Post‐operative behavioural management in bariatric surgery: a systematic review and meta‐analysis of randomized controlled trials

Recent research has provided evidence that bariatric surgery maximizes long‐term weight loss in patients with severe obesity. However, a substantial number of patients experience poor weight loss outcome and weight regain over time. Post‐operative behavioural management may facilitate long‐term weight control in bariatric surgery population. The objective of this systematic review and meta‐analysis was to determine the effects of post‐operative behavioural management on weight loss following bariatric surgery. Eligible articles were systematically searched in electronic databases. Among the 414 citations, five randomized controlled trials, two prospective and eight retrospective cohort trials analysing behavioural lifestyle interventions and support groups fulfilled the inclusion criteria. The main finding is that behavioural management had a positive effect on weight loss following surgery. In 13 studies, patients receiving behavioural management had greater weight loss than patients receiving usual care or no treatment. A meta‐analysis of five randomized controlled trials suggests greater weight loss in patients with behavioural lifestyle interventions compared with control groups. Post‐operative behavioural management has the potential to facilitate optimal weight loss following bariatric surgery, but conclusions were limited by the small and heterogeneous samples of studies. A more rigorous empirical evaluation on its clinical significance is warranted to improve effectiveness of bariatric surgery.     

Binge Eating,Binge Eating Disorder and Loss of Control Eating: Effects on Weight Outcomes after Bariatric Surgery

There is increasing evidence that patients who have problems with binge eating (BE) or BE disorder (BED) are quite common among the severely obese, including bariatric surgery candidates. The literature suggests that in many cases such eating behaviours improve after bariatric surgery, although this is not uniformly true. The current paper reviews the data on the development of BE, BED and loss of control (LOC) eating after bariatric surgery and the impact of these problems on long‐term weight outcome. A search was made of various databases regarding evidence of BE, BED and LOC eating post‐operatively in bariatric surgery patients. The data extracted from the literature suggests that 15 research studies have now examined this question. Fourteen of the available 15 studies suggest that the development of problems with BE, BED or LOC eating post‐bariatric surgery is associated with less weight loss and/or more weight regain post‐bariatric surgery. These data suggests that it is important to identify individuals at high risk for these problems, to follow them post‐operatively, and, if appropriate interventions can be developed if such behaviours occur in order to maximize weight loss outcomes. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.     

Early post‐operative psychosocial and weight predictors of later outcome in bariatric surgery: a systematic literature review

This is the first systematic review to synthesize the evidence concerning early post‐operative variables predictive of later weight and psychosocial outcomes in bariatric surgery. Eight electronic databases for empirical studies were searched (1954 to 2016). Most of the 39 included studies reported solely on weight outcomes; eating and psychosocial outcomes were less common. A better early weight loss trajectory was the most consistent predictor of more successful medium‐term weight outcome (≤24 months); however, its relationship to longer term weight loss maintenance is less certain. Early eating adaptation may be associated with later weight loss, but further research is needed. Evidence is lacking for associations between early adherence or early psychosocial variables and later outcome. In particular, the relationship between early post‐operative depression and later weight remains unclear. Little research has considered early prediction of later eating or psychosocial outcomes. Consideration of mediating or moderating relationships is lacking. The body of evidence is limited, and synthesis is hampered by heterogeneity in the type and time at which predictors and outcomes are measured and quality of statistical reporting. Further research on prospective prediction of bariatric surgery outcome is needed to guide early post‐operative intervention for those at greatest risk of poor outcomes.     

Does intensive multidisciplinary intervention for adults who elect bariatric surgery improve post‐operative weight loss,co‐morbidities,and quality of life? A systematic review and meta‐analysis

This systematic review and meta‐analysis of intervention studies aims to evaluate the effect of preoperative and/or post‐operative support for adults who elect bariatric surgery delivered by a multidisciplinary team (MDT) on post‐operative body composition, mental health, co‐morbidities, quality of life, and side effects. Six electronic databases were searched. Revman and GRADE were used to assess confidence in pooled effects. Included interventions (N = 1533 participants in total) focused on lifestyle counselling (n = 4 studies), psychology (n = 4 studies), or exercise (n = 10 studies); comparator groups were less intensive usual care. Intensive MDT interventions increased post‐operative weight loss (SMD: ?0.94; 95% CI: ?1.27 to ?0.61) if delivered post‐operatively. Preoperative and post‐operative intensive interventions improved symptoms of depression and anxiety, quality of life, diastolic blood pressure, and resting heart rate but not lipids or glycaemic measures. Whilst usual MDT care is important preoperatively, this review conditionally recommends intensive MDT interventions for enhanced post‐operative weight loss if delivered in the post‐operative period, led by any health professional, based on moderate evidence. This review also conditionally recommends preoperative and/or post‐operative lifestyle, nutrition, or psychology counselling and/or physical activity for improved mental and physical health. Further randomized controlled trials are required, which aim to specifically evaluate the best use of MDT resources.     

Incentivizing behaviour change to improve diabetes care

Behavioural economics refers to the study of psychological and cognitive factors that relate to decision‐making processes. This field is being applied increasingly to health care settings, in which patients receive tangible reinforcers or incentives for meeting objective behavioural criteria consistent with healthy lifestyles. This article reviews the background and efficacy of reinforcement interventions in general, and then as applied to behaviours related to diabetes prevention and management. Specifically, reinforcement interventions have been applied with some notable success towards promoting greater attendance at medical appointments, enhancing weight loss efforts, augmenting exercising regimes, improving medication adherence and increasing blood glucose monitoring. Suggestions for promising areas of future research are provided, keeping in mind the controversial nature of these interventions.     

The neurocognitive connection between physical activity and eating behaviour

As obesity rates increase worldwide, healthcare providers require methods to instill the lifestyle behaviours necessary for sustainable weight loss. Designing effective weight‐loss interventions requires an understanding of how these behaviours are elicited, how they relate to each other and whether they are supported by common neurocognitive mechanisms. This may provide valuable insights to optimize existing interventions and develop novel approaches to weight control. Researchers have begun to investigate the neurocognitive underpinnings of eating behaviour and the impact of physical activity on cognition and the brain. This review attempts to bring these somewhat disparate, yet interrelated lines of literature together in order to examine a hypothesis that eating behaviour and physical activity share a common neurocognitive link. The link pertains to executive functions, which rely on brain circuits located in the prefrontal cortex. These advanced cognitive processes are of limited capacity and undergo relentless strain in the current obesogenic environment. The increased demand on these neurocognitive resources as well as their overuse and/or impairment may facilitate impulses to over‐eat, contributing to weight gain and obesity. This impulsive eating drive may be counteracted by physical activity due to its enhancement of neurocognitive resources for executive functions and goal‐oriented behaviour. By enhancing the resources that facilitate ‘top‐down’ inhibitory control, increased physical activity may help compensate and suppress the hedonic drive to over‐eat. Understanding how physical activity and eating behaviours interact on a neurocognitive level may help to maintain a healthy lifestyle in an obesogenic environment.     

The use of motivational enhancement strategies for the maintenance of weight loss among obese individuals: a preliminary investigation

Aim:  To investigate the efficacy of motivational enhancement strategies integrated within a standard lifestyle modification program for the maintenance of weight loss and improved psychosocial functioning of obese adults.
Methods:  Twenty-two obese adults completed 20 sessions of a motivationally informed cognitive behavioural treatment for weight loss and maintenance. Treatment outcome measures included anthropometrics, obesity-specific quality of life, impulsive eating tendencies, body dissatisfaction, mood disturbance and maladaptive cognitions.
Results:  At post-treatment, there was a significant decrease in body weight (123.04 ± 22.06 vs. 116.84 ± 23.53, p < 0.001) with no significant change by the 12-month follow-up. Patients also reported significant improvements in obesity-related quality of life, impulsive eating tendencies, body dissatisfaction and maladaptive cognitions at post-treatment that were maintained at the 1-year follow-up.
Conclusions:  The implementation of motivational enhancement strategies within a cognitive behavioural program results in sustained weight loss that compares favourably to previous lifestyle modification programs.     

Comparative Effectiveness of Treatments for Binge‐Eating Disorder: Systematic Review and Network Meta‐Analysis

Psychological and pharmacological interventions for binge‐eating disorder have previously demonstrated efficacy (compared with placebo or waitlist control); thus, we aimed to expand that literature with a review of comparative effectiveness. We searched MEDLINE,® EMBASE,® Cochrane Library, Academic OneFile, CINAHL® for binge‐eating disorder treatment articles and selected studies using predetermined inclusion and exclusion criteria. Data were sufficient for network meta‐analysis comparing two pharmacological interventions; psychological interventions were analysed qualitatively. In all, 28 treatment comparisons were included in this review: one pharmacological comparison (second‐generation antidepressants versus lisdexamfetamine) and 26 psychological comparisons. Only three statistically significant differences emerged: lisdexamfetamine was better at increasing binge abstinence than second‐generation antidepressants; therapist‐led cognitive behavioural therapy was better at reducing binge‐eating frequency than behavioural weight loss, but behavioural weight loss was better at reducing weight. The majority of other treatment comparisons revealed few significant differences between groups. Thus, patients and clinicians can choose from several effective treatment options. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.     

Is social support associated with greater weight loss after bariatric surgery?: a systematic review

Social support may be associated with increased weight loss after bariatric surgery. The objective of this article is to determine impact of post‐operative support groups and other forms of social support on weight loss after bariatric surgery. MEDLINE search (1988–2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened studies, 10 reported on social support and weight loss outcomes. Five studies reported on support groups and five studies reported on other forms of social support (such as perceived family support or number of confidants) and degree of post‐operative weight loss (total n = 735 patients). All studies found a positive association between post‐operative support groups and weight loss. One study found a positive association between marital status (being single) and weight loss, while three studies found a non‐significant positive trend and one study was inconclusive. Support group attendance after bariatric surgery is associated with greater post‐operative weight loss. Further research is necessary to determine the impact of other forms of social support. These factors should be addressed in prospective studies of weight loss following bariatric surgery, as they may represent ways to improve post‐operative outcomes.     

Mindfulness‐based interventions for obesity‐related eating behaviours: a literature review

Mindfulness‐based interventions (MBIs) targeting eating behaviours have gained popularity in recent years. A literature review was conducted to determine the effectiveness of MBIs for treating obesity‐related eating behaviours, such as binge eating, emotional eating and external eating. A search protocol was conducted using the online databases Google Scholar, PubMed, PsycINFO and Ovid Healthstar. Papers were required to meet the following criteria to be included in this review: (i) describe a MBI or the use of mindfulness exercises as part of an intervention; (ii) include at least one obesity‐related eating behaviour as an outcome; (iii) include quantitative outcomes; and (iv) be published in English in a peer‐reviewed journal. A total of N = 21 papers were included in this review. Interventions used a variety of approaches to implement mindfulness training, including combined mindfulness and cognitive behavioural therapies, mindfulness‐based stress reduction, acceptance‐based therapies, mindful eating programmes, and combinations of mindfulness exercises. Targeted eating behaviour outcomes included binge eating, emotional eating, external eating and dietary intake. Eighteen (86%) of the reviewed studies reported improvements in the targeted eating behaviours. Overall, the results of this first review on the topic support the efficacy of MBIs for changing obesity‐related eating behaviours, specifically binge eating, emotional eating and external eating.     

Personality Subtypes in Female Pre‐Bariatric Obese Patients: Do They Differ in Eating Disorder Symptoms,Psychological Complaints and Coping Behaviour?

In the pre‐bariatric psychological assessment of 102 morbidly obese women, two personality subtypes emerged: a resilient/high functioning subtype with a ‘normal’ personality profile and an emotional dysregulated/undercontrolled subtype, characterized by high neuroticism and low extraversion/conscientiousness. Emotional dysregulated/undercontrolled patients showed more concerns about eating/weight/shape, more binge eating driven by emotions and external triggers, more psychological complaints (such as depression and anxiety) and more avoidance and depressive coping reactions than resilient/high functioning patients. Further research should clarify whether these clearly different psychological profiles are related to different outcomes (weight loss or well‐being) of bariatric surgery. Copyright © 2012 John Wiley & Sons, Ltd and Eating Disorders Association.     

The diabetes educator: trying hard, but must concentrate more on behaviour.

Current guidelines state that education is fundamental to help people with diabetes modify their lifestyle and prevent ill health and early death. However, many people with diabetes are not receiving adequate education. There is a widespread assumption that transferring knowledge will improve health outcomes but there is little empirical support for this assertion. Indeed, knowledge and behaviour are poorly correlated. Knowledge may be a necessary condition but is rarely a sufficient condition for behaviour change. Single interventions, cognitive or behavioural, have had disappointing results, unsurprisingly given the complexity of human behaviour. The most effective interventions are multifaceted and include education, behavioural and psychosocial elements, and target lifestyle change and factors such as self-efficacy and empowerment. We advocate that educational interventions should have multiple components. They should aim to improve patients' sense of self-efficacy and empowerment, and build attitudes towards diabetes that will support the lifestyle changes needed for successful self-management. These conclusions have implications for future research and clinical practice.     

Disturbances of weight control behaviours and psychological functioning in individuals presenting to an outpatient eating disorder unit: A descriptive study

The behavioural, psychological and demographic characteristsics of a sample of 169 patients presenting to a speciality eating disorder outpatient clinic are described. While disturbances of weight control involving restrictive eating are common within the sample, overeating and behaviours compensating for dietary failures are distributed more variably. The severity of these behavioural disturbances suggest that approximately 50 per cent of these patients would be currently classified as subclinical. Despite this, the psychological profile of the sample is equivalent to diagnosed eating disordered samples and identifies significant amounts of psychopathology. The study argues for a broadening of the empirical approaches to the understanding and treatment of all patients with disorders of eating and weight control.     

Disordered eating behaviours and cognitions in young women with obesity: relationship with psychological status

OBJECTIVE: To examine levels of eating disorder behaviours and cognitions of young women with obesity in the Australian Capital Territory, Australia and assess the impact upon psychological status. DESIGN: General population cross-sectional survey. SUBJECTS: A total of 4891 young women from the community aged 18-42 years, of which 630 were in the obese weight range. MEASUREMENTS: Body mass index (BMI), eating disorder psychopathology (eating disorder examination questionnaire), and psychological distress (K-10). RESULTS: Women with obesity had significantly higher levels of dietary restraint, eating concern, weight concern, shape concern, binge eating, misuse of diuretics, use of diet pills and fasting compared to other women in the community. These eating disorder cognitions and behaviours were associated with increased levels of psychological distress. In women with obesity, eating concern, weight concern, shape concern, dietary restraint and decreased age predicted psychological distress in a multivariate model. Among other women in the community, behaviours such as laxative misuse, 'hard' exercise and subjective bulimic episodes also contributed to the model predicting psychological distress. CONCLUSION: As disordered eating psychopathology is high in young obese women and negatively impacts upon psychological status, obesity prevention and treatment should consider eating disorder psychopathology and mental health outcomes.     

Cognitive training on eating behaviour and weight loss: A meta‐analysis and systematic review

Cognitive deficits play a role in the development and maintenance of overeating and obesity, and cognitive training in obesity refers to a family of interventions aimed at reducing overeating and obesity by improving these cognitive deficits. In this review, we synthesize the current literature on these issues by conducting a meta‐analysis of studies investigating the effects of cognitive trainings on eating behaviour and presenting a systematic review of studies investigating the effects of cognitive trainings on weight loss. We examined 66 independent experiments that examined the effects of cognitive training aimed at reducing cognitive bias or improving executive control on eating behaviour and weight loss. Overall, inhibition training, attention bias modification training, and episodic future thinking training significantly influenced eating behaviour; however, approach/avoidance training did not significantly influence eating behaviour. Moderator analyses indicated that the effect of inhibition training on eating behaviour was moderated by training task and food novelty, the effect of approach/avoidance training was moderated by food type, and the effect of episodic future thinking training was moderated by type of episodic future thinking. Literature reviewed on cognitive training and weight loss provided preliminary support for the effects of food‐specific inhibition training on weight loss from pre‐intervention to post intervention. However, because most of the included studies focused on short‐term outcomes in normal‐weight samples, longer duration studies in clinical populations (eg, individuals with obesity) are needed to examine the generalizability of these results.     

Child and youth participatory interventions for addressing lifestyle‐related childhood obesity: a systematic review

A growing number of childhood obesity interventions involve children and youth in participatory roles, but these types of interventions have not been systematically reviewed. We aimed to identify child and youth participatory interventions in the peer‐reviewed literature in order to characterize the approaches and examine their impact on obesity and obesity‐related lifestyle behaviours. We searched PubMed/Medline, psychINFO and ERIC for quasi‐experimental and randomized trials conducted from date of database initiation through May 2015 that engaged children or youth in implementing healthy eating, physical activity or weight management strategies. Eighteen studies met our eligibility criteria. Most (n = 14) trained youth to implement pre‐defined strategies targeting their peers. A few (n = 4) assisted youth to plan and implement interventions that addressed environmental changes. Thirteen studies reported at least one statistically significant weight, physical activity or dietary change outcome. Participatory approaches have potential, but variation in strategies and outcomes leave questions unanswered about the mechanisms through which child and youth engagement impact childhood obesity. Future research should compare child‐delivered or youth‐delivered to adult‐delivered health promotion interventions and more rigorously evaluate natural experiments that engage youth to implement environmental changes. With careful attention to theoretical frameworks, process and outcome measures, these studies could strengthen the effectiveness of child and youth participatory approaches.     

A sequenced group psychotherapy model for bulimia nervosa patients: a pilot study

The main objective with this study was to develop a sequenced treatment model for group psychotherapy with bulimia nervosa patients including cognitive‐behavioural therapy and interpersonal psychotherapy techniques. This study comprises 29 participants in four successive treatment groups who meet the DSM‐IV criteria for bulimia nervosa or eating disorder NOS. All the participants were measured pre‐ and post‐treatment using the following instruments: a semi‐structured interview for eating disorder symptomatology (BAB.4.1), Eating Disorder Inventory (EDI‐2), Symptom Check List (SCL‐90), Beck's Depression Inventory (BDI), Coping Resources Inventory (CRI) and Body Mass Index (BMI). Ratings for the participants' weight phobia, bingeing and vomiting decreased significantly. Significant pre‐ to post‐ differences were demonstrated for EDI, SCL and CRI but not for BDI. A 1‐year follow‐up, including both clinical and self ratings, showed that the improvement was sustained and that progress seemed to have continued. In addition to post‐treatment effects, now both BDI and the interpersonal sensitivity subscale of the SCL showed significant changes. The results suggest that there is reason to continue the development of a sequenced treatment model based on CBT and IPT techniques and to test the model in a controlled study. Copyright © 1999 John Wiley & Sons, Ltd and Eating Disorders Association.     

Patient experiences of outcomes of bariatric surgery: a systematic review and qualitative synthesis

Although bariatric surgery is the most effective treatment for severe and complex obesity, less is known about its psychosocial impact. This systematic review synthesizes qualitative studies investigating the patient perspective of living with the outcomes of surgery. A total of 2,604 records were screened, and 33 studies were included. Data extraction and thematic synthesis yielded three overarching themes: control, normality and ambivalence. These were evident across eight organizing sub‐themes describing areas of life impacted by surgery: weight, activities of daily living, physical health, psychological health, social relations, sexual life, body image and eating behaviour and relationship with food. Throughout all these areas, patients were striving for control and normality. Many of the changes experienced were positive and led to feeling more in control and ‘normal’. Negative changes were also experienced, as well as changes that were neither positive nor negative but were nonetheless challenging and required adaptation. Thus, participants continued to strive for control and normality in some aspects of their lives for a considerable time, contributing to a sense of ambivalence in accounts of life after surgery. These findings demonstrate the importance of long‐term support, particularly psychological and dietary, to help people negotiate these challenges and maintain positive changes achieved after bariatric surgery.     

Understanding and effectively addressing disparities in obesity: A systematic review of the psychological determinants of emotional eating behaviours among Black women

Emotional eating may be a particularly important contributor to differences in body weight and weight loss response to behavioural interventions among non‐Hispanic Black women. We performed a systematic review on the impact of psychological factors (stress, anxiety, depression, and discrimination) upon emotional eating and weight among non‐Hispanic Black women, applying the Preferred Reporting Items for Systematic Reviews and Meta‐analysis for relevant studies. The initial search yielded 4593 articles with 15 accepted for review. Based on this review, there is a suggestion that negative emotions, in particular, perceived stress, may be predictive of emotional eating among non‐Hispanic Black women. Results from the only two longitudinal studies identified by the review indicate that stress influences emotional eating, and emotional eating predicts weight gain over time. Findings from this review highlight the need for more studies that examine various negative emotions that may lead to emotional eating and weight gain among non‐Hispanic Black women. Findings from this review also highlight the need for more rigorous studies to differentiate the effects of emotional eating from that of the physiologic (ie, activation of the hypothalamic‐pituitary axis) responses to stress and its impact on high‐risk groups.     

Examining the psychosocial impact of implantable cardioverter defibrillators: a literature review.

BACKGROUND: The implantable cardioverter defibrillator (ICD) has proven to be superior to medications in treating potentially life-threatening ventricular arrhythmias, resulting in reduced mortality rates. Despite the number of patients receiving this therapy, its psychosocial impact is not well understood. HYPOTHESIS: The purposes of this paper are (1) to review the available literature documenting the psychosocial impact of the ICD on patients, (2) to hypothesize possible mechanisms for this psychosocial impact, and (3) to suggest clinical risk profiles and indications for psychological consultation. METHODS: Electronic and library searches (e.g., MEDLINE, PsychLit) were used to gather studies examining the psychosocial impact of the ICD. Only studies investigating psychosocial outcomes (e.g., psychological distress, quality of life, social and role functioning), either prospectively or cross-sectionally, were admitted into the review. No literature reviews or secondary sources were included. RESULTS AND CONCLUSIONS: Current research suggests that ICD-specific fears and symptoms of anxiety (e.g., excessive worry, physiological arousal) are the most common psychological symptoms experienced by ICD recipients, with approximately 13-38% of recipients experiencing diagnosable levels of anxiety. Depressive symptoms are reported at rates that are generally consistent with other cardiac populations. Although the incidence of psychological disorders appears to be similar to that found in general cardiac populations, specific ICD-related concerns such as fear of shock, fear of device malfunction, fear of death, and fear of embarrassment have been identified. Selected psychological theories such as classical conditioning, learned helplessness, and a cognitive appraisal model help to explain the occurrence of psychological symptoms post implantation. Psychosocial adjustment risk profiles indicate that young ICD recipients and those with high discharge rates may experience the most adjustment difficulties.