Jane Ogden Professor in Health P sychology University of Surrey UK just about Overview Success The problem Predictors of weight regain What happens Solutions A success story Remains most effective method of weight loss 12 yrs Cochrane Review 2014 ID: 1039213
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1. Weight regain post bariatric surgeryJane OgdenProfessor in Health PsychologyUniversity of SurreyUK (just about!)
2. OverviewSuccessThe problemPredictors of weight regainWhat happens?Solutions??
3. A success story.....Remains most effective method of weight loss (1-2 yrs; Cochrane Review, 2014)All > non surgeryLRYGB=Sleeve> Band (BMI diff -5.2)BPD>RYGB for super obese (BMI diff-7.3)SOS: 10 yr -16.1% weight lossBand: -47% EWL Bypass: -67% EWLNon surgery: -2.46kg by 1 year (NICE 2014); 95% regain by 5 yrs; mean gained by 10 yrs
4. The problem.... Weight regain....
5. DefinitionsIncrease of at least 10% of lowest post op weightKg regainedChange in BMI% EWL(nightmare reporting!)
6. Weight regainRoux en Y: 23.7% (2 yrs) (Da Silva et al, 2016) 23.4% (mean 6yrs) (Cooper et al, 2015)41% (10 yrs) (Monaco-Ferreira & Leandro-Mehi, 2016)Sleeve: 59% (10kg); 45% (15kg); 13% (>25kg) (10yrs) (Felsenreich et al, 2016)SOS – 2-10yrs: 23.4% -16.1%
7. Predictors of weight regainPt vs surgical factors (Karmali et al, 2013)Multifactorial (Kushner & Sorensen, 2015)Behaviour / diet / psychological / physical / medical (Mcgrice & Don Paul, 2015)
8. BehaviourPoor dietLack of activity Non follow upsEndocrinologyHigher plasma ghrelin Abnormal glucose toleranceNon modifiableYoungerFemaleTime since surgeryNo co-morbiditiesGenetics??SurgicalStomal dilation Pouch lengthRevisionNew procedurePsychologyBinge eating Depression Drug & alcohol Impulsivity
9. What actually happens?.......... (Ogden et al, 2005; 2006; Ogden, Avenell and Ellis, 2011)
10. Cheating‘I found that if I chewed the food tremendously to a pulp I could actually get more of it, erm, quite frequently...I actually ate anything I felt like eating’
11. Rebelling‘I was really depressed about not having to eat initially. That really, really got to me. So much so that I rebelled and tried to eat stuff that I used to eat. (Laura)
12. GrazingThey say that you mustn’t drink in-between eating because it causes a flush but I would drink during eating . . . I mean I would have chinese half well quarter of the chinese at night, I’d get up in the middle of the night and have some more and then I would get up and the rest probably for breakfast’ (Ruth).
13. Substitute behaviours“Post surgery, I definitely transferred to alcohol ‘cos I couldn’t eat… It was easier and easier to drink to fulfil the need in me.”
14. Why?
15. Emotional regulation“If you’ve used food as your comfort, your security blanket, as your friend, then how do you deal with it if you can’t use that anymore? There’s no mechanism for me as to how I should deal with things apart from eating.”
16. Solutions?.....
17. What is needed???Evidence basedLong term weight lossBenefits outweigh costsDo no harmCosts TimeMoneyQuality of lifeHealth
18. BehaviourPoor dietLack of activity Non follow upsEndocrinologyHigher plasma ghrelin Abnormal glucose toleranceNon modifiableYoungerFemaleTime since surgeryNo co-morbiditiesGenetics???SurgicalStomal dilation Pouch lengthRevisionNew procedurePsychologyBinge eating Depression Drug & alcohol Impulsivity
19. BehaviourPoor dietLack of activity Non follow upsEndocrinologyHigher plasma ghrelin Abnormal glucose toleranceNon modifiableYoungerFemaleTime since surgeryNo co-morbiditiesGenetics???SurgicalStomal dilation Pouch lengthRevisionNew procedurePsychologyBinge eating Depression Drug & alcohol Impulsivity
20. Non modifiable...Screen out?Tailor treatments?Ignore ☑
21. BehaviourPoor dietLack of activity Non follow upsEndocrinologyHigher plasma ghrelin Abnormal glucose toleranceNon modifiableYoungerFemaleTime since surgeryNo co-morbiditiesGenetics???SurgicalStomal dilation Pouch lengthRevisionNew procedurePsychologyBinge eating Depression Drug & alcohol Impulsivity
22. EndocrinologyMedication post surgerySome short term evidenceNo long term evidenceSide effects?Quality of life?Not sure!(Stanford et al, 2017)
23. BehaviourPoor dietLack of activity Non follow upsEndocrinologyHigher plasma ghrelin Abnormal glucose toleranceNon modifiableYoungerFemaleTime since surgeryNo co-morbiditiesGenetics???SurgicalStomal dilation Pouch lengthRevisionNew procedurePsychologyBinge eating Depression Drug & alcohol Impulsivity
24. SurgeryRefashioning of stoma / pouch not effective in longer termBanded gastric bypass no long term follow upDistalisation of RYGB malnutritionConversion to BPD / DS complications and difficultTailored to patient HOW???Not easy solution
25. BehaviourPoor diet Lack of activity Non follow upsEndocrinologyHigher plasma ghrelin Abnormal glucose toleranceNon modifiableYoungerFemaleTime since surgeryNo co-morbiditiesGenetics???SurgicalStomal dilation Pouch lengthPlastic surgeryPsychologyBinge eating Depression Drug & alcohol Impulsivity
26. Psychology and behaviour.......
27. Screening.....Binge eatingMixed evidenceFair?Drugs / alcohol / suicidalityEvidence?Fair?Ongoing (n=373): 70 referred /3 removed from pathwayNot fair? (apart from minority)
28. Pre surgery work up....No real evidence Cost?Time?Good use of resources?But strong evidence for managing expectations and preparation pre surgery for other proceduresCould be brief and simple and cheap??
29. Post surgery interventions....For weight lossMeta analysis: improved EWLStandardised mean difference 1.6 %EWLNo real benefit(Rudolph and Hilbert, 2013)
30. Our study (Ogden et al, 2015)
31. For weight regainRemote HELP intervention (10 wks; n=11)Reversed weight regain for 3 months (+5.1%)Acceptance based intervention (10 wks; n=11)Reversed / stopped regain (+3.58kg)CBT / DBT (6 wks; n=28)Regain decreased (+1.6kg)Just extra follow ups?Could be useful??(Himes et al, 2015; Bradley et al, 2016; 2017)
32. BehaviourPoor dietLack of activity Non follow upsEndocrinologyHigher plasma ghrelin Abnormal glucose toleranceNon modifiableYoungerFemaleTime since surgeryNo co-morbiditiesGenetics???SurgicalStomal dilation Pouch lengthRevisionNew procedurePsychologyBinge eating Depression Drug & alcohol Impulsivity
33. Therefore....Pre surgeryScreen out?Tailor?Add support?Post surgeryAdd support?Post weight gainMore surgery?Add psychology?
34. My view?.....
35. My view .....Pre surgeryScreen out? (small minority)Tailor? Add support? Post surgeryAdd support? Post weight regainMore surgery? ? (plastic??)Add support?☑Add follow ups ☑☑
36. AND....Is it a problem????
37. Number Needed to Treat (NNTs)Bandolier / NNT.comNNTs.......1 – it works2 – 2 people take it / 1 person benefits650 – 650 people take it / 1 person benefits
38. Condition Treatment Duration of treatment Outcome NNT Acute otitis mediaAntibioticsshort courseNo symptoms at 7-14 days7AIDSindinavir 38 weeksfirst clinical event (AIDS or death)19 Anginaisosorbide dinitrate4 to 6 weeksprevention exercise induced angina5.0 Arthritisglucosamine3 to 8 weeksimproved symptoms5 back painepidural steroid75% relief at 60 days6Childhood depressionAntidepressantsnot statedImprovedNotDementiagingkoone yearADAS-Cog 4 points better7.9 Erectile dysfunctionalprostadil (transurethral)over 3 month perioderection enabling intercourse2.3 Fluvaccinationno flu23Fungal nail infectionTerbinafine12/24 weeksCured at 48 weeks2.7 Gastric ulcer with NSAID - preventionmisoprostol4 weekspresence of gastric ulcer13H pyloritriple therapyeradication1.1
39. Head licePermethrin14 daysCure1.1 Hip fracture preventioncalcium and vitamin D3 yearsprevent one fracture20 Hypertension in the elderlyDrug treatmentsat least 1 yearPrevention of CV over 5 years18 Lipid loweringstatinsmean 4 years plusall bad things35 GI bleeding NSAID useMisoprostol6 monthsPrevent any GI complication166 MIACE inhibitor [AIRE trial]death within 6 months18MigraineOral sumatriptansingle doseHeadache relieved at 2 hours2.6 MI Aspirin plus streptokinase1 infusion of streptokinase, 1 mnth of aspirin5 wk vascular mortality, prevent one death20*Peptic ulcerTriple therapy6-10 weeksUlcers remaining cured at one year1.8 Stroke primary prevention MRC:17,354WOSCOPS 6595benzoflurazide propranolol privastatin5.5 yrs4.9yrsPrevent one stroke at one year850641Stroke secondary preventionCATS 1072 SALT 13604S 4444TiclopidineAspirinsimvastatin2 years2.7yrs5.4yrs15 38 83
40. Our most effective drugs...anti retrovirals for HIV (NNT: 5 for deaths prevented in one year) statins after a stroke or heart attack (NNT: 83 for deaths prevented by five years or 415 in any one year)
41. Our most effective drugs...anti retrovirals for HIV (NNT: 5 for deaths prevented in one year) statins after a stroke or heart attack (NNT: 83 for deaths prevented by five years or 415 in any one year)Bariatric surgery: 1.5???Dieting: 50???
42. To concludeThe problemWeight regainNeed solutionPre / post / post weight gainOptionsScreen out?Tailor?Support?Wait THEN tailor AND follow upBUT - Is it that big a problem???