Preoperative predictors of adherence to dietary and physical activity recommendations and weight loss one year after surgery

Personal, external, and psychological factors influencing adherence to nutrition and diet in patients undergoing metabolic/bariatric surgery: a systematic synthesis of mixed methods research

AIMS

To offer a holistic view of the personal, external, and psychological factors influencing adherence to nutrition and diet in patients undergoing metabolic/bariatric surgery.

METHODS

This systematic synthesis of mixed methods research involved a comprehensive search for articles in English databases, including PubMed, Cochrane Library, Web of Science, EBSCO, Scopus, and Embase, as well as Chinese databases. The search encompassed articles published from the inception of the database up to June 2023. Following the evaluation of literature quality and extraction of relevant information from the selected studies, data from both quantitative and qualitative studies were integrated. The extracted data were analyzed separately, and themes were identified and summarized to elucidate the factors influencing adherence to nutritional and dietary guidelines. The methodology adhered to the guidelines recommended by the Joanna Briggs Institute (JBI) for mixed methods systematic evaluations.

RESULTS

Three themes and their corresponding descriptive elements were identified, including: (1) Personal factors: subjective factors (attitude, capability, awareness, behaviors), objective factors (age, sex, work status, economic level, physical activity, dietary habits, weight change); (2) External factors: medication (quantity of pills, complexity of intake times, side effects, unpleasant smell or taste), surgery factor, social influences (family members, dietitians, and peers); (3) Psychological factors: self-efficacy, attachment anxiety, and mental health problems.

CONCLUSIONS

The synthesis provided a comprehensive overview of the factors influencing postoperative compliance of nutrition and diet among patients undergoing metabolic and bariatric surgery. It emphasizes the necessity for clinical staff to tailor interventions based on these diverse factors, as well as to attach importance to patients' mental health, giving multidimensional dietary guidance and health care.

Influence of mental and behavioral factors on weight loss after bariatric surgery: A systematic review and meta-analysis

INTRODUCTION

Multiple factors are related to lower weight loss after bariatric surgery. This review and meta-analysis evaluates the influence of several mental and behavioral factors on weight loss.

METHOD

Six electronic databases were searched. Percentage excess weight loss (%EWL) was calculated for all moderator and non-moderator groups of the variables: symptoms of depression, anxiety and binge eating, compliance, physical activity, quality of life, and body image. All moderators, surgery types, and follow-up moments were analyzed separately.

RESULTS

In total, 75 articles were included in the review; 12 meta-analyses were conducted. Higher postoperative compliance to follow-up was associated with 6.86%-13.68% higher EWL. Preoperative binge eating was related to more weight loss at 24- and 36-month follow-up (7.97% and 11.79%EWL, respectively). Patients with postoperative binge eating symptoms had an 11.92% lower EWL. Patients with preoperative depressive symptoms lost equal weight compared to patients without symptoms.

CONCLUSION

Despite the high heterogeneity between studies, a trend emerges suggesting that the presence of postoperative binge eating symptoms and lower postoperative compliance may be associated with less weight loss after bariatric-metabolic surgery. Additionally, preoperative depressive symptoms and binge eating do not seem to significantly impact weight loss.

Multidisciplinary combined treatment based on bariatric surgery for metabolic syndrome: a review article

As a chronic, multifactorial disease, obesity is associated with a global social and economic burden. This condition significantly affects normal daily life and healthy social interactions, and shortens the life expectancy of patients. Compared with traditional weight-loss methods, the emergence of bariatric surgery has effectively improved the management of obesity. Furthermore, bariatric surgery can also inhibit the progression of multiple metabolic diseases. Despite its potential advantages, bariatric surgery cannot completely eliminate the possibility of weight regain and inadequate weight loss following the procedure. For super-obese patients, bariatric surgery still remains a surgical risk. In addition, the psychological problems and poor eating habits of obese patients also affect the weight loss effect and daily life. Thus, various adjuvant therapies involving multiple disciplines have attracted people's attention. Recently, it has been recognized that the combination of multiple interventions based on bariatric surgery is more advantageous than a single intervention in alleviating the complex and diverse metabolic diseases associated with obesity. The combined therapy considerably enhances the long-term efficacy of bariatric surgery and plays a positive role in the mental health and social lives of patients. In this article, the authors review this multidisciplinary combination therapy to enhance the current understanding of the treatment of obesity.

Formation Mechanisms, Interrelationships, and Effects of Cognitive Factors on Diet and Physical Activity During the Post-Bariatric Surgery Period: A Cross-Sectional Study Based on Compensatory Carry-Over Action Model

Background

Diet and physical activity (PA) are pivotal behaviors for managing energy balance post-bariatric surgery. Given the need for dual behavioral management, understanding the interplay of cognitive factors influencing these behaviors is crucial. This study applied the compensatory carry-over action model (CCAM) to explore the impact of cognitive factors on behaviors and their subsequent effects on subjective health outcomes.

Methods

This cross-sectional study was conducted among patients at the third month after bariatric surgery in China. Data on diet and PA status, behavioral cognitive factors (intention, self-efficacy, compensatory belief, transfer cognition), and subjective health outcomes (perceived stress, well-being, quality of life) were collected. Structural equation model (SEM) was employed to test hypotheses in CCAM and assess mediation relationships.

Results

Analysis of data from 239 patients revealed the following: (1) Among antecedent cognitive factors, only compensatory belief significantly influenced diet (P<0.001). (2) Intention and self-efficacy directly correlated with their respective behaviors, while compensatory belief affected intention, and transfer cognition impacted self-efficacy (P<0.05), aligning with CCAM hypotheses. (3) PA demonstrated significant influence only on perceived stress (P=0.004), whereas diet significantly affected all subjective health outcomes (P<0.05). (4) Mediation analysis indicated intention partially mediated the relationship between compensatory belief and diet and fully mediated the relationship between compensatory belief and PA. Self-efficacy completely mediated the relationship between transfer cognition and diet and PA.

Conclusion

Transfer cognition's carry-over effect did not directly influence behaviors among antecedent cognitions. Interventions should primarily target improving diet by mitigating compensatory belief. Moreover, diet exhibited a more pronounced impact on overall health compared to PA. Consequently, prioritizing dietary intervention over PA intervention is warranted based on the analysis of CCAM and the aim of promoting joint behaviors post-bariatric surgery.

Assessing the Clinical Efficacy of a Virtual Reality Tool for the Treatment of Obesity: Randomized Controlled Trial

BACKGROUND

Virtual reality (VR) interventions, based on cognitive behavioral therapy principles, have been proven effective as complementary tools in managing obesity and have been associated with promoting healthy behaviors and addressing body image concerns. However, they have not fully addressed certain underlying causes of obesity, such as a lack of motivation to change, low self-efficacy, and the impact of weight stigma interiorization, which often impede treatment adherence and long-term lifestyle habit changes. To tackle these concerns, this study introduces the VR self-counseling paradigm, which incorporates embodiment and body-swapping techniques, along with motivational strategies, to help people living with obesity effectively address some of the root causes of their condition.

OBJECTIVE

This study aims to assess the clinical efficacy of ConVRself (Virtual Reality self-talk), a VR platform that allows participants to engage in motivational self-conversations.

METHODS

A randomized controlled trial was conducted with 68 participants from the bariatric surgery waiting list from the obesity unit of the Vall d'Hebron University Hospital in Barcelona, Spain. Participants were assigned to 1 of 3 groups: a control group (CG), which only received treatment as usual from the obesity unit; experimental group 1 (EG1), which, after intensive motivational interviewing training, engaged in 4 sessions of VR-based self-conversations with ConVRself, and underwent embodiment and body-swapping techniques; and experimental group 2 (EG2), which engaged in 4 VR-based sessions led by a virtual counselor with a prerecorded discourse, and only underwent the embodiment technique. In the case of both EG1 and EG2, the VR interventions were assisted by a clinical researcher. Readiness to change habits, eating habits, and psychological variables, as well as adherence and satisfaction with ConVRself were measured at baseline, after the intervention, 1 week after the intervention, and 4 weeks after the intervention.

RESULTS

Regarding the primary outcomes, EG1 (24/68, 35%) and EG2 (22/68, 32%) showed significant improvements in confidence to lose weight compared to the CG (22/68, 32%) at all assessment points (β=-.16; P=.02). Similarly, EG1 demonstrated a significant increase after the intervention in readiness to exercise more compared to the CG (β=-.17; P=.03). Regarding the secondary outcomes, EG1 participants showed a significant reduction in uncontrolled eating (β=.71; P=.01) and emotional eating (β=.29; P=.03) compared to the CG participants, as well as in their anxiety levels compared to EG2 and CG participants (β=.65; P=.01). In addition, participants from the experimental groups reported high adherence and satisfaction with the VR platform (EG1: mean 59.82, SD 4.00; EG2: mean 58.43, SD 5.22; d=0.30, 95% CI -0.30 to 0.89).

CONCLUSIONS

This study revealed that using VR self-conversations, based on motivational interviewing principles, may have benefits in helping people with obesity to enhance their readiness to change habits and self-efficacy, as well as reduce dysfunctional eating behaviors and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05094557; https://www.clinicaltrials.gov/study/NCT05094557.

Associations of adherence to physical activity and dietary recommendations with weight recurrence 1-5 years after metabolic and bariatric surgery

BACKGROUND

Little is known about longer-term adherence to recommended physical activity (PA) and dietary behaviors after metabolic and bariatric surgery (MBS) and whether adherence is associated with weight recurrence.

OBJECTIVES

To explore (1) changes in and associations between adherence to PA and general dietary recommendations after MBS and (2) whether PA and dietary behaviors interact to predict weight recurrence.

SETTING

University hospital; public practice.

METHODS

Participants completed ActiGraph PA monitoring, dietary questionnaire, and weighing 1 and 5 years after surgery. Parametric and non-parametric tests evaluated changes in and associations between adherence to PA and dietary recommendations. Multiple linear regression explored associations of adherence and weight recurrence 5 years post-surgery.

RESULTS

A total of 73 participants (66% loss to follow-up, 80.8% females) were included. From 1 to 5 years after surgery, adherence to PA recommendations did not change (23.5% versus 20.5%, P = .824), whereas adherence to dietary recommendations decreased (P = <.001). Adherence to PA recommendations is positively associated with eating fruits and vegetables and limiting intake of sugar and fat at 1 year (P < .05) and negatively associated with choosing meat with less fat at 5 years (P = .018). Adherence to PA and dietary behaviors did not independently contribute or interact to predict weight recurrence.

CONCLUSIONS

Adherence to recommendations was poor. Dietary adherence decreased from 1 to 5 years post-surgery, whereas PA adherence remained stable. PA adherence was positively associated with adherence to some dietary recommendations at 1 year but not at 5 years. Neither behavioral adherences were associated with weight recurrence. Additional research is needed to understand how to improve adherence and its relationship with other health outcomes after MBS.

The role of anxiety and depression in understanding the relationship between coping and weight loss 24 months after bariatric surgery

BACKGROUND

The relationship between coping (i.e., how a person deals with stress) and weight loss after bariatric surgery is relatively inconsistent. Anxiety and depression may contribute to the lack of consistent findings in this area. It is possible that coping, including interpersonal, intrapersonal, and maladaptive coping, predicts weight loss among individuals with higher levels of anxiety or depression but not among those with lower levels of anxiety and depression.

OBJECTIVE

The aim of this study was to examine the moderating role of anxiety and depression on the association between coping and weight loss in patients 24 months after bariatric surgery.

SETTING

University Hospital, West Virginia, U.S.A.

METHODS

Participants included 841 patients who underwent bariatric surgery, 396 of whom had 24-month weight loss data (mean age, 43.21 yr [SD, ±11.40 yr]). We ran 3 moderation models to test whether the relationship between various coping styles and postoperative weight loss was moderated by anxiety and depression symptoms.

RESULTS

There was a statistically significant interaction between anxiety and depression on the association between interpersonal coping and percent excess weight loss (%EWL). Anxiety and depression also moderated the relationship between maladaptive coping and %EWL. Anxiety and depression did not moderate the association between intrapersonal coping and %EWL, but intrapersonal coping positively predicted %EWL at 24 months after bariatric surgery.

CONCLUSIONS

Maladaptive coping predicted less weight loss for patients with high levels of anxiety and/or depression. Interpersonal coping predicted more weight loss for patients with low levels of anxiety and/or depression. Clinicians should take patient levels of anxiety and depression into account when making recommendations to promote weight loss among patients pursuing bariatric surgery.

Psychometric Properties of the Brief Coping Orientation to Problems Experienced Inventory Among Patients Pursuing Bariatric Surgery

The Brief COPE Inventory is a widely used scale that measures how a person copes with a specific situation. Despite its widespread use, the factor structure of this scale is somewhat unclear and has not been tested among patients pursuing bariatric surgery. We tested competing factor analytic models of the Brief COPE Inventory among patients pursuing bariatric surgery to identify the best fitting factor model for use in pre-surgical psychological evaluations. We also examined reliability and validity of the subscales from the best fitting model of coping. Participants included 1984 patients pursuing bariatric surgery (Mage = 42.58 years, SD = 10.89, 81.39% female). The best fitting model of the Brief COPE Inventory among patients pursuing bariatric surgery was a three-factor model including interpersonal, intrapersonal, and maladaptive coping strategies. These results were replicated in a subset of the original sample and demonstrated appropriate convergent and discriminant validity with several key outcomes. The Brief COPE Inventory can be conceptualized as a multidimensional scale assessing interpersonal coping, intrapersonal coping, and maladaptive coping among patients pursuing bariatric surgery. Future work should examine how these subscales are related to surgical outcomes among people receiving treatment for excess weight.

Psychological predictors of adherence to lifestyle changes after bariatric surgery: A systematic review

Objective

Adherence to lifestyle changes after bariatric surgery is associated with better health outcomes; however, research suggests that patients struggle to follow post-operative recommendations. This systematic review aimed to examine psychological factors associated with adherence after bariatric surgery.

Methods

PubMed, PsycInfo, and Embase were searched (from earliest searchable to August 2022) to identify studies that reported on clinically modifiable psychological factors related to adherence after bariatric surgery. Retrieved abstracts (n = 891) were screened and coded by two raters.

Results

A total of 32 studies met the inclusion criteria and were included in the narrative synthesis. Appointment attendance and dietary recommendations were the most frequently studied post-operative instructions. Higher self-efficacy was consistently predictive of better post-operative adherence to diet and physical activity, while pre-operative depressive symptoms were commonly associated with poorer adherence to appointments, diet, and physical activity. Findings were less inconsistent for anxiety and other psychiatric conditions.

Conclusions

This systematic review identified that psychological factors such as mood disorders and patients' beliefs/attitudes are associated with adherence to lifestyle changes after bariatric surgery. These factors can be addressed with psychological interventions; therefore, they are important to consider in patient care after bariatric surgery. Future research should further examine psychological predictors of adherence with the aim of informing interventions to support recommended lifestyle changes.

Intrapersonal coping predicts greater weight loss 24 months after bariatric surgery

PURPOSE

Coping is related to numerous health outcomes, including weight loss. However, the relationship between coping and weight loss after bariatric surgery remains unclear.

OBJECTIVES

The first objective of this study was to examine cross-sectional relationships between coping, anxiety, and depression. The second objective was to determine whether baseline anxiety and depression predicted weight loss 24 months after bariatric surgery. The final objective was to identify which aspects of coping are related to weight loss 24 months after bariatric surgery.

MATERIALS AND METHODS

Participants included 1203 adults who completed a pre-surgical bariatric evaluation, including 841 patients who underwent bariatric surgery, 396 of whom had 24-month weight data. Psychological variables were collected during a pre-surgical psychological evaluation. Weight-related variables were obtained through patients' electronic medical records 24 months after surgery.

RESULTS

Baseline intrapersonal coping (e.g., problem-solving, acceptance) predicted both weight loss variables at 24 months after surgery. However, baseline interpersonal and maladaptive coping were not related to weight loss. Baseline anxiety and depression similarly did not predict weight loss after surgery.

CONCLUSION

Use of intrapersonal coping strategies at baseline predicted weight loss 24 months after bariatric surgery. Clinicians should assess and bolster these self-reliant coping strategies prior to surgery to improve patient outcomes.

Associations of changes in physical activity and sedentary time with weight recurrence after bariatric surgery: a 5-year prospective study

BACKGROUND

Increasing physical activity and limiting sedentary time may minimize weight recurrence after bariatric surgery. However, few studies have evaluated potential associations of objectively-measured physical activity and sedentary time with post-surgical weight recurrence over time.

AIMS

To evaluate associations of change in physical activity and sedentary time with weight recurrence after bariatric surgery.

METHODS

Participants from the Oslo Bariatric Surgery Study, a prospective cohort study, wore an ActiGraph monitor for seven days at 1- and 5 years after surgery to assess daily physical activity and sedentary time. Participants' weight was measured at in-person clinic visits. Chi-square Test and Paired-samples T-test evaluated group differences and change over time, while Pearson's Correlation, multiple logistic and linear regression investigated associations between variables.

RESULTS

Five years after surgery 79 participants (70.5% response rate, 81% female) (mean (sd) age: 54.0 (±9.3), BMI: 32.1 (±4.7)) had valid monitor data. Participants increased their sedentary time (71.4 minutes/day (95% CI: 54.2-88.6, p = <0.001)) and reduced daily steps (-1411.1 (95% CI: 737.8-208.4), p = <0.001), light physical activity (-54.1 min/day (95% CI: 40.9-67.2, p = <0.001)), and total physical activity (-48.2 (95% CI: 34.6-63.3), p = <0.001) from 1- to 5 years after surgery. No change was found for moderate-to-vigorous intensity physical activity. No associations were found between changes in steps, physical activity or sedentary time and weight recurrence.

CONCLUSION

Participants increased sedentary time and decreased light- and total physical activity between 1- and 5 years post-surgery. Overall, changes in physical activity and sedentary time were not associated with weight recurrence. Interventions to help patients increase physical activity and limit sedentary time after bariatric surgery are needed.

Adolescents' and professionals' experiences of metabolic and bariatric surgery and requirements for preoperative and postoperative support through mHealth: a qualitative study

OBJECTIVES

This study aimed to explore adolescents' and professionals' incentives and experiences of metabolic and bariatric surgery (MBS) and to explore perceived needs and requirements for preoperative and postoperative support through an mHealth intervention to improve long-term healthy lifestyle behaviour and health outcomes.

DESIGN

An inductive qualitative study using in-depth semistructured interviews.

SETTING

Three hospital-based specialist paediatric obesity treatment units in Sweden.

PARTICIPANTS

A total of 18 participants (14 women and 4 men). Nine adolescents aged between 17 and 22 years who had undergone or were about to undergo surgery, and nine professionals, including researchers and clinicians working in various professional roles such as physiotherapist, dietician, nurse, psychologist, physician and pedagogue.

RESULTS

Both informant groups of participants highlighted that undergoing MBS is a complex process, and hence actions are required on several levels to optimise the positive, long-term effects of surgery. Efficient communication between the healthcare professionals and adolescents was considered crucial and a key success factor. Informants acknowledged the need for additional support that relates to psychosocial well-being and mental health in order to understand, form and accept new behaviours and identity. An mHealth intervention should be seen as complementary to physical appointments, and informants acknowledged that an app could be a way of improving access to healthcare, and a useful tool to allow for individually tailored and easily available support.

CONCLUSIONS

The findings address the importance of a personal encounter and a need for additional support that relates to psychosocial well-being, mental health and healthy lifestyle behaviour. These findings should be incorporated into future research concerning mHealth interventions in MBS during adolescence.

Determinants of Dietary Adherence Among Chinese Patients After Bariatric Surgery Based on the Attitude-Social Influence-Efficacy Model

PURPOSE

To explore main determinants of dietary adherence among Chinese patients after bariatric surgery based on the Attitude-Social influence-Efficacy (ASE) model.

METHODS

A cross-sectional survey was conducted by using convenience sampling method to select 288 participants in a tertiary hospital in Jiangsu, China. General information and disease-related information were collected as well as applying the Dietary Adherence Scale after Bariatric Surgery (DASBS) and Attitude-Social influence-Efficacy Questionnaire after Bariatric Surgery (ASEQBS). Univariate analysis, correlation analysis, and multivariate analysis were used to identify determinants of dietary adherence among patients after bariatric surgery.

RESULTS

A total of 288 questionnaires were effectively collected. The mean DASBS score was 54.90 ± 10.08 among post-bariatric patients. Univariate analysis results showed that education level, time since surgery, smoking, exercise, participation in peer support groups, and participation in nutrition counseling had significant effects on postoperative diet adherence level of patients (P < 0.05). The correlation analysis results showed that the total score of dietary adherence was positively correlated with the total score of intention, attitude, social influence, and self-efficacy, and the correlation coefficients were 0.511, 0.550, 0.460, and 0.484, respectively (P < 0.05). The results of multiple linear regression analysis showed that time since surgery, attitude, intention, social influence, exercise, and self-efficacy entered the regression equation (P < 0.05). The standardized regression coefficients of attitude and intention are 0.237 and 0.196, respectively. The regression model could explain 44.0% of the total variation.

CONCLUSION

The dietary adherence of Chinese post-bariatric patients is at an upper-middle level, which needs to be further improved. Time since surgery, exercise, intention, attitude, social influence, and self-efficacy had significant effects on patients' dietary adherence. Attitude had the greatest effect on dietary adherence, followed by intention. The results shed light on that these factors should be emphasized to take personalized intervention strategy in designing dietary intervention program, in order to improve the patient's dietary adherence and surgical outcomes.

Adherence Factors Related to Exercise Prescriptions in Healthcare Settings: A Review of the Scientific Literature

Purpose: Physical activity on prescription (PAP) is being introduced in healthcare systems around the world. To apply a successful treatment is as important as to know if the patient is able to follow-up. In order to contribute to the development of effective PAP strategies, we have analyzed PAP-related adherence factors with a multi-dimensional approach. Methods PAP adherence factors in studies published in the WoS, Pubmed, and PsycInfo were reviewed, according to the WHO five dimensions adherence model. In a setting of prediction or adherence analysis of adults with high-risk factors or chronic diseases, the methods used to measure physical activity (PA), PAP treatments, PAP adherence, and mentioned theories related to human behavior change were analyzed. Results A total of 32 studies fulfilled our inclusion criteria. According to the WHO five dimensions adherence model, these total clustered adherence variables were observed: social/economic (n = 100), healthcare system/healthcare team (n = 18), condition-related (n = 61), therapy-related (n = 20), and patient-related (n = 47). PAP adherence has mainly been measured by adherence to measurement methods and by calculating attended versus total sessions scheduled. PA level was measured mainly by questionnaires and exercise referrals were the most frequent PAP resource in analyzed studies. Transtheoretical model of behavior change was the theory most referenced. Conclusion A lack of considering health system/healthcare-team factors and therapy-related factors has been identified, as most studies only analyze social/economic factors in non-pharmacological PAP adherence studies in healthcare settings. A multidimensional approach should be adopted to analyze PAP adherence in healthcare settings.

Factors Related to Weight Loss Maintenance in the Medium-Long Term after Bariatric Surgery: A Review

Despite bariatric surgery being the most effective treatment for obesity, some individuals do not respond adequately, especially in the long term. Identifying the predictors of correct weight maintenance in the medium (from 1 to 3 years after surgery) and long term (from 3 years and above) is of vital importance to reduce failure after bariatric surgery; therefore, we summarize the evidence about certain factors, among which we highlight surgical technique, psychological factors, physical activity, adherence to diet, gastrointestinal hormones or neurological factors related to appetite control. We conducted a search in PubMed focused on the last five years (2015–2021). Main findings are as follows: despite Roux-en-Y gastric bypass being more effective in the long term, sleeve gastrectomy shows a more beneficial effectiveness–complications balance; pre-surgical psychological and behavioral evaluation along with post-surgical treatment improve long-term surgical outcomes; physical activity programs after bariatric surgery, in addition to continuous and comprehensive care interventions regarding diet habits, improve weight loss maintenance, but it is necessary to improve adherence; the impact of bariatric surgery on the gut–brain axis seems to influence weight maintenance. In conclusion, although interesting findings exist, the evidence is contradictory in some places, and long-term clinical trials are necessary to draw more robust conclusions.

Daily Timing of Meals and Weight Loss After Bariatric Surgery: a Systematic Review

The timing of food intake throughout the day can alter circadian clocks and metabolism to modulate the course of obesity. We conducted a systematic literature review to determine whether the timing of meals could alter the change in body weight after bariatric surgery in adults. Twelve cohort studies examined the association between meal timing and changes in body weight after bariatric surgery. Eight studies suggested an association between meal timing and weight loss. All studies examined simple exposure variables such as frequency of breakfast or dinner consumption and overnight meals. Overall, the low-quality evidence that food consumption at the end of the day is associated with lower weight loss after bariatric surgery in adults warrants further research.

Development and Validation of a Questionnaire to Assess the Determinants of Dietary Adherence Among Patients After Bariatric Surgery

PURPOSE

This study was aimed to develop a questionnaire to assess the determinants of dietary adherence among patients after bariatric surgery based on the attitude-social influence-efficacy (ASE) model and to evaluate its psychometric properties.

PATIENTS AND METHODS

According to semi-structured interview, Delphi expert consultation and pilot study, the initial questionnaire was formed and applied to investigate 319 patients after bariatric surgery in a tertiary hospital in Jiangsu Province, China. The reliability and validity of the scale were tested.

RESULTS

The 28-item of the attitude-social influence-efficacy questionnaire after bariatric surgery (ASEQBS) was formed. The results of exploratory factor analysis showed that four factors, including intention, attitude, social influence, and self-efficacy, could be extracted, and the cumulative variance contribution rate reached 59.98%. Confirmatory factor analysis showed the model fit well. The content validity index of each item was 0.800-1.000, and the content validity index of the ASEQBS was 0.857. The total Cronbach's α of the ASEQBS was 0.920, the split-half reliability was 0.774, and the retest reliability was 0.922.

CONCLUSION

The results suggest that ASEQBS is a valid and reliable measure of determinants of dietary adherence. It may be useful to evaluate the influence factors of dietary adherence and helpful to evaluate the efficacy of tailored dietary intervention programs.

How are bariatric patients coping during the coronavirus disease 2019 (COVID-19) pandemic? Analysis of factors known to cause weight regain among postoperative bariatric patients

Background

The global coronavirus disease 2019 (COVID-19) pandemic is wreaking havoc on society. Bariatric patients are more prone to severe infection due to their high body mass index (BMI) and are more vulnerable to the effects of isolation, such as depression or disruption of their health habits.

Objectives

To quantify the impact of self-quarantine on bariatric patients and self-quarantine’s relationship with weight gain.

Setting

Academic hospital, United States.

Methods

A 30-item survey examining several known contributors to weight regain was distributed among the postoperative bariatric patients of our clinic. Changes in eating habits, exercise, depression, social support, loneliness, and anxiety were studied, among others.

Results

A total of 208 patients completed the survey (29.3% response rate). A large percentage of patients reported increases in their depression (44.2%), loneliness (36.2%), nervousness (54.7%), snacking (62.6%), loss of control when eating (48.2%), and binge eating (19.5%) and decreases in their social support (23.2%), healthy food eating (45.5%), and activity (55.2%). Difficulty in accessing vitamins was reported by 13%. Patients more than 18 months out of surgery regained more than 2 kg during an average of 47 days. Risk factors for weight regain were found to be loss of control when eating, increases in snacking and binge eating, reduced consumption of healthy food, and reduced physical activity.

Conclusion

Bariatric patients are negatively affected by the COVID-19 pandemic and subsequent social isolation on many levels. This patient population is vulnerable to crisis situations; thus, additional intervention is needed to address behaviors that lead to weight regain.

Adherence to Vitamin Supplementation Recommendations in Youth Who Have Undergone Bariatric Surgery as Teenagers: a Mixed Methods Study

Purpose

Adherence to vitamin supplementation recommendations after bariatric surgery is generally poor, which is associated with nutritional deficiencies. Patients’ own perspectives and reasons for poor adherence to vitamin supplementation recommendations have not yet been studied in depth. The purpose of this study was first to measure the accuracy of self-reported adherence to supplementation recommendations by using objective measures of vitamin D levels in blood and thereafter to explore perceptions of barriers and facilitators to participants’ adherence to supplementation recommendations.

Material and Method

Participants were recruited from a prospective study investigating the outcome of bariatric surgery in adolescents with severe obesity. Mixed methods were used, including a quantitative part where vitamin D levels were analysed through 25(OH)D levels in blood and/or a questionnaire on adherence to supplementation programmes 5 years after surgery (n = 40) plus a qualitative part with semi-structured interviews (n = 20).

Results

We found a convergence between self-reported adherence to vitamin supplementation and vitamin D 25(OH)D levels in blood indicating honestly in self-reported responses. The qualitative evaluations resulted in the categories awareness and personal capability and external factors. In the analysis, an overall theme emerged; capacity is crucial for adherence in youth who have undergone bariatric surgery.

Conclusion

Bariatric surgery is a comprehensive procedure that requires lifelong treatment afterwards. There is coherence between what adolescents actually do and what they say they do. Capacity is crucial for adherence and social support has been shown to be important.

Missing Something? Comparisons of Effectiveness and Outcomes of Bariatric Surgery Procedures and Their Preferred Reporting: Refining the Evidence Base

Comparisons of effectiveness of bariatric surgery (BS) procedures encompass weight loss, metabolic/clinical outcomes, and improvements or worsening of comorbidities. Post-operative physical activity (PA) and diet influence such outcomes but are frequently not included in comparisons of effectiveness. We assessed the value and necessity of including post-operative PA/diet data when comparing effectiveness of BS. Including post-operative PA/diet data has significant benefits for BS and patients. The paper proposes an explicit preferred reporting system (Preferred REporting of post-operative PHYsical activity and Diet data in comparisons of BS effectiveness: PRE-PHYD Bariatric). Including post-operative PA/diet data could result in more accurate appraisals of effectiveness of BS procedures. This could translate into better 'individualized' BS by achieving a better 'fit' between patient and procedure.

Are there really any predictive factors for a successful weight loss after bariatric surgery?

BACKGROUND

Currently, bariatric surgery is the most effective treatment for severe obesity and its metabolic complications; however, 15-35% of the patients that undergo bariatric surgery do not reach their goal for weight loss. The aim of this study was to determine the proportion of patients that didn't reach the goal of an excess weight loss of 50% or more during the first 12 months and determine the factors associated to this failure.

METHODS

We obtained the demographic, anthropometric and biochemical information from 130 patients with severe obesity who underwent bariatric surgery in our institution between 2012 and 2017. We used self-reports of physical activity, caloric intake and diet composition. An unsuccessful weight loss was considered when the patient lost < 50% or more of the excess weight 12 months after surgery. We compared the characteristics between the successful and unsuccessful groups in order to find the factors associated with success.

RESULTS

We included 130 patients (mean age 48 ± 9 years, 81.5% were women). One year after surgery, 26 (20%) had loss < 50% EBW. Unsuccessful surgery was associated with an older age, previous history of hypertension, abdominal surgery or depression/anxiety, also the number of comorbidities and unemployment affected the results. These patients loss enough weight to improve some of their comorbidities, but they are more prone to regain weight 2 years after surgery.

CONCLUSIONS

A fifth of the patients undergoing bariatric surgery may not lose enough weight to be considered successful by current standards. Some patients may benefit from the surgery in the short term, but they are more likely to regain weight after 2 years. The factors influencing this result are still controversial but may be population-specific. Early detection of the patients that are more likely to fail is imperative to establish additional therapeutic strategies, without denying them the opportunity of surgery or waiting for weight re-gain to occur.

The relationship between food insecurity and binge and night eating symptoms in prebariatric surgery patients is mediated by depressive symptoms

BACKGROUND

Eleven percent of households in the United States experience food insecurity, which is a lack of access to adequate, desirable food for a healthy lifestyle. Although food insecurity is associated with increased risk of obesity and nonadherence to dietary management of chronic diseases such as diabetes, the correlates of food insecurity have not yet been studied in a bariatric surgery population.

OBJECTIVES

To replicate, in a bariatric sample, previous findings that food insecurity is related to eating pathology and to test the hypothesis that this relationship is mediated by depressive symptoms.

SETTING

University hospital, United States.

METHODS

Two hundred forty bariatric surgery candidates responded to self-report measures of food insecurity and mood, night-eating, and binge-eating symptoms. The sample was 74% female and 71% white, with a mean age of 41.09 (11.84) years. Based on responses to the United States Department of Agriculture Adult Food Security Survey Model, 15.8% were categorized as food insecure and 25.8% as marginally food secure. Multiple regression models with bootstrapping for confidence interval estimates were used to explore mediation hypotheses.

RESULTS

Food insecurity was positively associated with symptoms of night eating and binge eating, and these relationships were cross-sectionally mediated by depressive symptoms.

CONCLUSIONS

Food insecure bariatric candidates may be at increased risk of poorer postoperative outcomes because of lack of access to needed food and the detrimental mental health impact of this lack of access.

Executive Function, Eating Behavior, and Preoperative Weight Loss in Bariatric Surgery Candidates: An Observational Study

BACKGROUND

Individual differences in executive function may influence eating behavior, weight loss (WL), and WL maintenance in obesity treatment. Executive function, which designates top-down cognitive control processes, has been related to eating behaviors which may impact weight, and has been found to be predictive of WL in both behavioral WL programs and after bariatric surgery. Currently, we lack knowledge on the role of executive function in the period before bariatric surgery. If executive function impacts eating behavior and WL in the preoperative period, it may be a target for clinical attention in this stage.

OBJECTIVES

We aimed to examine the relationship between objective performance-based measures of executive function, eating patterns, and WL in the preoperative period.

METHOD

Baseline data in an ongoing observational longitudinal study of bariatric surgery patients were used. Eighty patients completed neuropsychological testing and self-report questionnaires 4 weeks prior to surgery.

RESULTS

We found that working memory predicted WL before surgery and inhibitory control predicted adherence to dietary recommendations.

CONCLUSION

Our study indicates that executive function may play a role in short-term WL and dietary adherence prior to surgery, suggesting that executive function in the preoperative period deserves an extended research focus.

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.

Measurement of adherence in bariatric surgery: a systematic review

After bariatric surgery, rates of adherence to behavioral recommendations, including attending regular appointments and following specific dietary, physical activity, and vitamin use recommendations, tend to be highly variable across studies. Lack of consistency in measurement of adherence is a likely contributor to this variability, making it challenging to determine the prevalence and impact of nonadherence in this population. PubMed was searched for articles measuring behavioral adherence or compliance in patients after bariatric surgery, resulting in 85 articles. Articles were reviewed for the definition and measurement of adherence in each area (appointment attendance, as well as dietary, physical activity, and vitamin use adherence), and on the use and reporting of recommended adherence measurement strategies. Over half of the articles measured adherence to appointment attendance. Significant variability was found across adherence definitions and measurement methods, and use of recommended adherence measurement strategies was poor. Adherence was mostly commonly measured via self-report (either verbal or written) using cutoffs for adherent versus nonadherent behavior. Over half of studies assessed adherence up to ≥2 years postsurgery. Recommendations for ways to improve adherence measurement in patients who have had bariatric surgery are outlined.

Predictors of Physical Activity After Gastric Bypass-a Prospective Study

BACKGROUND

Most patients do not meet the recommended level of physical activity after bariatric surgery, and psychological factors underlying postoperative physical activity remain poorly understood. This study aimed at identifying self-regulatory predictors of physical activity after bariatric surgery.

METHODS

Questionnaire data including self-regulation variables and the short-version of the International Physical Activity Questionnaire were obtained in a prospective cohort of 230 patients 1 year after Roux-en-Y gastric bypass. The study sample consisted of participants consenting to wear an ActiGraph GT3X+ accelerometer for seven consecutive days, 18-24 months after surgery (n = 120).

RESULTS

A total of 112 participants with complete self-report data provided valid accelerometer data. Mean age was 46.8 years (SD = 9.3), and 81.3% was women. Preoperative and postoperative BMI was 44.8 ± 5.5 and 30.6 ± 5.0 kg/m², respectively. Total weight loss was 28.9% (SD = 7.5). By objective measures, 17.9% of the participants met the recommended level of moderate-to-vigorous-intensity of physical activity of ≥150 min/week, whereas 80.2% met the recommended level according to self-reported measures. Being single, higher education level, and greater self-regulation predicted objective physical activity in multivariate regression analysis. Greater self-regulation also predicted self-reported physical activity. Weight loss 1 year after surgery was not associated with self-reported or objectively measured physical activity.

CONCLUSIONS

Despite large differences between accelerometer-based and subjective estimates of physical activity, the associations of self-regulatory factors and weight loss with postoperative physical activity did not vary depending on mode of measurement. Self-regulation predicted both objective and self-reported physical activity. Targeting patients' self-regulatory ability may enhance physical activity after gastric bypass.

Weight regain in patients with symptoms of post-bariatric surgery hypoglycemia

BACKGROUND

Weight regain (WR) and symptoms of post-bariatric surgery hypoglycemia (PBSH) are metabolic complications observed in a subset of postbariatric patients. Whether hypoglycemic symptoms are an important driver of increased caloric intake and WR after bariatric surgery is unknown.

OBJECTIVE

This study aims to determine whether patients with PBSH symptoms have greater odds for WR.

SETTING

Tertiary academic hospital.

METHODS

Patients who underwent Roux-en-Y gastric bypass or sleeve gastrectomy at our tertiary academic hospital from August 2008 to August 2012 were mailed a survey, from which weight trajectory and PBSH symptoms were assessed. Percent WR was calculated as 100×(current weight-nadir weight)/(preoperative weight-nadir weight) and was compared between dates of survey completion and bariatric surgery. The primary outcome was WR≥10%, as a reflection of the median WR among respondents. Multivariable logistic regression was used to determine clinical factors that indicate greater odds for WR≥10% at the P<.05 level.

RESULTS

Of 1119 potential patients, 428 respondents (40.6%) were eligible for analysis. WR was observed in 79.2% (n = 339), while 20.8% (n = 89) experienced either weight loss or no WR at a mean of 40.6±14.5 months. Median WR was 10.8% (interquartile range, 5.6-19.4). Odds of WR≥10% was significantly increased in those who experienced PBSH symptoms (odds ratio [OR] = 1.66; 95% confidence interval [CI]: 1.04-2.65), reported less adherence to nutritional guideline (OR = 2.36; 95% CI: 1.52-3.67), and had a longer time since surgery (OR = 1.05; 95% CI: 1.03-1.07).

CONCLUSIONS

We found evidence that the presence of PBSH symptoms was associated with WR. Future studies should elucidate the role of hypoglycemia among other factors in post-bariatric surgery WR.