InterventionThe impact of preoperative counseling on postoperative treatment adherence in bariatric surgery patients: A randomized controlled trial
Introduction
Bariatric surgery is an effective treatment for patients with severe obesity as it leads to significant and sustainable weight loss and improvement in obesity-related comorbid conditions [1]. Successful weight loss is defined as more than 50% excess weight loss (EWL). In a review of the clinical effectiveness of bariatric surgery, percent EWL was reported to be between 63% and 78% following gastric bypass surgery [1]. Yet, in a meta-analysis of the effectiveness of surgical treatment of obesity, 15–20% of the patients failed to achieve 50% EWL [2].
Psychological well-being, physical exercise, and healthy eating habits are associated with weight loss and postoperative sustained improvement in quality of life [3], [4], [5], [6], [7]. Adherence to the recommended life-style after surgery varies among patients. In a study by Thomas et al. most patients (>85%) took recommended vitamins as prescribed while only 5% had more than 5 meals each day, and 24% engaged in moderate to vigorous physical activity for ≥30 min daily 6 months after surgery [8].
Weight loss after bariatric surgery is associated with regular attendance to postoperative follow-up [7], [9], [10], [11], [12], [13]. In a study by Steffen et al. with a multi-intervention program that combined bariatric surgery, an intensive program for life-style changes, and regular consultations by obesity specialists, the EWL was 61% seven years after surgery [11]. They also had a significant decrease in prevalence of metabolic syndrome, hypertension, and type 2 diabetes and significant improvements in quality of life at follow-up seven years after surgery. This study showed a significant relationship between number of consultations per patient during the follow-up period and weight loss at follow-up seven years after surgery. Several studies have reported an effect of attendance to group sessions aimed at support and guidance for postoperative life-style changes on weight loss after surgery [7], [9], [10], [14]. Attendance to such groups is related to degree of postoperative weight loss as described by Song et al. where patients who had attended 5 or more support group meetings had 56% EWL, while the patients who had attended less than 5 group meetings had 47% EWL (p < 0.05) [10]. Further, one study reported a significant positive linear relationship between the number of support group meetings the patients had attended postoperatively and percent EWL one year after gastric banding [9].
Preoperative group counseling has been studied in patients with comorbid psychiatric disorders. In one study patients with preoperative binge eating disorder (BED) had a significant reduction in episodes of binge eating following preoperative cognitive-behavioral group treatment [15]. In a study by Wild et al. patients with preoperative comorbid psychiatric disorders had a reduction in level of depression, improvement in mental quality of life, and enhancement of treatment motivation following preoperative group intervention [16]. Preoperative interventions to prepare patients for life-style changes are suggested for all patients undergoing bariatric surgery [17]. In particular, preoperative instructions about exercise and identification and minimization of barriers to exercise are supposed to increase postoperative compliance with exercise guidelines [6]. In a study by Wouters et al., preoperative cognitions about exercise, such as not regarding oneself as a sportive type of person and not perceiving physical exercise as something beneficial for health, were negative predictors for physical activity after surgery [18]. Presurgical interventions targeting these cognitions are supposed to increase physical activity after surgery [18]. However, it is reasonable to question the effectiveness of a preoperative intervention. One study found that patients that were offered a behavioral intervention before surgery were less likely to attend and complete the behavioral intervention compared to patients that were offered the intervention after surgery [19]. Further, in one study, patients went through a mandatory preoperative education program (a notebook with relevant information, two appointments with the surgeon). In addition, they were offered preoperative educational seminars and postoperative support groups. They also had to pass a preoperative test of their knowledge of the bariatric procedure and the necessary life style changes before bariatric surgery. The patients had the same test one year after surgery. The central findings were that many patients did not remember essential information from their preoperative education, and 17% of the patients thought they would lose weight regardless of what they ate or did [20]. However, adherence to treatment guidelines was not reported in the Madan et al.’s study.
In the present randomized controlled trial, we wanted to study whether attending a preoperative counseling program could improve weight loss or adherence to treatment guidelines (eating habits and physical exercise) in patients undergoing bariatric surgery.
Section snippets
Study population
The patients were all referred for bariatric surgery from general practitioners (GPs) to the Department of Surgery at Haugesund Hospital on the West coast of Norway. This region includes both urban and rural areas. A total of 169 patients with obesity were screened for participation in the study. The inclusion period lasted 15 months. Twenty-five patients were excluded for several reasons (pregnancy, bariatric surgery at private hospitals, did not want bariatric surgery, lack of consent, or
Sociodemographic and clinical characteristics
Sociodemographic and clinical characteristics at baseline are reported in Table 1. Of the 141 patients, 103 (73%) were women, with a mean age of 42 years (range 22–65, SD = 10.4) and a mean BMI of 45.2 kg/m2 (range 33.4–64.6, SD = 5.3). There were no significant differences at baseline between the Treatment group, the Control group and the Reference group in age, gender, civil status, BMI, work status, or education. Patients in the Reference group had higher prevalence rates of social phobia and
Discussion
In the present study of obese patients treated with bariatric surgery there was a substantial weight loss (mean weight loss of 44.5 kg) and 88% of the patients achieved 50% EWL at follow-up one year after surgery. Seventy-four percent had more than 5 meals a day as recommended and 37% reported daily physical exercise for more than 30 min. There were no differences in weight loss or adherence to treatment guidelines (eating habits, recommended vitamin intake, physical activity) between patients in
Acknowledgements
The authors are grateful for the statistical assistance provided by Oddbjorn Hove (PhD), Section of Mental Health Research, Haugesund Hospital, Helse Fonna HF, and for the financial support of the Western Regional Health Authority, Norway.
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
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