Transcript Obesity and Eating Disorders: Can We Talk?

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
% Excess weight loss
0
-10
-20
-30
-40
TAU
-50
BEH
-60
-70
-80
-90
0
12
24
36
Months since surgery
48
60
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 nonsurgical 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
50
45.5
45
37.5
40
32.6
35
%
30
25
20
24.9
26.6
Surgery
Candidates
19.3
National
Comorbidity
Survey (NCS)
15
10
5
0
Mood
Kalarchian et al., 2007, Am J Psychiatry
Anxiety
Substance Abuse
or Dependence
Psychiatric Disorders are Associated
with Higher BMI
55
54.2
54
53.3
53
BMI
52
51
Any
51
49.6
50
49
48
47
Current
Lifetime
None
Psychiatric Disorders are Associated
with Lower Physical Functioning
100
Any
SF-36 Subscale Score
90
None
80
70
60
50
40
30
20
10
0
Physical
Functioning
Physical
Limitations
Pain
General Health
Perceptions
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
40
35
% BMI
Loss
30
25
6mo
12mo
No LOC
24mo
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. RENEW
Intervention
Delivery:
PREP: One-on-one,
prior to surgery
RENEW: Groups for
patients > 3 years after
surgery
Treatment
Adaptations:
Education and
Longer-term
preparation for surgery adjustment
Patient Population:
Candidates for surgery
Patients with suboptimal 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
Randomization
Surgery
Usual Care
Post
Pre
Intervention
6 month
Follow-up
12 month
Follow-up
24 month
Follow-up
PREP Model of Treatment Effects
Eating Behavior
↓ Caloric intake
↑ Nutritional quality
Preoperative
Lifestyle
Intervention
Exercise Behavior
↑ Physical activity
↓ Sedentary activity
Postoperative
Outcomes
Preoperative
Outcomes
↓ Body Weight/BMI
↑ Preparation for surgery
↑ Compliance
↓ Behavior-related eating
problems
↓ Complications
↓ Outpatient visits with
conditions
Knowledge
↑ Knowledge about
surgery and obesity
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)