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Journal Watch—July 2016

| July 1, 2016

THIS MONTH’S TOPIC: Patient Expectations for Weight Loss

Patient expectations of bariatric and body contouring surgery.
Poulsen L, Klassen A, Jhanwar S, Pusic A, Roessler KK, Rose M, Sørensen JA. Plast Reconstr Surg Glob Open. 2016;4(4):e694.
Synopsis: The aim of this study was to identify patient expectations along the weight loss journey and/or body contouring surgery. This qualitative study took an interpretive description approach. Between September 2009 and February 2012, 49 patients were interviewed postbody contouring surgery. Data were analyzed using a line-by-line approach whereby expectations were identified and labeled as expected, unexpected, or neutral. Participants described expectations according to appearance, health-related quality of life, and patient experience of care. The authors found that two areas stood out in terms of unmet expectations: appearance and physical health (i.e., recovery from body contouring surgery). Most participants who underwent bariatric surgery expected neither the extent of excess skin after weight loss nor how the excess skin would make them look and feel. For recovery, participants did not expect that it would be as long or as hard as it was in reality.
The authors concluded that a full understanding of outcomes and expectations for this patient population is needed to enhance patient education and improve shared medical decision making. Education materials should be informed by the collection of evidence-based patient-reported outcome information using measures such as the BODY-Q. A patient-reported outcome scale measuring patient expectations is needed for obese and bariatric patients.
PMID: 27200256

A comparison of behavioral and psychological characteristics of patients opting for surgical and conservative treatment for morbid obesity.
Kvalem IL, Bergh I, von Soest T, Rosenvinge JH, Johnsen TA, Martinsen EW, Mala T, Kristinsson JA. BMC Obes. 2016 Feb 5;3:6.
Synopsis: The researchers conducted a study to compare patients scheduled for bariatric surgery with patients receiving conservative treatment for morbid obesity on measures of behavioral and psychosocial characteristics considered predictors of their adoption of and adherence to long-term lifestyle recommendations. Baseline clinical and questionnaire data from the prospective “Oslo Bariatric Surgery Study” were used to examine potential differences between bariatric surgery patients (n = 301) and patients receiving conservative weight loss treatment (n = 261).
The surgical group was characterized by their younger age (43.8 vs. 46.2 years, p <0.01), higher percentage of women (79.1 vs. 70.1 %, p <0.05), and higher body mass index (BMI; 45.0 vs. 41.9 kg/m(2), p <0.001). A multiple logistic regression analysis, adjusting for group differences in BMI, gender, and age, showed that the surgical group had higher self-efficacy (Odds ratio; OR = 3.44, 95 % Confidence interval; CI 1.65, 7.14), more positive outcome expectations (OR = 1.53, 95 % CI 1.23, 1.89), and plans that were more explicit for changing their eating behaviors (OR = 1.80, 95 % CI 1.06, 1.93). The surgical patients were also less ready to change physical activity levels (OR = 0.59, 95 % CI 0.48, 0.73), had tried more types of unhealthy weight loss methods in the past (OR = 1.16, 95 % CI 1.01, 1.33), drank soda more frequently (OR = 1.24, 95 % CI 1.02, 1.50), had fewer binge eating episodes (OR = 0.38, 95 % CI 0.20, 0.71), and had more depressive symptoms (OR = 1.19, 95 % CI 1.09, 1.29).
The researchers concluded that patients opting for bariatric surgery had more positive expectations of the treatment outcomes and stronger beliefs in their ability to achieve these outcomes. Those starting conservative treatment had stronger beliefs in readiness to change physical activity levels. Future studies should explore the effect of interventions for bariatric surgery patients, promoting postoperative physical activity and stress realistic outcome expectations. The potential effects of incorporating this knowledge in intervention strategies remain to be explored.
PMID: 26885374

Expectations and patients’ experiences of obesity prior to bariatric surgery: a qualitative study.
Homer CV, Tod AM, Thompson AR, Allmark P, Goyder E. BMJ Open. 2016 Feb 8;6(2):e009389.
Synopsis: The authors conducted a qualitative study among areas served by two bariatric surgery multidisciplinary teams in the north of England to understand the experiences and expectations of people seeking bariatric surgery in England and identify implications for behavioral and self-management interventions.
The authors used modified photovoice methods and triangulating photography with semistructured indepth interviews that were analyzed using framework techniques.
Participants were recruited through hospital-based tier 4 bariatric surgery multidisciplinary teams. The study included 18 adults (14 women and 4 men) who accepted for bariatric surgery, and were aged between 30 and 61 years.
The authors found that problems included stigmatization, shame, poor health, physical function, and reliance on medications. Participants expected surgery to result in major physical and psychological improvement. They described how this expectation was rooted in their experiences of stigma and shame. These feelings were reinforced by previous unsuccessful weight loss attempts. Participants expected extreme and sometimes unrealistic levels of sustained weight loss, as well as improvements to physical and mental health. The overall desire and expectation of bariatric surgery was of ‘normality’. Participants had received previous support from clinicians and in weight management services; however, they reported that their expectations of surgery had not been reviewed by services, and expectations appeared to be unrealistic. Likewise, their experience of stigmatization had not been addressed.
The authors concluded that the unrealistic expectations identified through their study may negatively affect postoperative outcomes. The findings indicate the importance of services addressing feelings of shame and stigmatization, and modifying patient’s expectations and goals for the postoperative period.
PMID: 26857104

The gap between expectations and reality of exercise-induced weight loss is associated with discouragement.
Thomas DM, Kyle TK, Stanford FC. Prev Med. 2015;81:357-60.
Synopsis: The aim of this study was to identify individuals who become discouraged when exercise fails to achieve weight loss. Representative samples of U.S. adults were recruited using Google Consumer Surveys in August to October 2014. Respondents were asked about beliefs and potential discouragement regarding the role of exercise and weight loss. An analysis of variance was performed to predict individuals that become discouraged if exercise does not lead to weight loss.
The results revealed that the belief that exercise is a very effective way to lose weight was common (71% of respondents). Stronger belief that exercise is an effective way to lose weight (p<0.001) in individuals with higher weight status (p=0.04) positively predicted discouragement with exercise. Higher weight status combined with the belief that exercise reduces weight was a significant positive predictor of discouragement (p=0.01).
The authors concluded that individuals with higher weight status that believe that exercise is an effective way to lose weight are more likely to become discouraged when exercise does not lead to weight loss. Prescribing exercise for weight loss might contribute to discouragement. Future studies should evaluate ways to encourage exercise without promoting the belief that exercise will yield weight loss.
PMID: 26500086

Weight loss expectations and attrition in treatment-seeking obese women.
Dalle Grave R, Calugi S, Compare A, El Ghoch M, Petroni ML, Tomasi F, Mazzali G, Marchesini G. Obes Facts. 2015;8(5):311-8.
Synopsis: The aim of this study was to investigate the role of weight loss goals on attrition in a cohort of women with obesity seeking treatment at eight Italian medical centres.
A total of 634 women with obesity, consecutively enrolled in weight loss programmes, were included in the study. Weight loss goals were evaluated with the Goals and Relative Weights Questionnaire (GRWQ), reporting a sequence of unrealistic (‘dream’ and ‘happy’) and more realistic (‘acceptable’ and ‘disappointing’) weight loss goals. Attrition was assessed at 12 months on the basis of patients’ medical records.
At 12 months, 205 patients (32.3%) had interrupted their programme and were lost to follow-up. After adjustment for age, baseline weight, education and employment status, attrition was significantly associated with higher percent acceptable and disappointing weight loss targets, not with dream and happy weight loss.
The authors concluded that in “real-world” clinical settings, only realistic expectations might favor attrition whenever too challenging, whereas unrealistic weight loss goals have no effect. Future studies should assess the effect of interventions aimed at coping with too challenging weight goals on attrition.
PMID: 26444382

Should providers encourage realistic weight expectations and satisfaction with lost weight in commercial weight loss programs? a preliminary study.
Ames GE, Thomas CS, Patel RH, McMullen JS, Lutes LD. Springerplus. 2014 Aug 28;3:477.
Synopsis: This study investigated variables associated with attrition among 30 patients with obesity who completed a liquid meal replacement program (LMR) and enrolled in a 52-week Small Changes Maintenance intervention (SCM). Patients lost a median 18 percent of body weight during LMR and completed assessments about weight expectations and weight satisfaction pre- and post-SCM.
Of the 30 patients who started SCM, eight (27%) were lost to attrition. Odds of SCM attrition were higher in patients who lost ≤ 18.2% of pre-LMR weight (OR: 12.25, P=0.035), had lower satisfaction (≤7) pre-SCM (OR: 10.11, P=0.040), and who expected further weight loss of 9.1 kg or more pre-SCM (OR: 10.11, P=0.040). SCM completers significantly increased weight loss expectations by a median of 2.3kg from pre-SCM to post-SCM (WSR P=0.049) that paralleled weight regained post-SCM (2.7kg).
The authors found that after completion of a medically-supervised commercial weight loss program, patients with the greatest expectations for further weight loss and the lowest weight satisfaction were more likely to drop out of SCM. They concluded that failure to participate in maintenance treatment may lead to regain of greater than half of lost weight over the next year. Among SCM completers, lower expectations for further weight loss and greater weight satisfaction appeared to be associated with continued engagement in maintenance treatment.
PMID: 25279285

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