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Substance Use Following Bariatric Weight Loss Surgery

Authors:
  • New York Obesity Nutrition Research Center

Abstract and Figures

Objective To assess substance use before and after bariatric weight loss surgery (WLS). There is a paucity of research investigating the occurrence of substance use following bariatric WLS. It was hypothesized that patients who underwent WLS would exhibit an increase in substance use (drug use, alcohol use, and cigarette smoking) following surgery to compensate for a marked decrease in food intake. Design Prospective study. Setting A major urban community hospital. Participants A total of 155 participants (132 women and 23 men) who underwent WLS were recruited from a preoperative information session at a bariatric surgery center. Intervention Participants received either laparoscopic Roux-en-Y gastric bypass surgery (n = 100) or laparoscopic adjustable gastric band surgery (n = 55). Participants completed questionnaires to assess eating behaviors and substance use at preoperative baseline and 1, 3, 6, 12, and 24 months after surgery. Main Outcome Measure Substance use as assessed by the Compulsive Behaviors Questionnaire. Results Participants reported significant increases in the frequency of substance use (a composite of drug use, alcohol use, and cigarette smoking, hereafter referred to as composite substance use) 24 months after surgery. Specifically, participants experienced a significant increase in the frequency of composite substance use from baseline to 24 months after surgery (P = .02), as well as significant increases from 1 month, 3 months, and 6 months to 24 months after surgery (all P ≤ .002). In addition, participants who underwent laparoscopic Roux-en-Y gastric bypass surgery reported a significant increase in the frequency of alcohol use from baseline to 24 months after surgery (P = .011). The response rate to the survey was 61% at 1-month follow-up, 41% at 3-month follow-up, 43% at 6-month follow-up, 49% at 12-month follow-up, and 24% at 24-month follow-up. Conclusions Patients may be at increased risk for substance use following bariatric WLS. In particular, patients who undergo laparoscopic Roux-en-Y gastric bypass surgery may be at increased risk for alcohol use following WLS. Our study is among the first to document significant increases in substance use following WLS using longitudinal data.
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ONLINE FIRST
ORIGINAL ARTICLE
Substance Use Following Bariatric
Weight Loss Surgery
Alexis Conason, PsyD; Julio Teixeira, MD; Chia-Hao Hsu, PhD; Lauren Puma, MS;
Danielle Knafo, PhD; Allan Geliebter, PhD
Objective:To assess substance use before and after bar-
iatric weight loss surgery (WLS). There is a paucity of
research investigating the occurrence of substance use
following bariatric WLS. It was hypothesized that pa-
tients who underwent WLS would exhibit an increase in
substance use (drug use, alcohol use, and cigarette smok-
ing) following surgery to compensate for a marked de-
crease in food intake.
Design:Prospective study.
Setting:A major urban community hospital.
Participants:A total of 155 participants (132 women
and 23 men) who underwent WLS were recruited from
a preoperative information session at a bariatric surgery
center.
Intervention:Participants received either laparo-
scopic Roux-en-Y gastric bypass surgery (n=100) or lapa-
roscopic adjustable gastric band surgery (n=55). Par-
ticipants completed questionnaires to assess eating
behaviors and substance use at preoperative baseline and
1, 3, 6, 12, and 24 months after surgery.
Main Outcome Measure:Substance use as assessed
by the Compulsive Behaviors Questionnaire.
Results:Participants reported significant increases in the
frequency of substance use (a composite of drug use, al-
cohol use, and cigarette smoking, hereafter referred to
as composite substance use) 24 months after surgery. Spe-
cifically, participants experienced a significant increase
in the frequency of composite substance use from base-
line to 24 months after surgery (P=.02), as well as sig-
nificant increases from 1 month, 3 months, and 6 months
to 24 months after surgery (all P.002). In addition, par-
ticipants who underwent laparoscopic Roux-en-Y gas-
tric bypass surgery reported a significant increase in the
frequency of alcohol use from baseline to 24 months af-
ter surgery (P=.011). The response rate to the survey was
61% at 1-month follow-up, 41% at 3-month follow-up,
43% at 6-month follow-up, 49% at 12-month follow-
up, and 24% at 24-month follow-up.
Conclusions:Patients may be at increased risk for sub-
stance use following bariatric WLS. In particular, pa-
tients who undergo laparoscopic Roux-en-Y gastric by-
pass surgery may be at increased risk for alcohol use
following WLS. Our study is among the first to docu-
ment significant increases in substance use following WLS
using longitudinal data.
JAMA Surg. 2013;148(2):145-150. Published online
October 15, 2012. doi:10.1001/2013.jamasurg.265
BARIATRIC WEIGHT LOSS SUR-
gery (WLS) leads to mark-
edly reduced food intake
and body weight over a rela-
tively short period of time.
Patients may lose upwards to 60% of their
excess body weight or about 30% of their
initial body weight within 1 year after gas-
tric bypass surgery.1-3 Although WLS is
often an effective treatment for clinically
severe obesity and comorbid medical con-
ditions, it requires major changes in life-
style for which many patients may be in-
adequately prepared.
There have been anecdotal accounts in
the popular media4-6 (but few research pub-
lications to date7-10) of symptom substitu-
tion in patients after they have under-
gone WLS. One of the few studies on this
topic found that post-WLS patients are
overrepresented in substance abuse treat-
ment centers.7A retrospective study by Ert-
let et al8concluded that a small percent-
age of patients (less than 3% of their
sample) spontaneously developed alco-
hol dependence approximately 7 years af-
ter surgery. Another retrospective study10
found that 28.4% of participants re-
ported having a problem with alcohol af-
ter WLS compared with 4.5% prior to
WLS. All these previous studies were lim-
ited by the absence of preoperative base-
line measurements and a lack of longitu-
dinal data.
Author Aff
Obesity Nu
Center (Drs
and Geliebt
Division of
Surgery (Dr
St Lukes–R
Center, Col
and Long Is
C.W. Post (
New York.
Author Affiliations: New York
Obesity Nutrition Research
Center (Drs Conason, Hsu,
and Geliebter and Ms Puma),
Division of Minimally Invasive
Surgery (Dr Teixeira),
St Lukes–Roosevelt Hospital
Center, Columbia University,
and Long Island University,
C.W. Post (Dr Knafo),
New York.
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145
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Recently, another study9was published that exam-
ined alcohol use from a longitudinal perspective. King
et al9used data from the multicenter Longitudinal As-
sessment of Bariatric Surgery–2 project to assess 1945 par-
ticipants before WLS, 1 year after WLS, and 2 years after
WLS. They found that the frequency of alcohol use sig-
nificantly increased for participants who underwent either
Roux-en-Y gastric bypass (RYGB) surgery or adjustable
gastric band (AGB) surgery; however, only participants
who underwent RYGB surgery experienced a significant
increase in alcohol use disorders 2 years after WLS com-
pared with before WLS and 1 year after WLS. In con-
trast, participants who underwent AGB surgery did not
experience a significant increase in alcohol use disor-
ders after WLS.
Symptom substitution theory posits that the success-
ful elimination of a particular symptom without treat-
ing the underlying cause will result in the appearance of
a substitute symptom.11 Symptom substitution theory
would predict an increase in substance use following WLS
because the surgery largely eliminates excessive eating12
without adequately addressing potential underlying psy-
chopathology. Studies have shown that drugs, alcohol,
and food trigger similar responses in the brain13-15 and
that bariatric surgery candidates whose condition has been
diagnosed as binge-eating disorder (BED) display addic-
tive personalities similar to individuals addicted to sub-
stances.16 Therefore, alcohol and drugs (including nico-
tine) are likely to substitute for overeating following WLS.
The present study was designed to test the hypothesis
that, following WLS, participants experience an in-
crease in substance use, specifically alcohol, cigarettes,
and recreational drugs, compared with baseline (ie, be-
fore WLS).
METHOD
PARTICIPANTS
Our study included 155 participants (132 women and 23 men)
(Table 1) who were recruited from a preoperative informa-
tion session at a bariatric surgery center at a major urban com-
munity hospital. Patients underwent either laparoscopic RYGB
(LRYGB) surgery (n=100) or laparoscopic AGB (LAGB) sur-
gery (n=55) (Table 1). All participants provided informed con-
sent, and our study was approved by the hospital’s institu-
tional review board.
MATERIALS
The materials included a demographic questionnaire, the Ques-
tionnaire on Eating and Weight Patterns–Revised (QEWP-R),
which included participants’ self-reported height and weight,
and the Compulsive Behaviors Questionnaire (CBQ) (eAppen-
dix, http://www.jamasurg.com).
The QEWP-R is a 28-item self-report measurement to as-
sess eating disorders, including BED.17 The QEWP-R has dem-
onstrated adequate test-retest reliability (= 0.42),18 signifi-
cant convergence (= 0.57) with the Structured Clinical
Interview for Diagnostic and Statistical Manual of Mental Dis-
orders (Third Edition Revised) for diagnosing BED,19 good sen-
sitivity (0.74), and good specificity (0.35)20 at distinguishing
BED from other disorders.
The CBQ was developed by the authors of the present study
to assess the following behaviors (eAppendix): alcohol use, rec-
reational drug use, cigarette smoking, shopping, gambling, sexual
activity, internet use, and exercise during the past month. The
present study focuses on the substance use items from the CBQ.
Ratings were on a 10-point Likert scale with scores ranging from
0 to 10 for each item: (1) How often do you engage in [the be-
havior] (frequency); (2) have other people complained about
[the behavior]? (complaining); and (3) do you feel that you
have a problem with [the behavior]? (self-diagnosed prob-
lem). Participants were also asked 2 yes/no questions: (1) Are
you currently in therapy? (2) Since your surgery, have you en-
gaged in any behaviors that you feel substitute for eating? If
participants responded “yes” to question 2, they were then asked,
“if so, what behaviors?” and provided space to answer in an
open-ended format. The 2 yes/no questions (including the open-
ended portion of the question asking about substitute behav-
iors) were not analyzed in the present study. The quantitative
responses for frequency, complaining, and self-diagnosed prob-
lem regarding substance use (alcohol use, recreational drug use,
and cigarette smoking) were analyzed separately and as a com-
bined mean. In addition, data were categorized into nonusers
(score of 0 on CBQ frequency item) and users (score of 0on
CBQ frequency item). The number of users at each time point
is expressed as a percentage of the total sample in Table 2.
DESIGN AND PROCEDURE
The present prospective study used a repeated-measures de-
sign to assess participants at baseline prior to undergoing WLS
and to follow them for 24 months after WLS. Patients were pre-
sented with the opportunity to participate in a research study
at a presurgery consultation meeting that occurred approxi-
Table 1. Characteristics of 155 Participants Who Underwent
Bariatric Weight Loss Surgery
Characteristic Participants, No. (%)
Age, y
Mean (SD) 40 (11)
Range 18-69
Baseline BMIa
Mean (SD) 46 (7)
Range 34-85
Sex
Male 23 (15)
Female 132 (85)
Ethnicity
Hispanic 73 (47)
Black (not Hispanic) 49 (32)
White (not Hispanic) 27 (17)
Asian 2 (1)
Other 4 (3)
Education
Less than high school 13 (8)
High School graduate or GED 21 (14)
Some college or associates degree 67 (43)
College graduate 54 (35)
Baseline BED statusb
BED 9 (6)
Subthreshold BED symptoms 59 (40)
Non-BED symptoms 79 (54)
Abbreviations: BED, binge-eating disorder; BMI, body mass index
(calculated as weight in kilograms divided by height in meters squared);
GED, General Education Development.
aFor 153 participants (99%).
bFor 147 participants (95%).
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mately 3 weeks prior to the patients’ surgery dates. Patients were
instructed that participation in this research study would not
affect the surgical process and that their responses to question-
naire items would be kept confidential from the surgery staff.
After agreeing to participate in the study and after signing the
informed consent form, participants were given the packet of
questionnaires that included the QEWP-R and the CBQ. In ad-
dition to this baseline assessment, participants were assessed
with the same measures 1, 3, 6, 12, and 24 months after un-
dergoing WLS. The postsurgery data collection was coordi-
nated with the participants’ scheduled surgery follow-up ap-
pointments. A research assistant was present at all assessments.
If a participant did not attend the follow-up appointment with
the surgeon, then the questionnaires were mailed with a self-
addressed stamped envelope to the participant to complete at
home and mail back to the researchers. All participants re-
ceived a $4.50 MetroCard (or equivalent cash value) as com-
pensation each time they filled out the packet of question-
naires. All questionnaires were scored by 2 independent scorers
and then entered into an SPSS (SPSS Inc) database. The data
entered were checked by 3 independent scorers to minimize
errors.
DATA ANALYSIS
Data were analyzed using SPSS version 18.0 with missing val-
ues. Descriptive analyses were performed, and frequencies were
added to provide demographic information at baseline (Table 1).
The missing values analysis function in SPSS was used to ana-
lyze the pattern of missing data. We used Little’s test for miss-
ing completely at random to analyze missing data because this
test has the ability to assess if missingness is dependent on any
variables in the data set and to examine all variables while con-
trolling for risk of type I error.21 The test for missing com-
pletely at random was not significant for any of the variables
in the data analysis, indicating that the data met the assump-
tions required to be missing completely at random. Mixed-
model repeated-measures analysis of variance was used to ana-
lyze the data set. The mixed-model repeated-measures analysis
can accommodate missing data.22,23 Based on the mixed-
models method, estimated means and variances are reported.
Data were clustered by participant, and time was used as the
within-subjects factor. Type of surgery and BED status before
WLS were used as between-subject factors, and body mass in-
dex (calculated as weight in kilograms divided by height in me-
ters squared) before WLS and changes in body mass index over
time were entered as covariates. When the overall Fvalue was
significant, Sidak post hoc analysis (which controls for type I
error in multiple comparisons) was used to conduct paired com-
parisons for differences between time points.
RESULTS
Participants reported a change in the frequency of sub-
stance use (a composite of drug use, alcohol use, and ciga-
rette smoking, hereafter referred to as composite sub-
stance use) over time points (Table 2; Figure 1)
(F5,350.6 = 8.3, P.001). The frequency of composite sub-
stance use decreased from baseline (M= 0.81) to 1-month
follow-up (M= 0.42; P= .001) but was no longer de-
creased at 3-month follow-up (M= 0.57; P= .39). Then,
the frequency of composite substance use increased sig-
Table 2. Data From Compulsive Behaviors Questionnaire (CBQ)a
Type of Substance Use
Estimated Mean (SEM) CBQ Score
FValueBaseline 1 mo 3 mo 6 mo 12 mo 24 mo
Composite substance use
Frequency 0.81 (0.08) 0.42 (0.10)b0.57 (0.11) 0.65 (0.65) 0.88 (0.88)c1.25 (1.25) b,c,d,e 8.3f
Participants, No. 155 94 64 67 76 38
Users, % 60.0 22.3 42.2 41.8 57.9 63.2
Other people complain 0.25 (0.06) 0.20 (0.07) 0.20 (0.08) 0.24 (0.08) 0.28 (0.08) 0.18 (0.11) 0.22
Self-diagnose 0.17 (0.06) 0.15 (0.07) 0.18 (0.08) 0.14 (0.08) 0.20 (0.08) 0.17 (0.11) 0.10
Alcohol use
Frequency 2.29 (0.41) 1.16 (0.42)b1.45 (0.44) b1.73 (0.44) 2.38 (0.43)c,d 3.10 (0.47)c,d,e 11.5 f
Participant, No. 155 95 64 67 76 38
Users, % 61.3 20.2 40.6 40.3 53.9 63.2
Other people complain 0.34 (0.08) 0.28 (0.11) 0.19 (0.13) 0.51 (0.12) 0.20 (0.12) 0.14 (0.16) 1.20
Self-diagnose 0.15 (0.05) 0.10 (0.06) 0.08 (0.07) 0.07 (0.07) 0.13 (0.07) 0.09 (0.09) 0.30
Drug use
Frequency 0.11 (0.06) 0.12 (0.08) 0.07 (0.09) 0.15 (0.09) 0.04 (0.09) 0.45 (0.12) 2.08
Participants, No. 155 94 64 67 76 38
Users, % 4.5 5.3 1.6 3.0 2.6 13.2
Other people complain 0.05 (0.03) 0.09 (0.04) 0.07 (0.05) 0.01 (0.05) 0.04 (0.05) 0.03 (0.06) 0.50
Self-diagnose 0.07 (0.03) 0.10 (0.04) 0.04 (0.05) 0.00 (0.05) 0.02 (0.05) 0.00 (0.07) 0.87
Cigarette use
Frequency 0.44 (0.12) 0.46 (0.14) 0.45 (0.15) 0.41 (0.15) 0.58 (0.15) 0.61 (0.18) 0.49
Participants, No. 153 90 64 67 75 37
Users, % 10.4 6.7 14.1 7.5 16.0 8.1
Other people complain 0.44 (0.12) 0.30 (0.15) 0.34 (0.17) 0.19 (0.17) 0.48 (0.16) 0.30 (0.21) 0.64
Self-diagnose 0.41 (0.13) 0.35 (0.15) 0.42 (0.16) 0.31 (0.16) 0.36 (0.16) 0.45 (0.20) 0.16
aBased on mixed-models method; hence, estimated mean values are reported.
bPost hoc tests show significant differences when compared with baseline (P.05).
cPost hoc tests show significant differences when compared with 1 month (P.05).
dPost hoc tests show significant differences when compared with 3 months (P.05).
ePost hoc tests show significant differences when compared with 6 months (P.05).
fFvalue significant at P.001.
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nificantly at 24 months (M= 1.25) relative to baseline
(P= .019), 1 month, 3 months, and 6 months (P.002).
There was no significant change over time in the ratings
of complaints or self-diagnosed problems with compos-
ite substance use.
In the overall sample, the frequency of reported alco-
hol use changed significantly over time (Table 2; Figure 1)
(F5,305.8 = 11.53, P.001). The frequency decreased sig-
nificantly from baseline (M= 2.29) to 1 month (M= 1.16;
P.001) and from baseline to 3 months (M=1.45;
P= .009). There were no significant increases from base-
line (M= 2.29) to 24 months (M= 3.07; P= .10), but there
were significant increases from 1 month (M= 1.16) to
12 months (M= 2.38; P.001), from 1 month (M= 1.16)
to 24 months (M= 3.07; P.001), from 3 months
(M=1.45) to 12 months (M= 2.38; P= .016), from 3
months (M=1.45) to 24 months (M= 3.07; P.001),
and from 6 months (M= 1.735) to 24 months (M= 3.07;
P= .001). There was no significant change over time in
the ratings of complaints or self-diagnosed problems.
There was a significant interaction between type of sur-
gery and frequency of alcohol use (F5,300.6 = 2.93, P= .013)
over time points (Figure 2). Those who underwent
LRYGB surgery reported decreases in the frequency of
alcohol use from baseline (M= 1.86) to 1 month
(M= 0.39; P.001) and from baseline to 3 months
(M= 0.64; P= .002). The frequency of alcohol use then
increased at 24 months (M= 3.08) relative to baseline
(P= .011) and 12 months (M= 1.91; P= .048). There were
no significant changes in the reported frequency of al-
cohol use for participants who underwent LAGB sur-
gery. There were no significant changes in complaints
or self-diagnosed problems in either the LRYGB group
or the LAGB group.
There was no significant effect of time on the fre-
quency of recreational drug use (Table 2; Figure 1)
(F5,406.13 = 2.085, P= .07) and no significant change over
time in the ratings of complaints or self-diagnosed prob-
lems. There was no significant effect of time on the fre-
quency of cigarette smoking (Table 2; Figure 1)
(F5,323.1 = 0.49, P= .78) or on the frequency of com-
plaints or self-diagnosed problems.
There was no significant interaction between receiv-
ing a BED diagnosis at baseline (based on the QEWP-R)
and any of the following types of substance use over time:
frequency of composite substance use (F5,328.2 = 0.86,
P= .51), frequency of alcohol use (F5,288.2 = 0.75, P= .59),
frequency of recreational drug use (F5,381.32 = 0.17, P= .97),
or frequency of cigarette smoking (F5,304.10 = 0.60, P= .70).
There was also no significant interaction between sur-
gery type and frequency of composite substance use
(F5,343.3 = 0.51, P= .77), frequency of recreational drug
use (F5,398.0 = 0.82, P= .53), or frequency of cigarette smok-
ing (F5,316.4 = 0.97, P= .44). Controlling for baseline body
mass index or change in body mass index did not have
any significant effect and did not change any of the
findings.
COMMENT
Although there have been anecdotal reports of increases
in substance use following WLS,4-6 this is one of the first
research studies to investigate the phenomenon from a
longitudinal perspective. Our study examined the course
of substance use (alcohol, cigarettes, recreational drugs,
and composite substance use) during the first 24 months
after WLS. Based on symptom substitution theory, we hy-
pothesized that participants would experience an in-
crease in frequency of substance use following WLS, which
was supported by our findings.
The frequency of composite substance use among our
participants appeared to follow a “J”-shaped curve over
time. Participants experienced an immediate decrease in
the frequency of composite substance use following WLS,
but these improvements were not maintained by 3-month
follow-up, and there was a significant increase in the fre-
quency of composite substance use from baseline to 24-
month follow-up. Furthermore, results indicated that par-
ticipants who had undergone LRYGB surgery experienced
significant increases in the frequency of alcohol use over
0
4
3
Mean Frequency of Substance Use, CBQ Score
Time Since WLS, mo
2
1
Baseline 1 3 6 12 24
Frequency of alcohol use
Frequency of composite substance use
Frequency of cigarette smoking
Frequency of drug use
Figure 1. Estimated mean frequency of substance use by category for
bariatric weight loss surgery (WLS) based on Compulsive Behaviors
Questionnaire (CBQ) scores of 155 participants. The values represent mean
values, and the error bars indicate SEM.
– 0.5
4.0
3.5
Mean Frequency of Alcohol Use, CBQ Score
Time Since WLS, mo
2.5
2.0
3.0
1.0
1.5
0.5
0.0
Baseline 1 3 6 12 24
LRYGB surgery
LAGB surgery
Figure 2. Estimated mean frequency of alcohol use for laparoscopic
Roux-en-Y gastric bypass (LRYGB) surgery and laparoscopic adjustable
gastric band (LAGB) surgery based on Compulsive Behaviors Questionnaire
(CBQ) scores of 155 participants. The values represent mean values, and the
error bars indicate SEM.
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time. Participants experienced an initial decrease in the
frequency of alcohol use immediately following RYGB sur-
gery and then a significant increase 24 months after RYGB
surgery. These increases were not reported in those who
underwent LAGB surgery. This result of increased alco-
hol use associated with RYGB surgery but not AGB sur-
gery is consistent with the recent findings by King et al,9
who reported an increased prevalence of alcohol use dis-
orders following RYGB surgery but not following AGB
surgery. The present study did not find any significant
changes in participants’ reported frequencies of ciga-
rette smoking or recreational drug use.
The initial decrease in the frequency of substance use
(both alcohol use and composite substance use) within
the month following surgery may be related to the WLS
recovery process. In the first month after surgery, pa-
tients are requested to follow a strict liquid diet and then
progress to a pureed food diet. Patients are still recover-
ing from surgery and adjusting to dietary changes dur-
ing this time. In addition, patients are advised to refrain
from alcohol use after surgery, owing to excess caloric
intake and changes in the metabolism of alcohol follow-
ing gastric bypass surgery. Participants tend to adhere
to the postsurgical dietary recommendations more closely
immediately following surgery and less so further along
the postoperative time line. Compliance with postsurgi-
cal diet is likely reflected in the decreased frequency of
substance use reported during the immediate postopera-
tive period.
Recent research has revealed that patients become in-
toxicated more quickly with less alcohol following RYGB
surgery and take longer to return to sobriety than be-
fore surgery.24 Because patients have a reduced toler-
ance for alcohol after RYGB surgery, they may experi-
ence the rewarding aspects of alcohol use sooner and more
frequently, which may contribute to the increase in fre-
quency of alcohol use after LRYGB surgery.
Our study did not find any significant changes over
time in the reported frequency of other people complain-
ing about participants’ substance use or participants think-
ing they have a problem with substance use. These ques-
tions may be less sensitive than the frequency questions.
Future research should examine the problematic nature
of substance use following WLS with other validated mea-
surements. Our study provides evidence that patients ex-
perience an increase in the frequency of their substance
use; it does not provide evidence of a quantitative in-
crease in substance or alcohol use (ie, number of drinks)
or that these behaviors are problematic for either the par-
ticipant or others.
Although the baseline data were collected approxi-
mately 3 weeks prior to undergoing WLS, the CBQ has
patients rating their frequency of substance use in the past
month (from 7 to 3 weeks before surgery), which pro-
vides a more accurate depiction of true baseline sub-
stance use. Participants were instructed that participa-
tion in this research study would not affect their surgical
process and that their responses to questionnaire items
would be kept confidential from the surgery staff. De-
spite these efforts to encourage accurate reporting, it is
possible that participants underreported substance use
at baseline in attempt to present themselves as a good
candidate for surgery. However, the significant in-
creases in the frequency of alcohol use found in only the
participants who had undergone RYGB surgery and the
lack of significant changes in the frequency of cigarette
smoking and recreational drug use bolster our confi-
dence that we are capturing actual increases in the fre-
quency of substance use (alcohol use and composite
substance use). Had effects been due primarily to un-
derreporting at baseline, we would have expected in-
creases in the frequency of other substance uses and no
differences for type of surgery.
Other limitations of our study include missing data
(Table 2) (common in longitudinal research studies) be-
cause some participants missed 1 or more of the fol-
low-up time points. Because the data were determined
to be missing completely at random, there were no unique
characteristics inherent in those who missed a fol-
low-up time point. In addition, substance use was as-
sessed using a nonstandardized self-report question-
naire. However, the questions had a high level of face
validity and contained basic questions about the fre-
quency and problematic nature of substance use.
Despite these limitations, our study provides evi-
dence that the frequency of substance use increased fol-
lowing WLS; more specifically, the frequency of alcohol
use increased following LRYGB surgery. Heinberg et al25
suggested the need to identify patients who may be at in-
creased risk for alcohol problems following WLS and pro-
posed a preoperative preventative intervention for these
patients. Based on the present study, undergoing RYGB
surgery appears to increase the risk for alcohol use fol-
lowing WLS. Risks and benefits should be weighted when
recommending LRYGB surgery to patients who may be
at increased risk of developing problems with alcohol af-
ter WLS, such as those with a personal or family history
of alcohol abuse or dependence. Further research is
needed to identify factors related to increased risk of al-
cohol use following WLS. In addition, patients should
be screened at their follow-up visits with surgeons and
other medical professionals to determine whether they
have developed substance use problems by using simple,
easy-to-use screening measures, such as the Alcohol Use
Disorders Test,26 the Brief Alcohol Screening Instru-
ment for Medical Care,27 or the Michigan Alcohol Screen-
ing Test.28 Evaluation should focus on the time period
starting 1 year after RYGB surgery, when alcohol prob-
lems seem most likely to develop.
Accepted for Publication: August 13, 2012.
Published Online: October 15, 2012. doi:10.1001/2013
.jamasurg.265
Correspondence: Alexis Conason, PsyD, New York Obe-
sity Nutrition Research Center, St Lukes–Roosevelt Hos-
pital Center, 1111 Amsterdam Ave, Room 1019, New
York, NY 10025 (drconason@gmail.com).
Author Contributions: Dr Conason had full access to all
the data in the study and takes responsibility for the in-
tegrity of the data and the accuracy of the data analysis.
Study concept and design: Conason, Teixeira, Hsu, Knafo,
and Geliebter. Acquisition of data: Conason, Hsu, and Puma.
Analysis and interpretation of data: Conason and Gelieb-
ter. Drafting of the manuscript: Conason, Hsu, and Knafo.
JAMA SURG/ VOL 148 (NO. 2), FEB 2013 WWW.JAMASURG.COM
149
©2013 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by Abigail Frawley on 09/05/2016
Critical revision of the manuscript for important intellec-
tual content: Conason, Teixeira, Puma, and Geliebter. Sta-
tistical analysis: Conason, Hsu, and Geliebter. Adminis-
trative, technical, and material support: Hsu and Puma.
Study supervision: Teixeira, Hsu, Knafo, and Geliebter.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the Center for Bar-
iatric and Minimally Invasive Surgery at St Luke’s–
Roosevelt Hospital for allowing recruitment of patients
from their bariatric WLS program. We also thank the stu-
dent interns, including Maya Weltsch, Toba Auerbach,
and Nicole Gleyzer, and research coordinator Yi Han (Ian)
Ang.
Online-Only Material: The eAppendix is available at http:
//www.jamasurg.com.
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... Bariatric surgery (BS) has been associated with an increased risk of alcohol use disorder (AUD) and alcohol-related liver disease (ALD) [1][2][3], depending on the type of bariatric surgery performed. Notably, a large prospective multicenter cohort study followed 2348 patients before surgery and annually after Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) for up to 7 years [4]. ...
... While bariatric surgery is a clear risk factor for AUD [1][2][3], there is less information about the association of bariatric surgery and ALD. Furthermore, it is unclear whether sAH patients with a history of BS are phenotypically different from those without prior BS. ...
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Purpose: Patients with prior bariatric surgery (BS) are at risk to develop alcohol use disorder (AUD) and alcohol-related liver disease (ALD). Severe alcoholic hepatitis (sAH) is one of the most severe manifestations of ALD with a 28-day mortality of 20-50%. The impact of prior BS on patients presenting with sAH was assessed. Methods: From 01/2008 to 04/2021, consecutive patients admitted to a tertiary referral center with biopsy-proven sAH were included in a database. Results: One hundred fifty-eight sAH patients of which 28 patients had a history of BS (BS group) were identified. Of this BS group, 24 patients underwent a Roux-en-Y gastric bypass (RYGB), 3 a biliopancreatic diversion, 1 an adjustable gastric band, and no patients a sleeve gastrectomy. The proportion of patients with BS increased threefold over time during the study period. Patients in the BS group were significantly younger at diagnosis of sAH (44.3 years vs 52.4 years), were more frequently female, and had a higher body mass index and a higher grade of steatosis on liver biopsy. The correlation between BS and a younger age at diagnosis remained significant in a multivariate regression analysis. There were no differences in disease severity between both groups. Furthermore, there were no differences in corticosteroid response, 28-day, 90-day, or 1-year survival. Conclusion: Prior BS is independently associated with a younger age of presentation with sAH, but is not independently associated with a different disease severity or outcome. These findings support the need for early detection of AUD in patients who underwent BS, in particular RYGB.
... It should also be noted that emotional eating may be the first step in the development of binge eating disorder and its extreme subtypes such as food addiction [25]. Interestingly in some post-bariatric surgery patients, an increased frequency of addictive disorders has been observed, for example food addiction replaced by alcohol addiction called: "cross addiction" or "addiction transfer" [26][27][28]. The association of emotional eating with depression and poor emotional regulation skills suggests that obesity is a psychosomatic disease and the treatment of obese people with pervasive emotional eating should not focus on calorie-restricted diets but on emotion regulation skills. ...
... It should also be noted that emotional eating may be the first step in the development of binge eating disorder and its extreme subtypes such as food addiction [25]. Interestingly in some post-bariatric surgery patients, an increased frequency of addictive disorders has been observed, for example food addiction replaced by alcohol addiction called: "cross addiction" or "addiction transfer" [26][27][28]. The association of emotional eating with depression and poor emotional regulation skills suggests that obesity is a psychosomatic disease and the treatment of obese people with pervasive emotional eating should not focus on calorierestricted diets but on emotion regulation skills. ...
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Obesity is one of the most dangerous epidemics of the 21st century. In 2019, the COVID-19 pandemic began and caused many deaths among patients with obesity with and without complications. Simultaneously, the lockdown related to the COVID-19 pandemic caused a host of emotional problems including anxiety, depression, and sleep disturbances. Many people began to cope with their emotions by increasing food (emotional eating) and alcohol consumption and in combination with decreased physical activity, promoted the development of overweight and obesity. Emotional eating, also known as stress eating, is defined as the propensity to eat in response to positive and negative emotions and not physical need. It should be noted that emotional eating may be the first step in the development of binge eating disorder and its extreme subtypes such as food addiction. Interestingly in some post-bariatric surgery patients, an increased frequency of addictive disorders has been observed, for example food addiction replaced by alcohol addiction called: “cross addiction” or “addiction transfer”. This data indicates that obesity should be treated as a psychosomatic disease, in the development of which external factors causing the formation of negative emotions may play a significant role. Currently, one of these factors is the COVID-19 pandemic. This manuscript discusses the relationships between the COVID-19 pandemic and development of emotional eating as well as potential implications of the viral pandemic on the obesity pandemic, and the need to change the approach to the treatment of obesity in the future.
... Die Ergebnisse zur vergleichsweise niedrigen geschätzten Prävalenz einer alkoholbezogenen Störung in unserer Stichprobe decken sich demnach mit bisherigen deutschen AUDIT-Resultaten und auch mit dem Positionspapier der American Society for Metabolic and Bariatric Surgery (Parikh, Johnson, Ballem, American Society for Metabolic & Bariatric Surgery Clinical Issues, 2016), das problematischen Alkoholkonsum bei Patient_innen vor Adipositaschirurgie als ein minderheitliches Phänomen beschreibt, und den Ergebnissen der dort referierten Studien (Conason et al., 2013;Ertelt et al., 2008;King et al., 2012;Wee et al., 2014). Alternativ könnten bei Personen, die eine Adipositaschirurgie anstreben, auch Dissimulationstendenzen bezogen auf Alkoholkonsum bestehen. ...
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Zusammenfassung: Zielsetzung: Bei Personen vor Adipositaschirurgie wurden die Prävalenzen von Food Addiction (FA), alkoholbezogener Störung, Angst- und depressiven Störungen geschätzt. Zudem wurde untersucht, ob FA-Symptome mit Alkoholkonsum, Lebensqualität sowie Essstörungs-, Angst- und Depressionssymptomatik assoziiert sind und ob es Unterschiede zwischen Personen mit und ohne FA in diesen Variablen gibt. Methodik: Bei 419 Personen mit Adipositas wurden FA, Alkoholkonsum, gewichtsbezogene Lebensqualität, Essstörungs-, Angst- und Depressionssymptomatik mit validierten Fragebögen erfasst. Unterschiede in den psychopathologischen Variablen zwischen Patient_innen mit und ohne FA wurden mit non-parametrischen Verfahren untersucht. Ergebnisse: Die geschätzten Prävalenzen von riskantem Alkoholkonsum (11 %) und alkoholbezogener Störung (5 %) waren in der aktuellen Stichprobe geringer als in bevölkerungsbasierten Stichproben, die geschätzten Prävalenzen von Food Addiction (38 %), Essstörungen (79 %), Depression (30 %) und Angststörungen (24 %) hingegen deutlich höher. FA-Symptome waren nicht mit Alkoholkonsum und gewichtsbezogener Lebensqualität assoziiert. Hingegen zeigten sich positive Korrelationen von FA-Symptomen mit globaler Essstörungspathologie, Depressions- und Angstsymptomatik. Es zeigten sich keine Unterschiede zwischen Personen mit/ohne FA hinsichtlich der Häufigkeit von früherem oder aktuellem riskanten Alkoholkonsum oder alkoholbezogener Störung. Schlussfolgerungen: Die Ergebnisse bestätigen frühere Befunde eines fehlenden Zusammenhangs von FA mit Alkoholkonsum bei Menschen vor chirurgischer Adipositasbehandlung. Längsschnittstudien mit großen Stichproben und langfristigen Follow-Ups sollten eine etwaige postoperative Symptomverlagerung von FA zu Substanzkonsum untersuchen.
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Background New-onset substance use disorder (SUD) following bariatric surgery is a significant concern that is likely multi-factorial, although the etiologies are unclear. Previous studies have identified variable rates of SUD along with utilizing different methods and measures. The objective of this study is to evaluate new-onset SUD diagnoses among adults following bariatric surgery and compare these rates to those in the general population as well as those diagnosed with overweight or obesity. Methods Data was extracted from TriNetX Research Platform and used to build three cohorts of adults: those who had bariatric surgery (bariatric surgery cohort), those diagnosed with obesity or overweight, and a general population cohort. Rates of incident SUD were compared among these three groups. Initial encounters for all individuals were from January 1, 2018, to June 30, 2019. Results The incidence rate of SUD in patients with a history of bariatric surgery was 6.55% (n = 2523). When compared to the general population, persons who had any type of bariatric procedure had a decreased risk of new-onset SUD with an overall odds ratio (OR) [95% confidence limits (CL)] of 0.89 [0.86, 0.93]. When compared to persons with overweight or obesity, bariatric patients were less likely to develop any form of SUD (OR: 0.65 [0.62, 0.67]). Conclusion While overall rates of new-onset SUD are lower among those who had bariatric surgery, they also vary by surgery and substance type. Efforts should still be made to address new-onset SUD in order to optimize the post-surgical care of patients. Graphical Abstract
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Chapter
Obwohl sich Parallelen zwischen der Adipositas und Abhängigkeitserkrankungen zeigen, gibt es derzeit keine überzeugenden Erkenntnisse, diese beiden Volkserkrankungen auf eine gemeinsame Ursache zurückzuführen. Bei sehr adipösen Menschen scheint es eine höhere Prävalenz von allgemeiner Psychopathologie und Abhängigkeitserkrankungen zu geben. Jeder bariatrische Patient sollte im Rahmen einer strukturierten psychosozialen Evaluation auf das Vorliegen einer Abhängigkeitserkrankung untersucht werden, da diese eine Kontraindikation für die Operation darstellt. Insbesondere die Subgruppe der Roux-en-Y-Gastric-Bypass-Patienten hat ein deutlich erhöhtes Risiko für das Neuauftreten oder einen Rückfall für eine Alkoholgebrauchsstörung. Für diesen Befund liegen belastbare Erkenntnisse über Pathomechanismen vor. Weitere Risikogruppen sind jüngere und männliche Patienten, Raucher und insbesondere Kandidaten, die ein regelmäßiges und problematisches Trinkverhalten vor der Operation zeigten.
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Change is constant in everyday life. Infants crawl and then walk, children learn to read and write, teenagers mature in myriad ways, and the elderly become frail and forgetful. Beyond these natural processes and events, external forces and interventions instigate and disrupt change: test scores may rise after a coaching course, drug abusers may remain abstinent after residential treatment. By charting changes over time and investigating whether and when events occur, researchers reveal the temporal rhythms of our lives. This book is concerned with behavioral, social, and biomedical sciences. It offers a presentation of two of today's most popular statistical methods: multilevel models for individual change and hazard/survival models for event occurrence (in both discrete- and continuous-time). Using data sets from published studies, the book takes you step by step through complete analyses, from simple exploratory displays that reveal underlying patterns through sophisticated specifications of complex statistical models.
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A common concern when faced with multivariate data with missing values is whether the missing data are missing completely at random (MCAR); that is, whether missingness depends on the variables in the data set. One way of assessing this is to compare the means of recorded values of each variable between groups defined by whether other variables in the data set are missing or not. Although informative, this procedure yields potentially many correlated statistics for testing MCAR, resulting in multiple-comparison problems. This article proposes a single global test statistic for MCAR that uses all of the available data. The asymptotic null distribution is given, and the small-sample null distribution is derived for multivariate normal data with a monotone pattern of missing data. The test reduces to a standard t test when the data are bivariate with missing data confined to a single variable. A limited simulation study of empirical sizes for the test applied to normal and nonnormal data suggests that the test is conservative for small samples.
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Established clinical guidelines identify current alcohol abuse and dependence as contraindications for weight loss surgery. However, guidance on how to best assess alcohol use in bariatric patients has not been elucidated. Furthermore, concerns with postoperative alcohol use/abuse and increased sensitivity warrant the development of recommendations on appropriate interventions for patients pursuing weight loss surgery. Our objective was to review the current data on bariatric surgery and substance abuse/addiction, with an emphasis on alcohol use, offer guidance on how to assess the risk of such problems, and provide preliminary recommendations on treating high-risk patients. The relevant published data on alcohol use, abuse, and dependence in pre- and postoperative bariatric patients was reviewed. Also, the putative mechanisms of increased alcohol sensitivity after weight loss surgery were examined. Although current alcohol abuse/dependence is less than that in population-base rates, bariatric surgery candidates have a greater history of alcohol use disorders. Physiologic changes after surgery can also change vulnerability to problematic alcohol use, and many patients continue to consume alcohol after surgery. Assessment techniques and strategies to provide informed consent and education on alcohol were included from the Bariatric and Metabolic Institute at the Cleveland Clinic. Weight loss surgery candidates might have a greater lifetime risk of alcohol use disorders and greater sensitivity to the intoxicating effects of alcohol after surgery. Adequate screening, assessment, and preoperative preparation could help mitigate this risk. Future research should examine the efficacy of such risk management strategies.
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This study examined the relationship between addictive personality and maladaptive eating behaviors in bariatric surgery candidates. Ninety-seven bariatric surgery candidates completed the Eysenck Personality Questionnaire (EPQ-R) Addiction Scale, the Overeating Questionnaire (OQ), binge-eating questions from the Questionnaire of Eating and Weight Patterns (QEWP-R), and the Eating Attitudes and Behaviors Questionnaire. Participants with Binge Eating Disorder (BED) displayed addictive personality scores comparable to individuals addicted to substances (M=17.5, SD=5.3). Addictive personality was associated with Overeating (r=.45, p<.001), Cravings (r=.31, p=.005), Affective Disturbances (r=.62, p<.001) and Social Isolation (r=.53, p<.001). Addictive personality was associated with maladaptive eating behaviors, suggesting the potential for addictive eating.