Behavioral Assessment of Candidates for

Bariatric Surgery: A Patient-Oriented

Approach
Thomas A. Wadden* and David B. Sarwer*†

Abstract it believed contraindicated surgery. Instead, it discussed

WADDEN, THOMAS A. AND DAVID B. SARWER. broader issues that included the goal of selecting “well-
Behavioral assessment of candidates for bariatric surgery: informed and motivated patients” who should have an op-
a patient-oriented approach. Obesity. 2006;14(Suppl 2): portunity to discuss weight loss approaches other than sur-
53S– 62S. gery and the advantages and disadvantages of each. The
This paper discusses the behavioral evaluation of patients panel also noted the need to consider changes in mood and
who seek bariatric surgery and the psychosocial complica- quality of life that may occur with surgery and weight loss.
tions most frequently observed in these individuals. The It concluded that, “There must be full discussion with the
effects of such complications on surgical outcome are patient of the probable outcome of the surgery, of the
briefly examined, as is the challenge of predicting therapeu- probable extent to which it will eliminate the patient’s
tic response on the basis of preoperative variables. The problems, of the compliance that will be needed in the
paper concludes with a description of the goals and methods postoperative regimen, and of the possible complications
of a behavioral assessment used at the University of Penn- from surgery, both short- and long-term” (2).
sylvania. This evaluation includes the use of the Weight and Mental health professionals vary in the methods and
Lifestyle Inventory, a questionnaire that guides our inter- criteria they use to evaluate candidates for bariatric surgery
view with patients. (1,3). Most conduct an interview to identify psychosocial
factors believed to contraindicate or compromise surgery.
Key words: bariatric surgery, psychosocial status, as- Many administer symptom inventories to screen for depres-
sessment, Weight and Lifestyle Inventory, mood sion, and some include formal testing of psychopathology,
personality, or cognitive function (1,3). The lack of a uni-
form approach is not surprising given the lack of well-
Introduction defined contraindications to surgery (1). In addition, there
Patients who seek bariatric surgery typically are required has been limited study of presurgical, behavioral factors that
to complete a behavioral (i.e., psychiatric) examination with predict an unfavorable outcome, as judged by suboptimal
a mental health provider to determine their appropriateness weight loss or complications that include excessive vomit-
for surgery (1). This practice resulted from recommenda- ing, bingeing, or dumping (4,5). The lack of data has led
tions of a consensus development conference in 1991 spon- some surgeons to conclude (we believe prematurely) that
sored by the NIH (2). The consensus panel concluded that candidates need not routinely undergo a preoperative be-
patients “. . . should be selected carefully after evaluation by havioral evaluation (6).
a multidisciplinary team with medical, surgical, psychiatric,
and nutritional expertise.” The panel, however, did not
identify any specific behaviors or psychiatric disorders that Psychosocial Status of Patients with
Extreme Obesity
Perhaps the principal reason mental health professionals
Departments of *Psychiatry, Weight and Eating Disorders Program and †Surgery, Univer- have been included in the preoperative assessment of sur-
sity of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
Address correspondence to Thomas A. Wadden, Weight and Eating Disorders Program, gery candidates is the high prevalence of psychiatric and
University of Pennsylvania School of Medicine, 3535 Market Street, Suite 3029, Philadel- behavioral complications observed in this population. The
phia, PA 19104.
E-mail: [email protected]
literature on this topic has been reviewed recently by several
Copyright © 2006 NAASO authors (to whom the reader is referred) and is only high-

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Behavioral Evaluation of Bariatric Surgery Candidates, Wadden and Sarwer

lighted here (4,5,7). The reviews found that depression is viduals has been described as the “last socially acceptable
common among persons with extreme obesity. A recent form of prejudice” (25). Overweight individuals are rou-
population study, for example, found that persons with a tinely labeled, even by health care professionals, as “lazy,
BMI ⬎ 40 kg/m2 were 5 times more likely to have experi- ugly, awkward, and sloppy” (26). Such ridicule likely en-
enced an episode of major depression in the past year than genders negative body image and feelings of inferiority in
were individuals of average weight (8). Among persons many obese individuals (4,7). Studies also have documented
seeking bariatric surgery, ⬃50% reported a lifetime history that obesity is associated with adverse economic and social
of depression or other affective disturbance (4,5,7). In five consequences, particularly in women (27,28). Extreme obe-
separate studies, 23% to 47% of patients reported using sity, for some, carries a substantial emotional toll that ex-
psychotropic medication at the time of their presurgical ceeds the burden imposed by its physical complications.
behavioral assessment (9 –13).
Predicting Surgical Outcome Based on
Eating Disorders Psychosocial and Behavioral Status
Factors responsible for the increased rate of depression in Practitioners have long desired to identify baseline pre-
persons with extreme obesity are not clear but may include dictors of weight loss and related outcomes (29). Such
the co-occurrence of eating disorders. Approximately 10% predictors would allow them to effectively target patients at
to 25% of candidates for bariatric surgery appear to suffer risk of a poor response. These individuals could be provided
from binge eating disorder (BED),1 which is characterized alternative therapies or assistance, before treatment, in ad-
by the consumption of an objectively large amount of food dressing problems (e.g., depression, low self-efficacy)
in a brief period (⬍2 hours), during which the individual thought to result in a suboptimal outcome. As applied to
experiences subjective loss of control (14 –17). Binge epi- bariatric surgery, this strategy would include: defining a
sodes are followed by remorse and distress. They are not priori what constituted a poor treatment response; identify-
followed, however, by purging (e.g., vomiting), which dis- ing variables that reliably predicted suboptimal outcome;
tinguishes BED from bulimia nervosa (14). A minority of and demonstrating that preoperative intervention, to ame-
bariatric surgery candidates also suffer from the night eating liorate behavioral or psychosocial complications, improved
syndrome, in which ⬎35% of daily food intake is consumed postoperative outcome. In cases in which alternative thera-
after dinner, and sleep is disrupted by episodes of nocturnal pies were recommended, their benefit, relative to bariatric
eating (18). Estimates of the prevalence of this syndrome in surgery, would need to be evaluated.
surgery candidates vary markedly, depending on the criteria
used, as discussed by Allison et al. (19) in this supplement. Predictors of Outcome
To date, there has been limited success in identifying
Health-Related Quality of Life consistent behavioral predictors of outcome after bariatric
The risk of depression also is probably increased in surgery (4,30). The majority of studies found that baseline
persons with extreme obesity because of impaired health- psychiatric status, particularly depression, did not predict
related quality of life. This term refers to the burden of postoperative weight loss (13,30 –33). One study, in fact,
suffering and the limitations in vocational and social func- found that greater baseline symptoms of depression were
tioning associated with illness (20). Numerous population associated with greater (not smaller) weight loss (33).
and clinical studies have shown that, as compared with Some studies have suggested that BED is associated with
average weight individuals, persons with extreme obesity smaller weight loss after bariatric surgery (34 –37). Dymek
report significantly greater bodily pain and impairments in et al. (34), for example, found that patients with BED who
physical functioning, work, and social interactions (21–23). underwent gastric bypass (GBP) lost significantly less
These are likely to be long-standing impairments, given the weight at 6 months than individuals who were free of this
chronicity of obesity, and could increase vulnerability of disorder (38.5% reduction in excess weight vs. 53.9%).
patients to depression and other affective disturbance. Kalarchian et al. (36) examined patients 2 to 7 years after
GBP and found that reports of current binge eating were
associated with weight gain (from the point of maximum
Prejudice and Discrimination
weight loss). BED status, however, was not determined
Even quality of life scales, however, cannot adequately
before surgery in this study, which also was a limitation of
capture the adverse emotional consequences of the preju-
two other studies (35,37). In contrast to these reports, Pow-
dice and discrimination to which extremely obese individ-
ers et al. (38) found no relationship between preoperative
uals are daily subjected (24). Disparagement of obese indi-
binge eating status and weight loss as assessed in clinic 2
years postoperatively and by self-report at an average of 5.5
1
Nonstandard abbreviations: BED, binge eating disorder; GBP, gastric bypass; WALI,
years. Malone and Alger-Mayer (39) obtained a similar
Weight and Lifestyle Inventory. negative finding.

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Behavioral Evaluation of Bariatric Surgery Candidates, Wadden and Sarwer

Clinical Significance of Predictors history, and identify areas of potential concern. The Beck
Thus, at present, there are not adequate data to determine Depression Inventory has excellent reliability and validity.
whether the presence of BED, before surgery, is associated The WALI has generally acceptable reliability, as described
with smaller weight loss or other undesirable outcomes. in several papers in this supplement. The instrument’s pre-
Even if BED were consistently associated with diminished dictive validity, however, has not been demonstrated, and
weight loss, it is not clear how this finding would alter the WALI is best viewed, at present, as a method of eliciting
treatment recommendations. For example, patients with and organizing clinical information. The goals and methods
binge eating in the study by Dymek et al. (34) still lost of the WALI have been described in detail by Wadden and
nearly 40% of their excess weight, which is substantially Phelan (45).
more than they would lose with behavioral or pharmaco-
logical treatments for obesity (40). Although it is possible
that cognitive behavioral treatment for binge eating (41), A Patient-Oriented Behavioral Evaluation
We generally begin the behavioral assessment by thank-
provided before surgery, might improve weight loss in
ing patients for completing the questionnaires and explain-
patients with BED, there have been no studies of this issue.
ing that we want to review their responses with them to
Prediction of outcome and, thus, screening are likely to
learn more about their weight and dieting histories, eating
improve as investigators study larger numbers of patients,
and activity habits, and related information to understand
whose behavior is well-characterized before surgery, and
what has led them to seek bariatric surgery. We often
who are carefully followed for 2 or more years postopera-
indicate that “we are not going to try to psychoanalyze you”
tively. The Bariatric Surgery Consortium, which will assess
but instead “want to help you decide if surgery is the right
patients at six sites, using a common protocol, should
choice for you.” The interview usually addresses the fol-
greatly facilitate this effort.
lowing five areas, although not necessarily in the following
Research also is needed to identify postoperative behav-
order.
iors that are associated with suboptimal outcome. Binge
eating, for example, observed after GBP, is likely to be
Knowledge of Bariatric Surgery
associated with poor adherence to dietary recommendations
Throughout the interview, we seek to determine how well
(17,36). Even if binge eating does not limit weight loss,
informed candidates are of the nature of the operation they
patients with this complication would seem to be at in-
plan to have, of its potential risks and benefits, and of the
creased risk of plugging, vomiting, and dumping, all of
changes they must make in their eating and lifestyle habits,
which can adversely affect physical and emotional health
both short- and long-term. A majority of candidates seem
(4,17,36,42). These individuals should receive dietary or
well informed, having researched the operation by talking
behavioral counseling to address these complications, al-
with their surgeon, attending support groups offered by our
though there have been no systematic studies of the benefits
program, or, increasingly, by using the Internet. They also
of such intervention.
are aware of the likelihood of experiencing vomiting, dump-
ing, and related complications as they adjust to the operation
and their new eating plan.
Behavioral Evaluation Conducted at the A small minority of candidates seem to have only mar-
University of Pennsylvania ginal knowledge of the operation they seek and its require-
All candidates for bariatric surgery at the Hospital of the ments. They decide on surgery after having heard about it in
University of Pennsylvania complete a behavioral evalua- a media report and speak in the vaguest of terms about risks,
tion with a mental health professional, all of whom also expected outcomes, and postsurgical dietary requirements.
have expertise in obesity (which we believe is critical to We use the interview to educate such individuals but typi-
conducting a thorough evaluation). The assessment is de- cally recommend that they meet again with their surgeon or
signed to meet the broad objectives proposed by the 1991 the program’s dietitian and attend several meetings of the
NIH consensus panel (2), while also identifying psychopa- program’s support group. They also may be provided with
thology that, if uncontrolled, could contraindicate or com- web sites and recommended readings. These practices are
promise surgery. The evaluation is conducted as a semi- intended to ensure that candidates are fully informed about
structured interview that is organized, in part, around the surgery, its risks, and its behavioral consequences. We
patients’ responses to the Weight and Lifestyle Inventory rarely encounter persons who are not mentally competent to
(WALI) (43). The WALI assesses patients’ weight and make a decision concerning surgery (10), although this is an
dieting histories, eating and activity habits, social and psy- obvious consideration.
chological status, and current life stressors. Surgery candi-
dates complete both the WALI and the Beck Depression Weight and Dieting Histories
Inventory (44) before the interview. Clinicians can review We devote a substantial portion of the interview to re-
both questionnaires before the interview, grasp the patients’ viewing patients’ weight and dieting histories, as assessed

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Behavioral Evaluation of Bariatric Surgery Candidates, Wadden and Sarwer

by the WALI. This includes assessing the age of onset of need for insurers to pay for non-surgical therapies, particu-
obesity and the history of the condition in parents and other larly in these special circumstances (52).
family members. As discussed by Crerand et al. (46) in this Expectations of Surgery. We conclude this portion of the
supplement, persons with extreme obesity (BMI ⬎ 40 kg/ interview by discussing candidates expected weight losses
m2) typically have an earlier age of onset of obesity and after surgery. We inform them that most persons lose ⬃30%
stronger family history of the disorder than do persons with of their initial weight after GBP and compare this amount
class I-II obesity. Such characteristics may well be associ- with their expectations (53). The effects of unrealistic ex-
ated with a greater genetic (or biological) predisposition to pectations on weight loss and other outcomes after surgery
the disorder (45). Whitaker et al., for example, found that are not known. Instead of focusing on weight loss per se, we
the strongest predictor of obesity as an adult was child or ask candidates to describe improvements in health or activ-
adolescent onset of this disorder, in combination with a ities of daily living that they seek, such as being able to play
parental history; 70% to 75% of children with these two risk with their children or to sit comfortably on an airplane.
factors were obese as adults (47). These events are far better measures of success than is
With such individuals, we indicate that they may well weight loss alone.
have a genetic predisposition to obesity that has made it
difficult to control their weight, despite lifelong efforts to do Eating and Activity Habits
so. We often describe a study by Bouchard et al. (48) that The WALI seeks to obtain an overview of the candidate’s
found that some persons gained more weight than others, dietary intake, focusing on the number of meals and snacks
when overfed by the same number of calories; genetics consumed daily and whether the individual has a structured
contributed to the differences observed. This finding reso- eating plan. It also inquires about foods typically eaten and
nates with the experience of many patients, who are per- favorite foods. The goal is to identify changes in food intake
plexed by their body weight when they compare their eating that will be required after surgery, particularly a reduction in
and activity habits with their less obese peers. The message sweets (associated with the dumping syndrome). The need
for such patients is that they should not needlessly blame to consume multiple small meals throughout the day is also
themselves for their obesity. discussed and how such an eating pattern will fit the can-
Repeat Dieters. Most expert panels have recommended didate’s work and social schedule. These issues are dis-
bariatric surgery as the final treatment option after diet, cussed in greater detail with the program’s dietitian who
exercise, lifestyle modification, and pharmacotherapy have provides an overview of the postoperative diet, as pre-
been exhausted (2,49,50). We agree with this recommenda- scribed short and long term. Clinicians who wish to assess
tion and have found that the great majority of our surgery dietary intake more thoroughly can use the Block Food
candidates have made multiple, significant efforts to lose Frequency Questionnaire (54) or a 24-hour food recall.
weight, as reported by Gibbons et al. (51) in this supple- Alcohol Intake. Alcohol consumption is routinely as-
ment. Patients often are ashamed of their failed attempts at sessed as part of dietary intake. We rarely encounter patients
weight control. We express our admiration for their deter- with current alcohol dependence or abuse, although some
mination and resolve to control their weight, which have studies have suggested that a significant minority of surgery
frequently gone unrecognized by health care professionals. candidates have a history of substance abuse (4,7). Active
Novice Dieters. As bariatric surgery has increased in substance abuse or dependence is considered a contraindi-
popularity in the last few years, our clinicians have encoun- cation to surgery (55).
tered a growing number of patients (⬃10%) who have not Eating Disorders. The WALI also includes the Question-
participated in any organized weight loss programs before naire on Eating and Weight Patterns (56), used to diagnose
seeking surgery (51). They, for example, have not enrolled BED and bulimia nervosa, and the Night Eating Question-
in Weight Watchers or a lifestyle modification class at the naire (57), which assesses this latter syndrome. As noted
YMCA or been prescribed a weight loss medication. With previously, we do not routinely defer patients from surgery
many of these patients, we recommend that they attend the on the basis of BED or the night eating syndrome, given the
program’s support group and follow a modified version of absence of data to warrant this practice. We do, however,
the postoperative diet for several months to best prepare determine how concerned they are about the potential effect
them for the dietary changes required after surgery. of their eating disorder on their adherence to the postoper-
In other cases, particularly with individuals with a rela- ative diet. Persons with significant concern are provided a
tively low BMI (⬍45 kg/m2) and no major health compli- referral for cognitive behavioral therapy, which they may
cations, we recommend that they try Weight Watchers or pursue either before or concurrent with surgery. Current
another conservative approach. Some patients have agreed evidence suggests that binge eating, in those affected, is
to, but others have responded, somewhat paradoxically, that most likely to reoccur 18 to 24 months after surgery (4,36).
they cannot afford these treatments. By contrast, their in- In contrast to BED and NES, we believe that bulimia
surance will cover the surgery. Such cases underscore the nervosa is a contraindication to bariatric surgery. Patients

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Behavioral Evaluation of Bariatric Surgery Candidates, Wadden and Sarwer

with this disorder would seem at high risk of excessive naires, including the Medical Outcomes Scale-Short Form
vomiting after surgery with its attendant effects on oral (60) or the Impact of Weight on Quality of Life scale (61).
health, electrolyte balance, and cardiac function (58). We With persons who seem to have significant symptoms of
have encountered only a handful of patients with bulimia depression, even after accounting for conditions associated
nervosa in the ⬎2000 candidates evaluated. We refer these with their weight, we suggest that medication, psychother-
individuals to an eating disorders specialist and their family apy, or their combination could help them (e.g., decrease
physician to resolve the condition before surgery. feelings of hopelessness, worthlessness, or marked fatigue).
Physical Activity. Physical activity is briefly assessed to Patients are encouraged to speak with their primary care
determine the patient’s pattern of lifestyle and programmed physician or are provided with a mental health referral. The
activity and any physical conditions that limit mobility. Not goal of such referral is to alleviate patients’ current emo-
surprisingly, most bariatric surgery candidates report low tional suffering.
levels of activity that they are eager to increase with weight Most candidates are receptive to recommendations that
loss. they seek assistance for their mood (or other complications)
and are scheduled for a follow-up visit in our clinic 8 to 12
Social/Psychological Status weeks later to assess their progress. A small number of
We assess psychological status in several ways, including individuals disagree with our recommendations. Ultimately,
by attending to patients’ appearance, speech, thought, we respect their right to refuse our advice, except in cases of
mood, and appropriateness of affect in describing them- suicidal ideation, active psychosis, or other contraindica-
selves and in responding to questions. This global assess- tions previously described. In the absence of data to show a
ment is complemented by reviewing the patient’s history of clear relation between psychiatric status and unfavorable
psychiatric illness and any treatment received, including outcome of bariatric surgery, stipulating that patients cannot
pharmacotherapy. We also examine responses to the Beck have surgery until they have received psychiatric care pre-
Depression Inventory (44), a 21-item self-report question- sents significant ethical concerns. Such practice potentially
naire, with scores of 0 to 63, that yields ratings of minimal could prevent some patients from obtaining the surgery,
(0 to 13), mild (14 to 19), moderate (20 to 28), and severe needed to improve their weight and associated health com-
(⬎29) symptoms of depression. As reported by Wadden et plications. We inform the surgeon of our concerns but leave
al. (59), in this supplement, ⬃70% to 75% of surgery the final decision to the surgeon and patient.
candidates report minimal to mild symptoms of depression Family Members. The decision to seek bariatric surgery is
that generally are not of clinical concern, unless patients a significant one, not only for the patient, but for his or her
have suicidal ideation. These latter individuals, and those family members. This section of the interview, thus, in-
who score in the moderate to severe range of depression, quires about patients’ living arrangements, their satisfaction
require further examination, not only of potential suicidal with their spouse (partner) and other intimate relationships,
ideation, but also of their sleep, concentration, cognition and whether family members and friends support the deci-
(including self-critical thoughts), and vocational and social sion to undertake surgery. In cases in which family mem-
function. With individuals who have a history of depression, bers are opposed, we attempt to clarify their perceived
or other conditions, we ask how they are functioning now, concerns (e.g., risk of health complications) and offer to
as compared with their best and worst times. We also speak with relatives to provide an objective view of the
inquire who is treating them and typically ask permission to surgery and its risks and benefits. We also address patients’
contact practitioners to obtain their assessment of the pa- occasional concerns that family members may try to sabo-
tient’s psychiatric status (and whether they support the tage their weight loss efforts. Candidates who report they
individual’s decision to have surgery). Such consultation is are dissatisfied with their marriages (or other intimate rela-
invaluable, given that these practitioners have far better tionships) are informed that surgery and weight loss are
appreciation for patients’ functioning than we can achieve unlikely to resolve these problems (62). We also ensure that
in a one-time interview. patients have identified relatives or friends who will assist
Untreated Conditions. A small minority of surgery can- in their care in the initial days and weeks after the operation.
didates score in the moderate to severe range of depression
but report no history of depression or other emotional com- Planning for Surgery and Postoperative Care
plications. They often deny that they feel depressed or A separate section of the WALI inquires about stressors
believe that their dysphoria and related symptoms are at- or major life events expected in the next several months.
tributable to their obesity. With such individuals, we devote The purpose of this assessment is to ensure that the candi-
greater attention to assessing how obesity affects their qual- date has chosen a propitious time to undergo surgery, rela-
ity of life, in the areas of physical health, mobility, sleep, tively free of stressors such as starting a new job, changing
work, social interactions, body image, and self-esteem. homes, or getting a divorce. Ideally, the patient should have
Practitioners may wish to administer additional question- 3 to 4 weeks of protected time to undergo the operation,

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Behavioral Evaluation of Bariatric Surgery Candidates, Wadden and Sarwer

recover from it physically, and begin to adopt new lifestyle We inform patients that we will send their surgeon a letter
habits, the most important of which is adhering to the “that describes what we discussed today.” (Appendix A and
postoperative diet. As noted previously, we always ask B provide examples of two typical letters written to sur-
candidates to identify family members or friends who will geons.) We wish patients success with the surgery, whether
assist them with postoperative needs that may include trans- they pursue it immediately or in a few months, and encour-
portation, caring for children, or assisting with meal prep- age them to contact us for any needed assistance.
aration and other activities of daily living. We also inquire
whether patients have any questions about what to tell their
employer, coworkers, or friends about the operation and its
Conclusion
effects on their functioning and availability. In cases in We trust that future research will reveal reliable behav-
which candidates report extremely stressful life events, we ioral predictors of improvements in weight and health after
discuss whether they might delay surgery until the stressors bariatric surgery. Such findings could guide surgeons in
have resolved (if they seem short term). At a minimum, we selecting the most appropriate operation for a candidate or
discuss how they can cope optimally with the challenges allow dietitians and mental health professionals to provide
they face. pre- or postoperative counseling to improve long-term out-
Postoperative Care. This part of the interview concludes come. Until such data are obtained, however, we believe
by reviewing the patients’ plans for postoperative care. We that a patient-oriented behavioral evaluation, as described
reiterate the importance of regular postoperative visits with here, provides candidates an invaluable opportunity to dis-
the surgeon, dietitian, and other medical staff and strongly cuss their often life-long struggle with their weight and the
encourage all candidates to attend our program’s monthly distress it has caused them. We want to ensure that these
patient support group meetings. We also ask them to iden- individuals, so many of who have been stigmatized because
tify their biggest concerns about adhering to the postoper- of their weight, receive any psychosocial care they need and
ative diet or adjusting to life after surgery (and weight loss). the opportunity to make a fully informed decision concern-
We examine the concerns and identify potential resources ing the surgery they seek.
for handling them. We always encourage patients to contact
us with any difficulties, whether 3 days or 3 years after
surgery. Acknowledgments
This work was supported, in part, by Grants K23-
DK60023, K24-DK65018, and R01-DK069652 from the
Summarizing the Findings
National Institute of Diabetes, Digestive, and Kidney Dis-
We conclude the interview by providing patients a brief
ease.
summary of our findings concerning their weight and diet-
ing histories, eating and activity habits, social/psychological
status, and readiness for bariatric surgery. As described References
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Behavioral Evaluation of Bariatric Surgery Candidates, Wadden and Sarwer

47. Whitaker RC, Wright JA, Pepe MS, et al. Predicting obe- mass index (BMI) of 43 kg/m2. She is single and lives with
sity in young adulthood from childhood and parental obesity. her two daughters. She has been employed with the post
N Engl J Med. 1997;337:869 –73. office for the past 25 years.
48. Bouchard C, Tremblay A, Despres JP, et al. The response
to long-term overfeeding in identical twins. N Engl J Med.
Biological Factors
1990;322:1477– 82.
49. National Heart, Lung, and Blood Institute. Clinical guide-
Ms. Green reported that she has been overweight since
lines on the identification, evaluation, and treatment of over- early adulthood. She is currently below her highest adult
weight and obesity in adults: the evidence report. Obes Res. weight of 297 lbs. reached several months ago. She reported
1998;6(Suppl):51–210S. losing approximately 25 lbs. since that time secondary to
50. World Health Organization. Obesity: Preventing and Man- following a low-carbohydrate diet and by reducing her
aging the Global Epidemic (Publication No. WHO/NUT/ portion sizes.
NCD). Geneva, Switzerland: World Health Organization; Ms. Green reported her mother is and father was obese.
1998. Her two siblings are of average weight. Her medical history
51. Gibbons LM, Sarwer DB, Crerand CE, et al. Previous and current medications are known to you. Of note, she
weight loss experiences of bariatric surgery candidates: how reported a history of heart disease and hypertension.
much have patients dieted prior to surgery? Obesity. 2006; Ms. Green’s family history suggests a significant biolog-
14(Suppl 2):70S–5S. ical predisposition to obesity.
52. Tsai AG, Asch DA, Wadden TA. Insurance reimbursement
for obesity treatment. J Am Diet Assoc. 2005 (in press).
53. Brolin RE. Bariatric surgery and long-term control of morbid
Environmental Factors
obesity. JAMA. 2002;288:2793– 6. Ms. Green reported eating two to three meals and several
54. Block G, Hartman AM, Dresser CM, et al. A data-based snacks each day. She reported eating large portion sizes of
approach to diet questionnaire design and testing. Am J Epi- calorically dense foods at many of her meals. She often
demiol. 1986;124:453– 69. works during the evening and overnight hours, which alters
55. Sugerman HJ. Preface to obesity surgery. Surg Clin North her eating schedule and often increases her reliance on take-
Am. 2001;81:iv. out food and fast food. Currently, Ms. Green is on a low-
56. Yanovski SZ. The Questionnaire on Eating and Weight Pat- carbohydrate diet. She denied any behaviors consistent with
terns-Revised. Obes Res. 1993;1:306 –24. binge eating disorder. She denied any compensatory or
57. Allison KC, Stunkard AJ, Thier SL. Overcoming Night purging behaviors.
Eating Syndrome: A Step-By-Step Guide to Breaking the Cy- Ms. Green has made several previous weight loss at-
cle. Oakland, CA: New Harbinger; 2004. tempts, including self-directed diets, commercial programs,
58. Pomeroy C, Mitchell JE. Medical complications of anorexia
and FDA-approved weight-loss medications. These ap-
nervosa and bulimia nervosa. In: Eating Disorders and Obe-
proaches have been moderately successful, typically result-
sity: A Comprehensive Handbook. 2nd ed. New York: Guil-
ing in a 5–10% weight loss. Unfortunately, she has been
ford Press; 2002, pp. 278 – 85.
59. Wadden TA, Butryn ML, Sarwer DB, et al. Comparison of unable to maintain these losses over long periods of time.
psychosocial status in treatment-seeking women with class III She reported no experience with very-low-calorie diets,
vs. class I-II obesity. Obesity. 2006;14(Suppl 2):89S–97S. nutritional counseling, or hospital-based programs. She re-
60. Ware JE, Sherbourne CD. The MOS 36-item short-form ported a moderate level of physical activity at present,
health survey (SF-36): I. Conceptual framework and item walking several times each week.
selection. Med Care. 1992;30:473– 83. In summary, Ms. Green’s reported eating calorically
61. Kolotkin RL, Crosby RD. Psychometric evaluation of the dense foods and large portions sizes, both of which are
impact of weight on quality of life-lite questionnaire likely contributors to her obesity.
(IWQOL-lite) in a community sample. Qual Life Res. 2002;
11:157–71. Social/Psychological Factors
62. Rand CSW, Juldau JM, Robbins L. Surgery for obesity and
Ms. Green denied any psychiatric treatment history. Her
marriage quality. JAMA. 1982;247:1419 –22.
Beck Depression Inventory-II score was 7, suggestive of an
average number of depressive symptoms. She described her
mood as “good” and her affect was appropriate. She denied
Appendix A any symptoms of depression upon questioning. She re-
August 3, 2005 vealed that her father was an alcoholic but denied any
Dear Dr. Smith: alcohol problems herself. She also revealed a history of
We met today with Ms. Betty Green whom you referred physical abuse from past boyfriends. Upon questioning, she
for a behavioral assessment of her appropriateness for bari- denied involvement in a physically abusive relationship at
atric surgery. Ms. Green is a 47 year-old, African-American present. She reported no suicidal ideation. No evidence of a
female. She is 5⬘7⬙ with a weight of 272.4 lbs. and body thought disorder was found.

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Behavioral Evaluation of Bariatric Surgery Candidates, Wadden and Sarwer

Timing binge eating disorder. She denied any compensatory or

Ms. Green reported no significant life stressors at this purging behaviors following these episodes.
time. This appears to be an excellent time to have surgery. Ms. Smith has made several previous weight loss at-
tempts, including self-directed diets, commercial programs,
Summary and over-the-counter as well as FDA-approved weight-loss
Ms. Green appears to be an appropriate candidate for medications, and behaviorally-based programs. These ap-
bariatric surgery. Her BMI is above 40, she has heart proaches have been moderately successful, typically result-
disease, hypertension, and she has tried several more con- ing in a 5–15% weight loss. Unfortunately, she has been
servative weight loss approaches without long-term success. unable to maintain these losses over long periods of time.
Weight loss following surgery will likely decrease her risk She reported no experience with very-low-calorie diets or
of weight related health problems in the future and improve nutritional counseling. She stated that she has not tried to
her quality of life. lose weight in the past several years and that she became
Please call me if you have any questions regarding this interested in bariatric surgery after seeing it on television.
patient. Ms. Smith reported that she is not physically active at this
time secondary to degenerative disc arthritis in her back.
In summary, Ms. Smith’s binge eating, regular consump-
Appendix B tion of calorically dense foods and beverages, and lack of
August 31, 2005 physical activity are likely contributors to her obesity.
Dear Dr. Jones:
I met today with Ms. Alice Smith whom you referred for Social/Psychological Factors
a behavioral assessment of her appropriateness for bariatric For the past 5 years, Ms. Smith has been taking Prozac
surgery. Ms. Smith is a 54 year-old, Caucasian female. She 40mg/d for depression, as prescribed by her primary care
is 5⬘1⬙ with a weight of 270 lbs. and body mass index (BMI) physician. She indicated that she has experienced a number
of 51 kg/m2. She is married and lives with her husband and of significant life stressors over the past few years, includ-
three of her four adult children. She has been employed as ing issues related to her oldest son’s and her husband’s use
a telephone operator for the past 24 years. of alcohol. Her Beck Depression Inventory-II score was 32,
suggestive of a major depressive episode. She described her
Biological Factors mood as “irritable” and her affect was flat. She became
Ms. Smith reported that she first recognized being over- tearful several times during the assessment. Upon further
weight during childhood. She is currently at her highest questioning, she reported difficulty sleeping, decreased ap-
adult weight of 270 lbs. reached this year. She reported a petite, and trouble concentrating. She also reported signifi-
weight increase of 40 lbs. in the past two years as a result of cant loss of interest in pleasurable activity. She reported no
eating “the wrong foods.” suicidal ideation. No evidence of a thought disorder was
Ms. Smith reported her mother and father were average found.
weight. Her two half-sibling are average weight. Her med-
ical history and current medications are known to you. Of Timing
note, she reported a history of hypertension and sleep apnea. Ms. Smith reported a number of life stressors at this time.
In summary, Ms. Smith’s early onset of overweight pro- They appear to be impairing her function, as noted above.
vides evidence for a moderate biological predisposition to
obesity. Summary
While Ms. Smith has a BMI above 40, hypertension and
Environmental Factors sleep apnea, I have concerns about her appropriateness for
Ms. Smith reported eating two meals and several snacks surgery at this time. First, her symptoms of depression do
each day. She reported that she typically skips breakfast and not appear to be well-controlled at this time. As a result,
eats a very large lunch. For example, she will often eat two they may interfere with her ability to make the necessary
large fast food hamburgers, a large order of French fries, a behavioral and dietary changes to ensure a successful post-
large regular soda, and serving of ice cream. She reported operative result. Second, her current diet is quite poor and
eating similarly large portion sizes for dinner. Approxi- Ms. Smith reported binge eating several times per week.
mately twice per week, she reported that she will “lose Third, as compared to our typical surgery candidate, she
control” during her evening snack and eat a large bag of reported little knowledge of the postoperative behavioral
potato chips while watching television. During these epi- and dietary changes.
sodes, she reported eating without hunger and past the I made several recommendations to Ms. Smith. First, I
feeling of fullness. She also reported feelings of dysphoria referred her to our outpatient psychiatry unit for additional
and guilt. Thus, she appears to meet diagnostic criteria for assessment and treatment of her depressive symptoms. Sec-

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Behavioral Evaluation of Bariatric Surgery Candidates, Wadden and Sarwer

ond, I encouraged her to attend the Bariatric Surgery Pro- cerns in the next 3 months, she will likely be a more
gram’s monthly support group for the next several months. appropriate candidate for surgery. We have scheduled a
This will provide her with additional information on the tentative follow-up visit at the end of November to reassess
postoperative behavioral and dietary requirements. I shared her status.
these concerns with Ms. Smith and she reported to be in Please call me if you have any questions regarding this
agreement with them. If she is able to address these con- patient.

62S OBESITY Vol. 14 Supplement March 2006