Behavioural Disorders in obese: Important to evaluate before WLS

Laparoscopic Bariatric surgery is one of the most effective treatments of morbid obesity, resulting in significant and sustained weight loss as well as improvement of various other related co-morbidities and quality of life.

Along with all other co morbid conditions like Type 2 Diabetes Mellitus, Hypertension, and PCOD etc., the prevalence of psychosocial disorders, including suicidal behavior, as well as substance abuse or eating disorders, is quite high among morbidly obese individuals.

That is why, while evaluating for bariatric surgery, a psychiatric evaluation of individuals undergoing bariatric surgery is a must nowadays, since one might miss a pre-existing mental illness leading to inadequate treatment before and after surgery.

Some these issues like lack of physical activity before and after surgery, lack of improvement in quality of life, persistence or recurrence of sexual dysfunction, and history of ill-treatment in childhood might contribute to suicidal ideas if not assessed preoperatively.

These patients might have very high expectations of body appearance post-operatively and might be disappointed by the physical outcomes of the surgery. Sometimes weight regain might also lead to suicidal behaviors.

It has been found that after bariatric surgery, the alcohol sensitivity of certain individuals might rise. Alterations in the GI tract after surgery lead to altered absorption of alcohol. It has been seen on several occasions that certain individuals continue alcohol consumption after surgery. Therefore all candidates of bariatric surgery are counseled and educated about the ill effects of alcohol after bariatric surgery and to minimize the use of it.

When undergoing the dietary pattern of morbidly obese patients, there is high prevalence of compulsive eating disorder. These problems can also persist after bariatric surgery. Few patients may develop ‘loss of control’ eating, and even self-induced vomiting. These conditions are associated with less weight loss and increased fear of weight regain.

According to Dr. Atul NC Peters, one of the pioneers of weight loss treatment in Delhi and among the top 10 obesity surgeons in India, it is important that such follow up programs are developed, which address these types of problems focusing on psycho-social factors as well as eating disorders for a successful outcome.

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Obesity in Children and Adolescents

The prevalence of obesity is increasing in both children and adolescents, in both sexes, and in various ethnic and racial groups.

Many factors, including genetics, environment, metabolism, lifestyle, and eating habits, are believed to play a role in the development of obesity. However, more than 90% of cases are idiopathic; less than 10% are associated with hormonal or genetic causes.

There is no single definition of obesity in childhood and adolescence.

Consensus committees all over the world have concluded that children and adolescents be considered overweight or obese if the BMI exceeds the 85th or 95th percentiles, on curves generated from the 1963-1965 and 1966-1970 NHANES, or exceeds 30 kg/m2 at any age.

During childhood and adolescence, excess fat accumulates when total energy intake exceeds total energy expenditure. Reduced energy expenditure is attributed to modern day sedentary life style. This is particularly associated with excessive television viewing, excessive computer use and insufficient physical activity. Also this is often seen when feedings are supplemented with additives such as carbohydrates or fat.

Some hormonal dysfunction like that in ghrelin leptin hormonal axis may be the causative factor in as many as 10% of obese children, particularly in those who appear to manifest familial morbid obesity.

Race and ethnicity are also associated with increased rates of obesity in children and adolescents.

Childhood obesity is predictive of adult obesity such as with 80% of teenagers who are obese continue to be obese as adults.

This is associated with an increased incidence of type2 diabetes, hypertension, gallstones, and hypercholesterolemia.

There are serious chest conditions associated with childhood obesity like reactive airways, poor exercise tolerance, increased work of breathing, and increased oxygen consumption.

They might develop obesity-hypoventilation syndrome experience right-sided heart failure with right ventricular hypertrophy.

Acute complications of childhood obesity include, hyperlipidemia, accelerated growth and bone maturation, ovarian hyperandrogenism and gynecomastia, cholecystitis, pancreatitis, and pseudotumor cerebri.

There is increased incidence of fatty liver and they might develop liver cirrhosis and kidney disease.

Obstructive Sleep apnea and sleep-disordered breathing are common in children and adolescents with obesity which might lead to  neurocognitive dysfunction.

Excess weight in children can cause numerous orthopedic disorders, including genu valgum, slipped capital femoral epiphysis, with bowing of the long bones.

Emotional and psychosocial sequelae are also widespread in obese children.

Social isolation, peer problems, and lower self-esteem are frequently observed.

Gout and colorectal cancer rates are found to be increased among men who had obesity as adolescents as well as arthritis.

Any therapeutic intervention in the child with obesity in aimed to achieve control of weight gain and reduction in body mass index (BMI) safely and effectively and to prevent the long-term complications of obesity in childhood and adulthood.

These might also require psychiatric assistance for unusual eating disorders or severe depression. It involves a team involving nurse educators, nutritionists, exercise physiologists, and counsellors.

Parents must advice children to walk at least 20 to 30 min daily. Limit their television timings and must indulge in vigorous exercise with children. Low calorie balanced diet, in association with patient and parent education, behavioral modification, and exercise can limit weight gain in many patients with mild or moderate obesity. Reductions in total and saturated fat may be particularly useful in adolescents who consume large quantities of high fat, snack, and packaged fast foods, including french fries, pizza, chips, and crackers. Also they might sometimes require and care if evidence of psychopathology or dysfunction is present.

According to Dr. Atul NC Peters, one of the pioneers of weight loss treatment in Delhi and among the top 10 obesity surgeons in India, various bariatric surgical procedures have been performed in “carefully selected” patients with a body mass index (BMI) >40 kg/m 2 who have severe comorbidities such as nonalcoholic fatty liver disease. It is important to consider several other factors before deciding whether a child or adolescent should undergo bariatric surgery like previous attempts at weight loss, and ability to adhere to follow-up care. Laparoscopic  sleeve gastrectomy is the most widely performed procedure in childhood obesity nowadays. Evidence suggests that bariatric surgery can decrease the grade of steatosis, hepatic inflammation, and fibrosis in Non Alcoholic Fatty Liver Disease. With more and more people opting for various bariatric surgical procedures, weight loss surgery cost in Delhi has been such that it is becoming affordable day by day and several finance and loan schemes are also available in special circumstances

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