Why it is important and how to achieve it.

Transcription

1 Sustained behavioural change following bariatric surgery. Why it is important and how to achieve it. A/Prof Leah Brennan Australian Catholic University Centre for Eating, Weight and Body Image

2 AACE/TOS/ASMBS Guidelines Preoperative (R27/8) Psychosocial and behavioural evaluation Postoperative (R42) If weight regain/failure to lose weight, evaluation for (a)decreased patient adherence with lifestyle modification, (c)development of maladaptive eating behaviors, (d)psychological complications Interventions should first include a multidisciplinary approach including... behaviour modification Postoperative (R45) All patients should be encouraged to attend support groups

3 NHMRC Guidelines Long-term weight management is difficult, due to strong physiological responses.regular support over the long term is essential, along with repeated lifestyle interventions.. Bariatric surgery overall clinical pathway for adult weight management that is delivered by a multidisciplinary team. planning for continuing follow-up. Achieving long-term weight loss therefore requires weight management strategies to be continued after bariatric surgery has been performed. Post-surgical long term follow-up monitoring and treating comorbidities, including psychological distress and risk of suicide promoting the benefits of physical activity and healthy eating providing support for behavioural change providing support for healthy nutrition and sustained levels of physical activity

4 Why is it important?

5 Why is it important? OUTCOMES! Behaviour change important* for Weight loss Metabolic health Nutritional adequacy Gastrointestinal symptoms (e.g., vomiting) Post-surgical complications Quality of life Psychosocial functioning *Behaviour change impacts likely vary across types of surgery

6 Supporting Behaviour Change (Kalarchian & Marcus, 2015) Bariatric surgery outcomes the result of behavioural, cognitive, neuronal and hormonal mechanisms Not everyone achieves optimal weight loss and/or weight loss maintenance Variability may be due to differences in adherence to post-surgical eating/activity behaviour and capacity to self-manage behaviours Most patients could benefit from additional skills and support to promote optimal outcomes Adjunct behaviour change intervention could help optimise outcomes Interventions Behaviour change Psychological (mental health, adjustment)

7 Pre-Surgical Psychological Interventions (Kalarchian & Marcus, 2015) Psychological evaluation prior to surgery recommended and may lead to intervention Interventions typically target disordered, and depression and anxiety symptomatology Reductions in depression Reductions in anxiety Reductions in disordered eating Improvements in QoL Improvements evident pre-surgery, not always evident long term Some evidence that effective treatment of BED pre-surgery is associated with greater post-surgical weight loss

8 Post-Surgical Psychological Interventions (Beck et.al., 2012; Kalarchian & Marcus, 2015) Psychological interventions and support groups 9 studies included (poor methodology) 5 psychological interventions 4 support groups

9 Post-surgical Psychological Interventions (Beck et.al., 2012) 5 psychological interventions Individual or group, CBT, psychodynamic, or brief therapy 4 sessions to 6 months biweekly Led by psychologists Weight loss outcomes 4 of 5 studies demonstrated significant positive effect Overall small but significant effect on weight loss (Esr = 0.17, p <.001) Other outcomes??

10 Post-surgical Support Groups (Beck et.al., 2012) 4 support groups 15 to 20 participants Led by nurses or dietitians 1-2 hours, 12 months Goals; (1) adapt to new lifestyle, (2) deal with emotional problems, (3) prevent relapse Weight loss outcomes 3 of 4 studies attendance significant positive association with weight loss Overall significant medium effect (Esr = 0.21, p <.0001) 2 studies showed dose effect Other outcomes??

11 Pre-Surgical Behaviour Change Interventions (Kalarchian & Marcus, 2015; Liu, 2016) Behaviour change interventions Improved weight loss Reduced energy intake Improved eating quality Increased physical activity Reduced disordered eating Reduced negative emotions Generally positive outcomes pre-surgery (some failed to find an effect) Unclear whether benefits extend post-surgery

12 Post-Surgical Behaviour Change Interventions (Rudolph & Hilbert, 2013; Kalarchian & Marcus, 2015) 15 studies, variety of interventions & research designs 5 RCTs, 2 prospective cohort trials, 8 retrospective cohort trials Variety of interventions, timings, durations, clinicians 8 Behavioural weight loss interventions 7 support groups 13 of 15 studies Improved weight loss (MA confirmed greater excess weight loss)

13 Pre- & Post-Surgical Behaviour Change Interventions (Stewart & Avenell, 2016) 11 RCTs (8 included in meta-analyses Diet, physical activity and/or behaviour change strategies Weight outcomes Use of behavioural interventions was associated with greater weight loss (range of weight loss measures)

14

15 Pre- and Post-Surgical Behaviour Change Interventions (Stewart & Avenell, 2016) 11 RCTs (8 included in meta-analyses Diet, physical activity and/or behaviour change strategies Weight outcomes Use of behavioural interventions was associated with greater weight loss (range of weight loss measures) Secondary outcomes Rarely reported, limited evidence of Fewer comorbidities and post-surgical complications Less vomiting/dumping and nausea Attrition Average 37% attrition (no difference between intervention arms)

16 Behaviour Change & Psychological Interventions Available research suggests Pre-surgical interventions result in significant improvements pre-surgery, long-term impacts are unclear. Post-surgical interventions result in small but significant improvements in weight loss, less research re non weight impacts BUT Very few studies Varied interventions, not possible to determine which intervention characteristics are associated with success Methodological limitations Primarily focused on weight outcomes, limited non-weight outcome reporting

17 How to Achieve it?

18 How to Achieve it? What behaviours????

19 How to achieve it? (Post-surgical behaviour change interventions) Limited research in bariatric surgery settings Available research suggests behavioural/cognitive behavioural stategies are helpful Guided by general weight loss literature Behavioural/cognitive behavioural weight loss intervention LEARN, Look Ahead, Diabetes Prevention Program More intensive interventions more effective Frequent sessions important initially for establishing new behaviours Longer interventions delay weight regain Both group and individual interventions effective Telephone and web-based intervention are effective

20 Behavioural/Cognitive Behavioural Weight Loss Interventions Goal Sustained health behaviour change to achieve weight loss (and associated biopsychosocial benefits) Increased awareness Goal Behaviours, antecedents and consequences Barriers to behaviour change Relapse triggers Strategies to change Behaviours, antecedents and consequences Environmental, organisational, social and personal barriers to change Relapse triggers and responses

21 Behavioural/Cognitive Behavioural Weight Loss Interventions Typical Strategies Goal settings (outcomes and behaviour change goals) Self-monitoring** Recognising hunger and satiety** Planning Problem solving Self-care Assertiveness Cognitive restructuring (cognitive diffusion) Coping strategies (acceptance) Primary goals for weight loss Relapse prevention strategies

22 Behavioural/Cognitive Behavioural Weight Loss Interventions Typical Session Agenda setting Homework review Introduce new strategies Practice strategies in session Set homework (practice strategy) Discuss any percieved barriers to change (problem solve if necessary) Session close

23 Our Interventions Designed to be consistent with Medicare funding Less intensive than those evaluated in research Behaviour Change (Chronic Disease Management) 5 sessions (allied health professionals) 1. Goal setting and self-monitoring 2. Eating behaviours 3. Activity behaviours 4. Barriers to behaviour change (environmental, organisational, social, personal) 5. Maintenance and relapse prevention Psychological Wellbeing (Better Outcomes) 10 sessions Cognitive behavioural programs using guided self-help materials NOTE: Can be delivered via video conference for those in eligible areas

24

25 Sustained behavioural change following bariatric surgery. Why it is important and how to achieve it. A/Prof Leah Brennan Australian Catholic University Centre for Eating, Weight and Body Image