Shenelle A. Edwards-Hampton, PhD
A comprehensive psychosocial evaluation is the standard of practice with potential bariatric surgery candidates. Pre-surgery psychosocial evaluations gather information via clinical interview and administration of objective psychological measures. Such evaluations have a dual purpose: first to screen for contraindications for surgery, and second to identify pre-surgery and post-surgery psychological treatment needs.
A new referral left you a voice message seeking an appointment. When you return the call, the individual indicates that she is working with a medical program with the goal of undergoing bariatric surgery. The potential patient requested a psychosocial evaluation that the medical program requires before the individual can proceed to surgery. Such requests leave one wondering, “am I qualified to see this patient?” How do I determine my competency to provide this service? How can I uphold my duty to “do no harm?” If I do agree to complete the bariatric evaluation, what questions does the bariatric medical team want answered? What psychological topics and issues should I cover in the evaluation?
Obesity and Intervention Options
More than one third of adults in the United States are obese. This rate has remained steady over the last decade and a half. Moreover, there has been a rapid increase in the incidence of morbid obesity in the U.S. More than 6.6% of the population are estimated to be morbidly obese, and thus are candidates for weight loss surgery (Sturm & Hattori, 2013). Some of the leading causes of preventable death are directly related to obesity, including heart disease, stroke, type 2 diabetes, and cancer. Obesity has a significant economic impact in the U.S. In 2008, the estimated annual medical cost of obesity was $147 billion.
Non-surgical weight loss treatments, even when successful, facilitate approximately 10% total weight loss and are associated with a greater than 99% chance for weight regain (Weiss, Galuska, Khan, et al., 2007). Successful surgical weight loss treatments, on the other hand, facilitate anywhere from 50–75% loss of excess weight, have a failure rate of less than 20%, and have up to a 65% chance of resolving type 2 diabetes, hypertension, hyperlipidemia, and sleep apnea (Kokkinos, Alexiadou, Liaskos, et al., 2013). Bariatric surgery is the most effective and robust obesity treatment that exists and is growing rapidly in popularity. From 2011 to 2015 total estimated bariatric procedures completed in the U.S. rose from 158,000 to 196,000 per year. There are three surgical interventions for obesity that are commonly performed at medical centers. These include the Sleeve Gastrectomy (SG), the Roux-en-Y Gastric Bypass (RYGBP), and the Biliopancreatic Diversion with Duodenal Switch (BP/DS).
A significant minority of patients (e.g., up to 20%) experience limited outcomes from bariatric surgery. Suboptimal outcomes can include inadequate weight loss, weight regain, lack of resolution of medical comorbidities, and lower quality of life following surgery. Despite what many believe, weight regain can occur quickly following surgery. Some amount of weight regain has been documented in up to 50% of postsurgical patients in the 24 months following surgery (Magro et al., 2008). Patient variables associated with poor outcomes following bariatric surgery include untreated pre-operative psychiatric symptoms (such as depression, anxiety, or bipolar disorder) and uncontrolled personality disorders. Untreated disordered eating behaviors, particularly binge eating and grazing behaviors, are also associated with suboptimal postsurgical outcomes. Specific cognitive profiles, such as individuals who are highly impulsive or have deficits in their ability to comprehend and implement behavioral and dietary changes, are at higher risk for poor outcomes.
Thus, psychological assessment and treatment focused on lifestyle changes before and after bariatric surgery is crucial to maximizing patients’ success. Accordingly, nationally accredited bariatric centers and managed care providers require patients to undergo pre-surgical psychosocial evaluations. Further, The National Institutes of Health, the American Association of Clinical Endocrinologists, the American Society for Metabolic and Bariatric Surgery, and the Obesity Society Guidelines for the Clinical Management of Bariatric Surgery Patients, have long recommended that assessment of bariatric surgery candidates include pre-surgical psychological evaluations. Currently, approximately 90% of bariatric programs include some level of psychosocial assessment prior to surgery (Bauchowitz et al., 2005; Peacock & Zizzi, 2011), suggesting that pre-surgical assessment has become standard practice amongst bariatric centers nationwide.
Nature and Conduct of Bariatric Pre-Surgical Assessment
Pre-surgery psychosocial evaluations typically gather information via clinical interview and objective psychological measures. The first goal of the pre-surgical psychological evaluation is to identify possible contraindications for surgery, such as uncontrolled substance abuse, uncontrolled psychiatric conditions, or inability to consent to care. More thorough bariatric evaluations assess the following: psychosocial functioning, cognitive barriers, surgical knowledge and attitudes, expectations for outcomes, health behaviors, compliance with treatment recommendations, perceived social support, current life stressors and self-care, and postsurgical planning. At minimum, psychological testing should include objective assessment of psychiatric functioning, substance use, disordered eating behaviors, and personality functioning. Ideally, secondary outcomes from bariatric evaluations include treatment of pre-existing psychopathology, identification of need for additional post-operative psychological care, and alternative treatment recommendations for patients who are determined to be unsuitable surgical candidates.
Weight History and Eating Behaviors
Prior to preauthorizing weight loss surgery (WLS), many managed care providers require that multiple weight loss attempts be made by a bariatric patient and documented by a medical provider. Importantly, assessment of frequency, duration, and types of weight loss interventions can provide the examiner with valuable information about the patient’s level of motivation, personal responsibility, and physiological and behavioral contributors to the patient’s weight history. For example, an individual who identifies “genetics” as the sole reason for his or her weight gain may have limited insight or be unwilling to take personal responsibility for his or her behavior. The efficacy of WLS hinges on behavioral change. Thus, it is crucial that the patient is aware of and willing to alter the maladaptive lifestyle behaviors that have contributed to his or her obese status. Few previous attempts at weight loss may reflect limited motivation and reluctance to put personal effort into meeting weight-related goals; this may also be the case with an individual whose attempts at weight loss are limited to use of over-the-counter weight loss medications. Importantly, past barriers to successful weight loss are likely to continue to serve as barriers to postsurgical success. Once barriers are identified (i.e., emotional eating), the examiner can work with the patient to identify ways to minimize or overcome barriers (i.e., identification and utilization of positive coping strategies).
Patient variables associated with poor outcomes following bariatric surgery include untreated pre-operative psychiatric symptoms (such as depression, anxiety, or bipolar disorder) and uncontrolled personality disorders.
Ideally, when an individual is engaged with a surgical program to undergo WLS, he or she is meeting regularly with a dietician who has provided the patient with dietary instructions to prepare him or her for postsurgical lifestyle behaviors. It is important that the psychologist is knowledgeable of these recommendations for the purpose of assessing compliance. Surgical programs vary slightly with regard to pre- and postsurgical dietary recommendations. Typically, however, patients are required to practice eating small portions of high protein, low fat/sugar/carbohydrate foods every three hours. Other common recommendations include limiting caffeine intake, increased duration of meals, increased chewing and abstaining from carbonated beverages and from drinking while eating. These strategies help to promote satiation, reduce hunger, and limit side effects of regurgitation or dumping syndrome following weight loss surgery.
Patients who are non-compliant, or unable to consolidate pre-surgical dietary recommendations, are at higher risk for suboptimal postsurgical outcomes and are suboptimal surgical candidates. Ways to assess knowledge and compliance with dietary recommendations may include reviewing daily food journals or asking the patient to complete a 24-hour food recall. The surgical dietician is also a valuable resource for consultation and corroborating a patient’s self-report.
Night Eating Syndrome (NES) is characterized by behaviors that contraindicate postsurgical recommendations of regular, small eating episodes and low carbohydrate intake.
Eating style is another important area for assessment. Specifically, grazing and binge eating behaviors are associated with suboptimal weight loss and weight regain. It can be challenging for a general provider to differentiate between over-eating and binge eating behaviors in a morbidly obese patient. Generally, if the patient endorses frequently eating a very large amount of food in small period of time (more than a similar person in a similar context) and a sense of loss of control or disassociation during the eating episode, they qualify for binge eating behaviors. Night Eating Syndrome (NES) is characterized by behaviors that contraindicate postsurgical recommendations of regular, small eating episodes and low carbohydrate intake. It is important to note that, in some circumstances, NES can be triggered by medications.
Weight loss occurs when there is a negative energy balance. Put more simply, weight loss occurs when the amount of energy expended exceeds the amount of energy consumed. The majority of the energy we consume is expended via “fueling” our bodily systems, commonly known as our metabolic functioning. Physical activity is another means by which energy can be expended. However, the efficacy of physical activity in creating a negative energy balance (weight loss) is often vastly over-estimated. Rather, findings suggest that physical activity, particularly building and sustaining lean muscle mass, facilitates a negative energy balance via its impact on metabolic functioning. Specifically, lean muscle mass is associated with reduced efficiency in metabolic functioning; the body requires more energy (burns more calories) to operate day-to-day physiological functions. It can be very valuable to provide this psychoeducation to patients when emphasizing the importance of physical exercise, particularly strength training following WLS. Due to the powerful restrictive and malabsorptive mechanisms of WLS, many postsurgical patients will lose weight over the first 6–18 months following surgery despite failure to engage in exercise. However, much of the weight loss is likely to be loss of lean muscle mass, causing metabolic slowing, and priming the body for weight regain.
The benefit of exercise on emotional well-being is well-documented. Given the significant role that exercise plays in patients’ physical and emotional health, the patient’s history of physical activity should be assessed by the provider. With this knowledge, the provider can assist the patient in making small, reasonable goals to increase physical activity, such as identifying ways in which the patient can “move more.”
Knowledge and Self-Care
The examiner should also be attentive to the patient’s level of cognitive functioning, including his or her ability to recall and communicate information. At the time of the clinical interview, patients should be able to describe the surgical procedure that he or she wants to undergo, identify risks associated with the procedure, and identify postsurgical recommendations and risks associated with noncompliance. Level of education, literacy, and self-reported occupational history can provide collateral information related to the patient’s cognitive functioning. Poor knowledge of the surgical procedure and associated side effects can significantly negatively impact patient satisfaction, quality of life, and safety following surgery. For example, if a patient fails to comprehend and implement the necessary vitamin regimen following WLS he or she can experience malnutrition and vitamin deficiencies that have irreversible side effects (ie. deficiencies in vitamin A can lead to blindness).
Importantly, cognitive dysfunction is not an outright contraindication for WLS. With appropriate accommodations, such as providing information to patients in written and verbal format, and involvement of a committed, high functioning caregiver, cognitively limited patients can experience good success following WLS. The examiner plays a critical role in identifying possible cognitive limitations and assisting the patient in identifying sufficient accommodations.
The patient’s history of compliance with medications and medical recommendations is a strong predictor of his or her compliance with postsurgical recommendations. Thus compliance with taking medication regularly, sleep apnea treatment, and attending medical appointments, etc., offers valuable information. Typically, pervasive noncompliance with medications and medical recommendations is a contraindication for WLS.
Patients who report multiple significant life stressors are likely to experience difficulty managing the rigorous lifestyle changes required after surgery. Stressors may be associated with the patient’s family, place of employment, community, finances, or social functioning. High emotional awareness and intelligence, use of positive coping strategies, and strong perceived social support can serve as powerful protective factors, pre- and post-surgery, when a patient is faced with significant life stressors. Of note, it is not uncommon for patients’ close friends and family members to be unsupportive of the patient’s decision to undergo WLS. This is often very discouraging and defeating for patients, leading to increased ambivalence and anxiety. More often than not, opposition to WLS is rooted in misconceptions about WLS or an underlying interpersonal problem. Psychoeducation, and when indicated, counseling can resolve these barriers within family and social systems.
Patients commonly report significant exhaustion and cognitive fatigue following WLS. These symptoms can last for several months following WLS, particularly if the patient engages in too many cognitively straining activities too soon following WLS. Thus, it is recommended that patients identify a caregiving plan that involves a 3–4 week leave of absence from his or her place of employment. The patient should also have a caregiver who agrees to transport the patient home from the hospital and is available to assist the patient in the first few days following the surgery (in the event of a medical emergency).
Unfortunately, findings in the literature related to psychiatric predictors of postsurgical outcomes are unclear and inconsistent. However, approximately 70% of bariatric patients have a lifetime history of a psychiatric diagnosis and approximately 50% present to the WLS evaluation with an active anxiety disorder (Mitchell et al., 2012; Sarwer, Wadden, & Fabricatore, 2005). Importantly, history of a psychiatric diagnosis is not a predictor of poor weight loss outcomes and many psychological symptoms improve following weight loss surgery. However, poorly controlled psychiatric conditions, such as depression, anxiety, or bipolar disorder, can interfere with compliance and limit postsurgical success when left untreated. At a minimum, the psychologist should assess the patient’s current and past psychiatric symptoms, associated treatment, and whether or not the patient benefited from treatment. When indicated, the provider should make referrals for counseling and/or medication management prior to WLS.
Eating disorders, particularly those that are commonly comorbid with obesity, such as binge eating disorder or bulimia are also associated with poor outcomes following WLS, though the exact nature of the relationship is unknown. For example, it is possible that the underlying culprit is impulse control, as this cognitive profile is also associated with poor outcomes following weight loss surgery. Information related to impulse control can be gathered via questions related to frequency of risk-taking behaviors, compulsions, or legal difficulties.
High emotional awareness and intelligence, use of positive coping strategies, and strong perceived social support can serve as powerful protective factors . . . when a patient is faced with significant life stressors.
Importantly, there has also been increased attention and concern related to the emergence of substance use disorders following bariatric surgery. Alcohol Use Disorders (AUD) were acknowledged by 1 out of 5 patients at some point in the five years following RYGBP among patients who denied any history of AUD prior to undergoing surgery (Sogg, 2017). Some recent research suggests that RYGBP may also contribute to increased risk of opiate misuse. Nicotine use makes postsurgical patients more susceptible to medical complications such as infection, slowed healing, and gastric ulcers. Thus, thorough assessment of current and past substance use is also important.
Additional areas of assessment that are less common, but may be of benefit in making treatment recommendations and maximizing outcomes include: history of abuse, neglect, or trauma, weight-related ridicule, or use of food for the purpose of comfort, companionship, control, or dissociation.
Use of psychological testing is standard amongst bariatric centers. Test data provides objective information that can be used to corroborate patients’ self-report during the clinical interview. Further, testing provides a layer of protection against subjective examiner bias and attempts by patients to present favorably. Findings can confirm or challenge clinical impressions and facilitate efficient clinical interviewing.
Despite the common use of psychological tests in bariatric evaluations, there is no consensus regarding specific measures that should be administered during the evaluation and a wealth of measures is available for use. However, the Allied Health
Sciences section of the American Society for Bariatric Surgery (ASMBS) provides some standard guidelines for practitioners. Test selection should be determined based on the referral question, test quality, the examiner’s skillset in test interpretation, and to an extent, personal preference.
With regard to general content, the battery of psychological tests administered to a bariatric candidate typically includes anywhere from 5 to 7 measures, assessing current/past psychopathology, eating behaviors, substance use, and personality functioning. More detailed information and recommendations related to testing can be located in the companion article in the current volume (Goodpaster, 2017).
Levels of Involvement in Bariatric Surgery Evaluations
Now that some time has been spent exploring the purpose and value of pre-surgical assessment, we will revisit the case example described above. You have been asked to provide a pre-surgical psychosocial assessment for a bariatric patient; what do you do? As a “generalist” clinician with accredited training and many years of experience assessing psychosocial functioning and implementing behavioral interventions, do you eagerly and appreciatively accept the referral? Or, should you graciously decline the referral and explain that such referrals should be limited to a “specialist” in bariatrics, who has received extensive supervised training in assessing and treating bariatric patients? Is there any responsible “middle road” course of action?
The first important consideration is your level of experience in working with bariatric patients. A traditional psychologist in general practice may receive referrals for bariatric evaluations infrequently, only 1–2 times per year. Within this context, you might conduct a routine psychological evaluation that identifies any clear contraindications for surgery, initiates a treatment plan, and identifies the possible need for more in-depth assessment. A screening evaluation of this kind can highlight an individual’s psychosocial strengths and limitations. Identification of any major “red flags” warrants a referral for a more in-depth psychological evaluation.
Or, you may find yourself with a steadier referral stream from a nearby surgical practice, indicating an intermediate level of clinical experience in bariatric assessments. Should you intend to accept these referrals, it is important to gain greater knowledge and expertise in the field. This might include seeking additional information from the referral source regarding the information they want you to capture, reviewing the literature related to bariatric evaluations, or consulting with an expert in the field. Additionally, the intermediate evaluator should attend continuing education workshops, attend sessions at conferences, and seek supervision related to working with bariatric patients. If available, graduate level coursework in behavioral medicine is ideal. It is also important for the intermediate psychologist to attempt to expand their relationship with the referral source to become partially integrated with the medical team. This might include attending clinical team meetings, providing verbal feedback to providers, and providing psychoeducation to team members.
The most advanced level of involvement for a psychologist is full-time employment within an interdisciplinary bariatric program. Bariatric psychologists are most commonly employed within academic medical settings and actively contribute to bariatric knowledge via peer-reviewed articles and presentations at conferences. In addition to completing bariatric evaluations, the bariatric psychologist typically offers behavioral health interventions for patients both pre- and post-surgery. Further, he or she often serves as a liaison between the patient and the interdisciplinary team, helping the team to understand and optimally interact within the patient’s unique psychosocial context. This level of specialization is typically initiated in pre-doctoral coursework and practicum experiences and extends through to supervised postdoctoral training. While relatively uncommon, a generalist psychologist could become specialized via returning to a university for training in behavioral medicine and re-engaging in full-time supervision.
The incidence of morbid obesity has grown rapidly over the past few years, leading to increased use of surgical intervention for the treatment of obesity. Bariatric surgery can be extremely effective for weight loss and resolution of weight-related medical comorbidities. However, the efficacy of bariatric surgery is largely thought to hinge on psychosocial variables such as patient compliance, social functioning, and eating behaviors. Accordingly, pre-bariatric surgical psychological evaluations have become the standard of care in attempt to maximize outcomes. Consequently, psychologists are routinely being asked by surgical teams to complete these evaluations. This has left many of us wondering whether we should provide the evaluation, and if so, what it should include. The intent of this article was to provide some concrete answers to these popular questions. As a general rule of thumb, as the stream of referrals that you accept from surgical programs gets larger and larger, so too should your theoretical and practical knowledge base of weight loss surgery.
Shenelle A. Edwards-Hampton, PhD, is the Director of Behavioral Health in the Weight Management Center. She earned her PhD in Clinical Psychology from Fuller School of Psychology in Pasadena, CA in 2011. She completed a 2-year postdoctoral fellowship in Behavioral Medicine and Neuropsychology at the Medical University of South Carolina, prior to being recruited to Wake Forest Baptist Medical Center to build a behavioral health program with in a surgical and non-surgical weight management center. She is a longstanding committee member of The Obesity Society (TOS) and a regular speaker/moderator at Obesity Week, the largest obesity conference in the world.
Bauchowitz, A. U., Gonder-Frederick, L. A., Olbrisch, M. E., Azarbad, L., Ryee, M. Y., Woodson, M., . . . Schirmer, B. (2005). Psychosocial evaluation of bariatric surgery candidates: a survey of present practices. Psychosom Med, 67(5), 825-832. doi:10.1097/01.psy.0000174173.32271.01
Goodpaster, K. (2017) The role of psychological testing in pre-surgical bariatric psychological evaluations. Journal of Health Service Psychology, 43, 67–73.
Kokkinos, A., Akexiadou, K., Liaskos, C., et.al. (2013) Improvement in cardiovascular indices after roux-en-Y gastric bepass or sleeve gastrectomy for morbid obserity. Obesity Surgery, 23, 31-38.
Magro, D. O., Geloneze, B., Delfini, R., Pareja, B. C., Callejas, F., & Pareja, J. C. (2008). Long-term weight regain after gastric bypass: a 5-year prospective study. Obesity Surgery, 18(6), 648-651. doi:10.1007/s11695-007-9265-1
Mitchell, J. E., Selzer, F., Kalarchian, M. A., Devlin, M. J., Strain, G. W., Elder, K. A., . . . Yanovski, S. Z. (2012). Psychopathology before surgery in the longitudinal assessment of bariatric surgery-3 (LABS-3) psychosocial study. Surg Obes Relat Dis, 8(5), 533-541. doi:10.1016/j.soard.2012.07.001
Peacock, J. C., & Zizzi, S. J. (2011). An assessment of patient behavioral requirements pre- and post-surgery at accredited weight loss surgical centers. Obesity Surgery, 21, 1950-1957. doi:10.1007/s11695-011-0366-5
Sarwer, D. B., Wadden, T. A., & Fabricatore, A. N. (2005). Psychosocial and behavioral aspects of bariatric surgery. Obesity Research, 13(4), 639-648. doi:10.1038/oby.2005.71
Sogg, S. (2017). Comment on: Alcohol and other substance use after bariatric surgery: prospective evidence from a us multicenter cohort study. Surg Obes Relat Dis. doi:10.1016/j.soard.2017.04.014
Sturm, R., & Hattori, A. (2013). Morbid obesity rates continue to rise rapidly in the United States. Int J Obes (Lond), 37(6), 889-891. doi:10.1038/ijo.2012.159
Weiss, E.C., Galuska, D.A., Khan, L.K., Gillespie, C., and Serdula, M.K. (2007). Weight regain in US adults who experienced substantial weight loss, 1999-2002. American Journal of Preventive Medicine, 33, 34-40.