A Randomised Trial of Text Message Support for Reducing Weight Regain Following Sleeve Gastrectomy

Feasibility and preliminary efficacy of an online nutrition education intervention for those with a sleeve gastrectomy: A pilot randomised control trial

BACKGROUND

A sleeve gastrectomy (SG) is a lifelong treatment that improves health and better outcomes are associated with follow-up. However, there is lack of access or high attrition to aftercare. This potentially contributes to sub-optimal dietary intake and a lack of evidence for nutrition interventions. The present study assessed the feasibility and preliminary efficacy of a nutrition intervention to improve diet quality in Australian adults living with a SG.

METHODS

Adults (n = 96) post-SG were recruited into a cross-sectional diet quality study, with 68 eligible for randomisation to an intervention or wait-list control group. Over 10 weeks, a Facebook group was used to post daily nutrition education. Feasibility outcomes included participant recruitment, engagement, retention and acceptability. Preliminary efficacy was assessed using change in Australian Recommended Food Score (ARFS). Linear mixed models were used to measure differences in mean outcome between the experimental groups over time.

RESULTS

Sixty-eight participants (97% female) aged 48.2 ± 9.8 years, body mass index 33.1 ± 5.8 kg/m2, and mean ± SD ARFS 39 ± 9 points were randomised to the intervention, with 66% retention at 10 weeks. At follow-up, diet quality increased for the intervention group (mean ARFS, 95% confidence interval = 0.2 [-1.5 to 1.9]) and decreased for the control group (mean ARFS, 95% confidence interval= -2.0 [-5.2 to 1.2]) with no between group difference (p = 0.2). Participants (n = 30) rated the intervention positively.

CONCLUSIONS

Recruiting and retaining adults post-SG into a nutrition intervention is feasible. Low-cost recruitment attracted strong interest from women to identify greater support to know what to eat following SG. A future fully powered trial to assess intervention efficacy is warranted.

Enhancing Clinical Success Through Intensive Dietary Support in Bariatric Patients: a Retrospective Study in Asian Population

BACKGROUND

Weight loss surgery is an established intervention for obesity and related conditions, ensuring sustained weight reduction and improved comorbidities. Post-bariatric surgery, maintaining nutritional adequacy and weight loss necessitates ongoing, intensive dietary support. This research aims to discern the impact of standard care vs. intensive dietary support on outcomes following bariatric surgery within an Asian demographic. This study aims to research the part that intensive dietary support plays in contrast to standard care in altering weight loss and BMI change following bariatric surgery.

METHODS

A retrospective analysis of medical records from a Malaysian tertiary care hospital documented bariatric surgeries conducted from January 2020 to January 2022. Rigorous criteria selected 200 patients from 327, evenly split between standard care and intensive dietary support groups. The latter underwent six mandatory visits with a surgeon and a dietitian in the initial 3 months post-surgery. A dual-review mechanism was implemented for data interpretation, increasing robustness, and reducing biases in our findings.

RESULTS

At 6 and 12 months, the intensive dietary support group exhibited significantly greater weight loss and BMI reduction (p < 0.01). Postoperative complications did not significantly differ between groups.

CONCLUSION

In an Asian population, intensive dietary support enhances weight loss and BMI reduction compared to standard care after bariatric surgery.

The Utilisation of Digital Applications for Measuring Patient Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis of Comparative Studies

In the context of escalating obesity rates, bariatric surgery holds a crucial role in managing severely obese patients. With a demonstrated effectiveness in weight loss and with the advent of ambulatory surgery, bariatric surgery allows for a streamlined care pathway, ideally suited for postoperative surveillance using digital health applications. The aim of this systematic review and meta-analysis is to evaluate the effect of eHealth-delivered health services or support for adults undergoing bariatric surgery. Five studies, encompassing 2210 patients, were analysed. The intervention group showed a 10% increase in total weight reduction and a 22% reduction in excess weight loss. ED visitation rates also trended towards reduction. Despite the absence of clear statistical superiority for DHA, the findings suggest potential benefits of DHA in postoperative monitoring.

A non-randomised feasibility study of a mHealth follow-up program in bariatric surgery

BACKGROUND

Behavioural support via mobile health (mHealth) is emerging. This study aimed to assess the feasibility, acceptability, cost, and potential effect on weight of a mHealth follow-up program in bariatric surgery.

METHODS

This was a non-randomised feasibility study describing intervention development and proof in the concept of a mHealth follow-up program in bariatric surgery. The study compares a prospective cohort with a historical control group and was conducted in a tertiary bariatric surgery service in Australia. The intervention group included individuals who had bariatric surgery (2019-2021) and owned a smart device, and the historical control group received usual postoperative care (2018). The intervention involved usual care plus codesigned biweekly text messages, monthly email newsletters, and online resources/videos over a 6-month period. The primary outcome measures included feasibility (via recruitment and retention rate), acceptability (via mixed methods), marginal costs, and weight 12 months postoperatively. Quantitative analysis was performed, including descriptive statistics and inferential and regression analysis. Multivariate linear regression and mixed-effects models were undertaken to test the potential intervention effect. Qualitative analysis was performed using inductive content analysis.

RESULTS

The study included 176 participants (n = 129 historical control, n = 47 intervention group; mean age 56 years). Of the 50 eligible patients, 48 consented to participate (96% recruitment rate). One participant opted out of the mHealth program entirely without disclosing their reason (98% retention rate). The survey response rate was low (n = 16/47, 34%). Participants agreed/strongly agreed that text messages supported new behaviours (n = 13/15, 87%); however, few agreed/strongly agreed that the messages motivated goal setting and self-monitoring (n = 8/15, 53%), dietary change (n = 6/15, 40%), or physical activity (n = 5/15, 33%). Interviews generated four main themes (n = 12): 'motivators and expectations', 'preferences and relevance', 'reinforced information", and 'wanting social support'. The intervention reinforced information, email newsletters were lengthy/challenging to read, and text messages were favoured, yet tailoring was recommended. The intervention cost AUD 11.04 per person. The mean 12-month weight was 86 ± 16 kg and 90 ± 16 kg (intervention and historical control) with no statistically significant difference. Intervention recipients enrolled at 3 months postoperatively demonstrated a statistically significant difference in 12-month weight (p = 0.014).

CONCLUSION

Although this study observed high rates of recruitment and retention, findings should be considered with caution as mHealth may have been embraced more by the intervention cohort as a result of the 2019 coronavirus pandemic. Of the various digital strategies developed and tested, the text message approach was the most acceptable; however, future intervention iterations could be strengthened through tailoring information when possible. The use of email newsletters and online resources/videos requires further testing of effectiveness to determine their value for continued use in bariatric surgery services.

Patient reported satisfaction levels with the use of telemedicine for general surgery-A systematic review of randomized control trials

Background

As healthcare continues to evolve in the wake of COVID-19 pandemic, surgeons are presented with the opportunity to integrate telemedicine into healthcare in tandem with in-person consultations. We aimed to perform a systematic review of randomized controlled trials to assess patient satisfaction with telemedicine interventions in general surgery.

Methods

A systematic review was performed in accordance to the PRISMA guidelines. Randomized control trials (RCTs) were included. The risk of bias 2.0 assessment was used to determine potential bias.

Results

In total, 11 prospective, randomized trials involving 1,598 patients (mean age: 49.1 years) were included. Overall 45.5% (5/11) of the trials compared videoconferencing or telephone follow up to traditional in person follow up. Three studies used smart technologies which include activity tracking devices in combination with a website and mobile application (27.3%). The other 3 interventions involved accelerated discharge on post operative day (POD) 1 with tele videoconferencing on POD 2, Post-operative daily text messages with education videos and video calling capability, and supportive text messages post-operatively. Telemedicine was shown to provide similar levels of patient satisfaction compared to controls in all 11 included RCTs.

Conclusion

Patient reported satisfaction with the use of telemedicine is similar to standard of care models in general surgery. With several shortcomings confounding the results in support of telemedicine, further experimentation with telemedicine interventions will likely improve patient reported satisfaction with using telemedicine for peroperative surgical care.

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.

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.

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.

Behaviour change theories and techniques used to inform nutrition interventions for adults undergoing bariatric surgery: A systematic review

Aim

This systematic review aimed to describe behaviour change theories and techniques used to inform nutrition interventions for adults undergoing bariatric surgery.

Methods

A systematic search was conducted across PubMed, PsycInfo, CENTRAL, EMBASE and CINAHL from inception until 09 March 2021. Eligible studies were randomised controlled trials involving nutrition interventions performed by a healthcare provider, to adults that were waitlisted or had undergone bariatric surgery and received a nutrition intervention explicitly informed by one or more behaviour change theories or behaviour change techniques. Screening was conducted independently by two authors. Behaviour change techniques were examined using the behaviour change technique taxonomy version one which includes 93 hierarchical techniques clustered into 16 groups. Quality of included studies was assessed using Cochrane risk of bias 2.0.

Results

Twenty‐one publications were included, involving 15 studies and 14 interventions, with 1495 participants. Bias was low or had some concerns. Two interventions reported using behaviour change theories (transtheoretical model and self‐determination theory). Thirteen behaviour change technique taxonomy groupings and 29 techniques were reported across 14 interventions. Common techniques included ‘1.2 Problem solving’ (n = 9 studies), ‘3.1 Social support (unspecified)’ (n = 9 studies), ‘1.1 Goal setting (behaviour)’ (n = 6 studies) and ‘2.3 Self‐monitoring of behaviour’ (n =‐ 6 studies).

Conclusion

While behaviour change techniques have been included, behaviour change theory is not consistently reported and/or adopted to inform nutrition interventions for adults undergoing bariatric surgery. Integrating behaviour change theory and techniques in nutrition interventions is important for researchers and bariatric surgery teams, including dietitians, to effectively target behaviours for this population.

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.

Social Support for People with Morbid Obesity in a Bariatric Surgery Programme: A Qualitative Descriptive Study

Background—Morbid obesity (MO) is a chronic metabolic disease affecting physical, psychological and social wellbeing. Bariatric surgery is a reliable method for losing weight in the long term, improving the quality of life, body image and social life of people with MO. Current literature recognises the importance of social support in controlling weight and coping with MO. The objective of this study was to describe and understand experiences related to social support for patients with MO included in a bariatric surgery programme. Methods—A qualitative descriptive study, where data collection included thirty-one interviews with people diagnosed with MO involved in a bariatric surgery programme. Results—Three main themes emerged from the analysis: (1) accepting the problem in order to ask for help, (2) the need for close support and (3) professional support: opposing feelings. Conclusions—A partner, family and friends are the key pillars of social support for those with MO included in a bariatric surgery programme. Healthcare professionals gave formal support; the bariatric surgery team provided information, trust and assurance. Nurses provided healthcare 24 h a day, making them the main formal support for people in the bariatric surgery programme.

Behavioral weight management interventions in metabolic and bariatric surgery: A systematic review and meta-analysis investigating optimal delivery timing

Metabolic and bariatric surgery (MBS) yields unprecedented clinical outcomes, though variability is high in weight change and health benefits. Behavioral weight management (BWM) interventions may optimize MBS outcomes. However, there is a lack of an evidence base to inform their use in practice, particularly regarding optimal delivery timing. This paper evaluated the efficacy of BWM conducted pre- versus post- versus pre- and post-MBS. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included pre- and/or post-operative BWM interventions in adults reporting anthropometric and/or body composition data. Thirty-six studies (2,919 participants) were included. Post-operative BWM yielded greater decreases in weight (standardized mean difference [SMD] = -0.41; 95% confidence interval [CI]: -0.766 to -0.049, p < 0.05; I² = 93.5%) and body mass index (SMD = -0.60; 95% CI: -0.913 to -0.289, p < 0.001; I² = 87.8%) relative to comparators. There was no effect of BWM delivered pre- or joint pre- and post-operatively. The risk of selection and performance bias was generally high. Delivering BWM after MBS appears to confer the most benefits on weight, though there was high variability in study characteristics and risk of bias across trials. This provides insight into the type of support that should be considered post-operatively.

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.

Text messaging to help women with overweight or obesity lose weight after childbirth: the intervention adaptation and SMS feasibility RCT

Background

There is a need to develop weight management interventions that fit seamlessly into the busy lives of women during the postpartum period.

Objective

The objective was to develop and pilot-test an evidence- and theory-based intervention, delivered by short message service, which supported weight loss and weight loss maintenance in the postpartum period.

Design

Stage 1 involved the development of a library of short message service messages to support weight loss and weight loss maintenance, with personal and public involvement, focusing on diet and physical activity with embedded behaviour change techniques, and the programming of a short message service platform to allow fully automated intervention delivery. Stage 2 comprised a 12-month, single-centre, two-arm, pilot, randomised controlled trial with an active control.

Setting

This study was set in Northern Ireland; women were recruited via community-based approaches.

Participants

A total of 100 women with overweight or obesity who had given birth in the previous 24 months were recruited.

Interventions

The intervention group received an automated short message service intervention about weight loss and weight loss maintenance for 12 months. The active control group received automated short message service messages about child health and development for 12 months.

Main outcome measures

The main outcomes measured were the feasibility of recruitment and retention, acceptability of the intervention and trial procedures, and evidence of positive indicative effects on weight. Weight, waist circumference and blood pressure were measured by the researchers; participants completed a questionnaire booklet and wore a sealed pedometer for 7 days at baseline, 3, 6, 9 and 12 months. Outcome assessments were collected during home visits and women received a voucher on completion of each of the assessments. Qualitative interviews were conducted with women at 3 and 12 months, to gather feedback on the intervention and active control and the study procedures. Quantitative and qualitative data were used to inform the process evaluation and to assess fidelity, acceptability, dose, reach, recruitment, retention, contamination and context.

Results

The recruitment target of 100 participants was achieved (intervention, n = 51; control, n = 49); the mean age was 32.5 years (standard deviation 4.3 years); 28 (28%) participants had a household income of < £29,999 per annum. Fifteen women became pregnant during the follow-up (intervention, n = 9; control, n = 6) and withdrew from the study for this reason. At the end of the 12-month study, the majority of women remained in the study [85.7% (36/42) in the intervention group and 90.7% (39/43) in the active control group]. The research procedures were well accepted by women. Both groups indicated a high level of satisfaction with the short message service intervention that they were receiving. There was evidence to suggest that the intervention may have a positive effect on weight loss and prevention of weight gain during the postpartum period.

Limitations

The interviews at 3 and 12 months were conducted by the same researchers who collected other outcome data.

Conclusions

An evidence- and theory-based intervention delivered by short message service was successfully developed in conjunction with postpartum women with overweight and obesity. The intervention was acceptable to women and was feasible to implement in the 12-month pilot randomised controlled trial. The progression criteria for a full randomised controlled trial to examine effectiveness and cost-effectiveness were met.

Future work

Some minor refinements need to be made to the intervention and trial procedures based on the findings of the pilot trial in preparation for conducting a full randomised controlled trial.

Trial registration

Current Controlled Trial ISRCTN90393571.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information. The intervention costs were provided by the Public Health Agency, Northern Ireland.