Preoperative and post‐operative psychosocial interventions for bariatric surgery patients: A systematic review

Psychosocial interventions are increasingly being utilized to help patients prepare for, and adjust to changes following, bariatric surgery in order to optimize psychosocial adjustment and weight loss. The current systematic review examined the impact of preoperative and post‐operative psychosocial interventions with a behavioural and/or cognitive focus on weight, dietary behaviours, eating pathology, lifestyle behaviours, and psychological functioning. A PsycINFO and Medline search of publications was conducted in March 2019. Two authors assessed retrieved titles and abstracts to determine topic relevance and rated the quality of included studies using a validated checklist. Forty‐four articles (representing 36 studies) met the study inclusion criteria. The current evidence is strongest for the impact of psychosocial interventions, particularly cognitive behavioural therapy, on eating behaviours (eg, binge eating and emotional eating) and psychological functioning (eg, quality of life, depression, and anxiety). The evidence for the impact of psychosocial interventions on weight loss, dietary behaviours (eg, dietary intake), and lifestyle behaviours (eg, physical activity) is relatively weak and mixed. Psychosocial interventions can improve eating pathology and psychosocial functioning among bariatric patients, and the optimal time to initiate treatment appears to be early in the post‐operative period before significant problematic eating behaviours and weight regain occur.     

Effective strategies for weight loss in post‐partum women: a systematic review and meta‐analysis

Post‐partum weight loss is critical to preventing and managing obesity in women, but the results from lifestyle interventions are variable and the components associated with successful outcomes are not yet clearly identified. This study aimed to identify lifestyle intervention strategies associated with weight loss in post‐partum women. MEDLINE, EMBASE, PubMed, CINAHL and four other databases were searched for lifestyle intervention studies (diet or exercise or both) in post‐partum women (within 12 months of delivery) published up to July 2014. The primary outcome was weight loss. Subgroup analyses were conducted for self‐monitoring, individual or group setting, intervention duration, intervention types, the use of technology as a support, and home‐ or centre‐based interventions. From 12,673 studies, 46 studies were included in systematic review and 32 randomized controlled trials were eligible for meta‐analysis (1,892 women, age 24–36 years). Studies with self‐monitoring had significantly greater weight lost than those without (?4.61 kg [?7.08, ?2.15] vs. ?1.34 kg [?1.66, ?1.02], P = 0.01 for subgroup differences). Diet and physical activity when combined were significantly more effective on weight loss compared with physical activity alone (?3.24 kg [?4.59, ?1.90] vs. ?1.63 kg [?2.16, ?1.10], P < 0.001 for subgroup differences). Lifestyle interventions that use self‐monitoring and take a combined diet‐and‐exercise approach have significantly greater weight loss in post‐partum women.     

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.     

Third‐wave cognitive behaviour therapies for weight management: A systematic review and network meta‐analysis

This systematic review and network meta‐analysis synthesized evidence on the effects of third‐wave cognitive behaviour therapies (3wCBT) on body weight, and psychological and physical health outcomes in adults with overweight or obesity. Studies that included a 3wCBT for the purposes of weight management and measured weight or body mass index (BMI) pre‐intervention and ≥ 3 months post‐baseline were identified through database searches (MEDLINE, CINAHL, Embase, Cochrane database [CENTRAL], PsycINFO, AMED, ASSIA, and Web of Science). Thirty‐seven studies were eligible; 21 were randomized controlled trials (RCT) and included in the network meta‐analyses. Risk of bias was assessed using RoB2, and evidence quality was assessed using GRADE. Random‐effects pairwise meta‐analysis found moderate‐ to high‐quality evidence suggesting that 3wCBT had greater weight loss than standard behavioural treatment (SBT) at post‐intervention (standardized mean difference [SMD]: ?0.09, 95% confidence interval [CI]: ?0.22, 0.04; N = 19; I² = 32%), 12 months (SMD: ?0.17, 95% CI: ?0.36, 0.02; N = 5; I² = 33%), and 24 months (SMD: ?0.21, 95% CI: ?0.42, 0.00; N = 2; I² = 0%). Network meta‐analysis compared the relative effectiveness of different types of 3wCBT that were not tested in head‐to‐head trials up to 18 months. Acceptance and commitment therapy (ACT)‐based interventions had the most consistent evidence of effectiveness. Only ACT had RCT evidence of effectiveness beyond 18 months. Meta‐regression did not identify any specific intervention characteristics (dose, duration, delivery) that were associated with greater weight loss. Evidence supports the use of 3wCBT for weight management, specifically ACT. Larger trials with long‐term follow‐up are needed to identify who these interventions work for, their most effective components, and the most cost‐effective method of delivery.     

Lifestyle intervention for preventing weight gain in young adults: a systematic review and meta‐analysis of RCTs

Younger generations of Australians are gaining weight faster than their parents. Associated health consequences are likely to ensue unless weight gains are prevented; however, it is unclear how to effectively intervene in this population. Electronic databases for health sciences were searched from April to the end of August 2011. Nine studies were included in the review, eight in the meta‐analysis, from 771 abstracts reviewed for eligibility criteria: randomized controlled trials of lifestyle interventions, published in English (1980 onward), aimed at preventing weight gain among healthy subjects 18–35 years. Mean body weight change was the primary outcome. The combined weighted mean change in intervention participants was ?0.87 kg (95% CI ?1.56, ?0.18) and in control participants 0.86 kg (95% CI 0.14, 1.57). Post hoc meta‐regression analyses revealed evidence‐based interventions of 4 months or longer duration were significantly associated with greater weight loss (?1.62 [95% CI ?3.21, ?0.04], P = 0.045). The small number, short duration and large heterogeneity of trials means the effectiveness of lifestyle intervention for preventing young adult weight gain remains unclear. Future trials conducted over longer periods with larger samples are urgently required to develop effective programmes that will protect against weight gains in future generations.     

Changes in physical activity behaviour and physical function after bariatric surgery: a systematic review and meta‐analysis

Although physical activity performed after bariatric surgery is associated with enhanced weight loss outcomes, there is limited information on patients' physical activity behaviour in this context. This systematic review and meta‐analysis assessed pre‐operative to post‐operative changes in physical activity and physical function outcomes among obese adults undergoing bariatric surgery. A total of 50 studies met inclusion criteria with 26 papers reporting data for meta‐analysis. Increases in both objectively recorded and self‐reported physical activity at 12 months were demonstrated. Studies indicated that there was a shift towards a greater amount of active time, but of a lower intensity within the first 6 months of bariatric surgery, suggested by a reduction in moderate to vigorous physical activity but an increase in step count. A standardized mean difference (SMD) of 1.53 (95% CI: 1.02–2.04) based on nine studies indicated improved walking performance at 12 months. Similarly, analysis of five studies demonstrated increased musculoskeletal function at 3–6 months (SMD: 1.51; 95% CI: 0.60–2.42). No relationship was identified between changes in weight and walking performance post‐surgery. More studies assessing physical activity, physical function and weight loss would help understand the role of physical activity in optimizing post‐operative weight and functional outcomes.     

Weight maintenance: challenges,tools and strategies for primary care physicians

Obesity is recognized as a chronic disease and one of the major healthcare challenges facing us today. Weight loss can be achieved via lifestyle, pharmacological and surgical interventions, but weight maintenance remains a lifetime challenge for individuals with obesity. Guidelines for the management of obesity have highlighted the role of primary care providers (PCPs). This review examines the long‐term outcomes of clinical trials to identify effective weight maintenance strategies that can be utilized by PCPs. Because of the broad nature of the topic, a structured PubMed search was conducted to identify relevant research articles, peer‐reviewed reviews, guidelines and articles published by regulatory bodies. Trials have demonstrated the benefit of sustained weight loss in managing obesity and its comorbidities. Maintaining 5–10% weight loss for ≥1 year is known to ameliorate many comorbidities. Weight maintenance with lifestyle modification – although challenging – is possible but requires long‐term support to reinforce diet, physical activity and behavioural changes. The addition of pharmacotherapy to lifestyle interventions promotes greater and more sustained weight loss. Clinical evidence and recently approved pharmacotherapy has given PCPs improved strategies to support their patients with maintenance of weight loss. Further studies are needed to assess the translation of these strategies into clinical practice.     

Assessing the impact of diet,exercise and the combination of the two as a treatment for OSA: A systematic review and meta‐analysis

This study aimed to provide an updated systematic review and meta‐analysis of randomized controlled trials (RCT) investigating the effectiveness of lifestyle interventions on weight loss and the impact on the severity of obstructive sleep apnoea (OSA). A systematic search of five databases between 1980 and May 2018 was used to identify all RCT which employed a lifestyle intervention (i.e. diet‐only, exercise‐only or combination of the two) aiming to reduce the severity of OSA (assessed using the apnoea–hypopnoea index (AHI)). Random‐effects meta‐analyses followed by meta‐regression were conducted. Ten RCT involving 702 participants (Intervention group: n = 354; Control group: n = 348) were assessed in two meta‐analyses. The weighted mean difference in AHI (?8.09 events/h, 95% CI: ?11.94 to ?4.25) and body mass index (BMI, ?2.41 kg/m², 95% CI: ?4.09 to ?0.73) both significantly favoured lifestyle interventions over control arms. Subgroup analyses demonstrated that all interventions were associated with reductions in the AHI, but only the diet‐only interventions were associated with a significant reduction in BMI. No association was found between the reduction in AHI or BMI and the length of the intervention, or with baseline AHI and BMI levels. All lifestyle interventions investigated appear effective for improving OSA severity and should be an essential component of treatment for OSA. Future research should be directed towards identifying subgroups likely to reap greater treatment benefits as well as other therapeutic benefits provided by these interventions.     

The role of glucagon in weight loss‐mediated metabolic improvement: a systematic review and meta‐analysis

Aims This meta‐analysis aimed to investigate the role of glucagon suppression in regulating glucose homeostasis following diet or bariatric surgery. Methods A comprehensive search of intervention and observational studies was conducted in Medline, Scopus, Web of Science, PubMed and Embase. Random effects model meta‐analysis was performed. Primary outcomes were (i) body weight change, (ii) fasting glucagon, (iii) fasting glucose and (iv) fasting insulin concentrations. Results Twenty articles reporting data from 29 interventions were eligible for analysis. Bariatric surgery caused greater weight loss than diet (bariatric ?29.7 kg [CI:‐36.8, ?22.6]; diet ?5.8 kg [CI: ?8.4, ?3.3]; P  < 0.00001), an effect that remained significant after adjusting for study duration (P  < 0.05). Mean fasting glucagon decreased in parallel with weight loss (?11.8 ng/L [CI: ?15.9, ?7.8]; P  < 0.00001) with no difference between bariatric and diet intervention. Both fasting glucose, and insulin decreased following weight loss (both P  < 0.00001; glucose ?1.7 mmol/L [CI: ?2.0, ?1.3]; insulin ?50.6 pmol/L [CI: ?66.5, ?34.7] with greater decrease in fasting insulin between bariatric versus diet (P  = 0.01). Conclusions Synergistic suppression of fasting glucagon and insulin resistance may act together to restore normoglycaemia following weight loss. Whether suppression of plasma glucagon may contribute to increased hunger after weight loss and gradual weight regain is not yet known.     

A systematic review with meta‐analyses of text message‐delivered behaviour change interventions for weight loss and weight loss maintenance

Short Message Service (SMS)‐delivered behaviour change interventions are frequently used to support weight management. This systematic review examines the effectiveness of SMS‐delivered behaviour change interventions for weight management. Electronic databases were searched for randomised controlled trials (RCTs) comparing SMS‐delivered adult weight management interventions to control groups, published between 1990 and 2018. Weight change was examined using random effects meta‐analyses at intervention cessation and postintervention follow‐up. Subgroup analyses examined intervention duration, SMS frequency, theory use, SMS interactivity, and SMS tailoring. Fifteen studies met inclusion criteria (2705 participants). For weight loss interventions (n = 12, 1977 participants), the mean difference in weight change was ?2.28 kg (95% confidence interval [CI] ?3.17 to ?1.36 kg). No studies reported postintervention follow‐up. For weight loss maintenance interventions (n = 3, 728 participants), the mean difference in weight change was ?0.68 kg (95% CI, ?1.31 to ?0.05 kg), and postintervention follow‐up (n = 2, 498 participants) effects were ?0.57 kg (95% CI, ?1.67 to 0.53 kg). No subgroup differences were found. SMS‐delivered behaviour change interventions for weight loss led to significant small to moderate weight loss and weight loss maintenance compared with control groups. Evidence on long‐term effects is limited. SMS‐delivered behaviour change interventions are a potentially effective and scalable intervention option for obesity treatment.     

Nurse-led intervention for the management of bariatric surgery patients: A systematic review

The prevalence of obesity has become a global health concern, and severe obesity is associated with various chronic diseases and decreased quality of life. Bariatric surgery has shown success in treating obesity. Nevertheless, some patients experience weight regain and unsatisfactory outcomes. Multidisciplinary interventions have been shown to improve postoperative outcomes. Case managers, often specialized nurses, play a crucial role in patient support and coordination of care. However, the diverse design of case-managing interventions hinders the assessment of their success. Thus, the aim of this review is to identify the most successful structural characteristics of case-managing interventions, with or without the support of e-Health, in the process of perioperative management of bariatric surgery patients. A systematic literature review was conducted following the PRISMA guidelines. PubMed, MEDLINE, EBSCOhost, and CINAHL databases were searched for relevant studies published in the last 10 years. Eligible studies included randomized controlled trials, controlled clinical studies, case studies, or observational studies that evaluated perioperative care in bariatric surgery. The PICO framework was used to frame the search strategy. The initial search yielded 225 articles, of which 10 studies met the inclusion criteria. Nurse-led case-managing interventions with a multidisciplinary approach showed positive results in weight loss, physical activity, and quality of life. Patient-centered care models were found to promote adherence to treatment and patient satisfaction. E-Health technologies improved quality of life but not weight loss. The duration of behavioral interventions and the long-term outcomes after surgery remained unclear. Nurse-led case-management interventions, with a focus on behavioral change and multidisciplinary approaches, show promise in improving outcomes in bariatric surgery patients. Patient-centered care models and longer term interventions may contribute to sustained weight loss and better postoperative outcomes. Further research is needed to determine the optimal duration of interventions and the long-term effects on weight maintenance.     

Efficacy and safety of lorcaserin in obese adults: a meta‐analysis of 1‐year randomized controlled trials (RCTs) and narrative review on short‐term RCTs

Lorcaserin is a new anti‐obesity drug recently approved by US Food and Drug Administration. We conducted a systematic review and meta‐analysis of randomized controlled trials (RCTs) to evaluate the association of lorcaserin therapy with weight loss and adverse events in obese adults (18–65 years old). Weight loss of 3.23 kg (95% confidence interval [CI]: 2.70, 3.75) and body mass index reduction of 1.16 kg m^?2 (95% CI: 0.98, 1.34) was observed compared with placebo in RCTs of 1 year duration. The use of lorcaserin for 8 and 12 weeks reduced weight of 1.60 kg (95% CI: 0.34, 2.86) and 2.9 kg (95% CI: 2.2, 3.5), respectively. In comparison to placebo, lorcaserin decreased waist circumference, blood pressure, total cholesterol, low‐density lipoprotein‐cholesterol and triglycerides, however did not statistically affect heart rate or high‐density lipoprotein‐cholesterol. Headache, nausea and dizziness were found to be significantly higher in the patients receiving lorcaserin than patients receiving placebo, whereas diarrhoea is no more likely than in patients receiving placebo. In conclusion, lorcaserin achieves modest weight loss and appears to be well tolerated. Clinical and pharmacovigilance studies with longer study duration are needed to inform of the long‐term efficacy and safety of lorcaserin.     

Does weight loss in overweight or obese women improve fertility treatment outcomes? A systematic review

This systematic review assessed the effect of weight loss in overweight and/or obese women undergoing assisted reproductive technology (ART) on their subsequent pregnancy outcome. Weight losses achieved by diet and lifestyle changes, very‐low‐energy diets, non‐surgical medical interventions and bariatric surgery translated into significantly increased pregnancy rates and/or live birth in overweight and/or obese women undergoing ART in 8 of the 11 studies reviewed. In addition, regularization of the menstrual pattern, a decrease in cancellation rates, an increase in the number of embryos available for transfer, a reduction in the number of ART cycles required to achieve pregnancy and a decrease in miscarriage rates were reported. There were also a number of natural conceptions in five of the six studies that reported this outcome. Non‐surgical medical weight loss procedures and bariatric surgery induced the greatest weight losses, but their use, as well as that of very‐low‐energy diets, for weight loss prior to ART requires careful consideration. While the overall quality of the studies included in this review was poor, these results support the clinical recommendation of advising overweight and/or obese women to lose weight prior to ART. Prospective randomized controlled trials are required to establish efficacious evidence‐based guidelines for weight loss interventions in overweight and/or obese women prior to ART treatment.     

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.     

Targeting epicardial adipose tissue with exercise,diet, bariatric surgery or pharmaceutical interventions: A systematic review and meta‐analysis

Epicardial adipose tissue (EAT) and pericardial adipose tissue (PAT) are metabolically active fat depots implicated in cardiovascular disease, and EAT has potential as a novel cardiac risk factor, suitable as a target for interventions. The objective of this systematic review and meta‐analysis was to investigate the evidence whether EAT and PAT volume can be reduced by weight‐loss interventions (exercise, diet, bariatric surgery or pharmaceutical interventions). A systematic literature search identified 34 studies that were included in the qualitative synthesis (exercise, n = 10, diet, n = 5, bariatric surgery, n = 9 and pharmaceutical interventions, n = 10). Of the 34 studies, 10 reported sufficient data to be included in the meta‐analysis. The meta‐analysis was only conducted for changes in EAT volume, since only few controlled studies reported changes in PAT (n = 3) or total cardiac adipose tissue volume (n = 1). A significant pooled effect size (ES) for reduction in EAT volume was observed following weight‐loss interventions as compared with control interventions (ES = ?0.89, 95% CI: ?1.23 to ?0.55, P < 0.001). When comparing the effect of exercise training versus control on EAT volume reduction, there was a significant pooled ES favouring exercise training (ES: ?1.11, 95% CI: ?1.57 to ?0.65, P < 0.001). Similarly, the ES of pharmaceutical versus control interventions on EAT volume reduction was significant, favouring pharmaceutical interventions (ES: ?0.79, 95% CI: ?1.37 to ?0.21, P < 0.0072). In conclusion, this systematic review and meta‐analysis provides evidence that exercise, diet, bariatric surgery and pharmaceutical interventions can reduce cardiac adipose tissue volume.     

Physical activity and weight loss following bariatric surgery

Physical activity is a cornerstone in the medical management of obesity and could be important for weight loss following bariatric surgery. This review aims to describe the evolution of physical activity following massive weight loss induced by bariatric surgery, and to identify the relationship between physical activity and amount of weight loss. A literature search identified 20 publications (19 studies) reporting physical activity data in relation to bariatric surgery. All studies were observational. Self‐assessment of physical activity was used in all the studies. Objective measures (pedometry) were used in two studies. The time frame for physical activity assessment varied: before surgery in two publications, after surgery in nine, and longitudinal pre‐ to post‐operative evolution in nine. The latter nine publications found an increase in physical activity after bariatric surgery. In 10/13 studies where it was described, there was a positive relationship between physical activity level and amount of weight loss. In conclusion, observational evidence of self‐reported physical activity suggests that physical activity increases after bariatric surgery and that physical activity is associated with surgically induced weight loss. However, these findings warrant further evaluation using objective measures of physical activity and testing in controlled trials.     

Lessons from obesity management programmes: greater initial weight loss improves long-term maintenance

It is a common belief that weight loss achieved at a slow rate is better preserved than if the weight is lost more rapidly. However, the literature shows that initial weight loss is positively, not negatively, related to long‐term weight maintenance. There is evidence from randomised intervention trials to support that a greater initial weight loss induced without changes in lifestyle e.g. liquid formula diets or anorectic drugs) improves long‐term weight maintenance, providing it is followed by a 1–2 years integrated weight maintenance programme consisting of lifestyle interventions involving dietary change, nutritional education, behaviour therapy and increased physical activity. In conclusion, we find evidence to suggest that a greater initial weight loss as the first step of a weight management programme may result in improved sustained weight maintenance.     

Impact of bariatric surgery on serum uric acid levels and the incidence of gout—A meta‐analysis

Gout is characterized by high serum uric acid (SUA) levels and arthritis. It is associated with obesity and metabolic syndrome. Bariatric surgery has been associated with decreased SUA levels and overall gout incidence. This meta‐analysis aims to summarize the current evidence on bariatric surgery, gout and SUA levels. A literature review was performed on papers published from 2000 up till December 2018. Original studies investigating the impact of bariatric surgery on SUA levels or gout incidence were evaluated. Twenty studies with a total of 5,233 patients were analysed. Majority (n=14) had a follow‐up duration of at least 12 months. The mean preoperative body mass index (BMI) was 45.2kg m^?2. The mean preoperative SUA level was 6.5mg dL^?1. Subgroup analysis demonstrated a mean decrease in SUA levels (?0.73mg dL^?1) from the third postoperative month onwards, which was sustained until the third postoperative year (?1.91mg dL^?1). There was a rise in SUA levels in the first post‐operative month. Meta‐regression analyses demonstrated a proportionate linear relationship between the change in BMI and SUA levels. Post‐bariatric surgery weight loss is associated with reduced SUA levels and decreased incidence of gout attacks. However, this is only evident from the third post‐operative month onwards.     

Bariatric Surgery: Effects on the Metabolic Complications of Obesity

Bariatric surgery is increasing at an enormous rate in all countries but the indications for the operation on the basis of metabolic derangements are not clear, as only one controlled randomized trial specifically for a comorbidity has been performed. Thus, it is not clear if bariatric surgery should be offered to all obese patients with long standing type 2 diabetes or poorly controlled hypertension or hypertriglyceridemia, even though these conditions clearly respond in most patients to bariatric surgery and weight loss. It would appear that patients with early type 2 diabetes with reasonable control and a greater body mass index gain more benefit from the operation. More randomized trials are required.