Behavior Intervention for Bariatric Surgery Patients: How Can Outcomes Be Improved?

Melissa A. Kalarchian, Ph.D.

Associate Professor of Psychiatry and Psychology

What do we know?

Long-term weight control is related to making and sustaining permanent changes in eating and activity

Overall, bariatric surgery is associated with significant weight loss and improvements in obesity-related comorbidities among severely overweight indiviudals

Bariatric Surgery Bariatric surgery appears to be the most

effective treatment for class III obesity (BMI > 40)

Also recommended for individuals with class II obesity (BMI 35-39.9) and serious comorbid risk factors (e.g., CHD, type 2 diabetes)

NIH Consensus Development Panel, 1991

10 Year Weight Changes in SOS Study (Sjostrom et. al., 2004, NEJM)

Types of Procedures

Restriction only (e.g., Lap-Band, sleeve gastrectomy)

Restriction plus malapsorption (e.g., gastric bypass, biliopancreatic diversion)

Roux-en-Y Gastric Bypass

Lap-Band

Surgical Treatment Outcomes

In a large meta analysis (N > 22,000), overall weight loss was 61% of excess weight (Buchwald et. al., 2004, JAMA )

Improvements or resolution in– Diabetes (86%)– Hyperlipidemia (70%)– Hypertension (79%) – Obstructive sleep apnea (84%)

Overall Outcomes can Obscure Individual Variability

A significant minority of patients will experience inadequate weight loss or significant weight regain

For example, in the SOS study, 25% of patients had lost less than 10% of initial body weight, and 9% had gained weight at 10 year follow-up

Behavior Intervention may Improve Outcomes

Phase Body Weight Behavioral Targets

I: Preoperative Energy imbalance results in development of clinically severe obesity (BMI > 40)

Decision making Preparation for surgery

II: Postoperative Caloric expenditure exceeds intake, resulting rapid initial weight loss; weight loss continues for a discrete period

Compliance with dietary and lifestyle recommendations from health care team Adaptations to rapid weight loss

III: Longer-term Adjustment Patients exhibit variability in outcomes; most maintain a significant weight loss, but also remain obese (BMI > 30)

Maintenance of changes in eating and behavior Psychosocial adjustment Lifelong medical surveillance

Theoretical Model for Improving Postoperative Weight Control

-90

-80

-70

-60

-50

-40

-30

-20

-10

0

0 12 24 36 48 60

Months since surgery

% E

xces

s w

eig

ht

loss

TAU

BEH

Body Weight is not the only Target for Behavioral Intervention

Other important outcomes include– Compliance with diet and exercise guidelines– Co-morbid psychiatric disorders– Loss of control over eating

The relationships among weight, eating, exercise, and mental health are complex and reciprocal

Diet and Exercise National Weight Control Registry (NWCR)

data indicate that surgery patients report higher fat intake and lower physical activity than those who lost weight through non-surgical means (Bond et al., Int J Obes, 2009; Klem et al., Int J Obes, 2000)

Patients may experience greater health benefits after bariatric surgery if diet and exercise behaviors are targeted for intervention

Psychiatric Disorders

Psychaitric disorders are a major concern for this patient population

Bariatric surgery patients with a history of psychiatric disorders may benefit from careful monitoring and tailored intervention

Lifetime Psychiatric Disorders are Common

45.5

37.5

32.6

19.3

24.9 26.6

0

5

10

15

20

25

30

35

40

45

50

Mood Anxiety Substance Abuseor Dependence

%

SurgeryCandidates

NationalComorbiditySurvey (NCS)

Kalarchian et al., 2007, Am J Psychiatry

Psychiatric Disorders are Associated with Higher BMI

54.2

53.3

51

49.6

47

48

49

50

51

52

53

54

55

Current Lifetime

BM

I Any

None

Psychiatric Disorders are Associated with Lower Physical Functioning

0

10

20

30

40

50

60

70

80

90

100

PhysicalFunctioning

PhysicalLimitations

Pain General Health Perceptions

SF

-36

Su

bs

ca

le S

co

re

Any

None

Psychiatric Disorders Predict Poorer Short-Term Outcomes

Linear regression was used to examine Mood, Anxiety, Eating and Substance disorders as predictors of postoperative weight outcomes after controlling for demographic factors (BMI, sex, age, race)

Mood and Anxiety were related to BMI change (ps < .001), but eating and substance disorders were not (Kalarchian et al., SOARD, 2008)

“Binge” or “Loss of Control” Eating

A growing body of literature suggests that the onset or recurrence of subjective binge eating (or loss of control over eating) is a marker of poor long-term outcome

Postoperative binge eating may be a possible target for clinical intervention

Postoperative Loss of Control Predicts Longer-Term Outcome

LOC at Follow-up

25

30

35

40

6mo 12mo 24mo

% BMI Loss

No LOC With LOC

White, Kalarchian et al., J Clin Psy, 2010

Adapting Behavior Intervention Consider the needs of participants, type of

surgery, and target outcomes. For example:– Patients travel a significant distance to seek care in

surgical Centers of Excellence, and some have physical limitations so consider alternate modes of intervention delivery (e.g., telephone, Web)

– Include psychoeducation specific to the surgical procedure (e.g., realistic expectations for gastric banding)

– Tailor intervention techniques to the target outcomes (e.g., limiting high calorie liquids to reduce dumping and improve weight control after bypass)

Integrating Behavioral Intervention with Surgical Care

Include a multidisciplinary team approach, integrating behavioral intervention with routine care

Always rule out surgical causes for complications or poor outcomes before pursuing strictly behavioral intervention

Typical Schedule of Postoperative Care

Discharge 2 weeks 6 weeks Every 2 – 3 months Every 6 months Annually thereafter

Clinical Intervention Research

Behavior intervention research in bariatric surgery is very limited

In our work, theory-driven intervention development--along with focus groups and clinical case studies--has been used to adapt standard behavior interventions to the needs of bariatric surgery patients

PREP vs. RENEWIntervention Delivery:

PREP: One-on-one, prior to surgery

RENEW: Groups for patients > 3 years after surgery

Treatment Adaptations:

Education and preparation for surgery

Longer-term adjustment

Patient Population: Candidates for surgery Patients with sub-optimal outcomes

Key research questions:

Does a pre-operative intervention decrease weight before surgery and reduce complications after?

Is a post-operative intervention feasible and effective for treating failure?

Preoperative Behavior Intervention – PREP study

RCT: 200 patients receive behavioral intervention or usual care prior to surgery– Aim 1: To determine the impact of a

preoperative lifestyle intervention on weight and psychosocial outcomes before operation

– Aim 2: To determine if preoperative intervention reduces surgical risks and behavior-related complications after operation

PREP Study Timeline

Pre Post

Surgery

Usual Care

Intervention

6 month Follow-up

12 month Follow-up

24 month Follow-up

Randomization

PREP Model of Treatment Effects

Preoperative Outcomes

↓ Body Weight/BMI↑ Preparation for surgery

Exercise Behavior↑ Physical activity

↓ Sedentary activity

Knowledge↑ Knowledge about surgery and obesity

Eating Behavior↓ Caloric intake

↑ Nutritional quality

PreoperativeLifestyle

Intervention

Postoperative Outcomes↑ Compliance

↓ Behavior-related eating problems

↓ Complications↓ Outpatient visits with

conditions

SURGERY

Postoperative Behavior Intervention – RENEW Study

Pilot: 36 patients participated in a group intervention for long-term weight loss failure– Aim 1: To describe patients who fail to lose

weight or experience regain– Aim 2: To document the feasibility and

preliminary efficacy of a lifestyle intervention for this subgroup of patients

RENEW Participants

Over age 21 Had bariatric surgery at least 3 years ago BMI > 30 < 50% Excess weight loss Medical clearance from PCP and Surgeon

(including recent upper GI)

Modeled Weight Change in Kg

Weight Change

Baseline Month 6 Month 12

Brief Summary

Adjunct behavioral interventions may help to optimize patient outcomes in bariatric surgery

The PREP and RENEW studies are examples of pre- and post-operative behavior intervention studies

The treatments were adapted for the type of surgery, target outcomes, and needs of the participants

University of Pittsburgh Obesity and Nutrition Research Center Pilot/Feasibility Study

Optimizing Lifestyle Adjustment in Weight Loss Surgery (K23 DK62291)

Preoperative Lifestyle Intervention in Weight Loss Surgery (R01 DK077102)

Behavioral Intervention for Weight Loss Failure Surgery (R03 DK078562)

Optimizing Long-term Weight Control in Bariatric Surgery (ASMBS Foundation)