Project HELP: a Remotely Delivered Behavioral Intervention for Weight Regain after Bariatric Surgery

Evaluating the Impact of a Virtual Health Coaching Lifestyle Program on Weight Loss after Sleeve Gastrectomy: A Prospective Study

Bariatric surgery (BS) is a leading treatment for obesity; however, adverse side effects (e.g., pain and infection) can deter patients or affect weight maintenance. This study investigates how a post-operative virtual health coaching lifestyle program, monitoring virtual weekly goal progress made by patients, affects weight loss after BS, specifically sleeve gastrectomy. Patients recruited for this 6-month study were classified with a BMI > 30 kg/m2 90 days post-operatively. Patients were prescribed lifestyle support delivered by certified health and wellness coaches (InHealth Lifestyle Therapeutics™). Demographic variables (e.g., age, weight, height, and gender) were obtained and compared according to initial, 3-, 6-month, and current weight through repeated measures ANOVA and post hoc comparison. Thirty-eight adult participants were included, with a mean age of 52 years ± 12.9 and with a majority (n = 35; 97%) of them being female. There were significant differences in weight reported across all five time points (p < 0.05), with the greatest weight difference seen between the initial (250.3 ± 45.5 lbs.) and final time points (226.7± 40.4 lbs.). This study suggests post-operative virtual health coaching can enhance weight loss outcomes after sleeve gastrectomy. Further research is needed to assess the long-term effects and cost-effectiveness of such a form of coaching for bariatric surgery patients.

Pharmacological treatment of non-responders following bariatric surgery

Obesity is a complex chronic disease and requires a long-term multidisciplinary management. Even patients undergoing bariatric surgery, one the most effective treatments for obesity, can have insufficient weight loss (IWL) than expected (primary non responder) or weight regain (WR) after a successful primary procedure (secondary non responder). A poor response represents a challenge of bariatric surgery that can induce persistence or recurrence of obesity-related comorbidities, prejudicing benefits of surgery. Increasing evidence suggests that weight loss medications represent a useful strategy in obesity care also after bariatric surgery procedures. This narrative review summarizes the evidence concerning anti-obesity therapy in the management of no-responders to primary bariatric surgery. Available data on liraglutide (one randomized double-blind placebo-controlled trial, three prospective and three retrospective studies), naltrexone/bupropion (three retrospective studies), orlistat (one case control prospective and one retrospective studies) and topiramate and phentermine (five retrospective studies) have been considered. Available data suggest that weight loss medications could offer a significant adjunctive benefit to lifestyle and behavioral modifications in the life-long management of obesity. Newer treatment modalities including the use of anti-obesity drugs provide patients and healthcare providers with more options in the management of poor response after bariatric surgery.

Patient Satisfaction and Healthcare Utilization with the Transition to Virtual Care in a Multidisciplinary Bariatric Program

BACKGROUND

The COVID-19 pandemic saw an acceleration in virtual-visits (VV) for healthcare delivery. However, the impact of virtual care in metabolic/bariatric surgery (MBS) programs is not well described.

METHODS

Appointment data from three time-points: pre-pandemic (1/1/19-3/15/20, n = 19,290), pandemic (3/16/20-10/31/21, n = 29,459) and current-state (11/1/21-12/31/2022, n = 24,270) was retrieved in our multi-hospital ambulatory MBS program. Appointments were grouped by health care provider (HCP) (MD, dietician, and psychologist) and type (VV and in-person). Surveys assessing patient satisfaction were distributed electronically. All pre-op and post-op appointment data was analyzed for the time-points above. Appointment completion rates and patient reported preferences were described.

RESULTS

Our data showed an increase in scheduled VV from 0.5% for all HCP visits to 81% during the pandemic and a current VV visit of 77%. The number of completed VV increased for all HCPs, most prominently for dieticians. Parallel to this, the percentage of no-show visits also improved for all HCP, with MDs having the lowest no-show rate currently. Survey data revealed 89% of patients experience added benefits with VV and > 90% reported their VV experience as very good. VV were preferred over in-person visits for psychologists and dietitians (> 61%), but the majority preferred to see MDs in-person (70%).

CONCLUSIONS

Our findings reveal significant changes in healthcare utilization trends since the transition to virtual care. While overall satisfaction with virtual care is high, most patients prefer in-person visits with MDs. Thus, multi-disciplinary MBS care can be performed effectively using a hybrid model to ensure efficient distribution of resources.

Acceptability and Feasibility of the Telehealth Bariatric Behavioral Intervention to Increase Physical Activity Before Bariatric Surgery: A Single-Case Experimental Study (Part I)

BACKGROUND

Physical activity (PA) can play an important role in optimizing metabolic/bariatric surgery (MBS) outcomes. However, many MBS patients have difficulty increasing PA, necessitating the development of theory-driven counseling interventions. This study aimed to (1) assess the feasibility and acceptability of the TELEhealth BARIatric behavioral intervention (TELE-BariACTIV) trial protocol/methods and intervention, which was designed to increase moderate-to-vigorous intensity physical activity (MVPA) in adults awaiting MBS and (2) estimate the effect of the intervention on MVPA.

METHODS

This trial used a repeated single-case experimental design. Twelve insufficiently active adults awaiting MBS received 6 weekly 45-min PA videoconferencing counseling sessions. Feasibility and acceptability data (i.e., refusal, recruitment, retention, attendance, and attrition rates) were tracked and collected via online surveys, and interviews. MVPA was assessed via accelerometry pre-, during, and post-intervention.

RESULTS

Among the 24 patients referred to the research team; five declined to participate (refusal rate = 20.8%) and seven were ineligible or unreachable. The recruitment rate was 1.2 participants per month between 2021-09 and 2022-07. One participant withdrew during the baseline phase, and one after the intervention (retention rate = 83.3%). No participant dropouts occurred during the intervention and 98.6% of sessions were completed. Participants' anticipated and retrospective acceptability of the intervention was 3.2/4 (IQR, 0.5) and 3.0/4 (IQR, 0.2), respectively. There was a statistically significant increase in MVPA [Tau-U = 0.32(0.11; 0.51)] from pre- to post-intervention.

CONCLUSION

Despite a low recruitment rate, which could be explained by circumstances (COVID-19 pandemic), results support feasibility, acceptability, and preliminary efficacy of the TELE-Bari-ACTIV intervention for increasing MVPA in patients awaiting MBS.

Vitamin D and the Metabolic Phenotype in Weight Loss After Bariatric Surgery: A Longitudinal Study

PURPOSE

To evaluate the influence of vitamin D (VD) concentrations coupled with metabolic phenotypes preoperatively and 6 months after Roux-en-Y gastric bypass (RYGB) on body variables and weight loss.

MATERIALS AND METHODS

A longitudinal, retrospective, analytical study comprising 30 adult individuals assessed preoperatively (T0) and 6 months (T1) after undergoing Roux-en-Y gastric bypass. The participants were distributed preoperatively into metabolically healthy obese (MHO) and metabolically unhealthy obese individuals (MUHO) according to the HOMA-IR classification, as well as the adequacy and inadequacy of vitamin D concentrations in the form of 25(OH)D. All participants were assessed for weight, height, body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), visceral adiposity index (VAI), body circularity index (BCI), body adiposity index (BAI), weight loss, and assessment of 25(OH)D and 1,25(OH)2D concentrations using high-performance liquid chromatography with an ultraviolet detector (HPLC-UV). The statistical program used was SPSS version 21.

RESULTS

VD adequacy and a healthy phenotype in the preoperative period may play an important role concerning body fat distribution, as the body averages for WHtR (0.020*) and BCI (0.020*) were lower in MHO participants. In comparison, those with VD inadequacy and MUHOs had higher BAI averages (0.000*) in the postoperative period. Furthermore, it is possible that VD inadequacy before and after RYGB, even in the presence of an unhealthy phenotype, may contribute to the increase in VAI values (0.029*) after this surgery. Only those with inadequate VD and MUHOs had higher 25(OH)D concentrations. Besides, this unhealthy phenotype had a greater reduction in BMI in the early postoperative period (p < 0.001).

CONCLUSION

This study suggests that VD adequacy and the presence of a healthy phenotype appear to have a positive impact on the reduction of visceral fat in the context of pre- and postoperative obesity. In addition, there was a greater weight reduction in those with VD inadequacy and in MUHO, which suggests that the volumetric dilution effect of VD and catabolism after bariatric surgery is more pronounced in this specific metabolic phenotype.

Weight Regain after Metabolic Surgery: Beyond the Surgical Failure

Patients undergoing metabolic surgery have factors ranging from anatomo-surgical, endocrine metabolic, eating patterns and physical activity, mental health and psychological factors. Some of the latter can explain the possible pathophysiological neuroendocrine, metabolic, and adaptive mechanisms that cause the high prevalence of weight regain in postbariatric patients. Even metabolic surgery has proven to be effective in reducing excess weight in patients with obesity; some of them regain weight after this intervention. In this vein, several studies have been conducted to search factors and mechanisms involved in weight regain, to stablish strategies to manage this complication by combining metabolic surgery with either lifestyle changes, behavioral therapies, pharmacotherapy, endoscopic interventions, or finally, surgical revision. The aim of this revision is to describe certain aspects and mechanisms behind weight regain after metabolic surgery, along with preventive and therapeutic strategies for this complication.

Positive Program Evaluation and Health Maintenance among Post-Metabolic and Bariatric Surgery Patients Following a 6-Week Pilot Program

PURPOSE

Despite lifestyle changes and medication therapies, weight loss is difficult to maintain. Metabolic and bariatric surgery (MBS) is an effective route for significant weight reduction. However, post-operation there are limited opportunities to support weight loss maintenance. The following study aimed to pilot test a 6-week, 6-session nutrition and support program for post-MBS surgery patients.

MATERIALS AND METHODS

A 6-week post-MBS pilot nutrition and support program was developed to test feasibility and acceptability. Participants completed a baseline survey that included demographics, weight changes, success post-surgery, and self-efficacy of leading a healthy lifestyle. Weight change, percent total weight loss, self-efficacy, and program evaluation measures were assessed.

RESULTS

Participants (n = 18) were recruited from a local MBS clinic, predominately female (88.9%), non-Hispanic white (94.4%), received sleeve gastrectomy surgery (100%), and were 2-3 years post-operation (44.4%). Eight of the 18 participants attended the in-person sessions, serving as the intervention group. Both weight loss over and behavioral variables remained stable for both groups across the 6 weeks with no significant differences from pre to post program (p > 0.05). For program evaluation, intervention participants "agreed" or "strongly agreed" with 10 of 11 program satisfaction measures.

CONCLUSION

Following the program, weight loss was maintained among both intervention and control groups. Intervention feedback indicated that the program's approach to provide nutrition education and support was successful and acceptable. Future enhancement of the intervention should include a broader multidisciplinary approach, longer intervention period, and intentional recruitment of participants with a weight regain.

The nature of expectations of bariatric surgery in patients during the pre- and post-operative period: A unicentric, qualitative study of patient perspectives

Many patients (20%-30%) experience suboptimal weight loss (WL) after bariatric surgery (BS), and unrealistic preoperative WL expectations may be a contributing factor. This study aimed to describe the nature of patients' general expectations of BS during the pre-surgical period, and how patients determined whether their expectations and WL goals (WLGs) were realistic. The extent to which patients' expectations and WLGs were met and/or changed during the post-surgical period was also assessed. Semi-structured interviews were conducted with 15 preoperative patients recruited approximately 6-months before surgery. Focus groups were also conducted with 14 post-operative patients recruited approximately 6-months after surgery. Interviews and focus groups were audio-recorded, transcribed verbatim and analysed using qualitative content analysis. Preoperative patients reported expectations that BS would positively impact physical and psychological health, social relationships, as well as quality of care. Preoperative patients perceived that they and their health care professionals had unrealistically high expectations of WL. Post-operative patients reported being generally satisfied with the outcomes of surgery, even though many did not reach their expected WL. Finally, most post-operative patients reported changing their expectations from pre- to post-surgery. This study provides data that may help inform the development of preoperative interventions focusing on helping patients set realistic expectations for WL and related outcomes, which could better prepare patients for the challenges they will face after surgery.

Racial Differences in Psychiatric Symptoms, Maladaptive Eating, and Lifestyle Behaviors After Bariatric Surgery

There are several psychological and behavioral factors associated with poorer outcomes following bariatric surgery, yet it is unknown whether and how these factors may differ by race. In this cross-sectional study, individuals who underwent bariatric surgery from 2018 to 2021 and up to 4 years post-surgery were invited to complete an online survey. Psychiatric symptoms, maladaptive eating patterns, self-monitoring behaviors, and exercise frequency were examined. Participants (N = 733) were 87% women, 63% White, with a mean age of 44 years. Analyses of covariance demonstrated that White individuals endorsed greater anxiety symptoms (p =.01) and emotional eating due to depression (p = .01), whereas Black individuals endorsed greater depression severity (p = .02). Logistic regression analyses demonstrated that White individuals were more likely to experience loss of control eating (OR= 1.7, p = .002), grazing (OR= 2.53, p <.001), and regular self-weighing (OR= 1.41, p <.001) than Black individuals, and were less likely to skip meals (OR= .61, p = .04), or partake in nighttime eating (OR= .40, p <.001). There were no racial differences in binge eating, emotional eating due to anxiety or frustration, use of a food diary, or exercise. Thus, depressive symptoms, skipping meals, and nighttime eating may be important, modifiable intervention targets to optimize the benefits of bariatric surgery and promote equitable outcomes.

The Effects of a Web-Based Interactive Nurse Support Program Based on the Health Promotion Model on Healthy Living Behaviors and Self-Efficacy in Patients Who Regained Weight after Bariatric Surgery: A Randomized Controlled Trial

PURPOSE

This study was conducted in order to determine the effects of web-based interactive nursing support program prepared in line with Health Promotion Model (HPM) on healthy lifestyle behaviors and self-efficacy of patients who regained weight following metabolic and bariatric surgery.

MATERIALS AND METHODS

A total of 62 patients with a history of weight regain at least two years after metabolic and bariatric surgery were divided into intervention (n = 31) and control (n = 31) groups by stratified randomization. The intervention group was given a web-based interactive nurse support program based on HPM for 10 weeks and followed up by telephone 12 times (every two weeks) in 6 months. No attempt was made to the control group during the study. The data were collected a total of 3 times before the training, in the 12th week and in the 6th month.

RESULTS

In the last test after the web-based interactive nurse support program and telephone follow-up, the difference was found to be statistically significant in terms of BMI, healthy lifestyle behaviors, eating behaviors, and general self-efficacy mean scores of the patients in the intervention group (p < 0.05). In addition, after the study, it was determined that the physical activity, nutrition, spiritual development, emotional eating and the Dutch Eating Behavior scales total score averages and Self-Efficacy Scale total score averages of the intervention group changed positively compared to the control group, and this change was statistically significant (p < 0.05). There was no difference between the groups in the mean scores of health responsibility, interpersonal relationships, stress, restrictive eating, external eating and Healthy Lifestyle Behaviors-II Scale (p > 0.05).

CONCLUSION

It can be stated that the web-based interactive nurse support program based on HPM is applicable in patients who regain weight after metabolic and bariatric surgery, and it contributes positively to the healthy lifestyle behaviors, BMI, eating behaviors, and general self-efficacy of these patients. In order to ensure the continuity of post-operative patient follow-up, it is recommended to increase the importance of telephone counseling and to establish follow-up program based on the HPM.

How to address weight regain after bariatric surgery in an individualized way

Bariatric surgery is the most effective obesity treatment. As a chronic and progressive disease, weight loss response to surgery will vary individually. Thus, insufficient weight loss or regain can happen after surgery, but they lack a standard definition. There are different mechanisms underlying weight regain and/or insufficient weight loss, such as genetics, maladaptive eating behaviors, and the inadequate choice of index operations, among others. Patients with weight regain or insufficient weight loss should be submitted to an individualized and comprehensive evaluation by a multidisciplinary team. This may help identify the causes and direct the appropriate treatment individually. Options for patients with insufficient weight loss and/or weight regain following bariatric surgery include repair of postoperative complications, conversion into another operation, endoscopic therapies with inconsistent outcomes, and dietary/behavioral counseling. Revision and conversion surgeries have higher complication rates than primary operations. Although there is no standard pharmacological regimen for that indication, the new agents seem efficient and safe to promote the loss of the regained weight and even be adjunctive to selected patients before they reach the plateau. This review aims to summarize the knowledge of the best approach for patients with weight regain/insufficient weight loss and suggests an algorithm to customize the approach and therapeutic options after bariatric surgery.

What About My Weight? Insufficient Weight Loss or Weight Regain After Bariatric Metabolic Surgery

Context

This review study aimed to investigate the definition, etiology, risk factors (RFs), management strategy, and prevention of insufficient weight loss (IWL) and weight regain (WR) following bariatric metabolic surgery (BMS).

Evidence Acquisition

Electronic databases were searched to retrieve relevant articles. The inclusion criteria were English articles with adult participants assessing the definition, prevalence, etiology, RFs, management strategy, and prevention of IWL/WR.

Results

Definition: The preferred definition for post-BMS IWL/WR are the terms "Lack of maintenance of total weight loss (TWL)>20%" and "weight change in percentage compared to nadir weight or weight loss". Prevalence: The exact prevalence of IWL/WR is still being determined due to the type of BMS and various definitions. Etiology: Several mechanisms, including hormonal/metabolic, dietary non-adherence, physical inactivity, mental health, and anatomic surgical failure, are possible etiologies of post-BMS IWL/WR. Risk factors: Preoperative body mass index (BMI), male gender, psychiatric conditions, comorbidities, age, poor diet, eating disorders, poor follow-ups, insufficient physical activity, micronutrients, and genetic-epigenetic factors are the most important RFs. Management Strategy: The basis of treatment is lifestyle interventions, including dietary, physical activity, psychological, and behavioral therapy. Pharmacotherapy can be added. In the last treatment line, different techniques of endoscopic surgery and revisional surgery can be used. Prevention: Behavioral and psychotherapeutic interventions, dietary therapy, and physical activity therapy are the essential components of prevention.

Conclusions

Many definitions exist for WR, less so for IWL. Etiologies and RFs are complex and multifactorial; therefore, the management and prevention strategy is multidisciplinary. Some knowledge gaps, especially for IWL, exist, and these gaps must be filled to strengthen the evidence used to guide patient counseling, selection, and improved outcomes.

How to get back on track? Experiences of patients and healthcare professionals regarding weight recurrence and needs for an intervention after bariatric-metabolic surgery

Background

Multidisciplinary lifestyle interventions are recommended as a first step in treating weight recurrence after bariatric-metabolic surgery (BMS). However, little is known about the experience of patients and healthcare professionals (HCP) with these interventions and how they should be tailored to the patients' needs. The aim of this study was to gain more insight into the experiences and needs of patients and HCP regarding weight recurrence after BMS and an intervention to get Back on Track. In addition, attitudes towards integrating e-Health into the care program were explored.

Methods

A qualitative process evaluation of an intervention for weight recurrence, the Back on Track (BoT), was conducted by means of in-depth interviews and focus groups with 19 stakeholders, including patients and HCP involved in BoT. Interviews were transcribed verbatim. Data were analyzed through thematic analysis.

Results

Patients and HCP reported a wide array of causes of weight recurrence. Patients found it difficult to decide when weight recurrence is problematic and when they should ask for help. Patients reported feeling like the exception and ashamed, therefore experiencing a high threshold to seek help. E-Health was seen as a promising way to improve tailoring, screening, autonomy for the patient, and accessible contact.

Conclusion

Patients should be adequately counselled on weight recurrence after BMS and the importance of intervening early. It is important to lower the threshold for seeking help. For example by offering more long-term standard care or by adding e-Health to the intervention.

Nutrition, Physical Activity, and Prescription of Supplements in Pre- and Post-bariatric Surgery Patients: An Updated Comprehensive Practical Guideline

Only in the USA, 315 billion dollars are spent annually on the medical cost of obesity in adult patients. Till now, bariatric surgery is the most effective method for treating obesity and can play an essential role in reducing the direct and indirect costs of obesity treatment. Nonetheless, there are few comprehensive guidelines which include nutrition, physical activity, and supplements, before and after surgery. The purpose of the present narrative review is to provide an updated and comprehensive practical guideline to help multidisciplinary teams. The core keywords include nutrition, diet, physical activity, exercise, supplements, macronutrients, micronutrients, weight reduction, bariatric surgery, Roux-en-Y Gastric Bypass, Sleeve Gastrostomy, Laparoscopic Adjustable Gastric Banding, and Biliopancreatic diversion with duodenal switch which were searched in databases including PubMed/Medline, Cochrane, and some other sources such as Google Scholar. We answered questions in five important areas: (a) nutritional strategies before bariatric surgery, (b) nutrition after bariatric surgery, (c) physical activity before and after bariatric surgery, (d) weight regain after bariatric surgery, and (e) micronutrient assessments and recommendations before and after bariatric surgery. Some new items were added in this updated guideline including "weight regain" and "pregnancy after bariatric surgery." Other fields were updated based on new evidence and guidelines.

Weight Regain After Bariatric Surgery: Scope of the Problem, Causes, Prevention, and Treatment

PURPOSE OF REVIEW

Although bariatric surgery is the most effective treatment of severe obesity, a proportion of patients experience clinically significant weight regain (WR) with further out from surgery. The purpose of this review is to summarize the prevalence, predictors, and causes of weight regain.

RECENT FINDINGS

Estimating the prevalence of WR is limited by a lack of consensus on its definition. While anatomic failures such as dilated gastric fundus after sleeve gastrectomy and gastro-gastric fistula after Roux-en-Y gastric bypass can lead to WR, the most common causes appear to be dysregulated/maladaptive eating behaviors, lifestyle factors, and physiological compensatory mechanisms. To date, dietary, supportive, behavioral, and exercise interventions have not demonstrated a clinically meaningful impact on WR, and there is limited evidence for pharmacotherapy. Future studies should be aimed at better defining WR to begin to understand the etiologies. Additionally, there is a need for non-surgical interventions with demonstrated efficacy in rigorous randomized controlled trials for the prevention and reversal of WR after bariatric surgery.

Weight recurrence after Sleeve Gastrectomy versus Roux-en-Y gastric bypass: a propensity score matched nationwide analysis

BACKGROUND

Literature remains scarce on patients experiencing weight recurrence after initial adequate weight loss following primary bariatric surgery. Therefore, this study compared the extent of weight recurrence between patients who received a Sleeve Gastrectomy (SG) versus Roux-en-Y gastric bypass (RYGB) after adequate weight loss at 1-year follow-up.

METHODS

All patients undergoing primary RYGB or SG between 2015 and 2018 were selected from the Dutch Audit for Treatment of Obesity. Inclusion criteria were achieving ≥ 20% total weight loss (TWL) at 1-year and having at least one subsequent follow-up visit. The primary outcome was ≥ 10% weight recurrence (WR) at the last recorded follow-up between 2 and 5 years, after ≥ 20% TWL at 1-year follow-up. Secondary outcomes included remission of comorbidities at last recorded follow-up. A propensity score matched logistic regression analysis was used to estimate the difference between RYGB and SG.

RESULTS

A total of 19.762 patients were included, 14.982 RYGB and 4.780 SG patients. After matching 4.693 patients from each group, patients undergoing SG had a higher likelihood on WR up to 5-year follow-up compared with RYGB [OR 2.07, 95% CI (1.89-2.27), p < 0.01] and less often remission of type 2 diabetes [OR 0.69, 95% CI (0.56-0.86), p < 0.01], hypertension (HTN) [OR 0.75, 95% CI (0.65-0.87), p < 0.01], dyslipidemia [OR 0.44, 95% CI (0.36-0.54), p < 0.01], gastroesophageal reflux [OR 0.25 95% CI (0.18-0.34), p < 0.01], and obstructive sleep apnea syndrome (OSAS) [OR 0.66, 95% CI (0.54-0.8), p < 0.01]. In subgroup analyses, patients who experienced WR after SG but maintained ≥ 20%TWL from starting weight, more often achieved HTN (44.7% vs 29.4%), dyslipidemia (38.3% vs 19.3%), and OSAS (54% vs 20.3%) remission compared with patients not maintaining ≥ 20%TWL. No such differences in comorbidity remission were found within RYGB patients.

CONCLUSION

Patients undergoing SG are more likely to experience weight recurrence, and less likely to achieve comorbidity remission than patients undergoing RYGB.

Addressing a critical need: A randomised controlled feasibility trial of acceptance and commitment therapy for bariatric surgery patients at 15-18 months post-surgery

Bariatric surgery is an effective treatment for obesity. However, around one in five people experience significant weight regain. Acceptance and Commitment Therapy (ACT) teaches acceptance of and defusion from thoughts and feelings which influence behaviour, and commitment to act in line with personal values. To test the feasibility and acceptability of ACT following bariatric surgery a randomised controlled trial of 10 sessions of group ACT or Usual Care Support Group control (SGC) was delivered 15-18 months post bariatric surgery (ISRCTN registry ID: ISRCTN52074801). Participants were compared at baseline, 3, 6 and 12 months using validated questionnaires to assess weight, wellbeing, and healthcare use. A nested, semi-structured interview study was conducted to understand acceptability of the trial and group processes. 80 participants were consented and randomised. Attendance was low for both groups. Only 9 (29%) ACT participants completed > = half of the sessions, this was the case for 13 (35%) SGC participants. Forty-six (57.5%) did not attend the first session. At 12 months, outcome data were available from 19 of the 38 receiving SGC, and from 13 of the 42 receiving ACT. Full datasets were collected for those who remained in the trial. Nine participants from each arm were interviewed. The main barriers to group attendance were travel difficulties and scheduling. Poor initial attendance led to reduced motivation to return. Participants reported a motivation to help others as a reason to join the trial; lack of attendance by peers removed this opportunity and led to further drop out. Participants who attended the ACT groups reported a range of benefits including behaviour change. We conclude that the trial processes were feasible, but that the ACT intervention was not acceptable as delivered. Our data suggest changes to recruitment and intervention delivery that would address this.

Supporting Weight Management during COVID-19 (SWiM-C): twelve-month follow-up of a randomised controlled trial of a web-based, ACT-based, guided self-help intervention

OBJECTIVES

We developed a guided self-help intervention (Supporting Weight Management during COVID-19, "SWiM-C") to support adults with overweight or obesity in their weight management during the COVID-19 pandemic. This parallel, two-group trial (ISRCTN12107048) evaluated the effect of SWiM-C on weight and determinants of weight management over twelve months.

METHODS

Participants (≥18 years, body-mass-index ≥25 kg/m²) were randomised to the SWiM-C intervention or to a standard advice group (unblinded). Participants completed online questionnaires at baseline, four months, and twelve months. The primary outcome was change in self-reported weight from baseline to twelve months; secondary outcomes were eating behaviour (uncontrolled eating, emotional eating, cognitive restraint of food intake), experiential avoidance, depression, anxiety, stress, wellbeing and physical activity.

INTERVENTIONS

SWiM-C is based on acceptance and commitment therapy (ACT). Participants had access to an online web platform with 12 weekly modules and email and telephone contact with a trained, non-specialist coach. Standard advice was a leaflet on managing weight and mood during the COVID-19 pandemic.

RESULTS

388 participants were randomised (SWiM-C: n = 192, standard advice: n = 196). The baseline-adjusted difference in weight change between SWiM-C (n = 119) and standard advice (n = 147) was -0.81 kg (95% CI: -2.24 to 0.61 kg). SWiM-C participants reported a reduction in experiential avoidance (-2.45 [scale:10-70], 95% CI: -4.75 to -0.15), uncontrolled eating (-3.36 [scale: 0-100], 95% CI: -5.66 to -1.06), and emotional eating (-4.14 [scale:0-100], 95% CI: -7.25 to -1.02) and an increase in physical activity (8.96 [MET-min/week], 95% CI: 0.29 to 17.62) compared to standard advice participants. We found no evidence of an effect on remaining outcomes. No adverse events/side effects were reported.

CONCLUSIONS

Whilst we were unable to conclude that the intervention had an effect on weight, SWiM-C improved eating behaviours, experiential avoidance and physical activity. Further refinement of the intervention is necessary to ensure meaningful effects on weight prior to implementation in practice.

TRIAL REGISTRATION NUMBER

ISRCTN 12107048.

Evaluation of High-Interval Education to Improve Outcomes for Bariatric Patients With Health Disparities

A correlation of health disparities, socioeconomic barriers, and health literacy were hypothesized as causative factors of poor weight loss, weight regain, and loss to clinical follow-up in postbariatric patients. This study explored nurse practitioner-led interventions to address health disparities and improve outcomes. This pilot project evaluated 3-month weights of an intervention cohort as compared with a retrospective cohort. The intervention cohort received a weekly educational phone call from the clinical nurse practitioner. Quantitative data based on 3-month weights reveal an average excess body weight percentage lost at the 3-month postoperative clinical visit (36.54 ± 0.11, p = .2929) in the retrospective cohort ( n = 30) as compared with the intervention cohort ( n = 30; 33.46 ± 0.11, p = .2929). Participants responding to the barriers screening tool did not correspond with the actual needs represented by the population. Food access and transportation were leading factors affecting weight loss. This project revealed implications including the need for development of bariatric-specific social needs assessments, the need to explore telehealth as a modality to improve patient education, the need to modify education to overcome deficits in health literacy. Findings also validate the role of the nurse practitioner as a leader of multidisciplinary care teams.

The effects of using telemedicine for introductory bariatric surgery seminars during the COVID-19 pandemic

Background

The COVID-19 pandemic required immediate systematic change in healthcare delivery. Many institutions relied on telemedicine as an alternative to in-person visits. There is limited data in the bariatric surgery literature to determine how telemedicine impacts patient volume. This study evaluates the effects of using telemedicine for introductory bariatric surgery seminars on patient volume at a single institution.

Methods

A retrospective review was performed before and after implementing virtual introductory seminars for bariatric surgery patients at a comprehensive metabolic and surgery center. The effect on attendance rates for introductory seminars and completion rates of bariatric surgery was evaluated.

Results

The introductory seminar attendance rate for the in-person/pre-telemedicine period, April 2019 to February 2020, was compared to that of the virtual/post-telemedicine period, June 2020 to April 2021. A total of 836 patients registered for an introductory seminar during the pre-telemedicine period with a 65.79% attendance rate. In the post-telemedicine period, 806 patients registered with a 67.87% attendance rate, which was not statistically different (p = 0.37, 95% CI − 0.03–0.07). Completion rates of bariatric surgery were analyzed using June 2019 to October 2019 as the pre-telemedicine period and June 2020 to October 2020 as the post-telemedicine period. Similarly, there was no difference between the pre-telemedicine surgery rate of 23.43% and post-telemedicine surgery rate of 19.68% (p = 0.31, 95% CI − 0.11–0.04).

Conclusion

Despite abruptly transitioning to virtual introductory bariatric seminars, there was no change in attendance rates nor was there a difference in the number of patients progressing through the program and undergoing bariatric surgery at our institution. This demonstrates similar efficacy of telemedicine and in-person introductory seminars for bariatric surgery patients, which supports telemedicine as a promising tool for this patient population in the post-pandemic era.

Graphical abstract

Management of Weight Regain Following Bariatric Surgery: Behavioral Intervention and Pharmacotherapy

INTRODUCTION

Bariatric surgery is the most effective intervention currently available for significant and durable weight loss, but weight regain after surgery is not uncommon. This paper focuses on updates in behavioral interventions and pharmacotherapy to combat weight regain after bariatric surgery.

AREAS COVERED

This paper critically reviews both prospective and retrospective studies assessing pharmacotherapy in post-bariatric surgical patients published within the past 5 years. It also evaluates updates in behavioral therapies and delivery of the therapies in this patient population.

EXPERT OPINION

Weight regain after bariatric surgery is common. Patients who experience weight regain should be evaluated and treated by a multidisciplinary team. Antiobesity pharmacotherapy should be considered for those who qualify as an adjunct to lifestyle modifications, along with behavioral interventions such as cognitive behavioral therapy.

Behavioral Interventions After Bariatric Surgery

Purpose of Review

Bariatric surgery is the most effective and durable treatment for severe obesity. Postoperative behavioral weight management approaches are available for optimizing weight change for both short- and long-term outcomes.

Recent Findings

Varying settings such as groups and telemedicine along with techniques such as cognitive behavioral therapy have been assessed in the post-bariatric surgery population. The assessment and application of these programs have been limited due to methodological, financial, and attrition-related constraints.

Summary

This review aims to summarize the current evidence for different postoperative behavioral interventions on postoperative outcomes, specifically highlighting weight loss. Future opportunities for study include mechanisms for overcoming some of the barriers to implementing these programs in clinical, non-research settings.

Acceptability and feasibility of the TELEhealth BARIatric behavioural intervention to increase physical ACTIVity (TELE-BariACTIV): A single-case experimental study protocol (Preprint)

Background

Regular physical activity (PA) is recommended to optimize weight and health outcomes in patients who have undergone metabolic and bariatric surgery (MBS). However, >70% of patients have low PA levels before MBS that persist after MBS. Although behavioral interventions delivered face-to-face have shown promise for increasing PA among patients who have undergone MBS, many may experience barriers, preventing enrollment into and adherence to such interventions. Delivering PA behavior change interventions via telehealth to patients who have undergone MBS may be an effective strategy to increase accessibility and reach, as well as adherence.

Objective

This paper reports the protocol for a study that aims to assess the feasibility and acceptability of the protocol or methods and the Telehealth Bariatric Behavioral Intervention (TELE-BariACTIV). The intervention is designed to increase moderate-to-vigorous intensity PA (MVPA) in patients awaiting bariatric surgery and is guided by a multitheory approach and a patient perspective. Another objective is to estimate the effect of the TELE-BariACTIV intervention on presurgical MVPA to determine the appropriate sample size for a multicenter trial.

Methods

This study is a multicenter trial using a repeated (ABAB’A) single-case experimental design. The A phases are observational phases without intervention (A1=pre-MBS phase; A2=length personalized according to the MBS date; A3=7 months post-MBS phase). The B phases are interventional phases with PA counseling (B1=6 weekly pre-MBS sessions; B2=3 monthly sessions starting 3 months after MBS). The target sample size is set to 12. Participants are inactive adults awaiting sleeve gastrectomy who have access to a computer with internet and an interface with a camera. The participants are randomly allocated to a 1- or 2-week baseline period (A1). Protocol and intervention feasibility and acceptability (primary outcomes) will be assessed by recording missing data, refusal, recruitment, retention, attendance, and attrition rates, as well as via web-based acceptability questionnaires and semistructured interviews. Data collected via accelerometry (7-14 days) on 8 occasions and via questionnaires on 10 occasions will be analyzed to estimate the effect of the intervention on MVPA. Generalization measures assessing the quality of life, anxiety and depressive symptoms, and theory-based constructs (ie, motivational regulations for PA, self-efficacy to overcome barriers to PA, basic psychological needs satisfaction and frustration, PA enjoyment, and social support for PA; secondary outcomes for a future large-scale trial) will be completed via web-based questionnaires on 6-10 occasions. The institutional review board provided ethics approval for the study in June 2021.

Results

Recruitment began in September 2021, and all the participants were enrolled (n=12). Data collection is expected to end in fall 2023, depending on the MBS date of the recruited participants.

Conclusions

The TELE-BariACTIV intervention has the potential for implementation across multiple settings owing to its collaborative construction that can be offered remotely.

International Registered Report Identifier (IRRID)

DERR1-10.2196/39633

The Value of Tracking Data on the Behavior of Patients Who Have Undergone Bariatric Surgery: Explorative Study

Background

To maintain the benefits of a bariatric procedure, patients have to change their lifestyle permanently. This happens within a context of coresponsibilities of health care professionals and their social support system. However, most interventions are focused on the patient as an individual. In this explorative pilot study, behavioral, contextual, and experiential data were gathered to obtain insight on coresponsibility.

Objective

The aim of this study is to explore the use of trackers by patients who have undergone bariatric surgery in a data-enabled design approach.

Methods

Behavioral and contextual data on the households of patients who have undergone bariatric surgery were explored using a smartphone with an interactive user interface (UI), weight scale, activity bracelet, smart socket, accelerometer motion sensor, and event button to find examples of opportunities for future interventions.

Results

A total of 6 households were monitored. Approximately 483,000 data points were collected, and the participants engaged in 1483 conversations with the system. Examples were found using different combinations of data types, which provided the obesity team a better understanding of patient behaviors and their support system, such as a referral to a family coach instead of a dietician. Another finding regarding the partners was, for example, that the conversational UI system facilitated discussion about the support structure by asking for awareness.

Conclusions

An intelligent system using a combination of quantitative data gathered by data tracking products in the home environment and qualitative data gathered by app-enhanced short conversations, as well as face-to-face interviews, is useful for an improved understanding of coresponsibilities in the households of patients who have undergone bariatric surgery. The examples found in this explorative study so far encourage research in this field.

Effects and Acceptability of Technology-Based Physical Activity Interventions in Bariatric Surgery: a Scoping Review

The aim of this scoping review is to highlight current trends in the emerging field of technology-based physical activity interventions (TbPAI) in pre- and post-bariatric surgery. Original articles published between 2000 and 2020 on eHealth, bariatric surgery, and physical activity were identified through electronic searches of eight databases. Screening, data extraction, and charting were performed independently by two authors and disagreements were resolved by consensus. Nine full-text articles were included in this review. The studies reported that the physical activity outcomes had improved and the interventions were positively perceived by the target population. We highlight some consistent findings, as well as knowledge gaps, and suggest how future studies could be improved.

Designing Digital Health Technology to Support Patients Before and After Bariatric Surgery: Qualitative Study Exploring Patient Desires, Suggestions, and Reflections to Support Lifestyle Behavior Change

Background

A patient’s capability, motivation, and opportunity to change their lifestyle are determinants of successful outcomes following bariatric surgery. Lifestyle changes before and after surgery, including improved dietary intake and physical activity levels, have been associated with greater postsurgical weight loss and improved long-term health. Integrating patient-centered digital technologies within the bariatric surgical pathway could form part of an innovative strategy to promote and sustain healthier behaviors, and provide holistic patient support, to improve surgical success. Previous research focused on implementing digital technologies and measuring effectiveness in surgical cohorts. However, there is limited work concerning the desires, suggestions, and reflections of patients undergoing bariatric surgery. This qualitative investigation explores patients’ perspectives on technology features that would support behavior changes during the pre- and postoperative periods, to potentially maintain long-term healthy lifestyles following surgery.

Objective

This study aims to understand how digital technologies can be used to support patient care during the perioperative journey to improve weight loss outcomes and surgical success, focusing on what patients want from digital technologies, how they want to use them, and when they would be of most benefit during their surgical journey.

Methods

Patients attending bariatric surgery clinics in one hospital in the North of England were invited to participate. Semistructured interviews were conducted with purposively sampled pre- and postoperative patients to discuss lifestyle changes and the use of digital technologies to complement their care. The interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data. Ethical approval was obtained from the National Health Service Health Research Authority.

Results

A total of 20 patients were interviewed (preoperative phase: 40% (8/20); postoperative phase: 60% (12/20). A total of 4 overarching themes were developed and related to the optimization of technology functionality. These centered on providing tailored content and support; facilitating self-monitoring and goal setting; delivering information in an accessible, trusted, and usable manner; and meeting patient information-seeking and engagement needs during the surgical pathway. Functionalities that delivered personalized feedback and postoperative follow-up were considered beneficial. Individualized goal setting functionality could support a generation of digitally engaged patients with bariatric conditions as working toward achievable targets was deemed an effective strategy for motivating behavior change. The creation of digital package of care checklists between patients and clinicians was a novel finding from this study.

Conclusions

Perceptions of patients undergoing bariatric surgery validated the integration of digital technologies within the surgical pathway, offering enhanced connectedness and support. Recommendations are made relating to the design, content, and functionality of digital interventions to best address the needs of this cohort. These findings have the potential to influence the co-design and integration of person-centered, perioperative technologies.

Beyond Calorie Tracking: A Pilot Trial of a Remotely Delivered Behavioral Weight Loss Intervention Using an Ad Libitum Plant-Based Diet (Preprint)

Background

Many traditional lifestyle interventions use calorie prescriptions, but most individuals have difficulty sustaining calorie tracking and thus weight loss. In contrast, whole food plant-based diets (WFPBDs) have previously shown significant weight loss without this issue. However, most WFPBD interventions are face-to-face and time-intensive, and do not leverage gold standard behavioral strategies for health behavior change.

Objective

This open pilot trial was the first to evaluate the feasibility of a fully featured, remotely delivered behavioral weight loss intervention using an ad libitum WFPBD.

Methods

Over 12 weeks, participants (N=15) with overweight or obesity received a newly designed program that integrated behavioral weight loss and a WFPBD prescription via weekly web-based modules and brief phone coaching calls. Assessments were performed at baseline, midtreatment (6 weeks), and after treatment (12 weeks).

Results

The intervention was rated as highly acceptable (mean 4.40 out of 5, SE 0.18), and attrition was low (6.7%). In all, intention-to-treat analyses revealed that 69% (10.4/15) of the participants lost 5% of their weight (mean –5.89, SE 0.68 kg). Predefined benchmarks for quality of life were met.

Conclusions

A pilot digital behavioral weight loss intervention with a non–energy-restricted WFPBD was feasible, and the mean acceptability was high. Minimal contact time (80-150 minutes of study interventionist time per participant over 12 weeks) led to clinically relevant weight loss and dietary adherence for most participants (10.4/15, 69% and 11.8/15, 79%, respectively), and quality of life improvements (reliable change indices >1.53). We hope that this work will serve as a springboard for future larger scale randomized controlled studies evaluating the efficacy of such programs for weight loss, dietary change, and quality of life.

Trial Registration

ClinicalTrials.gov NCT04892030; https://clinicaltrials.gov/ct2/show/NCT04892030

Patients’ Experiences of Weight Regain After Bariatric Surgery

Purpose

Bariatric surgery is a successful obesity treatment; however, an estimated 1/5 of patients have regained more than 15% of their body weight 5 years post-surgery. To increase the understanding of patients who experienced weight regain after bariatric surgery, we conducted a qualitative study.

Materials and Methods

We recruited 16 adult participants (4 men, 12 women) at an obesity clinic in Stockholm, Sweden, 2018 to 2019, and performed semi-structured individual interviews. The transcribed recorded interview data was analyzed with thematic analysis.

Results

Participants had undergone gastric bypass surgery on average 10 years prior to study and regained 36% (range 12 to 71%) of their weight from their nadir. Participants experienced challenges such as eating in social settings, loneliness, family difficulties, increases in appetite, and physical and mental health problems, which distracted them from weight management. Participants responded to weight regain with emotional distress, particularly with hopelessness, discouragement, shame, and frustration (theme: loss of control and focus). Nonetheless, participants experienced remaining benefits from the surgery, despite weight regain. Social support, self-care, and behavioral strategies were perceived as facilitators for weight management (theme: reducing the burden of weight management).

Conclusions

Weight regain after bariatric surgery was perceived to be an unexpected and difficult experience that induced hopelessness, discouragement, shame, and frustration. Results indicate that internal and external circumstances such as psychosocial factors, changes in appetite, and physical and mental health problems may contribute to loss of control over weight. Social support, self-care, and behavioral strategies might facilitate long-term post-surgical weight management.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-05908-1.

Development of a Web-Based, Guided Self-help, Acceptance and Commitment Therapy-Based Intervention for Weight Loss Maintenance: Evidence-, Theory-, and Person-Based Approach

Background

The long-term impact and cost-effectiveness of weight management programs depend on posttreatment weight maintenance. There is growing evidence that interventions based on third-wave cognitive behavioral therapy, particularly acceptance and commitment therapy (ACT), could improve long-term weight management; however, these interventions are typically delivered face-to-face by psychologists, which limits the scalability of these types of intervention.

Objective

The aim of this study is to use an evidence-, theory-, and person-based approach to develop an ACT-based intervention for weight loss maintenance that uses digital technology and nonspecialist guidance to minimize the resources needed for delivery at scale.

Methods

Intervention development was guided by the Medical Research Council framework for the development of complex interventions in health care, Intervention Mapping Protocol, and a person-based approach for enhancing the acceptability and feasibility of interventions. Work was conducted in two phases: phase 1 consisted of collating and analyzing existing and new primary evidence and phase 2 consisted of theoretical modeling and intervention development. Phase 1 included a synthesis of existing evidence on weight loss maintenance from previous research, a systematic review and network meta-analysis of third-wave cognitive behavioral therapy interventions for weight management, a qualitative interview study of experiences of weight loss maintenance, and the modeling of a justifiable cost for a weight loss maintenance program. Phase 2 included the iterative development of guiding principles, a logic model, and the intervention design and content. Target user and stakeholder panels were established to inform each phase of development, and user testing of successive iterations of the prototype intervention was conducted.

Results

This process resulted in a guided self-help ACT-based intervention called SWiM (Supporting Weight Management). SWiM is a 4-month program consisting of weekly web-based sessions for 13 consecutive weeks followed by a 4-week break for participants to reflect and practice their new skills and a final session at week 18. Each session consists of psychoeducational content, reflective exercises, and behavioral experiments. SWiM includes specific sessions on key determinants of weight loss maintenance, including developing skills to manage high-risk situations for lapses, creating new helpful habits, breaking old unhelpful habits, and learning to manage interpersonal relationships and their impact on weight management. A trained, nonspecialist coach provides guidance for the participants through the program with 4 scheduled 30-minute telephone calls and 3 further optional calls.

Conclusions

This comprehensive approach facilitated the development of an intervention that is based on scientific theory and evidence for supporting people with weight loss maintenance and is grounded in the experiences of the target users and the context in which it is intended to be delivered. The intervention will be refined based on the findings of a planned pilot randomized controlled trial.

Behavioral Interventions to Attenuate Driven Overeating and Weight Regain After Bariatric Surgery

Weight regain after bariatric surgery is associated with problematic eating behaviors that have either recurred after a period of improvement or are new-onset behaviors. Problematic eating behaviors after bariatric surgery have been conceptualized in different ways in the literature, such as having a food addiction and experiencing a loss of control of eating. The intersection of these constructs appears to be driven overeating defined as patients' experiences of reduced control of their eating which results in overeating behavior. The purpose of this review is to define patient experiences of driven overeating through the behavioral expression of emotion-based eating, reward-based eating, and executive functioning deficits-namely impulsivity-which is associated with weight regain after having bariatric surgery. Delineating concepts in this way and determining treatment strategies accordingly may reduce distress related to the inevitable return of increased hunger, cravings, portion sizes, and tolerance for highly palatable foods after surgery. Along with standard behavioral weight maintenance strategies, topics including acceptance, motivation, emotion-based eating, reward-based/impulsive eating, physical activity, and self-compassion are discussed. These concepts have been adapted for patients experiencing weight regain after having bariatric surgery and may be particularly helpful in attenuating driven overeating and weight regain.

Psicanálise no tratamento multidisciplinar e cirúrgico da obesidade mórbida: estudo de caso

O objetivo do estudo é avaliar o processo psicoterapêutico de abordagem psicanalítica kleiniana como contribuição na melhoria da saúde de pacientes submetidos a cirurgia bariátrica. O método é de estudo de caso baseado na análise de vinheta clínica, acompanhado de levantamento bibliográfico. Analisaram-se trechos de conversas do processo psicoterapêutico de uma mulher obesa de 53 anos que procurou uma instituição dedicada ao tratamento cirúrgico da obesidade grave com enfoque multiprofissional. Após diagnóstico de obesidade mórbida, foi efetuada uma avaliação psicológica inicial. Como extensão, seguiu-se o processo psicoterapêutico de abordagem psicanalítica com frequência de uma vez por semana, passando depois a duas vezes. Dois meses após o primeiro encontro, a paciente submeteu-se à cirurgia bariátrica. A psicoterapia já tem a duração de três anos. Como resultado, a paciente tornou-se mais capaz de entrar em contato com o sentimento de desamparo associado ao fator destrutividade, que aparece em cenas narrativas de vingança, inveja e ciúme. Concluiu-se que o processo psicanalítico se mostrou efetivo: a paciente adquiriu mais condições de preservar suas redes afetivas constituintes, e tornou-se menos vulnerável à ansiedade e impulsividade, favorecendo a permanência da redução da obesidade e evitando a formação de outras situações de padecimento, como o alcoolismo. Essas observações confirmam algumas referências já apontadas na literatura.

Psychosocial and behavioral correlates of weight loss 12 to 15 years after bariatric surgery

While significant weight loss occurs post-bariatric surgery, partial weight regain is common. Psychological and dispositional variables have been examined as predictors of weight change, but most studies have focused on the relationship of preoperative constructs to shorter-term postoperative outcomes. The goal of the current study was to examine associations between weight loss and postoperative psychosocial and behavioral factors up to an average of 13.7 years after surgery. The current study was conducted at a large bariatric center in a Midwestern U.S. city. The sample was comprised of 125 adult patients who participated in the second wave of a long-term bariatric surgery outcome study, examining weight history, physical activity, and psychological health and functioning. Correlations between percent total weight loss (%TWL) and psychosocial and behavioral variables were examined. The variables that had significant correlations with %TWL were used in stepwise linear regressions to determine their contribution to %TWL. These same variables were tested to determine differences among those in the highest and lowest weight loss quartiles. Life satisfaction, conscientiousness, positive affect, and regular exercise were positively associated with weight loss in the entire sample and were significantly higher among those in the highest versus the lowest weight-loss quartile. Experiencing a stressful event and food addiction symptoms were negatively associated with weight loss. Positive affect, fewer food addiction symptoms, and regular exercise significantly predicted weight loss, accounting for 23% of the variance in %TWL. Long-term weight loss maintenance after bariatric surgery may be related to positive affect, conscientiousness, regular physical activity, and an addictive-type relationship with food. Future studies should explore these relationships and develop approaches to deal with the interaction between dispositional tendencies and lifestyle factors.

Are eHealth interventions for adults who are scheduled for or have undergone bariatric surgery as effective as usual care? A systematic review

This systematic review aimed to evaluate the effect of eHealth-delivered interventions for adults who undergo bariatric surgery on postoperative weight loss, weight loss maintenance, eating psychopathology, quality of life, depression screening, and self-efficacy. Six electronic databases were searched, with 14 studies (across 17 reports) included, involving 1633 participants. With substantial heterogeneity, qualitative descriptions have been provided. Interventions were delivered via an online program or internet modules (n = 2), telephone (n = 2), text messages (n = 2), videoconferencing (n = 3), mobile application (n = 1), and audiovisual media (n = 1). Three studies included a combination, including internet modules and telephone (n = 1), wireless fidelity scales, emails, and telephone (n = 1), and a combination of online treatment, weekly emails, and access to a private Facebook group (n = 1). All the eHealth interventions, except for one, implemented behavior change techniques, including self-monitoring, problem solving, social support, goal setting, and shaping knowledge. Both eHealth intervention and control groups lost weight across the included studies, and eHealth was found to be as effective as or more effective than the control for weight loss. Two studies measured weight loss maintenance; both eHealth and control groups regained weight in the longer term. The interventions showed significant improvement on assessment measures for eating psychopathology. In conclusion, when bariatric surgery patients have limited or no access to healthcare teams or require additional support, eHealth may be a suitable option. Future studies implementing eHealth interventions would benefit from reporting intervention components as per the behavior change techniques taxonomy and further consideration of delivering eHealth in a stepped care approach would be beneficial.

Weight Loss Outcomes and Lifestyle Patterns Following Sleeve Gastrectomy: an 8-Year Retrospective Study of 212 Patients

PURPOSE

Sleeve gastrectomy (SG) is an effective treatment for extreme obesity; however, long-term weight loss outcomes remain largely understudied. We aimed to examine the long-term weight changes following SG and patient characteristics and lifestyle patterns related to weight loss outcomes.

MATERIALS AND METHODS

Data from medical records of patients operated in a tertiary university medical center between 2008 and 2014 were reviewed, along with information derived from a telephone questionnaire. Information included the following: current medical status, medications, side effects, behavior, lifestyle habits, and weight changes.

RESULTS

A total of 212 patients (69.3% females) were included, with a median follow-up duration of 8 years post-SG. Mean age and baseline body mass index (BMI) of participants were 39.7 ± 12.0 years and 42.2 ± 4.9 kg/m², respectively. Mean BMI, percentage excess weight loss, and percentage total body weight loss were 33.1 ± 6.1, 55.5 ± 27.5%, and 21.7 ± 10.7%, respectively. Higher baseline BMI was found to be the strongest independent predictor for insufficient weight loss (OR = 0.90, P = 0.001, 95% CI 0.85, 0.96). Sweetened beverage intake, usage of psychiatric medications, higher initial BMI, and lower age were significant predictors for increased weight gain from nadir weight (P < 0.0001, P = 0.005, P = 0.035, and P < 0.0001, respectively).

CONCLUSIONS

SG patients were found to maintain a notable long-term weight loss. Nevertheless, weight regain and insufficient weight loss were prevalent in the long-term post-operative period, and were related to certain lifestyle patterns. Clinical practice should emphasize the relationship between post-operative weight loss outcomes and specific behaviors. Efforts should be made to educate patients on the need for lifelong follow-up and support.

Weight regain and eating behavior in physically active and inactive women after 24 months of bariatric surgery

PURPOSE

This research has tested the association between anthropometric profile and eating behavior according to the practice of physical activity in women with more than 24 months after bariatric surgery.

METHODS

It is a transversal study accomplished with 44 adult women, in which sociodemographic and anthropometric data of eating behavior as well as physical activity practice have been collected.

RESULTS

The average of overweight loss was satisfactory (> 50%), the average of weight regain was of 16.4 ± 11.2%, being the weight regain (kg) statistically lower in the physically active group (p = 0.049). There had been predominance of emotional eating in both groups (active p = 0.025; inactive p = 0.040); significant inverse correlation (β =  - 0.286; IC - 0.317; - 0,005; p = 0.044) between food restriction behavior and weight regain (%) depending on postoperative period; and the time of physical activity practice (min) has presented inverse correlation, statistically significant (β =  - 0.311; IC - 0.048; - 0,001; p = 0.039) on the weight regain (%) independent of postoperative period.

CONCLUSIONS

The physically active participants have presented the lowest weight regain and predominance of emotional eating domain, evidencing the need to model eating behavior and to encourage the practice of physical activity in these patients.

LEVEL III

Case-control analytic study.

Perioperative nutrition care and dietetic practices in the scope of bariatric surgery in Saudi Arabia using adapted protocols for evaluation

Objectives:

This study evaluates the availability of perioperative nutritional care protocols and the practices of bariatric registered dietitians in Saudi Arabia. The primary outcomes of the study were conducted using an adapted American survey “with permission.”

Methods:

A cross-sectional survey of a selected 32 dietitians providing bariatric services completed a self-administered online questionnaire from 12 hospitals in Jeddah, Saudi Arabia.

Results:

All surveyed dietitians were females, mainly Saudi nationals (93.9%, n = 30), and accredited by the Saudi Commission for Health Specialties (93.8%, n = 30). Only 37.5% (n = 6) of the dietitians were specialized in bariatric surgery. Perioperative common practices of dietitians included a conduct of screening for nutrition risk before (44%, n = 14) and after surgery (62.5%, n = 20) and applied a nutrition management protocol that is mainly based on the application of nutrition care process (62.5%, n = 20). Dietitians (81%, n = 26) reported the importance of having standardized protocols for nutritional management of patients undoing bariatric surgery, where 69% (n = 22) confirmed the availability of pre-operative written protocols in hospitals and 75% (n = 24) confirmed the existence of post-operative protocols. Pre-operative practices included using approaches for weight loss before surgery, for example, very low and low-calorie diet. Dietitians (25%, n = 8) see two to ten patients per month. The sleeve gastrectomy procedure is the most often performed surgery.

Conclusion:

This is the first study to evaluate the perioperative nutrition care protocols and practices related to bariatric surgery in Saudi Arabia. Perioperative bariatric protocols are available, but some dietitians are not aware of their availability and contents. Researchers emphasize the importance of creating national protocols by the Saudi Credentials Body to standardize practices within the field.

A Review of Telemedicine Interventions for Weight Loss

Purpose of Review

Telemedicine has become popular as an alternative for in-person weight loss treatment during the COVID-19 pandemic. This review focuses on weight loss interventions utilizing real-time telemedicine.

Recent Findings

Telemedicine interventions are usually run as a weekly counseling and educational session or as a complement to a primarily Web-based intervention. A wide variety of healthcare professionals may provide the intervention. Common content includes portion control, increased physical activity, and relapse prevention. Self-monitoring is associated with intervention success. Modalities considered include online chats, text messages, phone calls, and videoconferences. Videoconferencing may be especially useful in capturing the interpersonal connection associated with in-person care but is understudied compared to other modalities. While many interventions show improvements in weight and weight-related outcomes, small sample sizes limit generalizability. Technology access and digital literacy are both necessary.

Summary

Telemedicine interventions can successfully help patients with obesity lose weight. Telemedicine interventions provide a safe, remote alternative and may expand treatment access to hard-to-reach populations. Further research is needed on telemedicine weight loss treatments for seniors, men, and ethnic minorities, as well as on the impact of long-term interventions.

Telematics pre-operative psychological and nutritional assessment in candidates for bariatric surgery during COVID-19 phase 2: a pilot prospective observational study

BACKGROUND

Obesity represents a risk factor for COVID-19 infection. Therefore, in order to reduce COVID-19 related comorbidities in obese population a continuation of obesity treatment is needed. However, bariatric procedures were postponed because of COVID-19 restrictions, delaying treatment for obese patients seeking for surgery. This study aimed to test the feasibility of a telematics pre-operative psychological and nutritional assessment as an alternative tool during COVID-19 outbreak.

METHODS

Twenty-six patients were contacted. The pre-operative assessment consisted in 3-weekly one-to-one online sessions and a final in-person multidisciplinary session. The protocol feasibility has been evaluated on the following outcome: rejection rate (%), dropout rate (%), compliance and satisfaction's degree.

RESULTS

Eighteen participants completed the whole protocol and 10% dropped-out. Seventy-two percent of participants obtained an excess weight loss ≥5%. All participants were satisfied of the telematics assessment.

CONCLUSIONS

COVID-19 emergency has changed standard hospital procedures and this study could represent a landmark for an online pre-operative assessment method to adopt in case of new restrictions.

Developing Workshops to Enhance Hope Among Patients With Metastatic Breast Cancer and Oncologists: A Pilot Study

PURPOSE

Hope is a modifiable entity that can be augmented. We evaluated the feasibility, acceptability, and efficacy of a short intervention to increase hopefulness in patients with advanced breast cancer and oncologists.

METHODS

We enrolled eligible participants to two cohorts: one for patients with metastatic breast cancer and one for medical, radiation, or surgical oncologists. The intervention, a half-day hope enhancement workshop, included groups of 10-15 participants within each cohort. Participants in both cohorts completed preworkshop, postworkshop, and 3-month evaluations, which included the Adult Hope Scale (AHS), Herth Hope Index (HHI), and Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) measures in patients, and the AHS, HHI, and a burnout self-assessment tool in physicians.

RESULTS

We consented 13 patients and 26 oncologists for participation in the workshop and 76.9% (n = 10) of consented patients and 100% (n = 26) of consented physicians participated. Postworkshop, all participants planned to incorporate what they learned into their daily lives. In patients, AHS scores increased from preworkshop to postworkshop, and the mean change of 5.90 was significant (range 0-15, SD: 4.7, t = 3.99, P = .0032). HHI scores also increased, although the mean change was not significant. AHS and HHI scores did not significantly change in oncologists from preworkshop to postworkshop. At 3 months, less than half of the participants responded to the evaluation.

CONCLUSION

We found that conducting a hope-enhancement workshop for patients with metastatic breast cancer and oncologists was feasible, generally acceptable to both populations, and associated with increased hopefulness in patients. Next steps should focus on confirming this effect in a randomized study and maintaining this effect in the postworkshop interval.

Weight Regain and Insufficient Weight Loss After Bariatric Surgery: Definitions, Prevalence, Mechanisms, Predictors, Prevention and Management Strategies, and Knowledge Gaps-a Scoping Review

Some patients experience weight regain (WR) or insufficient weight loss (IWL) after bariatric surgery (BS). We undertook a scoping review of WR and IWL after BS. We searched electronic databases for studies addressing the definitions, prevalence, mechanisms, clinical significance, preoperative predictors, and preventive and treatment approaches including behavioral, pharmacological, and surgical management strategies of WR and IWL. Many definitions exist for WR, less so for IWL, resulting in inconsistencies in the reported prevalence of these two conditions. Mechanisms and preoperative predictors contributing to WR are complex and multifactorial. A range of the current knowledge gaps are identified and questions that need to be addressed are outlined. Therefore, there is an urgent need to address these knowledge gaps for a better evidence base that would guide patient counseling, selection, and lead to improved outcomes.

Multidisciplinary Approach for Weight Regain-how to Manage this Challenging Condition: an Expert Review

Weight regain is a multifactorial condition that affects many patients following bariatric surgery. The purpose of the paper is to review the multidisciplinary approach for the management of weight regain. We performed a search in current clinical evidence regarding the causes, consequences, and treatments of weight regain. The multidisciplinary approach with periodic monitoring is of fundamental importance to prevent or treat weight regain. Several therapeutic options are ranging from nutritional to surgical options, which should be tailored according to patients' anatomy, lifestyle behavior, and compliance. Specialized multidisciplinary care is the key to achieve optimal long-term weight loss and maintenance goals following bariatric surgery.

Digital technology to support lifestyle and health behaviour changes in surgical patients: systematic review

BACKGROUND

Digital technologies (such as smartphone applications, activity trackers, and e-learning platforms) have supported patients with long-term conditions to change their lifestyle health behaviours. The aim of this study was to examine the effectiveness of digital technologies in supporting patients undergoing elective surgery to change their health behaviours.

METHODS

A systematic review was conducted of articles reporting a digital intervention supporting behaviour change in adult patients who underwent elective bariatric, oncological or orthopaedic surgery. MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus were searched from inception to March 2019 for quantitative intervention studies with a specific focus on physical activity, dietary intake, and weight loss in patients before and after surgery (PROSPERO: CRD42019127972). The Joanna Briggs Institute critical appraisal checklist was used to assess study quality.

RESULTS

Of 3021 citations screened, 17 studies were included comprising 4923 surgical patients; these included experimental (pre-post design, feasibility studies, and RCTs) and observational studies. Three factors were identified as effective for supporting health behaviour change in elective surgical populations: digital technology delivery, implementation, and theoretical underpinning. Six of eight studies that referred to behaviour change theories observed significant improvements in health behaviour relating to reduced weight regain, and improved lifestyle choices for physical activity and diet. Meta-analysis was not possible because of heterogeneous outcome measures.

CONCLUSION

Digital technologies may effectively support behavioural change in patients undergoing elective surgery.

[Body composition assessment before and after weight loss following a Roux-en-Y gastric bypass. Are bioimpedanciometry estimations reliable?]

Introduction

Introduction: in patients with severe and morbid obesity it has been observed that bioimpedance (BIA) assessment generates an underestimation of fat mass (FM) and weight loss as FM after bariatric surgery, overestimating the loss of fat-free mass (FFM) and muscle mass. Objective: to evaluate the reliability of bioelectrical impedance analysis (BIA) to estimate total body water (TBW), fat-free mass (FFM), fat mass (FM), and its changes after 6 months of a Roux-en-Y gastric bypass (RYGBP), in patients with severe and morbid obesity. Methods: thirty-six patients approved for RYGBP were prospectively studied. TBW was measured by deuterium (D), and FM and FFM were calculated. A dual-frequency BIA device (5 and 200 kHz) (Bodystat Dualscan®) was used to estimate FM, FFM, TBW, extracellular water (ECW), intracellular water (ICW), and ECW/ICW ratio. Results: before RYGBP, BIA overestimated TBW by 2.6 ± 4.3 L (p = 0.002) and FFM by 3.5 ± 5.7 kg (p = 0.002), and underestimated FM% by 2.98 ± 4.7% (p = 0.002). The ECW/ICW ratio showed a significant and positive correlation with the difference BIA-D for FFM (r = 0.49; p = 0.002). After surgery, the differences between BIA and D were not significant, and the estimation error of FFM did not correlate with the ECW/ICW ratio. Conclusions: BIA generates an underestimation of FM as reported in patients with severe and morbid obesity, which is attenuated after weight reduction, underestimating weight loss as FM and overestimating FFM loss. Future research may assess whether these errors are reproduced by other BIA devices.

Digital and Mobile Technologies to Promote Physical Health Behavior Change and Provide Psychological Support for Patients Undergoing Elective Surgery: Meta-Ethnography and Systematic Review

BACKGROUND

Digital technology has influenced many aspects of modern living, including health care. In the context of elective surgeries, there is a strong association between preoperative physical and psychological preparedness, and improved postoperative outcomes. Health behavior changes made in the pre- and postoperative periods can be fundamental in determining the outcomes and success of elective surgeries. Understanding the potential unmet needs of patients undergoing elective surgery is central to motivating health behavior change. Integrating digital and mobile health technologies within the elective surgical pathway could be a strategy to remotely deliver this support to patients.

OBJECTIVE

This meta-ethnographic systematic review explores digital interventions supporting patients undergoing elective surgery with health behavior changes, specifically physical activity, weight loss, dietary intake, and psychological support.

METHODS

A literature search was conducted in October 2019 across 6 electronic databases (International Prospective Register of Systematic Reviews [PROSPERO]: CRD42020157813). Qualitative studies were included if they evaluated the use of digital technologies supporting behavior change in adult patients undergoing elective surgery during the pre- or postoperative period. Study quality was assessed using the Critical Appraisal Skills Programme tool. A meta-ethnographic approach was used to synthesize existing qualitative data, using the 7 phases of meta-ethnography by Noblit and Hare. Using this approach, along with reciprocal translation, enabled the development of 4 themes from the data.

RESULTS

A total of 18 studies were included covering bariatric (n=2, 11%), cancer (n=13, 72%), and orthopedic (n=3, 17%) surgeries. The 4 overarching themes appear to be key in understanding and determining the effectiveness of digital and mobile interventions to support surgical patients. To successfully motivate health behavior change, technologies should provide motivation and support, enable patient engagement, facilitate peer networking, and meet individualized patient needs. Self-regulatory features such as goal setting heightened patient motivation. The personalization of difficulty levels in virtual reality-based rehabilitation was positively received. Internet-based cognitive behavioral therapy reduced depression and distress in patients undergoing cancer surgery. Peer networking provided emotional support beyond that of patient-provider relationships, improving quality of life and care satisfaction. Patients expressed the desire for digital interventions to be individually tailored according to their physical and psychological needs, before and after surgery.

CONCLUSIONS

These findings have the potential to influence the future design of patient-centered digital and mobile health technologies and demonstrate a multipurpose role for digital technologies in the elective surgical pathway by motivating health behavior change and offering psychological support. Through the synthesis of patient suggestions, we highlight areas for digital technology optimization and emphasize the importance of content tailored to suit individual patients and surgical procedures. There is a significant rationale for involving patients in the cocreation of digital health technologies to enhance engagement, better support behavior change, and improve surgical outcomes.

Telemedicine intervention on physical activity recovery after bariatric surgery: the MyGoodTrip randomized controlled trial (Preprint)

BACKGROUND

Despite bariatric surgery showing significant weight loss trajectories for many patients, a substantial proportion regain weight after the first year following surgery. The addition of telemedicine to standard care could support patients with engaging in a more active lifestyle and thus improve clinical outcomes.

OBJECTIVE

Our aim was to evaluate a telemedicine intervention program dedicated to the promotion of physical activity including digital devices, teleconsultation, and telemonitoring the first 6 months following bariatric surgery.

METHODS

This study employed a mixed methods design based on an open-label randomized controlled trial. Patients were included during the first week after bariatric surgery; then, they were randomized into 2 intervention groups: The TelePhys group received a monthly telemedicine consultation focusing on physical activity coaching, while the TeleDiet group received a monthly telemedicine consultation involving diet coaching. Data were collected using a watch pedometer and body weight scale, both of which were connected wirelessly. The primary outcome was the difference between the 2 groups in the mean numbers of steps at the first and sixth postoperative months. Weight change was also evaluated, and focus groups and interviews were conducted to enrich the results and capture perceptions of the telemedicine provided.

RESULTS

Among the 90 patients (mean age 40.6, SD 10.4 years; 73/90, 81% women; 62/90, 69% gastric bypass), 70 completed the study until the sixth month (n=38 TelePhys; n=32 TeleDiet), and 18 participants agreed to be interviewed (n=8 Telephys; n=10 TeleDiet). An increase in the mean number of steps between the first and sixth months was found in both groups, but this change was significant only in the TeleDiet group (P=.01). No difference was found when comparing both intervention groups. Interviewed participants reported having appreciated the teleconsultations, as the individualized tailored counseling helped them to make better choices about behaviors that could increase their likelihood of a daily life in better health. Weight loss followed by social factors (such as social support) were identified as the main facilitators to physical activity. Family responsibilities, professional constraints as well as poor urban policies promoting physical activity, and lack of accessibility to sport infrastructure were their major barriers to postoperative lifestyle adherence.

CONCLUSIONS

Our study did not show any difference in mobility recovery after bariatric surgery related to a telemedicine intervention dedicated to physical activity. The early postoperative timing for our intervention may explain the null findings. eHealth interventions aiming to change behaviors and carried out by clinicians require support from structured public health policies that tackle patients' obesogenic environment in order to be efficient in their struggle against sedentary lifestyle-related pathologies. Further research will need to focus on long-term interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02716480, https://clinicaltrials.gov/ct2/show/NCT02716480.

An exercise-based educational and motivational intervention after surgery can improve behaviors, physical fitness and quality of life in bariatric patients

Introduction

Unhealthy lifestyles may hinder bariatric surgery outcomes. This non-randomized controlled study aimed to evaluate the effects of an integrated post-operative exercise-based educational and motivational program in improving behaviors, quality of life, anthropometric features, cardiorespiratory and physical fitness in bariatric patients respect to the only surgical intervention.

Methods

A group of adult sedentary bariatric patients chose to attend a 12-month exercise program integrated with diet education and motivational support, or to receive usual care. Dietary habits, binge eating disorder, physical activity, obesity-related quality of life, Body Mass Index, waist and hip circumference, VO₂max, strength and flexibility were assessed at the start and at the end of the study in both groups.

Results

On a total of 82 patients enrolled, follow-up measures were obtained from 28 (85.7% females, mean age 38.2±8.7) and 42 (71.4% females, mean age 40.2±9.5) patients included in the intervention and control group, respectively. All the behavioral and physical outcomes improved significantly in the participants to the intervention, while the control group showed lesser changes, especially regarding quality of life and physical fitness.

Conclusions

Notwithstanding the self-selection, these results suggest that a timely postoperative behavioral multidisciplinary program for bariatric patients may be effective in establishing healthy behaviors which can lead to better surgery outcomes.

Telehealth Opportunities and Challenges for Managing Pediatric Obesity

Telehealth is well positioned to address the common challenges of providing high-quality care to children and adolescents with obesity. The potential benefits of telehealth for pediatric obesity are applicable across the full spectrum of care from diagnosis and assessment to ongoing management. This article reviews the emerging field of telehealth for the treatment of pediatric obesity. The challenges of the current approach to pediatric obesity care are explored, and the potential benefits of incorporating and implementing telehealth in this field are presented. The care of pediatric patients with obesity is particularly well suited for telehealth.

The limits and challenges of antiobesity pharmacotherapy

INTRODUCTION

Pharmacotherapy is a useful adjunct when patients with obesity are unable to achieve adequate benefit from lifestyle interventions.

AREAS COVERED

This review covers the history of antiobesity drugs, efficacy, and risks of currently approved drugs, limits of their usefulness in clinical practice, gaps in knowledge, methodological limitations of clinical trials, and reasons for underutilization.

EXPERT OPINION

In randomized controlled trials, currently approved antiobesity drugs have yielded an average weight loss ranging from approximately 3% to 9% relative to placebo at 1 year. Inadequate inclusion of racial and ethnic minorities and men, and high dropout rates in clinical trials limit generalizability of these findings to clinical practice. Weight loss achieved with antiobesity drugs is generally associated with lowered glycemia, but improvements in blood pressure and lipid measures tend to be marginal. There is limited evidence for sustained weight loss beyond 1 year and for safety and efficacy of antiobesity drugs in children and adolescents, and in post-bariatric surgery patients. None have demonstrated reduction in major adverse cardiovascular events or other significant disease outcomes. Limited health insurance coverage and negative perceptions of physicians have hindered the utilization of antiobesity drugs.