Weight regain post bariatric surgery
Professor Jane Ogden from the University of Surrey in the UK explores the issue of weight regain post bariatric surgery. The research investigates factors contributing to weight regain after the surgery, shedding light on potential strategies to address this concern for better patient outcomes and long-term success. By focusing on understanding these factors, this study aims to provide valuable insights into optimizing post-bariatric surgery care and support.
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Presentation Transcript
Weight regain post bariatric surgery Jane Ogden Professor in Health Psychology 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 (1-2 yrs; Cochrane Review, 2014) All > non surgery LRYGB=Sleeve> Band (BMI diff -5.2) BPD>RYGB for super obese (BMI diff-7.3) SOS: 10 yr -16.1% weight loss Band: -47% EWL Bypass: -67% EWL Non surgery: -2.46kg by 1 year (NICE 2014); 95% regain by 5 yrs; mean gained by 10 yrs
Definitions Increase of at least 10% of lowest post op weight Kg regained Change in BMI % EWL (nightmare reporting!)
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%
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)
Non modifiable Younger Female Time since surgery No co-morbidities Genetics?? Endocrinology Higher plasma ghrelin Abnormal glucose tolerance Psychology Binge eating Depression Drug & alcohol Impulsivity Surgical Stomal dilation Pouch length Revision New procedure Behaviour Poor diet Lack of activity Non follow ups
What actually happens?.......... (Ogden et al, 2005; 2006; Ogden, Avenell and Ellis, 2011)
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
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)
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).
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.
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.
What is needed??? Evidence based Long term weight loss Benefits outweigh costs Do no harm Costs Time Money Quality of life Health
Non modifiable Younger Female Time since surgery No co-morbidities Genetics??? Endocrinology Higher plasma ghrelin Abnormal glucose tolerance Psychology Binge eating Depression Drug & alcohol Impulsivity Surgical Stomal dilation Pouch length Revision New procedure Behaviour Poor diet Lack of activity Non follow ups
Non modifiable Younger Female Time since surgery No co-morbidities Genetics??? Endocrinology Higher plasma ghrelin Abnormal glucose tolerance Psychology Binge eating Depression Drug & alcohol Impulsivity Surgical Stomal dilation Pouch length Revision New procedure Behaviour Poor diet Lack of activity Non follow ups
Non modifiable... Screen out? Tailor treatments? Ignore
Non modifiable Younger Female Time since surgery No co-morbidities Genetics??? Endocrinology Higher plasma ghrelin Abnormal glucose tolerance Psychology Binge eating Depression Drug & alcohol Impulsivity Surgical Stomal dilation Pouch length Revision New procedure Behaviour Poor diet Lack of activity Non follow ups
Endocrinology Medication post surgery Some short term evidence No long term evidence Side effects? Quality of life? Not sure! (Stanford et al, 2017)
Non modifiable Younger Female Time since surgery No co-morbidities Genetics??? Endocrinology Higher plasma ghrelin Abnormal glucose tolerance Psychology Binge eating Depression Drug & alcohol Impulsivity Surgical Stomal dilation Pouch length Revision New procedure Behaviour Poor diet Lack of activity Non follow ups
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
Non modifiable Younger Female Time since surgery No co-morbidities Genetics??? Endocrinology Higher plasma ghrelin Abnormal glucose tolerance Psychology Binge eating Depression Drug & alcohol Impulsivity Surgical Stomal dilation Pouch length Plastic surgery Behaviour Poor diet Lack of activity Non follow ups
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)
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??
Post surgery interventions.... For weight loss Meta analysis: improved EWL Standardised mean difference 1.6 %EWL No real benefit (Rudolph and Hilbert, 2013)
Our study (Ogden et al, 2015) 160 140 120 100 baseline 12 months FU 80 60 40 20 0 control intervention
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)
Non modifiable Younger Female Time since surgery No co-morbidities Genetics??? Endocrinology Higher plasma ghrelin Abnormal glucose tolerance Psychology Binge eating Depression Drug & alcohol Impulsivity Surgical Stomal dilation Pouch length Revision New procedure Behaviour Poor diet Lack of activity Non follow ups
Therefore.... Pre surgery Screen out? Tailor? Add support? Post surgery Add support? Post weight gain More surgery? Add psychology?
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
AND.... Is it a problem????
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
Condition Treatment Duration of treatment Outcome NNT Acute otitis media Antibiotics short course No symptoms at 7-14 days 7 AIDS indinavir 38 weeks first clinical event (AIDS or death) 19 Angina isosorbide dinitrate 4 to 6 weeks prevention exercise induced angina 5.0 Arthritis glucosamine 3 to 8 weeks improved symptoms 5 6 Not back pain epidural steroid 75% relief at 60 days Childhood depression Antidepressants not stated Improved Dementia gingko one year ADAS-Cog 4 points better 7.9 Erectile dysfunction alprostadil (transurethral) over 3 month period erection enabling intercourse2.3 Flu vaccination no flu 23 2.7 Fungal nail infection Terbinafine 12/24 weeks Cured at 48 weeks Gastric ulcer with NSAID - prevention misoprostol 4 weeks presence of gastric ulcer 13 H pylori triple therapy eradication 1.1
Head lice Permethrin 14 days Cure 1.1 20 Hip fracture prevention calcium and vitamin D 3 years prevent one fracture Hypertension in the elderly Drug treatments at least 1 year Prevention of CV over 5 years18 Lipid lowering statins mean 4 years plus all bad things 35 GI bleeding NSAID use Misoprostol 6 months Prevent any GI complication 166 MI ACE inhibitor [AIRE trial] death within 6 months 18 Migraine Oral sumatriptan single dose Headache relieved at 2 hours2.6 MI Aspirin plus streptokinase 1 infusion of streptokinase, 1 mnth of aspirin 5 wk vascular mortality, prevent one death 20* Peptic ulcer Triple therapy 6-10 weeks Ulcers remaining cured at one year 1.8 Stroke primary prevention MRC:17,354 benzoflurazide propranolol privastatin 5.5 yrs Prevent one stroke 850 WOSCOPS 6595 4.9yrs at one year 641 Stroke secondary prevention CATS 1072 Ticlopidine 2 years 15 SALT 1360 Aspirin 2.7yrs 38 4S 4444 simvastatin 5.4yrs 83
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)
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???
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???
