Early Adherence Targeted Therapy (EATT) for Postbariatric Maladaptive Eating Behaviors

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.

Live psychotherapy by video versus in-person: A meta-analysis of efficacy and its relationship to types and targets of treatment

In-person psychotherapy (IPP) has a long and storied past, but technology advances have ushered in a new era of video-delivered psychotherapy (VDP). In this meta-analysis, pre-post changes within VDP were evaluated as were outcome differences between VDP versus IPP or other comparison groups. A literature search identified k = 56 within-group studies (N = 1681 participants) and 47 between-group studies (N = 3564). The pre-post effect size of VDP was large and highly significant, g = +0.99 95% CI [0.67-0.31]. VDP was significantly better in outcome than wait list controls (g = 0.77) but negligible in difference from IPP. Within-groups heterogeneity of effect sizes was reduced after subgrouping studies by treatment target, of which anxiety, depression, and posttraumatic stress disorder (PTSD) (each with k > 5) had effect sizes nearing 1.00. Disaggregating within-groups studies by therapy type, the effect size was 1.34 for CBT and 0.66 for non-CBT. Adjusted for possible publication bias, the overall effect size of VDP within groups was g = 0.54. In conclusion, substantial and significant improvement occurs from pre- to post-phases of VDP, this in turn differing negligibly from IPP treatment outcome. The VDP improvement is most pronounced when CBT is used, and when anxiety, depression, or PTSD are targeted, and it remains strong though attenuated by publication bias. Clinically, therapy is no less efficacious when delivered via videoconferencing than in-person, with efficacy being most pronounced in CBT for affective disorders. Live psychotherapy by video emerges not only as a popular and convenient choice but also one that is now upheld by meta-analytic evidence.

"If you're offered help, take it": A qualitative study examining bariatric patients' experience of telephone-based cognitive behavioural therapy

The increased recognition of patients' mental health needs after bariatric surgery has resulted in the emergence of accessible psychosocial interventions; however, there is a dearth of literature on patient experience and satisfaction with these interventions. We explored patients' perceptions and experiences of telephone-based cognitive behavioural therapy (Tele-CBT) in this qualitative study. Ten participants from the Toronto Western Hospital Bariatric Surgery Program in Toronto, Canada who completed the Tele-CBT (ClinicalTrials.gov Identifier: NCT02920112) were individually interviewed from November 2014 to June 2016 until thematic saturation occurred (ie, no more new coding groups emerged). Interviews were transcribed, independently coded, checked for discrepancies, and analysed using grounded theory. Four themes emerged: (1) participants were generally satisfied with Tele-CBT (eg, therapeutic alliance, resources provided, relevance of therapy to their own bariatric journey), (2) participants noticed emotional, cognitive, and behavioural changes following therapy, (3) the optimal time to deliver the Tele-CBT was when weight loss plateaued, generally at one-year post-surgery, and (4) participants found the telephone modality convenient. CBT was generally found to be helpful and the telephone format increased convenience and accessibility. Patients reported learning skills and receiving resources that could help them improve their well-being following bariatric surgery.

Preoperative and post-operative psychosocial interventions for bariatric surgery patients: A systematic review

Psychosocial interventions are increasingly being utilized to help patients prepare for, and adjust to changes following, bariatric surgery in order to optimize psychosocial adjustment and weight loss. The current systematic review examined the impact of preoperative and post-operative psychosocial interventions with a behavioural and/or cognitive focus on weight, dietary behaviours, eating pathology, lifestyle behaviours, and psychological functioning. A PsycINFO and Medline search of publications was conducted in March 2019. Two authors assessed retrieved titles and abstracts to determine topic relevance and rated the quality of included studies using a validated checklist. Forty-four articles (representing 36 studies) met the study inclusion criteria. The current evidence is strongest for the impact of psychosocial interventions, particularly cognitive behavioural therapy, on eating behaviours (eg, binge eating and emotional eating) and psychological functioning (eg, quality of life, depression, and anxiety). The evidence for the impact of psychosocial interventions on weight loss, dietary behaviours (eg, dietary intake), and lifestyle behaviours (eg, physical activity) is relatively weak and mixed. Psychosocial interventions can improve eating pathology and psychosocial functioning among bariatric patients, and the optimal time to initiate treatment appears to be early in the post-operative period before significant problematic eating behaviours and weight regain occur.

Replication and extension of dietary adherence as a predictor of suboptimal weight-loss outcomes in postbariatric patients

BACKGROUND

Sarwer et al. found that poor dietary adherence at 6 months postoperatively predicted lower weight loss.

OBJECTIVES

To replicate and extend these findings.

SETTING

University bariatric clinic.

METHODS

Fifty-four adults (72% female; age 51.1 ± 11.3 yr; mean body mass index [BMI] = 43.8 ± 7.4 kg/m²; 53.7% = Roux-en-Y gastric bypass, 42.6% = laparoscopic sleeve gastrectomy, and 3.7% = gastric banding) were identified as low or high dietary adherers following the method of Sarwer et al. Patients self-reported dietary adherence with a 9-point Likert scale. Splitting the group at the median, low adherers scored <7 and high dietary adherers ≥7. BMI, percentage excess weight loss (%EWL), and percentage total weight loss (%TWL) were prospectively assessed at 12, 24, and 36 months. Two-tailed independent t tests and Cohen's d effect sizes were used to compare between-group outcomes.

RESULTS

BMI did not differ between low (n = 24) and high (n = 30) dietary adherers at 6 months after surgery. At 12 months, the BMI of low (n = 17) adheres was significantly higher (34.1 ± 4.61 versus 30.3 ± 3.90 kg/m², P = .006, d = 0.90) than that of high (n = 25) adherers, with significantly less %EWL (49.0 ± 24% versus 70.7 ± 21.5%; P = .004; d = 0.95) and %TWL (20.7 ± 11.5% versus 28.9 ± 10.5, P = .02, d = 0.74). At 24 months, BMI remained significantly higher for low (n = 12) versus high (n = 10) adherers (33.7 ± 4.77 versus 29.7 ± 3.82 kg/m², P = .045, d = 0.92), but %EWL and %TWL were not significantly different, despite large effect sizes. At 36 months, moderate effects supported continued higher BMIs and lower %EWL and %TWL for low (n = 5) versus high (n = 8) adherers. Attrition from follow-up was 22.2% (12 mo), 59.3% (24 mo), and 75.9% (36 mo). Post hoc analyses revealed no impact of baseline characteristics on low follow-up rates except younger age (at 1 yr).

CONCLUSIONS

Findings that 6-month postoperative dietary adherence predicts 12-month BMI, %EWL, and %TWL were replicated. Medium to large effects suggest findings extend to 24 and 36 months, with low follow-up rates likely affecting statistical significance.

Cognitive behavioral therapy and predictors of weight loss in bariatric surgery patients

PURPOSE OF REVIEW

Bariatric surgery is the most effective treatment for morbid obesity. However, 20-30% of patients undergoing bariatric surgery experience premature weight stabilization or weight regain postoperatively. We report on the recent literature of predictors of weight loss and the efficacy of cognitive behavioral therapy (CBT) in bariatric patients.

RECENT FINDINGS

Preoperative disordered eating behaviors do not appear to be significantly predictive of postoperative weight loss. Postoperative disordered eating behaviors, eating disorders, and depressive symptoms have been found to be associated with less optimal weight loss results. Recent studies show that CBT can contribute in reducing disordered eating behaviors and depressive symptoms. Some studies also show that pre and postoperative CBT interventions can promote weight loss. New applications of CBT such as by telephone, internet, or virtual reality might contribute to more accessible and low-cost treatments for the large group of bariatric patients worldwide.

SUMMARY

CBT seems to be effective in reducing risk factors for weight regain after bariatric surgery, such as disordered eating behavior and depression. Controlled studies with long-term follow-up and larger sample sizes are needed to investigate the long-term effect of CBT interventions on weight loss results and psychological well-being.