Psychological health of patients and how it may contribute to weight regain KYLIE MURPHY CLINICAL AND HEALTH PSYCHOLOGIST
Overview Psychological health of those seeking bariatric surgery Causes and predictors of suboptimal weight loss and weight regain Strategies for addressing weight regain
Psychological health of patients
da Luz, Sainsbury, et al (2017)
NES
Colles, et.al (2008)
Devlin, King, Kalarchian. et al (2016)
Suboptimal weight loss and weight regain CAUSES & PREDICTORS
Surgery and weight loss 20-30% of bariatric patients fail to reach targeted weight loss (25-35% of TBW) 30-70% fail to maintain 20% weight loss 10 years post surgery Food intake reduced initially via mechanical restriction and hormonal changes The ability and desire to consume greater amounts of food returns over time, making it harder to stick to dietary recommendations Surgery does not address psychological factors that lead to overeating, such as responsivity to internal and external cues Bradley, Forman et al (2016, 2017)
Causes of weight recidivism Nutritional non-compliance Mental health Increased caloric intake Binge eating Maladaptive eating Depression Hormonal/metabolic imbalances Alcohol and drug use Physical inactivity Impulsive behavioural traits Anatomic/surgical factors Multiple psychiatric disorders AGB, VSG, RYGB Revisional surgery Karmali, Brar, Shi, Sharma, de Gara & Birch (2013); Shukla, He, Saunders, Andrew & Aronne (2018)
Behavioural predictors Weight maintenance Improved control over food urges Improved control over eating habits Self-monitoring Weight regain Lack of control over food urges Concerns over drug and alcohol use Poor postoperative wellbeing Poor adherence to follow up Odom, Zalesin, et al (2010)
Study N = 167 (over 3 years) 83% F, M age 49yrs M BMI Preop 45.68, Postop 35.94 95% sleeve gastrectomy Successful 50+% EWL (46.1% of sample) %EWL 71.34 +/- 15.59 Unsuccessful %EWL 26.26 +/- 22.96 Weight Regainers Regained >20% of lowest postop weight, n = 34.7% 55.6% were unsuccessful
Psychological response to weight regain We know what we have to do, we just can t do it. I had every dietician referral ever, and it s the same thing, eat all the green stuff; we all know it, we just don t do it I am thinking (that) they re thinking, well what are you doing here, what are you doing here if you can t do what you ve had this thing for?.. When I am in a failure mode, I am not interested in going back. I ll come back when I am ready to tackle it again. But until I am ready to do that, what good am I to them? What good they are to me? My shame would not allow me to go back. You don t want to own up to it, you don t want to face up to it, the emotional anguish is so great for you. If you are feeling miserable about it, you won t go. I didn t have that relationship with them to want to overcome my fears and embarrassment and vulnerabilities to work with the on that. So the easiest option was to opt out. Moroshko, Brennan, Brown & O Brien (2013)
Psychological response to weight regain Gaining weight after surgery a double-failure Gain weight > reduced quality of life > reduced self-esteem - I can t lose weight even with surgery Guilt, self-contempt, low self-esteem, shame Betrayed trust of surgical team Breaking an alliance > now a problem patient > feels rejected Exacerbated sensitivity to criticism Need for help is higher but fear of criticism/rejection can prevent adherence to follow up or help seeking Surgical regret still low Caravalho, et al. (2014)
Strategies to help address weight regain
Why we eat what we eat Biological models of eating Innate preferences (i.e., taste) and sensations of hunger and satiety Psychological models of eating Cognitions, learning, experiences, expectations and control Meaning of food Emotional roles emotional management and eating moderated by emotional state Food and conflict - eating vs denial; guilt vs pleasure; health vs pleasure; self-control vs out of control Social roles family communication, religious identity, power relations, social power Food and health healthy v unhealthy; changing recommendations Ogden in Buckroyd & Rother (2008)
Regulation of food intake Hunger Physical or psychological sensations related to hunger Cognitive restraint Intentional, chronic effort to limit food intake to lose weight or prevent weight gain Disinhibition Tendency to lose control over food intake (often accompanied by overeating or binge eating) Sarwer, Dilks & West-Smith (2011)
CBT model of overeating Risk factors Consequence of weight gain Feedback cycle Cassin, et al (2013)
CBT model of weight regain Goals and expectations Weight loss goals Primary goals Relationship between them Abandon weight loss efforts Underestimate or minimise achievements Overwhelmed by further weight loss Neglect weight maintenance Return to previous habits Regain weight Cooper & Fairburn (2001)
Primary goals for weight loss Reasons for wanting to lose weight Identifying primary goals may help patients to Focus on the bigger picture Maximise their intrinsic motivation Prioritise behaviour change Take emphasis off goals outside of a client s specific control Cooper & Fairburn (2001)
Behavioural strategies Psychoeducation Goal setting Self monitoring Stimulus control Healthy eating (food choices) Increasing physical activity/exercise Identifying & overcoming barriers Managing challenging situations
Acceptance and mindfulness strategies Basic principle Help clients enact goal-directed behaviours that are in line with values in spite of aversive (or non-preferred) internal experiences Specific skills Distress tolerance Present-moment awareness of internal cues Clarity of personal values Linking values to in-the-moment decision making Psychological distancing (diffusion) Bradley, Forman et al (2017)
Bradley, Forman et al (2016)
Summary Bariatric surgery does not cure obesity, but it does produce the most weight loss and improves or resolves several serious comorbidities Achieving optimal weight loss requires sustained lifestyle change Our relationship with food is complex and psychological factors play a large role in determining long-term weight loss success Understanding the factors that lead to suboptimal loss and recidivism is crucial so that they can be minimised or prevented Need to improve and refine treatments targeting weight regain Combining traditional behavioural strategies with acceptance and mindfulness strategies may help improve treatment success
Thank you kylie@kdmpsychology.com