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Original Article

Journal of Addictions Nursing & Volume 29 & Number 1, 32Y42 & Copyright B 2018 International Nurses Society on Addictions

Bariatric Outcomes: Self-Management


for Sustained Surgical Success
A Multicomponent Treatment for Dysregulated Overeating in Bariatric Surgery Patients
Laura M. Anderson, PhD m Thomas P. Chacko, MA

Abstract could be implemented by nurses and other health


Binge eating disorder, food addiction, and dysregulated professionals with minimal support.
overeating are common among people with severe obesity Keywords: Bariatric Surgery, Binge Eating Disorder,
and prevalent among bariatric surgery populations. These Dialectical Behavior Therapy, Food Addiction, Mobile
problematic eating habits share commonalities with other Health, Self-Management
addictions. Effective, holistic self-management is needed
to promote long-term weight loss and psychosocial
adjustment among patients who are severely obese DYSREGULATED OVEREATING: BINGE
who undergo surgery, especially those with clinically EATING DISORDER, FOOD ADDICTION,
remarkable levels of binge eating, food addiction, or AND OBESITY
dysregulated overeating.This article aims to briefly review Chronic overeating is a heterogeneous problem, sometimes char-
binge eating disorder, food addiction, and obesityVas acterized by unintended or impulsive overindulgenceVoften
well as issues surrounding surgery for individuals who are likened to other addictive behaviors (Carlier, Marshe,
severely obeseVand introduce the Bariatric Outcomes: Cmorejova, Davis, & M[ller, 2015). Many patients who are
Self-management for Sustained Surgical Success obese show severely dysregulated overeating, with 15% to
(BOSSSS) program. The BOSSSS program is holistic, one quarter of bariatric surgery patients meeting the Diagnostic
skill based, and designed to promote weight loss, prevent and Statistical Manual of Mental Disorders, Fifth Edition
weight regain, and improve well-being in patients with (DSM-5; American Psychiatric Association, 2013) criteria for
severe obesity with a history of bariatric surgery. Preliminary binge eating disorder (BED): Those diagnosed with BED and
survey data suggest that bariatric surgery patients report a impulsive overeating are also more likely to struggle with post-
lack of skill-based emotional and behavioral support operative weight loss (Chao et al., 2016; Dawes et al., 2016).
designed to help them over the long term. The BOSSSS Consequently, BED, food addiction (FA), and obesityV
program is rooted in self-determination theory, integrating along with relevant psychological comorbiditiesVhave
mobile health technology across program components. attracted theoretical and empirical attention.
Self-determination theory-based interventions are personalized Regardless of how we label the various forms of dysregulated
and encourage autonomy, competence, and social support eating above, a public health crisis continues to demand our
among participating patients and providers. The behavioral attention. In the United States, obesity remains one of the
self-regulation training within BOSSSS is energy balance three leading causes of preventable illness and death (Danaei
self-monitoring and titration. Emotional self-regulation is et al., 2009). Incidences of obesity and a myriad of coexisting
addressed via a specialized version of dialectical behavior physical and psychosocial conditions (Fontaine & Barofsky,
skills therapy, emphasizing promotion of coping skills and use 2001; Guh et al., 2009) have steadily risen in the United States
of adaptive, healthy substances in immediate environments. (Ogden, Carroll, Kit, & Flegal, 2012), resulting in enormous
The BOSSSS program has been well received by patients and public health priority (Department of Health and Human
Services, 2010) and economic challenge (Bour, 2015; Finkelstein,
Trogdon, Cohen, & Dietz, 2009; Karmali et al., 2013). Of partic-
Laura M. Anderson, PhD, and Thomas P. Chacko, MA, School of
Nursing, University at Buffalo, State University of New York. ular concern, 17% of U.S. children and over a third of adults are
The authors report no conflicts of interest. The authors alone are re- obese (Ogden, Carroll, Kit, & Flegal, 2014). Evidence suggests
sponsible for the content and writing of the article. that dysregulated overeating associated with BED and FA is
Correspondence related to content to: Laura M. Anderson, PhD, School of a common problem among individuals who are obese and
Nursing, University at Buffalo South Campus, Wende 205, 3435 Main severely obese (Ivezaj, White, & Grilo, 2016; Jones, Cleator, &
Street, Buffalo, NY 14214.
Yorke, 2016).
E-mail: pulse@buffalo.edu It is especially important that we, as nurses, are mindful of
DOI: 10.1097/JAN.0000000000000210 dysregulated overeating (i.e., the impulsive and out-of-control

32 www.journalofaddictionsnursing.com January/March 2018

Copyright © 2018 International Nurses Society on Addictions. Unauthorized reproduction of this article is prohibited.
overeating associated with both BED and FA) and related is- criteria of other addictions (Meule & Gearhardt, 2014). For exam-
sues when treating patients who are severely obese and/or ple, food craving is found to be a critical component in
patients who have had bariatric surgery. Although there is de- dysregulated or addictive eating behaviors and eating disorders
bate in the literature about the existence of FA and the degree (Joyner, Gearhardt, & White, 2015). In addition, hyperpalatable
of overlap with BED (Ivezaj et al., 2016), there is clear overlap, foods activate and amplify neural reward mechanisms
and as nurses and holistic health practitioners, we are ulti- resulting in tolerance, showing biological and behavioral phe-
mately most concerned with effective interventions to treat nomena comparable with addictive substances (Gearhardt,
dysregulated overeating associated with obesity and mental Davis, Kuschner, & Brownell, 2011; Smith & Robbins, 2013).
health difficulties. FA, likewise, is found to be directly associated with psycho-
This tripartite article briefly reviews existing evidence on pathology (Gearhardt et al., 2012; Meule & Gearhardt, 2014;
the aforementioned associations, examines obesity interven- Parylak, Koob, & Zorrilla, 2011), in addition to being medi-
tions and postoperative bariatric outcomes, and describes a ated by BED (Imperatori et al., 2014).
novel self-management program to help promote weight loss Germane to this context is the role of affect-driven behaviors
and sustained positive outcomes in patients who are obese such as emotional or stress eating: These may be conceptualized
with a bariatric surgery history. The Bariatric Outcomes: as a form of emotional regulation influencing food intake
Self-management for Sustained Surgical Success (BOSSSS) (Blechert, Goltsche, Herbert, & Wilhelm, 2014; Singh, 2014).
program is an individualized, evidence-based self-manage- Importantly, psychological comorbidities in overeating and obe-
ment intervention that combines specialized cognitive sity are at least as significant as coexisting physiological
behavior skills therapy (e.g., dialectical behavior skills therapy problems. We cannot overlook psychological factors. For in-
[DBsT]) and behavioral therapy while harnessing the conve- stance, obesity is associated with risk for depression and diabetes
nience and accessibility of modern technology. (Labad et al., 2010; Mannan, Mamun, Doi, & Clavarino, 2016).
It is not uncommon for practitioners to focus predomi-
Commonalities Between Food and Other nantly on physiological comorbidities, especially given
Addictive Substances imminent mortality risk. However, a failure to attend to be-
The inclusion of BED as a separate category in DSM-5 represents havioral and emotional skill deficits may result in overlooking
a concerted effort to understand the etiology, symptomatology, difficulties like BED and FAVproblems that directly contrib-
and distress associated with BED along with other eating disor- ute to escalating body weight. These behavioralYemotional
ders. Notwithstanding, the extant body of literature on BED is difficulties can be targeted readily in proactive interventions
scant to explicate the dysregulation within BED in terms of designed to reduce behaviors and insufficient coping strate-
frequency and quantity of food ingestion and any overlap gies that contributed to weight and health problem(s).
with FA (Ivezaj et al., 2016). Some have explained dysregulated
and nonnormative eating behaviors in BED by drawing com- Relationship Between BED, FA, and
parisons with substance addictions. Indeed, there is evidence to Obesity
support overlap between BED and FA (e.g., Cassin & von Although the inconclusive relationship between BED and
Ranson, 2007; Gearhardt, Corbin, & Brownell, 2009). For ex- FA (Schulte, Grilo, & Gearhardt, 2016) poses conceptualY
ample, results of a recent study of adults with overweight or methodological hindrances in research and clinical inter-
obesity revealed that 26.7% (n = 134) of the participants met vention, there is clear psychological distress and social
criteria for FA (i.e., based on the Yale Food Addiction Scale), dysfunction associated with BED or FA. Moreover, regardless
12% (n = 60) met criteria for BED, and 1.7% of those with of the debated status of FA, it is clinical utility that ultimately
BED (n = 37) had co-occurring FA. This complex overlap justifies diagnostic and nosological systems (Pai, Vella, &
between BED and FA has been noted in several other studies Richardson, 2014; Phelps, Angst, Katzow, & Sadler, 2008).
(e.g., Gearhardt et al., 2012; Gearhardt, White, Masheb, & Therefore, given recent emphases on precision and individu-
Grilo, 2013). alized interventions, FA as a separate diagnostic category may
FA is most often described as consuming large portions of offer clinical utility for those who are obese. An additional
food without being able to reduce the amountVeven when the challenge in justifying a unique diagnostic category: Unlike
behavior is accompanied by negative consequences. In addi- other substances of addiction (i.e., those not essential for
tion, FA is associated with biochemical reward pathways survival), food ingestionVincluding palatability-induced
observed in other addictions, including tolerance (i.e., one hyperphagiaVhas social and legal legitimacy. This may
needs more to feel satisfied) and withdrawal, especially with mask addiction potential and reduce concerns about social
foods that are high in fat, sugar, and/or salt (Dimitrijevi(, functioning and individual distress.
Popovi(, Sabljak, wkodric-Trifunovi(, & Dimitrijevi(, 2015;
Fortuna, 2010; Pursey Stanwell, Gearhardt, Collins, & Burrows, BELLING THE CAT: MANAGING SEVERE
2014; Santos, Cadieux, & Ward, 2018). Although FA is not included OBESITY AND POSTSURGICAL WEIGHT
in DSM-5/ICD-10 (International Classification of Diseases; REGAIN
World Health Organization, 1992) as a disorder, an emerging One of the most effective clinical management tools for severe
body of literature documents its similarities with diagnostic obesity (BMI Q 40) or obesity (BMI Q 35) is bariatric surgery

Journal of Addictions Nursing www.journalofaddictionsnursing.com 33

Copyright © 2018 International Nurses Society on Addictions. Unauthorized reproduction of this article is prohibited.
(Bour, 2015; Courcoulas et al., 2013, 2014). Given the chronic being most susceptible to weight regain (Magro et al., 2008).
negative (health and psychosocial) outcomes of dysregulated Elevated weight regain has also been documented longitudi-
overeating and the complex interplay of BED, FA, and obesity, nally (Courcoulas et al., 2015).
more individuals are selecting invasive (i.e., relative to behav- As noted, perioperative bariatric patients show elevated
ioral modification alone) surgical weight reduction, including psychiatric problems, including substance use (Bour, 2015;
Roux-en-Y gastric bypass and vertical sleeve gastrectomy Kalarchian et al., 2016; Kofman et al., 2010; Odom et al., 2010).
(Bour, 2015; Jensen et al., 2014; Kofman, Lent, & Swencionis, This may engender recidivism or weight regain (Dykstra,
2010). Surgical interventions have become the most potent Switzer, Sherman, Karmali, & Birch, 2014; Magro et al.,
medical solutions for severe obesity (Jensen et al., 2014; Kofman 2008). Three factors have been noted as primary contributors
et al., 2010). However, surgeryVfor those who may struggle to weight regain, namely, anatomic, behavioral/psychological,
with dysregulated overeatingVhas inherent limitations with and hormonal/metabolic issues (Dykstra et al., 2014). There
regard to long-term, sustained weight loss. has also been evidence to support the idea that postsurgical be-
First, surgical clinical management of obesity, although ef- havioral and emotional factors are the most salient, changeable
fective and often supported by a multidisciplinary treatment contributors to weight regain (Karmali et al., 2013; Odom
team, generally fails to address dysregulated overeating. In a et al., 2010) Surely, any patients struggling with FA and/or
study of more than 100 postoperative bariatric surgery pa- BED would be particularly vulnerable to recidivism.
tients conducted by our team, 100% of them reported Unfortunately, the Longitudinal Assessment of Bariatric
wanting more skill-based support for (a) coping with feelings Surgery Consortium and others have also shown thatVdespite
without food and (b) regulating emotions, stress, and nega- short-term alleviation of emotionalYbehavioral disordersV
tive affect. Most (70%) of the patients indicated that the depression, disordered eating, quality of life, and alcohol use
psychosocial support they received pertained to coping with deteriorate in improvement, worsening after the first postop-
the immediate surgical environment and the most imminent erative year (Kalarchian et al., 2016; Mitchell et al., 2014, 2016;
short-term physiological changes. In this particular cohort of Sheets et al., 2015). Of significance, postoperative elevated risk
adults, more than 80% reported a daily eating situation for new onset (Li & Wu, 2016; Widemann, Saules, & Ivezaj,
(i.e., before and after surgery) wherein they felt that behavioral 2013) or relapse (Li & Wu, 2016) in substance abuse or addic-
or emotional factorsVversus hungerVdrove eating behaviors tion transfer (from food to substances; Ivezaj et al., 2016; Li
(Salinas & Anderson, 2015). Ultimately, this preliminary work & Wu, 2016; Wiedemann, Saules, & Ivezaj, 2013) may also
revealed that bariatric surgery treatment protocols may benefit impede optimal long-term outcomes. It should be noted that
greatly from specialized, skill-based behavioral and emotional the literature has been inconsistent with regard to addiction
interventions. transfer as a phenomenon: That is, even with minimal to no
A second concern for patients with subclinical or clinical binge eating, sometimes, substance abuse and other addictive
BED/FA symptoms comes from variable postoperative out- behaviors increase postsurgically (Mitchell et al., 2016).
comes for existing bariatric surgical procedures. Freire, Although mechanisms remain unclear, emerging evidence
Borges, Alvarez-Leite, and Toulson Davisson Correia (2012) suggests that postoperative neurobiological changes in brain
studied 100 subjects with obesity who underwent Roux-en-Y signaling and functional connectivity changes in brain regions
gastric bypass and discovered elevated weight regain, with involved in controlling reward, impulsivity, sensory perception,
14.7% reporting significant weight gain within the 2 ensuing memory, and anticipation may be associated with these problem-
years and 69.7% regaining substantial weight between 2 atic and dysregulated addictive behaviors (Blum, Thanos, & Gold,
and 5 years. Indeed, weight regain in patients who have had 2014; Thanos et al., 2013, 2015). In addition, postsurgery alcohol
bariatric surgery is a serious public health concern. It may consumption is associated with a quicker, lower intoxication
trigger the reemergence of multiple obesity-related comor- threshold (Buffington, 2007; Ertelt et al., 2008; Klockhoff,
bidities and health care costs (Karmali et al., 2013). Nearly N.slund, & Jones, 2002) and longer duration required to restore
40% of patients who underwent bariatric surgery experience sobriety (Woodard, Downey, Hernandez-Boussard, & Morton,
excessive weight regain (i.e., 25%+ of total lost weight; Cooper, 2011). Anatomical changes, brainYgut signaling, neurobio-
Simmons, Webb, Burns, & Kushner, 2015), especially in the logical differences, and even social changes (i.e., friend group
second year and beyond, as indicated by the Longitudinal As- or social setting differences) after bariatric surgery likely contrib-
sessment of Bariatric Surgery Consortium (Courcoulas et al., ute to the phenomenon being described as addiction transfer.
2013, 2014). Ultimately, the multimodal risk factors described may result
Notably, Odom and colleagues (2010) found that subjects in a ‘‘perfect storm’’ for those who are genetically or physiolog-
with low compliance with postoperative consultations ically at risk for addiction. It is important to note, of course,
showed 4.6 times greater likelihood of weight regain than that this is a minority of bariatric surgery patients; however,
those with regular follow-up care. Similar trends in weight those patients with preexisting BED/FA symptoms may be
regain (OR = 6.4) were reported (1 year postoperatively) in overrepresented among those who struggle with postopera-
subjects who had a history of bariatric surgery and comorbid tive substance use.
psychiatric conditions (Rutledge, Groesz, & Savu, 2011), with Finally, presurgical and postsurgical substance use was as-
those in the most severe preoperative obesity classifications sociated with poor weight loss outcomes 1Y2 years after

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surgery (Adams, Gabriele, Baillie, & Dubbert, 2012). Thus, BOSSSS is a self-management approach based on the
weight recidivism and comorbid conditions, including prob- above understanding that behavioral and emotional factors
lematic substance use, present public health concerns and are critical contributors to weight regain among patients
enormous health care costs (Karmali et al., 2013). This is es- who are severely obese and have had bariatric surgeryV
pecially relevant within a long-term clinical management especially those struggling with addictive overeating,
protocol for patients who are severely obese who present with binge eating, or dysregulated overeating (Dykstra et al.,
subclinical or clinical BED, FA, and dysregulated overeating. 2014; Karmali et al., 2013; Odom et al., 2010; Sheets et al.,
Overall, although several surgical and behavioral clinical 2015). Indeed, failure in achieving desired postbariatric
intervention protocols have had partial or limited success outcomes may be attributed largely to deficits in psychological
managing obesity (Jensen et al., 2014), surgical options have resources and skills (Magro et al., 2008). As such, sustaining
been the most powerful for patients who are severely obese. optimal weight loss postsurgically is contingent on effective
Again, however, long-term benefits have been questioned, emotional and behavioral self-regulation (Courcoulas et al.,
and skill-based behavioralYemotional interventions have 2015; Kalarchian et al., 2016; Kalarchian & Marcus, 2015;
been short term and limited, at best. Given the multifactorial Sheets et al., 2015).
nature of weight regain (Schag et al., 2016) and the heteroge- BOSSSS is theoretically novel given its adherence to self-
neous needs of bariatric patients struggling with dysregulated determination theory (SDT), holistic health, and incorpora-
overeating (Himes et al., 2015), postoperative therapeutic tion of mobile or mHealth self-monitoring and data sharing.
interventions must be multicomponent and customized. Participants are empowered to design and tailor elements of
Extant postbariatric psychological interventions have been energy balance (dietary and physical activity) and emotional
heterogeneous and have included acceptance-based therapy self-regulatory interventions. Participants receive a template
(Bradley et al., 2016), DBsT (Himes et al., 2015), group-based set of daily rules they must follow to meet BOSSSS goals, but
approaches (Bradley et al., 2016; Himes et al., 2015), and cog- they have free will in determining how exactly they realize
nitive behavioral interventions (Kalarchian & Marcus, 2015; daily goals. The program was designed as a 12-week, small-
Rudolph & Hilbert, 2013). However, there is increasing rec- group program, with Weeks 1Y2 focusing on introducing
ognition that holistic self-management skills are vital (Jones the program and participants and establishing baseline eating
et al., 2016) for sustaining positive surgery outcomes among and activity habits. Weeks 3Y12 incorporate behavioral self-
patients who are severely obese with histories of dysregulated managementVor energy balance self-monitoring and titration
or addictive overeating. Therefore, the third part of this dis- (EBST)Vwith the expectation that patients will continue some
cussion will introduce a novel approach designed to promote form of EBST for life. Weeks 7Y12 then integrate specialized
long-term, healthy self-management of feelings, behaviors, emotional/behavioral coping skills through dialectical behav-
and weight among those who were or are obese and struggling ioral skills therapy for tolerating negative affect, stress, and
with FA, BED, or subclinical dysregulated overeating. The avoiding substances.
BOSSSS program, described below, fills a gap in the existing SDToffers an ideal framework for personalizing behavioralY
treatment literature because of its holistic self-management emotional weight control. The combination of novel and inno-
approach. vative elements in BOSSSS can provide substantive information
on the critical issue of long-term weight loss and maintenance in
BOSSSS patients who have had bariatric surgery. Finally, the BOSSSS
In reviewing the evidence of postsurgical weight regain, espe- program is currently being modified and digitized to utilize
cially among those with FA or BED symptoms, many of the telehealth technologies and reach more patients in rural and dis-
most poignant factors contributing to recidivism are associ- tal areas nationwide. Before introducing additional details of the
ated with emotional dysregulation and could be addressed program, it is critical to address the buy-in insurers inherent
with skill-based cognitive behavior therapies such as DBsT within BOSSSS.
(Linehan, 1993). DBsT with a special emphasis on using
healthy substances in the environment to cope constitutes ‘‘Buy-In Insurance:’’ SDT and Mobile
the emotional self-regulation training within BOSSSS. Fur- Technologies
thermore, it has been consistently documented that patients It is well documented that buy-in is critical in human health
who engage in sustained self-monitoring are much less likely behavior outcomes (Schroeder, 2007). As such, two guiding
to regain weight after nonsurgical and surgical weight loss in- buy-in insurers within BOSSSS include SDTand mobile tech-
terventions (Bour, 2015; Odom et al., 2010; Wing et al., 2008). nology integration (see Figure 1 for illustration).
Consequently, skill-based behavior therapy to train and rein-
force lifelong weight-specific self-monitoring is the second Self-Determination Theory
critical element of the BOSSSS approach. Behaviorally, BOSSSS SDT is a key, missing ingredient in postbariatric interven-
teaches patients specific skills to manage and navigate (a) tions. SDT emphasizes the processes of initiating and
proximal factors and controllable immediate environments, maintaining health behaviors, arguing that the human
(b) obesogenic or fattening environments outside immediate needs of autonomy, competence, and relatedness are criti-
control, and (c) thoughts, behaviors, and feelings. cal to motivation and the ultimate goal of internalizing and

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Copyright © 2018 International Nurses Society on Addictions. Unauthorized reproduction of this article is prohibited.
integrating health behaviors (Ryan & Deci, 2000; Ryan, Patrick, per se; instead, patients tailor elements of the program to
Deci, & Williams, 2008). That is, when individuals feel that maximize buy-in and satisfaction.
they have free will and control over decision-making (auton-
omy), feel confident and able to change (competence), and Competence
feel connected to and supported by a health care professional Competence involves a perceived belief in one’s mastery of
or therapist (relatedness), they will be intrinsically motivated the skills for change. Accompanied by autonomy, competence
and committed to lifestyle changes. SDT can inform self- and confidence operate reciprocally toward achieving a desired
management approaches, rousing individuals to control outcome (Patrick & Williams, 2012; Ryan et al., 2008). In the
and manage health behaviors with support from a caring pro- postbariatric context, the sense of loss of control (Jones et al.,
fessional. Therefore, SDT offers a clinical framework for 2016) and impulsivity (Schag et al., 2016) may be accompanied
patients who have had bariatric surgery and clinicians alike. by perceived insufficient competence to address barriers to
Below, we introduce the three psychological needs of SDT in change. For instance, it has been suggested that a significant
the postsurgical context. number of individuals undergo revisional bariatric surgery,
arguably because of lack of competent regulation of food
Autonomy cravings (Ogden, Avenell, & Ellis, 2011). On the other hand,
Autonomy deals with freedom of choice and being agentic ac- perceived mastery of relevant health behavior skills is posi-
tors on our immediate health environments. Medication tively associated with better health outcomes (Patrick &
compliance and other health-related behaviors may not be in- Williams, 2012).
trinsically enjoyable activities, hence not often personally
endorsed (Ryan et al., 2008). For instance, postbariatric Relatedness
weight loss nadir at 12Y18 months is seen to rebound after Desire for shared experience is central to relatedness. It is the
surgical effects wane, and patients struggle to maintain the psychological need to feel close to significant others (Patrick
weight loss, often unsuccessfully (Jones et al., 2016). In other & Williams, 2012). In the clinical context, relatedness often
words, postsurgery benefits are hard to sustain in the absence suggests that change is supported by the relationship between
of autonomous motivation even when controlled motivation practitioner and patients (Ryan et al., 2008). In the BOSSSS
is high (Ryan et al., 2008). BOSSSS promotes autonomy by program, clinicians have regular contact with patients,
offering a menu of choices in both emotional and behavioral supported by mobile technologies noted below, and patients
self-management domains. There is no prescribed program are encouraged to join online support communities within
the mHealth environment.
Ultimately recognizing the importance of the aforemen-
tioned psychological needs, SDT helped guide BOSSSS
intervention development to ensure buy-in and success with
preventing weight recidivism. In fact, recidivism, within an
SDT framework, would be strongly associated with deficits in
one’s autonomy, competence, and relatedness/social support.
Therefore, SDT can inform self-management approaches
toward optimal health outcomes.

Mobile Technologies
Alongside SDT, we propose the inclusion of technological inte-
gration in the form of mobile health or mHealth technologies.
Given that technology is accessible, portable, interactive, and in-
dividualized (Barello et al., 2016) and that nearly 70% of the U.S.
population owns a smartphone (Pew Research Center, 2015),
utilizing mHealth for health benefits is viable and valuable
(Mundi, Lorentz, Grothe, Kellogg, & Collazo-Clavell, 2015;
Rogers et al., 2016; Stevens, Jackson, Howes, & Morgan,
2014). Promisingly, two recent modules (Bond & Thomas,
2015; Mundi et al., 2015) that used smartphone-based inter-
ventions in the preoperative and postoperative bariatric
stages were found to be effective in promoting sustained
Figure 1. BOSSSS: working concept model. BOSSS = Bariatric and maximal weight loss. Although there are a few reviews
Outcomes: Self-management for Sustained Surgical Success; of (a) smartphone applications (apps) for weight loss patients
SDT = self-determination theory; TI = tech integration; EBST = energy (e.g., Connor, Brady, Tulloh, & de Beaux, 2013; Stevens et al.,
balance self-monitoring and titration; DBsT = dialectical behavior 2014) and (b) the importance of technology in behavioral as-
skills therapy. sessment and intervention with bariatric surgery patients

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(Bond & Thomas, 2015), there are no existing studies that self-care hygiene habit (i.e., brushing teeth or showering).
have utilized mHealth alongside SDT in a skill-based and They are required to step on the scale every day, and it is
holistic (i.e., weight loss and self-regulation of feelings and be- recommended that they do so after first morning bladder
haviors) postoperative bariatric program. mHealth and SDT void, before eating, and without clothing. Patients are, like-
complement one another, as there are apps and functions that wise, taught a daily mantra (‘‘Data, not self-worth’’) to help
help patients promote autonomy, competence, and, especially, reframe any emotional response to the number on the scale.
relatedness. Patients also must be coached and supported as they learn
about natural variations in daily body weight (i.e., based on
Behavioral Self-Regulation: EBST hormones, water retention, food consumed, intestinal waste).
As noted in Figure 1, the behavioral self-regulation component Preliminary evidence suggests that patients habituate emo-
of BOSSSS is a comprehensive energy balance (energy or calo- tionally, ultimately ‘‘getting used to’’ daily self-weighing
ries in relative to energy or calories out) self-monitoring (Anderson & Kalarchian, 2017).
approach. Titration is included because patients are required Finally, patients are required to use the same mobile health
to track their weekly average calories and weight, routinely, app for EBST/behavioral self-monitoring. Fatsecret calorie
and make adjustments based on personal data trend lines. counter app was selected as it has a comparable database with
The process is scaffolded such that patients receive consider- other similar apps, works well across platforms, has a large
ably more support from the therapist or interventionist online social support community, and, most importantly,
during the first 2Y4 weeks of the program (relative to Weeks has functionality that automatically sends all user data to a
5Y12 of active intervention). selected health professional, complete with two-way messag-
ing functionality, on a daily basis. Weekly summary data are
Development of BOSSSS Behavioral also provided to both the user and the health professional.
Self-Regulation Component, per Fatsecret is especially compatible with SDT, as there are many
Preliminary Evidence: EBSM Y EBST social support options within the online community and the
Energy balance self-management (EBSM) was piloted with a connectedness with the health provider is daily and regular.
group of low-income parents (n = 38) who had regained lost Health providers receive email notifications anytime there
weight (Anderson, Symoniak, & Epstein, 2014). Although is a message from a patient, and daily summary food diaries
participants lost weight with EBSM, they reported (a) contin- for all patients come in one email to the health provider’s
ued distress due to emotional eating and a lack of coping skills inbox. Any health provider can enroll, and registration is
and (b) some dissatisfaction with a program that lacked free for patients and providers. Figure 3 is a sample snapshot
personalization. As such, the concept of EBSM was updated of a daily email received by a Fatsecret health professional
to ‘‘energy balance self-management and titration’’ (as well (i.e., summary of all patients at top followed by all food
as the integration of emotional self-regulation via DBsT, diaries).
noted below).
Energy balance self-management and titration does not re- Emotional Self-Regulation: Tailored DBsT
strict any food group, instead focusing on a daily ‘‘energy-in’’ The emotional self-regulation component of BOSSSS is
budget (e.g., daily calorie goal) and personalized physical ac- addressed using a modified version of DBsT. The four key
tivity or ‘‘energy-out’’ mindfulness goal. Energy out is more skill areas in DBsT are mindfulness, emotional regulation,
flexible due to (a) individual variability in energy expenditure distress tolerance, and interpersonal effectiveness. The
(MacLean et al., 2015) and (b) evidence suggesting that indi- aforementioned skill areas have special applicability to
viduals who are severely obese tend to avoid and/or dislike populations struggling with emotions or substance/food
exercise (Ekkekakis, Lind, & Vazou, 2010; Ekkekakis, Vazou, misuse or abuse.
Bixby, & Georgiadis, 2016). Participants were able to choose As a licensed psychologist with specialized training in
any wearable physical activity device suiting their interests, DBsT, the primary author has utilized DBsT since 2007.
activity, and personal style. No specific minimum physical ac- Within BOSSSS, DBsT is partially focused on developing
tivity was required; however, participants were encouraged to skills that do not involve calorie-dense food or substances.
increase physical activity in small ways and measure it on their Pleasurable, calorie-free beverages (i.e., flavored sparkling
selected device. There are specific daily rules/requirements for water with a fresh citrus wedge), specialized hobbies (i.e.,
monitoring energy in, energy out, and accountability/ titration adult coloring or crafting), and individualized pleasant ac-
(see Figure 2). tivities that integrate multiple sensory modalities are all
Furthermore, as noted, although EBSM was originally promoted as alternative sources of reinforcement (i.e., vs.
taught as an important daily skill, there was no focus on a food or alcohol). These skills promoting alternative sources
daily feedback loop or personalized titration. EBST incorpo- of reinforcement are unique to BOSSSS and are, according to
rates a feedback loop and behavioral adjustment/titration patient reports, one of the most effective program components.
based on self-weighing data, analysis of mobile health data, Indeed, motivational and executive function processes impli-
and feedback from the app and therapist. Patients are taught cated in the development of drug addiction are often targeted
to conceptualize self-weighing similarly to any other daily via impulse control (i.e., within DBsT) and reinforcement

Journal of Addictions Nursing www.journalofaddictionsnursing.com 37

Copyright © 2018 International Nurses Society on Addictions. Unauthorized reproduction of this article is prohibited.
Figure 2. Energy balance self-monitoring and titration within BOSSSS.

alternatives due to reinforcement pathology observed in the specific one or two skills within the domain that resonate
addictive behaviors. A full description of reinforcement pa- most with them.
thology and obesity is available elsewhere (Carr, Daniel,
Lin, & Epstein, 2011). Self-Management: The Key to Long-Term
Clinical observations and published evidence suggest that Postoperative Success
patients who have had bariatric surgery are responsive to Self-management is an active partnership with health providers
DBsT (Himes et al., 2015). In addition, preliminary data from (de Silva, 2011) and requires collaborative, proactive problem
the ‘‘Characteristics of Obese Patients Evaluated for Surgery’’ solving. In addition, the National Health Service identifies self-
studyVa survey of 68 patients who have had bariatric management as a key to better health outcomes (NHS, 2017).
surgeryVrevealed that most of the patients reported wanting Patients who have had bariatric surgery are expected to navi-
specific skills and tools for coping with feelings and changing gate through substantial changes including eating behaviors,
maladaptive behaviors postoperatively. This was an aspect of food composition, nutrition supplements, psychological
treatment and aftercare that 90%Y100% of patients deemed issues, and physical activity (Rudolph & Hilbert, 2013).
lacking in two preliminary studies (Detschner, Lelito, & However, having generally engaged rather passively with the
Anderson, 2014; Salinas & Anderson, 2015). bariatric surgery process, these patients are often unprepared
As noted, DBsT includes mindfulness, distress tolerance, to initiate active and lifelong self-management of postbariatric
emotional regulation, and interpersonal effectiveness adjustments (Jones et al., 2016). Therefore, the American
(Linehan, 1993). One skill area is taught weekly for each of Society for Metabolic and Bariatric Surgery notes that mental
4 weeks, with an introduction to DBsT conducted in the first health professionals are key in helping patients adjust to life
week (Weeks 7Y11 of intervention). As per SDT (Ryan et al., after surgery (Mechanick et al., 2009).
2008) and because patients who have had bariatric surgery Weight-specific behavioral self-regulation aims to mitigate
show variable levels of emotional dysregulation, it makes factors contributing to postoperative weight gain such as loss
sense to tailor DBsT to maximize the likelihood of use and of control, impulsivity, and lack of compliance (Bocchieri,
long-term adoption. As an example, within DBsT skills of Meana, & Fisher, 2002; Jones et al., 2016; Meany, Concei0,o,
the four domains, patients must follow the template skill & Mitchell, 2014; Schag et al., 2016). In particular, patients
‘‘domain’’ of the week; however, they are permitted to select who have had bariatric surgery have been noted to be less

38 www.journalofaddictionsnursing.com January/March 2018

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Figure 3. Sample health professional email summary: Fatsecret professional.

compliant with follow-up clinics when they experienced 2017). Future studies will continue to rigorously evaluate
weight regain (Jones et al., 2016). Furthermore, postbariatric the feasibility and effectiveness of the existing program as well
weight regain exposed these patients to elevated social scrutiny as telehealth and online versions of the program. Finally, we
and stigma (Brewis, 2014), necessitating additional skills for aim to adapt BOSSSS such that it is introduced at the patient’s
behavioral and emotional self-regulation. Moreover, a signifi- first encounter at a bariatric clinic and continued well after
cant number of these people have been observed to continually surgery. BOSSSS meets patients where they are, allowing for
use food as a coping mechanism for regulating emotions after customized evidence-based interventions, maximizing the
the bariatric surgery (Ogden et al., 2011). Thus, BOSSSS pro- likelihood of long-term adoption, weight loss, and enhanced
vides an evidence-based method to directly meet needs and well-being.
teach lifelong self-regulatory skills to patients who may be
struggling after surgery. Acknowledgments: This research was supported, in part,
by initiation funds provided by the University at Buffalo
CONCLUSION School of Nursing. Furthermore, Mr. Lenny Moses, CEO of
Although bariatric surgery is among the most potent, effec- FatSecret, has been supportive throughout all phases of inter-
tive treatments for severe obesity, patients with FA, BED, or vention development, especially with regard to mHealth
other forms of dysregulated overeating are at an increased risk integration. Finally, the primary author wishes to extend
for weight regain, long-term psychological difficulties, and her sincere gratitude to Dr. Melissa Kalarchian of Duquesne
potential substance misuse. BOSSSSVwith conceptual un- University School of Nursing for her thoughtful, generous
derpinnings in SDT (Ryan & Deci, 2000), skill-based mentoring.
cognitive behavioral therapies, and reinforcement pathology
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