A pilot randomized controlled trial examining the feasibility, acceptability, and efficacy of Adapted Motivational Interviewing for post-operative bariatric surgery patients
Introduction
Bariatric surgery refers to a group of surgical procedures performed to facilitate substantial weight loss by reducing the size of the stomach and/or limiting absorption in the small intestine. It is considered a highly efficacious treatment for extreme obesity; however, bariatric surgery patients frequently report difficulty initiating and maintaining healthy behavioral changes following surgery (Elkins et al., 2005). Sustained weight loss after the initial ‘honeymoon’ period requires adherence to a set of prescribed post-operative dietary guidelines (e.g., consume three small meals and two snacks daily, consume meals/snacks every 3 to 4 h)(Yale & Weiler, 1991), and the majority of patients (57%) report suboptimal adherence (Toussi, Fujioka, & Coleman, 2009). For instance, approximately half of patients report ‘grazing’ 6 months following surgery (Saunders, 2004). Although unable to consume large quantities of food in one sitting (i.e., objective binges), many patients continue to experience loss of control over eating following surgery (Saunders, 1999). Grazing and other deviations from the dietary guidelines have been found to account for a significant amount of the variance in long-term bariatric outcomes including premature weight loss plateaus and weight regain (Hsu et al., 1998, Hsu et al., 1997). Notably, approximately 20% to 50% of bariatric patients begin to regain weight within the first 18 to 24 months following surgery (Shah, Simha, & Garg, 2006).
Mental illness has also been implicated in poor adherence to dietary guidelines after surgery. Bariatric candidates present with elevated rates of psychiatric co-morbidity (Saunders, 1999). Over one-third of individuals seeking bariatric surgery have a current psychiatric diagnosis, the most common of which are anxiety disorders (18%) and mood disorders (12%) (Mitchell et al., 2012). The presence of psychopathology following surgery has been associated with attenuated weight loss (Malik, Mitchell, Engel, Crosby, & Wonderlich, 2014). Depression and eating pathology in particular are among the most consistent negative predictors of weight loss outcomes (Meany et al., 2014, Sheets et al., 2015). A proposed mechanism that accounts for this relationship is that people eat as a means of coping with emotional difficulties (Whiteside et al., 2007). Thus, post-operative psychopathology may contribute to challenges with weight loss and weight maintenance following bariatric surgery.
Adjunctive psychosocial interventions may help patients adhere to dietary guidelines and improve eating behaviors following surgery (Nijamkin et al., 2013, Poole et al., 2005, Zuckoff, 2012). Although not yet tested empirically in bariatric patients, Motivational Interviewing (MI) holds promise for such purposes. Originally developed in the field of addictions, MI is based upon the notion that motivation for change does not reside solely within the client, but rather it can be fostered in interactions with a clinician (Moyers & Martin, 2006). Modification of even the most habitual behavior is dependent upon an individual's readiness for change, which stems from both the perceived importance of change and confidence in one's ability to change (Prochaska, DiClemente, & Norcross, 1992). Accordingly, MI is a client-centered, yet directive method for enhancing intrinsic motivation for change (Miller & Rollnick, 2012) by targeting the client's beliefs about the importance of change and his/her self-efficacy for making changes (Bandura, 1977, Burke et al., 2003). Since its development, MI has been combined with other psychosocial interventions to create adaptations of MI (AMI) (Burke et al., 2003). Considerable evidence has supported the efficacy of AMI in improving a broad range of disease indicators and health behaviors (Rubak, Sandbaek, Lauritzen, & Christensen, 2005), as well as treatment adherence (Teeter & Kavookjian, 2014).
In addition to AMI improving health behaviors and treatment adherence broadly, three specific lines of research justify the application of AMI with bariatric patients. First, AMI has been found to improve dietary behaviors beyond standard psychoeducation alone (VanWormer & Boucher, 2004). Second, AMI has been shown to improve different aspects of disordered eating, particularly binge eating (Cassin, von Ranson, Heng, Brar, & Wojtowicz, 2008). Finally, AMI has been found to increase adherence to weight management programs (e.g., appointment attendance, completion of food diaries) (Smith, Heckemeyer, Kratt, & Mason, 1997).
The current randomized wait-list pilot trial examined the acceptability, feasibility, and preliminary efficacy of AMI for improving self-efficacy and eating behaviors in post-operative bariatric surgery patients. It was hypothesized that participants who received AMI as an adjunct to standard bariatric care would report increases in readiness for change, confidence in their ability to change (self-efficacy), and adherence to the dietary guidelines, as well as decreases in binge eating symptomatology following AMI. Moreover, it was hypothesized that participants receiving AMI would improve to a greater extent than those receiving standard bariatric care alone.
Section snippets
Participants
Post-operative patients were recruited from the Toronto Western Hospital Bariatric Surgery Program between August 2013 and March 2014 using emails (3.1%) and brochures at appointments and support group meetings (96.9%). Of the 66 patients who expressed interest, 55 met the following inclusion criteria: 1) received surgery at least 4 months ago, 2) fluent in English, 3) able to attend one in-person appointment, and 4) access to the Internet. The mean age of study participants was 49.2 years (SD =
Randomization and attrition
Participant flow is shown in Fig. 1. Fifty-one participants were randomly assigned to either the AMI group (n = 23) or the WLC group (n = 28). Across groups, the completers (n = 44) did not differ from the dropouts (n = 7) on any demographic variables or baseline characteristics. All analyses were performed with completers only (n = 44), including three WLC participants who completed all questionnaires during the wait-list period but withdrew before receiving AMI (Lavori, 1992).
The treatment groups did
Discussion
The addition of one AMI session to standard post-operative bariatric care was found to improve confidence for change, dietary adherence, and binge eating symptoms. Immediately following the AMI session, participants reported moderate to large improvements in readiness for change and confidence in ability to change. Similarly, they reported moderate improvements in their perceived self-efficacy for resisting overeating in tempting situations and for adhering to the post-operative guidelines. AMI
Conclusions and future research
Limitations notwithstanding, the current study suggests that AMI is an acceptable and feasible brief intervention that has the potential to improve self-efficacy and eating behaviors in post-operative bariatric patients. A larger randomized controlled trial is warranted with a more diverse sample, the inclusion of additional validated and reliable outcome measures, the consideration of an increased dose of AMI (i.e., booster sessions), and a longer follow-up period in order to gain additional
Role of funding sources
This study was funded by a Ryerson University Health Research Fund Grant awarded to the last author (Dr. S. Cassin). Ryerson University had no role in the study of design, collection, analysis, or interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication.
Contributors
Ms. David conducted literature searches, designed the study methodology, secured REB approval at the hospital and university, recruited participants, ran participants and collected data via questionnaires, and conducted the statistical analysis. Dr. Wnuk designed the study methodology, trained Ms. David on the electronic and paper charting systems at the hospital to facilitate recruitment, and distributed flyers to patients seen at post-operative follow-up appointments. Dr. Sockalingam approved
Conflict of interest
Dr. Cassin received funding for this study though the Ryerson University Health Research Fund. Dr. Cassin also holds an operating grant from the Canadian Institutes of Health Research. Dr. Sockalingam holds operating grants from the Canadian Institutes of Health Research and Shire International. All other authors declare that they have no conflicts of interest.
Acknowledgments
This study was supported by a Ryerson University Health Research Fund Grant awarded to the last author (Dr. S. Cassin). The authors wish to thank Molly Atwood and Aliza Friedman for completing treatment adherence ratings for the current trial.
References (34)
- et al.
Brief, four-session group CBT reduces binge eating behaviours among bariatric surgery candidates
Surgery for Obesity and Related Diseases
(2009) - et al.
Cognitive behavioral therapy for bariatric surgery patients: Preliminary evidence for feasibility, acceptability, and effectiveness
Cognitive and Behavioral Practice
(2013) - et al.
The assessment of binge eating severity among obese persons
Addictive Behaviors
(1982) - et al.
Psychopathology before surgery in the longitudinal assessment of bariatric surgery-3 (LABS-3) psychosocial study
Surgery for Obesity and Related Diseases
(2012) - et al.
Therapist influence on client language during motivational interviewing sessions
Journal of Substance Abuse Treatment
(2006) - et al.
Difficulties regulating emotions: Do binge eaters have fewer strategies to modulate and tolerate negative affect?
Eating Behaviors
(2007) - et al.
Weight control after vertical banded gastroplasty for morbid obesity
American Journal of Surgery
(1991) “Why won't my patients do what's good for them?” Motivational interviewing and treatment adherence
Surgery for Obesity and Related Diseases
(2012)Self-efficacy: Toward a unifying theory of behavioural change
Psychological Review
(1977)- et al.
The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials
Journal of Consulting and Clinical Psychology
(2003)
Adapted motivational interviewing for women with binge eating disorder: A randomized controlled trial
Psychology of Addictive Behaviors
Self-efficacy in weight management
Journal of Consulting and Clinical Psychology
Noncompliance with behavioural recommendations following bariatric surgery
Obesity Surgery
(1998). Nonsurgical factors that influence the outcome of bariatric surgery: A review
Psychosomatic Medicine
Eating disturbances and outcome of gastric bypass surgery: A pilot study
The International Journal of Eating Disorders
Clinical trials in psychiatry: Should protocol deviation censor patient data?
Neuropsychopharmacology
Psychopathology in bariatric surgery candidates: A review of studies using structured diagnostic interviews
Comprehensive Psychiatry
Cited by (18)
Psychological assessment and motivational interviewing of patients seeking bariatric and metabolic endoscopic therapies
2020, Techniques and Innovations in Gastrointestinal EndoscopyCitation Excerpt :Nonadherence to postbariatric surgery recommendations and missed follow up appointments are common after surgery [70]. However, a single session of adapted MI in postoperative weight-loss surgery patients was associated with improvements in motivation and self-efficacy [71]. In those experiencing weight regain following weight loss surgery, a combination of cognitive behavioral therapy and MI indicated patients experienced an increase in confidence and motivation, and renewed their behavioral compliance to postsurgical recommendations [72].
Measurement of adherence in bariatric surgery: a systematic review
2018, Surgery for Obesity and Related DiseasesCitation Excerpt :Defining dietary adherence. Adherence to dietary/eating behavior recommendations was the second most commonly assessed adherence area (n = 34 articles; Table 2 [25,35,52,56,59,61–101]). Bariatric surgery patients are given specific guidelines regarding both the content (e.g., grams of protein per day) and process (e.g., 3–6 small meals per day) of eating after surgery.
Motivational Interviewing and Mindfulness in Weight Management
2017, Practical Guide to Obesity MedicinePsychological predictors of adherence to lifestyle changes after bariatric surgery: A systematic review
2024, Obesity Science and PracticePsychosocial intervention for improving health in patients with bariatric surgery: a Meta-analysis
2023, Chinese Journal of Nursing
This study was conducted in the Department of Psychology at Ryerson University.