OBESITY
Definition
Obesity is a chronic, debilitating condition and a risk factor for severe comorbidity as type 2 diabetes, hyperlipidemia, hyper- tension, obstructive sleep apnea, heart disease, stroke, asthma, back and lower extremity weight-bearing degenerative problems, several forms of cancer, depression. Presence of these comorbid conditions bears a higher mortality rate ((Hensrud & Klein, 2006); (Potter, 2006);(Buchwald et al., 2004)) and has been estimated to account for more than 2.5 million deaths per year world-wide (World Health Organization, 2002). In comparison with a normal-weight individual, a 25-year-old morbidly obese man has a 22% reduction in expected remaining lifespan, representing an approximate loss of 12 years of life (Fontaine, Redden, Wang, Westfall, & Allison, 2003).
In regards to the nosographic status of obesity, ICD-10 comprises a chapter on “obesity and other hyperalimentation syndrome” among “Endocrine, nutritional and metabolic diseases “
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E66.0 Obesity due to excess calories-
E66.1 Drug-induced obesity•
Use additional external cause code (Chapter XX), if desired, to identify drug.-
E66.2 Extreme obesity with alveolar hypoventilation•
Pickwickian syndrome-
E66.8 Other obesityMorbid obesity
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E66.9 Obesity, unspecified-
Simple obesity NOSProposed medical definitions of Obesity rely on various clinical indexes and criteria, of which most widely employed is Qutelet’s1 Index, commonly known as Body Mass Index. defined as the individual's body mass divided by the square of height – thus measured in units of kg/m2. The 1998 U.S. “National Heart, Lung and Blood Institute” guidelines define BMI ranges for the conditions of Overweight and Obesity ( with ranges between 25-29.9 kg/m2, and >30 kg/m2 , respectively).
Furthermore, Obesity is graded in three categories; Ist grade (BMI <34.9 kg/m2), II grade (BMI between 35 kg/m2 and 39,9 kg/m2) and III grade - or morbid - obesity (BMI >40 kg/m2 ). This classification has been utilised in epidemiology and clinical research, and is also routinely employed in bariatric surgery for staging and patient selection. Alternative grading systems have been proposed, among others, by Mason and collegues who separated III grade obese subjects in two groups, one comprising patients with BMI<50 and the other BMI≥50, defined super-obese patients2. The super-obesity concept comes from post-surgical observations of subject treated with vertical sleeve gastroplasty: subjects with a BMI≥50 didn’t just show a worse outcome in terms of weight loss, but also higher complication rates and post-surgical mortality (Brolin, Kenler, Gorman, & Cody, 1989; Mason et al., 1987).
1 Quetelet LAJ (1871). Antropométrie ou Mesure des Différences Facultés de l'Homme. Brussels: Musquardt.
Obesity Epidemics
In adults, WHO defines overweight condition as having a body mass index (BMI) of ≥25.0 kg/m2, with further distinction in obesity (having a BMI of ≥30.0 kg/m2) and pre-obesity (having a BMI of 25.0–29.9 kg/m2) (Galea, 2013).
An alarmingly rising trend in prevalence of obesity has been shown all over the world, so much that it has been characterised as a global epidemic. According to data shown by an International Obesity Task Force, over 1 billion adults are overweight and just shy of one third (310 milions) satisfy criteria for obesity. Estimates for children and adolescents amount to 160 e 40 million cases, respectively (Forestieri, n.d.). More recent WHO estimates show a worldwide prevalence of 35% for overweight and 12% for obesity in adults .
US epidemiological surveys show that the majority of americans are overweight or obese; furtherly, Morbid - or third grade- Obesity range underwent a quadruple rise in prevalence over a 14 years span, so that in 2004 6,4% of women and 3,3% of men in the USA were affected by morbid obesity ((Hedley et al., 2004; Ogden, Carroll, Curtin, & McDowell, 2006; Sturm, 2003)). Part of these estimates should be read taking into account the changes of threshold criteria for overweight, that actually led in 1998 to the inclusion of more than 20 million americans in a previously smaller population of overweight subject. The quota of super-obese population has been on the rise, too, by a 75% from 2000 to 2005 (Sturm, 2007).
Prevalence of obesity in Europe has shown a three-fold rise during the two last decades and is (said to be) destined to reach a further, two-fold increase over the next thirty years without a thorough intervention (Brug, 2006). Available data from a 2008 survey show a prevalence of overweight and obesity of, respectively, 40% and 20%.
In our country, too, obesity is a pressing and growing health issue, Overweight subjects constitute a share of 35% , with a prevalence of male subjects, while the clear-cut obese population amounts to 10%, with slight gender and geographical difference in prevalence (which proved to be higher among females and in southern Italy). More recent WHO data (2008) show a prevalence of overweight and obesity respectively around 49,2% and 17,2% among adult population
The main worry about these data is the fact that, given a 25% increase of overweight cases the last twenty years, this increase is mainly sustained by an obese population which has grown in comparison to the whole overweight group. Italy is also sporting the highest european quota of both overweight (36%) and obese (10-15%) children/teenagers. This further increase of has been framed in the 2007 report from Istituto Auxologico Italiano, publishing data showing a 6 million increase of italian overweight population in just four years, with indication of an emergent increase in pediatric patients.
Obesity Treatment
Therapy of obesity is defined by the achievement of a 5-10% weight reduction and long-term maintenance of this goal. In terms of metabolic balance, a negative balance must be maintained during both the weight reduction and maintenance phase.
The first approach has to rely on behavioural modifications, bent on reaching enduring lifestyle changes. Short-term interventions as the association of diet and physical activity, with or without drug therapy, can help achieve intermediate results that have proven to be fleeting, at best, in the absence of actual behavioural modifications. A 2010 Italian Consensus Document by Donini & coll recommends an articulated, multi-professional approach consisting in parallel interventions relying on nutritional, motor/functional rehabilitation, psychoeducation and focused pychotherapy, rehabilitation nursing and pharmacotherapy always associated to nutrition and physical activity programs and in cases selected by a BMI threshold (>30 Kg/m2 or >27 Kg/m2 in subjects bearing other risk-factors or comorbid conditions)(Donini et al., 2010). In cases where the degree of weight reduction is not adequate, or when severity of either obesity or associated conditions can be considered life-threatening, bariatric surgery is considered as a valid indication.
Taking into account the impact of obesity on both expectancy and quality of life, not mentioning the relevant sanitary and social costs, the epidemiology data mentioned above bear severe social implications. These figures, together with the poor success rates of purely behavioural or pharmacological intervention when applied to severely obese subjects, have probably paved the way for surgical treatment of obesity, contributing at least to its rise in popularity among both the general public and health care institutions (Sarwer et al., 2004).
Although with some exceptions, clinical obervation shows that the feed-forward cycle of weight gain in the morbidly obese can be interrupted only by physically restricting oral intake; with this concept in mind, even baratric surgery can’t be defined a cure for obesity. However surgical interventions can enhance long-term patient safety, quality of life and determine, overtime, a satisfying weight reduction(Benotti, Wood, Rodriguez, Carnevale, & Liriano, 2006; Mauri et al., 2008; Murray, 2003)
Bariatric surgery is generally an effective intervention, but it does not lead to equal results .The long term-efficacy is predominantly due to patient compliance to adequate dietary rules.. (Van Hout et al., 2003)
Bariatric Surgery
In 2008 the Italian Society for Obesity Surgery (SICOB) published a Guideline statement which summarized main international consensus and guidelines up to 2007.
These are the resulting, current indications for Bariatric Surgery in patients aged between 18 and 60 years3:
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BMI ≥ 40 Kg/m2 or BMI ≥ 35 Kg/m2 in presence of comorbid conditions expected to show a measure of improvement, up to resolution, following a considerable post-operative weight loss-
A history of failed medical treatment (defined as no (none?) or non-significant weight loss, or afailure to maintain achieved results)
These guidelines stress the concept of a minimum threshold, while pointing out that patients should be evaluated using the maximum lifetime BMI level, not taking into account any weight loss 3 Reported as comprising up to 97,5% of SICOB-registered patients
occurred since. The same guidelines also admit an indication for selected cases that, in a case-control research setting, could benefit from bariatric surgery although within a lower BMI range (30-35 Kg/m2). A “close attention” is recommendend in regard to a thorough patient information and, conversely, his or her full compliance to a long post-operatory follow-up and an enduring, lifetime commitment to adhere to long-lasting adequate dietary habits, along with structured physical exercise.
Separate guidelines, regulating Bariatric surgery indications in special populations (identified by age or specific endocrine conditions) fall outside the scope of this study.
Contraindication Criteria are:
1. absence of a documented history of medical treatment of obesity 2. patients unable to adhere to a prolonged follow-up protocol;
3. Psychiatric Disorders (Psychotic Disorders, Severe Depression, Personality Disorders, Eating Disorders (Nervous Bulimia) )
4. Alcohol or Substance dependence disorder
5. Comorbid conditions associated to a shortened life expectancy;
6. Patients unable to provide to own personal care and deprived of adequate family and social support
An Overview of Surgical Techniques
The last decades have seen a score of surgical procedures proposed for severe obesity, although many have been cast aside as treatment options due to scant results or
. The few procedures selected can be efficiently categorised, according to therapeutic mechanism, in three groups:
Gastric reduction techniques (Adjustable Gastric Banding, Vertical Sleeve Gastrectomy).
These procedures involve a reduction in size of gastric lumen, from a simple inlet restriction (GB) to an actual lumen resizing (VBG) that should cause an earlier sense of repletion[??] and diminish overall hunger. Food digestion and absorption of nutrients should not be impaired or altered anyhow, although changes in exposure to gastric acid milieu could be relevant. The main
prescriptions are of pyshcoeducational nature as patients are requested to follow indications regarding food ingestion habits.
Gastric reduction with associated gastro-jejunal bypass (Laparoscopic Roux-en-Y Gastric Bypass - RYGB).
As above, stomach lumen is greatly reduced. In addition the associated rearrangement of small gut anatomy prevents normal nutrient absorption along the duodenal tract. The resulting malabsorption, along with an altered balance of digestive neuroendocrine signalling determines a stronger modification of hunger sensation (and patients’ ability to control it) and an actual reduction of caloric absorption. Gastric bypass interferes with micro-and oligonutrients absorption (Iron,
Calcium, vitamins) and drug bioavailability, thus determining lifelong dietary supplement and therapeutic adjustment.
Gastric reduction with associated malabsorption (Scopinaro’s technique, or bilio-pancreatic diversion, “duodenal switch”, bilio-jejunal-by-pass).
A lesser extent of gastric reduction makes the by-pass component more prevalent in determining the effect. Weight reduction is thus obtained through a stronger reduction of nutrient absorption, so that a significative quota of ingested food is directly eliminated. This kind of procedure is often associated with both better results in terms of weight loss and stronger, less tolerable side effects. The risk of nutrient deficiency syndrome is much higher and (PariniNebiolo, n.d.).
OBESITY AND PSYCHOPATHOLOGY
Whether there’s a clear link between obesity and psychiatric disorders is still widely debated. Everyday clinical practice puts health care professionals in a position where they have to evaluate obesity as a consequence or a risk, causal or modulatory factor for a host of conditions. In a society that, as we documented, is more and more vulnerable to metabolic abnormalities, the psychiatric population appears empirically more subject to them: aside from diagnostic interviewing and exclusion of eating disorder comorbidty, any psychoeducational approach delivered alongside prescriptions commonly involves some degree of nutrition-related information or, at the very least, eating-behavioural assessment. Literature data do confirm a higher likelihood for psychiatric patients to be overweight and suffer from obesity-related comorbidities; this is commonly
considered to happen as a hyatrogenic effect, but even drug-naive psychiatric patients show a three-fold increase in central obesity (Ruelaz, 2009).
Furtehrmore, any evaluation of psychiatric coomorbidity in the severely obese subject should be carried considering the effects of metabolic disturbances and clear-cut comorbid condition on SNC functioning. Aside from the easily discernible consequences of a cerebrovascular event or protracted, serious metabolic alterations (unbalanced diabetes, thyreopathy, and so on), obese patient can show soft to moderate neuropsychological impairment. The evidence of these results, also when evaluation data are corrected for conditions acting as confounding factors, has led some authors to hypothesise a “Dysexecutive Syndrome” linked to obesity (Boeka & Lokken, 2008; Gunstad, Paul, Cohen, & Tate, 2007). Raji and colleagues [8] examined gray matter and white matter volume differences in elderly subjects using tensor based morphometry (TBM). They found that BMI, fasting plasma insulin, and type 2 diabetes were strongly linked with atrophy in the frontal, temporal, and subcortical brain regions, with patients with a BMI >30 showing more atrophy in the frontal lobes, anterior cingulate, hippocampus, and thalamus compared to people with normal BMI. The authors concluded that higher BMI was associated with lower brain volumes(Votruba, Marshall, Finks, & Giordani, 2014).
These conclusions are relevant for managing the obese patient in light of the increased risk for developing Cognitive Impairment Syndromes (notably Alzheimer’s Disease), but any neuropsychological deficit could be underpinned by abnormal SNC conditions that can shape and cloud the expression of psychopathological syndromes.
Petry & colleagues analysed data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), revealing a higher 12-month prevelnce of DSM-IV mood and anxiety disorders in the obese group vs normal weight subjects(Petry, Barry, Pietrzak, & Wagner, 2008).
Petry’s results match those from another work by Scott, whose cross-sectional analysis targeted the possible association between psychiatric disorders and obesity in a general population sample, studying the first via the Composited International Diagnostic Interview (CIDI 3.0) and evaluating various moderators. This research showed a significant association between Obesity and Major Depressive Disorder (OR=1,27), Bipolar Disorder (OR=1,47), Anxiety Disorders such as PTSD (OR=2,64), Panic Disorder and Agoraphobia (OR=1,27), with demographic variables acting as modulators for the association between obesity and mood disorders only (Scott et al., 2007). A further study has described teenage obesity as a risk factor for developing depression in adult life, as well as showing an increased chance for males with central obesity to expres depressive symptoms, confronted with non-obese females(Herva et al., 2006).
On the other hand, the association between obesity and clear-cut DSM-IV psychiatric diagnosis has found no confirmation in some works: a 2006 german survey couldn’t find a significative association in 4181 adults; furthermore, although the obesity condition was found to be associated with comorbid somatic conditions and indicators of lower socio-economic status, subjects in the obese group bore more favorable scores in family and social functioning/support indexes; the authors point out the need for a specific psychiatric evaluation with more thorough exploration of dimensional psychopathology(Hach et al., 2007).
Research focused on the more severely obese subjects (III grade or worse obesity) show a higher prevalence of psychiatric disorders, although there are wide differences in observed prevalence rates(Rosenberger et al., 2006). Review articles show the prevalence of lifetime psychiatric diagnosis to range from 20% to 70% across bariatric populations (Sarwer et al., 2004), (Malik, Mitchell, Engel, Crosby, & Wonderlich, 2014). One research group observed a group of obese candidates to surgery finding a 64,4% prevalence of psychiatric diagnosis, with at least half of these
bearing one comorbid disorder, with Major Depression and Binge Eating Disorder being the single two more prevalent conditions (respectivey 28% and 24%)(Sarwer et al., 2004).
Another study by Kalarchian showed a similar DSM-IV Axis I lifetime prevalence rate of 66% and a current prevalence of 38% (Kalarchian et al., 2007).
These data show the more common comorbid psychiatric disorders to be, in order of prevalence. mood disorders, anxiety disorders, Eating disorders and substance use disorders ((Jones-Corneille et al., 2012; Rosenberger et al., 2006; Sarwer et al., 2004).
Eating Disorder comorbidity
Everyday clinical practice shows a strong prevalence of eating disorder types as atypcal, partial and subthreshold syndromes. Although outside the threshold of DSM diagnostic criteria, these entities represent abnormal eating behaviours believed to impact on everyday functioning, thus playing a role as modulators of bariatric surgery response (Saunders 2004).
In non-clinical populations, research data suggest that ED partial syndromes have a higher prevalence than “Fully expressed” Eating Disorders (Shisslak, Crago, & Estes, 1995), with a full beahvioural picture that can be distinguished only by the dimensional “magnitude” of symptoms (Striegel-Moore et al., 2000).
Subthreshold binge episodes are frequently referred by patients in ambulatory clinical settings: these “subjective” binge episodes feature the repeated ingestion of small quantities of food for a prolonged time, sometimes coupled with feelings of loss of control. This eating pattern is commonly referred to as “Grazing” and also as “grignottage” (“munching”, although this term is probably besti suited to identify the simple behaviour). The grazing construct has been described as a sub-threshold eating disorder and detected in studies on patients treated with RYGB both before
(Burgmer et al., 2005), (Saunders, 1999) and after (de novo) surgery (Saunders, 2003),(Hsu, Betancourt, & Sullivan, 1996).
While a part of the literature show that eating habits can improve, mostly in the short-term post-surgical period, some authors have proven the tendency of eating disorders to persist, or relapse, after bariatric intervention; the same studies found an association between post-surgical ED symptoms and a worse outcome both in terms of a lesser and brief early weight loss and higher rates of subsequent weight gain ((Hsu, Sullivan, & Benotti, 1997), (Kalarchian et al., 2002)).
Saunders & colleagues found DSM-IV BED prevalence rates of 30% among RYGB candidates, not considering binge-type partial syndromes (EDNOS); the authors point out the need to explore and widen the range of assessed eating disorder syndromes in order to develop much needed interventions, both in preparation and in follow-up to surgery.(Saunders, 2001). Ten years later, Wadden, Falcounbridge and Sarwer reported estimates ranging from 5% to 50%, pointing out a tendency of self-report instruments to overstimate BED criteria, while clinical interviews led to prevalence estimates from 5% to 25% (Wadden et al., 2011)
MATERIALS AND METHODS
Study Protocol Summary
Study subjects have been recruited among patients hospitalised in UO Medicina Generale 3, consecutively sent to OU Psichiatria 2 for Psychiatric Evaluation
