A Health Services Research Agenda for Bariatric Surgery Within the Veterans Health Administration.

In 2016, the Veterans Health Administration (VHA) held a Weight Management State of the Art conference to identify evidence gaps and develop a research agenda for population-based weight management for veterans. Included were behavioral, pharmacologic, and bariatric surgery workgroups. This article summarizes the bariatric surgery workgroup (BSWG) findings and recommendations for future research. The BSWG agreed that there is evidence from randomized trials and large observational studies suggesting that bariatric surgery is superior to medical therapy for short- and intermediate-term remission of type 2 diabetes, long-term weight loss, and long-term survival. Priority evidence gaps include long-term comorbidity remission, mental health, substance abuse, and health care costs. Evidence of the role of endoscopic weight loss options is also lacking. The BSWG also noted the limited evidence regarding optimal timing for bariatric surgery referral, barriers to bariatric surgery itself, and management of high-risk bariatric surgery patients. Clinical trials of pre- and post-surgery interventions may help to optimize patient outcomes. A registry of overweight and obese veterans and a workforce assessment to determine the VHA's capacity to increase bariatric surgery access were recommended. These will help inform policy modifications and focus the research agenda to improve the ability of the VHA to deliver population-based weight management.

Preoperative lifestyle intervention in bariatric surgery: initial results from a randomized, controlled trial.

OBJECTIVE: To document preoperative outcomes of a behavioral lifestyle intervention delivered to patients prior to bariatric surgery in comparison to treatment as usual (insurance-mandated physician supervised diet). DESIGN AND METHODS: After completing a baseline assessment, candidates for surgery were randomized to a 6-month, evidence-informed, manualized lifestyle intervention (LIFESTYLE, n = 121) or to preoperative care as usual (USUAL CARE, n = 119). At 6 months, 187 participants remained candidates for bariatric surgery and were included in the analyses. RESULTS: LIFESTYLE participants lost significantly more weight than those receiving USUAL CARE [8.3 ± 7.8 kg vs. 3.3 ± 5.5 kg, F(1,183) = 23.6, P < 0.0001], with an effect size of 0.72. Additionally, logistic regression modeling indicated that LIFESTYLE patients were significantly more likely to lose at least 5% of initial body weight than those in USUAL CARE [OR (95% CI) = 2.94 (1.253, 6.903)], as were participants who were heavier [OR (95% CI) = 1.07 (1.001-1.14) for each unit increase in BMI] or with larger improvements in eating behaviors [OR (95% CI) = 1.1 (1.049, 1.145) for each unit increase on the Eating Behavior Inventory). CONCLUSIONS: A behavioral lifestyle intervention for severely overweight individuals leads to clinically significant weight loss prior to bariatric surgery. Post-surgery follow-up will allow us to examine the impact of the preoperative intervention on postoperative outcomes.

Self-reported binge eating in severe pediatric obesity: impact on weight change in a randomized controlled trial of family-based treatment.

OBJECTIVE: This study sought to document self-reported binge eating in a large sample of severely obese children and to examine the impact of binge eating on changes in percent overweight among children randomized to family-based behavioral treatment (intervention) versus control (usual care). PARTICIPANTS AND METHODS: As part of a larger randomized controlled trial, 192 children aged 8-12 years (M=10.2, s.d.=1.2) with a mean body mass index (BMI) percentile of 99.2 (s.d.=0.7) completed assessments at baseline and 6-, 12-, and 18 months post-randomization. A parent or guardian also participated. Child psychological symptoms, including binge eating, were measured before randomization using self-report questionnaires. Child height and weight were measured at baseline, 6-, 12-, and 18 months. The primary study outcome was percent overweight (that is, percent over median BMI for age and sex). RESULTS: Twenty-two children (11.5%) endorsed binge eating at baseline (Binge Eating Group). Children in the Binge Eating Group were younger and had more depressive, anxiety, and eating disorder symptoms, and lower self-esteem than children in the rest of the sample (No Binge Eating Group). There also were differences between the Binge Eating and No Binge Eating groups with respect to the short-term effects of treatment group assignment on change in percent overweight during the study. Specifically, improvements in percent overweight in the intervention condition relative to usual care were documented in the No Binge Eating Group only. Among children in the Binge Eating Group, those assigned to intervention showed a 2.6% increase in percent overweight, on average, at the completion of acute treatment as compared to an 8.5% decrease among children without binge eating. However, these effects were not maintained during follow-up. CONCLUSION: Results of this study suggest the importance of considering binge eating in the development of weight management programs for severely obese youth.

Is family-based behavioral weight control appropriate for severe pediatric obesity?

OBJECTIVE: Although the efficacy of family-based behavioral treatment for moderate pediatric obesity has been well established, few studies have focused on the treatment of severe obesity. We sought to evaluate the acceptability and feasibility of a family-based intervention for severely obese children. METHOD: Twenty-four families with children aged 8-12 years who were > or =160% of their ideal body weight participated in a 10-12-session behavioral intervention. Participants were weighed and their heights measured at the start of each treatment session and during a follow-up visit 4-13 (M = 7.8) months posttreatment. Children also completed measures of depressive symptoms and anxiety at pretreatment, posttreatment, and follow-up, and eating attitudes were assessed at pretreatment and follow-up. RESULTS: One third of the families did not complete treatment. However, children who completed the program lost a significant amount of weight and reported significant improvements in depression, anxiety, and eating attitudes that were maintained over time. DISCUSSION: A short-term, family-based behavioral intervention was successful in moderating weight gain for most children and had positive effects on children's mood and eating disorder symptoms. Future randomized, controlled trials of longer interventions are necessary to determine the success of this approach.

Assessment of eating disorders in bariatric surgery candidates: self-report questionnaire versus interview.

OBJECTIVE: To compare the Eating Disorder Examination (EDE), an investigator-based interview for the assessment of the specific psychopathology of eating disorders, with the EDE-Q, a self-report questionnaire based directly on it. METHOD: Ninety-eight morbidly obese gastric bypass surgery candidates were administered both instruments. RESULTS: The four subscale scores (Restraint, Eating Concern, Weight Concern, and Shape Concern) generated by the EDE and EDE-Q were significantly correlated, although the questionnaire scores were significantly higher. Eating Concern and Shape Concern exhibited the lowest levels of agreement. Frequency of binges (objective bulimic episodes) as rated by the EDE and EDE-Q was significantly correlated and was not significantly different. However, variability in ratings contributed to only modest agreement with respect to classification of patients as binge eaters. DISCUSSION: Overall, there were lower levels of agreement between the EDE and EDE-Q than have been previously found in other samples.

Effects of bariatric surgery on binge eating and related psychopathology.

The Beck Depression Inventory (BDI), the Three-Factor Eating Questionnaire (TFEQ), and the Eating Disorder Examination (EDE) were administered to 50 morbidly obese patients before and after gastric bypass surgery. Subjects were classified as non-binge or binge eaters prior to surgery. Though the two groups differed markedly before operation, they were largely indistinguishable 4 months afterward. All binge eating had ceased and mood had improved markedly. TFEQ Restraint scores increased, and Disinhibition and Hunger scores decreased. EDE Eating Concern, Shape Concern, and Weight Concern scores dropped. EDE Restraint scores decreased in non-binge eaters and increased in binge eaters. The overall findings indicate that gastric bypass surgery had a positive short-term impact on non-binge and binge eaters alike.

Binge eating in bariatric surgery patients.

OBJECTIVE: Eating behavior, attitudes toward eating and body weight and shape, and depression were assessed in a sample of 64 morbidly obese gastric bypass surgery candidates. METHOD: The Beck Depression Inventory (BDI), the Three-Factor Eating Questionnaire (TFEQ), and the Eating Disorder Examination (EDE) were administered at the first preoperative visit. RESULTS: Twenty-five subjects (39%) reported at least one binge episode per week on average over the 3 months prior to seeking treatment. Binge eaters had significantly higher TFEQ Disinhibition and Hunger scores than nonbinge eaters. Binge eaters also differed from nonbinge eaters in terms of attitudes toward eating, shape, and weight. DISCUSSION: A significant number of gastric bypass surgery candidates report binge eating. The findings are consistent with other studies showing binge eaters to be a distinctive subgroup of the obese.

Do children lose and maintain weight easier than adults: a comparison of child and parent weight changes from six months to ten years.

Recent research has shown weight maintenance for obese preadolescent children over 60 and 120 month intervals, while studies on adults consistently show they fail to maintain weight loss. This paper is designed to examine differences in percent overweight changes at 6, 60 and 120 months in obese parents and children from 113 families who participated in randomized controlled outcome studies evaluating family-based behavioral treatment. Analyses showed children had significantly greater changes in percent overweight than their parents at each time point. Chi-Square and Logistic Regression analyses showed children were more likely than their parents at each time point to have percent overweight decreases greater than 20%, with over 20% of the children and less than 1% of the parents showing changes this large. The implications of these results for weight control are discussed. These results suggest there may be differences in the efficacy of treating obesity in children versus adults.

Effects of decreasing sedentary behavior and increasing activity on weight change in obese children.

Obese children 8-12 years old from 61 families were randomized to treatment groups that targeted increased exercise, decreased sedentary behaviors, or both (combined group) to test the influence of reinforcing children to be more active or less sedentary on child weight change. Significant decreases in percentage overweight were observed after 4 months between the sedentary and the exercise groups (-19.9 vs. -13.2). At 1 year, the sedentary group had a greater decrease in percentage overweight than did the combined and the exercise groups (-18.7 vs. -10.3 and -8.7) and greater decrease in percentage of body fat (-4.7 vs. -1.3). All groups improved fitness during treatment and follow-up. Children in the sedentary group increased their liking for high-intensity activity and reported lower caloric intake than did children in the exercise group. These results support the goal of reducing time spent in sedentary activities to improve weight loss.