Behavior Intervention for Bariatric Surgery Patients: How Can Outcomes Be Improved? Melissa A....
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Transcript of Behavior Intervention for Bariatric Surgery Patients: How Can Outcomes Be Improved? Melissa A....
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)