COVID-19 and the Challenges in Recovering from Bariatric Surgery
In late summer of 2020, the Centers for Disease Control and Prevention (CDC) released a report that essential workers, unpaid adult caregivers, younger adults, and persons from racial and ethnic minority populations were experiencing worsening mental health conditions and outcomes due to the Coronavirus Disease 2019 (COVID-19) pandemic. The CDC noted a troubling increase in symptoms of anxiety and depression, trauma- and stressor-related disorders, and people having started or increased substance use to cope with the stress related to COVID-19.
Sarah Messiah, Ph.D., M.P.H, already knew that other populations within the United States (U.S.) were also experiencing increased stress and mental health conditions due to the pandemic. She is Director of the Center for Pediatric Population Health at the University of Texas Health Science Center in Dallas, TX. “I’m trying to learn how childhood experiences influence adult health outcomes, particularly obesity and cardiometabolic-related problems,” Dr. Messiah says.
Early in the pandemic, she and her research team reported in Clinical Obesity that COVID-19 stay-at-home orders were having a detrimental impact on the mental health of individuals with obesity. Survey participants reported increased anxiety and depression, and stockpiling food, as well as having more difficulty achieving weight loss goals and managing stress-related eating.
“We also heard through our surgeons that some of their patients who had completed bariatric surgery were using substances, including opioids, to cope with their stress,” Dr. Messiah says. Those informal conversations guided her and her team to begin formally assessing how people with obesity or patients recovering from bariatric surgery were coping during and after the initial lockdown in 2020. She was awarded a COVID-19 supplemental grant from NIMHD to continue this work.
Accessing Mental Health
Metabolic and bariatric surgeries (MBS) are some of the most effective treatments for severe obesity. MBS usually result in significant weight loss for the patient. In 2019, over 250,000 bariatric surgeries were performed in the U.S. – a total that has steadily increased each year since 2011. There are different types of weight loss surgeries, some of which reduce the intake of calories by decreasing the size of the stomach or small intestine in the patient, whereas others affect the gastrointestinal tract by altering hormonal signaling to influence digestion.
Dr. Messiah has studied the socioecological contributors to disparities experienced by people with obesity and access to MBS for the last 11 years. “During the early phases of the pandemic, we were all staying in our homes,” Dr. Messiah says. “For many patients who had bariatric surgery, this new reality was detrimental.”
Recent estimates suggest that lifetime psychiatric illness can occur in as many as 50-70% of patients who have had MBS. Dr. Messiah understood this was a population that could be vulnerable to the stress-related effects of practicing and maintaining social distancing. Her research team found that during the lockdown, patients recovering or having had MBS reported increased sleep problems, feelings of anxiousness, and depression. A follow-up survey after the stay-at-home orders were lifted revealed that many patients were still reporting depression and were more than 20 times as likely to report substance use.
Dr. Messiah knew that stress-eating and substance use can be detrimental to the long recovery commonly experienced by patients having bariatric surgery. She wanted to know how to use this new information to inform clinical decisions moving forward. “Bariatric surgery is a tool, not the answer,” she says. “Lifestyle changes after the surgery are necessary to help the patient succeed in their weight loss journey. All patients must have a mental health clearance before they can proceed, and this new information can help us better prepare our patients, especially in response to the challenges of the pandemic.”
Accessibility and Complications
Dr. Messiah also thought about how the pandemic could worsen accessibility to MBS, which were postponed in most hospitals like the majority of elective surgeries. Insurance coverage is also still a significant barrier to accessing these treatments. “Fifteen years ago, there were a very limited number of plans that covered this surgery,” she says. “Now, a lot of employee health plans and Medicaid will cover bariatric surgery.”
However, an analysis of surgeries performed in states with expanded Medicaid coverage due to the Affordable Care Act found that while there was an increase in surgeries among lower-income non-Hispanic White individuals, there was no such increase in non-Hispanic Black/African American or Hispanic individuals. In addition to race/ethnicity, other major barriers to bariatric surgery include accessibility to the surgeons and post-op care teams. Many teams are found in specialized clinics in urban centers. Some patients experience transportation, financial, or other logistical issues to be able to be seen, have the surgery, and recover, especially if they live far away.
Messiah’s lab is ramping up the next phase of their studies to identify factors to help patients who have had bariatric surgery maintain their weight loss and avoid later complications. They are studying how care teams can help their patients promote positive mental health, sustain supportive lifestyle changes, and manage the logistical barriers the pandemic has worsened.
Elisa Morales-Marroquín, Ph.D., M.S., is a third-year postdoctoral researcher in Dr. Messiah’s laboratory. She has studied bariatric surgery through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program’s (MBSAQIP) database. MBSAQIP contains aggregated data from hundreds of thousands of patients across the U.S. who have had MBS. It tracks patients pre- and post-operation.
Dr. Morales-Marroquín discovered that individuals with uncontrolled type 2 diabetes were more likely to have hospital readmission and less weight loss in the first 30 days following bariatric surgery. “Another risk of bariatric surgery is the development of potential infections,” Dr. Morales-Marroquín says. “We were the first group to show that consuming immunosuppressants prior to surgery increased by 95% the risk of C. Difficile infection post-surgery.”
This may further exacerbate complications due to COVID-19. Whereas corticosteroid use can help patients requiring supplemental oxygen while recovering from COVID-19, it may now predispose them to post-surgical complications in the future.
Dr. Messiah and her team hope that identifying these and other factors contributing to MBS accessibility and long-term recovery, especially while navigating the stressors of the pandemic, will reduce the disparities in who is receiving the surgery. “The pandemic provided unique opportunities to listen to patients that we may not have had the opportunity to previously,” Dr. Messiah says. “We hope to make the most of this new information to support their care and long-term health improvements.”
Page updated March 15, 2022