Grothe, Karen

Introduction: Psychosocial assessments by behavioral health (BH) professionals before metabolic and bariatric surgery (MBS) are recommended by national guidelines. Accordingly, insurance companies often require patients to undergo psychosocial assessments before MBS. This paper reviews the historical evolution of the MBS psychosocial assessment, clarifies the role of BH professionals within the team before and after MBS, and describes strategies to effectively utilize psychosocial assessments to optimize patient outcomes. Methods: Authors conducted a manual search of the available literature and completed a narrative review. Results: The original intent of the psychosocial assessment for MBS was to correlate psychiatric profiles to weight loss outcomes or identify which patients were predicted to succeed or “fail” after MBS. Historically, these evaluations were gatekeeping mechanisms, which invalidates the myriad ways that psychosocial assessments can identify and support patients. Controversy exists about the necessity of these evaluations, leading some MBS team members and patients to see it as an unavoidable “checkbox” with little clinical utility outcomes. Conclusion: Viewing the psychosocial assessment as a checkbox minimizes the potential benefits to patients and MBS team members. Additionally, it diminishes the expertise of BH professionals who are uniquely trained to support this patient population toward an optimal surgical outcome.

Background Obesity is increasingly common in kidney transplant candidates and may limit access to transplantation. Obesity and diabetes are associated with a high risk for post-transplant complications. The best approach to weight loss to facilitate active transplant listing is unknown, but bariatric surgery is rarely considered due to patient- and physician-related apprehension, among other factors. Methods We aimed to determine the magnitude of weight loss, listing, and transplant rates in 28 candidates with a mean BMI of 44.4±4.6 kg/m 2 and diabetes treated conservatively for 1 year post weight-loss consultations (group 1). Additionally, we evaluated 15 patients (group 2) who met the inclusion criteria but received bariatric intervention within the same time frame. All patients completed a multidisciplinary weight management consultation with at least 1 year of follow-up. Results In the conservatively managed group (group 1), the mean weight at the time of initial consultation was 126.5±18.5 kg, and the mean BMI was 44.4±4.6 kg/m 2 . At 1 year post weight-loss consultation, the mean weight decreased by 4.4±8.2 kg to 122.9±17 kg, and the mean BMI was 43±4.8 kg/m 2 , with a total mean body weight decrease of 3% ( P =0.01). Eighteen patients (64%) did not progress to become candidates for active listing/transplantation during the follow-up time of 4±2.9 years, with 15 (54%) subsequently developing renal failure/diabetes-related comorbidities prohibitive for transplantation. In contrast, mean total body weight decreased by 19% at 6 months post bariatric surgery, and the mean BMI was 34.2±4 and 32.5±3.7 kg/m 2 at 6 and 12 months, respectively. Bariatric surgery was strongly associated with subsequent kidney transplantation (HR=8.39 [95% CI 1.71 to 41.19]; P =0.009). Conclusions A conservative weight-loss approach involving multidisciplinary consultation was ineffective in most kidney transplant candidates with diabetes, suggesting that a more proactive approach is needed.

The efficacy and safety of a fluid‐filled intragastric balloon (IGB) for weight loss in patients with cirrhosis on the liver transplantation (LT) waiting list is unknown. We enrolled stable compensated patients with body mass index >35 kg/m2 and on the waiting list for IGB placement endoscopically for a maximum of 6 months. A total of 8 patients (7 men) aged mean ± SD, 56 ± 4.6 years with Model for End‐Stage Liver Disease–sodium (MELD‐Na) scores 14.1 ± 3.4 experienced weight reduction (146 ± 22.2 kg versus 127 ± 21.6 kg [P = 0.005] with IGB in place and 130 ± 24.6 kg [P = 0.014] at 6 months), with a total body weight loss of 12.2% ± 8.8% with IGBs in place and 10.9% ± 8.9% at 6 months. Body fat decreased from 48.6% ± 5.8% to 40.6% ± 6.4% (P = 0.001) and lean mass increased from 51.3% ± 6% to 59.4% ± 6.4% (P = 0.001). No change in MELD‐Na scores occurred (P = 0.770). Early balloon retrieval was attributed to accommodative symptoms (n = 2) and liver decompensation (n = 1). Mallory Weiss tears (n = 3), but no portal hypertensive bleeding, occurred. Liver decompensation and/or hepatocellular carcinoma (HCC) developed in 3 patients. A total of 4 patients with LT ± sleeve gastrectomy maintained overall weight loss. Of 4 patients who did not receive transplants, 2 experienced weight regain. IGB results in short‐term weight loss in patients with cirrhosis awaiting LT, with body fat loss without lean mass loss. Adverse effects were common. Decompensation and HCC did occur, with uncertainty of the relation to weight loss, and thus careful patient selection and close follow‐up are required.

INTRODUCTION: Obesity is associated with postnatal depression; however, the prevalence of postnatal depression in women after bariatric surgery has not been further evaluated. METHODS: For this observational investigation, women, ages 18-45 years, with pregnancy from 1989-2015 and bariatric surgery were identified using the Olmsted County Rochester Epidemiology Project and ICD-9 codes. Those with surgery after pregnancy and/or without permission to use their records were excluded. Charts were reviewed for maternal and infant characteristics and outcomes. Postnatal depression was identified from a positive screen, referral for mood disorder, antidepressant medication increase, suicidality, or provider diagnosis from delivery to 12 months postpartum. RESULTS: Ninety-one women with pregnancy >23 weeks after surgery and available data were reviewed. The average body mass index at time of surgery was 47±8.6 kg/m2 (N=88) and at time of pregnancy 32±6.6 kg/m2 (N=89). The average age at surgery was 29±4.1 years and at delivery 33±4.4 years. Roux-en-Y gastric bypass was the most common surgery (N=70, 77%). Pregnancy outcomes included: 14% preterm deliveries (<37 weeks, N=13), 67% vaginal deliveries (N=61), no stillbirths, and 97% singleton deliveries (N=88). Mean singleton birthweight was 3225 grams (±471, N=86). Postnatal depression was noted in 38% of women (N=35), which is significantly higher than that for obese women in general (13-18%) when a 1-sample proportion test is conducted for comparison (38%vs18%, p <0.0001). CONCLUSION: Postnatal depression may be increased in women with a history of bariatric surgery. Further investigation is needed, but particular care should be taken to screen and diagnose these high-risk women.

Study Objective The extended‐release ( ER ) form of venlafaxine is preferred because of improved patient adherence, but the immediate‐release (IR) form is frequently used after Roux‐en‐Y gastric bypass ( RYGB ) surgery because of concerns for malabsorption. The objective of this study was to determine whether a statistically significant and predictable change in the bioavailability of venlafaxine ER capsules occurs after RYGB . Design Prospective nonblinded single‐dose pharmacokinetic study. Setting Clinical research unit at a large tertiary care medical practice. Patients Ten adult pre–bariatric surgery patients who met the criteria for noncomplicated RYGB were enrolled and served as their own controls. Interventions Patients were administered one venlafaxine ER 75‐mg capsule at two visits—the first visit at least 1 week before undergoing RYGB and the second visit 3–4 months after RYGB . Blood samples were collected at predetermined intervals over 48 hours after each dose, and the pharmacokinetics of venlafaxine were measured. Measurements and Main Results Plasma levels of venlafaxine and its primary metabolite, O ‐desmethylvenlafaxine ( ODV ), were compared at baseline and 3–4 months after RYGB . The areas under the serum concentration–time curves from 0–24 hours ( AUC 0–24 ) for venlafaxine (mean ± SD 734 ± 602 vs 630 ± 553 ng·hr/ml, p=0.22) and ODV (mean ± SD 894 ± 899 vs 1083 ± 972 ng·hr/ml, p=0.07) were similar before and after RYGB . Using a bioequivalence approach, differences in pre‐ RYGB and post‐ RYGB values of AUC 0–24 , peak serum concentration, and time to peak serum concentration were not statistically significant for either venlafaxine or ODV. Conclusion This study suggests that RYGB does not significantly alter the amount of venlafaxine or its active metabolite, ODV , absorbed from a venlafaxine ER capsule or the time over which it is absorbed.

Spillover of lipoprotein lipase-generated fatty acids from chylomicrons into the plasma free fatty acid (FFA) pool is an important source of FFA and reflects inefficiency in dietary fat storage. We measured spillover in 13 people with type 2 diabetes using infusions of a [3H]triolein-labeled lipid emulsion and [U-13C]oleate during continuous feeding, before and after weight loss. Body fat was measured with dual energy X-ray absorptiometry and computed tomography. Participants lost ∼14% of body weight. There was an ∼38% decrease in meal-suppressed FFA concentration (P &lt; 0.0001) and an ∼23% decrease in oleate flux (P = 0.007). Fractional spillover did not change (P = NS). At baseline, there was a strong negative correlation between spillover and leg fat (r = −0.79, P = 0.001) and a positive correlation with the trunk-to-leg fat ratio (R = 0.56, P = 0.047). These correlations disappeared after weight loss. Baseline leg fat (R = −0.61, P = 0.027) but not trunk fat (R = −0.27, P = 0.38) negatively predicted decreases in spillover with weight loss. These results indicate that spillover, a measure of inefficiency in dietary fat storage, is inversely associated with lower body fat in type 2 diabetes.