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Bariatric Surgery:  Who is it for?

Recent government estimates indicate that 64.5% of the adult population in the United States is overweight or obese (Weight-control Information Network, 2004a).  Bariatric Surgeons utilize the Body Mass Index or BMI as the most common way of determining one’s weight status.  This is done by multiplying one’s weight in pounds (W) by 703 and dividing that number by one’s height in inches (H) squared (BMI= W x 703/H²) (Weight-control Information Network, 2004b). 

Utilizing the BMI formula, approximately one-third of the population is overweight (BMI: 25-29.9) and an equal number are obese (BMI: >30).  Those who are morbidly obese (BMI: >40) constitute 4.7% of the population in the United States (American Obesity Association, 2002).  Individuals with a BMI of at least 40 (about 100 pounds overweight for a man or 80 pounds overweight for a woman) or those whose BMI is between 35 and 39.9 with a serious chronic medical disorder such as type 2 diabetes, heart disease, or severe sleep apnea are the most common candidates for consideration of bariatric surgery (Weight-control Information Network, 2004b).

In 2002, there were nearly 70,000 bariatric surgeries in the United States (Davis, et al., 2006).  The surgeries involve restricting food intake and/or the amount of calories and nutrients that the body can absorb.  The Roux-en-Y gastric bypass and the Biliopancreatic diversion, involving restriction of both food intake and/or malabsorption were formerly the most widely accepted of the bariatric surgeries (Weight-control information Network, 2004b).  Currently, however, the Lap Band® is the most common procedure for bariatric surgery worldwide (Angrisani et al., 2003).  It is a restrictive procedure that involves laparoscopic surgery to implant a gastric silicone band around the upper part of the stomach.  The inner band is filled, via a port located  under the skin of the abdomen, with saline to create a smaller stomach pouch.  This technique  has been shown to result in significant, long term weight loss (O’Brien et al., 2006).

The need for psychological evaluations for prospective bariatric surgeries was recognized by the National Institutes of Health in 1991.  When I have been asked to complete such an evaluation, I take into consideration three factors:  1) the stated questions by the referring surgeon, the literature on pre-surgical bariatric evaluations (e.g., Wadden and Sarwer, 2006), and government recommendations (National Society for Bariatric Surgery, 2004).  By taking into account these three sources, I try to design an evaluation that best fits the needs of the patient and the surgeon, and is  consistent with the best practices in the field.  The type of questions I use when thinking about performing a pre-surgical bariatric evaluation is as follows:

• Reasons for wanting surgery

• Patient’s understanding of obesity and how it affects health

• Attitude about physical activity

• Mental status

• Current social support

• History of being overweight

• History of weight loss

• Marital and family history

• Personal history including employment

• Substance Abuse

• Previous psychological treatment

I often also employ one or more of three psychological instruments including the MMPI, Beck Depression Inventory and the Manifest Anxiety Scale.  The evaluation ends with answers to five questions:  These are:  What is the patient’s motivation to have surgery?; Does the patient understand the procedure?; Does the patient understand the aftercare requirements?; Are there factors that may interfere with compliance with dietary restrictions and postoperative instructions?; Is any additional psychological counseling indicated? 

Bariatric surgery is an option for those persons who meet the criteria for the procedure.  It is important to work with a psychologist or alternate mental health professional post-surgery to deal with the psychological issues that likely played a role in the etiology of the obesity and factor into potentially interfering with an optimal level of success, post-surgically.   

References

Weight-control Information Network. (2004a). Weight and waist measurement:  Tools for adults.  Downloaded October 27, 2006 from http://win.niddk.nih.gov/publications/tools. 
Htm#bodymassindex.

Weight-control Information network (2004b).  Gastrointestinal surgery for severe obesity.  Downloaded October 27,2006 from http://win.niddk.ih.gov/publications/gastric.htm.

Angrisani, L. et al., (2003).  Lap Band® adjustable gastric banding system.  Surgical Endoscopy, 17, 409-412.

O’Brien, P.E., et al., (2006).  Treatment of Mild to Moderate Obesity with Laparoscopic Adjustable Gastric Banding or an Intensive Medical Program.  Annals of Internal Medicine, 144, 625-633.

Wadden, T.A., & Sarwer, D.B. (2006).  Behavioral assessment of candidates for bariatric surgery:  A patient-oriented approach.  Surgery for Obesity and Related Diseases, 2., 171-179.

November 2006