THE EFFECT OF BARIATRIC SURGERY ON THE MENTAL STATE OF PATIENTS IN ISRAEL: A SYSTEMATIC REVIEW

Purpose: The purpose of this systematic review is to investigate the impact of bariatric surgery on the mental state of patients in Israel. The study aims to address how bariatric surgery affects the mental state of patients and whether there is an association between the mental state post-surgery and weight loss. Theoretical Reference: This review utilizes the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to systematically gather and analyze research evidence. The theoretical foundation is based on existing literature examining the relationship between bariatric surgery, mental health, and weight loss outcomes. Method: The study employs a systematic review method, adhering to the PRISMA guidelines. Eligibility criteria included studies published in English or Hebrew in the last 10 years, focusing on the effects of bariatric surgery on the mental state of patients in Israel. A comprehensive search strategy was used to identify relevant articles from electronic databases, and data were extracted and summarized in a table format. Results and Conclusion: A total of 10 studies were included in the final review. The results indicate that bariatric surgery generally improves the mental state of patients in Israel, both in the short term and long term. Key findings suggest improvements in depression, anxiety, and overall mental health post-surgery. However, there are contradictions regarding the timeline of these improvements and their association with weight loss. Some studies found no direct link between mental health improvements and weight loss, while others identified factors like emotional regulation and self-management as crucial for maintaining mental health post-surgery. Implications of Research: T he findings highlight the need for tailored mental health support for bariatric surgery patients, focusing on emotional regulation and self-management strategies. Healthcare providers should consider these factors when planning post-operative care to enhance the overall well-being of patients. Originality/Value: This review fills a gap in the literature by specifically examining the mental health outcomes of bariatric surgery patients in Israel. It provides valuable insights for healthcare professionals and policymakers to improve the holistic care of patients undergoing bariatric surgery, emphasizing the importance of addressing psychological well-being alongside physical health outcomes.


INTRODUCTION
1.1 BACKGROUND Bariatric surgery, gastric bypass, or metabolic surgery is a procedure commonly used to reduce weight loss in overweight or obese individuals.Bariatric surgery is recommended in individuals with a body mass index (BMI) of greater than 40 or a BMI of over 35 accompanied by obesity-related health problems.The surgical procedure changes the body's digestion process by reshaping the stomach to allow food to bypass the small intestine.The procedure leads to reduced absorption of calories and the individual feels full much faster after eating.
However, there are different types of bariatric surgeries.One of the common types of bariatric surgery is known as Roux-en-Y or gastric bypass, which involves surgical removal of the small intestine and the top of the stomach (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], n.d).Another type of bariatric surgery is known as sleeve gastrectomy, which entails removing up to 80% of the stomach leading to significant weight loss.
Biliopancreatic diversion with duodenal switch (BPD/DS) is another procedure that entails creating biliopancreatic diversion to reduce appetite and the absorption of nutrients (NIDDK, n.d.).
Data from the International Federation for Surgery for Obesity and Metabolic Disorders (IFSO) (2023) shows that 480970 bariatric operations were conducted in 24 countries for patients with obesity.Most operations involved sleeve gastrectomy but Roux-en-Y gastric bypass was the most frequent revisional operation.In Israel, the National Registry of Bariatric Surgery notes that about 14,000 bariatric surgeries are conducted annually.A study by Kaplan  2020) found that 42,296 bariatric surgeries were conducted between 2014 and 2018, with females representing 68% of the patients.Overall, the findings indicate an overall trend in which bariatric surgery is decreasing in Israel, which could be attributed to the popularity of One Anastomosis-Mini Gastric Bypass (OAGB-MGB) (Kaplan et al., 2020).These findings are corroborated by data showing that of all 8,200 surgeries in Israel in 2021, 5,635 were OAGB, representing 68.2% (Abu-Abeid et al., 2024).8000 OAGB were performed in Israel.

PROBLEM STATEMENT
Studies examining barriers to the uptake of bariatric surgery in Israel have found that the key challenges include a lack of scientific information and regulatory enforcement (Beglaibter et al., 2020), the workload and experience of primary care physicians (Zoabi et al., 2024), and body stigma and psychological distress among candidates of bariatric surgery (Geller et al., 2012).The existing research literature examines the factors that influence individuals to undergo bariatric surgery and the associated health outcomes.However, there is a paucity of research on the effects of bariatric surgery on the psychological state of patients, particularly in Israel.Preliminary findings suggest that bariatric surgery induces short-term changes among adolescents, including improvements in mental, physical, and social factors, which are not related to excess weight loss (Goldenshluger et al., 2022).A study by Monteleone et al. (2022) found that depression, stress, and body shape are strong psychopathological predictors of bariatric surgery outcomes after 3 years of operation.A similar study conducted in Poland and Germany found that bariatric surgery led to a significant decrease in psychiatric symptoms, including depression, anxiety, and stress, after 12 months of treatment, compared to conservatively treated patients (Paczkowska et al., 2022).It has been suggested that depression and anxiety symptoms improve from 3 weeks after bariatric surgery but the improvements in symptoms are independent of preoperative BMI (Aylward et al., 2023).Although the consensus is that bariatric surgery can improve the mental state of patients, there are contradictions in the literature on how soon the improvements in psychiatric symptoms occur and whether such improvements are associated with pre-surgery BMI or post-surgery body weight loss.
Moreover, concerns abound about the increase in adverse mental health issues, including selfharm, suicide, and alcohol use disorder (Law et al., 2023).Further research is required to investigate the short-term and long-term effects and the course of psychiatric symptoms in patients after undergoing bariatric surgery.ii.Is there an association between the mental state of patients after undergoing bariatric surgery and weight loss?

RESEARCH QUESTIONS
The study methodology was designed to address three specific research questions: How does bariatric surgery affect the mental state of patients in Israel?; How long do the psychiatric symptoms of patients change after bariatric surgery, and Is there an association between the mental state of patients after undergoing bariatric surgery and weight loss postoperation?

STUDY DESIGN
The study design was conducted based on the Preferred Reporting Items for Systematic Review and Metanalysis (PRISMA) Guidelines (Page et al., 2021).A systematic review is a formal research method that relies on explicit and systematic methods to gather and analyze available research evidence to address a clearly defined question (Page et al., 2021).A systematic literature review is justified for this study because it envisages providing a conclusive summary of the current evidence on the research topic.Moreover, a systematic review allows the researcher to appraise and synthesize the evidence.

ELIGIBILITY CRITERIA
Studies were included in the systematic review if they met the following criteria: (1) they were published in English or Hebrew in the last 10 years; (2) examine the effects of bariatric surgery on the mental state of patients; (3) sampled a population of patients from Israel.
Studies that did not meet the criteria were excluded.were searched manually to identify additional relevant studies.Mental health websites were also searched to identify grey literature and credible unpublished manuscripts.

STUDY SELECTION
The researcher evaluates the methodological validity of each of the retrieved studies based on the inclusion criteria.The overall process of selecting relevant papers was based on the PRISMA framework or search process (See Figure 1).

Figure 1
PRISMA flow diagram for systematic review (Adopted from Page et al., 2021). The

RESULTS
Figure 1 shows the PRISMA flowchart summarizing the data collection process.A total of 97 articles were identified in the initial search process.13 duplicate records and 20 other records were removed before screening.The remaining 64 records were screened and 28 were removed for not meeting the inclusion criteria.36 reports were prepared for retrieval but 5 of these reports could not be retrieved for various reasons.The remaining 31 papers were examined for eligibility, whereby 1 article was removed because it was published in Arabic, 8 papers were removed because they did not focus on the effects of bariatric surgery on the mental state of patients, and 10 papers were removed for not focusing on patients in Israel.A total of 10 studies were included in the final review.The reviewed papers are summarized in Table 1.
All the papers included in the final review provided Level III evidence, and most papers used cross-sectional, prospective cohort studies, case-control studies, or retrospective studies with similar evidence levels.The sample varied from 36 to 266, including diverse patient populations, including adolescents and adults.The study period or follow-up period varied from a short period of 1 year to a maximum of 10 years.The majority of the studies involved bariatric surgery candidates and post-operative patients across different medical institutions, including pre-surgical bariatric centers to tertiary university medical centers.A cross-sectional study in 2 pre-and post-operative cohorts to study the quality of life and depression after primary sleeve gastrectomy.
Patients (n = 160) who underwent primary SG in both cohorts received psychiatric/psychological evaluation before and after surgery.
1 and 2 years.11 The consensus in most of the studies is that bariatric surgery improves the mental state of patients in Israel, both in the short term (Goldenshluger et al., 2022: Mishali & Kisner, 2022) and in the long term (Canetti et al., 2021;Oved et al., 2021).However, the researchers examined different aspects of mental state of bariatric surgery patients, including psychological distress due to body image dissatisfaction (Geller et al., 2020), emotional eating (Geller et al., 2020), eating disorders, effective symptoms, and interpersonal and psychosocial functioning (Monteleone et al., 2022), social rejection (Goldenshluger et al., 2022), self-esteem, neuroticism, and fear of intimacy (Canetti et al., 2016).The broad approach to mental health issues is consistent with the wide spectrum of mental health, which spans from wellness to mental suffering.Goldenshluger et al. (2022) found significant short-term (9 months) improvements in mental health by 9.5% (p ≤ 0.002) and improvement in social parameters, such as social rejection, which decreased significantly (p = 0.02) and participation in school social activities, which increased significantly (p = 0.008).overall, the research found that mental health was associated with baseline social rejection ((r = 0.514, p < 0.001), but there was no relationship between any of the improvements with the % excess weight loss.However, body image dissatisfaction (BID) has been associated with suicidality, depression, and anxiety in both Israel and the United States.In both cultures, the correlation between BID and depression and anxiety was mediated by emotional eating.A longer study with a follow-up period of 3 years found worse psycho-social functioning after bariatric surgery, with depression, stress, and shape concerns being the most prevalent concerns.
A few of the studies linked mental health after undergoing bariatric surgery to weight loss (Canetti et al., 2016;Ben-Porat et al., 2021;Mishali & Kisner, 2022).In the study by Ben-Porat et al. (2021) bariatric surgery patients maintain long-term weight loss, with a mean BMI, % excess weight loss, and % total body weight loss of 33.1 ± 6.1, 55.5 ± 27.5%, and 21.7 ± 10.7%, respectively.For patients who do not attain satisfactory weight loss, the findings showed that higher baseline BMI was the strongest independent predictor, (OR = 0.90, p = 0.001, 95% CI 0.85, 0.96).Further research on the factors that predict increased weight gain from nadir weight showed that sweetened beverage consumption, use of psychiatric medications, higher BMI, and lower age were the most significant factors (P < 0.0001, P = 0.005, P = 0.035, and P < 0.0001, respectively).These findings suggest the need for clinical practice to focus on promoting the relationship between weight loss outcomes and specific behaviors post-bariatric operation.On the other hand, Mishali and Kisner (2022) found that effective emotional regulation is associated with successful bariatric surgery based on weight maintenance.Patients who have difficulties in emotional regulation have challenges maintaining weight loss.12 However, some studies show contradictory findings with no relationship between the mental state after surgery and weight loss.For example, Goldenshluger et al. (2022) found that BMI decreased by 30% and all physical parameters improved significantly after bariatric surgery (p ≤ 0.001).However, the improvements were not associated with the extent of % excess weight loss.

DISCUSSION
The purpose of this study was to examine the impact of bariatric surgery on the mental

LIMITATIONS
This study has several limitations.Firstly, there is a lack of studies examining the mental state of Israeli patients following bariatric surgery.Even for the studies addressing the research topic, researchers used different methodologies thus making it difficult to compare the effect of surgery on patients.The diversity of the mental health issues examined also made it difficult to assess the impact of surgical operations on the mental health of patients.In many studies, there were no adequate baseline psychiatric assessments.Moreover, the papers analyzed in this study did not account for differences in the surgical procedures and the specific psychiatric issues patients may experience.Future research should aim to focus on specific types of bariatric surgery and certain mental health issues for the same patient demographic.

CONCLUSION
This study has found that bariatric surgery has complex implications for the mental state of Israeli patients.In some patients, bariatric surgery can improve their mental state but some patients may experience deterioration in mental wellbeing.Factors that influence the impact of bariatric surgery on mental health include patients' emotional regulation and self-management.

The
Effect of Bariatric Surgery on the Mental State of Patients in Israel: A Systematic Review ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-16 | e08149 | 2024.5 1.3 AIMS OF THE STUDY The purpose of this paper is to investigate the impact of bariatric surgery on the mental state of patients in Israel.The study addresses two specific research questions: i.How does bariatric surgery affect the mental state of patients in Israel?

The
Effect of Bariatric Surgery on the Mental State of Patients in Israel: A Systematic Review ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-16 | e08149 | 2024.6 2.4 SEARCH STRATEGY A search string was developed to identify the most relevant sources.The search string combined the following keywords: (Effects, [bariatric surgery OR gastric bypass], [mental state OR psychiatric symptoms], Patients, Israel) with Boolean operators.The key string was used to identify articles from the following electronic databases: MEDLINE, PUBMED, Science Direct, Psych, SCOPUS, Google Scholar, and ProQuest.The reference lists of retrieved papers Effect of Bariatric Surgery on the Mental State of Patients in Israel: A Systematic Review ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-16 | e08149 | 2024.7 2.6 DATA COLLECTION PROCESS Data extracted from each of the articles meeting the inclusion criteria was entered into a summary table consisting of the following fields: authors, year of publication, sample and setting, research design and purpose, study period/follow-up, findings, and evidence level.
Bariatric Surgery on the Mental State of Patients in Israel: A Systematic Review ___________________________________________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-16 | e08149 | 2024.10 their associations with weight outcomes following bariatric surgery.need to eat sweets, binge eating, and feeling guilty and sad.About half of the patients achieved excess weight loss of more than 50% and developed certain eating pathologies related to weight outcomes.Canetti et al., 2021.A qualitative study to evaluate the mental health and psychological functioning of bariatric patients before and after bariatric surgery after 1 and 10 years of follow-up.A sample (n =36) of bariatric surgery patients and 34 participants of a weight loss program were assessed at baseline, after 1 year, and after 10 years. 1 to 10 years.The surgery group achieved successful weight loss after 10 years compared to baseline health quality of life scores.However, mental health, neuroticism, sense of control, and fear of intimacy deteriorated compared to preoperative levels.III The Effect of Bariatric Surgery on the Mental State of Patients in Israel: A Systematic Review ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-16 | e08149 | 2024.
state of patients in Israel.Two specific research questions were defined.The first question examined how bariatric surgery affects the mental state of patients in Israel.The investigation focused on Israel because cultural and lifestyle factors can influence mental health.The consensus is that bariatric surgery improves the mental health of Israeli patients post-operation, albeit with researchers examining a broad spectrum of mental health issues and symptoms.For example,Geller et al. (2020) examined the relationship between BID and psychological distress variables among bariatric surgery candidates in Israel and the United States.The key mental health issues examined in this study were suicidal ideation, depressive symptoms, anxiety, and emotional eating disorders.Analyses using mediation models and path analysis found a positive correlation between depression, anxiety, and suicidality in both Israeli and U.S. samples.In both cultures, emotional eating mediated the correlation between BID and depression and anxiety.These findings demonstrate that BID can lead to psychological distress in surgery candidates.Studies that examined mental health before bariatric surgery also suggested that the development of psychopathology before surgery predicts the post-operative mental state of the patient within 3 years(Monteleone et al., 2022).This study focused on affective symptoms, shape concerns, eating attitudes, and interpersonal and psycho-social functioning.The findings demonstrated that only affective symptoms and shape concerns predict post-surgery eating disorder and psychosocial functioning.However, researchers have also established the longterm effects of bariatric surgery on mental health.For example, Oved et al. (2021) found that eating and lifestyle behaviors affect weight outcomes in the long term (> 5 years) post-surgery.The study found that eating pathologies and the associated eating patterns were related to weight outcomes.The second research question examined whether the mental state of patients postsurgery is associated with weight loss.Research shows that weight loss after bariatric surgery can improve healthy habits, mood, self-esteem, and body image of patients in Spain (Diaz-The Effect of Bariatric Surgery on the Mental State of Patients in Israel: A Systematic Review ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-16 | e08149 | 2024.13Gonzalez, 2024).However, there is a lack of research in the context of Israeli patients.In a study conducted in a tertiary university medical center in Israel,Ben-Porat et al. (2021) found that patients maintained long-term weight loss, albeit with significant weight regain and insufficient weight loss associated with specific lifestyle patterns.The most significant predictors of weight regain were consumption of sweetened beverages, use of psychiatric medications, higher initial BMI, and lower age, (P < 0.0001, P = 0.005, P = 0.035, and P < 0.0001, respectively).Goldenshluger et al. (2022) found that physical parameters significantly improved (p ≤ 0.002) after bariatric surgery in a sample of 97 adolescents recruited in a multicenter prospective cohort study in Israel.However, the study findings indicated no relationship between physical improvements and excess weight loss.Overall, various factors could mediate the link between weight loss and mental health improvements post-surgery.Mishali and Kisner ((2022) demonstrated that patients who exhibit effective emotional regulation are likely to maintain weight loss after surgery.Shinan-Altman emphasizes the role of self-management in improving mental and physical health after bariatric surgery.The study found that emotional eating was the only variable affecting patients' capability for self-management.

The
Effect of Bariatric Surgery on the Mental State of Patients in Israel: A Systematic Review ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-16 | e08149 | 2024.14 While bariatric surgery aims to foster weight loss, this study has established no direct link between mental health improvements and weight loss.The lack of research in this area suggests the need for further investigations to underpin the relationship between weight loss maintenance and mental health status after bariatric surgery.