Nov 29, 2023

Improving eating behaviours after surgery: How telephone therapy makes a difference

A selection of food, including green beans, grapefruit, potatoes, celery, and legumes, laid out on a table.
By Ben Gane
Dr. Sanjeev Sockalingam
Dr. Sanjeev Sockalingam

Bariatric surgeries are used to treat patients with health problems related to severe obesity1. They involve making changes to a patient’s digestive system to help them lose weight. These surgeries are used when other obesity treatment options such as behavioural treatments or medications haven't worked.

While these bariatric surgeries are proven and effective, many patients struggle to manage their eating habits after their surgery, putting them at risk of regaining weight and losing the health benefits that surgery provides.

Professional support can help them develop and maintain healthier eating behaviours, but this type of care is expensive and can be difficult to access.

Cognitive Behavioural Therapy (CBT) is a form of psychotherapy with an excellent track record for helping people change harmful eating behaviour patterns. It can also be delivered by telephone or online, making it an effective, accessible form of care.

Dr. Sanjeev Sockalingam and his team set out to test if CBT delivered over the phone, or “tele-CBT”, can help patients manage their eating and stay healthy after bariatric surgery.

In addition to Dr. Sockalingam, Dr. Stephanie Cassin was a co-lead on this study and Dr. Raed Hawa and Dr. Susan Wnuk were co-investigators. All three are faculty members in the University of Toronto Department of Psychiatry.

We spoke to Dr. Sockalingam about their findings.

What are the key features of tele-CBT for bariatric surgery patients?

Patients who participated in our study received seven hour-long sessions of tele-CBT with a therapist. These sessions focused on introducing strategies based on the cognitive behavioural model that the patient could use to develop healthier eating habits and avoid overeating. Participants were expected to complete homework between sessions, such as filling out food records, engaging in enjoyable activities and self-care, and completing worksheets.

What motivated this research?

Metabolic and bariatric surgeries are proven, effective treatments for severe obesity. However, patients may be at risk of regaining weight, and jeopardizing the health benefits of the surgery, if they have symptoms of disordered eating. Disordered eating is a term for a range of irregular eating behaviors that may or may not meet the criteria for a formal diagnosis of a specific eating disorder. Disordered eating may include restrictive eating, compulsive eating, or irregular or inflexible eating patterns.

Our team identified an opportunity to use tele-CBT to support patients experiencing eating difficulties after bariatric surgery. We found that the tele-CBT intervention can help reduce binge eating, emotional eating, depressive symptoms, and anxiety. Tele-CBT was also more effective when it was provided to patients after surgery, rather than before surgery.

What was the most important finding of this study, in your opinion?

Our study found that compared to patients who did not receive tele-CBT, those who did had significantly less depressive and anxiety symptoms as well as lower binge eating and emotional eating symptoms. This difference was seen immediately after the tele-CBT sessions and continued three months after the sessions as well. This lasting effect was observed after seven sessions of CBT.

How does this change treatment in the future?

We can now confidently state that CBT and psychological interventions are important to bariatric surgery aftercare for patients experiencing eating, mood, or anxiety difficulties. With the expansion of virtual mental health care, this study indicates that virtually-delivered CBT can potentially increase access to this treatment for patients who may find it difficult to travel to clinics in person.

Any next steps?

We are about to complete final data collection, examining patients three years after bariatric surgery. We will be able to see whether the tele-CBT sessions are still having an impact three years after surgery.

Additionally, we are planning to study the effectiveness of a guided self-help version of CBT, with online modules and workbooks, as compared to our current tele-CBT model with a therapist by phone. If this version of the treatment leads to similar improvements for patients, it could make this type of treatment even easier to access.

What is the major take-home message for the public?

Tele-CBT is an effective resource to help patients after bariatric surgery who may be struggling with mental health or disordered eating symptoms. We found that one year after bariatric surgery is a good time to offer this intervention, as this is the time when patients may see some challenging pre-surgery behaviours resurface and their weight begins to plateau or even increase slightly. Having tele-CBT as a tool to tackle these challenges can help patients improve their mental health outcomes following surgery and be more successful in caring for their health.

1. Although obesity is defined by body mass index for bariatric surgery eligibility, obesity treatments such as metabolic and bariatric surgery are indicated only for the treatment of obesity as defined by the Canadian Obesity Guidelines, which state that obesity is a chronic and complex disease characterized by abnormal or excessive body fat (adiposity), that impairs health.

ImPACT logo: Psychiatry articles that change treatment

ImPACT Committee includes Krista Lanctôt, Alastair Flint, Meng-Chuan Lai and Simone Vigod.

Efficacy of Telephone-Based Cognitive Behavioral Therapy for Weight Loss, Disordered Eating, and Psychological Distress After Bariatric Surgery: A Randomized Clinical Trial.  Sockalingam S, Leung SE, Ma C, Tomlinson G, Hawa R, Wnuk S, Jackson T, Urbach D, Okrainec A, Brown J, Sandre D, Cassin SE. JAMA Netw Open. 2023 Aug 1;6(8) e2327099.