psychological effects and outcome predictors of three bariatric surgery interventions: a 1-year...
TRANSCRIPT
ORIGINAL ARTICLE
Psychological effects and outcome predictors of three bariatricsurgery interventions: a 1-year follow-up study
Giovanni Castellini • Lucia Godini •
Silvia Gorini Amedei • Carlo Faravelli •
Marcello Lucchese • Valdo Ricca
Received: 21 December 2013 / Accepted: 1 April 2014 / Published online: 16 April 2014
� Springer International Publishing Switzerland 2014
Abstract
Purpose Weight loss surgery efficacy has been demon-
strated for morbid obesity. Different outcomes have been
hypothesized, according to specific bariatric surgery
interventions and psychological characteristics of obese
patients. The present study compared three different sur-
gery procedures, namely laparoscopic adjustable gastric
band (LAGB), Roux-en-Y gastric bypass (RYGB) and
biliopancreatic diversion (BPD), in terms of weight loss
efficacy and psychological outcomes.
Methods Eighty-three subjects seeking bariatric surgery
have been evaluated before and 12 months after surgery
intervention, by means of a clinical interview and different
self-reported questionnaires, including Eating Disorder
Examination Questionnaire, Emotional Eating Scale, Binge
Eating Scale, Beck Depression Inventory, Symptom
Checklist and State-Trait Anxiety Inventory.
Results BPD group (26 subjects) showed the greatest
weight loss, followed by RYGB (30 subjects), and LAGB
group (27 subjects). All the treatments were associated
with a significant improvement of anxiety, depression, and
general psychopathology, and a similar pattern of reduction
of binge eating symptomatology. BPD group reported a
greater reduction of eating disorder psychopathology,
compared to the other groups. Pre-treatment emotional
eating severity was found to be a significant outcome
modifier for the three treatment interventions.
Conclusions These results suggest that all the three types
of bariatric surgery significantly improved psychopathol-
ogy and eating disordered behaviors. They also support the
importance of a pre-treatment careful psychological
assessment in order to supervise the post-surgical outcome.
Keywords Bariatric surgery � Eating psychopathology �General psychopathology � Morbid obesity � Weight loss
Introduction
Morbid obesity is a severe medical condition characterized
by a poor outcome for dietary, pharmacological or psy-
chotherapeutic treatments [1].
Over the past 10 years different studies have supported a
good efficacy of weight loss surgery, as gastroplasty, gas-
tric bypass or biliopancreatic diversion seems to have an
important impact on weight loss outcome with high per-
centages of excess weight loss [2]. Furthermore, the effi-
cacy of bariatric surgery has been demonstrated also in the
improvement of frequent obesity comorbidities such as
diabetes, hyperlipidemia, hypertension and obstructive
sleep apnea, which were improved or completely resolved
after surgery in most of the patients [3].
G. Castellini � L. Godini � S. G. Amedei � V. Ricca
Psychiatric Unit, Department of Neuropsychiatric Sciences,
Florence University School of Medicine, Viale Morgagni 85,
50134 Florence, Italy
L. Godini � S. G. Amedei � M. Lucchese
Bariatric Surgery Unit, Careggi Hospital, Viale Morgagni 85,
50134 Florence, Italy
C. Faravelli
Department of Psychology, University of Florence, Via di San
Salvi 12, Complesso di San Salvi, Padiglione 26,
50135 Florence, Italy
V. Ricca (&)
Psychiatric Unit, Department of Neuropsychiatric Sciences,
Florence University School of Medicine, Largo Brambilla 3,
50134 Florence, Italy
e-mail: [email protected]
123
Eat Weight Disord (2014) 19:217–224
DOI 10.1007/s40519-014-0123-6
Obese subjects referring to bariatric surgery facilities
show high rates of current and lifetime Axis I mental dis-
orders [4], in particular affective, anxiety and binge eating
disorders [5]. Several evidences suggest that weight loss
surgery is associated with an improvement in psychologi-
cal condition; however, high psychiatric comorbidity
seems to last after the surgery interventions [5]. Further-
more, psychiatric comorbidities have been proposed as
significant outcome modifiers of bariatric surgery [5, 6]. In
particular, considering eating disorders symptoms, pre-
operative binge eating behavior seems to be associated
with more eating-related and general psychopathology and
low weight loss after surgery, whereas post-operative binge
eating behavior significantly predicts poorer post-surgical
weight loss and psychosocial outcomes [7]. Therefore,
patients reporting loss of control over eating, above all
after surgery, have been identified as a distinctive subgroup
with a less favorable outcome, including weight regain [8].
To date, few studies have compared the clinical and
psychopathological outcomes of different types of bariatric
surgery interventions [5], and in most of the cases the
comparison included only patients treated with the vertical
banded gastroplasty or gastric bypass [8, 9]. Moreover,
some studies were conducted on relatively small samples
[10], with high drop-out rates at the post-operative
assessment points [9, 10], and without an adequate eating
psychopathology assessment at different time points [1].
The aim of the present study was to compare different
surgical interventions, in terms of weight loss, psycho-
pathological outcomes, and outcome predictors. In partic-
ular, we evaluated the effect of restrictive [laparoscopic
adjustable gastric banding (LAGB)], malabsorptive [bilio-
pancreatic diversion (BPD)], restrictive and malabsorptive
[Roux-en-Y gastric bypass (RYGB)] bariatric surgery
procedures.
Materials and methods
Participants
The present study was designed as a follow-up survey, and
was performed by the Psychiatric Unit of the University of
Florence (Italy) and the Bariatric Surgery Unit.
All the diagnostic procedures and the psychometric tests
were part of the routine clinical assessment for obese
patients performed at our clinics. Before the collection of
data, during the first routine visit, the procedures of the
study were fully explained; after that, the patients were
asked to provide their written informed consent to the
participation in the present study. The protocol was
approved by the Ethics Committee of the Institution.
The patients were recruited among a consecutive series
of overweight and obese subjects referring for the first
time to the Obesity Surgery Clinic of the University of
Florence (Italy) and candidates for bariatric surgery.
Patients were enrolled from September 2010 to December
2011. The inclusion criteria were age between 18 and
65 years, body mass index (BMI) [40 kg/m2 or BMI
[35 kg/m2 with severe obesity-related disease, over
5 years of obesity and failure in previous weight reduction
therapies, absence of previous bariatric intervention, and
the patient’s complete understanding of the surgical pro-
cedure and its risks. The exclusion criteria were illiteracy,
mental retardation, high surgical risk, current comorbid
severe mental disorders, such as bulimia nervosa and
vomiting behaviors, schizophrenia, bipolar disorder,
severe major depression, suicide ideation and psychoactive
substance dependence, assessed by means of the structured
clinical interview for diagnostic and statistical manual of
mental disorders (DSM-IV) [11].
Design of the study
Psychopathological, behavioral and sociodemographic
data were collected through a face-to-face interview on
the first day of admission (baseline T0; 21.2 ± 14.8 week
before surgery), and 1 year after the surgery treatment
(T1) by two expert psychiatrists who were unaware of the
kind of surgical procedure (LG, SGA) and had not
therapeutic relationship with any of the participants they
assessed. During the visits, BMI was calculated and the
psychopathological evaluation was performed. Further-
more, during the first visit, the patients were evaluated by
a dietitian and a surgeon. As already reported in a pre-
vious study by our group [12], patients choose by their
own initiative to address to the Bariatric Surgery Unit of
Florence. Patients were assessed at their first contact with
the clinic, before the evaluation of the inclusion/exclusion
criteria for starting a surgical or medical intervention.
The bariatric surgical procedure is determined after
completing all the assessments, composed by a psychi-
atric visit (a clinical interview and specific psychopath-
ological questionnaires), a dietitian visit and a surgical
visit. If the patient was evaluated as eligible to the sur-
gery, he/she received detailed information about the
treatment.
At T1, the patients were evaluated by the same psy-
chiatrists during a specialist control visit, and those sub-
jects who were not attending the clinic for control visits
were contacted by telephone and invited to the clinic for a
follow-up visit.
The three bariatric surgery procedures (LAGB, BPD,
RYGB) took place in exclusion.
218 Eat Weight Disord (2014) 19:217–224
123
Assessment
Anthropometric measurements were made using standard
calibrated instruments. Height (m) was measured using a
wall-mounted stadiometer and weight (kg) using electronic
scales with an upper weight limit of 300 kg. BMI was
calculated as weight in kilograms divided by the square of
height in meters.
Diagnosis of obesity (BMI [30 kg/m2) was performed
according to a single clinical criterion suggested by recent
clinical guidelines developed by the National Heart, Lung
and Blood Institute [13].
The results of bariatric surgery on body weight were
evaluated through the use of the percentage of the excess
BMI loss (%EBMIL = 100 9 [(initial BMI - final BMI)/
(initial BMI-25)] [14]. In order to assess the current and
lifetime prevalence of mental disorders, patients were
interviewed by two expert clinicians (LG, SGA) by means
of the structured clinical interview for DSM-IV [11].
Current eating attitudes and behaviors were specifically
investigated by means of the Eating Disorder Examination
Questionnaire (EDE-Q).
The self-reported EDE-Q consists of 38 items, assessing
the core psychopathological features of eating disorders,
and contains four subscales: dietary restraint, eating con-
cern, weight concern, and shape concern. The dietary
restraint subscale is an admixture of cognitions and
behaviors pertaining to dietary restriction. The three other
subscales evaluate the dysfunctional attitudes regarding
eating and overvalued thoughts regarding weight and
shape. The global score represents the mean of the four
subscale scores [15]. The EDE-Q has been reported to
show a good validity also in bariatric surgery candidates
[16].
In order to investigate the severity of binge eating, the
Binge Eating Scale (BES) was applied [17].
The BES has been proposed as a rapid screening
instrument for BED in obese patients, and it examines both
behavioral signs (eating large amounts of food) and feeling
or cognition during a binge episode (loss of control, guilt,
fear of being unable to stop eating) through 16 items. The
BES was already used in bariatric surgery populations
showing good psychometric properties [18, 19].
Emotional eating was assessed by means of the Emo-
tional Eating Scale (EES) [20], a 25-item self-report
questionnaire that indicates the extent to which specific
feelings lead a subject to feel an urge to eat. Each item
consists of an emotion term (e.g., jittery, angry, helpless),
and the 5-point scale used was anchored on ‘‘no desire to
eat’’ and ‘‘an overwhelming urge to eat,’’ with ‘‘a small
desire to eat,’’ ‘‘a moderate desire to eat,’’ and ‘‘a strong
desire to eat’’. The 25 items form 3 subscales, reflecting
eating in response to anger (anger/frustration), anxiety
(anxiety), and depressed mood (depression). For a further
characterization of the psychopathological features of the
patients, the Beck Depression Inventory (BDI) [21],
Symptom Checklist (SCL-90-R) [22] and State-Trait
Anxiety Inventory (STAI) [23] were also applied.
Treatment
At Bariatric and Metabolic Surgery Unit of University of
Florence (Italy), three main surgical options are performed:
LAGB as ‘‘restrictive’’ procedure, BPD as ‘‘malabsorp-
tive’’ procedure, and RYGB as ‘‘restrictive and malab-
sorptive’’ procedure.
LAGB is one of the most important types of bariatric
restrictive procedures. LAGB is a restrictive procedure and
consists on the limitation of the luminal diameter of the
stomach, without the exclusion of some segments of the
gastrointestinal tract. This procedure involves a foreign
material (the ‘‘band’’) that is an adjustable plastic and sil-
icone ring, placed around the proximal stomach just
beneath the gastroesophageal junction. An access present
in the subcutaneous area links to the band and it allows to
adjust the constriction level by the injection or withdrawal
of saline [24].
The BPD is a primarily malabsorptive procedure with
some restrictions. It consists of a partial gastrectomy where
a 200–500 mL proximal gastric pouch, a distal Roux and
proximal biliary limb are created by division of the small
bowel 250 cm proximal to the terminal ileum. The gastric
pouch is attached to the end of the Roux limb, and the
biliary limb is connected 50 cm proximal to the ileocecal
valve, thereby obtaining a very short common [24].
The RYGB consists of a malabsorbitive and restrictive
procedure. It determines the creation of a small, vertically
oriented gastric pouch (*30 mL) that is attached to a Roux
limb formed by division of the jejunum about 40–60 cm
from the ligament of Trietz. The biliary limb is anasto-
mosed to the Roux limb 150 cm from the gastrojejunos-
tomy [24].
The patients have been allocated to a specific surgical
option in relation to the BMI ([50 kg/m2) or metabolic
criteria. Subjects with BMI \45 kg/m2 underwent LAGB,
patients with BMI between 45 and 50 kg/m2 underwent
RYGB, and patients with BMI[50 kg/m2 underwent BPD.
Furthermore, if diabetes mellitus, blood lipid disorders,
impaired glucose tolerance or low resting metabolic rate
was present, RYGB or BPD was the procedure of choice.
Statistical analyses
Continuous variables were reported as mean ± standard
deviation (SD), whereas categorical variables were repor-
ted as percentages. Univariate analysis of variance
Eat Weight Disord (2014) 19:217–224 219
123
(ANOVA, with Bonferroni post hoc test) and Chi square
(v2) were used for continuous and categorical variables,
respectively. Linear mixed models (ANOVA mixed model
with random intercept) were adopted for longitudinal data.
Linear mixed models are a proper method to analyze
repeated measures data because they take into account the
dependencies within the data. They are more flexible in
handling missing data than other methods, such as regres-
sion and ANOVA, and they are able to model within
subjects’ random effects, thereby allowing for individual
variation in intercepts and/or regression slopes. Linear
mixed models were used to study the variation (time effect)
of BMI and psychological variables from baseline to 1-year
follow-up. BMI and psychological variables were the
dependent variables for each model, and time was entered
as independent variable, together with age and BMI before
surgery as covariates. At first, we tested the between
treatment group effect (time by treatment interaction), and
subsequently we evaluated the time effect within each
treatment group (LAGB, BPD, RYGB). For each model,
we considered: random subject level effects, and time, age,
BMI before surgery as fixed effects.
Linear regression analyses were performed to evaluate
associations between psychological variables percentage
variation and excess of BMI loss, and between psycho-
logical variables at baseline and excess of BMI loss, in
order to identify moderators of weight loss outcome. All
analyses were performed using SPSS for windows 15.0
(Chicago Inc., USA).
Results
From the 133 consecutive patients initially included in the
follow-up study, 42 were excluded and 37 did not meet
inclusion criteria because of illiteracy (2), mental retarda-
tion (1), severe mental disorders (28) and medical contra-
indication (6), while 5 patients refused the surgical
treatment. Ninety-one patients were enrolled in the study:
30 were allocated to LAGB; 31 were allocated to RYGB
and 30 were treated with BPD, as reported in the consort
flow diagram of the study. Patients who were not available
at follow-up (three in the LAGB group, one in the RYGB
group and four in the BPD) were excluded from the
analyses.
The final sample consisted of 83 Caucasian outpatients
(75 women; 90.4 %) with a mean ± standard deviation age
of 45.3 ± 10.1 years. Twenty-seven subjects underwent
LAGB, 30 underwent RYGB and 26 BPD.
The main DSM-IV diagnoses observed at baseline were:
unipolar depression (20 subjects, 24.1 %), obsessive com-
pulsive disorder (5 subjects, 6.0 %), panic disorder (11
subjects, 13.3 %), and binge eating disorder (22 subjects,
26.5 %). No significant difference was found between
groups in terms of rates of the mentioned diagnoses.
No significant differences were found among the three
groups of patients in terms of sociodemographic, clinical
and psychopathologic variables at baseline (Table 1), with
the exception of BMI which was higher in RYGB and BPD
when compared with LAGB group. At 1-year follow-up
(Table 1), BMI was no longer different between the
groups. Other comparisons at follow-up were not signifi-
cant. As far as the excess of BMI loss is concerned (Fig. 1),
a different effect of treatment was found (F = 5.16;
p = 0.008), with RYGB and BPD groups reporting greater
weight loss compared with LAGB.
The different pattern of treatment effects on psycho-
logical variables was evaluated (Table 2). A slight effect of
group was found in terms of general psychopathology
change, and all the three groups showed a significant
reduction of SCL-90, BDI and STAI scores. LAGB group
showed a higher BDI reduction, as compared with the other
groups.
Considering eating disorder specific psychopathology,
all the groups showed a significant reduction in most of the
psychological measures taken into account, with the
exception of EDE-Q restraint.
However, a different pattern of response was found
between groups (time by treatment effect). BPD group
reported a higher reduction of EDE-Q total score, com-
pared with the other groups, while RYGB group reported
an intermediate effect. Only BPD was associated with a
reduction in all EDE-Q subscales scores. All the treatments
showed a significant reduction in BES scores with a lower
reduction in BPD subjects, while a reduction in EES total
score was found in RYGB and BPD, but not in LAGB
group.
EDE-Q total score variation rate [calculated as (EDE-Q
at baseline - EDE-Q at follow-up)/EDE-Q at baseline]
was found to be positively associated with excess of BMI
loss only in the RYGB group (R2 = 0.65; b = 0.80;
p = 0.015). This means that the higher rate of variation of
EDE-Q was associated with the higher BMI loss.
Other correlations were not significant
Finally, the effect of baseline psychological variables on
excess of BMI loss was calculated. Within all the psy-
chological variables only emotional eating at baseline was
found to be associated with the excess of BMI loss
(R2 = 0.08; b = -0.24; p = 0.03). In particular, the
higher baseline EES values were reported at baseline and
the lower was found to be the excess of BMI loss. The
analyses were performed for the whole sample and the
results were confirmed for each group of treatment
separately.
220 Eat Weight Disord (2014) 19:217–224
123
Discussion
To our knowledge, this is one of the few studies which
compared different bariatric surgery procedures, in terms
of weight loss and psychopathological outcomes. The
evaluation of bariatric surgery effects on general and eating
disorder specific psychopathology is of relevance, consid-
ering the increasing evidences of their role as potential
predictors of sustained weight loss in the long term after
surgery interventions [25].
According to our main results:
– The three types of bariatric surgical procedures showed
a different pattern of efficacy on weight loss, with BPD
group reporting the greatest weight loss;
– ‘‘Malabsorptive’’ and ‘‘restrictive and malabsorptive’’
procedures showed a higher reduction of eating disor-
der psychopathology as compared with the restrictive
intervention; however, all the treatments showed a
significant improvement in terms of binge eating
behaviors;
– A high emotional eating at baseline resulted to be
associated with a lower weight loss after surgery
interventions.
The different efficacy of surgical interventions in terms
of weight loss seems to support previous researches which
reported that weight loss outcomes strongly favor RYGB
over LAGB [26] and that RYGB is associated to a lower
%EWL (percentage of excess of weight loss) than BPD [2].
The mechanisms whereby RYGB and BPD produce
weight loss may be represented by malabsorption of
nutrients, decreased intake, food aversion, altered
Table 1 BMI and psychopathological variables at baseline (T0) and 1 year after surgery (T1)
Baseline 1 year after surgery
LAGB (n: 27) RYGB (n: 30) BPD (n: 26) ANOVA,
v2LAGB
(n: 27)
RYGB
(n: 30)
BPD (n: 26) ANOVA
Age (years) 43.85 ± 11.36 43.63 ± 9.83 48.84 ± 8.36 2.28
Gender (women) 23 (83.2 %) 28 (93.3 %) 24 (92.3 %) 1.24
BMI (kg/m2) 44.79 ± 5.3 49.49 ± 6.76 50.57 ± 6.55 6.26*** 34.91 ± 6.22 34.39 ± 7.14 32.5 ± 5.55 0.97
SCL-90 GSI 0.96 ± 0.58 1.28 ± 0.69 1.14 ± 0.5 1.88 0.65 ± 0.60 0.80 ± 0.52 0.92 ± 0.54 0.77
BDI 16 ± 11.07 18.34 ± 11.31 17.76 ± 12.06 0.28 6.66 ± 6.46 8.53 ± 6.45 9.88 ± 6.64 0.80
STAI 45.12 ± 9.18 44.68 ± 10.21 44.5 ± 11.32 0.01 36.14 ± 10.5 40.72 ± 6.49 38.00 ± 13.67 0.59
EES 46.25 ± 9.88 43.14 ± 12.43 46.76 ± 10.01 0.52 1.30 ± 1.03 0.75 ± 0.73 0.79 ± 0.51 1.69
EDE-Q total score 1.40 ± 0.93 1.64 ± 0.89 1.67 ± 0.91 0.50 1.80 ± 1.28 2.20 ± 1.18 1.2 ± 0.89 1.97
EDE-Q restraint 1.78 ± 1.4 1.96 ± 1.39 2.01 ± 1.49 0.17 1.61 ± 1.31 1.78 ± 1.59 0.88 ± 1.01 1.30
EDE-Q eating
concern
1.61 ± 1.52 2.09 ± 1.08 1.94 ± 1.85 0.53 1.18 ± 1.53 1.08 ± 1.49 0.25 ± 0.27 1.51
EDE-Q weight
concern
3.27 ± 1.2 3.43 ± 1.33 3.06 ± 1.45 0.54 1.87 ± 1.36 2.37 ± 1.22 1.42 ± 1.40 1.50
EDE-Q shape
concern
4.09 ± 1.4 4.42 ± 1.22 4.05 ± 1.57 0.59 2.53 ± 1.82 2.55 ± 1.13 2.29 ± 1.69 2.44
BES 15.5 ± 9.6 20.11 ± 9.51 16.11 ± 8.53 1.92 6.00 ± 6.43 6.13 ± 4.15 11.22 ± 9.93 2.10
Statistics—continuous variables are reported as mean ± standard deviation
BDI Beck Depression Inventory, BES Binge Eating Scale, BPD biliopancreatic diversion, BMI body mass index, EDE-Q Eating Disorder
Examination Questionnaire, EES Emotional Eating Scale Total Score, LAGB laparoscopic adjustable gastric band, RYGB Roux-en-Y gastric
bypass, STAI State-Trait Anxiety Inventory, SCL-90 GSI Symptom Checklist (SCL 90-R) global severity index
*** p \ 0.001
Fig. 1 Excess body mass index (BMI) loss: 100 9 [(initial BMI -
final BMI)/(initial BMI-25)]. LAGB laparoscopic adjustable gastric
band, BPD biliopancreatic diversion, RYGB Roux-en-Y gastric
bypass
Eat Weight Disord (2014) 19:217–224 221
123
metabolism, or a combination of them [27]. Cummings
et al. showed that gastric bypass disrupts ghrelin secretion
by isolating ghrelin producing cells from direct contact
with ingested nutrients which normally regulate ghrelin
levels. This effect, associated to an adaptation in the levels
of other gut hormones (increase of peptide YY, glucagon-
like peptide 1, oxyntomodulin and reduction of leptin and
insulin) that promote satiety, may contribute to the efficacy
of the bariatric procedures in reducing weight [28, 29].
The greatest %EBMI loss in BPD group confirmed
results of previous studies [2], and it can be interpreted also
as the subjects who underwent BPD had a lower weight
regain during the first post-operative year, as compared
with other treatments.
Furthermore, a significant effect of treatment on general
psychopathology was found independently from bariatric
procedure, according to the previous researches demon-
strating a reduction of Axis I comorbidity after bariatric
surgery [30].
The significant decrease of depressive symptoms after
surgery [5] confirmed the existence of a complex rela-
tionship between obesity and depression [31]. Biological
mechanisms have been implicated, such as HPA-axis
dysregulation, as well as diabetes mellitus and insulin
resistance which have been found to increase the risk of
depression [31]. Furthermore, weight-related stigmatiza-
tion [32], increased body dissatisfaction and decreased self-
esteem might increase the risk of depression [31]. In gen-
eral, a significant reduction in weight has been frequently
associated with a post-operative improvement in all
patients’ psychopathologic parameters, given the reduced
perception of criticism and self-blame associated with
relevant weight loss after bariatric surgery [9].
As far as pathological eating behaviors are concerned,
we found that eating disorder specific psychopathology was
similarly present in the treatments groups, according to the
previous studies reporting that a substantial percentage of
bariatric surgery patients suffered from binge eating
symptoms [33]. All the considered surgical interventions
demonstrated to be efficacious in reducing pathological
eating behaviors, and eating disorder specific psychopa-
thology. Sanchez Zaldvar et al. [34] showed that after ba-
riatric surgery the impulse to thinness and corporal
dissatisfaction improved in patients with morbid obesity.
Moreover, we found that bariatric surgery was effective in
reducing the severity of binge eating (BES scores),
according to the previous studies [34] which suggested that
the gastric restrictive procedures make physiologically
very difficult to binge eat. However, it is of note that
RYGB and BPD were associated with a higher reduction in
EDE-Q scores and emotional eating. A possible explana-
tion could be that in RYGB patients obtained a higher
weight loss after surgery, and a more relevant weight loss
outcome determined a better outcome in terms of eating
disorder specific psychopathology. The positive correlation
between EDE-Q reduction and excess of BMI loss seems to
support such hypothesis. Alternatively, we may hypothe-
size that a higher reduction of eating pathology in RYGB
and BPD group may be one of the mechanisms favoring the
weight loss [8].
Finally, our data showed that emotional eating prior to
undergo bariatric surgery was associated with different
pattern of weight loss after intervention, since higher pre-
treatment emotional eating levels predicted lower excess of
BMI loss, for all the three treatment groups. Previous
studies demonstrated that emotional eating was a main-
taining factor of binge eating [35], and an important
Table 2 Treatment effects on BMI and psychopathological variables
Treatment
by time
effect (F)
Treatment
effect of
gastric
banding
Treatment
effect of
gastric
bypass
Treatment
effect of
biliopancreatic
diversion
Time effect
(b)
Time
effect (b)
Time effect (b)
BMI 62.2*** 0.65*** 0.73*** 0.82***
SCL-90
GSI
2.86* 0.26* 0.36* 0.23*
STAI 2.70 0.48** 0.24* 0.27*
BDI 7.46*** 0.44** 0.46** 0.38*
BES 11.6*** 0.49** 0.68*** 0.34*
EDE-Q
total
score
7.08** 0.31* 0.38** 0.62***
EDE-Q
restraint
1.08 0.01 0.04 0.36*
EDE-Q
eating
concern
3.59* 0.09 0.31* 0.44*
EDE-Q
weight
concern
9.64*** 0.41* 0.47** 0.61**
EDE-Q
shape
concern
7.52*** 0.32* 0.39** 0.58**
EES 4.43** 0.03 0.46** 0.48**
Statistical analyses—data reported in the table represent the F and bvalues for linear mixed models assessing the variation (time effect) of
BMI and psychological variables from baseline to 1-year follow-up.
The first column reports the F values for differences in treatment
effects (time by treatment interaction), and the other columns report
the b values for the time effects within different treatment groups.
Data are age and baseline BMI adjusted
BDI Beck Depression Inventory, BES Binge Eating Scale, BMI body
mass index, SCL-90 GSI Symptom Checklist (SCL 90-R) global
severity index, STAI State-Trait Anxiety Inventory, EDE-Q Eating
Disorder Examination Questionnaire, EES Emotional Eating Scale
Total Score
* p \ 0.05; ** p \ 0.01; *** p \ 0.001
222 Eat Weight Disord (2014) 19:217–224
123
outcome modifier in psychological treatments [36]. Our
findings support the importance of this psychopathological
dimension, which seems to play a relevant role even in
obese patients who underwent bariatric surgery, and stress
the importance of a careful assessment of different psy-
chological variables in obese subjects attending different
bariatric surgery interventions, in order to identify potential
outcome predictors for weight loss.
However, it is important to note that even if emotional
eating was associated with %EBML, it accounts for a
limited proportion of its variance in the model. Therefore,
it is possible that in sever obese subjects, weight loss
depends on several other clinical variables than
psychopathology.
One limitation of the current data set is that it
included a limited number of patients. Therefore, the
results of the present study should be confirmed by
larger studies. However, it is important to note that,
despite the relatively small sample size, significant dif-
ferences were found between treatment groups. A second
limitation is that some important psychological data of
this study were obtained by means of self-reported
questionnaires, thus possibly determining potential sub-
jective bias. Errors or memory biases could have affected
the retrospectively collected data. Finally, the follow-up
length of this study is very short (only 12 months);
indeed, considering that the weight loss curves observed
after LAGB, RYGB and DBP (with the LAGB having a
slower a more prolonged weight loss phase) show dif-
ferent slopes and duration, at the end of 1 year only a
part of the long-term effects of these different procedures
can be captured. Therefore, further studies with longer
follow-up period are needed.
Conclusion
In conclusion, our results support the importance of a
careful assessment of different psychological variables in
obese subjects attending different bariatric surgery inter-
ventions, in order to supervise the post-surgical outcome.
Conflict of interest The authors declare that they have no conflict
of interest.
References
1. Pull CB (2010) Current psychological assessment practices in
obesity surgery programs: what to assess and why. Curr Opin
Psychiatry 23:30–36. doi:10.1097/YCO.0b013e328334c817
2. Topart P, Becouarn G, Ritz P (2013) Weight loss is more sus-
tained after biliopancreatic diversion with duodenal switch than
Roux-en-Y gastric bypass in superobese patients. Surg Obes
Relat Dis 9:526–530. doi:10.1016/j.soard.2012.02.006
3. MacLean LD, Rhode BM, Sampalis J, Forse RA (1993) Results
of the surgical treatment of obesity. Am J Surg 165:155–160
4. American Psychiatric Association (2000). The diagnostic and
statistical manual of mental disorders, 4th edn (text rev). doi:10.
1176/appi.books.9780890423349
5. de Zwaan M, Enderle J, Wagner S et al (2011) Anxiety and
depression in bariatric surgery patients: a prospective, follow-up
study using structured clinical interviews. J Affect Disord
133:61–68. doi:10.1016/j.jad.2011.03.025
6. Karlsson J, Taft C, Ryden A, Sjostrom L, Sullivan M (2007) Ten-
year trends in health-related quality of life after surgical and
conventional treatment for severe obesity: the SOS intervention
study. Int J Obesity 31:1248–1261
7. de Zwaan M, Hilbert A, Swan-Kremeier L et al (2010) Com-
prehensive interview assessment of eating behavior
18–35 months after gastric bypass surgery for morbid obesity.
Surg Obes Relat Dis 6:79–85. doi:10.1016/j.soard.2009.08.011
8. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin
RE, LaMarca LB (2002) Binge eating among gastric bypass
patients at long-term follow-up. Obes Surg 12:270–275
9. Papageorgiou GM, Papakonstantinou A, Mamplekou E, Terzis I,
Melissas J (2002) Pre- and postoperative psychological charac-
teristics in morbidly obese patients. Obes Surg 12:534–539
10. Rosik C (2005) Psychiatric symptoms among prospective bari-
atric surgery patients: rates of prevalence and their relation to
social desirability, pursuit of surgery, and follow-up attendance.
Obes Surg 15:677–683
11. First MB, Spitzer RL, Gibbon M, Williams JBW (1995) Struc-
tured clinical interview for DSM-IV axis I disorders. Patient
edition (SCID-P, version 2). Biometrics Research, New York
State Psychiatric Institute, New York
12. Castellini G, Godini L, Amedei SG, Galli V, Alpigiano G, Mu-
gnaini E, Veltri M, Rellini AH, Rotella CM, Faravelli C, Luc-
chese M, Ricca V (2013) Psychopathological similarities and
differences between obese patients seeking surgical and non-
surgical overweight treatments. Eat Weight Disord 19:95–102
13. National Institutes of Health (1998) Clinical guidelines on the
identification, evaluation, and treatment of overweight and
obesity in adults—the evidence report. Obes Res 6(Suppl
2):51–209
14. Deitel M, Gawdat K, Melissas J (2007) Reporting weight loss.
Obes Surg 17:565–568
15. Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJ (2004)
Validity of the Eating Disorder Examination Questionnaire
(EDE-Q) in screening for eating disorders in community samples.
Behav Res Ther 42:551–567
16. Grilo CM, Henderson KE, Bell RL, Crosby RD (2013) Eating
disorder examination-questionnaire factor structure and construct
validity in bariatric surgery candidates. Obes Surg 23:657–662.
doi:10.1007/s11695-012-0840-8
17. Gormally J, Block S, Daston S, Rardin D (1982) The assessment
of binge eating severity among obese persons. Addict Behav
7:47–55
18. Grupski AE, Hood MM, Hall BJ, Azarbad L, Fitzpatrick SL,
Corsica JA (2013) Examining the Binge Eating Scale in screening
for binge eating disorder in bariatric surgery candidates. Obes
Surg 23:1–6. doi:10.1007/s11695-011-0537-4
19. Hood MM, Grupski AE, Hall BJ, Ivan I, Corsica J (2012) Factor
structure and predictive utility of the Binge Eating Scale in ba-
riatric surgery candidates. Surg Obes Relat Dis 9:942–948
20. Arnow B, Kenardy J, Agras WS (1995) The Emotional Eating
Scale. The development of a measure to assess coping with
negative affect by eating. Int J Eat Disord 18:79–90
21. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An
inventory for measuring depression. Arch Gen Psychiatry
4:561–571
Eat Weight Disord (2014) 19:217–224 223
123
22. Derogatis LR, Lipman RS, Covi L (1973) SCL-90: an outpatient
psychiatric rating scale-preliminary report. Psychopharmacol
Bull 9:13–28
23. Spielberg CD, Gorsuch RL, Lushene RE (1970) Manual for the
State-Trait Anxiety Inventory (self-evaluation questionnaire).
Consulting Psychologists Press, Palo Alto
24. Noria SF, Grantcharov T (2013) Biological effects of bariatric
surgery on obesity-related comorbidities. Can J Surg 56:47–57.
doi:10.1503/cjs.036111
25. Walfish S (2010) Psychological correlates of laparoscopic
adjustable gastric band and gastric bypass patients. Obes Surg
20:423–425. doi:10.1007/s11695-008-9666-9
26. Angrisani L, Lorenzo M, Borrelli V (2007) Laparoscopic
adjustable gastric banding versus Roux-en-Y gastric bypass:
5-year results of a prospective randomized trial. Surg Obes Relat
Dis 3:127–132
27. Beckman LM, Beckman TR, Earthman CP (2010) Changes in
gastrointestinal hormones and leptin after Roux-en-Y gastric
bypass procedure: a review. J Am Diet Assoc 110:571–584.
doi:10.1016/j.jada.2009.12.023
28. Cummings DE, Weigle DS, Frayo RS et al (2002) Plasma ghrelin
levels after diet-induced weight loss or gastric bypass surgery.
N Engl J Med 346:1623–1630
29. Ionut V, Burch M, Youdim A, Bergman RN (2013) Gastroin-
testinal hormones and bariatric surgery induced weight loss.
Obesity 21:1093–1103. doi:10.1002/oby.20364
30. Gertler R, Ramsey-Stewart G (1986) Pre-operative psychiatric
assessment of patients presenting for gastric bariatric surgery
(surgical control of morbid obesity). Aust N Z J Surg 56:157–161
31. Luppino FS, de Wit LM, Bouvy PF et al (2010) Overweight,
obesity, and depression: a systematic review and meta-analysis of
longitudinal studies. Arch Gen Psychiatry 67:220–229. doi:10.
1001/archgenpsychiatry.2010.2
32. Chen EY, Bocchieri-Ricciardi LE, Munoz D et al (2007)
Depressed mood in class III obesity predicted by weight-related
stigma. Obes Surg 17:669–671
33. Kalarchian MA, Wilson GT, Brolin RE, Bradley L (1998) Binge
eating in bariatric surgery patients. Int J Eat Disord 23:89–92
34. Sanchez Zaldvar S, Arias Horcajadas F, Gorgojo Martınez JJ,
Sanchez Romero S (2009) Evolution of psychopathological
alterations in patients with morbid obesity after bariatric surgery.
Med Clin (Barc) 133:206–212. doi:10.1016/j.medcli.2008.11.045
35. Chesler BE (2012) Emotional eating: a virtually untreated risk
factor for outcome following bariatric surgery. Sci World J
2012:365961. doi:10.1100/2012/365961
36. Castellini G, Mannucci E, Lo Sauro C et al (2012) Different
moderators of cognitive-behavioral therapy on subjective and
objective binge eating in bulimia nervosa and binge eating dis-
order: a three-year follow-up study. Psychother Psychosom
81:11–20. doi:10.1159/000329358
224 Eat Weight Disord (2014) 19:217–224
123