Researchers Correlate Psychosocial Characteristics With Weight Recurrence Following Bariatric Surgery

Metabolic and bariatric surgery (MBS) for the treatment of class III (or severe) obesity can lead to sustained weight loss and a long-term reduction in comorbidities. Over time, however, postoperative weight recurrence can become problematic for a subset of patients, particularly those with ongoing disordered eating. Alcohol misuse — a known risk of MBS — may also be associated with less optimal weight outcomes.

In a new study published in Surgery for Obesity and Related Diseases, researchers have sought to understand the relationship between psychosocial functioning and weight recurrence in the critical decade following MBS. Using the Minnesota Multiphasic Personality Inventory – 3 (MMPI-3), the most widely used measure of personality and psychopathology in psychology, investigators evaluated patients for a host of factors that may help predict their long-term postsurgical outcomes.

“Patients uniformly lose unwanted pounds in the first year following MBS, but many are unable to maintain that weight loss once the initial effects of surgery begin to dissipate,” explains study coauthor Leslie Heinberg, PhD, MA, Vice Chair for Psychology and Director of Enterprise Weight Management at Cleveland Clinic. “As clinicians, our ability to help our patients successfully avoid weight recurrence requires an understanding of the psychological factors that put them most at risk.”

Study specifics

Researchers evaluated 163 patients (30.7% male and 69.3% female), all of whom had met or surpassed their six-year postoperative milestone. In addition to the MMPI-3, participants were asked to answer several other clinically validated questionnaires designed to measure disordered eating, alcohol use, quality of life, and adherence to postoperative recommendations.

Although weight recurrence was highly variable six years following MBS, on average, patients had regained approximately 31% of the weight they had initially lost. The surveys also revealed a prevalence of psychopathology, alcohol use, and problematic eating behaviors.

In particular, high scores in the MMPI-3’s Emotional/Internalizing Dysfunction (EID) domain – used to pinpoint problems with mood and affect – were associated with greater weight recurrence, suggesting that mood-related problems may play a modest role in predicting this outcome. Depression-related constructs also appeared to predict more weight recurrence.

In addition, elevated MMPI-3 EID scores were associated with a lower quality of life and a number of problematic psychosocial factors beyond body weight. Elevated scores on the Externalizing Dysfunction (BXD) scale — used to identify impulsive behaviors — were associated with poorer behavioral adherence and problematic alcohol use after MBS.

“Depression, anxiety, emotional distress and aggression not only were associated with more weight gain, but they also appear to portend other problematic outcomes, including alcohol misuse,” Dr. Heinberg explains. “Conversely, positive emotional experiences, low impulsivity, and general feelings of well-being appear to safeguard against unwanted outcomes, including poor body image.”

Heinberg notes that the study was limited by several factors, including its small sample size and the fact that all participants were deemed psychologically healthy enough to undergo their initial surgery.

Avoiding postsurgical pitfalls

Heinberg says the findings support a greater need for postsurgical psychological interventions, which may help patients anticipate and mitigate the challenges ahead. In addition to weight recurrence, alcohol misuse is a serious risk that affects an estimated one in five patients who have undergone MBS. Approximately 25% of these patients develop the problem de novo, meaning they did not have difficulties with alcohol prior to surgery.

“Unfortunately, alcohol is replete with empty calories,” Dr. Heinberg cautions. “Overconsumption can also reduce dietary inhibitions, causing patients to lose sight of their postsurgical goals. For far too many patients, it’s a troubling – and perfect – storm.”

Although MMPI-3 scales may help predict who may be at higher risk of developing a new-onset alcohol or substance use disorder and less likely to adhere to appointments and a postoperative regimen, Heinberg notes that these findings have yet to be confirmed by a prospective investigation.

Future implications

Research indicates that psychological difficulties and other adverse outcomes are most likely to arise after the first two years following MBS, says Heinberg, once the regular stressors of life have re-emerged. “This is why it’s so important to invest in future studies aimed at identifying the ideal timing of postoperative interventions.”

She notes that the use of a well-validated, psychological test that is focused on psychological constructs — rather than diagnoses — may better illuminate how psychosocial factors can be used to predict weight recurrence and other relevant outcomes. She hopes to see future studies designed to prospectively track participants’ MMPI-3 scale scores and weight over time.

“Obesity is a highly complex disease with a variety of drivers, and it is best managed with multidisciplinary, multimodal care,” she says. “Appropriate treatment may begin with surgery and medications – both of which can be powerful tools – but nutritional and psychological interventions are essential to long-term success. It’s clear that outcomes are partly shaped by the patient’s personality and emotional experience, so we are remiss if we fail to address those patterns and behaviors.”