04
The problem.... Weight regain....<br>
05
Definitions Increase of at least 10% of lowest post op weight
Kg regained
Change in BMI
% EWL
(nightmare reporting!)<br>
06
Weight regain Roux 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%<br>
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Predictors of weight regain Pt vs surgical factors (Karmali et al, 2013)
Multifactorial (Kushner & Sorensen, 2015)
Behaviour / diet / psychological / physical / medical (Mcgrice & Don Paul, 2015)<br>
08
Behaviour
Poor diet
Lack of activity
Non follow ups Endocrinology
Higher plasma ghrelin Abnormal glucose tolerance Non modifiable
Younger
Female
Time since surgery
No co-morbidities
Genetics?? Surgical
Stomal dilation
Pouch length
Revision
New procedure Psychology
Binge eating
Depression
Drug & alcohol
Impulsivity<br>
09
What actually happens?..........
(Ogden et al, 2005; 2006; Ogden, Avenell and Ellis, 2011)<br>
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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’<br>
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)<br>
12
Grazing They 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).<br>
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.”<br>
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.”<br>
17
What is needed??? Evidence based
Long term weight loss
Benefits outweigh costs
Do no harm
Costs
Time
Money
Quality of life
Health<br>
18
Behaviour
Poor diet
Lack of activity
Non follow ups Endocrinology
Higher plasma ghrelin Abnormal glucose tolerance Non modifiable
Younger
Female
Time since surgery
No co-morbidities
Genetics??? Surgical
Stomal dilation
Pouch length
Revision
New procedure Psychology
Binge eating
Depression
Drug & alcohol
Impulsivity<br>
19
Behaviour
Poor diet
Lack of activity
Non follow ups Endocrinology
Higher plasma ghrelin Abnormal glucose tolerance Non modifiable
Younger
Female
Time since surgery
No co-morbidities
Genetics??? Surgical
Stomal dilation
Pouch length
Revision
New procedure Psychology
Binge eating
Depression
Drug & alcohol
Impulsivity<br>
20
Non modifiable... Screen out?
Tailor treatments?
Ignore ☑<br>
21
Behaviour
Poor diet
Lack of activity
Non follow ups Endocrinology
Higher plasma ghrelin Abnormal glucose tolerance Non modifiable
Younger
Female
Time since surgery
No co-morbidities
Genetics??? Surgical
Stomal dilation
Pouch length
Revision
New procedure Psychology
Binge eating
Depression
Drug & alcohol
Impulsivity<br>
22
Endocrinology Medication post surgery
Some short term evidence
No long term evidence
Side effects?
Quality of life?
Not sure!
(Stanford et al, 2017)<br>
23
Behaviour
Poor diet
Lack of activity
Non follow ups Endocrinology
Higher plasma ghrelin Abnormal glucose tolerance Non modifiable
Younger
Female
Time since surgery
No co-morbidities
Genetics??? Surgical
Stomal dilation
Pouch length
Revision
New procedure Psychology
Binge eating
Depression
Drug & alcohol
Impulsivity<br>
24
Surgery Refashioning of stoma / pouch
not effective in longer term
Banded gastric bypass
no long term follow up
Distalisation of RYGB
malnutrition
Conversion to BPD / DS
complications and difficult
Tailored to patient
HOW???
Not easy solution<br>
25
Behaviour
Poor diet
Lack of activity
Non follow ups Endocrinology
Higher plasma ghrelin Abnormal glucose tolerance Non modifiable
Younger
Female
Time since surgery
No co-morbidities
Genetics??? Surgical
Stomal dilation
Pouch length
Plastic surgery Psychology
Binge eating
Depression
Drug & alcohol
Impulsivity<br>
26
Psychology and behaviour.......<br>
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Screening..... Binge eating
Mixed evidence
Fair?
Drugs / alcohol / suicidality
Evidence?
Fair?
Ongoing (n=373): 70 referred /3 removed from pathway
Not fair? (apart from minority)<br>
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 procedures
Could be brief and simple and cheap??<br>
29
Post surgery interventions.... For weight loss
Meta analysis: improved EWL
Standardised mean difference 1.6 %EWL
No real benefit
(Rudolph and Hilbert, 2013)<br>
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Our study (Ogden et al, 2015)<br>
31
For weight regain Remote 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)<br>
32
Behaviour
Poor diet
Lack of activity
Non follow ups Endocrinology
Higher plasma ghrelin Abnormal glucose tolerance Non modifiable
Younger
Female
Time since surgery
No co-morbidities
Genetics??? Surgical
Stomal dilation
Pouch length
Revision
New procedure Psychology
Binge eating
Depression
Drug & alcohol
Impulsivity<br>
33
Therefore.... Pre surgery
Screen out?
Tailor?
Add support?
Post surgery
Add support?
Post weight gain
More surgery?
Add psychology?<br>
35
My view ..... Pre surgery
Screen out? (small minority)
Tailor?
Add support?
Post surgery
Add support?
Post weight regain
More surgery? ? (plastic??)
Add support?☑
Add follow ups ☑☑<br>
36
AND....
Is it a problem????<br>
37
Number Needed to Treat (NNTs) Bandolier / NNT.com
NNTs.......
1 – it works
2 – 2 people take it / 1 person benefits
650 – 650 people take it / 1 person benefits<br>
38
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)<br>
39
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???<br>
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To conclude The problem
Weight regain
Need solution
Pre / post / post weight gain
Options
Screen out?
Tailor?
Support?
Wait THEN tailor AND follow up
BUT - Is it that big a problem???<br>
