Obesity Surgery, Counseling, and Psychological Well-Being

Obesity has become a global epidemic causing enormous human and economic costs. According to the World Health Organization in 2011 overweight and obesity represent the fifth leading risk of death globally, with 2.8 million adults dying each year as a result of excess weight. Worldwide, estimates of overweight and obesity have reached 1.5 billion and 500 million respectively. In addition to an overall increased mortality among this population, a large body of evidence has shown that excess weight is linked to several chronic illnesses including cardiovascular diseases (e.g. stroke), diabetes mellitus (type 2), certain cancers (e.g. breast and colon cancer) and osteoarthritis. Furthermore, obesity inflicts major economic losses. Past research has confirmed that obesity is associated not only with higher medical expenditures due to greater usage of medical services but also with increased non-medical costs, for example due to absenteeism from work.

While the continuous rise of overweight and obesity is a major concern globally, it has reached particular urgency in the MENA region where prevalence rates of both conditions have risen to alarming levels. For example, two recent systematic literature reviews focusing on the Arabian Gulf States reported overweight and obesity rates from 25 to 48% and 13 to 49% respectively across the six countries. UAE-specific data showed obesity rates ranging from 26 to 47%. Additionally, the authors identified the UAE as the Gulf state with the highest hypertension and diabetes rates. In fact, the 2011 UAE diabetes figure of 19% has been confirmed to be one of the highest in the world. When looking at MENA countries outside the Gulf, the highest obesity rates were reported for Syria and Jordan (38% and 35%, respectively).

In order to tackle the increasing burden of obesity, effective intervention and prevention approaches are required. While behavioral and pharmacological treatments (e.g. low calorie diets, exercise, medication) are successful means for overcoming overweight and mild obesity, cases of more severe obesity usually fail to respond to such interventions. Instead, more radical measures such as bariatric surgery are typically needed to achieve substantial weight loss. Past research has shown that most patients lose significant amounts of weight after surgery. However, weight loss maintenance remains problematic with weight regain and other adjustment difficulties (e.g. adapting healthy eating behaviors) being common. Yet, little is known about the risk factors that may trigger weight relapse. Previous research in this context has pointed toward high levels of mental health problems among obese individuals including bariatric surgery patients. Affective, anxiety and eating disorders (in particular binge eating symptoms) were most commonly reported with prevalence rates reaching up to 84%. However, the impact of preoperative psychopathology on actual surgery outcomes is not well understood. Results remain inconsistent and further research is needed to determine whether or not psychological factors jeopardize successful surgery outcomes. Another important question in this regard is whether postoperative interventions that focus on patients' psychological health are helpful in sustaining the achieved weight loss and in coping with postoperative adjustment difficulties. Until now, only few empirical studies have addressed this question. Findings so far indicated a positive impact of postoperative counseling on patients' weight management and overall well-being. However, small sample sizes, differences in study methodology (e.g. qualitative vs. quantitative), and the diversity of therapeutic interventions provided impede any firm conclusions.

In addition to these uncertainties, it is important to recognize that research in the field of bariatric surgery and mental health has been almost entirely restricted to Western countries. Despite repeated searches of several databases (e.g. PsycInfo, Academic Search Premier, and Medline) and examination of bibliographies of relevant papers no matching studies from MENA countries could be found. This lack of regional data is a major concern given the difficulty of generalizing findings cross-culturally on the one hand and the high obesity rates in this part of the world on the other. MENA-based research in this field would yield vital insights for policy makers, commissioners and practitioners in the management and delivery of evidence-based best-practice and patient-oriented care.

Therefore, the proposed study aims to:

1. Examine psychological health before and after bariatric surgery among obese patients in the UAE and Jordan
2. Investigate the impact of patients' psychological health on postoperative weight loss, and
3. Assess the efficacy of group-based counseling to improve patient outcomes (i.e. weight loss and psychological health) after bariatric surgery

The study hypotheses are as follows:

1. Participants with higher levels of psychological health problems before surgery will lose less weight (in %) during the first 12 months after surgery than patients with lower levels of psychological health problems.
2. Participants who receive postoperative counseling in addition to standard treatment will lose more weight (in %) during the first 12 months after surgery than patients who are provided with standard treatment only.
3. Participants who receive postoperative counseling in addition to standard treatment will show less psychological health problems at 12 months after surgery than patients who are provided with standard treatment only.