Reprinted from Eating Disorders Review
May/June 2010 Volume 21, Number 3
©2010 Gürze Books
Persons with super-obesity, or a body mass index (BMI) greater than 40 kg/m2, have high risk of morbidity, poorer-than-normal quality of life, and some also face premature death. Since the late 1990s, bariatric surgery, particularly Roux-en-Y gastric bypass, has emerged as the best treatment option.
Until now, there has been little information about the long-term outcome of these patients. A group at the School of Health Professions and the University Hospitals of Geneva, Switzerland, has reported their findings after following a cohort of 80 women (mean age: 40 years) who underwent Roux-en-Y bypass between 1997 and 2002 (J Am Diet Assoc. 2010; 110:527). Body composition was measured by bioelectrical analysis and diet was assessed with a food diary. Physical activity was estimated using a pedometer. Questionnaires were used to evaluate eating disorders, psychological factors, and quality of life among the patients. At the last follow-up visit, 8 years after the procedure, Maaike Kruseman, MPh, RD, and colleagues used a semi-structured interview to measure the benefits and difficulties of the surgery, as well as to record the patients’ perceptions of their quality of life.
At least half had disordered eating patterns
The average weight loss was 30.7 kg; excess weight loss of at least 50% was noted in 47 patients, or 59% of the group. Between the baseline visit and the last visit, the relative proportions of fat mass/total body weight decreased and fat-free mass/total body weight increased. The mean energy intake was 2355 kcal at baseline and 1680 kcal at the 8-year mark. Despite their success in losing excess weight, slightly more than half of the patients reported having disordered eating patterns, including episodes of binge eating or the night eating syndrome.
Factors connected to successful outcomes
Younger age at the time of bypass surgery was associated with a weight loss of at least 50% of excess body weight at 8 years. Neither BMI at baseline nor body composition at baseline predicted successful weight loss at 8 years but excess weight loss and body composition 1 year after surgery were associated with at least 50% loss of excess body weight after 8 years.
When patients were asked about their satisfaction with the surgery, 85% said they were satisfied and would undergo the procedure again. Seventy-four percent were satisfied with their postoperative follow-up; however, 35 patients indicated they would have appreciated a more intensive follow-up, particularly if it were accompanied by psychological support. Eleven patients asked for longer and more in-depth dietary supervision, such as cooking classes or a support group. In addition to gastrointestinal difficulties, including dietary restrictions, patients did say that it was easier to eat less and that they now had better control of food intake. Some reported feeling guilty when weight loss stopped or weight increased, and wished they had more overall support from family members and medical staff.
What needs improvement?
Most weight loss occurred shortly after surgery; more than half of patients regained at least 5 kg between the first and eighth year, and many expressed feelings of guilt and shame about this. At baseline, one year after surgery and at the eighth year follow-up, dietary intake was suboptimal, according to the authors. Energy intake decreased, as expected, but carbohydrate intake fell below the recommended 40% to 65% of total energy intake, whereas fat intake was above the recommended 20% to 35% of total energy intake recommended by the Institute of Medicine and the USDA Dietary Guidelines. This pattern changed little between the first year after surgery and the 8-year follow-up point, suggesting that even basic dietary changes are difficult to achieve in this population. Fifty percent of the sample did not reach the recommended protein intake level: protein intake dropped from 1.5 gm at baseline to an average of 0.8 gm recorded at the final visit.
During follow-up, the authors reported that eating behaviors and psychological state did not improve significantly. Successful and unsuccessful patients alike reported similar rates of problematic eating behaviors, depression and anxiety. Such patterns can be easily overlooked by family and caregivers because the patient’s weight loss is the usual measure of success. Thus, patients may successfully lose weight but still feel like failures. Some patients said they ‘felt alone with their new body, their scar, and their fears.’ The authors stressed the importance of periodic follow-up screening to detect disordered eating patterns and underlying psychological disorders in this patient population.