Remotely Delivered Interventions for Obesity Treatment.

PURPOSE OF REVIEW: This review synthesizes recent research on remotely delivered interventions for obesity treatment, including summarizing outcomes and challenges to implementing these treatments as well as outlining recommendations for clinical implementation and future research. RECENT FINDINGS: There are a wide range of technologies used for delivering obesity treatment remotely. Generally, these treatments appear to be acceptable and feasible, though weight loss outcomes are mixed. Engagement in these interventions, particularly in the long term, is a significant challenge. Newer technologies are rapidly developing and enable tailored and adaptable interventions, though research in this area is in its infancy. Further research is required to optimize potential benefits of remotely delivered interventions for obesity.

Remote assessments and behavioral interventions in post-bariatric surgery patients.

Sustained weight loss and health improvements after bariatric surgery require long-term monitoring and, for a significant minority of patients, postoperative intervention. Unfortunately, many patients demonstrate difficulty engaging in long-term follow-up and treatment due to time restrictions, geographic limitations, and financial burden. Conducting assessments and interventions remotely may help to mitigate these barriers, allowing for greater access to care and improved outcomes. This review will summarize the results of research using remote methods to conduct assessments and implement interventions with patients after bariatric surgery. Benefits and challenges of implementing these approaches will be highlighted, and future directions in this area will be discussed.

Measurement of adherence in bariatric surgery: a systematic review.

After bariatric surgery, rates of adherence to behavioral recommendations, including attending regular appointments and following specific dietary, physical activity, and vitamin use recommendations, tend to be highly variable across studies. Lack of consistency in measurement of adherence is a likely contributor to this variability, making it challenging to determine the prevalence and impact of nonadherence in this population. PubMed was searched for articles measuring behavioral adherence or compliance in patients after bariatric surgery, resulting in 85 articles. Articles were reviewed for the definition and measurement of adherence in each area (appointment attendance, as well as dietary, physical activity, and vitamin use adherence), and on the use and reporting of recommended adherence measurement strategies. Over half of the articles measured adherence to appointment attendance. Significant variability was found across adherence definitions and measurement methods, and use of recommended adherence measurement strategies was poor. Adherence was mostly commonly measured via self-report (either verbal or written) using cutoffs for adherent versus nonadherent behavior. Over half of studies assessed adherence up to ≥2 years postsurgery. Recommendations for ways to improve adherence measurement in patients who have had bariatric surgery are outlined.

What do we know about mobile applications for diabetes self-management? A review of reviews.

Diabetes is a chronic illness with significant health consequences, especially for those who are unable to adhere to the complex treatment regimen. Self-management tasks such as regular medication and insulin use, frequent blood sugar checks, strict diet management, and consistent exercise can be quite challenging. Mobile technologies, specifically mobile applications (apps), present a unique opportunity to help patients improve adherence to these behaviors. The availability of commercial diabetes self-management apps is increasing rapidly, making it difficult for patients and providers to stay informed about app options. A number of reviews have described commercial app technology and use for patients with diabetes. The aims of this article are to summarize the results and themes of those reviews, to review outcomes of apps described in the research literature, and to identify areas for further consideration in the use of mobile apps for diabetes self-management.

Managing severe obesity: understanding and improving treatment adherence in bariatric surgery.

Severe obesity (body mass index ≥40 kg/m2) is a chronic disease that is associated with significantly increased risk of serious and chronic health problems as well as impaired quality of life. For those with severe obesity, bariatric surgery is the most effective treatment for significant and long-term weight loss and resolution of comorbid medical conditions, particularly diabetes. Long-term success is thought to depend to some degree on the patient's ability to adhere to a complex set of behaviors, including regular attendance at follow up appointments and following stringent dietary, exercise, and vitamin recommendations. Here, we summarize the current research on behavioral adherence in patients with severe obesity presenting for bariatric surgery and we highlight challenges and make recommendations for improved self-management before and after surgery.

Development of a novel mindfulness and cognitive behavioral intervention for stress-eating: a comparative pilot study.

Stress-related eating is increasingly cited as a difficulty in managing healthy eating behaviors and weight. However few interventions have been designed to specifically target stress-related eating. In addition, the optimal target of such an intervention is unclear, as the target might be conceptualized as overall stress reduction or changing emotional eating-related thoughts and behaviors. This pilot study compared the effects of three interventions targeting those components individually and in combination on stress-related eating, perceived stress, and weight loss to determine whether the two intervention components are effective alone or are more effective when combined. Fifty-three overweight participants (98% female) who reported elevated levels of stress and stress-eating and were at risk for obesity were randomly assigned to one of three six-week interventions: a modified mindfulness-based stress reduction (MBSR) intervention, a cognitive behavioral stress-eating intervention (SEI), and a combined intervention that included all MBSR and SEI components. All three interventions significantly reduced perceived stress and stress-eating, but the combination intervention resulted in greater reductions and also produced a moderate effect on short term weight loss. Benefits persisted at six week follow-up.The pattern of results preliminarily suggests that the combination intervention (MBSR+SEI) may yield promise in the treatment of stress-related eating.

Mindfulness meditation as an intervention for binge eating, emotional eating, and weight loss: a systematic review.

Mindfulness-based approaches are growing in popularity as interventions for disordered eating and weight loss. Initial research suggests that mindfulness meditation may be an effective intervention for binge eating; however, no systematic review has examined interventions where mindfulness meditation was the primary intervention and no review has examined its effect on subclinical disordered eating or weight. Using the PRISMA method for systematic reviews, we reviewed 14 studies that investigated mindfulness meditation as the primary intervention and assessed binge eating, emotional eating, and/or weight change. Results suggest that mindfulness meditation effectively decreases binge eating and emotional eating in populations engaging in this behavior; evidence for its effect on weight is mixed. Additional research is warranted to determine comparative effectiveness and long-term effects of mindfulness training.

Dietary self-monitoring in patients with obstructive sleep apnea.

Self-monitoring of food intake is a cornerstone of behavioral weight loss interventions, but its use has not been evaluated in the treatment of obese patients with obstructive sleep apnea (OSA). This pilot study described patterns of adherence to dietary self-monitoring in obese patients with OSA and determined associations between self-monitoring and weight loss, psychosocial functioning, and adherence to continuous positive airway pressure treatment. Participants completed a 6-week behavioral weight loss intervention focused on dietary self-monitoring. Approximately one-third of participants were adherent to self-monitoring throughout the course of the intervention and experienced more weight loss than those who did not self-monitor regularly. More frequent dietary self-monitoring also appeared to be associated with adherence to other health behaviors. These preliminary data suggest that use of dietary self-monitoring may be beneficial for promoting weight loss and adherence to other important health behaviors in OSA patients.

Impact of a brief dietary self-monitoring intervention on weight change and CPAP adherence in patients with obstructive sleep apnea.

OBJECTIVE: Weight loss can decrease the severity of obstructive sleep apnea (OSA) in many obese individuals; however, very few studies have investigated the effects of behavioral weight loss interventions for patients with OSA. The aims of this pilot study were to determine the feasibility and initial effects on weight and continuous positive airway pressure (CPAP) use of a brief minimal-contact self-monitoring-based weight loss intervention (SM). An additional aim was to investigate the association between weight loss and CPAP adherence. METHODS: Forty obese men and women diagnosed with mild or moderate OSA were randomized to either the SM or an attention-control (AC) condition. SM participants completed daily dietary logs for 6 weeks. Participants were weighed at baseline, post-treatment (6 weeks), and at a 6-week follow up. RESULTS: Recruitment and retention were good in this study and attrition rates did not differ significantly by group. Intent to treat repeated measures ANOVA indicated a main effect of time (but not group), such that both groups lost weight over time. Pearson r correlations between weight change and CPAP adherence indicated that among SM participants, 6-week weight loss was correlated with CPAP adherence at post-treatment and follow-up, such that SM participants with greater weight loss at 6 weeks had greater CPAP adherence at 6 and 12 weeks. CONCLUSION: This study provides initial support for the beneficial effects of a minimal-contact weight loss intervention for patients with obstructive sleep apnea and highlights a possible association between weight loss and CPAP adherence.

Factor structure and predictive utility of the Binge Eating Scale in bariatric surgery candidates.

BACKGROUND: Screening for binge eating before bariatric surgery is a component of the recommended clinical practice for bariatric surgery candidates. The Binge Eating Scale (BES) is 1 of the most commonly used self-report measures of eating behaviors in preoperative evaluations; however, the factor structure of this measure has not been evaluated in the bariatric population. The aims of the present study were to report the mean, standard deviation, and reliability of the BES for patients seeking bariatric surgery; to evaluate the 2-factor structure of the BES using confirmatory factor analysis; and to investigate the association between the BES and its factors with surgical weight loss. The setting was an academic medical center. METHODS: A total of 530 patients completed the BES as a component of their psychological evaluation before undergoing Roux-en-Y gastric bypass surgery. RESULTS: Approximately one third of patients reported at least mild to moderate binge eating, with 9% of patients reporting severe binge eating on the BES. The BES demonstrated good internal consistency. The results of the confirmatory factor analysis indicated that a 2-factor structure, consisting of feelings/cognitions related to binge eating and behavioral manifestations of binge eating, was the best fit to the data. Nonsignificant correlations were found between the BES and its 2 factors with short-term postoperative weight loss. CONCLUSION: The BES measures 2 aspects of binge eating in bariatric surgery candidates, feelings/cognitions and behavioral manifestations of binge eating. Consideration of these factors in patients presenting for bariatric surgery could allow for a more detailed understanding of binge eating in this population.

Examining the Binge Eating Scale in screening for binge eating disorder in bariatric surgery candidates.

BACKGROUND: This study assessed the utility of the Binge Eating Scale (BES) as a measure of binge eating disorder (BED) in a bariatric surgery-seeking population by (a) determining the optimal BES cut score for predicting BED, (b) calculating concordance statistics, and (c) determining the predictive value of each BES item. METHODS: Four hundred seventy-three patients presented for a psychological evaluation prior to Roux-en-Y gastric bypass surgery. The BES and the SCID semi-structured interview for BED were administered. RESULTS: Receiver operating characteristic curve analyses identified an optimal BES cut score of 17, which correctly classified 78% of patients with BED. A cut score of 27 improved this statistic, but significantly increased the number of false negatives, which is undesirable for a screening assessment. Discriminant function analyses revealed that nearly all BES items significantly predicted BED. CONCLUSIONS: The BES is a valid screener of BED for patients seeking bariatric surgery; however, false positives can be expected. Administering the BES as part of a comprehensive psychological evaluation can help improve the assessment and treatment of patients presenting for bariatric surgery.

Confirmatory factor analysis of the Beck Depression Inventory-II in bariatric surgery candidates.

Screening for depression is an integral part of psychological evaluations conducted prior to bariatric surgery. The Beck Depression Inventory-II (BDI-II) is the most commonly used measure of depression in these treatment evaluations. The reliability and validity of the BDI-II has not yet been evaluated within bariatric surgery-seeking samples, evidencing a significant gap in the present literature. The purpose of the present study is to evaluate the structural validity of the BDI-II and to examine the reliability and convergent and criterion validity of this instrument within a bariatric surgery-seeking sample. The study population consisted of 505 ethnically diverse bariatric surgery candidates presenting for presurgical psychological evaluations in a midwestern urban academic medical center. Confirmatory factor analytic results indicated that a 3-factor model consisting of affective, cognitive, and somatic factors was the best fitting model of depression within this sample. Internal consistency reliability was satisfactory for each subscale, ranging from .72 to .82. Moderate to large correlations were observed between each BDI-II subscale and a measure of depression previously validated with bariatric surgery candidates indicating adequate convergent validity. On the basis of clinical interview, 14% of the sample was diagnosed with current major depression. Significant mean differences were observed between depressed and nondepressed patients with respect to each BDI-II subscale score, demonstrating criterion-related validity. The BDI-II is a reliable and valid measure of depression for bariatric surgery candidates. Understanding the factor structure of the BDI-II can be useful for planning potential presurgical psychological interventions.

Revisiting the revised master questionnaire for the psychological evaluation of bariatric surgery candidates.

BACKGROUND: This study aims to evaluate the Revised Master Questionnaire (MQR), a measure of cognitive and behavioral difficulties related to weight management, for use in bariatric surgery evaluations. The MQR's five domains include stimulus control, hopelessness, motivation, physical attribution, and energy balance knowledge, all of which are relevant to bariatric surgery evaluation. METHODS: Participants were 790 bariatric surgery candidates presenting for psychological evaluation in an urban medical center. Internal consistency reliability analyses were performed on the overall scale and subscales. Confirmatory factor analysis using principal components analysis was performed and the results compared with the original behavioral weight loss sample. Convergent validity with the Beck Depression Inventory (BDI) and Binge Eating Scale (BES) were evaluated. Differences in normative data for subgroups of the bariatric sample (by obesity category and by surgery type) were also evaluated. RESULTS: Alpha coefficients and mean inter-item correlations were largely acceptable and similar to the original behavioral weight loss sample. Factor analyses supported the consistency of the underlying factor structure. Convergent validity between the BDI and BES and relevant subscales was obtained. Overall, bariatric surgery candidates had significantly more adaptive scores than behavioral weight loss patients on three of the five scales; however, scores on physical attribution and energy balance knowledge were significantly lower. Candidates for gastric banding surgery had significantly more adaptive scores on all five subscales than candidates for gastric bypass surgery. CONCLUSIONS: The MQR evaluates important but under-assessed weight control-related constructs and has acceptable psychometric properties. Based on these findings, it is recommended for use as a component of the psychological evaluation for bariatric surgery.

Do patients seeking laparoscopic adjustable gastric banding surgery differ from those seeking gastric bypass surgery? A comparison of psychological profiles across ethnic groups.

BACKGROUND: Understanding presurgical psychological functioning is important in determining whether patients may benefit from psychological support before or after undergoing bariatric surgery. However, few studies have directly explored whether presurgical psychosocial profiles differ for patients presenting for different bariatric surgeries and what, if any, impact ethnic background might have. The present study compared presurgical depressive symptomatology, binge eating symptoms, and psychopathology in Caucasian and African American laparoscopic adjustable gastric banding (LAGB) and gastric bypass (RYGB) patients. METHODS: Patients (n=272) presenting for either LAGB or RYGB surgery completed self-report measures of depressive symptomatology (BDI), binge eating symptoms (BES), and psychopathology/personality (PAI) as part of the presurgical psychological evaluation. RESULTS: RYGB patients endorsed more depressive symptomatology, binge eating symptoms, somatic complaints, and antisocial features than LAGB patients, though higher BMI in the RYGB patients accounted for differences in binge eating symptoms. When the sample was examined by ethnic group, LAGB-RYGB differences were found only in African American, and not Caucasian, patients. CONCLUSIONS: Psychosocial profiles appear to differ for African American patients presenting for LAGB and RYGB surgeries; however, some of these differences are accounted for by differences in presurgical BMI. Gaining a better understanding of the initial psychological characteristics of bariatric surgery candidates may improve clinicians' abilities to identify and address specific areas of concern for these patients.

Psychosocial correlates of binge eating in Hispanic, African American, and Caucasian women presenting for bariatric surgery.

Research suggests that that binge eating, stress, and depression are prevalent among individuals seeking bariatric surgery. However, ethnic differences in the prevalence of binge eating and binge eating disorder (BED) in this population remain unclear, as does the impact of depression and stress on any such relationship. Further, no studies to date have examined the prevalence of binge eating in Hispanic women presenting for bariatric surgery. This study sought to (a) compare the prevalence and severity of binge eating symptomatology and BED diagnosis in Hispanic, African American, and Caucasian women presenting for gastric bypass surgery, (b) examine the impact of depressive symptoms and stress on binge eating symptomatology, and (c) investigate whether ethnicity moderated any relationship between depression, stress, and binge eating. Results indicated that Hispanic women exhibited equal rates of binge eating symptomatology, BED, and depressive symptomatology as African American and Caucasian women. However, Caucasian women exhibited greater binge eating symptomatology than African American women, and African American women endorsed greater levels of stress than Caucasian women. Across all ethnic groups, depressive symptomatology, but not stress, significantly predicted binge eating severity. These findings suggest that Hispanic women presenting for bariatric surgery report binge eating rates equivalent to Caucasian and African American women, and that depressive symptoms are an important predictor of binge eating in female bariatric surgery candidates across ethnic groups.

Food addiction: true or false?

PURPOSE OF REVIEW: Food addiction has been implicated as a putative causal factor in chronic overeating, binge eating, and obesity. The concept of food addiction has been controversial historically due to definitional and conceptual difficulties and to a lack of rigorous scientific data. RECENT FINDINGS: Support for the food addiction hypothesis comes from alterations in neurochemistry (dopamine, endogenous opioids), neuroanatomy (limbic system), and self-medication behaviors. Foods identified as having potential addictive properties include sweets, carbohydrates, fats, sweet/fat combinations, and possibly processed and/or high salt foods. Eating topography has been identified as a necessary factor in neural pathway changes that promote addiction-like properties in response to some foods. A recently developed food addiction scale shows promise in identifying food addiction. SUMMARY: Recent findings have strengthened the case for food addiction. These findings may serve to validate the perception of food addiction in patients and inform psychoeducational, cognitive-behavioral, and/or pharmacological treatment for chronic food cravings, compulsive overeating, and binge eating that may represent a phenotype of obesity. Screening for food addiction has the potential to identify people with eating difficulties that seriously compromise weight management efforts. Future research should include a focus on human food addiction research; evaluating the impact of treatment on underlying neurochemistry; and prevention or reversal of food addiction in humans.