Obesity in the United States has increased to epidemic numbers over the last decade. Practitioners need to reverse the trend. To address the problem of depression in obesity, a practice guideline from a bariatric clinic for under-served populations was proposed to an expert panel. The Spell Out on First Use (PHQ-9) screening is a valid and reliable self-screening tool to assist the practitioner in determining the level of depression if any. The PHQ-9 has nine questions. No formal screening existed at the bariatric clinic, and the practice guideline (with algorithm and revised workflow) was proposed for use at the clinic. The expert panel consisted of the medical director, a surgeon, a psychiatrist, and a nurse practitioner at the clinic. The expert panel reviewed the materials and made one recommendation: to implement the PHQ-9 upon intake when the patient is being admitted to the program, and the panel recommends administering PHQ-9 prior to assessment by practitioners All panel members were in agreement about full implementation of the practice guideline, provided that an educational program on the revised workflow in the clinic was first presented. The expert panel also reviewed and approved the algorithm and the treatment pathways identified for patients to use in the practice after the results of the PHQ-9 are compiled. It is expected that use of the depression screening tool and recommended guidelines in the bariatric clinic will result in more effective treatment for the patients and thus better outcomes-a significant positive social change.

Title: Psychological Factors of Weight Loss in Patients after Bariatric Surgery Author: PhDr. Markéta Zajícová Department: Department of Psychology, Charles University in Prague, Faculty of Arts Supervisor: PhDr. Tamara Hrachovinová, PhD. Abstract: Obesity with its comorbidities has enormous impacts on the life of the individual as well as the whole society. Therefore, the attention is paid to the treatment of obesity, where bariatric surgery appears to be one of the most effective. The surgical solution offers excellent results in terms of weight reduction in the short- and medium-term period, but the increased number of weigh gain cases appears in long-term perspective. The aim of this thesis is to find out whether any of the psychological factors that are included in the psychological assessment prior to the bariatric surgery, can predict the development of weight after the surgical procedure. The research is retrospective and quantitative; it focuses on monitoring variables from psychological assessment as well as weight development from the time of the surgery to 4 years after the surgery with intervals of 3, 6, 9 months and 1, 2, 3, 4 years. Attention is focused not only on the weight itself, but also on the weight change (compared to the initial weight and the comparison between consecutive...

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Background: Bariatric surgery is the most effective treatment for severe obesity, resulting in much larger and longer-lasting weight loss compared with those seen with other treatment options. It also results in significant improvements in several weight-related comorbidities. Despite these favorable outcomes, bariatric surgery remains underused in the United States. Objective: The goal of this dissertation was to investigate the impact of insurance-related factors on the access and utilization of bariatric procedures. The goal was achieved via three studies. The first study examined temporal changes in patient characteristics and insurer type mix among adult bariatric surgery patients in Southeastern Pennsylvania, as well as the associations between payer type, insurance plan type, cost-sharing arrangements (among traditional Medicare beneficiaries), and bariatric surgery utilization. The second study investigated whether there is an association between precertification criteria, such as 3-6 months preoperative supervised medical weight management (MWM), and documented 2-year weight history and the likelihood of undergoing bariatric surgery. The third study examined whether there is an association between insurance-mandated MWM requirement, as well as cardiology and pulmonology evaluations and short-term inpatient healthcare utilization. Data Source: Pennsylvania Health Care Cost Containment Council’s (PHC4) databases in Southeastern Pennsylvania during 2014-2018. Study Population: In Study 1, all adult patients in the PHC4 dataset who underwent the most common types of bariatric surgery during 2014-2018 (N = 14,348) and a 1:1 matched sample of surgery patients and those who were eligible for surgery but did not undergo surgery were identified. In Study 2, privately insured patients within the PHC4 dataset who underwent bariatric surgery in 2016 and individuals who met the eligibility criteria but did not undergo surgery were identified and 1:1 matched (N = 1,054). The population of Study 3 consisted of all adult patients within the PHC4 dataset with a diagnosis of severe obesity who underwent the most common bariatric surgical procedures in 2016 and for whom the insurance-mandated precertification requirements were known (N = 2,717). Results: Over the five years, there was an increase in the proportion of Black individuals (37.1% in 2014 vs 43.0% in 2018), Hispanics (5.4% vs 8.0%), and Medicaid beneficiaries (18.5% in 2014 vs 26.9% in 2018) who underwent surgery. The odds of undergoing bariatric surgery based on payer type were statistically different (22% smaller odds) only between Medicare beneficiaries compared to privately insured individuals. There were significantly different odds of undergoing surgery based on insurance plan type within Medicare and private insurance payer categories. Individuals with traditional Medicare plans with no supplementary insurance and those with dual eligibility had smaller odds of undergoing surgery (42% and 32%, respectively) compared to those with private secondary insurance. The insurance requirement for 3-6 months MWM was associated with smaller odds of undergoing surgery (odds ratio [OR] = 0.459, 95% confidence interval [CI] 0.253 to 0.832, P = 0.010), after controlling for insurance plan type and the requirement for documented weight history. The documented weight history requirement was not a significant predictor of the odds of undergoing surgery (P = 0.132). The requirement for MWM, as well as pulmonology and cardiology examinations, were not associated with the patient length of stay, the number of all-cause rehospitalizations, and the number of all-cause rehospitalization days, after adjusting for patient age, sex, race, ethnicity, the Elixhauser Comorbidity Score, type of the surgery, facility where the surgery was performed, primary payer type, and the estimated median household income. The absence of the precertification requirement for pulmonology and cardiology evaluations was associated with smaller odds of rehospitalizations with common cardiac and pulmonary conditions during the study period, (OR = 0.43, 95% CI 0.23 to 0.80, P = 0.008), after controlling for patient age, sex, race, ethnicity, estimated median household income, and the Elixhauser Comorbidity Score. Conclusions and Significance: Medicaid expansion in Pennsylvania appears to have improved access to bariatric surgery among Black and Hispanic individuals. Nevertheless, insurance plan type, cost-sharing arrangements, and precertification requirements, such as insurance-mandated 3-6 months of MWM requirement, remain key determinants for the access and utilization of bariatric surgery. Additionally, the MWM requirement, as well as the preoperative cardiology and pulmonology evaluations, were not associated with a reduction in inpatient healthcare utilization during the first postoperative year. Careful examination of the bariatric surgery benefit design and application of value-based insurance design to bariatric surgery may improve the access to this potentially life-saving surgery for many Americans. / Public Health

Bakgrund: Idag lider nästan hälften av alla vuxna män och kvinnor i Sverige av övervikt eller fetma. Bariatrisk kirurgi blir en allt vanligare metod för viktreducering och minskning av de fetmarelaterade komorbiditeterna. De vanligaste operationerna resulterar i kraftig viktreducering, men forskning visar att en del av patienterna går upp kilona senare. Syfte: Syftet med denna litteraturstudie är att belysa patienters upplevelser av sin livssituation efter bariatrisk kirurgi. Metod: En litteraturstudie med kvalitativ metod. Studien sammanställer 15 vetenskapliga artiklars resultat. Resultat: Studiens resultat visar på att det vardagliga livet påverkas av den minskade vikten och att en känsla av självständighet infinner sig i samband med att patientens mobilitet ökar. En stor andel patienter upplever sig hämmade av en extrem trötthet efter att ha genomgått kirurgin. Fysiska biverkningar har negativ inverkan på livskvalitén. Resultatet visar på att många upplever sig mer respekterade och uppmärksammade efter viktnedgången. Relationer till familj och vänner visar sig kunna påverkas både positivt och negativt efter ingreppet. Ökat självförtroende och bättre självkänsla är ett av resultaten av viktnedgången. Men att förändra bilden av sig själv tar för många lång tid. Relationen till mat är en central del i behandlingen. Många av patienterna har tidigare använt mat för att hantera känslor. Efter ingreppet finns känslorna kvar och nya sätt för att hantera dem arbetas fram. Det kan i en del fall resultera i att personen utvecklar exempelvis ett spelberoende eller alkoholmissbruk. Konklusion: Ett önskat resultat kräver stöd från sjukvården. Stöd i att orka med vardagen efter ingreppet, hantera det nya sociala livet, acceptera och se sitt nya jag samt bearbeta sin relation till mat upplevs som mest centralt. / Background: Currently almost half of the adult Swedish population struggle with overweight or obesity. Bariatric surgery is becoming a commonly used method for weight loss and reduction of obesity-related comorbidities. The most common procedures often lead to great weight loss, but research shows that postoperative weight gain is common. Aim: The aim of this literature review is to illustrate patient perception and experience of their life situation after going through bariatric surgery. Method: This is a literature review performed with a qualitative approach. The review is based on the result of 15 scientific articles. Results: The study shows that everyday life is affected by the weight loss after bariatric surgery, and that the patients gain independence and greater mobility. Many patients experience that they are inhibited by enormous fatigue after their surgery. Physical side effects have a negative impact on their quality of life. The results show that many feel that they receive greater respect and positive attention after weight loss. Relationships with family and friends are affected in both positive and negative ways. Confidence and self-esteem are affected positively by weight loss, but a change of body image doesn’t always come naturally and takes a long time for many. The relationship with food is a central part of the treatment as a whole considering that emotional eating is common with obese patients. The emotional issues are left unresolved after surgery and patients find new ways of coping with them that don’t include food. In some cases patients fall into new addictions like gambling addiction or drug abuse. Conclusion: To achieve successful results after bariatric surgery, one must get sufficient support from health care providers. Support in handling everyday life, social aspects and accepting the new self. Support in coping with the issue of emotional eating is considered to be essential for successful outcome.

This thesis focuse on bariatric-metabolic surgery and its impact on serum concentrations of various metabolic parameters. The thesis is divided into two parts - theoretical and practical. Basic facts about bariatric-metabolic surgery such as its history, indications, contraindications, surgical methods and their results, nutrition after surgery and the frequency of micronutrient's deficits are described in the theoretical part. Furthermore, information about calcium-phosphate metabolism and metabolites such as calcium, phosphorus, magnesium, vitamin D, vitamin K, parathyroid hormone and osteomarkers is also included. The influence of nutrition and nutritional status on the quality of bone tissue is also mentioned. Last section of the theoretical part is focused on the important vitamins and minerals. The practical part discusses measurements of selected metabolites in serum before and half a year after the surgery. Results of questionnaires which were given to respondents are also included. Questionnaires were focused on lifestyle, nutrition, physical activities and whether the patients take some supplements of micronutrients and protein concentrates. The goal of this work is to evaluate the effect of the surgery on serum concentrations of metabolic parameters and their effect on the health and...

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The purpose of this study was to determine if post-operative serum albumin and percentage of weight loss improved in patients who received formalized pre-operative nutrition counseling. Nutrition intervention was measured quantitatively. A retrospective review of records was conducted on 77 RYGB patients (68 female subjects and 9 male subjects), ages 21-64, during January 2001 through January 2006. The results indicated that patients who received pre-operative nutrition intervention had better clinical outcomes of serum albumin than those with no nutrition intervention from a registered dietitian. However, outcomes regarding percentage of weight loss varied. Both pre-operatively and at the 3 month post-operative visit the weight of subjects who received nutrition intervention seemed to be increasing by the 6 month post-operative visit the subjects with no nutrition intervention had lost more weight.

Morbid obesity, defined by having a BMI of 40 or greater, has gained increasing attention. Despite a greater number of bariatric surgery cases for the treatment of obesity, research has demonstrated concerning results for patients, particularly involving weight regain and the development of mental illness. Patients seeking bariatric surgery are often required to complete a psychological evaluation to determine readiness for the procedure and associated post-operative lifestyle changes. However, research suggests mixed results in determining predictors for post-surgical success. Few studies have looked at emotionality and eating patterns in bariatric surgery seeking patients, though emotional eating is often talked about in the literature. It is likely that emotional eating and problematic patterns of emotional regulation that may contribute to obesity carry implications for post-surgical mental health and weight loss maintenance. In the current study, 30 bariatric surgery-seeking patients have thus far completed the Dutch Eating Behaviors Questionnaire and the Difficulties in Emotion Regulation Scale. Preliminary data suggest a significant relationship between emotional eating patterns and a difficulty in emotion regulation (r= .397, p = .049). Trends toward significance were also discovered between difficulties in emotion regulation and restricted and external eating patterns (restrained, r = -.356, p = .081; external, r = .330, p = .099). This preliminary data is part of a larger study on emotion and eating patterns in bariatric surgery seeking patients, and additional data will help us better understand these relationships. Results may have implications for intervention regarding emotional dysregulation prior to and following bariatric surgery.