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