White Paper AGA: An Episode-of-Care Framework for the Management of Obesity-Moving Toward High Value, High Quality Care: A Report From the American Gastroenterological Association Institute Obesity Episode of Care and Bundle Initiative Work Group.

The American Gastroenterological Association acknowledges the need for gastroenterologists to participate in and provide value-based care for both cognitive and procedural conditions. Episodes of care are designed to engage specialists in the movement toward fee for value, while facilitating improved outcomes and patient experience and a reduction in unnecessary services and overall costs. The episode of care model puts the patient at the center of all activity related to their particular diagnosis, procedure, or health care event, rather than on a physician's specific services. It encourages and incents communication, collaboration, and coordination across the full continuum of care and creates accountability for the patient's entire experience and outcome. This paper outlines a collaborative approach involving multiple stakeholders for gastrointestinal practices to assess their ability to participate in and implement an episode of care for obesity and understand the essentials of coding and billing for these services.

Bariatric surgery in patients with bipolar spectrum disorders: Selection factors, postoperative visit attendance, and weight outcomes.

BACKGROUND: As many as 3% of bariatric surgery candidates are diagnosed with a bipolar spectrum disorder. OBJECTIVES: 1) To describe differences between patients with bipolar spectrum disorders who are approved and not approved for surgery by the mental health evaluator and 2) to examine surgical outcomes of patients with bipolar spectrum disorders. SETTING: Academic medical center, United States. METHODS: A retrospective record review was conducted of consecutive patients who applied for bariatric surgery between 2004 and 2009. Patients diagnosed with bipolar spectrum disorders who were approved for surgery (n = 42) were compared with patients with a bipolar spectrum disorder who were not approved (n = 31) and to matched control surgical patients without a bipolar spectrum diagnosis (n = 29) on a variety of characteristics and surgical outcomes. RESULTS: Of bariatric surgery candidates diagnosed with a bipolar spectrum disorder who applied for surgery, 57% were approved by the psychologist and 48% ultimately had surgery. Patients with a bipolar spectrum disorder who were approved for surgery were less likely to have had a previous psychiatric hospitalization than those who were not approved for surgery. Bariatric surgery patients diagnosed with a bipolar spectrum disorder were less likely to attend follow-up care appointments 2 or more years postsurgery compared to matched patients without bipolar disorder. Among patients with available data, those with a bipolar spectrum disorder and matched patients had similar weight loss at 12 months (n = 21 for bipolar; n = 24 for matched controls) and at 2 or more years (mean = 51 mo; n = 11 for bipolar; n = 20 for matched controls). CONCLUSION: Patients diagnosed with a bipolar spectrum disorder have a high rate of delay/denial for bariatric surgery based on the psychosocial evaluation and are less likely to attend medical follow-up care 2 or more years postsurgery. Carefully screened patients with bipolar disorder who engage in long-term follow-up care may benefit from bariatric surgery.

Getting Off on the Right Foot: The Many Roles of the Psychosocial Evaluation in the Bariatric Surgery Practice.

A thorough and specialized pre-operative psychosocial assessment is an important part of a comprehensive bariatric treatment protocol. Over time, the presurgical psychosocial evaluation has evolved from a cut-and-dried process of recommending whether a patient should or should not undergo surgery to a more nuanced and multifaceted process that serves multiple functions. In this article, we review the many ways in which the pre-operative psychosocial evaluation can enhance patient outcomes and adjustment and even the functioning of the interdisciplinary bariatric surgery team.

Patient predictors of follow-up care attendance in Roux-en-Y gastric bypass patients.

BACKGROUND: Multidisciplinary care after bariatric surgery is important for long-term safety and optimal weight loss, yet many patients do not attend follow-up appointments. We sought to identify demographic, psychosocial, and weight-related variables that were associated with medical and behavioral health appointment attendance after bariatric surgery. METHODS: A retrospective chart review was conducted with consecutive patients (n=538) obtaining first-time Roux-en-Y gastric bypass surgery between August 2009 and August 2010. Demographic and psychosocial data were compared between high (>50%) and low (≤50%) medical appointment attendees and high (>50%) and low (≤50%) behavioral health group attendees in their first postoperative year. Percentage excess weight loss at 6 months after surgery was evaluated as a predictor of 12-month appointment attendance. RESULTS: High medical appointment attendees were more likely to be older, be Caucasian, and have lower phobic anxiety than low medical appointment attendees. High behavioral health attendees had shorter travel distance to the clinic and lower levels of hostility, anxiety, and phobic anxiety compared with low attendees. In multivariate analyses, race/ethnicity and phobic anxiety remained significant predictors of medical attendance, while travel distance to clinic predicted behavioral health attendance. Six-month percent excess weight loss predicted medical appointment attendance at 12 months. CONCLUSION: The identified predictors of poor attendance at medical and behavioral bariatric surgery follow-up appointments should inform efforts to increase follow-up and improve surgical outcomes.

The utility of the Beck Depression Inventory in a bariatric surgery population.

BACKGROUND: The Beck Depression Inventory (BDI) is commonly used in bariatric surgery psychological assessments. However, several items may be measuring physical consequences of obesity (e.g., sleep disturbance, chronic pain, or sexual dysfunction) rather than depressive symptoms. METHODS: Bariatric surgery candidates (n = 210) completed a series of assessments including the BDI, a chronic pain assessment, and a semistructured clinical interview. Total BDI scores, subscale scores, and endorsement patterns of somatic versus cognitive-affective items were examined based on (1) the presence or absence of a depressive diagnosis or (2) the presence or absence of chronic pain, and optimal cut points were determined. RESULTS: Both the total BDI and cognitive-affective subscale had good discriminating accuracy between participants with and without depression, with an optimal cut point of 12 for the BDI and 7 for the cognitive-affective subscale. Bariatric surgery candidates with chronic pain had significantly higher mean total scores on the BDI (M = 12.5 +/- 7.5) than those without chronic pain (M = 9.02 +/- 6.7; p < 0.01), and those with chronic pain were significantly more likely to endorse many of the physical items than those without chronic pain. CONCLUSIONS: The BDI, with or without the somatic items, appears to be a reasonable screening measure for depressive symptoms among bariatric surgery candidates and the subpopulation of those with chronic pain, although future investigations may wish to examine whether other measures would have improved discrimination accuracy.

Recent experiences of weight-based stigmatization in a weight loss surgery population: psychological and behavioral correlates.

OBJECTIVE: This study evaluated the association between experiences of weight-based stigmatization (e.g., job discrimination, inappropriate comments from physicians) within the past month, psychological functioning, and binge eating among a sample of individuals seeking weight loss surgery. METHODS AND PROCEDURE: Ninety-four obese adults (25 males and 69 females) seeking weight loss surgery underwent a diagnostic clinical interview and completed a battery of self-report questionnaires measuring experiences of weight-related stigmatization, psychological adjustment, and binge eating behavior. RESULTS: Weight-based stigmatization was a common experience within the past month among participants. Frequency of stigmatizing experiences was negatively associated with self-esteem and positively associated with depression, anxiety, body image disturbance, and emotional eating. Recent experiences of stigmatization were associated with a diagnosis of binge eating disorder. DISCUSSION: Weight-based stigmatization is a common experience among obese individuals seeking weight loss surgery, and these experiences are associated with deleterious consequences. It appears that environmental barriers (e.g., chairs too small, not being able to find medical equipment in an appropriate size) and interpersonal attacks are the most common stigmatizing experiences. These data justify future studies to better understand causal relationships and efforts to design and test interventions aimed at reducing weight-based stigmatization and the associated negative consequences.

Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults.

OBJECTIVE: To evaluate the associations between weight-based stigmatization, psychological distress, and binge eating behavior in a treatment-seeking obese sample. METHODS: Ninety-three obese adults completed three questionnaires: 1) Stigmatizing Situations Inventory, 2) Brief Symptoms Inventory, and 3) Binge Eating Questionnaire. Correlational analyses were used to evaluate the association between stigmatizing experiences, psychological distress and binge eating behavior. RESULTS: Stigmatizing experiences predicted both binge eating behavior (R(2)=.20, p<.001) and overall psychological distress (R(2)=.18, p<.001). A substantial amount of the variance in binge eating predicted by weight-based stigmatization was due to the effect of psychological distress. Specifically, of the 20% of the variance in binge eating accounted for by stigmatizing experiences, between 7% and 34% (p<.01) was due to the effects of various indicators of psychological distress. CONCLUSIONS: These data suggest that weight-based stigmatization predicts binge eating behavior and that psychological distress associated with stigmatizing experiences may be an important mediating factor.

Psychological correlates of obese patients seeking surgical or residential behavioral weight loss treatment.

BACKGROUND: The purpose of this study was to gain a better understanding of the psychological factors related to obese individuals self-selecting for either a residential cognitive-behavioral-based program or surgical treatment program for weight loss. METHODS: Two patient samples with a body mass index of > or =35 kg/m(2) were administered a battery of psychological questionnaires, including the Beck Depression Inventory, Binge Eating Scale, and Impact of Weight on Quality of Life-Lite, at the evaluation for entry into either a surgical weight loss treatment program (n = 76) or cognitive-behavioral-based weight loss treatment program (n = 101). RESULTS: No significant difference was found in the mean body mass index of the 2 samples. No significant difference was found in the self-reported level of depressive symptoms of the 2 samples, with both samples obtaining a mean depressive symptom score in the mild range. Surgical treatment seekers, however, reported significantly greater emotional eating and attributed greater impairment in their quality of life to their weight. CONCLUSION: Individuals seeking a surgical approach to weight loss might perceive their weight as having a greater negative impact on their life than those selecting a residential behavioral lifestyle change approach, even when their weight and depressive symptoms are equivalent. Therefore, an individual's own cognitive appraisal of the negative consequences of their weight might correlate with their treatment choice.

Who is adherent with preoperative psychological treatment recommendations among weight loss surgery candidates?

BACKGROUND: Adherence to treatment regimens is critical for success with weight loss surgery. Weight loss surgery patients commonly undergo a psychological evaluation before surgery. When indicated, patients are provided with preoperative behavioral recommendations; yet, little is known about the adherence to these recommendations. In this study, we evaluated the following: (1) level of adherence to behavioral treatment plans; (2) characteristics that differentiate adherent patients from nonadherent patients; and (3) the weight loss of delayed-adherent patients compared with those whose surgery was not delayed. METHODS: We performed a case review of psychological evaluations, preoperative behavioral treatment plans, and subsequent adherence rates. RESULTS: Of the 837 patients evaluated, 68 (8%) had significant psychosocial issues and were given behavioral treatment recommendations before surgery. Of these 68 patients, 38 (56%) were adherent and subsequently underwent surgery, and 30 (46%) were nonadherent and were not offered surgery in our program. Adherence did not differ relative to body mass index, age, education, race, marital status, depression, anxiety, or rate of eating disorders. Adherence did differ by gender: 31% percent of the men were adherent to recommendations while 62% of the women were adherent. Individuals with complex treatment plans were less likely to be adherent than those with less complex recommendations. Additionally, increased hostility reduced the adherence rates. Patients adherent to the psychological recommendations had weight loss within 2 years, which was similar to that of patients who did not require behavioral treatment recommendations. CONCLUSION: The results of this study have provided information regarding adherence to preoperative psychological treatment recommendations. Although most patients are psychologically suitable for weight loss surgery at the initial evaluation, a better understanding of the factors influencing the adherence with preoperative behavioral programs could improve care for those with major psychosocial issues.

Changes in depressive symptoms and glycemic control in diabetes mellitus.

OBJECTIVE: To investigate if changes in depressive symptoms would be associated with changes in glycemic control over a 12-month period in patients with Type 1 and Type 2 diabetes. METHODS: Ninety (Type 1 diabetes, n = 28; Type 2 diabetes, n = 62) patients having Beck Depression Inventory (BDI) levels of >10 were enrolled in the study. Of those 90 patients, 65 patients completed a 12-week cognitive behavioral therapy intervention. BDI was assessed at baseline and thereafter biweekly during 12 months. Hemoglobin (HbA1c) and fasting blood glucose levels were assessed at baseline and at four quarterly in-hospital follow-up visits. Linear mixed-model analysis was applied to determine the effects of time and diabetes type on depressive symptoms, HbA1c levels, and fasting glucose levels. RESULTS: Mean and standard deviation baseline BDI and HbA1c levels were 17.9 +/- 5.8 and 7.6 +/- 1.6, respectively, with no significant difference between patients with Type 1 and Type 2 diabetes. Mixed-model regression analysis found no difference between the groups with Type 1 and Type 2 diabetes in the within-subject effect of BDI score on HbA1c or fasting glucose levels during the study. Depressive symptoms decreased significantly (p = .0001) and similarly over a 12-month period in both patients with Type 1 and Type 2 diabetes, whereas HbA1c and fasting glucose levels did not change significantly over time in either group. CONCLUSION: Changes in depressive symptoms were not associated with changes in HbA1c or fasting glucose levels over a 1-year period in either patients with Type 1 or Type 2 diabetes.

Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults.

OBJECTIVE: This study evaluated the relation among weight-based stigmatization, ideological beliefs about weight, and psychological functioning in an obese, treatment-seeking sample. RESEARCH METHODS AND PROCEDURE: Ninety-three obese, treatment-seeking adults (24 men and 69 women) completed a battery of self-report questionnaires measuring psychological adjustment, attitudes about weight, belief in the controllability of weight, and the frequency of weight-based stigmatization. RESULTS: Weight-based stigmatization was a common experience for participants. Frequency of stigmatizing experiences was positively associated with depression, general psychiatric symptoms, and body image disturbance, and negatively associated with self-esteem. Further, participants' own negative attitudes about weight problems were associated with their psychological distress and moderated the relation between the experience of stigmatization and body image. DISCUSSION: Weight-based stigmatization is a common experience for obese individuals seeking weight loss treatment and appears to contribute to poor mental health adjustment. The negative effects of these experiences are particularly damaging for those who hold strong antifat beliefs.

Body image partially mediates the relationship between obesity and psychological distress.

OBJECTIVE: Body image is considered as a potential mediator of the relationship between obesity and psychological distress. RESEARCH METHODS AND PROCEDURES: One hundred ten men and women in a residential weight control facility completed the Multidimensional Body Self-Relations Questionnaire, the Beck Depression Inventory, the Rosenberg Self-Esteem Scale, and the Binge Eating Scale. RESULTS: For both men and women, body-image satisfaction partially mediated the relationship between degree of overweight and depression/self-esteem. DISCUSSION: Sociodemographic factors that may influence the relationships among weight, body image, and depression/self-esteem are discussed.

Changing eating behavior: a preliminary study to consider broader measures of weight control treatment success.

This study evaluated changes in the self-reported eating behaviors (snacking, binge eating, portion sizes, and meal skipping) of 52 obese adults (33 women and 19 men) attending a residential weight loss facility on two consecutive occasions. For each of the eating patterns studied, subjects reported engaging in the behavior significantly less frequently at the time of their return visit. It is proposed that changes in eating behaviors provide a useful and appropriate nonweight based outcome measure for estimating treatment success in diet-seeking clients.