Weighty Issues

Educational Objectives

The goal of this program is to improve the identification of women with eating disorders  and improve prenatal care of women who have undergone bariatric surgery. After hearing and assimilating this program, the clinician will be better able to:

1.   Discuss characteristics associated with eating disorders in women.

2.   Identify and evaluate women with eating disorders.

3.   List the physiologic impact of obesity and qualifications for bariatric surgery.

4.   Counsel patients about the differences between gastric bypass and lap band bariatric procedures.

5.   Manage pregnant patients who have undergone bariatric surgery.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgments

Dr. Mangham was recorded at the 9th Annual Women’s Health Conference, sponsored by HealthPartners Institute for Medical Education, and held November 7, 2008, in Minneapolis, MN. Dr. Hess was recorded at the 11th An­nual Conference in Obstetrics, Gynecology and Women’s Health, sponsored by Boston University School of Med­icine, and held April 3-4, 2009, in Cambridge, MA. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Eating Disorders: Not Just for the Young

Deborah Mangham, MD, Assistant Medical Director, Park Nicollet Methodist Eating Disorders Institute, St. Louis Park, MN

General considerations: eating disorders becoming increasingly more common in adults; average age of onset  —anorexia nervosa (AN) 15 yr of age; bulimia nervosa (BN) 18 yr of age; binge eating disorder (BED) 25 yr of age; BED more prevalent than AN or BN; BED lasts longer, so clinician more likely to see patients with BED than AN or BN; embarrassment and difficulty acknowledging problem inhibits initiation of specific eating-disorder therapy; older women  —  tend to have more comorbidities; longer duration of eating disorder; prognosis inversely related to duration of illness; BED  —  falls under Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-1V) classification of eating disorder not otherwise specified (EDNOS); majority of eating disorder patients classified under BED, as patients not meeting criteria for AN or BN included in this diagnosis; similar to BN, but without compensatory purging; affects older patients; have fewer dietary restraints; many patients overweight; prevalence  —data (10,000 patients) show AN »1.0%; BN 1.5%; BED 3.5%; all 3 diagnoses have long duration (av­erage 6 yr for patient with AN)

Common themes: intense fear of gaining weight; body image distortion (can progress to body dysmorphic disorder; self-perception not based on reality); self-esteem totally dependent on weight; decreased stigma associated with treatment of mental health conditions and improved access to eating disorder–specific therapies likely reasons for increase in older women seeking treatment (treatment for BN available since 1990s); epidemiology  —  incidence of BN and BED increasing since 1960s (era of very thin fashion models [eg, Twiggy] as ideal of female beauty); stud­ies show slow increase in AN throughout last century, although currently at plateau; data show patients with eating disorders most likely to seek care from primary care provider; psychiatry and other mental health professionals seen, as well as complementary and alternative medicine (CAM) practitioners; only 30% of patients with AN seek treatment, patients with BN and BED much more likely to do so; AN considered egosyntonic illness (does not con­tradict person’s goals or view of self); therefore, patients not interested in cure; often, patient’s family initiates treatment; patient who binges and purges more likely to seek treatment because behaviors cause them distress

Characteristics of older patients: high scores on Beck Depression Inventory; significant anxiety measured by State-Trait Anxiety Inventory; compromised self-worth; elevated scores on all eating disorder assessments; ie, increased dietary restraint, eating concerns, weight and shape concerns (compared to normal population); data show 94% of eating disorder patients >30 yr of age have had illness since adolescence or experiencing relapse of preexisting ill­ness; de novo illness unusual (6%);  older patient more likely to engage in risky behaviors, eg, abuse of over-the-counter (OTC) laxatives and diuretics, purchase of prescription diuretics via Internet (can lead to hypokalemia), over-exercise; contributing factors  — inability to make life transitions or accept losses (eg, death, divorce, empty-nest syndrome, aging, changing appearance); data show majority of older patients struggle with eating issues for ³10 yr; drive for thinness as strong as in younger patients; body image dissatisfaction increases as women age (nor­mative discontent), and more prevalent than in past

Evaluation

 Scoff questionnaire: mnemonic for sick, control, one, fat and food; do you make yourself sick because you feel un­comfortably full? do you worry that you have lost control over your eating? (universally reported in BN and BED); have you lost >14 lb (one stone) in past 3 mo? do you believe yourself to be fat when others say you are too thin? would you say food dominates your life? 2 positive answers 100% sensitive for AN, BN, and binge eat­ing behavior (not BED); 87.5% specificity

Physical examination: temperature (hypothermia common); height, weight and body mass index (BMI); ortho­static blood pressure (BP) and pulse (changes related to increased parasympathetic tone); oropharynx  —  loss of dental enamel (amalgam islands) and translucent appearance related to vomiting; skin and hair  —  acrocyanosis, lanugo hair, and Russell’s sign (abrasions on knuckles); muscle wasting  —  BMI <19 (Asians excepted)

 Laboratory values: complete blood cell count (CBC) with differential  —  bone marrow sensitive to malnutrition, so abnormal values seen in white blood cells, hemoglobin, and platelets (in that order) with eating disorders; chem­istry battery  —  hypokalemia; liver function tests (LFTs)  —elevated liver enzymes common (resolve with weight gain); phosphorous and magnesium  —  levels tend to be low; thyroid function  —  euthyroid sick syndrome (with abnormal thyroid-stimulating hormone [TSH] levels) common with significant weight loss; speaker recommends repeat TSH testing after weight gain, rather than immediate treatment with thyroid medication; pregnancy  —  urine test; electrocardiography  —prolonged QT interval; dual-energy x-ray absorptiometry (DEXA)  —  decrease in bone mineral density (BMD) with 6 mo of amenorrhea; female athlete triad (amenorrhea, osteoporosis and disordered eating) common among female cross-country runners; lipids  —elevated cholesterol related to cortisol (stress hormone)

Bariatric Surgery: What the Obstetrician-Gynecologist Should Know

Donald T. Hess, Jr, MD, Assistant Professor of Surgery, Boston University School of Medicine; Director, Bar­iatric Surgical Service, Boston Medical Center, Boston, MA

Worldwide epidemic of obesity: 25% of industrialized world; 64% of United States population overweight; definitions  —  overweight defined BMI >25; obesity, BMI >30 (good predictor of development of health risks); obe­sity considered lifelong, progressive, life-threatening, genetically related, and multifactorial disease of excess fat storage, with multiple comorbidities

Physiologic impact of obesity: obstructive sleep apnea; hypoventilation syndrome; nonalcoholic fatty liver disease (steatohepatitis leading to cirrhosis); cholelithiasis; gynecologic abnormalities; phlebitis and venous stasis (in­creases risk for deep venous thrombosis); increased risk for cancer, pancreatitis, and heart disease; direct relation­ship between weight and diabetes; women develop type 2 diabetes with smaller increases in BMI than men; obesity and pregnancy  —spontaneous abortion; congenital abnormalities; gestational diabetes; preeclampsia; delivery complications; postterm onset of labor; failed induction; shoulder dystocia (increased incidence of third- and fourth-degree tears); neonatal macrosomia (with possible early neonatal death) also precursor for childhood obe­sity; mortality  —  higher risk for death with increasing weight; years of life lost believed greater when weight in­creases early in life; data show bariatric surgery for severe obesity associated with decreased overall mortality

Treatment options: estimated only 1% of patients qualifying for bariatric surgery undergo surgery; alternatives to surgery  —  diet, exercise, behavior modification; antiobesity medications (orlistat, sibutramine [Meridia], phenter­mine); challenge is sustaining weight loss; data show only 7 of 102 participants maintained weight loss at 9 yr; qualifications for surgery  —  BMI >40; BMI >35 with significant comorbidities (diabetes, hypertension, and sleep apnea most important); documented attempts at nonsurgical weight loss; why patients choose surgery  —  sustainable weight loss; desire to feel healthier; improvement in self-esteem; increased ability to “keep up” with children; increased fertility; bariatric surgery trends  —  number of bariatric procedures projected to continue in­creasing; 80% of bariatric surgery patients women, many in childbearing years

Gastric bypass (Roux-en-Y procedure): restrictive and malabsorptive procedure; small stomach pouch stapled and divided from main stomach; 2 variations, proximal and distal; malabsorption of fats; dumping syndrome  —  normally, pyloric valve releases food into intestine slowly; physiologic reaction to food rapidly leaving stomach; small bowel distention, flushing, and headache; remind patients to avoid eating sweets or foods high in fat; patients can forget to eat because of changes in ghrelin levels; mortality and complications  —  mortality 0.3%; increase with male sex, age, and BMI; pulmonary embolism after surgery or leak (staple line disconnects or does not heal) 2 most frequent causes of death; hemorrhage and stricture technical complications; late complications  —  anastomotic ul­cer; 5% of patients (may present with epigastric pain); treated with proton pump inhibitor and sucralfate (Carafate); internal hernia in pregnancy serious complication; expected outcomes from surgery  —  loss of two-thirds to three-quarters of excess body weight 12 to 18 mo after surgery; 60% of weight loss maintained at 14 yr; resolution of comorbidities  —  diabetes in 83% of patients; hypertension improved in 87% of patients and eliminated in 75%; sleep apnea in 85%

Laparoscopic adjustable gastric band (lap band): second most common bariatric surgery performed in United States; restrictive procedure; silastic band around stomach connected to subcutaneous port; no hormonal changes; no dumping syndrome or malabsorption; follow-up band adjustments recommended for optimal results; if band too tight, patient unable to enjoy healthy foods and likely to resort to eating foods that “slide down” more easily (eg, ice cream, sweets) or may develop reflux disease; over time, hunger may increase because ghrelin not as well sup­pressed as with other types of surgery; mortality and complications  —  mortality approaches zero; obstruction and perforation of stomach unlikely; band slip  —  as patient eats food, stomach distends and is pulled underneath band; this cuts off blood supply to stomach, leading to necrosis; resection required; band erosion  —  erosion seen from in­side stomach; rare complication; port-related problems; rate of reoperation (because of complications) higher than gastric bypass; weight loss at 1 yr averages »40%, 52% at 3 yr; long-term weight loss unknown in United States; Europe and Australia report loss of 50% excess weight long-term; comorbidities improve; not as effective as gastric bypass

Sleeve gastrectomy: stomach excised, leaving only narrow area; complications  —  leak or hemorrhage because of long staple line; stricture (treated by balloon dilation); mortality 0.39% (should improve with experience); stenosis; vitamin B₁₂ deficiency; resolution of comorbidities  —  diabetes »72%; hypertension 57%; sleep apnea 85%; gaining in popularity

Micronutrients at risk with bypass surgery: iron  —  lack of stomach acid compromises conversion of ferrous iron to ferric iron; intolerance to red meat because of narrow opening leads to less bioavailable heme; iron and ascorbic acid prescribed to make up for decreased acid; calcium  —  cells that absorb calcium in jejunum bypassed; BMD evaluated with bone scan at first and second year after surgery; calcium supplementation prescribed; vitamin B₁₂  —  decreased binding with intrinsic factor; replacement can be oral, sublingual, or intramuscular; vitamin D  —  fat-sol­uble; requires aggressive replacement to improve calcium absorption; folate and thiamine  —  deficiencies less com­mon

Pregnancy after weight-loss surgery: data show pregnancy after lap-band surgery as safe as in women with normal BMIs; Australian study of 79 patients with lap band showed gestational diabetes rates not significantly different from community; less pregnancy-induced hypertension seen relative to pre-lap band pregnancies; no significant difference in premature delivery, macrosomia or perinatal mortality, compared to community controls; gastrointes­tinal (GI) complications during antepartum period  —cholelithiasis (ursodeoxycholic acid given at time of surgery); marginal ulcer; internal hernia (potentially fatal complication); patient presenting with bowel obstruction who had gastric bypass should be treated as surgical emergency; computed tomography (CT) recommended during preg­nancy (minimal risk to fetus) to diagnose internal hernia; CT insensitive in less severe cases; diagnostic laparos­copy should be considered for patients with recurrent symptoms

Nutritional goals: determine baseline nutritional status early in pregnancy; deficiencies best corrected early or in preconception phase; multivitamin plus iron, in addition to prenatal vitamin, recommended (liquid or chewable form because of small opening between stomach and small intestine); vitamin A >5000 IU/day should be avoided (beta carotene can be given at higher dose); iron —  requirement increases in second half of pregnancy, due to ex­pansion of red blood cell mass and transfer of iron to fetus and placenta; postoperative dose of iron 40 to 100 mg of essential iron per day; during pregnancy, 30 to 60 mg per day; 180 to 220 mg with maternal anemia (should be given with vitamin C or ascorbic acid); folic acid  —  400 µg; 800 to 1000 µg in typical prenatal vitamin and 400 µg in multivitamin adequate; calcium  —1200 to 1500 mg with 800 IU of vitamin D

Other pregnancy considerations: oral glucose tolerance test (50-100 g), typically performed at 28 wk gestation, causes dumping syndrome in patients with history of gastric bypass; sweating, nausea, flushing, tachycardia, diar­rhea, crampy abdominal pain, and hypoglycemia; fasting and 2-hr postprandial glucose level, hemoglobin A_1C and continuous glucose sensor for 3 days other options; pregnant women with history of lap-band surgery should not have electrolyte imbalances or vitamin or iron deficiencies if supplements taken; pregnancy should be delayed 12 to 18 mo after weight-loss surgery (period of most rapid weight loss; concern baby may become malnourished); pregnancy may reduce long-term weight loss (controversial)

Weight gain during pregnancy: gastric bypass requires dietary counseling; lap banding requires active manage­ment; key elements of band management  —  close cooperation with obstetrician; fluid removed from band to mini­mize band restriction; determine optimal weight gain for pregnancy  (speaker recommends 15-20 lb); fluid added after 14 wk if weight gain excessive; fluid removed from band at 36 wk to minimize impact on delivery and estab­lish lactation (speaker recommends removal of fluid whenever patient having abdominal surgery)

General recommendations: instruct women to use contraception postoperatively, as fertility issues often resolved after surgical weight loss; patient presenting with GI complaints should be assessed for internal hernia; multidisci­plinary approach to prenatal care of bariatric patients important; determine baseline nutritional status early in course of pregnancy

Suggested Reading

Adams TD et al: Long-term mortality after gastric bypass surgery. N  Engl J Med 357:753, 2007; Beard JH et al: Reproductive con­siderations and pregnancy after bariatric surgery: current evidence and recommendations. Obes Surg 18:1023-7, 2008; Buchwald H et al: Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 122:248, 2009; Buchwald H et al: Bariatric surgery: a systematic review and meta-analysis. JAMA 292, 2004; Colquitt JL et al: Surgery for obesity. Cochrane Database Syst Rev 15;:CD003641, 2009; Cumella EJ et al: Comparison of middle-age and young women inpatients with eating dis­orders. Eat Weight Disord 13, 2008; Cunningham E: What effect does weight-loss surgery have on pregnancy outcomes. J Am Diet Assoc 109, 2009; Forman M et al: Characteristics of middle-aged women in inpatient treatment for eating disorder. Eat Disord. 13, 2005; Dao T et al: Pregnancy outcomes after gastric-bypass surgery. Am J Surg 192:762, 2006; Hudson JI et al: The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 61, 2007; Kally Z et al: 100 midlife women with eating disorders: a phenomenological analysis of etiology. J Gen Psychol 135, 2008; Morgan JF et al: The SCOFF ques­tionnaire: assessment of a new screening tool for eating disorders. BMJ 319:1467, 1999; Maggard et al: Pregnancy and fertility fol­lowing bariatric surgery. JAMA 300:2286, 2008.  Sjostrom L et al: Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 357:741, 2007; Sjostrom L: Bariatric surgery and reduction in morbidity and mortality: experiences from the SOS study. Int J Obes (Lond) 32 Suppl 7:S93, 2008 Widerman MW et al: Body dissatisfaction, bulimia, and depression among women: the mediating role of drive for thinness. Int J East Disord. 27, 2000.