Bariatric surgery is the most effective obesity treatment, but its positive effects don’t always last. Patients typically achieve weight loss of 20% to 35% within six to 24 months, and they often show improvements in weight-related health issues such as Type 2 diabetes and hypertension as well as psychosocial functioning.    

But 20% to 30% of patients who undergo bariatric surgery regain the weight over time. Surgeons in some cases recommend a second operation or prescribe weight loss drugs, which have shown promise but can be prohibitively expensive. A critical component of success in weight-loss maintenance after bariatric surgery depends on patients’ behavior and mindset toward healthful eating.   

Now a study by the College of Public Health will test a novel psychotherapeutic intervention, delivered using web-based materials and mobile phone surveys, to help patients maintain the weight loss and health benefits gained from bariatric surgery.   

“The most important thing is: what can we offer patients who are having these suboptimal outcomes?” says David Sarwer, associate dean for research and director of the college’s Center for Obesity Research and Education. “We need to be looking at interventions like this that are behaviorally based and can be delivered remotely, so we can reach people in their homes or workplaces and reduce the burden that comes with in- person clinical visits."  

Sarwer is principal investigator for the five-year study, funded by the National Institute of Diabetes and Digestive and Kidney Diseases, with co-investigators Lauren Bradley, assistant professor of behavioral sciences at Rush University Medical Center, and Graham Thomas, professor of psychiatry and human behavior at the Alpert Medical School of Brown University.  

The study will employ an approach called Acceptance and Commitment Therapy. It targets the challenges patients face by building acceptance and mindfulness skills that increase their capacity to experience uncomfortable internal states, such as food cravings, while encouraging them to commit to behavior guided by their goals and values, such as maintaining their weight after bariatric surgery.  

“When people undergo bariatric surgery, they still live in the environment where they gained a significant amount of weight in the first place,” Sarwer says. “We help patients identify their most meaningful goals with regards to their health and things they value. For example, we will remind them that they've made this significant investment in their health by undergoing bariatric surgery. They decided it’s important to them, for their families, their children, their grandchildren. We're helping them recommit to those goals, while accepting that those aspirational goals can be at odds with the challenges of the toxic food environment they’re facing each day.”  

Patients who regained more than 5% of their reduced weight after surgery will engage with web-based modules over the course of six months, designed to help them work through challenges with their diet and eating behavior. They will be asked to self-monitor their daily food intake using online accounts and will be given Wi-Fi-connected scales, which will transfer data wirelessly to researchers. Participants also will receive scheduled phone calls from coaches.  

To monitor participants’ situations on a granular level, researchers will use a technique called ecological momentary assessment, sending brief smartphone-based surveys several times per day during assessment periods. Each survey asks about experiences, behaviors, and environmental conditions occurring in the moment. This immediate feedback can be more informative than self-report questionnaires completed weeks or months later.   
 
“For people to be optimally successful with controlling their weight—whether they've had surgery or not—there need to be changes in behavior in relationship to the environment,” Sarwer says. “For example, I can decide I’m going to eat healthier—that I'm not going to eat cakes and cookies. But in my office, whenever it's somebody's birthday, my coworkers celebrate with those foods and I feel tempted. So how do I resist that temptation? The idea is that you realize there are going to be stressors in your life, you are going to be challenged by things beyond your control, such as cookies that appear in the office. You remind yourself that life is stressful, but you learn how to keep your eye on the bigger-picture goal of the commitment you made to your weight and health.”