Novel Behavioral Approaches to Postoperative Weight Regain: Acceptance-based Behavioral Treatments

| March 1, 2020

by Lauren E. Bradley, PhD

Dr. Bradley is with the Department of Psychiatry & Behavioral Sciences at Rush University Medical Center in Chicago, Illinois.

Funding: No funding was provided.

Disclosures: The author has no conflicts of interest relevant to the content of this article.

Abstract: A substantial subset of patients with obesity experience weight regain following bariatric surgery. As time from surgery increases, many of these patients demonstrate decreased adherence to rigorous dietary recommendations in response to the return of hunger, food cravings, and interest in high-calorie food. Acceptance-based behavioral treatments (ABBTs) provide patients with specialized psychological skills that target these factors that make long-term weight control difficult. This review provides an overview of ABBT for weight regain, a review of current empirical evidence for the use of ABBTs, and recommendations for applying ABBTs to postbariatric surgery patients.

Keywords: obesity, weight regain, acceptance-based behavioral treatment, behavioral intervention

Bariatric Times. 2020;17(3):14–15.

A significant minority of bariatric surgery patients experience suboptimal long-term weight outcomes, including weight regain.1–3 Weight regain threatens the benefits initially achieved from surgery, including improved health outcomes.4,5 It is therefore critical to develop effective interventions to stop and reverse weight regain in this subset of patients. When providing intervention, it is important to consider the unique factors that contribute to weight regain after bariatric surgery.

Causes of Weight Regain

Weight regain is often attributed to behavioral factors, such as decreased adherence to the rigorous postoperative diet recommendations.6–8 In the immediate aftermath of surgery, patients often report experiencing changes not only in their physical capacity to eat, but also in internal experiences that affect their adherence to lifestyle modifications. Specifically, physical and metabolic changes following weight loss surgery can lead to reduced hunger, food cravings, and reward value of high-calorie food.9 However, over time, these initial internal experiences can return to presurgery levels, making it harder for patients to adhere to the eating behavior changes that have facilitated short-term weight loss.10–12

Behavioral responses to the return of these internal experiences (e.g., cravings, hunger, interest in high calorie food) can include increased caloric consumption via increased food intake and/or the onset or return of maladaptive eating behaviors, (e.g., loss of control over eating, emotional eating, and grazing).13,14 In addition to increased biological drives to increase consumption of food, patients remain subjected to society’s “obesogenic environment,” which includes easy access to high-calorie food.

It is not likely that suboptimal adherence to diet recommendations over time is due to lack of knowledge of these recommendations. In fact, prior to surgery, patients undergo dietary counseling to prepare them for the significant lifestyle changes required for postoperative success. In addition, a meta-analysis of standard behavioral interventions to improve postoperative weight outcomes indicate minimal effects compared to control groups, which included treatment as usual, wait list controls, and minimal interventions.15 Therefore, simply providing patients behavioral recommendations is not likely sufficient to stop and reverse weight regain. It is important to directly target the theorized causes of decreased adherence, rather than providing standard information patients have already received.

Acceptance-based Behavioral Therapies

One novel treatment approach that directly addresses the challenges faced by postoperative patients includes acceptance-based behavioral treatments (ABBTs). Based on “third wave” cognitive behavioral treatments, including Acceptance and Commitment Therapy,16 ABBTs provide patients psychological skills that enhance their ability to engage in behaviors that are consistent with their values rather than based on transient internal experiences (e.g., thoughts, emotions, cravings, urges).17

In ABBTs, the standard behavioral strategies (e.g., calorie restriction, self-monitoring, stimulus control) are important treatment components, but they are combined with psychological skills that enhance a patient’s ability to engage in difficult behavior change over the long term. In other words, the standard behavior skills are considered to be the “what to do” and the acceptance-based skills are considered to the “how to do.”17

Below is a summary of the core concepts and strategies that comprise the basis of an ABBT for postoperative weight regain, adapted from Forman and Butryn’s ABBT treatment protocol for overweight and obesity in a nonsurgical population.18 See Weineland and Bradley19 for a more thorough review of the treatment elements.

Willingness to experience discomfort or less pleasurable experiences. Unlike standard cognitive behavioral approaches, patients are taught skills that enable them to cope with uncomfortable/less pleasurable internal experiences, rather than trying to change them. There are many facets of weight control that promote uncomfortable internal experiences, especially as time from surgery increases. Using ABBT, patients are better equipped to engage in weight control behaviors long term after surgery, especially as the physiological effects might weaken. When using this approach, it is beneficial to elicit examples from patients regarding their experiences that made weight loss more feasible during the active weight loss phase postsurgery compared to when they began to regain weight. For example, many patients report decreased food cravings or interest in high-calorie food during the first postoperative year, which could return over time. Clinicians can highlight that despite undergoing the most powerful intervention for weight control, it is impossible to completely eliminate internal experiences that make weight control difficult, such as cravings and interest in palatable foods. Patients are then taught strategies to better cope with these experiences to allow them to act independently of them, such as being willing to choose a less pleasurable food to stay within one’s calorie goal or willingness to engage in physical activity despite fatigue.

Psychological distance from uncomfortable internal experiences. One core strategy that enhances willingness is “defusion” or gaining psychological distance from internal experiences (e.g., thoughts, emotions, urges, cravings). This distance allows patients to see their thoughts, feelings, urges, and cravings for what they are (i.e., temporary activity in their brains and bodies). When one is able to get distance from those experiences, it enhances one’s ability act independently of them.

Clinicians may highlight that bariatric surgery patients have already likely demonstrated the skill of uncoupling their internal experiences and behaviors, as is most evident immediately before and after surgery when dietary restrictions were most rigorous. Patients might have experienced strong desires to consume solid foods during this time (especially preoperatively), but continued the liquid diet to enhance surgical safety. Patients can use this example to enhance their confidence in separating their internal experiences and behaviors to stop and reverse weight regain. Rather than saying to oneself “I can’t stand this craving, and I need to eat to get rid of it,” patients learn to get distance by labeling it as a thought, (e.g., “I’m having the thought that I can’t stand this craving, and I’m having the thought that I need to eat to get rid of it”). By acknowledging that these internal experiences are thoughts, patients can get distance from them, allowing them to uncouple their thoughts from their behaviors.

Mindful decision-making. Often, eating choices are automatic, driven by internal and external cues. Relying on automatic eating behavior makes it difficult to sustain long-term weight loss, as automatic choices tend to lead to the consumption or overconsumption of high-calorie food. Patients are taught strategies to slow down their decision-making process as it relates to choosing when to eat, the types of foods to eat, and when to stop eating. This strategy can be especially useful in helping postsurgery patients decrease behaviors shown to be particularly problematic for postoperative weight loss maintenance, including grazing. Grazing (i.e., eating small amounts of food continuously throughout the day) can be reduced by decreasing the automaticity of eating behavior and instead making mindful decisions about when to eat, even when it is small amounts. Strategies taught to patients to reduce automaticity of eating behavior include stopping and thinking before making eating-related decisions and identifying internal and external cues driving decisions to allow for the opportunity to make an intentional decision.

Values-driven behavior. A central component of ABBTs is enhancing a patient’s ability to engage in behavior that is driven by life values (i.e., freely chosen life domains that are most important to an individual) rather than based on transient internal experiences (e.g., thoughts, feelings, urges, cravings). Patients are first provided guidance on clarifying what their core values are. They are then taught strategies to tie in-the-moment decisions to their values. Living a valued life is framed as what makes engaging in difficult weight control behaviors day in and day out worth it.

A helpful strategy for patients to clarify their values is to have them recall the reasons why they were willing to undergo bariatric surgery in the first place. Patients can identify the reasons they were willing to experience potential risks and discomfort postsurgery, as well as undergo the rigorous preoperative appointments, medical tests, and behavior changes. These reasons likely overlap with their valued life domains (e.g., health). Once these values are clarified, patients are then taught strategies to bring them to the forefront of their mind when making eating- and physical activity-related decisions. An example is asking oneself if a decision is taking one closer to or further away from one’s values. A patient who committed to exercise in the morning might have a desire to sleep in instead. By asking themselves if sleeping in (rather than exercising) is taking them closer to or further away from their value of living a healthy lifestyle, they are better able to make a decision based on what is most important to them, rather than a fleeting internal experience.

Empirical Support for ABBTs

There has been growing support for the use of ABBTs for treating obesity nonsurgically.20–22 For example, Forman et al’s randomized, controlled trial (RCT)20 comparing ABBT to a standard behavioral approach showed greater weight losses in the ABBT patients (13.3% vs. 9.8%) at 12 months. ABBT has also been shown to be effective for managing food cravings after a seven-week intervention23 and in analog studies,24,25 as well as preventing weight gain in a nonsurgical population at 12 months.26

Although research is currently limited, there is emerging support for the use of ABBTs in postbariatric surgery patients. Uncontrolled trials evaluating ABBT in patients experiencing weight regain have demonstrated high levels of acceptability and significant weight losses during the 10-week interventions.27,28 Weineland et al29 also found greater improvements in disordered eating behavior in postbariatric surgery patients who were randomized to receive ABBT, compared to those assigned to treatment as usual, with improvements maintained at six-month follow-up.30 However, more research is essential to evaluate ABBT in larger samples compared to active treatment conditions.

Treatment Considerations

Delivery modality. Traditionally, obesity interventions are provided in-person through either individual or group-based treatment sessions. Preliminary research has supported the use of ABBTs in a group-based setting in postoperative patients.27 However, one challenge to providing interventions postoperatively is the demonstrated difficulty that patients have returning to follow-up appointments.31,32 Several reasons have been identified for suboptimal follow-up in this population, including geographic barriers and time constraints.27,33–35

One way to mitigate these barriers is the use of remote delivery modalities, including the use of phone and/or the internet to deliver treatment. Remotely delivered interventions hold promise for their reduced patient burden, cost-effectiveness, and increased reach of patients who might not receive intervention otherwise.36,37 Current research indicates receptivity and acceptability of remotely delivered interventions in bariatric surgery patients.38 However, this research is in its infancy, and more research is needed to optimize remotely delivered interventions in bariatric surgery patients. In addition, there are barriers to utilizing remotely delivered interventions, including security concerns, access to necessary technology, and reimbursement issues.38

Maximizing understanding and real-world applicability of ABBT strategies. ABBTs can include abstract concepts (e.g., psychological distancing) that can be difficult for patients and untrained professionals to understand and apply the way in which they are intended. ABBTs should be delivered by trained behavior specialists. It is recommended that providers undergo specialized training in ABBTs before administering them to patients. Strategies for clinicians to enhance patient understanding and applicability of treatment components include the following:

  • Providing concrete examples that patients can easily understand and apply in their own lives, including eliciting specific examples from patients’ experiences
  • Facilitating guided practice of strategies, including experiential exercises during the intervention, as well as homework assignments to practice skills in one’s own environment
  • Assessing patients’ understanding by directly asking patients their interpretation of strategies and providing corrective feedback as needed.

Conclusion

ABBTs offer a novel approach to address postoperative weight regain by directly targeting theorized causes of dietary nonadherence (e.g., hunger, food cravings, urges). Patients might benefit from receiving these specialized psychological strategies, rather than solely being provided a review of behavioral recommendations. Initial research supports the use of ABBTs in postbariatric surgery patients, though more research is needed with active control groups to better understand the effects of ABBTs. It is recommended that patients who are demonstrating weight regain be referred to trained behavioral specialists who can provide therapeutic skills that specifically address obesity-related issues.

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