Elsevier

Obesity Research & Clinical Practice

Volume 8, Issue 4, July–August 2014, Pages e299-e313
Obesity Research & Clinical Practice

Review
Psychological predictors of weight loss after bariatric surgery: A review of the recent research

https://doi.org/10.1016/j.orcp.2013.09.003Get rights and content

Summary

Background

Morbid obesity is the fastest growing BMI group in the U.S. and the prevalence of morbid obesity worldwide has never been higher. Bariatric surgery is the most effective treatment for severe forms of obesity especially with regard to a sustained long-term weight loss. Psychological factors are thought to play an important role for maintaining the surgical weight loss. However, results from prior research examining preoperative psychological predictors of weight loss outcome are inconsistent. The aim of this article was to review more recent literature on psychological predictors of surgical weight loss.

Methods

We searched PubMed, PsycInfo and Web of Science, for original prospective studies with a sample size >30 and at least one year follow-up, using a combination of search terms such as ‘bariatric surgery’, ‘morbid obesity’, ‘psychological predictors’, and ‘weight loss’. Only studies published after 2003 were included.

Results

19 eligible studies were identified. Psychological predictors of surgical weight loss investigated in the reviewed studies include cognitive function, personality, psychiatric disorder, and eating behaviour.

Conclusion

In general, recent research remains inconsistent, but the findings suggest that pre-surgical cognitive function, personality, mental health, composite psychological variables and binge eating may predict post-surgical weight loss to the extent that these factors influence post-operative eating behaviour.

Introduction

Obesity is a substantial public health problem worldwide. The prevalence of obesity has increased dramatically over the last three decades [1], [2], [3] with the most marked increase in more severe forms of obesity [4]. This is alarming considering that overweight and particularly morbid obesity, defined as Body Mass Index (BMI)  40 kg/m2, is associated with a marked increase in mortality [5] often caused by medical co-morbidities, such as diabetes, cardio-vascular disease, and cancer [6], [7]. In addition, psychological and social complications as well as impaired health-related quality of life (HRQOL) are prevalent among obese patients [8], [9].

Traditional weight loss strategies, such as behavioural therapy, low-caloric diets and pharmacological treatment, have shown good results for obesity class I and II (BMI 30–34.9 and 35–39.9 kg/m2, respectively) [10], but are usually ineffective in the long-term treatment of morbid obesity [11], [12], [13]. Most patients who present for bariatric surgery have already been unsuccessful in multiple attempts to achieve a sustained weight loss through non-surgical treatment programmes. Despite potential postoperative complications, such as gastric dumping syndrome, incisional hernia, and infections, bariatric surgery is currently considered the treatment of choice for these patients and may result in weight loss of up to 80% of the excess body weight with subsequent reductions in medical risk factors, obesity-related co-morbidities, and psychological symptoms [14], [15], [16]. However, bariatric surgery should be considered a ‘stepping stone’, and patients must be prepared to engage in comprehensive lifestyle changes. The generally positive results of bariatric treatment have been questioned by recent studies reporting that a substantial minority of bariatric patients have suboptimal weight loss often defined as less than 40–50% excess weight loss (EWL) for Gastric Bypass (GBP) [17], [18]. In addition, up to 20–30% of bariatric patients undergoing obesity surgery regain some if not all of their initial weight loss around 2 years after surgery [19], [20], [21], [22]. Non-surgical and psychological factors that affect the patients’ ability to adjust to the postoperative situation are likely to be involved in the course of this regain [23], [24], [25]. However, no pre-surgical psychological predictors have consistently been demonstrated [26], [27]. Identifying potential indicators of surgical success will not only enable better patient selection, but may also contribute to the improvement of treatment by facilitating the development of pre- and post-operative psychosocial interventions.

Generally, a successful outcome of obesity surgery involves three main goals: weight loss, improvements in HRQOL, and reduction of obesity-related comorbidities. The aim of this article is to review results from studies examining predictors of postoperative weight loss. Improvement of obesity-related comorbidities is assumed to depend on postoperative weight loss and will not be discussed here. According to a recent systematic review [26], the existing literature about potential predictors of success after bariatric surgery is far from conclusive. Herpertz and colleagues [26] summarised the results from studies conducted between 1980 and 2002. The overall conclusion of this review was that personality traits and psychiatric comorbidity do not seem to have predictive value for surgical weight loss. However, the authors suggested that severe psychiatric disorders including personality disorders may be a negative predictor of weight loss. Furthermore, depressive and anxiety symptoms directly related to obesity appeared to predict larger postsurgical weight loss. Thus, Herpertz et al. [26] emphasised that the severity of symptoms is more relevant for weight loss outcome than the specific character of the symptoms. These conclusions were supported by a review conducted by Van Hout et al. [27]. In the current article, we review results published more recently (2003–2012) and compare this research to previously published results.

Section snippets

Method

To identify relevant articles, we searched Pubmed, PsycInfo and Web of Science using combinations of search terms such as “Obesity”, “Obesity surgery”, “Bariatric surgery”, “weight loss”, “Predictors”, “Psychological”, “Psychiatric”, “Psychosocial”, and “Surgical outcome”. Initially, titles of the identified studies were screened and abstracts of the relevant studies were read. Furthermore, reference lists were checked for relevant studies. The remaining eligible studies were read in detail.

Predictors of outcome

In this review of predictors of weight loss after bariatric surgery, we identified 19 articles published after 2003 that explicitly investigated the predictive value of psychological factors. The investigated predictors of surgical weight loss included cognitive function [43], certain personality traits [31], [44], [45], [46], mental and psychiatric status [37], [47], [48], [49], [50], [51], [52], and eating behaviour, including BED [53], [54], [55], [56], [57], [58], [59]. In addition,

Conclusion

Some tentative conclusions can be drawn from this review of recent prospective studies with at least 1-year follow-up examining predictors of postoperative weight loss. Herpertz et al. [26] concluded that personality and moderate psychiatric comorbidity did not predict surgical weight loss whereas severe psychiatric psychopathology may be a negative predictor of weight loss. The studies conducted in 2003–2012 have provided some evidence that individual characteristics such as cognitive

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      Our findings add to the limited body of research on how religious involvement and spiritual practices relate to bariatric surgery outcomes [29], and this study is the first, to our knowledge, to assess how spirituality and specific spiritual practices might support patients’ lifestyle changes essential to weight loss and weight loss maintenance in the first years after surgery. In a review of what they found to be sparse literature, Wimmelmann et al. [29] observed that personality, a severe psychiatric disorder at baseline, persistence of psychiatric symptoms after surgery, and inappropriate postoperative eating behavior relate to health-related quality of life after surgery, but their literature review did not uncover any findings related to religiosity or spirituality. In a more recent report, spirituality moderated the relationship between impulsiveness and mental/physical quality of life among bariatric patients, but the relationship of spirituality to actual weight loss outcomes [30] was not examined.

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