Which weight loss surgery patients are at risk for development of
post-surgical substance use disorders?
Karen Saules1, Summar Reslan1, & Leslie M. Schuh2
1
Eastern Michigan University, Department of Psychology, Ypsilanti, MI
2
St. Vincent Bariatric Center of Excellence, Carmel, IN
Results
Introduction
Our research team has observed that weight loss surgery (WLS) patients are
overrepresented in substance abuse treatment (Saules et al., 2010; Wiedemann et
al., 2012). Specifically, we observed that between 2-6% of patients in an inpatient
detoxification/rehabilition program had a history of WLS, and over 90% of those
cases had the Roux-en-Y procedure. Despite typically achieving successful weight
loss outcomes (Pulcini et al., 2011), we have also observed that WLS patients in
substance abuse treatment had poorer quality of life than their non-WLS counterparts (Saules et al., 2011). Furthermore, over half of the post-WLS substance
abuse treatment patients whom we have interviewed described an onset of
substance abuse after surgery; those who admitted to substance use problems
prior to surgery typically were not using substances at or even near the time of their
weight loss surgery (Wiedemann et al., under review). Although it is a minority of
WLS patients who experience substance use disorders (SUDs) after surgery, the
magnitude of the SUD problem (i.e., warranting inpatient treatment) and the
associated consequences warrant a better understanding of who is most at risk.
Procedure
Measures
All participants were at least 24 mos
post-Roux-en-Y WLS. A convenience
sample of 141 gastric bypass patients
was recruited. Participants completed
a survey assessing eating- and
weight-related variables, mood, quality
of life, and substance use.
~MAST/AD (Westermeyer et al., 2004):
Score of five used as the cut-off score
indicating probable post-WLS SUD
Patients were recruited from those who
had participated in our previous studies
(n=37), a support group at Henry Ford
Hospital (Detroit, MI; n=15), and from
St. Vincent Bariatric Center of
Excellence (Carmel, IN; n=42 online
and n=47 by mail).
~Family History of SUD
~Depression (PHQ-9; Spitzer et al.,
1999),
~Postoperative eating-behavior: Food
addiction (YFAS; Gearhardt et al.,
2009), binge eating (QEWP-R; Spitzer
et al., 1993), TFEQ (Stunkard &
Messick, 1985), Power of Food (PFS),
food craving, grazing, night eating
syndrome, emotional eating, and
appetite for palatable foods.
79%
72.2%
27.8%
47.8%
12.3%
29.7%
10.1%
Age (M ± SD)
Race (% White)
Education (M ± SD)
53.4 ± 10.3
93%
14.5 ± 2.6
Surgery Age
Years Since Surgery
% Roux-en-Y
Excess Weight Loss
Total Weight Loss
47.0 ± 10.0 yrs
6.2 ± 2.7 yrs
100%
70.7% (± 22.3%)
35.5% (± 10.4%)
Because it is relatively easy to assess family history of SUD, we aimed to understand
whether other variables would explain additional variance, if included in a prediction
model. At the bivariate level, Nightime Eating, Power of Food, YFAS Food Addiction,
and TFEQ Hunger were significantly associated with post-WLS SUD. Family history
of SUD was thus entered on the first step of a multiple logistic regression model, and these
eating-related variables were added on a second step. Only Night Time Eating contributed
significant variance to the prediction of the development of post-WLS SUD in the
combined model
Percentage of participants in each SUD Category
80
Final Logistic Regression Model predicting Post-WLS SUD
Beta
S.E
Odds
95% CI
Ratio
Fam Hx SUD
1.19 .652
3.30†
0.92-11.85
Night time Eating
.141 .058
1.15*
1.03-1.30
Power of Food
-.009 .026
0.99
.94-1.04
YFAS Symptom Total
-.030 .213
0.97
.64-1.47
Hunger
.063 .129
1.07
.83-1.37
Note. N = 115. CI = Confidence interval, † p <.10 *p <.05
60
40
20
0
No SUD
Recovered
Relapsed
NOU
Percentage of Post-WLS SUD vs. Non SUD
participants with a Family History of SUD
50
Patient characteristics
Gender (% Female)
Marital Status
Married/Live with partner
Single/Divorced/Widowed
Employment Status
Full time
Part time
Retired/Disabled
Unemployed/Student
100
A total of 20 participants (14.3%) met criteria for a probable post-WLS SUD, 70% of whom
denied SUD before WLS -- a group we refer to as New Onset SUD. Post-surgical SUD
cases were significantly younger (M = 46.70, SD = 8.91) than non-SUD cases (M = 54.55, SD
= 10.15), t (134) = 3.25, p = .001. Post-surgical SUD cases also had bariatric surgery at a
younger age (M = 40.05, SD = 8.34) than non-post-surgical SUD cases (M = 48.09, SD =
9.79), t (139) = 3.47, p = .001. No other demographic variables were significantly associated
with post-surgical SUD classification.
Method
Recruitment
Predictors of Post-WLS SUD
40
30
20
10
0
Post-WLS SUD
Non SUD
Relative to non-SUD WLS patients, those with post-WLS SUD were significantly more
likely to have a family history of SUD, χ2 (1), = 4.18, p= .04, and they endorsed having
significantly more categories of family members with a SUD history, t (139) = 2.3, p =.023.
The odds of developing a probable post-surgical SUD were nearly three times as high for
those with a family history of SUD, OR = 2.67; 95% CI [1.02, 6.99], p = .046.
Presented at the 2012 Annual Meeting of The Obesity Society
Following bariatric surgery, patients find themselves abruptly confronted with an inability to eat, but perhaps limited resources for managing food urges through other means, which can create conditions that foster drug and/or alcohol dependence.
As the remaining eating-related variables (i.e., PFS, YFAS, and Hunger) were not
significantly associated with post-surgical SUD in the model that included all predictors,
the intercorrelation between these eating-related variables and NEQ were explored.
Results revealed a significant correlation between NEQ with YFAS symptom total, r = .29,
p = .001, PFS, r = .53, p = .001, and Hunger, r = .42, p = .001.
Discussion
Following bariatric surgery, patients find themselves abruptly confronted with an inability to eat, but perhaps limited resources for managing food urges through other means, which can create conditions that foster drug and/or alcohol dependence.
Those with a family history of SUD had roughly a three-fold risk of developing
post-WLS SUD, and each additional family member with a SUD history
compounded risk. Fortunately, family history of SUD is relatively easy to assess, and
participants commonly admit to having individuals with SUDs in their families. For
example, 29.3% of our total sample endorsed having at least one family member with a
SUD history. Given the stigma associated with having a SUD and the fact that it may
potentially become an obstacle to WLS authorization, patients may be reluctant to admit
to their own substance use difficulties. Therefore, screening for family history of SUD
may provide a more valid indicator of a patient’s post-WLS risk of developing or
relapsing to a SUD.
Our post-WLS SUD group also had significantly higher scores on the Night Eating
Questionnaire, the Power of Food Scale, YFAS Food Addiction, and TFEQ Hunger, with
Night Eating showing the strongest contribution to the prediction of post-WLS SUD in a
model that included family history and eating-related variables.
Results have practical implications in that family history of SUD can be easily assessed,
and at-risk patients can be advised accordingly. Results also have theoretical implications in that those most likely to develop post-WLS SUD appear to be those with
stronger affective, cognitive, and behavioral responses to food, providing some
support for the concept of “addiction transfer.”
Contact information: ksaules@emich.edu