Adherence to Lifestyle Changes Peaks One Month After Bariatric Surgery, Study Finds

Metabolic and bariatric surgery is a powerful intervention for the treatment of obesity, but it requires significant lifestyle modifications by patients. Now, a new study by Cleveland Clinic researchers shows that patient adherence to post-surgery recommendations peaks one month after the procedure and then steadily declines.

While adherence to lifestyle changes is linked to weight loss, researchers also found that the relationship was no longer statistically significant after controlling for the effects of time, suggesting that time itself might be a key factor in both patient adherence and weight outcomes.

The findings support more proactive, long-term follow-up programs to help patients continue following a healthy lifestyle in the years after surgery, says author Leslie Heinberg, PhD, FASMBS-IH, FTOS, FAED, Vice Chair for Psychology in the Department of Psychiatry and Psychology at Cleveland Clinic.

“People may need some booster visits to help them get back where they were after surgery in terms of following recommendations,” she says.

Adherence declines, but not back to baseline

The research is an ancillary study that grew out of a larger, NIH-funded prospective trial looking at biological and behavioral predictors of outcomes after bariatric surgery. Researchers wanted to determine if patient adherence to recommendations was a good predictor of weight loss and other outcomes over time.

“Patients have to change not just what but how they eat and drink. They have to take vitamins, they have to exercise, avoid certain types of foods, and come to their doctors' appointments,” says Dr. Heinberg. “It’s asking a lot of patients.”

Patients answered questionnaires before surgery and one month, six months, 12, 18, and 24 months after surgery. Researchers compared their responses with changes in the patients’ weight.

They found that patient adherence significantly increased from baseline to one month after surgery and then declined for the next two years.

“It’s very, very hard for people to maintain all these recommendations over two years,” says Dr. Heinberg. “The good news is that average adherence never returns to baseline, although it does go down quite a bit.”

While the decline in adherence was expected, researchers were surprised that there was not a stronger association with weight gain. But Dr. Heinberg notes that adherence has larger clinical implications beyond weight. Patients who don’t follow lifestyle modifications might develop vitamin deficiencies, not consume enough protein or miss out on needed medical visits.

Embedded psychological support

Dr. Heinberg explains that Cleveland Clinic is unique in having health psychologists embedded within its programs, including the Digestive Disease Institute.

“All patients are seen by a bariatric psychologist who really specializes in the care that they need,” she says.

Patients typically see a psychologist before surgery to prepare them for the procedure and work on behavioral changes. The psychologist may also address other issues the patient may have, such as underlying eating disorders. Patients also see their psychologist postoperatively at scheduled visits and have the option of requesting additional appointments in the years after surgery if they need follow-up support.

Beyond addressing any underlying mental or behavioral health concerns, these appointments often involve teaching patients behavior-change skills.

“That can focus on the patient’s triggers for problematic eating, for example, or identifying the barriers that are getting in the way of them adhering to their lifestyle changes, or finding healthy coping mechanisms in the face of stress,” she explains.

Next, researchers plan follow-up studies to better understand individual differences, comorbidities, and demographics that might predict which patients are most at risk of struggling to adhere to lifestyle changes after surgery.

Dr. Heinberg presented her research at the upcoming meeting of the American Society for Metabolic and Bariatric Surgery.