Www.obesity-academy.org 1 Bariatric Surgery Affects Eating and Exercising related Psychological Variables, but nobody knows… Elisabeth Ardelt-Gattinger

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Bariatric Surgery Affects Eating and Exercising related

Psychological Variables, but nobody knows…

Elisabeth Ardelt-Gattinger (Salzburg University, OAA) Markus Meindl (Salzburg University)

Susanne Ring-Dimitriou (Salzburg University,)Karl Miller (Private Medical School, Salzburg, OAA)

Daniel Weghuber (Private Medical School, Salzburg, OAA)

www.obesity-academy.org

Obese Adolescents? …Never Ending Story

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Replication of the 1961 Study

The obese child was reliably ranked last, even lower than children with gross physical disabilities, not only by children from different socioeconomic and ethnic backgrounds, but even by children who themselves had physical disabilities. Adults who worked with the physically disabled, who were themselves obese, and who were from various ethnic and racial backgrounds, demonstrated the same aversion to overweight children and adolsecents

(Latner, J. & Stunkard, A. (2013).Getting Worse: The Stigmatization of

Obese Children. Obesity Research,11 (3): 452–456.

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Obese Adolescents? …Never Ending Story

Obese youths face social stigma which is pervasive and have serious consequences for mental and physical health

(Puhl, Rebecca M.; Latner, Janet D.(2007). Stigma, obesity, and the health of the nation's children. Psychological Bulletin, 133(4): 557-580)

Obese adolescents are at greater risk for bullying & mobbing

Elkington, J.& Hartigan, P. (2012). Group, Leadership, and Individual Antecedents of Mobbing."Mobbing: Causes, Consequences, and Solutions: 93.

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Success? of conservative therapies

Metaanalyses show that weight loss through conservative therapy and prevention does not indicate any big changes (Ebbeling, Pawlik &

Ludwig,2002; Miller & Jacob, 2001; Stice et al., 2009)

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Solution? for fat&mobbed children

“Health at any Size” (Miller, 2002)

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Bariatric surgery is increasingly seen as the treatment of choice for moderately to morbidly obese patients with very good success rates regarding weight and quality of Life.

Its INTERDISCIPLINARY impact on “Health at any Size” = psychological functioning, healthy eating, physical fitness, and absence of psychological comorbidities, however, is still poorly investigated.

(Mechanick, J. et al. (2009). Obesity; Pull CB Curr Opin Psychiatry 2010; van Hout GC et al Obes Surg 2005; (Pataky Z et al Curr Opin Gastroenterol 2011).

What about Bariatric Surgery and HEALTH @ ANY SIZE post


Evaluation of Adults

The aim of the current study was to comprehensively evaluate the effect of bariatric surgery on cognitive variables related to HEALTHY LIVING:

food intake and exercise behaviour.

Since the most frequently used surgical methods were gastric banding (GB)and gastric bypass (GBP) and since these methods require different postoperative behavioural adaptation (O´Brien 2010) we distinguished these two in our analyses.

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Questionnaires

Toward this end we assessed surgery related changes measured on a broad set of psychological variables. The one well known cognitive variables: disinhibition and restraint eating (Stunkard & Wadden 1989; Canetti et al. 2009; Ouwehand & Papies, 2010).

Assessing new one we used a new well validated evaluation system (AD-EVA, Ardelt-Gattinger & Meindl, 2010).

Emotional: emotional eating, enjoyment of eating, addiction to overeating Motivational: adherence to recommendations, exercise motivation, Behavioral: kind of food intake, nutritional preferences Psychological disorders: Bulimia, Binge Eating Disorder


Subjects: 120 Adults

A total of 120 morbidly obese patients were assessed:

Pre: 33m/87f, 18–71 years, BMI 45.70±6.30 kg/m²) and Post: 18-24 months, Ø 20.8; BMI 33.75±6.85 kg/m²).

Gastric bypass (GBP, n=80) Gastric banding (GB, n=40)


Across both surgical methods, BMI and 9 out of 12 sub-scales changed significantly towards more favourable values of eating and exercise cognitions.

No changes were observed for - restraint eating - PWS - hedonic eating- preferences for healthy nutrition. No negative changes of any kind occurred.

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Change of variables related to food intake & exercise behaviour

Quest. Subscale T df Sig. Mean&SD, t1Patients t1

Mean&SD, t2Patients t2

Mean&SDNorm.weight

QPEC Restraint Eating 0.43 117 n.s. 28.02±9.86 28.49±9.81 25.41±8.61

Disinhibition 12.14 117 < 0.01 35.73±10.03 23.18± 8.07 23.74±6.37

Emot. Eating 9.34 116 < 0.01 22.18±9.23 14.29±6.95 13.67±6.62

QSEC Flex. Steering 13.43 116 < 0.01 31.57±7.56 44.31±7.54 43.15±7.09

Hedonic eating 0.65 116 n.s 23.47±4.04 23.73±3.48 26.03±3.00

Adh. recomm. 7.81 116 < 0.01 20.19±4.55 23.57±3.88 23.22±3.84

QATO Add.overeating 13.43 116 < 0.01 34.09±10.75 19.77±8.66 20.10±7.92

QPED PWS 1.72 109 n.s. 20.54±4.39 19.01(!)±5.17 10.10±3.46

QCED BulimiaBED

3.016.12

106106

< 0.05< 0.01

8.20± 8.067.44 ±6.55

4.03 ±10.692.16 ±5.21

3.49±6.272.14±3.47

QEM Exercise Motiv. 6.78 116 < 0.01 25.24 ±7.29 29.29(!)± 7.29 27.21±6.60

SPN Snacks 9.24 115 < 0.01 98.65 ±17.44 82.24±18.888 83.42±19.67

Healthy food 0.50 115 n.s. 54.13± 7.88 54.44 ±6.94 54.82±8.22

Fatty food 8.27 115 < 0.01 32.92 ±5.68 28.48(!) ±6.11 30.40±6.52

QLS Quality of Life 10.28 115 <.0.01 29.21±9.83 38.91±8.88 38.64±5.12 ±

BMI 18.06 118 <0.01 45.52 ±5.89 33.54 ±6.69 19-25

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With respect to Differences BP and GBPost Surgery…

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In seven variables a reversal had occurred.


Differences Bypass and Gastric Banding

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Variable Subscales F (1/118) Significance

Pathogenic

Eating Cognitions

Restraint 1.77 n.s.

Disinhibition 2.19 n.s.

Emot. Eating 0.34 n.s.

Salutogenic

Eating Cognitions

Flex. Steering 16.04 < 0.01

Hedonic Eating 0.08 n.s.

Adherence recommand. 1.89 n.s.

Addiction Overeating Addiciton 9.09 < 0.01

Eating Disorder

Precl. Eating Disord. 1.46 n.s.

Bulimia 27.32 < 0.01

Binge Eating 25.37 < 0.01

Quality of Life Quality of Life 1.34 n.s.

Exercise Motivation intrin.&extrin. 0.20 n.s.

Nahrungs-präferenzen

Snacks 4.22 < 0.05

Healthy 1.81 n.s.

Fatty Food 5.61 < 0.01.

BMI BMI 4.23 < 0.05


In-/decrease of eating disorder BP and GBPost Surgery

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Reversal of Values – Eating Disorders(We ask patients who a comorbid with bulimia or BED to undergo BP) *=<.05, **=<.01


Decrease = Improvement for BP onlyPost Surgery

Reversal of Values – Nutrition Preferences

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*=<.05, **=<.01


BP seems to require less control Post Surgery

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Reversal of Values – steering variables of eating behavior


BP are less addicted to overeating Post Surgery

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Reversal of Values – steering variables of addiction


Interdisc.(!) Evaluationsystem BAREV:Comparing disciplines and total Sum

BAREV©Hogrefe

Sub-total Medicine: 8 / 20

Sub-total Psychology: 6 / 10

Sub-total Sp. Science: 0 / 1

Sub-total Nutrition: -1 / 2

Very good and good 18 till 36 8 till 17 2 till 5 2 till 3Very bad and bad -18 till -36 -8 till -17 -2 till -5 -2 till -3

Sum total: 13 / 33Sum total Bypass / Gastric Banding≥30

20 till 29

8 till 19

7 till -7

-8 till -19

-20 till -29

≤ -30

7 points – very good success: excell. medical, psychological, sport- & dietary status

6 points – good success

5 points – modest success

4 points – stagnation

3 points – modest worsening

2 points – strong worsening

1 point – very strong worsening: alarming medical, psychological, sport- and dietary status

Interdisciplinary Quality Control System


8 Case Studies (5m/3f; 14 – 17 years)

Pre: BMI-sds: 3.55± 0.44 and Post: 18-24 months Bypass, Ø 1.49 ± .86)

5 adolescents

- BMI and 8 out of 12 sub-scales changed significantly towards more favourable values of eating and exercise cognitions.

No changes were observed for

- restraint eating, PWS, preferences for healthy nutrition.

No negative changes of any kind occurred.

1 Girl ‘forgot’ her vitamin B intake – major depression, 1 Boy developed ‘Sports – Bulimia’, 1 Boy – still high in addiction,

insomnia – successful therapy


Bypass seems to be…

Bypass seems to be a good option to cure successful weight loosing adults of addiction,eating disorders etc.

It seems e good option to prefer healthier nutrition and to become intrinsicly motivated for physical activity.

•We do not know enough about results of adults

But they may need more support post surgery

for their HEALTH@any SIZE

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2year versus minimal post bariatric follow up program (Hellbardt et al, 2014)

Both: BMI, assoc. diseases & concomitant medication sign. reduced, BUT

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Evaluation of 2 year program

3,6,9,12,18 and 24 months

- Deficiency symptoms prevented

due to supplement.& regular lab.

control

Minimal follow up 3rd & 18th month

- Control by general practitioner NO data about problems and deficiency symptoms could be drawn


AppointmentMedicine Nutrition

Physical fitness/activity

GUIDANCE and MONITORING

pre OP

Metabolic (including oGTT,

glucose clamp), surgical,

orthopedic assessment

Dietary assessment (incl. nutrition PA-Questionnairepreferences), screening for eating disorders, craving, etc. – Spiroergometry (Cardiopulmunary Fitness)AD_EVA test tool

OP

Transition to a normal diet, advice regarding protein demand and supplements

3 weeks post OP Medical & surgical visit

surgical visit

Transition from mash and soft to ordinary food should be completed

Individualized Training

(starts 2015)

7,11,15 weeks post OP

AD_EVA (NLP, QSM, FEV_salut, QCEQ) → BAREVSprioergometry (CPF)Long term feeding

AD_EVA (NLP, QSM, FEV_salut, QCEQ) → BAREVSpiroergometry (CPF) Individualized nutrition plans, long term feeding

6, 12 months post OP

Metabolic (12 mo including

oGTT), vitamin/trace element

status, surgical visit

2 year post OP Metabolic (including oGTT),

vitamin/trace element status,

surgical visit3 year post OP

Design of Youth Interdisciplinary Post Bariatric Program YIPBP OAA


Replication AND 2 years Follow up for adolescents

We urgently need

-replication of our studies for children / adolescents especially

- mandatory participation in

2 years follow up

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Www.obesity-academy.org 1 Bariatric Surgery Affects Eating and Exercising related Psychological Variables, but nobody knows… Elisabeth Ardelt-Gattinger