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

1. Behavior Intervention for Bariatric Surgery Patients: How Can Outcomes Be Improved? Melissa A. Kalarchian, Ph.D. Associate Professor of Psychiatry and Psychology

2. 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

3. 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

4. 10 Year Weight Changes in SOS Study (Sjostrom et. al., 2004, NEJM)

5. Types of Procedures • Restriction only (e.g., Lap-Band, sleeve gastrectomy) • Restriction plus malapsorption (e.g., gastric bypass, biliopancreatic diversion)

6. Roux-en-Y Gastric Bypass

7. Lap-Band

8. 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%)

9. 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

10. Behavior Intervention may Improve Outcomes

11. Theoretical Model for Improving Postoperative Weight Control

12. 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

13. 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

14. 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

15. Lifetime Psychiatric Disorders are Common Kalarchian et al., 2007, Am J Psychiatry

16. Psychiatric Disorders are Associated with Higher BMI

17. Psychiatric Disorders are Associated with Lower Physical Functioning

18. 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)

19. “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

20. Postoperative Loss of Control Predicts Longer-Term Outcome White, Kalarchian et al., J Clin Psy, 2010

21. 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)

22. 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

23. Typical Schedule of Postoperative Care • Discharge • 2 weeks • 6 weeks • Every 2 – 3 months • Every 6 months • Annually thereafter

24. 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

25. PREP vs. RENEW

26. 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

27. Randomization Surgery Usual Care Pre Post 6 month Follow-up 12 month Follow-up 24 month Follow-up Intervention PREP Study Timeline

28. Eating Behavior ↓ Caloric intake ↑ Nutritional quality Postoperative Outcomes ↑ Compliance ↓ Behavior-related eating problems ↓ Complications ↓ Outpatient visits with conditions Preoperative Lifestyle Intervention Exercise Behavior ↑ Physical activity ↓ Sedentary activity Preoperative Outcomes ↓ Body Weight/BMI ↑ Preparation for surgery Knowledge ↑ Knowledge about surgery and obesity SURGERY PREP Model of Treatment Effects

29. 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

30. 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)

31. Modeled Weight Change in Kg Weight Change Baseline Month 6 Month 12

32. 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

33. 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)