Six-year postoperative associations between the Minnesota Multiphasic Personality Inventory - 3 (MMPI-3) and weight recurrence, eating behaviors, adherence, alcohol misuse, and quality of life.

BACKGROUND: Metabolic and bariatric surgery (MBS) leads to beneficial and sustained outcomes. However, many patients evidence weight recurrence and psychosocial functioning may be associated with weight recurrence. The Minnesota Multiphasic Personality Inventory - 3 (MMPI-3) is validated for use in presurgical MBS evaluations and likely has clinical utility in understanding weight recurrence and other aspects of postoperative functioning. OBJECTIVE: The objective of the current investigation is to understand how postoperative psychosocial functioning relates to weight recurrence and other behaviors and constructs 6 years after MBS. SETTING: Cleveland Clinic Bariatric and Metabolic Institute. METHODS: A sample of 163 participants consented to take a battery of self-report measures related to psychological functioning, eating behaviors, adherence, alcohol misuse, and quality of life along with their postoperative weight. MMPI-3 scale scores were prorated from the Minnesota Multiphasic Personality Inventory - 2 - Restructured Form (MMPI-2-RF) or scored from the Minnesota Multiphasic Personality Inventory - 2 - Restructured Form - Expanded (MMPI-2-RF-EX). RESULTS: Weight recurrence was quite variable in this sample. Postoperative MMPI-3 scales related to emotional/internalizing dysfunction were modestly associated with higher weight recurrence. Postoperative MMPI-3 scale scores also demonstrated associations with other postoperative outcomes including measures of eating behaviors, adherence, alcohol misuse, and quality of life. CONCLUSIONS: Postoperative psychosocial functioning as assessed by the MMPI-3 was associated with weight recurrence and a number of other problematic psychological outcomes beyond weight recurrence.

Longer-Term Weight Loss Outcomes Are Not Primarily Driven by Diet Following Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

Metabolic and bariatric surgery (MBS) is the most effective long-term treatment for Class III obesity. Reduced dietary intake is considered a behavioral driver of post-surgical weight loss, but limited data have examined this association. Therefore, this study examined prospective, longitudinal relationships between dietary intake and weight loss over 24 months following Roux-en-Y Gastric Bypass and Sleeve Gastrectomy. Relationships between weight loss and dietary intake were examined using a validated 24-h dietary recall method. Associations between total energy/macronutrient intake and weight loss outcomes were assessed at 12-, 18-, and 24-months following MBS, defining patients as "responders" and "suboptimal responders". Consistent with previous literature, 12-month responders and suboptimal responders showed significant associations between weight loss and energy (p = 0.018), protein (p = 0.002), and total fat intake (p = 0.005). However, this study also revealed that many of these associations are no longer significant 24 months post-MBS (p > 0.05), despite consistent weight loss trends. This study suggests a short-term signal between these dietary factors and weight loss outcomes 12 months post-MBS; however, this signal does not persist beyond 12 months. These results are essential for interpreting and designing clinical studies measuring long-term post-surgical weight loss outcomes.

Associations Between Changes in Activity and Dietary Behaviors after Metabolic and Bariatric Surgery.

INTRODUCTION: Patients who undergo metabolic and bariatric surgery (MBS) are advised to make healthy activity and dietary changes. While previous research has examined post-surgical changes in activity and dietary behaviors separately, no study has assessed whether changes in these behaviors are beneficially associated with each other. We evaluated whether post-surgical improvements in activity behaviors related to favorable changes in dietary behaviors overall and by surgery type (Roux-en-Y gastric bypass [RYGB], sleeve gastrectomy [SG]). METHODS: At pre-surgery and 6- and 12-months post-surgery, participants (N = 97; 67 RYGB/30 SG) wore an accelerometer for 7 days and completed 24-h dietary assessments on 3 days. General linear models assessed associations between pre- to post-surgical changes in activity (moderate-to-vigorous physical intensity activity [MVPA], sedentary time [ST]) and dietary (total energy intake [EI; kcal/day], dietary quality [healthy eating index/HEI scores]) behaviors, with surgery type as a moderator. RESULTS: Participants on average: demonstrated small, non-significant post-surgical changes in MVPA and ST minutes/day (ps > .05); and reported significant post-surgical decreases in EI (p < .001), but no changes in HEI scores (ps > .25). Greater 12-month post-surgical increases in MVPA were significantly associated with greater decreases in EI, but only for RYGB participants (p < .001). DISCUSSION: Participants reported large decreases in EI, but made minimal changes in other behaviors after MBS. Results suggest greater increases in MVPA could assist with achieving greater decreases in EI, although this benefit appears to be limited to RYGB patients. Additional research is needed to confirm these findings and determine whether activity-dietary behavior associations differ beyond the immediate post-surgical year.

Reevaluating the Binge Eating Scale cut-off using DSM-5 criteria: analysis and replication in preoperative metabolic and bariatric surgery samples.

BACKGROUND: Metabolic and bariatric surgery is effective for sustained weight loss, but binge eating disorder (BED) can be associated with poorer outcomes and lead to weight regain. A common measure used to screen for BED is the Binge Eating Scale (BES). A BES cut-off score of ≥17 previously identified patients who have a high likelihood of meeting criteria for BED. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), lowered the threshold for meeting criteria for BED, and the psychometrics of the BES need to be reevaluated. OBJECTIVE: The objective of the current investigation is to evaluate whether alternative cut-scores on the BES result in better classification of BED based on the DSM-5 revision of the the BED diagnostic criteria. SETTING: Academic medical hospital in the Midwestern United States. METHODS: Patients (n =1133) seeking metabolic and bariatric surgery were randomly split into 2 samples for validation and replication. The validation sample consisted of 561 patients (30.1% men, 35% non-White). The replication sample consisted of 572 patients who were demographically similar to the first random split sample (e.g., 25.3% men, 34.4% non-White). RESULTS: Of these patients, 13.5% met DSM-5 criteria for BED in the validation sample and 13.8% met criteria for BED in the replication sample. Lowering the interpretative cut-off to ≥15 on the BES yielded sensitivity values of >.72, specificity values of >.67, and an accurate classification of BED in >.70 of patients across both samples. These classification values were as good as or better than the standard cut-off score of ≥17 in both samples. CONCLUSIONS: The BES is appropriate to screen for BED in patients who are seeking bariatric surgery. A 2-point decrease in the BES score for clinical interpretation is appropriate-lowering it from 17 to 15 given DSM-5 updates to diagnostic criteria.

Team Approach: Management of Mental Health in Orthopaedic Patients.

¼: Mental health evaluation should be considered an essential part of the routine preoperative assessment and should be managed by a multidisciplinary team composed of the primary care physician, orthopaedic provider, and behavioral health specialist. ¼: The scientific literature indicates that patients without comorbid psychiatric symptoms and adaptive coping strategies, resilience, and well-managed expectations have improved functional outcomes and satisfaction after orthopaedic procedures. ¼: Psychological issues are multifaceted and require treatment tailored to each individual patient. Therefore, close communication between all members of the care team is required to create and execute the perioperative plan.

Social Isolation and Loneliness During the COVID-19 Pandemic: Impact on Weight.

PURPOSE OF REVIEW: Social isolation and loneliness have long been identified as risk factors for poorer physical and mental health and increased mortality. These factors have also been shown to impact dietary behavior and physical activity which play a role in precipitating and maintaining obesity. Less is known about the impact of social isolation resulting from the COVID-19 pandemic in which social distancing is a major component of public health initiatives. This narrative review will examine the existing literature on the relationships between social isolation, loneliness, mental health, and weight as they relate to the COVID-19 pandemic. RECENT FINDINGS: Individuals with obesity are at very high risk for worsening course of COVID-19, hospitalization, and death. This population may also be more significantly impacted by the dietary and physical activity consequences resulting from lockdown, social distancing, and isolation. The pandemic has led to significant lifestyle disruptions. However, early studies have largely relied upon cross-sectional studies or convenience samples. Future research will need to study the impact more rigorously, particularly among populations at greatest risk.

Disordered eating following bariatric surgery: a review of measurement and conceptual considerations.

Eating disorders are associated with significant medical morbidity and mortality and serious psychological impairment. Individuals seeking bariatric surgery represent a high-risk group for evidencing disordered eating and eating disorders, with some patients experiencing the persistence or onset of disordered eating postsurgery. This review synthesizes the available literature on problematic or disordered eating in the bariatric field, followed by a review of measurement and conceptual considerations related to the use of eating disorder assessment tools within the bariatric population.

Six-year bariatric surgery outcomes: the predictive and incremental validity of presurgical psychological testing.

BACKGROUND: Research identifying preoperative psychosocial predictors of bariatric surgery outcomes has yielded inconsistent results with minimal examination of longer-term outcomes. Utilizing a broadband measure of personality and psychopathology during the preoperative evaluation helps to identify preoperative risk factors for suboptimal bariatric surgery outcomes. OBJECTIVE: Examine predictors of outcome and the incremental contribution of presurgical psychological testing to various long-term bariatric surgery outcomes. SETTING: Academic medical center. METHOD: A total of 168 postoperative patients (average of 6 postoperative years) consented to participate in the outcome study. Participants were weighed by the trained research/clinical staff and completed a battery of self-report questionnaires, including measures assessing eating attitudes and behaviors and weight-related quality-of-life (QoL). Patients had completed the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) as part of the institution's routine preoperative psychosocial evaluation. Weight loss was calculated as percent total weight loss (%TWL) and percent weight regain (%WR) was calculated as a percentage of maximum weight loss. Other preoperative data were obtained from a review of each patient's electronic medical record (EMR). From the initial sample, 145 patients were retained for analyses in the present study. RESULTS: Preoperative problematic eating variables predicted long-term postoperative problematic eating behaviors and body image concerns. Scores on preoperative MMPI-2-RF scales measuring Demoralization, Dysfunctional Negative Emotions, Antisocial Behaviors, and Hypomanic Activation were consistent incremental predictors of 6-year outcomes, accounting for an additional 3%-24% of the variability in postoperative eating behaviors and QoL. CONCLUSIONS: The preoperative psychological evaluation can be used to identify predictors of long-term bariatric surgery outcomes. Identification of these risk factors provides important targets for pre- and postoperative clinical interventions to maximize surgical outcomes.

DSM 5 Lifetime Psychiatric Diagnoses in Two Bariatric Surgery Programs.

Patients presenting for bariatric surgery have been shown to have high rates of psychiatric disorders. These studies have utilized structured interviews using older versions of the DSM. This study examined whether similar lifetime frequencies would be similar using the recent DSM-5. Participants (N = 131) were evaluated as part of a longitudinal study examining post-operative weight loss at two sites. Participants were administered the Structured Clinical Interview for DSM-5 (SCID5) pre-surgically. Lifetime estimates using the SCID5 were compared to the range and mean of 3 prior US studies and 2 international studies using the DSM-IV. Overall, frequency of psychiatric disorders was similar or lower than prior studies. Changes to diagnostic criteria may explain differences although future studies are needed to better characterize this population.

Associations among psychopathology and eating disorder symptoms and behaviors in post-bariatric surgery patients.

PURPOSE: A considerable number of post-bariatric surgery patients report problematic eating behaviors (PEBs) and/or eating disorders (EDs). Examining psychosocial variables associated with ED symptoms may identify targets for postoperative interventions to reduce these behaviors and improve surgical outcomes. METHODS: A total of 161 participants completed the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and the Eating Disorder Examination-Questionnaire (EDE-Q). Participants were classified into ED risk or no ED risk groups and subjective binge eating (SBE) or no SBE groups. Independent-sample t tests were computed to examine mean differences in total weight loss (%TWL) and MMPI-2-RF scale scores between the ED groups. Relative Risk Ratios (RRRs) were computed to determine which MMPI-2-RF scales were associated with increased risk of ED group membership. RESULTS: The ED risk group lost significantly less weight (19.36% TWL) than the no ED risk group (25.18% TWL). The SBE group lost significantly less weight (17.98% TWL) than the no SBE group (25.57% TWL). Participants in the ED groups scored significantly higher on internalizing and externalizing MMPI-2-RF scales than the no ED groups. These scales were associated with increased risk (1.55-2.55 times the risk) of being classified into the ED groups. CONCLUSIONS: Patients who experienced postoperative ED symptoms lost significantly less weight than patients without ED symptoms. Postoperative ED symptoms are related to, and may be impacted by, higher levels of internalizing and externalizing dysfunction after surgery. Postoperative assessment of and interventions targeting psychosocial dysfunction could decrease ED symptoms. LEVEL OF EVIDENCE: III: Evidence obtained from well-designed cohort or case-control analytic studies.

Refractory Chronic Pain and Obesity: Promising Implications for Multidisciplinary Pain Rehabilitation.

OBJECTIVE: Individuals with obesity frequently contend with chronic pain, but few studies address the clinical impact of coordinated pain services on this population. The current study addresses this topic by comparing the effectiveness of a comprehensive pain rehabilitation program for patients with and without obesity. METHODS: A retrospective analysis of registry data was conducted. Obesity was considered as one of three weight groups, based on the following body mass index cutoffs: normal weight (18.5 to < 25 kg/m2), overweight (25 to < 30 kg/m2), and obese (> 30 kg/m2). These groups were compared on the Pain Severity Ratings (PSR) Scale, the Pain Disability Index (PDI), and the Depression, Anxiety, Stress Scales-Short Form (DASS-SF). RESULTS: Groups differed on baseline pain disability and depression. Patients with obesity had higher scores on both the PDI (P = .028) and the DASS-SF depression subscale (P = .006). Contrary to the hypothesis, after controlling for baseline score and sex there were no significant differences between weight groups with regards to PSR, PDI, or any DASS-SF subscale at discharge. At 1-year follow-up, individuals who were overweight and obese had significantly more anxiety compared to individuals whose weight was in the normal range. CONCLUSIONS: Multidisciplinary pain rehabilitation programs appear to be an effective treatment intervention for patients who have concomitant chronic pain and obesity, to a degree comparable to patients who have chronic pain but do not contend with obesity. Implications for program development, clinical interventions, and future research are discussed.

Patients Desire Personalized, Specific, and Continuous Advice on Weight Management.

OBJECTIVE: To deliver effective care, healthcare systems should understand patients' preferences for weight management across a spectrum of needs. Our objective was to describe patients' perceptions of what helps or hinders weight loss and maintenance. METHODS: Semistructured interviews were conducted with patients who accessed weight management services at a large integrated health system in 2018. The interview guide was developed and iteratively refined through a literature search and by consulting experts. Questions included the respondent's weight history, interactions with the health system, and current health status. The analysis used a grounded theory approach, and each transcript was double-coded in 2019. Codes were sorted into themes. All discrepancies were resolved through team discussion. RESULTS: Fifteen patients were interviewed. The majority of respondents (87%) reported multiple weight loss attempts. Three themes were identified. First, advice should be matched to a patient's knowledge and prior experience (eg, using bariatric deck cards). As patients progressed, clinician advice also needed to advance (eg, explaining how to expand food options instead of defining a healthy diet). Second, respondents had a variety of motivating factors, and understanding where motivation is generated from can inform how to design a weight management approach. Third, patients need continual and long-term advice. Some respondents feared becoming ineligible for services if their weight dropped too much. CONCLUSIONS: Health systems can support patients by developing processes for identifying the extent of a patient's knowledge and giving personalized advice based on the patient's preferences and experiences. Reassessing needs at defined intervals may help patients attain and sustain their goals.

Factors Impacting Physician Referral To and Patient Attendance at Weight Management Programs Within a Large Integrated Health System.

BACKGROUND: Identifying which patients receive referrals to and which ones attend weight management programs can provide insights into how physicians manage obesity. OBJECTIVE: To describe patient factors associated with referrals, which primarily reflect physician priorities, and attendance, which reflects patient priorities. We also examine the influence of the individual physician by comparing adjusted rates of referral and attendance across physicians. DESIGN: Retrospective cohort study. PARTICIPANTS: Adults with a body mass index (BMI) ≥ 30 kg/m2 who had a primary care visit between 2015 and 2018 at a large integrated health system MAIN MEASURES: Referrals and visits to programs were collected from the EHR in 2019 and analyzed in 2019-2020. Multilevel logistic regression models were used to identify the association between patient characteristics and (1) receiving a referral, and (2) attending a visit after a referral. We compared physicians' adjusted probabilities of referring patients and of their patients attending a visit. KEY RESULTS: Our study included 160,163 adults, with a median BMI of 35 kg/m2. Seventeen percent of patients received ≥ 1 referral and 29% of those attended a visit. The adjusted odds of referral increased 57% for patients with a BMI 35-39 (versus 30-34) and 32% for each comorbidity (p < 0.01). Attending a visit was less strongly associated with BMI (aOR 1.18 for 35-39 versus 30-34, 95% CI 1.09-1.27) and not at all with comorbidity. For the physician-level analysis, the adjusted probability of referral had a much wider range (0 to 83%; mean = 19%) than did the adjusted probability of attendance (range 27 to 34%). CONCLUSIONS: Few patients attended a weight management program. Physicians vary greatly in their probability of referring patients to programs but not in their patients' probability of attending.

Psychosocial Functioning of Bariatric Surgery Patients 6-Years Postoperative.

INTRODUCTION: Mental health professionals routinely assess psychosocial risk factors prior to bariatric surgery to help identify factors that may impede surgical outcomes. Data regarding longer-term psychosocial functioning postoperatively are needed. PURPOSE: Assess the psychosocial functioning of patients who obtained bariatric surgery approximately 6 years ago. METHODS: A total of 161 patients consented to participate in the outcome study. Participants were compensated for their time and participation. Participants were weighed by the research/clinical staff and asked to complete a battery of self-report measures, including the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF). Other measures targeted adherence, eating behaviors/body image, alcohol use, and quality of life. RESULTS: Postoperative MMPI-2-RF scores indicate psychosocial functioning is largely similar to previously published pre-surgical functioning data. Six-year weight loss outcomes were lower than previous studies reported for a similar postoperative time period (mean %total weight loss = 22.98%; standard deviation = 11.71), though quality of life scores were relatively high. Postoperative MMPI-2-RF scale scores were associated with poorer psychosocial functioning, reduced adherence, greater eating behaviors/body image concerns, greater alcohol use severity, lower quality of life, and less overall weight loss. CONCLUSIONS: Psychological dysfunction 6 years after surgery is associated with various adverse outcomes. Ongoing, postoperative treatment may result in better long-term functioning for patients.

An Investigation of the Eating Concerns Scale of the Minnesota Multiphasic Personality Inventory-3 (MMPI-3) in a Postoperative Bariatric Surgery Sample.

Eating pathology is common pre-operatively and continues to be prevalent following bariatric surgery. A new version of the Minnesota Multiphasic Personality Inventory (MMPI), the MMPI-3, contains a new scale called Eating Concerns (EAT) that aims to assess problematic eating behaviors. The current investigation seeks to establish preliminary convergent validity of the MMPI-3 EAT scale in a postoperative bariatric surgery sample. Thirty-eight consecutive participants took the MMPI-3 and the Eating Disorder Examination-Questionnaire (EDE-Q). Higher MMPI-3 EAT scale scores were meaningfully associated with %Weight Regain (r = .37) and scale scores on the EDE-Q [Eating Concerns (r = .67), Weight Concerns (r = .39), Shape Concerns (r = .54), and the EDE total score (r = .59)]. Initial examination of the EAT Specific Problem Scale of the MMPI-3 yields good clinical utility in assessing eating pathology in a postoperative bariatric surgery sample.

Identifying mechanisms that predict weight trajectory after bariatric surgery: rationale and design of the biobehavioral trial.

Bariatric surgery is currently the most efficacious and durable intervention for severe obesity. The most commonly performed procedures in the United States are the Roux-en-Y gastric bypass and the sleeve gastrectomy, which involve significant anatomic and physiologic alterations that lead to changes in behavior and biology. Unfortunately, many patients experience suboptimal weight loss and/or substantial weight regain. Eating and physical activity/sedentary behaviors, mood, cognition, and the gut microbiome all change postoperatively and have an association with weight change. The longitudinal relationship between changes in the gut microbiome and postoperative weight trajectory has not been explored thoroughly, and the interactive associations among the gut microbiome and the other variables that impact weight have been similarly understudied. The following is a methods and design description for a prospective, 24-month longitudinal study of 144 bariatric surgery patients, at 2 sites, that aimed to identify predictors of weight loss trajectories over 24 months after Roux-en-Y gastric bypass and the sleeve gastrectomy. Specifically, the study will examine the relationships between empirically supported behavioral and biological variables and their combined impact on postoperative weight trajectories. Novel data collection will include intensive measurement of problematic eating behaviors and diet and physical activity postoperatively, which may be altered in parallel with, or in response to, changes observed in the gut microbiota. Identifying postoperative predictors of weight loss and co-morbidity resolution should inform development of novel interventions that are tailored to individual patients' risk profiles to optimize and sustain more favorable weight trajectories.

The COVID-19 Crisis: A Mental Health Perspective and Response Using Telemedicine.

With the outbreak of COVID-19, patients and providers were forced to isolate and become innovative in ways to continue exceptional patient care. The Cleveland Clinic went from mostly in-person medical appointments to all virtual/telemedicine care in about 2 weeks' time. In this piece, we show specifically the thought process and our conversion of the Mellen Center for Multiple Sclerosis Behavioral Medicine to ensure that our patients still receive exceptional care and patient experience. Additionally, we discuss the importance of innovating the training and supervision of postdoctoral trainees using telepsychology and virtual options.

Psychological correlates of patients with postural orthostatic tachycardia syndrome (POTS).

Psychological symptoms are frequently reported in patients with Postural Orthostatic Tachycardia Syndrome (POTS); however, the nature of these symptoms is not well understood. The current study described baseline psychological symptoms in patients with POTS, and examined associations between psychological and self-report autonomic symptoms. Participants reported mild anxiety symptoms, moderate depressive symptoms, severe somatization, and elevated anxiety sensitivity. Depressive symptoms and pain catastrophizing were significantly associated with autonomic symptoms. The current study adds to the literature by documenting elevated levels of anxiety sensitivity, and relationships between psychological and autonomic symptoms.

A review of the psychosocial aspects of clinically severe obesity and bariatric surgery.

For the past 2 decades, clinically severe obesity (operationalized as a body mass index ≥40 kg/m2) has increased at a more pronounced rate that less severe obesity. As a result, the surgical treatment of obesity (bariatric surgery) has become a more widely accepted, yet still underutilized, treatment for persons with severe obesity and significant weight-related health problems. Psychologists play a central role on the multidisciplinary team involved in the preoperative assessment and postoperative management of patients. They also have played a central role in clinical research which has enhanced understanding of the psychosocial and behavioral factors that contribute to the development of severe obesity as well as how those factors and others contribute to postoperative outcomes. This article, written specifically for psychologists and other mental health professionals who currently work with these patients or are considering the opportunity to do so in the future, reviews these contributions over the past 20 years. The article highlights how this work has become a fundamental part of international clinical care guidelines, which primarily focus on preoperative psychosocial screening. The article also outlines avenues for future research in the field, with a specific focus on the need for additional behavioral and psychosocial interventions to promote lifelong success after bariatric surgery. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Elucidating somatization in a dimensional model of psychopathology across medical settings.

Research using a categorical-polythetic classification system for mental illness has raised concern regarding the validity of categorical classification systems. Recent efforts suggest psychopathology is better understood from a dimensional framework, though there has been varying evidence of a somatization factor. The current investigation seeks to produce and validate a dimensional model of psychopathology, with a particular emphasis on the placement of somatization, across three nonoverlapping medical samples. Using a bariatric surgery seeking sample (n = 1,268), a spine surgery/spinal cord stimulator seeking sample (n = 1,711), and a chronic pain treatment seeking sample (n = 1,388), a dimensional model of psychopathology was replicated across all three samples using a dimensional measure of psychopathology (the Minnesota Multiphasic Personality Inventory-2-Restructured Form [MMPI-2-RF]). Clear evidence of a separate somatization factor was found in addition to broad internalizing, externalizing, and social detachment factors. Constructs assessable with the model yielded good convergent and discriminant validity coefficients with external criteria, and further supported the presence of a higher-order somatization construct. (PsycINFO Database Record (c) 2020 APA, all rights reserved).