Original articleAcceptance and commitment therapy for bariatric surgery patients, a pilot RCT
Introduction
Over the past decade, obesity has been recognized as an international health threat and a major public health challenge. In the US alone, 65% of the adult population is overweight and 30% is obese [1]. Obesity is directly or indirectly correlated with health issues such as high blood pressure, high cholesterol, Type 2 diabetes, coronary heart disease, congestive heart failure, stroke, gallstones, osteoarthritis, and some types of cancer, all of which may be causes of premature mortality [1].
Most weight control programs containing recommendations for dietary regimes and physical activity can produce significant weight loss [2]. While weight loss is commonly achieved, weight maintenance appears to be far more difficult. Five years after participating in a traditional weight loss program the participants maintain a weight loss of less than 3 kg [3]. Most participants do not maintain the behavior changes entailed in the new dietary or exercise routines and relapse in old habits that are associated with obesity, such as decreases in energy expenditure, dietary disinhibition and over eating [4], [5]. When targeting weight loss, cognitive behavior therapy (CBT) interventions include self-monitoring of food intake, stimulus control techniques, establishing a pattern of regular eating and cognitive strategies for dysfunctional thoughts and problems solving [2], [6]. CBT weight loss interventions result in significantly greater weight reduction as compared to placebo interventions, and increasing the treatment results in significantly increased weight reduction [2]. CBT interventions have also been effectively developed and evaluated for the treatment of binge eating among obese populations [7]. Participants are especially encouraged to identify and challenge problematic eating behavior and learn to cope with life stressors that trigger binge eating. At one-year follow-up, a reduction in binge eating is maintained, but the average weight loss is regained [7]. Despite the raised focus on psychological aspects of obesity [8], [9] and development of CBT interventions, treatments still fall short of that achieved in areas such as nicotine and alcohol dependence to which obesity has been compared [10].
Bariatric surgery (BS) is presently the intervention with best evidence for both short and long-term weight loss [11]. BS interventions are shown to correlate with an increased lifespan, [12] improved psychosocial functioning and mental well-being [13], [14]. While BS interventions result in significant long-term weight loss, 20–30% of patients regain some weight within 24 months following surgery [15], [16], [17], [18]. One possible factor contributing to weight gain is emotional eating behavior. A substantial number of BS patients report emotional eating. Emotional eating is defined as eating contingent upon emotions with the intentions of changing those feelings [19], [20]. Although BS creates structural restrictions to eating behavior, the tendency to control feelings by eating may remain present. One study shows that patients who struggle with binge eating, prior to surgery, have more uncontrolled eating and continuous grazing after surgery as compared to those who do not binge eat [21]. Subjective loss of control over eating, reported post BS has also been shown to be predictive of poorer psychosocial outcomes and less weight loss [22]. It is possible that binge eating, previously functioning as a way to relieve anxiety, is now transformed into uncontrolled eating and continuous grazing due to the surgical restriction [23]. One study showed that emotional eating is predictive of weight regain among BS patients [20].
If emotional eaters constitute a group of patients who consistently have poorer outcome in BS surgical intervention [19], [20], [21], [22], it is important to develop and evaluate psychological treatment focusing on the relationship between eating and emotions. A brief CBT intervention implemented prior to surgery showed a reduction in binge eating behaviors among BS candidates [24]. Although long-term data is needed to determine the sustainability of this improvement following BS, the combination of surgery and CBT interventions holds promise.
Negative self-stigmatization is a psychological phenomenon which appears to remain intact following successful BS surgery. Most patients with obesity, report a long history of stigmatizing experiences [25] and these social stereotypes, such as being lazy and stupid, appear to be internalized [26]. Experiences of obesity stigmatization are correlated with social isolation, depression and binge eating [27], [28]. Even though body shape and weight significantly change as the result of surgery, the long-term conditioning of self-stigmatization is likely to still have an impact. Reports of “phantom fat” in formerly overweight women show that perception of oneself as obese remains constant regardless of weight loss [28], [29]. Distressing preoccupation with weight also remains unchanged despite attainment of normal weight [30]. About 50% of those who underwent surgery continue to fear weight regain and report dissatisfaction with flabby skin, abdominal flap and pendulous breasts [31]. Reports of decline in quality of life one-year after BS may be due to perceived aesthetic deformity [32]. Teaching BS patients how to expose themselves to previously avoided emotions and thoughts may help in preventing weight regain and improve psychosocial adaption following surgery.
In acceptance and commitment therapy (ACT), a recent development within cognitive behavior therapy, the target of change is emotional avoidance. Experiential avoidance is defined as an unwillingness to remain in contact with negative private events (thoughts, emotions, physical sensations). Engagement in avoidance behaviors, which may be eating or drinking, results in short-term relief from those negative emotions. With time, these strategies lead to a decreased quality of life [33]. ACT based on learning theory aims at establishing psychological flexibility around negative private events so as to enable valued actions and enhance life quality. The main difference between ACT and CBT, is that while CBT strategies strive to change negatively perceived thoughts and feelings, ACT emphasizes acceptance of these private events. With regard to the treatment of obesity, CBT interventions are typically educational, containing specific instructions regarding diet and exercise. ACT interventions are less focused on reducing problem behavior and more focused on increasing valued actions. Oftenly, persons who have been struggling with excess weight will put values actions such as intimate relationships or involvement in valued physical activities on hold, while trying to lose weight. ACT focuses on helping these persons to let go off the weight battle and get back into living a valued life again. Participants learn to be less reactive to conditioned tendencies and more active in valued directions, via interventions that are mainly experiential.
The main processes of ACT are acceptance, mindfulness, defusion and commitment. Acceptance is a skill involving an active embracing of private events (thoughts, feelings and physical sensations) previously avoided. Following surgery, BS patients will be entering many situations and activities previously avoided such as showing oneself in public in a bathing suit, or going to an aerobics class. Acceptance of conditioned feelings of embarrassment or shame is a helpful skill as this person moves forward in valued activities. Mindfulness exercises teach patients to be present and aware of conditioned chains of behavior. As patients learn to observe stimuli, conditioned reactions and consequences, they are better in choosing actions, which are helpful and healthy for them, in the long run. Mindfulness practice, can for example, help patients to become aware that previous conditioned tendencies of excessive checking of body weight lead to more anxiety. In this way, mindfulness practice can help patients to become less reactive to impulses, and deliberately choose actions, which are helpful in the long run. Defusion aims to create a functional approach to thoughts. Fusion with a thought means identifying oneself with a thought. For example, if a person identifies herself with the thought, ‘I am fat and ugly’, then, this thought becomes, in a sense, a true description of reality. Defusion techniques help a person to see the thought ‘I am fat and ugly’ as just a thought, a verbal construction, conditioned from past experiences, rather than the truth. The patient learns to externalize and objectify ‘sticky thoughts’ which has previously led to uncontrolled eating. For example, the thought, “I’m worthless” is written down on paper or played by the therapist with the aim of illustrating what happens to the patient, physically and emotionally, when this thought appears. Seeing “Ím worthless” as a thought rather than a reality, creates more flexibility for valued actions. Committed action a skill used in ACT that utilizes public commitment to enable concrete steps towards valued action. All these processes aim at helping the patient to reconnect to her valued life, which has previously been put on hold pending weight loss. Rather than waiting to first lose weight, then go dancing, have an intimate relationship or take a challenging job, the patient learns to take steps in those valued directions, here and now, together with any private events which arise and act as obstacles. The aim of ACT is to increase conscious valued life quality.
ACT has been shown to be effective for overweight patients who present with body dissatisfaction and eating disordered behaviors. One study showed that overweight women who received an ACT intervention increased physical activity and reduced BMI as compared to a control group [34]. ACT has also been shown to enhance the effects of traditional CBT weight loss programs. One study showed that the addition of an ACT intervention to a traditional weight loss program improved the effects with regards to weight loss and maintenance, blood pressure, weight related stigma, quality of life, and physical activity as compared to those who only received the weight loss program [35]. Another study showed that ACT in combination with the LEARN program [36] for obese women was effective in terms of weight loss and life quality 6 months after the intervention [37].
Acceptance strategies have also been evaluated for persons with body dissatisfaction. In one study, 3 different methods are examined: acceptance, distraction and cognitive dissonance. Acceptance is shown to be most effective in improving appearance satisfaction as compared to a control condition [38]. For the current population of BS patients post surgery, a mindfulness-based intervention resulted in improvement in binge eating, depression, emotion regulation skills and increased motivation to change maladaptive eating behavior [39].
New cost effective methods are being developed for delivering psychological treatment. Internet interventions have proved to be a cost effective treatment option [40], [41].
Cognitive behavior therapy delivered as Internet-based self-help programs has been used successfully in the treatment of psychiatric disorders such as panic disorder, agoraphobia, posttraumatic stress disorder, depression and social phobia [42] as well as in the treatment of health problems [41]. This suggests that ACT, a recent cognitive behavior therapy, would be worth examining further as an Internet-based treatment package.
The aim of the current study is to conduct a randomized controlled trial, comparing the effectiveness of a short-term ACT intervention, delivered through 2 face-to-face sessions combined with an Internet-based treatment, with treatment as usual (TAU), performed by the BS team, for patients who have undergone BS. Effects are measured in terms of disordered eating behavior, body dissatisfaction, quality of life and acceptance for weight related thoughts and feelings.
Section snippets
Setting and participants
The research protocol was approved by the Regional ethical committee at the University of Uppsala, Sweden. Participants were recruited from a local center for minimally invasive surgery. The total population (n = 404) of BS patients who had undergone surgery were offered participation in the study, of which 39 remained after declaration of interest and screening. Exclusion criteria consisted of severe depression (MADRAS-S score 30) and suicidal attempts. Written informed consent was obtained for
Results
Analyses of pre-treatment data confirmed that the two groups were comparable on all outcome measures. Results based on ITT—analyses showed significant interaction effects and medium to large effect sizes on the dependent variables: eating disordered behaviors (EDE-Q total), SBEQ, BSQ, quality of life (WHOQOL-BREF) and acceptance for weight related thoughts and feelings (AAQ-W). Effect comparison of the two treatment conditions with respect to each of the dependent variables, before and after
Discussion
The present study represents a first attempt to apply and adapt ACT, a form of cognitive behavior therapy, exclusively for BS patients. The results show that this short-term, Internet-based ACT intervention, has significant effects on eating disordered behavior, self perceived body dissatisfaction, quality of life and acceptance of previously avoided thoughts and feelings related to weight, as compared to a TAU intervention for post BS patients. Medium and large effects were found in outcome
References (57)
- et al.
Long-term weight-loss maintenance: a meta-analysis of US studies
Am J Clin Nutr
(2001) - et al.
Testing a new cognitive behavioural treatment for obesity: a randomized controlled trial with three-year follow-up
Behav Res Ther
(2010) Psychological aspects of weight maintenance and relapse in obesity
J Psychosom Res
(2002)- et al.
A new cognitive behavioural approach to the treatment of obesity
Behav Res Ther
(2001) - et al.
A review of psychosocial outcomes of surgery for morbid obesity
J Psychosom Res
(2002) - et al.
The role of gastric surgery in the multidisciplinary management of severe obesity
Am J Surg
(1995) - et al.
Food and emotion
Behav Process
(2002) - et al.
Brief, four-session group CBT reduces binge eating behaviors among bariatric surgery candidates
Surg Obes Relat Dis
(2009) - et al.
Body image and psychosocial differences among stable average weight, currently overweight, and formerly overweight women: the role of stigmatizing experiences
Body Image
(2004) - et al.
Body image in obese patients before and after stable weight reduction following bariatric surgery
J Psychosom Res
(1999)