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We know that the weight loss outcome following bariatric surgery can be impressive. Patients lose as much as 35% of their initial body weight in the first 18 months postoperatively but does their psychosocial outcome also improve. Welcome to the Clinician's Roundtable. I am Dr. Leslie Lundt, your host, and with me today is Dr. David Sarwer, the Director of Clinical Services at the Centre for Weight and Eating Disorders at the University of Pennsylvania School of Medicine.
DR. LESLIE LUNDT:
Welcome to ReachMD, David.
DR. DAVID SARWER:
Thank you Dr. Lundt. It is a pleasure to be here today.
DR. LESLIE LUNDT:
So tell us about the outcomes, psychiatrically speaking, after bariatric surgery.
DR. DAVID SARWER:
Well, as you said in the very beginning, bariatric surgery is the most powerful tool that we have in the treatment of obesity and that on average patients who undergo gastric bypass procedures lose about 35% of their weight within about the first 18 months of surgery. Those who undergo the banding procedures which are less invasive actually lose a little bit less somewhere in the neighborhood of about 20 to 25% of their initial weight and both procedures are associated with significant improvements in general psychosocial status at least within the first 2 years after surgery. So, in a number of studies we have seen that patients show a significant reduction in depressive symptoms, impressive improvements in self esteem, and body image concerns, and improvements in quality of life as well, and what is really impressive is that these enhancements occur very early on in the postoperative process, in some cases within the first few months of having surgery when patients have perhaps only lost 20 to 25 pounds after surgery and this actually corresponds quite nicely with the improvements that we see in their medical comorbidities as well. So again, bariatric surgery is a very, very powerful tool when we look at improvements not only in weight and comorbidities but also psychosocial status.
DR. LESLIE LUNDT:
And what about actual psychopathology?
DR. DAVID SARWER:
The psychopathology question is an interesting one because the studies that have been done in this area have really kind of contradicted one another. Some studies, in fact, have suggested that some conditions like mood disorders will remit whereas other studies have not suggested that and I think the most important take-home message for listeners out there today is to realize that bariatric surgery while it may have very powerful psychosocial implications and we may see these wonderful improvements in psychological symptoms it is not a psychiatric treatment that we would never want to say to a patient nor do want a patient to ever suspect or expect that bariatric surgery is going to cure their long term struggles with depression or an anxiety disorder or it is going to resolve longstanding issues in a marriage.
DR. LESLIE LUNDT:
Do some measures actually deteriorate following surgery?
DR. DAVID SARWER:
There are some evidence that suggest that improvements in things like quality of life and depressive symptoms may in fact deteriorate after about the 2-year mark after surgery, but unfortunately there have been very few studies that have followed patients out that long to date. There is currently a consortium being undertaken by the National Institutes of Health called Labs which is the longitudinal assessment of bariatric surgery. It is a multicenter trial being conducted at 6 medical centres throughout the country which will actually be following patients for 4 years after bariatric surgery and that study should give us some of the most definitive evidence on whether or not some of these psychological improvements deteriorate after that second postoperative year. Intuitively, what we may be seeing is that as patients hit their weight plateaus around that 18 to 24 month mark many of them actually begin to regain some weight and it may be that we see some modest reductions in quality of life and self esteem as patients regain about 5 to 10% of the weight that they have lost.
DR. LESLIE LUNDT:
No, how about suicidality, does that seem to change?
DR. DAVID SARWER:
Yeah, suicidality is a very interesting issue in this field. In that, within the last couple of years there have been a number of studies that have shown that mortality improves quite dramatically after bariatric surgery and that the medical benefits related to bariatric surgery when you balance them against the initial risks associated with these procedures are actually realized within 3 to 5 years of surgery. However, it does seem like the mortality rate, the longer-term mortality rates after bariatric surgery are somewhat slightly artificially inflated because of suicide, that is if we track patients out 3 to 5 to 10 years after bariatric surgery there are a number of patients who are dying but they are dying because of suicide. Why that is, we do not really know and it's really one of the fascinating questions in this area for those of us who are mental health professionals who work with these patients. Is it a question of preexisting psychopathology that's coming back years later? Is it a question of patients who had unrealistic expectations associated with bariatric surgery that haven't been realized or it's in fact that some patients are really struggling to adjust to their new bodies and their new lives after surgery. They anecdotally hear from a lot of patients, you know, they are used to always being the fat person in the room and now that they have lost 100 pounds after surgery and they realize that they blend in with everybody else, well they always thought that they didn't want to be seen as the "fat person". Now what they are saying is that they are struggling to, you know, that they are being seen in a different light whether that is by a spouse, by their own children, by their coworkers, and a lot of patients do seem to struggle with that.
DR. LESLIE LUNDT:
So it really is counterintuitive. You would expect them to feel better after surgery and extensive weight loss.
DR. DAVID SARWER:
Well, I do think it's important that we know that the majority of patients do in fact feel better, that we are really talking about this relatively small minority of patients who seem to struggle after surgery. So for example, if we look at patients who lose weight after surgery about 80% of them have what's loosely defined as a successful outcome, but it seems like around 15 to 20% either don't lose as much weight as they should or they lose weight and then start to regain it back, but the improvements in psychosocial status seemed that that the vast majority of patients report improvements in psychosocial status, but there is this smaller minority that seems to struggle, that we are only beginning to really understand all of the unique issues that some of these patients are facing now.
DR. LESLIE LUNDT:
Is the suicidality related at all to the suboptimal weight loss? So people that don't lose as much as they thought they were going to lose.
DR. DAVID SARWER:
Yeah, you know, in some anecdotal reports and small case reports that appear in the literature at least in some cases it appears that the suicides are related to smaller weight losses. Unfortunately, the larger mortality based studies which have been done by epidemiologists looking at thousands of patients often time haven't had available to them the specific information that would allow us to say how much of an argument can we make that the suicide is in fact related to a smaller weight loss. Its, you know, often times it is very difficult to draw those kinds of conclusions, but again it is an issue that many of us who work in this field are definitely very concerned about because, you know, in some respects that is the worst outcome of all of these patients. That, you know, many of these patients report not only being healthier and reporting these wonderful improvements in psychosocial status, but it is obviously a tremendous tragedy when any of these patients ends up taking their own lives.
DR. LESLIE LUNDT:
If you are new to our channel you are listening to the Clinician's Roundtable on ReachMD.com on XM160, the Channel for Medical Professionals. I am Dr. Leslie Lundt, your host, and with me today is Dr. David Sarwer. We are discussing psychological outcomes following bariatric surgery.
DR. LESLIE LUNDT:
David, is anything regularly being done postop to support these patients from a psychological perspective?
DR. DAVID SARWER:
Well, in general, in the larger field of bariatric surgery, I think, there is a growing awareness that postoperative care in all of its forms from psychosocial and psychological interventions to ongoing dietary counseling to also helping patients increase their level of physical activity are all critically important in terms of the long term success of these patients. This is very much a shift in thinking for may GI surgeons who are very used to the idea that they operate on a patient and the patient is cured and is discharged from a practice. But we know from the behavioral weight control literature as well as the pharmacotherapy agents that are used for long term weight control that chronic long term care and continued contact with the provider is critically important to success and as a result we are seeing more and more programs being developed and now more currently being researched in terms of how looking at how important is it for patients to have regular followup with the program. Whether its coming to support groups, returning for their annual visits, seeing a mental health professional, and so on and one of the kind of interesting things looking forward is a potential utility of using the internet and web based applications to maintain contact with patient. So, if a patient comes to a bariatric surgery program from 90 minutes away it may be hard for them to physically come to that program even 4 or 5 times a year. But if there is a way that the dietitians and the mental health professionals can retain and maintain contact through the internet or through regular phone calls there is some evidence to suggest that that can also promote long term successful weight control.
DR. LESLIE LUNDT:
Is there any place for 12-Step groups, Overeating Anonymous, that sort of thing in these patients?
DR. DAVID SARWER:
No, in my clinical experience I have had a number of different patients who both have been in OA prior to bariatric surgery and then have used it in terms of a social support mechanism postoperatively and one of the things I will encourage all of my patients to do is to just make sure that they do have social support in a form that makes sense to them. If a patient feels like they get the support that they would like from OA or from a commercial program like Weight Watchers as long as they feel like they are not getting misinformation specific to their bariatric procedure, I think that that can be an appropriate resource for them. Unfortunately, I have also heard about OA groups, Overeaters Anonymous groups and what not who completely frown upon bariatric surgery and have very rigorous, almost unrealistic, if not draconian guidelines in terms of what patients have to do to stay in those groups and in those cases those patients probably are better off finding a resource more specifically dedicated to bariatric surgery.
DR. LESLIE LUNDT:
Any other tips, lets say lot of our audience is primary care. So, lets say they, you know, they are not directly involved in the bariatric surgery, what can those of us more on the periphery of the patient's care do to help their progress through surgery and then postop?
DR. DAVID SARWER:
That's a wonderful question and it is actually very much related to what we are just talking about that even though we were focusing on mental health care, the reality is there is a growing awareness from the bariatric surgery community that we need to do a better job communicating with the primary care physicians, the endocrinologists, the OB/GYN, and the other physicians out there who touch on the bariatric surgery patient. Whether that's helping provide the extremely obese patient with proper advise about when bariatric surgery is appropriate, what it can and cannot do, but more importantly how to appropriately manage these patients in a long term. So, there are a number of different educational programs and initiatives out there now where the major societies try to get primary care physicians and other related medical personnel to come and learn about bariatric surgery because there have been a number of primary care physicians and the like, you know, tell me wow, I now have 10 postop patients in my practice and I have no idea what their unique challenges are and I think as more and more patients have bariatric surgery if, in fact, we are having this, you know, 200 to 300,000 new patients a year this is going to be an issue that more and more of our physicians in primary care are going to be seeing on a regular basis.
DR. LESLIE LUNDT:
And of course most of us that trained a while ago had absolutely no exposure to this in our residency. So, we really do not know much about it.
DR. DAVID SARWER:
And it really speaks actually to a larger issue which is that there are really only a very small minority of medical schools in the United States do any training at all around the area of obesity let alone bariatric surgery and its interesting if we look at the rate of extreme obesity in the general population and then we extrapolate to the number of patients that we are getting procedures done only about 1% of Americans who are in fact heavy enough for bariatric surgery are actually getting it done. Now, some of that's probably insurance barriers and patients reluctant to have surgery, but many of us also believe that likely what's going on there is that there is a reluctance among primary care physicians and endocrinologist to recommend surgery because they are perhaps not up to speed with what surgery can and cannot do, when is it safe, when is it affective, and really how it can be such a powerful tool for patients?
DR. LESLIE LUNDT:
Perfect. Well, thank you for sharing your ideas with us today.
DR. DAVID SARWER:
Sure, thanks. It is a pleasure being here.
DR. LESLIE LUNDT:
We have been speaking with Dr. David Sarwer about the psychological outcomes following bariatric surgery. I am Dr. Leslie Lundt and you are listening to ReachMD, the Channel for Medical Professionals.
Please visit our web site at ReachMD.com which features our entire library through on demand podcast. You can always call us toll free with your comments and suggestions or ideas for future topics at 888-639-6157.
Thank you for listening.
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We know that the weight loss outcome following bariatric surgery can be impressive - patients lose as much as 35% of their initial body weight in the first 18 months post-op. Does their psychosocial outcome also improve? Host Dr. Leslie Lundt welcomes Dr. David Sarwer, director of clinical services at the Center for Weight and Eating Disorders at the University of Pennsylvania School of Medicine to discuss what happens after bariatric surgery.
We know that the weight loss outcome following bariatric surgery can be impressive - patients lose as much as 35% of their initial body weight in the first 18 months post-op. Does their psychosocial outcome also improve? Host Dr. Leslie Lundt welcomes Dr. David Sarwer, director of clinical services at the Center for Weight and Eating Disorders at the University of Pennsylvania School of Medicine to discuss what happens after bariatric surgery.
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