Gastric bypass-associated AUD: Progression and clinical implications

Bariatric surgery, particularly Roux-en-Y gastric bypass (RYGB), is a major advance in obesity treatment. It produces durable weight loss and has a positive effect on mortality and comorbidities such as diabetes, hypertension and obstructive sleep apnea. According to several large studies, however, gastric bypass can also be associated with an increased risk of alcohol use disorder (AUD), although the exact subgroup of patients who develop alcohol problems is difficult to predict.

To better understand this problem, Mayo Clinic researchers sought to describe the clinical phenotype of gastric bypass patients seeking treatment for AUD. The results of their study were published in the March 2015 issue of the Journal of Psychosomatic Research.

For the study, investigators retrospectively reviewed all patients evaluated by addiction treatment programs at Mayo Clinic's campus in Rochester, Minnesota, from 2004 to 2012. Of these, 44 had bariatric surgery, mainly gastric bypass. They were matched to 122 controls in the same treatment setting who were obese but had not undergone a weight-loss procedure.

According to study author Karen Grothe, Ph.D., L.P., a psychologist specializing in psychological aspects of obesity and bariatric surgery at Mayo’s campus in Minnesota, the study found a significant correlation between RYGB and alcohol consumption, regardless of age or body mass index. Some patients reported consuming about 2.5 drinks per drinking day before surgery compared with more than eight drinks per drinking day in the month prior to seeking treatment for AUD. For about half the patients, the struggle with alcohol was new onset.

The time course for the progression of alcohol consumption after surgery was especially striking. Study results indicate that patients who had undergone RYGB started drinking about 17 months after surgery and by three years met the criteria for AUD, although most didn't seek treatment until five years post-surgery.

Dr. Grothe says the reasons for the association between gastric bypass and AUD aren't entirely clear.

"One theory is that changes in alcohol absorption after gastric bypass make alcohol more addictive," she says. "We have had patients get DUIs after one glass of wine because peak blood alcohol concentration is higher and occurs rapidly — within two to 10 minutes of consumption. Most gastric bypass patients notice an increased sensitivity to alcohol; some are averse to that and drink less. But others may like the feeling and end up drinking more."

Another theory is addiction transfer from food. "People may think, 'I can't eat the way I used to, so I'll drink instead.' They often have more energy and may socialize more after weight loss, which could also lead to increased alcohol use," Dr. Grothe says.

Depression is another issue. Approximately 50 to 60 percent of people who undergo bariatric surgery are taking antidepressants at the time of the procedure. For most of them, depression improves in the first year or two after surgery, but can then trend to baseline. Not only can depression return, but surgery may also alter the absorption of antidepressant medications.

These findings, although not fully understood, have important clinical implications, calling for AUD preventive measures both before and after gastric bypass, Dr. Grothe says.

"The prevalence of post-surgical AUD could be 10 to 15 percent, and we need to educate patients about the risk," she explains. "We connect them with addiction experts before or after the procedure and enlist the support of family and friends. We are also recommending a significant lifelong reduction in alcohol or quitting completely for gastric bypass patients. We tell them we are learning about alcohol and bariatric surgery, but right now, we just don't know what is safe. If they do choose to drink, we ask patients to limit the amount, be in a safe place and definitely not to drive."

For more information

Cuellar-Barboza AB, et al. Change in consumption patterns for treatment-seeking patients with alcohol use disorder post-bariatric surgery. Journal of Psychosomatic Research. 2015;78:199.