. Obesity Canada has created evidence-based obesity competencies for medical education that can guide curriculum development, assessment and evaluation and be applied to health professionals' education programs in Canada and across the world. Methods: The Obesity Canada Education Action Team has seventeen members in health professions education and research along with students and patient experts. Through an iterative group consensus process using four guiding principles, key and enabling obesity competencies were created using the 2015 CanMEDS competency framework as its foundation. These principles included the representation of all CanMEDS Roles throughout the competencies, minimizing duplication with the original CanMEDS competencies, ensuring obesity focused content was informed by the 2020 Adult Obesity Clinical Practice Guidelines and the 2019 US Obesity Medication Education Collaborative Competencies, and emphasizing patient-focused language throughout. Results: A total of thirteen key competencies and thirty-seven enabling competencies make up the Canadian Obesity Education Competencies (COECs). Conclusion: The COECs embed evidence-based approaches to obesity care into one of the most widely used competency-based frameworks in the world, CanMEDS. Crucially, these competencies outline how to address and mitigate the damaging effects of weight bias and stigma in educational and clinical settings. Next steps include the creation of milestones and nested Entrustable Professional Activities, a national report card on obesity education for undergraduate medical education in Canada, and Free Open Access Medication Education content, including podcasts and infographics, for easier adoption into curriculum around the world and across the health professions spectrum.

A scoping review of obesity education interventions for current and prospective medical professionals in Canada.

Background: Obesity is a prevalent chronic disease in Canada. Individuals living with obesity frequently interact with medical professionals who must be prepared to provide evidence-based and person-centred care options. The purpose of this scoping review was to summarize existing educational interventions on obesity in Canada for current and prospective medical professionals and to identify key future directions for practice and research. Methods: A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The search strategy was conducted using Medline (via PubMed), Embase, Eric, CBCA, Proquest Education, and Proquest Theses. The inclusion criteria included delivery of an educational intervention on obesity for current medical professionals, medical undergraduate trainees, or residents administered in Canada. Data were extracted from the included studies to thematically summarize the intervention content, and main outcomes assessed. Future directions for research and practice were identified. Results: Eight studies met the inclusion criteria. The interventions ranged in terms of the mode of delivery, including interactive in-person workshops and seminars, online learning modules, webinars, and videos. The main outcomes assessed were attitudes towards patients living with obesity, self-efficacy for having sensitive obesity-related discussions, skills to assess obesity and provision of management options. All studies reported improvements in the outcomes. Future directions identified were the need to develop standardized obesity competencies for inclusion across medical education programs, further research on effective pedagogical approaches to integrating content into existing curricula and the need for broader awareness and assessment of the quality of obesity education resources. Conclusion: Although there have been few obesity-specific educational interventions for current and prospective medical professionals in Canada, existing evidence shows positive learning outcomes. These findings advocate for continued investment in the development of obesity medical training and educational interventions.

C-L Case Conference: Insomnia Disorder.

We present the case of a 67-year-old male with a history of major depressive disorder, panic disorder, treatment refractory hypertension, dyslipidemia, benign prostatic hypertrophy, and environmental allergies who was initially brought to medical attention following an unwitnessed fall. He subsequently developed symptoms of insomnia disorder. Experts in consultation-liaison psychiatry and sleep medicine provide guidance for this clinical scenario based on their experience and a review of current literature, exploring the epidemiology of insomnia disorder and comorbidities in relation to this case. Furthermore, we offer a review of current treatment for insomnia disorder, including non-pharmacologic methods such as cognitive behavioral therapy for insomnia and pharmacotherapy.

Efficacy of Telephone-Based Cognitive Behavioral Therapy for Weight Loss, Disordered Eating, and Psychological Distress After Bariatric Surgery: A Randomized Clinical Trial.

Importance: Weight regain after bariatric surgery is associated with recurrence of obesity-related medical comorbidities and deterioration in quality of life. Developing efficacious psychosocial interventions that target risk factors, prevent weight regain, and improve mental health is imperative. Objective: To determine the efficacy of a telephone-based cognitive behavioral therapy (tele-CBT) intervention at 1 year after bariatric surgery in improving weight loss, disordered eating, and psychological distress. Design, Setting, and Participants: This multisite randomized clinical trial was conducted at 3 hospital-based bariatric surgery programs, with recruitment between February 2018 and December 2021. Eligibility for participation was assessed among 314 adults at 1 year after bariatric surgery who were fluent in English and had access to a telephone and the internet. Patients with active suicidal ideation or poorly controlled severe psychiatric illness were excluded. Primary and secondary outcome measures were assessed at baseline (1 year after surgery), after the intervention (approximately 15 months after surgery), and at 3-month follow-up (approximately 18 months after surgery). Data were analyzed from January to February 2023. Interventions: The tele-CBT intervention consisted of 6 weekly 1-hour sessions and a seventh booster session 1 month later. The control group received standard postoperative bariatric care. Main Outcomes and Measures: The primary outcome was postoperative percentage total weight loss. Secondary outcomes were disordered eating (Binge Eating Scale [BES] and Emotional Eating Scale [EES]) and psychological distress (Patient Health Questionnaire-9 item scale [PHQ-9] and Generalized Anxiety Disorder-7 item scale [GAD-7]). The hypotheses and data-analytic plan were developed prior to data collection. Results: Among 306 patients 1 year after bariatric surgery (255 females [83.3%]; mean [SD] age, 47.55 [9.98] years), there were 152 patients in the tele-CBT group and 154 patients in the control group. The group by time interaction for percentage total weight loss was not significant (F1,160.61 = 2.09; P = .15). However, there were significant interactions for mean BES (F2,527.32 = 18.73; P < .001), EES total (F2,530.67 = 10.83; P < .001), PHQ-9 (F2,529.93 = 17.74; P < .001), and GAD-7 (F2,535.16 = 15.29; P < .001) scores between the tele-CBT group and control group across all times. Conclusions and Relevance: This study found that tele-CBT delivered at 1 year after surgery resulted in no change in short-term weight outcomes but improved disordered eating and psychological distress. The impact of these psychosocial improvements on longer-term weight outcomes is currently being examined as part of this longitudinal multisite randomized clinical trial. Trial Registration: ClinicalTrials.gov Identifier: NCT03315247.

Mental health outcomes in revisional versus primary bariatric surgery patients: A matched case control study.

OBJECTIVE: To determine whether depression and anxiety symptoms differ between revisional bariatric surgery patients and primary bariatric surgery patients, as such mental health outcomes can have long-lasting impacts on weight loss and the overall success of bariatric surgery. METHODS: An exploratory matched case control study was performed with a total of 50 patients - 25 patients who had received revisional surgery and 25 who had received primary bariatric surgery. Revisional patients were matched with primary patients on sex, age (±7 years), pre-operative BMI (±8.0) and time since surgery. Mental health outcomes of depressive and anxiety symptoms, as measured by the Patient Health Questionnaire 9-Item scale (PHQ-9) and Generalized Anxiety Disorder 7-Item scale (GAD-7) respectively, were compared between groups. RESULTS: No significant differences were found between the revisional and primary bariatric surgery groups across time (pre-surgery, 1-year post-surgery, 2-year post-surgery and 3-years post-surgery) for GAD-7 (f = 0.045, p = 0.987) and PHQ-9 (f = 0.277, p = 0.842) scores. CONCLUSION: Primary and revisional bariatric surgery patients do not have significant differences in depressive and anxiety scores. Revisional bariatric surgery can thus be effective in the remission of comorbid mental health conditions as trajectories remain comparable up to 3-years following surgery.

Telephone-based cognitive behavioural therapy for patients with postoperative bariatric surgery to manage COVID-19 pandemic-related mental health issues and distress (TELE-BARICARE): a protocol for a randomised controlled trial.

INTRODUCTION: Bariatric surgery is currently the most effective treatment for obesity, and is performed yearly in over 8000 patients in Canada. Over 50% of those who live with obesity also have a history of mental health disorder. The COVID-19 pandemic has made it difficult for people living with obesity to manage their weight even after undergoing bariatric surgery, which combined with pandemic-related increases in mental health distress, has the potential to adversely impact obesity outcomes such as weight loss and quality of life. Reviews of virtual mental health interventions during COVID-19 have not identified any interventions that specifically address psychological distress or disordered eating in patients with obesity, including those who have had bariatric surgery. METHODS AND ANALYSIS: A randomised controlled trial will be conducted with 140 patients across four Ontario Bariatric Centres of Excellence to examine the efficacy of a telephone-based cognitive behavioural therapy intervention versus a control intervention (online COVID-19 self-help resources) in postoperative bariatric patients experiencing disordered eating and/or psychological distress. Patients will be randomised 1:1 to either group. Changes in the Binge Eating Scale and the Patient Health Questionnaire 9-Item Scale will be examined between groups across time (primary outcomes). Qualitative exit interviews will be conducted, and data will be used to inform future adaptations of the intervention to meet patients' diverse needs during and post-pandemic. ETHICS AND DISSEMINATION: This study has received ethics approvals from the following: Clinical Trials Ontario (3957) and the University Health Network Research Ethics Committee (22-5145), the Board of Record. All participants will provide written informed consent prior to enrolling in the study. Results will be made available to patients with bariatric surgery, the funders, the supporting organisations and other researchers via publication in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: NCT05258578.

The Impact of Telephone-Based Cognitive Behavioral Therapy on Mental Health Distress and Disordered Eating Among Bariatric Surgery Patients During COVID-19: Preliminary Results from a Multisite Randomized Controlled Trial.

BACKGROUND: Patients undergoing bariatric surgery have high rates of psychiatric comorbidity, which may increase their vulnerability to COVID-19-related mental health distress. Exacerbation of mental health distress and disordered eating could have significant negative effects on long-term weight management and quality of life for these patients if untreated. OBJECTIVE: To determine the efficacy of a telephone-based cognitive behavioral therapy (Tele-CBT) intervention in improving depressive, anxiety, and disordered eating symptoms during COVID-19. METHODS: Participants were recruited as part of a larger randomized controlled trial study (clinicaltrials.gov ID: NCT03315247) between March 2020 and March 2021 and randomized 1:1 to receive Tele-CBT or standard bariatric care. Outcomes of Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Emotional Eating Scale (EES), and Binge Eating Scale (BES) were measured at baseline, immediately post-intervention, and 3 months post-intervention. Linear mixed models were used to test the effect of intervention group, time, and group-by-time interaction for each outcome. RESULTS: Eighty-one patients were included in the intention-to-treat analysis. Mean (SD) age of participants was 47.68 (9.36) years and 80.2% were female. There were significant group-by-time interactions for all outcomes and significant differences between groups across time. There were significant decreases in mean GAD-7 (p = 0.001), PHQ-9 (p < 0.001), EES-Total (p = 0.001), EES-Anger (p = 0.003), EES-Anxiety (p < 0.001), EES-Depression (p < 0.001), and BES (p = 0.002) scores for the Tele-CBT group at post-intervention and follow-up when compared to baseline and the control group. CONCLUSION: Tele-CBT is a feasible and effective treatment for improving psychological distress and disordered eating among post-operative bariatric surgery patients during the COVID-19 pandemic.

Case report: asenapine and anticholinergic toxicity.

While antipsychotic medications have long been associated with anticholinergic effects, asenapine has been purported to have no capacity for muscarinic cholinergic antagonism based on in vitro studies. Research in rat brain tissue has yielded different results, with one study finding more cholinergic M1-5 binding in the medial prefrontal cortex, dorsolateral frontal cortex and hippocampal CA1 and CA3 areas than would be predicted from in vitro findings. Moreover, it is structurally similar to other anticholinergic antipsychotics such as loxapine and, to a lesser degree, quetiapine, olanzapine and clozapine. This case report describes the anticholinergic toxidrome in a patient treated with benztropine and paroxetine at stable doses, with the emergence of the toxidrome after upward titration of asenapine. A broad differential was considered. With further consideration of the history, time-course, clinical features and physical examination, the presentation is most indicative of the anticholinergic toxidrome. Although not employed, physostigmine, the antidote for anticholinergic delirium, could help to differentiate this toxidrome and serve as a diagnostic and therapeutic intervention. We have presented this case to highlight the importance for clinicians to integrate history and bedside examination data with principles of pharmacology. In particular, asenapine should be added to the list of compounds with recognized anticholinergic potential.

"If you're offered help, take it": A qualitative study examining bariatric patients' experience of telephone-based cognitive behavioural therapy.

The increased recognition of patients' mental health needs after bariatric surgery has resulted in the emergence of accessible psychosocial interventions; however, there is a dearth of literature on patient experience and satisfaction with these interventions. We explored patients' perceptions and experiences of telephone-based cognitive behavioural therapy (Tele-CBT) in this qualitative study. Ten participants from the Toronto Western Hospital Bariatric Surgery Program in Toronto, Canada who completed the Tele-CBT (ClinicalTrials.gov Identifier: NCT02920112) were individually interviewed from November 2014 to June 2016 until thematic saturation occurred (ie, no more new coding groups emerged). Interviews were transcribed, independently coded, checked for discrepancies, and analysed using grounded theory. Four themes emerged: (1) participants were generally satisfied with Tele-CBT (eg, therapeutic alliance, resources provided, relevance of therapy to their own bariatric journey), (2) participants noticed emotional, cognitive, and behavioural changes following therapy, (3) the optimal time to deliver the Tele-CBT was when weight loss plateaued, generally at one-year post-surgery, and (4) participants found the telephone modality convenient. CBT was generally found to be helpful and the telephone format increased convenience and accessibility. Patients reported learning skills and receiving resources that could help them improve their well-being following bariatric surgery.

The Bariatric Interprofessional Psychosocial Assessment of Suitability Scale predicts binge eating, quality of life and weight regain following bariatric surgery.

Presurgical psychosocial evaluations are an important component of bariatric care; yet, bariatric programs vary widely in their assessment and interpretation of psychosocial risk. There is a need for validated clinical tools that help to standardize and streamline the assessment of variables relevant to surgical outcomes. The present study contributes to the validation of the Bariatric Interprofessional Psychosocial Assessment of Suitability Scale (BIPASS), a novel presurgical psychosocial evaluation tool, by: (a) examining the psychometric properties and optimal cutoff score, and; (b) examining the ability of the BIPASS tool to predict outcomes 1 and 2 years postsurgery, including weight regain, quality of life, psychiatric symptoms and adherence to postsurgical follow-up appointments. The BIPASS was applied retrospectively to the charts of 179 consecutively referred patients to a metropolitan bariatric surgery programme. Internal consistency for the BIPASS was acceptable, and interrater reliability was excellent. Higher BIPASS scores predicted higher binge eating symptomatology and lower mental health-related quality of life at 1 year postsurgery, and weight regain at 2 years (all P < .01). The BIPASS did not predict adherence to postsurgical follow-up appointments. Findings suggest that the BIPASS can be used to identify patients at increased risk of disordered eating, poor quality of life and weight regain early in the postsurgical course, thereby facilitating patient education and appropriate interventions.

Food Addiction Is Associated with Binge Eating and Psychiatric Distress among Post-Operative Bariatric Surgery Patients and May Improve in Response to Cognitive Behavioural Therapy.

The current study examined clinical correlates of food addiction among post-operative bariatric surgery patients, compared the clinical characteristics of patients with versus without food addiction, and examined whether a brief telephone-based cognitive behavioural therapy (Tele-CBT) intervention improves food addiction symptomatology among those with food addiction. Participants (N = 100) completed measures of food addiction, binge eating, depression, and anxiety 1 year following bariatric surgery, were randomized to receive either Tele-CBT or standard bariatric post-operative care, and then, repeated the measure of food addiction at 1.25 and 1.5 years following surgery. Thirteen percent of patients exceeded the cut-off for food addiction at 1 year post-surgery, and this subgroup of patients reported greater binge eating characteristics and psychiatric distress compared to patients without food addiction. Among those with food addiction, Tele-CBT was found to improve food addiction symptomatology immediately following the intervention. These preliminary findings suggest that Tele-CBT may be helpful, at least in the short term, in improving food addiction symptomatology among some patients who do not experience remission of food addiction following bariatric surgery; however, these findings require replication in a larger sample.

Psychiatric Management of Bariatric Surgery Patients: A Review of Psychopharmacological and Psychological Treatments and Their Impact on Postoperative Mental Health and Weight Outcomes.

BACKGROUND: Bariatric surgery is an effective treatment for severe obesity; however, high rates of psychiatric comorbidity complicate bariatric surgery care. As a result, importance has been placed on the need for ongoing psychiatric support in patients undergoing bariatric surgery. Given the lack of conclusive presurgery psychosocial predictors of postoperative mental health outcomes, studies have now shifted their focus to understand the long-term psychosocial sequalae that arise after surgery. Increasing evidence has demonstrated the potential for psychiatric care to stabilize psychiatric symptoms and minimize patient distress. OBJECTIVE: To review psychopharmacological and psychological interventions for patients undergoing bariatric surgery and their impact on mental health and weight outcomes after surgery. METHODS: We performed a comprehensive literature search in Ovid MEDLINE for studies examining the impact of psychopharmacological and psychological treatments on bariatric patients' postoperative mental health and weight outcomes. RESULTS: Overall, 37 studies were included in the review. Preliminary evidence suggests that psychiatric medications do not negatively impact weight loss or health-related quality of life in the short term; however, more rigorous research designs are needed. There are insufficient data on specific psychiatric medications and long-term impact on weight loss and psychosocial outcomes. Postoperative psychological interventions have evidence for improving eating psychopathology, anxiety, and depressive symptoms; however, effects on weight loss remain unclear. CONCLUSION: Evidence for psychopharmacological and psychological treatments remains preliminary. Consideration should be given to integrated, stepped-care models to provide personalized psychiatric interventions after surgery. Future research on expanding current psychiatric interventions, timing of delivery, and predictors of response is needed.

Predictors of suicidal ideation one-year post-bariatric surgery: Results from the Toronto Bari-Psych Cohort Study.

OBJECTIVE: Previous studies have shown higher rates of death by suicide, suicide attempts, suicidal ideation and non-suicidal self-directed violence (NS-SDV) in bariatric surgery patients. METHODS: Data came from the Toronto Bari-Psych Cohort study of adult patients who underwent bariatric surgery between 2010 and 2016. The MINI International Neuropsychiatric Interview was used to obtain lifetime psychodiagnostic data. Information about lifetime suicidal ideation, suicide attempts, NS-SDV and hospitalizations related to any of these phenomena was collected during clinical interview. Pre-surgery sociodemographic data, lifetime psychiatric disorders, mental health symptoms, mental health treatment, suicidal ideation and surgical complications were covariates. Logistic regression analyses were used to examine the relationship between these variables and suicidal ideation one-year post-surgery. RESULTS: Among a total of 284 participants, 4.2% reported a past suicide attempt and 15.1% reported past suicidal ideation. One-year post-surgery, no suicide attempts were reported. In the multivariate regression model, a history of suicidal ideation was the strongest predictor of suicidal ideation one-year post-surgery (p < 0.01), followed by younger age (p = 0.05). Mental health symptoms decreased from pre to post-surgery. CONCLUSION: One-year post-surgery, a history of suicidal ideation was the strongest predictor of post-surgery suicidal ideation. Results should be interpreted with caution given the short duration of follow-up.

Psychiatric Medication Use and Weight Outcomes One Year After Bariatric Surgery.

BACKGROUND: Given the high rates of psychiatric comorbidity in bariatric surgery patients, pharmacotherapy is common and could potentially influence weight loss outcomes. OBJECTIVE: We aimed to identify the impact of psychotropic medication use on percent total weight loss (%TWL) 1 year after bariatric surgery. METHODS: In this prospective cohort study, 190 patients were compared based on demographic variables (age, sex, relationship status, employment status), body mass index, %TWL, and psychotropic medication use before and 1 year after bariatric surgery. An analysis of variance test was used as a global test of significance for psychotropic medication comparisons related to %TWL. Significance of post hoc comparisons was calculated with the Tukey's Honestly Significance Difference test. RESULTS: Sixty-one of 190 (32.1%) patients were taking psychiatric medications before surgery; of those, 82% (50/61) continued to take psychiatric medications 1-year after surgery. %TWL did not significantly differ between patients taking no psychiatric medications, one medication, or more than one medication 1 year after surgery (31.4% vs. 29.9% vs. 34.4%, respectively). Among patients taking antidepressants, those taking serotonin-norepinephrine reuptake inhibitors had a significantly higher %TWL than those taking selective serotonin reuptake inhibitors (36.4% vs. 27.8%; P = 0.032). CONCLUSION: This longitudinal study suggests that psychiatric medication use was not associated with poorer %TWL at 1 year after bariatric surgery. Within class, antidepressant use may have differential effects on weight loss after bariatric surgery and warrants further investigation.