Patients' Pre and Post-Bariatric Surgery Experience of Dieting Behaviours: Implications for Early Intervention.

PURPOSE: Bariatric surgery works, in part, by surgically changing signals of hunger and satiety to achieve weight loss. Not all patients experience optimal outcomes. One potential explanation is that post-surgery dieting may subvert the ability to identify physiological cues of hunger and fullness. Dieting behaviours (e.g. restriction/cognitive restraint) are correlated with disordered eating, and disordered eating implicated in poor outcomes. This study examines the experience of dieting after bariatric surgery. METHOD: Seventeen adult participants who had undertaken bariatric surgery and residing in Australia participated in semi-structured interviews. Surgeries occurred in 2021 (n = 8), 2020 (n = 4), 2019 (n = 2), and one participant each had surgery in 2014, 2009, and 2004. Thematic analysis elicited themes related to post-operative dieting. RESULTS: All participants reported chronic pre-surgery dieting. Lifestyle change was the overarching post-surgical theme comprising (i) flexibility (e.g. allowing food, intuitive eating), and (ii) control, comprising surgery control (e.g. set portions, surgery instilled control) and dieting control (e.g. discipline, restriction/restraint). Descriptions of lifestyle change often mirrored pre-surgery descriptions of dieting. CONCLUSION: Post-surgery lifestyle change appears to encompass a tension between flexible/adaptive approaches to eating and the need to maintain control. Control may emerge as practices that mirror pre-surgery dieting with the potential to interfere with adaptive eating behaviours or promote disordered eating. Dieting behaviours may be a precursor to the development of disordered eating. Health care practitioners should regularly assess dieting behaviour post-surgery to enable early intervention where warranted. Future research should consider how post-surgery re-emerging dieting may be identified and measured to aid in intervention.

Internalised Weight Stigma Mediates Relationships Between Perceived Weight Stigma and Psychosocial Correlates in Individuals Seeking Bariatric Surgery: a Cross-sectional Study.

PURPOSE: Research suggests that internalised weight stigma may explain the relationship between perceived weight stigma and adverse psychological correlates (e.g. depression, disordered eating, body image disturbances). However, few studies have assessed this mechanism in individuals seeking bariatric surgery, even though depression and disordered eating are more common in this group than the general population. MATERIALS AND METHODS: We used data from a cross-sectional study with individuals seeking bariatric surgery (n = 217; 73.6% female) from Melbourne, Australia. Participants (Mage = 44.1 years, SD = 11.9; MBMI = 43.1, SD = 7.9) completed a battery of self-report measures on weight stigma and biopsychosocial variables, prior to their procedures. Bias-corrected bootstrapped mediations were used to test the mediating role of internalised weight stigma. Significance thresholds were statistically corrected to reduce the risk of Type I error due to the large number of mediation tests conducted. RESULTS: Controlling for BMI, internalised weight stigma mediated the relationship between perceived weight stigma and psychological quality of life, symptoms of depression and anxiety, stress, adverse coping behaviours, self-esteem, exercise avoidance, some disordered eating measures and body image subscales, but not physical quality of life or pain. CONCLUSION: Although the findings are cross-sectional, they are mostly consistent with previous research in other cohorts and provide partial support for theoretical models of weight stigma. Interventions addressing internalised weight stigma may be a useful tool for clinicians to reduce the negative correlates associated with weight stigma.

Pre-operative Restraint and Post-operative Hunger, Disinhibition and Emotional Eating Predict Weight Loss at 2 Years Post-laparoscopic Adjustable Gastric Banding.

INTRODUCTION: A principal mechanism of action in bariatric surgery is reduction in calorie consumption due to decreased hunger and increased satiety. Patients' ability to perceive post-operative changes to their hunger is therefore central to optimal results. This study examined factors that may impact how patients perceive post-operative hunger and how perception of hunger impacts eating and subsequent weight loss after laparoscopic adjustable gastric banding (LAGB). METHODS: Patients undertaking LAGB (n = 147) provided pre-surgery and 2-year weight loss data and pre-surgery and 12-month psychological data (perception of hunger, disinhibition related to eating, emotional eating). RESULTS: Path analysis demonstrated that patients with lower levels of pre-surgery cognitive restraint over eating experienced significantly greater reduction in perception of hunger at 12 months post-surgery. Perceived reduction in hunger was significantly associated with lower levels of both emotional eating and disinhibited eating. Finally, reduced emotional eating at 12 months significantly predicted 9% of the variance in percentage of total weight loss (%TWL) at 2 years after surgery. CONCLUSION: These initial findings suggest that preparation for bariatric surgery may be enhanced by psychoeducation regarding cognitive restraint over eating and its effect on hunger perception. In addition, psychological treatment that focuses on identifying and responding to changes in hunger may contribute to improved outcomes for those who have difficulty adjusting to post-operative eating behaviours.

Strategies to reduce attrition in weight loss interventions: A systematic review and meta-analysis.

The primary objective of the study was to identify the effect of intervention strategies on attrition within a weight loss programme among adults aged 18 to 65 years. The secondary objective of the study was to assess the impact of such intervention strategies among female-only weight loss programmes. The literature search was performed in Ovid (CINAHL Plus, MEDLINE, EMBASE, Cochrane [Cochrane Database of Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register], and PsycINFO). Studies must have identified weight loss as the main aim and compared the primary weight loss programme alone (control) with the primary weight loss programme coupled with an additional intervention strategy (intervention). Papers must have had a mean participant age between 18 and 65 years and available in English. Fifty-seven trials met the inclusion criteria and were included in the meta-analysis. Strategies that successfully reduced attrition included the incorporation of financial incentives (n = 8), a multicomponent approach (n = 13), and use of self-monitoring technology (n = 4). The majority of studies were of low to moderate methodological quality because of insufficient reporting. A limited number of female-only trials were found (n = 13). Implementation of financial incentives, multicomponent interventions, and self-monitoring technology help reduce attrition among adult weight loss programmes. Further studies are required to identify the impact of intervention strategies on attrition in women.

Long-Term Outcomes After Bariatric Surgery: a Systematic Review and Meta-analysis of Weight Loss at 10 or More Years for All Bariatric Procedures and a Single-Centre Review of 20-Year Outcomes After Adjustable Gastric Banding.

INTRODUCTION: Durability is a key requirement for the broad acceptance of bariatric surgery. We report on durability at and beyond 10 years with a systematic review and meta-analysis of all reports providing data at 10 or more years and a single-centre study of laparoscopic adjustable gastric banding (LAGB) with 20 years of follow-up. METHODS: Systematic review with meta-analysis was performed on all eligble reports containing 10 or more years of follow-up data on weight loss after bariatric surgery. In addition, a prospective cohort study of LAGB patients measuring weight loss and reoperation at up to 20 years is presented. RESULTS: Systematic review identified 57 datasets of which 33 were eligible for meta-analysis. Weighted means of the percentage of excess weight loss (%EWL) were calculated for all papers included in the systematic review. Eighteen reports of gastric bypass showed a weighted mean of 56.7%EWL, 17 reports of LAGB showed 45.9%EWL, 9 reports of biliopancreatic bypass +/- duodenal switch showed 74.1%EWL and 2 reports of sleeve gastrectomy showed 58.3%EWL. Meta-analyses of eligible studies demonstrated comparable results. Reoperations were common in all groups. At a single centre, 8378 LAGB patients were followed for up to 20 years with an overall follow-up rate of 54%. No surgical deaths occurred. Weight loss at 20 years (N = 35) was 30.1 kg, 48.9%EWL and 22.2% total weight loss (%TWL). Reoperation rate was initially high but reduced markedly with improved band and surgical and aftercare techniques. CONCLUSION: All current procedures are associated with substantial and durable weight loss. More long-term data are needed for one-anastomosis gastric bypass and sleeve gastrectomy. Reoperation is likely to remain common across all procedures.

Feeling fat in eating disorders: Testing the unique relationships between feeling fat and measures of disordered eating in anorexia nervosa and bulimia nervosa.

Although widely discussed in theories of eating disorders, the experience of "feeling fat" in this population has received little research attention. This study tested the unique relationships between feeling fat and measures of problematic eating behaviours and attitudes. Data were analysed from individuals with anorexia nervosa (AN; n = 123) and bulimia nervosa (BN; n = 51). Correlations revealed considerable unshared variance between feeling fat and shape and weight over-evaluation and depressive symptoms. Moreover, when over-evaluation and depressive symptoms were controlled, feeling fat predicted unique variance in restraint and eating concerns. Findings offer some support for the idea that feeling fat is a distinct and important component of body image concerns in eating disorders. Further research that develops a standardized measure of feeling fat is required. Further research that examines whether feeling fat is an important treatment mechanism is also needed.

Dropout from cognitive-behavioral therapy for eating disorders: A meta-analysis of randomized, controlled trials.

OBJECTIVE: Cognitive-behavioral therapy (CBT) is efficacious for a range of eating disorder presentations, yet premature dropout is one factor that might limit CBTs effectiveness. Improved understanding of dropout from CBT for eating disorders is important. This meta-analysis aimed to study dropout from CBT for eating disorders in randomized controlled trials (RCTs), by (a) identifying the types of dropout definitions applied, (b) providing estimates of dropout, (c) comparing dropout rates from CBT to non-CBT interventions for eating disorders, and (d) testing moderators of dropout. METHOD: RCTs of CBT for eating disorders that reported rates of dropout were searched. Ninety-nine RCTs (131 CBT conditions) were included. RESULTS: Dropout definitions varied widely across studies. The overall dropout estimate was 24% (95% CI = 22-27%). Diagnostic type, type of dropout definition, baseline symptom severity, study quality, and sample age did not moderate this estimate. Dropout was highest among studies that delivered internet-based CBT and was lowest in studies that delivered transdiagnostic enhanced CBT. There was some evidence that longer treatment protocols were associated with lower dropout. No significant differences in dropout rates were observed between CBT and non-CBT interventions for all eating disorder subtypes. CONCLUSION: Present study dropout estimates are hampered by the use of disparate dropout definitions applied. This meta-analysis highlights the urgency for RCTs to utilize a standardized dropout definition and to report as much information on patient dropout as possible, so that strategies designed to minimize dropout can be developed, and factors predictive of CBT dropout can be more easily identified.

The relative associations of shape and weight over-evaluation, preoccupation, dissatisfaction, and fear of weight gain with measures of psychopathology: An extension study in individuals with anorexia nervosa.

Recent research has demonstrated that certain components of body image (i.e., shape and weight over-evaluation, preoccupation, and dissatisfaction) in secondary school students shared a distinct clinical significance because of their differential relation to measures of psychopathology. The present study aimed to replicate and extend on these findings by examining the distinctiveness of these body image constructs, in addition to a fear of weight gain, in individuals with anorexia nervosa (AN)-a disorder this is facilitated and maintained by extreme body image concerns. Treatment-seeking females with AN (n = 124) completed a questionnaire battery that measured these constructs. Findings demonstrated that once any shared variance between body image components was removed in regression analyses, fear of weight gain was the only unique predictor of eating disorder psychopathology (e.g., dietary restraint and compulsive exercise), while over-evaluation and preoccupation were the only unique predictors of general psychopathology (e.g., depressive and anxiety symptoms). Overall, these findings demonstrate certain components of body image may operate differently in AN, and reinforce previous calls to consider and assess for distinct facets of body image in this population.

Psychosocial Predictors of Change in Depressive Symptoms Following Gastric Banding Surgery.

OBJECTIVE: The aim of this study is to identify psychosocial variables associated with the relationship between weight loss and change in depressive symptoms following gastric banding surgery. METHODS: Ninety-nine adults completed self-report questionnaires assessing depressive symptoms and other psychosocial variables (self-esteem, body image dissatisfaction, perceived physical health, and perceived weight-based stigmatisation) prior to gastric-band surgery and monthly for 6-month post-surgery. RESULTS: Weight, depressive symptoms, and other psychosocial variables improved significantly 1-month post-surgery and remained lower to 6 months. Weight loss from baseline to 1- and 6-months post-surgery significantly correlated with change in depressive symptoms. Body image dissatisfaction and self-esteem accounted for some of the variance in change in depressive symptoms from baseline to 1-month and baseline to 6-months post-surgery. CONCLUSIONS: Depressive symptoms improved significantly and rapidly after bariatric surgery, and body image dissatisfaction and self-esteem predicted change in depressive symptoms. Interventions targeting body image and self-esteem may improve depressive symptoms for those undergoing weight loss interventions.