The Psychological Aspects of Obesity & Bariatric Surgery
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1 The Psychological Aspects of Obesity & Bariatric Surgery Kelli E. Friedman, PhD Assistant Professor, Dept. of Psychiatry & Behavioral Sciences Assistant Professor, Dept. of Surgery Director, Psychological Services, Duke Center for Metabolic & Weight Loss Surgery Selection & Medical Management of Weight Loss Surgery Patients Cary, NC, March 3 rd, 2018
2 Presenter: Kelli E. Friedman, PhD As previously disclosed, these are the companies with which I have a financial or other relationships: Company Name Covidien Teleflex Gore Intuitive Surgical Nature of Relationship Consultant/Grant/Proctor Consultant Educational Grant Consultant
3 Why Psychology?
4 Why Psychology? As a psychiatrist, I have no doubt that a morbidly obese patient without other medical cause for obesity (i.e., thyroid disease) already has a severe psychiatric problem -Amanda Itzkoff, M.D., Department of Psychiatry, Mount Sinai Hospital
5 The Relationship Between Obesity & Psychopathology Obesity Psychopathology
6 The Relationship Between Obesity and Psychopathology Obesity Psychopathology
7 The Relationship Between Obesity and Psychopathology Obesity Psychopathology
8 The Relationship Between Obesity and Psychopathology Obesity Comorbidities Stigma Disability Psychopathology
9 The Role of Psychology in Obesity Psychological consequences of obesity Psychological contributors to obesity Behavioral Weight Loss Treatment (BWLT) Psychological aspects of surgical treatment
10 The Role of Psychology in Obesity Psychological consequences of obesity Psychological contributors to obesity Behavioral Weight Loss Treatment (BWLT) Psychological aspects of surgical treatment
11 Psychological Consequences of Obesity Depression Stigma and disability Extreme obese ~5x increase in risk of depression than average weight (Onyike et al., 2003) Relationship stronger for women (Herpertz et al., 2006) (WHY has not been well establish, but likely related to sociocultural factors as well as hormones and fat metabolism)
12 Psychological Consequences of Obesity Anxiety Embarrassment about weight Excessive checking Avoidant behaviors Eating pathology Stigma, body image dissatisfaction, & ineffectiveness of efforts to lose weight, can lead to yo-yo dieting, cycles of deprivation and overeating, etc.
13 The Role of Psychology in Obesity Psychological consequences of obesity Psychological contributors to obesity Behavioral Weight Loss Treatment (BWLT) Psychological aspects of surgical treatment
14 The Etiology of Obesity Psychological Factors Obesity BEHAVIOR
15 The Etiology of Obesity GENETICS Psychological Factors Obesity BEHAVIOR
16 The Etiology of Obesity GENETICS ENVIRONMENT Psychological Factors CULTURE Obesity BEHAVIOR ECONOMICS
17 The Etiology of Obesity Psychology/Behavior Person A Genes/Physiology Environment/ Economics Culture Person B Person C Person D
18 The Etiology of Obesity GENETICS ENVIRONMENT Psychological Factors CULTURE Obesity BEHAVIOR ECONOMICS
19 Psychological/Behavioral Contributors to Obesity Behavioral Factors Lifestyle Physical Inactivity Cognitive Patterns Psychiatric Symptoms
20 Psychological/Behavioral Contributors to Obesity Behavioral Factors Lifestyle Physical Inactivity Cognitive Patterns Psychiatric Symptoms
21 Psychological/Behavioral Contributors to Obesity Poor adherence Behavioral Patterns - Lifestyle
22 Psychological/Behavioral Contributors to Obesity Behavioral Patterns - Lifestyle Poor adherence Poor problem-solving skills
23 Psychological/Behavioral Contributors to Obesity Behavioral Patterns - Lifestyle Poor adherence Poor problem-solving skills Self-care skills deficit
24 Psychological/Behavioral Contributors to Obesity Behavioral Patterns - Lifestyle Poor adherence Poor problem-solving skills Self-care skills deficit Time demands
25 Psychological/Behavioral Contributors to Obesity Behavioral Patterns - Lifestyle Poor adherence Poor problem-solving skills Self-care skills deficit Time demands Lack of structure
26 Psychological/Behavioral Contributors to Obesity Behavioral Patterns - Lifestyle Poor adherence Poor problem-solving skills Self-care skills deficit Time demands Lack of structure Sleep deficit
27 Psychological/Behavioral Contributors to Obesity Behavioral Patterns - Lifestyle Poor adherence Poor problem-solving skills Self-care skills deficit Time demands Lack of structure Sleep deficit Stressors
28 Psychological/Behavioral Contributors to Obesity Behavioral Patterns - Lifestyle Poor adherence Poor problem-solving skills Self-care skills deficit Time demands Lack of structure Sleep deficit Stressors It s just plain hard to do!
29 Psychological/Behavioral Contributors to Obesity Behavioral Factors Physical Inactivity Embarrassment Skill deficit Time constraints Discomfort/Pain Disability Environment Cost
30 Psychological/Behavioral Contributors to Obesity Behavioral Factors Lifestyle Physical Inactivity Cognitive Patterns Psychiatric Symptoms
31 Psychological/Behavioral Contributors to Obesity Cognitive Factors All-or-nothing thinking Lack of self-efficacy Unrealistic expectations
32 Psychological/Behavioral Contributors to Obesity Behavioral Factors Lifestyle Physical Inactivity Cognitive Patterns Psychiatric Symptoms
33 Psychological Contributors to Obesity Eating Disorder Symptoms Binge Eating Disorder Consumption of unusually large amounts of food in a short period, with LOC Much more common in people with obesity Estimates of prevalence vary dramatically Overall community prevalence is a ~ 2% Higher in WLS-seeking population (estimates as high as 47%) Prevalence increases with severity of obesity
34 Psychological Contributors to Obesity Psychiatric Symptoms Depression/Anxiety Decrease motivation Decrease self-efficacy Decrease ability to engage in self-care Elicit eating as a coping mechanism Psychotropic medication may be weight-promoting
35 Psychological/Behavioral Contributors to Obesity Psychotic and Bipolar Disorders Decrease motivation Impulsivity Decrease ability to engage in self-care Psychotropic medication can be weight-promoting
36 The Role of Psychology in Obesity Psychological consequences of obesity Psychological contributors to obesity Behavioral Weight Loss Treatment (BWLT) Psychological aspects of surgical treatment
37 Behavioral Weight Loss Treatment Weight management: A set of skills that can be learned Target areas: Eating Activity Thinking patterns 3 Characteristics: Goal-oriented Process-oriented Focus on small, incremental changes (not OA) Butryn, Webb, & Wadden, (2011). Behavioral Treatment of Obesity, Psychiatric Clinics of North America, 34, , Wadden, Crerand, Brock, (2005)
38 Behavioral Weight Loss Treatment Components Self-monitoring Goal Setting Stimulus control Nutrition education Physical activity Problem-solving Cognitive restructuring Relapse prevention
39 Behavioral Weight Loss Treatment Components Self-monitoring Goal Setting Stimulus control Nutrition education Physical activity Problem-solving Cognitive restructuring Relapse prevention Groups
40 Behavioral Weight Loss Treatment Outcomes Average loss of 10% initial body weight in weeks Regain of 1/3 of lost weight in first year At 5 year follow-up, > 50% have regained all lost weight Most effective plan = one that the patient likes Maintenance is key Wadden, T, Butryn, M, Wilson, C (2007) Lifestyle Modification for the Management of Obesity. Gastroenterology, 132;6:
41 Behavioral Weight Loss Treatment Successful maintainers: Maintenance Use more behavioral strategies to control eating Consume a low-calorie, low-fat diet Engage in a high level of physical activity Weigh themselves frequently Eat breakfast Have a consistent meal pattern Wing & Phelan (2005)
42 The Role of Psychology in Obesity Psychological consequences of obesity Psychological contributors to obesity Behavioral Weight Loss Treatment (BWLT) Psychological aspects of surgical treatment
43 Goals of the Psychological Evaluation Old School Predicting weight loss Data suggests psychopathology does not predict weight loss (in relatively short term) Thus, some suggest the psychological evaluation is not necessary 1 The gatekeeper (obstacle) 1 Ashton, Favretti, & Segato, 2008
44 The Role of Psychology in Surgical Treatment
45 The Role of Psychology in Surgical Treatment Evaluation Determine suitability of surgical treatment Identify psychological factors that may impact outcome Motivating factors Expectations Psychiatric symptoms Assistant in informed consent process Develop appropriate treatment plan
46 Goals Beyond Psychiatric Diagnosis Help prepare patient for change Minimize emotional/behavioral distress through surgery Educate Optimize outcome (not just pounds lost) Clinic/hospital/staff burden Facilitator/Optimizer ( not gatekeeper ) Risk Management
47 Specific Contraindications for Bariatric Surgery Few specific contraindications for bariatric surgery Mental/cognitive impairment that limits ability to understand procedure thus precluding informed consent 1 AACE/TOS/ASMBS Guidelines (2008) Extremely high operative risk (e.g., severe congestive heart failure) Current drug or alcohol use Uncontrolled, severe psychiatric illness Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes required with bariatric surgery Inability or unwillingness to adhere to post-op regimen 1 DeMaria, 2007
48 Specific Contraindications for Bariatric Surgery Few specific contraindications for bariatric surgery Mental/cognitive impairment that limits ability to understand procedure thus precluding informed consent 1 AACE/TOS/ASMBS Guidelines (2008) Extremely high operative risk (e.g., severe congestive heart failure) Current drug or alcohol use Uncontrolled, severe psychiatric illness Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes required with bariatric surgery Inability or unwillingness to adhere to post-op regimen 1 DeMaria, 2007
49 The Role of Psychology in Surgical Treatment Adjustment to Post-Surgical Changes Lifestyle changes Emotional consequences Interpersonal consequences Body image issues Fear of regain Eating behaviors Substance abuse
50 Medication Use Among Bariatric Surgery Pts LABS Data (~5,000 patients) 1 Pre-surgery 39.9% on antidepressants 26.6% statins 17.9% beta-blockers 16.1% narcotics Post-surgery Pts often able to discontinue use of medications Antidepressants consistently the exception 1 Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. (2009).
51 Long-term Mortality after RNY Adams et al., NEJM
52 Long-term Mortality after RNY Adams et al., NEJM
53 Long-term Mortality after RNY Adams et al., NEJM
54 Long-term Mortality after RNY Data suggests not only the need for psychosocial evaluation, but also access to regular psychological follow-up after surgery Adams et al., NEJM
55 Physician Involvement
56 Physician Attitudes: Bariatric Surgery Bariatric surgery remains an underutilized treatment (Wolfe & Morton, 2005) 500 NJ family physicians (Ferrante et al, 2009) WLS infrequently recommended for pts w/ severe obesity Physician reported knowledge about surgery poor PCP & Endocrinologists (Sarwer et al., 2012) More years of experience = more positive attitudes Positive impression of surgery for obesity (80%) and type 2 DM (67%) 21% would refer pts with type 2 DM with BMI to randomized trail
57 Physician Involvement in Weight Loss Not commonly implemented (Galuska, Will, Serdula, & Ford, 1999) Repeated opportunities for intervention Balanced approach Pts often mention physician suggestion prompted to consider surgery Semantics
58 What s in a Name? Weight Problem Unhealthy Body Weight Weight Fatness Excess Fat Excess Weight Obesity Heaviness Large Size BMI Unhealthy BMI Wadden & Didie, 2003
59 What s in a Name? Weight Problem Unhealthy Body Weight Weight Fatness Excess Fat Excess Weight Obesity Heaviness Large Size BMI Unhealthy BMI Wadden & Didie, 2003
60 What s in a Name? Weight Problem Unhealthy Body Weight Weight Fatness Excess Fat Excess Weight Obesity Heaviness Large Size BMI Unhealthy BMI Wadden & Didie, 2003 Fatness
61 What s in a Name? Weight Problem Unhealthy Body Weight Weight Fatness Excess Fat Excess Weight Obesity Heaviness Large Size BMI Unhealthy BMI Wadden & Didie, 2003 Fatness
62 What s in a Name? Weight Problem Unhealthy Body Weight Weight Fatness Excess Fat Excess Weight Obesity Heaviness Large Size BMI Unhealthy BMI Wadden & Didie, 2003
63 What s in a Name? Weight Problem Unhealthy Body Weight Weight Fatness Excess Fat Excess Weight Obesity Heaviness Large Size BMI Unhealthy BMI Wadden & Didie, 2003
64 What s in a Name? Weight Problem Unhealthy Body Weight Weight Fatness Excess Fat Excess Weight Obesity Heaviness Large Size BMI Unhealthy BMI Wadden & Didie, 2003 Weight
65 Summary Obesity is an extremely complex phenomenon Physiology is a strong driver However, psychological factors: contribute to obesity are impacted by obesity are important to consider in any type of obesity treatment
66
67 Thank You Kelli E. Friedman, PhD
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