Remote assessments and behavioral interventions in post-bariatric surgery patients

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.

Predictors of early weight loss in post-bariatric surgery patients receiving adjunctive behavioural treatments for loss-of-control eating

This study examined baseline patient characteristics as predictors of early weight loss, defined as any weight loss within the first month of treatment, among patients receiving adjunctive behavioural treatments for loss-of-control (LOC) eating about 6 months after bariatric surgery. Participants were 126 patients in a treatment trial for LOC-eating (roughly 6 months postoperatively) categorized by early weight change following 1 month of treatment. Early weight-loss, defined as any weight loss following 1 month of treatment, and weight-gain, defined as any weight gain, groups were compared on sociodemographic and clinical variables assessed using a battery of reliably administered diagnostic and clinical interviews and established self-report measures, and on surgery-related variables (time since surgery, percent total [%TWL], and percent excess weight loss). Most patients (n = 99; 78.6%) lost weight after the first month of adjunctive treatments. Black patients (n = 24; 61.5%) were significantly less likely to achieve early weight loss compared to patients identifying as White (n = 60; 83%) or 'other' (n = 15; 100%) which was not predicted by any other sociodemographic variable. Severity of eating-disorder psychopathology, psychiatric comorbidity, and a broad range of psychosocial measures were not significantly predictive of early weight changes. Duration since surgery and percent weight loss from time of surgery to study enrolment 6-months post-surgery differed by early weight-loss and weight-gain groups. Findings suggest that among post-bariatric surgery patients receiving adjunctive behavioural treatments for LOC-eating, baseline patient characteristics, aside from race and surgery-related variables, do not predict early weight loss.

Role of 3D-CT gastric volumetric study in post-sleeve gastrectomy

Background

Gastric pouch volumetry after sleeve gastrectomy reflects successful surgery. We aimed to assess the impact of gastric pouch volume after sleeve gastrectomy on weight loss.

Method

The study was performed for 30 patients (22 females and 8 males) who underwent sleeve gastrectomy. Their ages ranged from 18 to 47 years. All patients underwent (multi-slice CT) MSCT examination at 12 months after surgery with oral administration of effervescent emulsion. Post-processing in multi-planar reconstruction and 3D reconstruction was performed to all cases. Gastric pouch volume was measured and correlated with body weight, body mass index (BMI), % reduction in excess body weight and ∆weight at 1 year.

Results

A significant positive association was found among gastric volume pouch and weight loss (P = 0.04), BMI reduction (P value < 0.0001) and ∆weight (P value = 0.013). A significant inverse association was found among gastric pouch volume and % reduction in excess body weight (P value = 0.013).

Conclusion

MSCT gastric volumetry is the gold standard imaging method for assessment of the gastric pouch volume after sleeve gastrectomy. Significant positive association was found among gastric volume pouch and weight loss, BMI reduction and ∆weight at 1 year, i.e., in spite of large gastric pouch volume at 1 year, there is adequate weight loss, BMI reduction and ∆weight. Yet, significant inverse association was found among gastric pouch volume and % reduction in excess body weight.

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.

Challenges in virtual collection of patient-reported data: a prospective cohort study conducted in COVID-19 era

Prior to the COVID-19 pandemic, patients attending ambulatory clinics at cancer centers in Ontario completed the Edmonton Symptom Assessment Scale (ESAS) at each visit. At our center, completion was via touchpad, with assistance from clinic volunteers. As of March 2020, clinic appointments were conducted virtually when possible and touch pads removed. We anticipated a negative impact on the collection of patient-reported outcomes (PROs) and the recognition of severe symptoms.

METHODS

We performed a prospective cross-sectional cohort study to investigate remote ESAS completion by patients with appointments at a weekly surgical oncology clinic. Patients in the initial study cohort were asked to complete and return the ESAS virtually (V). Given low completion rates, the ensuing cohort was asked to complete a hard-copy (HC) ESAS. For the final cohort, we provided remote, personal mentorship by a member of the care team to support virtual electronic ESAS completion (virtual-mentored (VM) cohort).

RESULTS

Between May and July 2020, a total of 174 patient encounters were included in the study. For the V cohort, 20/46 patients (44%) successfully completed and returned the electronic ESAS, compared to 49/50 (98%) for the HC cohort. For the VM cohort, the overall completion rate was 74% (58/78); however, 12 of these 58 patients did not independently complete a virtual ESAS. Virtual questionnaire completion was not predicted by age, sex, or tumor site, although patients who completed the ESAS were more likely to be in active management rather than surveillance (p = 0.04). Of all completed forms, 42% revealed a depression score of ≥2, and 27% an anxiety score of ≥4.

CONCLUSIONS

We identified significant barriers to the virtual completion of ESAS forms, with a lack of predictive variables. The severe degree of psychological distress reported by ~50% of respondents demonstrates the need for ongoing regular collection/review of these data. Innovative solutions are required to overcome barriers to the virtual collection of PROs.

Patients' experiences of telenursing follow-up care after bariatric surgery

AIM

To explore the postsurgical management experiences of bariatric patients after receiving telenursing follow-up care, using a telemonitoring platform for approximately 1 month.

BACKGROUND

Obesity prevalence rates among adult Canadians are increasing, and as such the number of bariatric surgeries. Adapting to life following bariatric surgery is challenging, and patients are often experiencing difficulties to adhere to the postsurgical behavioural recommendations. The use of technology has been introduced in bariatric aftercare programmes, yet patients voiced a desire to communicate with a clinician between routine visits to improve continuity of care. To our knowledge, there is a lack of research on emerging practice of telenursing to provide monitoring, support and aftercare to bariatric patients remotely.

DESIGN

A qualitative descriptive design was used.

METHODS

A total of 22 semi-structured interviews were thematically analysed. The SRQR checklist was used.

RESULTS

Participants embraced the idea of integrating telenursing care in bariatric aftercare programmes, as they viewed this novel approach to care as a way to overcome the current challenges of accessing bariatric services. The most salient benefit reported by participants was the timely advice and care provided by the telenurse. The provision of tailored nursing care and the accessibility to a first-line professional empowered participants to exercise greater control over their recovery process, which promotes self-management and enhances feelings of security and reassurance. Lastly, participants voiced areas of improvement to better the system and to render it most accessible and user-friendly.

CONCLUSION

Despite its novelty in bariatric aftercare, our findings indicated that patients are eager to integrate telenursing in mainstream services. Discussions are needed regarding patient adherence to telemonitoring, and the need to develop clinical follow-up protocols.

RELEVANCE TO CLINICAL PRACTICE

Results provide new insights into the importance of a telenurse in providing individualised care to bariatric patients.

Psychopathology and Adolescent Bariatric Surgery: A Topical Review to Support Psychologists in Assessment and Treatment Considerations

The rising rates of severe obesity among adolescents in the United States indicate a dire need for more intensive weight management strategies. While current evidence suggests that bariatric surgery is a safe and efficacious intervention for adolescents, the linkages with psychopathology before and after surgery are not well understood. Psychologists are an integral part of the interdisciplinary surgery team and play an important role in preparing youth for bariatric surgery as well as supporting adolescents post-surgery. The present manuscript reviews the literature on psychopathology in the context of adolescent bariatric surgery, discusses consideration of psychopathology as a contraindication for surgery, and provides recommendations on how psychologist members of the bariatric surgery team may balance attention to motivation and adherence to medical recommendations with assessment and treatment of psychopathology. Finally, the importance of continued research to confirm clinical consensus regarding decision-making and expansion of psychological resources within adolescent bariatric surgery programs are discussed.

Remote unaffiliated presurgical psychosocial evaluations: a qualitative assessment of the attitudes of ASMBS members

BACKGROUND

A psychosocial evaluation is an important component of the preoperative assessment process for people seeking metabolic and bariatric surgery (MBS), and is required for accreditation of MBS programs. Recently, independent companies without affiliations with MBS programs have been marketing remotely administered, unaffiliated psychosocial evaluations for MBS (RUS), and American Society for Metabolic and Bariatric Surgery (ASMBS) members have raised concerns about these evaluations.

OBJECTIVES

To explore ASMBS members' beliefs about RUS.

SETTING

Online survey.

METHODS

We developed a survey to evaluate ASMBS members' opinions, experiences, and/or concerns about in-person and RUS psychosocial evaluations for MBS.

RESULTS

In total, 635 ASMBS members responded to the online survey and 156 responded to an open-ended question on RUS. Responses were coded based on a manual developed for this study, yielding themes of concerns about the quality of RUS, lack of ongoing relationships in RUS, and conditions under which/reasons why RUS evaluations could be acceptable.

CONCLUSION

Respondents expressed both interest in and concerns about RUS in pre-MBS psychosocial evaluations. Use of RUS has the potential to improve access to MBS by providing a convenient and efficient means of completing the psychosocial evaluation. Conversely, respondents expressed concerns about the background and training of RUS providers, the quality of the reports, and the limited relationships between the RUS provider and both the MBS patient and the MBS team. We discuss the clinical and research implications of response themes, particularly for patients in rural areas or those who have other barriers to care.

A review of the psychosocial aspects of clinically severe obesity and bariatric surgery

For the past 2 decades, clinically severe obesity (operationalized as a body mass index ≥40 kg/m2) has increased at a more pronounced rate that less severe obesity. As a result, the surgical treatment of obesity (bariatric surgery) has become a more widely accepted, yet still underutilized, treatment for persons with severe obesity and significant weight-related health problems. Psychologists play a central role on the multidisciplinary team involved in the preoperative assessment and postoperative management of patients. They also have played a central role in clinical research which has enhanced understanding of the psychosocial and behavioral factors that contribute to the development of severe obesity as well as how those factors and others contribute to postoperative outcomes. This article, written specifically for psychologists and other mental health professionals who currently work with these patients or are considering the opportunity to do so in the future, reviews these contributions over the past 20 years. The article highlights how this work has become a fundamental part of international clinical care guidelines, which primarily focus on preoperative psychosocial screening. The article also outlines avenues for future research in the field, with a specific focus on the need for additional behavioral and psychosocial interventions to promote lifelong success after bariatric surgery. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

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.

Improving Access to Bariatric Surgery for Rural and Remote Patients: Experiences from a State-Wide Bariatric Telehealth Service in Australia

BACKGROUND

The state of Queensland, Australia, is large (1.85 million km²). The provision of bariatric care across the state is difficult as most major hospitals are concentrated in the capital city of Brisbane. We implemented a state-wide telehealth service to improve access for rural patients in a public bariatric service. We report our early experiences with this service.

METHODS

We reviewed all patients seen in the Bariatric Telehealth Clinic from 2017 to 2019. Patients underwent consultation through video-link software at their local hospital with the multidisciplinary team in Brisbane (surgeon, dietician and clinical nurse). Distances from Brisbane and number of visits were calculated. Telehealth patients were contacted by phone to complete a survey regarding their experiences. This was a 17-question Likert-style survey with scores from 1 (strongly disagree) to 5 (strongly agree).

RESULTS

A total of 85 new patients underwent their initial consultation via telehealth. Each patient had a variable number of in-person as well as telehealth consultations both before and after surgery. Mean distance from telehealth consultation site to Brisbane was 614 km (range 149-2472 km). In total, 41 (48%) completed the survey. With regard to telehealth saving time and money, improving access to bariatric care, and desire to use telehealth again, the mean score was 4 out of 5 or higher for all questions (i.e., agree or strongly agree). There was no identifiable post-operative complication that was caused or exacerbated by telehealth.

CONCLUSION

Bariatric surgical telehealth appointments are feasible and preferred by most patients residing in rural and remote locations. Each consultation avoids significant travel time and cost for the patient and health service, with no obvious adverse outcomes. Telehealth improves equity and access to specialist services for rural and remote patients.

A novel patient-reported outcome monitoring with clinical feedback system in bariatric surgery care: study protocol, design and plan for evaluation

BACKGROUND

Consultations before and after bariatric surgery should include structured assessments of patients' health-related quality of life (HRQOL) and mental health. One way to conduct this assessment is to implement patient-reported outcome monitoring with a clinical feedback system (PRO/CFS).

AIM

We will explore patients' and healthcare professionals' experiences when a PRO/CFS is an integrated part of bariatric surgery care.

METHODS AND ANALYSES

This is a design paper in which a PRO/CFS will be implemented in two bariatric outpatient clinics. All patients who have an appointment with a healthcare professional prior to, and 3 and 12 months after surgery, will be asked to complete six digital questionnaires measuring HRQOL, mental health, bowel symptoms and eating self-efficacy prior to each consultation. A digital summary report generated from the patient's responses will form the basis for the clinical consultation. A team of patient representatives, healthcare professionals and researchers will be involved in all phases of designing the PRO/CFS to ensure its relevance for clinical consultations. The patients' experiences will be explored with a generic 12-item questionnaire, developed for use in outpatient clinics, prior to and 12 months after bariatric surgery. We will conduct focus-group interviews with patients and healthcare professionals to explore their experiences when PRO/CFS is integrated into the consultations.

ETHICS AND DISSEMINATION

Written informed consent will be obtained for all participants in the study. The project is approved by the Norwegian Centre for Research Data, Department of Data Protection Services (ref. no. 282738). The project has also undergone Data Protection Impact Assessments, both at Førde Hospital Trust and at St. Olav Hospital (registration no. 2016/3912). Data from the qualitative and quantitative studies will be kept in de-identified form in a secured research database, and the findings will be published in international peer-reviewed journals and presented at scientific conferences.

Does Lifestyle Intervention After Gastric Bypass Surgery Prevent Weight Regain? A Randomized Clinical Trial

BACKGROUND

Weight regain after bariatric surgery often starts after 1-2 y, but studies evaluating strategies to prevent weight regain are lacking. The aim of this intervention was to evaluate the efficacy of a 2-y-group-based lifestyle intervention starting approximately 2 y after Roux-en-Y gastric bypass (RYGB) compared with usual care on weight regain and related metabolic risk factors.

METHODS

A total of 165 patients with a mean of 21 months (range 14-32) after RYGB were randomized to a lifestyle intervention group (LIG) or a usual care group (UCG). Of the 165 participants 86% completed the study. The LIG was offered 16 group meetings over 2 y with focus on healthy diet, physical activity, and behavioural strategies to prevent weight regain, in addition to usual care.

RESULTS

Mean (SD) total weight loss at study start was 30.1 ± 8.2%, while weight regain during the intervention was 4.9 ± 7.4 and 4.6 ± 9.2% in the LIG and UCG, respectively (P = 0.84). There were no differences in metabolic risk factors between the groups. The LIG participants attended 8 ± 4 group meetings, with no difference in weight regain between participants with high compared to lower participation. In all the participants, a positive association between weight increase from nadir to study start and weight regain during the intervention was found. Participants who reported physical activity ≥ 150 min/wk had smaller % weight regain compared with less active participants (β = - 5.2 [SE 2.0, 95% CI - 9.1 to - 1.4]).

CONCLUSION

We found no difference in weight regain between LIG and UCG.

Tracking physical activity using smart phone apps: assessing the ability of a current app and systematically collecting patient recommendations for future development

Background

Within the United Kingdom’s National Health System (NHS), patients suffering from obesity may be provided with bariatric surgery. After receiving surgery many of these patients require further support to continue to lose more weight or to maintain a healthy weight. Remotely monitoring such patients’ physical activity and other health-related variables could provide healthworkers with a more ‘ecologically valid’ picture of these patients’ behaviours to then provide more personalised support. The current study assesses the feasibility of two smartphone apps to do so. In addition, the study looks at the barriers and facilitators patients experience to using these apps effectively.

Methods

Participants with a BMI > 35 kg/m² being considered for and who had previously undergone bariatric surgery were recruited. Participants were asked to install two mobile phone apps. The ‘Moves’ app automatically tracked participants’ physical activity and the ‘WLCompanion’ app prompted participants to set goals and input other health-related information. Then, to learn about participants’ facilitators and barriers to using the apps, some participants were asked to complete a survey informed by the Theoretical Domains Framework. The data were analysed using regressions and descriptive statistics.

Results

Of the 494 participants originally enrolled, 274 participants data were included in the analyses about their activity pre- and/or post-bariatric surgery (ages 18–65, M = 44.02, SD ± 11.29). Further analyses were performed on those 36 participants whose activity was tracked both pre- and post-surgery. Participants’ activity levels pre- and post-surgery did not differ. In addition, 54 participants’ survey responses suggested that the main facilitator to their continued use of the Moves app was its automatic nature, and the main barrier was its battery drain.

Conclusions

The current study tracked physical activity in patients considered for and who had previously undergone bariatric surgery. The results should be interpreted with caution because of the small number of participants whose data meet the inclusion criteria and the barriers participants encountered to using the apps. Future studies should take note of the barriers to develop more user-friendly apps.

Trial registration

ClinicalTrials.gov- NCT01365416 on the 3rd of June 2011.

Remotely Delivered Interventions for Obesity Treatment

PURPOSE OF REVIEW

This review synthesizes recent research on remotely delivered interventions for obesity treatment, including summarizing outcomes and challenges to implementing these treatments as well as outlining recommendations for clinical implementation and future research.

RECENT FINDINGS

There are a wide range of technologies used for delivering obesity treatment remotely. Generally, these treatments appear to be acceptable and feasible, though weight loss outcomes are mixed. Engagement in these interventions, particularly in the long term, is a significant challenge. Newer technologies are rapidly developing and enable tailored and adaptable interventions, though research in this area is in its infancy. Further research is required to optimize potential benefits of remotely delivered interventions for obesity.

Disordered eating after bariatric surgery: clinical aspects, impact on outcomes, and intervention strategies

PURPOSE OF REVIEW

Disordered eating behaviors (DEBs) are associated with poor weight outcomes following bariatric surgery. We describe DEBs most relevant to this population, their associations with weight outcomes, and emerging data on interventions for DEBs.

RECENT FINDINGS

Loss of control eating episodes and grazing have been the most well studied DEBs in bariatric samples. Although DEBs often remit after surgery even without targeted intervention, a subgroup of patients have persistent or newly developed DEBs postoperatively. Preoperative DEBs have little effect on weight outcomes, whereas preoperative impulse control-related features commonly associated with DEBs (e.g., inhibitory control) may have stronger predictive value. Postoperatively, DEBs appear to exert robust effects on concurrently measured weight. Postoperative interventions hold promise for optimizing treatment outcomes.

SUMMARY

We recommend the following to improve clinical care and move research forward: a common language for DEB constructs is needed to improve cross-talk among researchers and care providers; diagnostic schemes and assessment tools may require tailoring for the bariatric population; mechanisms underlying improvements in DEBs following surgery should be clarified; ongoing monitoring of DEBs in the postoperative period is warranted; and a stepped-care approach may improve weight outcomes in a cost-effective manner.

Psychosocial Concerns Following Bariatric Surgery: Current Status

PURPOSE OF REVIEW

The purpose of this paper is to review the current status of research on psychosocial concerns following bariatric surgery.

RECENT FINDINGS

Bariatric surgery has a positive overall impact on weight and obesity-related comorbidities, as well as a positive short-term impact on mental health and psychosocial functioning. Nonetheless, research has documented a number of different psychosocial concerns that may emerge following surgery including maladaptive eating, substance use disorders, suicide, lack of social support, and excess skin. Moreover, special populations of patients may have distinctive psychosocial concerns based on sociodemographic factors such as age or severity of obesity. Available studies suggest that psychosocial interventions have a positive impact on post-surgery outcomes, particularly maladaptive eating. However, research is limited, and long-term data are lacking. Monitoring patients after bariatric surgery for negative psychosocial outcomes is warranted. Research is needed to develop and evaluate personalized approaches to optimize long-term weight loss and psychosocial adjustment.