OBES SURG
DOI 10.1007/s11695-016-2337-3
ORIGINAL CONTRIBUTIONS
Project HELP: a Remotely Delivered Behavioral
Intervention for Weight Regain after Bariatric Surgery
Lauren E. Bradley 1 & Evan M. Forman 2 & Stephanie G. Kerrigan 2 &
Stephanie P. Goldstein 2 & Meghan L. Butryn 2 & J. Graham Thomas 3 &
James D. Herbert 2 & David B. Sarwer 4
# Springer Science+Business Media New York 2016
Abstract
Background Weight regain following bariatric surgery is
common and potentially compromises the health benefits ini-
tially attained after surgery. Poor compliance to dietary and
physical activity prescriptions is believed to be largely respon-
sible for weight regain. Patients may benefit from developing
specialized psychological skills necessary to engage in posi-
tive health behaviors over the long term. Unfortunately, pa-
tients often face challenges to physically returning to the bar-
iatric surgery program for support in developing and maintain-
ing these behaviors. Remotely delivered interventions, in con-
trast, can be conveniently delivered to the patient and have
been found efficacious for a number of health problems, in-
cluding obesity. To date, they have received little attention
with bariatric surgery patients. The study aimed to evaluate a
newly developed, remote acceptance-based behavioral inter-
vention for postoperative weight regain.
Methods Patients at least 1.5 years out from surgery who ex-
perienced postoperative weight regain were recruited to re-
* Lauren E. Bradley
lauren_e_bradley@rush.edu
Evan M. Forman
evan.forman@drexel.edu
Stephanie G. Kerrigan
sgk36@drexel.edu
Stephanie P. Goldstein
spg38@drexel.edu
Meghan L. Butryn
mlb34@drexel.edu
J. Graham Thomas
John_G_Thomas@brown.edu
ceive the 10-week intervention. Participants were assessed at
baseline, mid-treatment, post-treatment, and at 3-month fol-
low-up.
Results Support for the intervention’s feasibility and accept-
ability was achieved, with 70 % retention among those who
started the program and a high mean rating (4.7 out of 5.0) of
program satisfaction among study completers. On average,
weight regain was reversed with a mean weight loss of
5.1 ± 5.5 % throughout the intervention. This weight loss
was maintained at 3-month follow-up. Significant improve-
ments in eating-related and acceptance-based variables also
were observed.
Conclusions This pilot study provides initial support for the
feasibility, acceptability, and preliminary efficacy of a remote-
ly delivered acceptance-based behavioral intervention for
postoperative weight regain.
Keywords Postoperative weight regain . Behavioral
intervention . eHealth . The research described in this paper
James D. Herbert
jh49@drexel.edu
David B. Sarwer
dsarwer@temple.edu
1
Department of Behavioral Sciences, Rush University Medical
Center, 1645 W. Jackson Blvd. Suite 400, Chicago, IL 60625, USA
2
Department of Psychology, Drexel University, Philadelphia, PA,
USA
3
Weight Control and Diabetes Research Center, Warren Alpert
Medical School of Brown University, Providence, RI, USA
4
Center for Obesity Research and Education, Temple University,
Philadelphia, PA, USA

was supported in part by grants to the first author from the
American Psychological Association and the Society for a
Science of Clinical Psychology.
Introduction/Purpose
Although bariatric surgery is the most successful weight loss
treatment, 20–30 % of patients fail to reach targeted weight
loss (i.e., 25 to 35 % of total body weight) or begin to regain
large amounts of weight beginning 6 to 24 months postoper-
atively [1–4]. Longer-term data suggest that 30 to 70 % of
patients fail to maintain a 20 % weight loss 10 years after
surgery, depending on type of surgery received [1]. These
suboptimal weight outcomes have critical implications, as
they have been linked with poorer postoperative health out-
comes [2, 3, 5, 6]. Poor long-term weight outcomes are largely
attributed to behavioral factors, including non-adherence to
the recommended postoperative diet and the development or
re-emergence of maladaptive eating behaviors (e.g., grazing,
loss of control eating, emotional eating) [7–10].
Immediately after surgery, compliance to postoperative di-
etary recommendations is facilitated by the physical and met-
abolic effects of surgery. Specifically, the volume of food that
can be consumed is limited by the restrictive nature of surgery
and changes in gut hormones are believed to mediate changes
in hunger and food preferences [11, 12]. However, it is possi-
ble that over time, some effects deteriorate, making adherence
increasingly difficult for patients. Specifically, following the
initial weight loss phase, patients report increased hunger,
food cravings, and ability to physically consume greater
amounts of food [13–16]. Long-term changes in eating behav-
ior are therefore necessary for sustained success post-surgery.
Given the need to enhance compliance with recommended
postoperative eating behaviors in order to improve weight loss
and related health outcomes, a number of studies have evalu-
ated the efficacy of postoperative behavioral weight control
interventions. A meta-analysis of controlled trials of these
interventions found minimal differences in percent excess
weight loss between treatment and control conditions (i.e.,
1.6 %) 6–12 months following the beginning of the interven-
tion [17], suggesting that the provision of behavioral skills
alone has modest effects on weight. Standard interventions
such as these provide participants with behavioral strategies
(e.g., self-monitoring, stimulus control) to target weight re-
gain. However, given the challenges reported by patients
who are regaining weight (e.g., return of food cravings, in-
creased hunger, ability to consume greater amounts of food),
there is a need for interventions that also provide
psychological skills to help patients appropriately engage in
weight control behaviors.
Acceptance-based treatments (ABTs) are a type of behav-
ioral intervention that provides patients with skills to enhance
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one’s willingness to experience a range of internal experiences
(e.g., thoughts, emotions, urges) in order to behave in ways
consistent with what is most important to them [18–20]. These
interventions are largely based on Acceptance and
Commitment Therapy (ACT) [21]. ABTs for weight control
specifically target the challenges faced by postoperative pa-
tients by helping individuals enact goal-directed behaviors
(e.g., healthy eating, physical activity) that are in line with
one’s values in spite of aversive (or non-preferred) internal
experiences, such as those that lead to dietary inadherence
[22, 23]. These skills (i.e., distress tolerance, present-
moment awareness of internal states, clarity of one’s personal
values and linking values to in-the-moment decision-making,
psychological distancing, or Bdefusion^ (as described in [20]))
are synthesized with behavioral elements known to be crucial
for weight control. It is hypothesized that ABTs will improve
post-surgery patients’ adherence to demanding dietary guide-
lines which will, in turn, enable weight loss maintenance in
the years following bariatric surgery.
Previous research supports the use of ABTs for weight loss
in nonsurgical populations [23–25], and several studies have
applied acceptance-based strategies to bariatric surgery pa-
tients; however, data are limited [26–28]. Weineland et al.
[26] reported improvements in disordered eating, body dissat-
isfaction, and quality of life following an ABT compared to
treatment as usual; however, changes in weight were not mea-
sured. Two mindfulness-based interventions have shown to
enhance postoperative weight outcomes; however, sample
sizes were small (i.e., n = 1 and n = 7 [27, 28]). Our previous
research also provides support for ABT for this population.
We conducted an open trial of a newly developed, 10-week,
ABT in-person group intervention for bariatric surgery pa-
tients who displayed a 10 % weight regain since their lowest
weight after surgery (n = 11; [29]). The intervention was
shown to be feasible and acceptable, with 72 % retention
(100 % retention in those who attended more than 1 session)
and high mean rating (4.25 out of 5.00) of program satisfac-
tion. In addition, a mean weight loss of 3.6 ± 3.0 % throughout
the 10-week intervention was observed. There were also sig-
nificant improvements in eating-related variables, including
decreased responsivity to internal cues.
Even with these encouraging results, delivering the inter-
vention postoperatively remains a significant challenge.
Patients struggle to return to their bariatric programs for reg-
ular follow-up, limiting the effective delivery of treatment.
Over two thirds of patients (72 %) miss appointments during
the first two postoperative years [30], and only 40 % of pa-
tients return for their first four annual follow-up visits [31].
Studies evaluating behavioral postoperative interventions sim-
ilarly report high attrition. For example, in one study, only
20 % of participants who expressed interest in a postoperative
intervention enrolled in the study and approximately 40 % of
consented participants withdrew from the study prior to group
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assignment [32]. In another study, 60 % of patients attended
half or less than half of the intervention sessions [33]. Several
studies have found a correlation between travel distance and
postoperative follow-up [34–36], indicating that in-person ap-
pointments may be difficult for many patients to attend.
Remote interventions (e.g., delivered via phone and/or
Internet) appear to be well-suited to address the challenges
of engaging bariatric surgery patients postoperatively.
Internet-based interventions targeting weight loss are particu-
larly desirable, due to cost-effectiveness, increased access, and
reduced patient burden [37]. Internet-based interventions have
been shown to result in meaningful weight losses in non-
surgical populations [38, 39]. Previous research has also sup-
ported the application of remotely delivered ABTs, including
those for type 2 diabetes [40], chronic pain [41], smoking
cessation [42], anxiety disorders [43–45], depression [46],
and tinnitus [47]. In addition, Weineland and colleagues’
(2012) ABT intervention for bariatric surgery patients (de-
scribed above [26]) combined face-to-face sessions with
Internet modules; 12 of 16 participants were retained from
study enrollment to follow-up [48].
The current study builds on this prior work and was de-
signed to investigate the feasibility, acceptability, and prelim-
inary efficacy of a novel remotely delivered ABT intervention
for postoperative weight regain. Based on our preliminary
data [29], we hypothesized that at post-treatment, patients
would demonstrate significant weight loss and improvements
in self-reported eating behavior, as well as change in the pos-
tulated mechanisms of action (i.e., acceptance of internal ex-
periences, defusion, or psychological distancing).
Materials and Methods
Participants
Participants were recruited by contacting respondents to a sur-
vey [13] of attitudes of patients on postoperative interventions
from the University of Pennsylvania Bariatric Surgery
Program and by posting advertisements through community
flyers and Craigslist. Inclusion criteria were 18–70 years old,
weight loss surgery (i.e., RYGB, gastric sleeve, gastric
banding) at least 1.5 years out from surgery, ≥10 % weight
regain of maximum weight loss or 5 % of their minimum
weight post-surgery, and weight regain lasting for at least
3 months prior to enrollment. Potential participants were ex-
cluded if they were enrolled in a structured weight loss pro-
gram, were pregnant/planned to become pregnant within
6 months of enrollment, had a medical condition that had
the potential to affect weight (e.g., Cushing’s disease) or
would limit one’s ability to make dietary or physical activity
changes, exhibited psychiatric symptoms that would interfere
with the ability to benefit from the intervention (i.e., inability
to provide consent or to implement behavior changes), or
reported acute suicidality. Medications known to affect body
weight (gain or loss), such as chronic systemic steroids or
psychiatric medications including lithium, tricyclic antide-
pressants, and anti-psychotic agents [49], were required to
be stable for at least 3 months.
Intervention
The intervention (Project HELP: Healthy Eating and Lifestyle
Post-surgery) was delivered via online modules. Specifically,
10 weekly sessions were developed using an e-learning soft-
ware suite (i.e., Articulate) and hosted on Coursesites (a popular
e-learning platform). Module content was developed by trans-
lating material from the treatment protocol used for the in-
person group program version of the intervention previously
described [29]. These modules included the presentation of
material using images, text, audio, and video to convey session
content comprehensively. Other components included interac-
tive exercises, examples of other Bpatients^ utilizing ABT skills
in the moment, quizzes that aimed to support participants’ un-
derstanding of the material, and directed assignments to be
completed throughout the week (i.e., BSkill Builders^).
Participants were assigned to view each module over the course
of the week (at any time they chose, with the ability to control
the flow of material, including replaying and rewinding module
materials). They were also asked to record their food intake
daily using MyFitnessPal and to record their weights and aver-
age daily calories in an online spreadsheet each week that self-
populated a graph to visually represent progress.
This intervention focused on ABT strategies with an empha-
sis on willingness to experience less pleasurable (e.g., choosing
low-calorie foods vs. more pleasurable calorically dense foods)
and aversive internal experiences (e.g., hunger, food cravings,
negative emotions). Strategies to increase willingness were
taught, including defusion (i.e., gaining distance from internal
experiences such that one gains the ability to act independently
of them). Mindful decision-making, as it relates to eating and
exercise, was also emphasized. Clarification of, and commit-
ment to, core values was another key component, as living life
in accordance with one’s values (e.g., health) makes willingness
to engage in difficult weight control behaviors worthwhile.
Standard behavioral techniques for weight loss (i.e., self-mon-
itoring, stimulus control, portion control, psychoeducation)
were also included in each module. These skills were framed
as the core behaviors necessary for weight control, while the
acceptance-based skills were presented as essential tools to en-
able the patients to continue to engage in these behaviors over
the long term despite the difficulties in doing so (see [50] for
more details on the application of these skills).
Following the introduction of each ABT skill, a behavioral
application section was included. In this section, participants
received specific examples of utilizing the ABT skill to engage

in particular weight control behaviors. Specifically, in most
modules, participants were given a list of common challenges
relating to the topic covered and they were able to choose
which challenge was most relevant to them. They would sub-
sequently see a specific example of a character utilizing ABT
skills in response to that behavioral challenge. Participants
were then prompted to plan for how they would personally
use these ABT skills in a similar situation (see Fig. 1 for an
example).
In order to ensure that participants were understanding and
applying the skills delivered, a brief (i.e., 20 min) telephone
call with a member of the study team (i.e., program coach)
was conducted every 2 weeks. Program coaches were ad-
vanced graduate students with at least 1 year of experience
delivering ABTs for weight control. The goal of these calls
Fig. 1 Screenshots from modules
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was to discuss and clarify the content of the session, discuss
how the participant utilized skills demonstrated in the mod-
ules, problem-solve difficulties in utilizing the skills, and re-
view homework. Feedback regarding weight losses and food
records was also provided. This component is particularly
important, as prior research conducted on Internet-based
weight loss treatments has shown that such feedback results
in significantly greater weight loss compared to when it is not
provided [51]. A discussion board feature was also available
to participants in the program. Topics were posted on the
discussion board by research staff designed to facilitate social
support among participants (which has been shown to be par-
ticularly important for bariatric surgery patients [52]).
As the primary aim of this study was to develop a feasible
and acceptable treatment, we implemented a structured plan to
OBES SURG
collect feedback from participants. After completing each
module, participants rated its helpfulness, ease of use, and
level of engagement on a 3-point scale (1 = BNot at all,^
2 = BSomewhat,^ 3 = BVery^). Participants were also
prompted to report technological challenges and provide
free-form feedback at the end of each module. In addition,
all participants completed a treatment acceptability question-
naire following the completion of the intervention to gather
additional feedback.
Procedures
Interested participants underwent a phone screen by study
personnel in order to determine eligibility. Eligible partici-
pants were invited to complete the 10 weekly online modules
(as well as phone check-ins with a program coach). Prior to
beginning the program, participants were required to complete
a brief tutorial, during which their assigned program coach
would walk them through the technical components of the
online program. Assessments time points included: (1) base-
line (within 2 weeks prior to starting the intervention), (2)
mid-treatment (after completing the fifth online module), (3)
post-treatment (at the completion of the final module), and (4)
follow-up (3 months following completion of the final mod-
ule). Participants were compensated $15 for completing the
mid-treatment assessment and $25 for the post-treatment and
3-month follow-up assessments. All assessments were con-
ducted remotely via online questionnaires.
Measures
Anthropometric Data
Weight was self-measured by participants using a digital
scale that they were required to purchase (if they did not
already own). Prior to weighing, a scale check was then
performed to assess the reliability of participants’ scales
and participants were given written instructions to enhance
the accuracy of self-measured weights (e.g., removing shoes
or extra layers of clothing, placing the scale on a hard, level
surface, weighing first thing in the morning). Participants
weighed themselves three times during each assessment
and the average of these weights was recorded. If recorded
weights differed by >1 lb., participants were contacted to
check accuracy of recording. Self-reported weights in bariat-
ric surgery patients have been shown to be reasonably accu-
rate, i.e., on average within 1 kg [53]. Within our sample,
self-recorded weights were very reliable (i.e., SD of mean
recorded weights within each subject was 0.1 lbs).
Participants also self-reported their height, which was used
to calculate BMI.
Treatment Acceptability and Feasibility
Treatment acceptability was measured using a questionnaire,
adapted by the investigators from previous measures used for
this purpose, using a 5-point Likert scale (1 = BNot at all,^
3 = BSomewhat,^ 5 = BVery^) to evaluate how helpful partic-
ipants found the treatment, their satisfaction with it, and how
likely they would be to recommend it to a friend. Feasibility of
the modules was assessed via a brief questionnaire following
the viewing of each module, as described above.
Eating-Related and Physical Activity Variables
Caloric intake was measured with an online system for dietary
self-monitoring (i.e., MyFitnessPal). Participants were
instructed to complete daily food records starting at baseline
through the end of the intervention. Calorie data from records
at baseline and post-treatment (calculated via MyFitnessPal)
were analyzed to calculate average daily caloric consumption
during the first and last week of the program. Use of electronic
tools has been shown to improve compliance with self-
monitoring compared to using paper records [54]. In addition
to serving as an outcome variable, this system also served as
the self-monitoring component of the intervention. A self-
monitoring record was considered complete for 1 day if a
participant entered at least three separate meals or if he/she
recorded at least 50 % of his/her daily calorie goal (as used by
[55]).
Loss of control eating was examined using the Eating
Disorder Examination Questionnaire (EDE-Q; [56]).
Because many bariatric surgery patients cannot physically
consume an objectively large amount of food in one sitting,
both subjective and objective binge episodes as assessed by
the EDE-Q were considered loss of control episodes [57].
Good concurrent validity with the EDE interview has been
established for the EDE-Q [58].
Disinhibition, restraint, and reactivity to internal and ex-
ternal cues were measured with The Eating Inventory [59],
which has been shown to be reliable and valid [60].
Disinhibition scores have been shown to decrease with weight
loss treatment as well as after bariatric surgery [7, 61], while
cognitive restraint has been shown to increase post-surgery
[7].
The Emotional Eating Scale (EES) was used to assess emo-
tional eating, which is a self-report measure that assesses the
relationship between overeating and negative emotions [62].
The EES is classified into three subscales (anger/frustration,
anxiety, depression). This measure has good construct validity
and adequate test-retest reliability [62] and has been previous-
ly used with post-bariatric surgery patients [27].
Grazing behavior over the past 2 weeks was assessed by
self-report based on the definition provided by Colles et al.
[9], i.e., Bthe consumption of smaller amounts of food

continuously over an extended period of time, eating more
than the subjects considers best for them,^ (p. 616). A ques-
tionnaire was created by the researchers due to the lack of
validated measures for this eating behavior [63]. In addition
to confirming these criteria in the form of yes or no questions,
participants were asked to what extent they grazed over the
past 2 weeks (from BNever^ to BAlways^).
The Food Cravings Questionnaire-Trait (FCQ-T; [64]) was
used to assess food cravings, which has been shown to have
excellent internal consistency (including in a bariatric surgery-
seeking population, [65]) and good test-retest reliability [64].
The Paffenbarger Physical Activity Recall [66], a 15-item,
interview-based measure for assessing physical activity, was
used. By converting these activities into metabolic equivalents
based on body mass, total expenditure from physical activity
was calculated.
Acceptance-Based Process Variables
The Acceptance subscale of the Philadelphia Mindfulness
Scale (PHLMS) was used to assess acceptance of internal
experiences [67]. Internal consistency and concurrent validity
with established measures has been demonstrated [67].
Acceptance of food-related internal experiences was mea-
sured with the Food-Related Acceptance and Action
Questionnaire (FAAQ), which has demonstrated good reli-
ability and validity [68].
Defusion was measured with the Drexel Defusion Scale
(DDS), a self-report measure assessing the extent of the ability
to defuse from different internal experiences, which has been
shown to have good internal consistency [69].
Acceptance of physical activity-related internal
experiences was evaluated with the Physical Activity
Acceptance Questionnaire (PAAQ). This 10-item measure as-
sesses self-reported acceptance of psychological and physical
discomfort associated with engaging in physical activity.
Good internal reliability and concurrent validity has been
demonstrated [70].
All measures were completed at each assessment point,
except that height was reported at baseline only and treatment
acceptability at post-treatment only.
Data Analysis
All variables are reported as mean ± standard deviation or
frequency and percentages. T tests were used to assess chang-
es in weight and secondary variables (eating behaviors and
acceptance-related constructs) pre- to post-treatment.
Completer analyses and intent-to-treat analyses (using last
weight carried forward for participants who provided a base-
line assessment weight) were conducted for weight data.
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Results
Participants
A total of 114 potential participants who indicated interest in the
study (via a recruitment survey, Craigslist ads, flyers, and refer-
rals from other research studies) were contacted. Of those 114,
60 were reached by phone or email and provided with further
information about the study. Of those reached, 8 did not meet
eligibility criteria, 20 were lost to contact, and 9 were no longer
interested in treatment. The remaining 23 potential participants
met eligibility criteria and agreed to join the program. Twenty
of those who met criteria were enrolled in the program (i.e.,
completed the baseline assessment and tutorial), and 16 of those
20 interacted with the first module (i.e., treatment Butilizers^)
and were included in analyses. Eleven of these participants
completed the intervention and post-treatment assessment
(i.e., treatment Bcompleters^). See the CONSORT diagram
(Fig. 2) for details on screening and enrollment.
Participant demographics are listed in Table 1. Of note, the
sample was predominantly White and female. Self-reported
surgery data (Table 1) indicated that the majority of partici-
pants received gastric bypass surgery (75 %), and mean time
since surgery was 5.1 ± 1.0 years.
Treatment Feasibility and Acceptability
Program retention was defined as completing at least 8 of 10
modules. Out of the 20 participants who enrolled in the study
(i.e., completed the tutorial and baseline assessment), 12 par-
ticipants completed 8 modules (60.0 %). However, of the 16
participants who utilized the modules, 75 % met retention
criteria defined above. The average time to program comple-
tion was 12.2 ± 4.0 weeks. Although the intervention was
designed to be completed within 10 weeks, participants were
unable to move onto the subsequent weekly module until they
completed the previous week’s module. The first two com-
pleters took an average of 20.2 ± 0.1 weeks to complete the
program (i.e., twice the intended amount of time). Following
this observation, personalized schedules, checklists, and struc-
tured reminders were implemented and the remaining partic-
ipants took an average of 10.4 ± 0.6 weeks to complete the
intervention. The average time spent interacting with each
module was 26.2 ± 10.2 min, and average time of each phone
coach call was 16.5 ± 3.6 min. On average, participants an-
swered quiz questions correctly 85.5 % of the time, indicating
adequate understanding and retention of material.
Program completers completed all five bi-weekly phone
sessions. For program utilizers, 77.5 % of phone coach calls
were completed. During the majority of the program, the dis-
cussion board was unused. Qualitative feedback indicated that
the discussion board was not user-friendly, which we were
unable to modify given the use of an already-developed
OBES SURG

Fig. 2 Consort diagram

platform. Additional instructions were provided to assist par-
ticipants and targeted posts were implemented; however, these
steps resulted in only one participant using this feature.
Among completers (those who completed the acceptability
questionnaire, n = 11) acceptability ratings were high, includ-
ing for overall helpfulness of ABT strategies (4.5/5 ± 0.8),
overall satisfaction with the program (4.7 ± 0.6), and confi-
dence in recommending the program to others (4.7 ± 0.6). The
average ratings of individual modules also indicate high ac-
ceptability, with participants rating them as Bvery^ helpful
71.1 % of the time, Bvery^ easy to use 90.6 % of the time,
and Bvery^ engaging 78.7 % of the time. The highest rated
acceptance-based strategies (rated at least 4.5 out of 5) were
acceptance, willingness, and mindful decision-making
strategies. The helpfulness of the phone coach calls were not
formally assessed; however, discussions with participants in-
dicated high acceptability and usefulness.
Participants were able to view modules 75.2 % of the time
without reporting technological issues. The most commonly
cited issue was user activity not being automatically recorded
by the program, requiring participants to re-enter quiz re-
sponses and feedback (i.e., 21.6 %).
When modules were viewed, skill builders were completed
79.8 % of the time, weekly self-monitored weights 93.8 % of
the time, and weekly self-monitored average calories 85.3 %
of the time. Participants only entered complete food records
67.4 % of days in the program. However, treatment com-
pleters recorded their food intake 74.8 % of the time.

Table 1 Participant
demographics and surgery Total sample Completers Utilized only Enrolled only
information (n = 20) (n = 11) (n = 5) (n = 4)

Age (year; M ± SD) 54.3 ± 12.1 50.7 ± 13.7 59.2 ± 5.3 58.0 ± 12.9
Women (%) 85.0 % 72.7 % 100 % 100 %
White (%) 80.0 % 81.8 % 80.0 % 75.0 %
African American (%) 20.0 % 18.2 % 20.0 % 25.0 %
Married or living with partner (%) 55.0 % 54.5 % 80.0 % 25.0 %
Employed full-time (%) 60.0 % 54.5 % 60.0 % 75.0 %
Gastric bypass (%) 75.0 % 72.7 % 80.0 % 75.0 %
Gastric sleeve (%) 15.0 % 27.3 % 0% 0%
Gastric banding (%) 10.0 % 0% 20.0 % 25.0 %
Time since surgery (year; M ± SD) 5.1 ± 1.0 5.1 ± 1.1 5.5 ± 0.7 4.6 ± 1.1

Completers participants who completed all modules and assessments; Utilized only interacted with at least the first
module, but did not complete the program; Enrolled only completed baseline assessment and tutorial only
 OBES SURG

Weight Outcomes

Among treatment completers, 10 out of 11 (i.e., 90.9 %) par-

ticipants demonstrated weight stabilization (within 0.2 kg) or
weight loss. Including treatment utilizers who provided at
least one additional weight after beginning treatment, 13 out
of 14 (i.e., 92.9 %) participants demonstrated weight stabili-
zation or weight loss. Treatment completers demonstrated sig-
nificant weight loss from pre- to post-treatment (5.1 ± 5.5 %;
5.9 ± 6.5 kg, t(10) = 3.02, p = .01). Intent-to-treat analyses also
revealed significant weight loss pre- to post-intervention
Fig. 4 Mean weight change since surgery from 2 years pre-treatment to
(3.9 ± 5.0 %; 4.4 ± 5.8 kg, t(15) = 3.05, p = .01). Percent post-treatment. Black square self-reported weights (via a screen), black
weight losses for each treatment completer are displayed in triangle self-measured weights
Fig. 3, and weight trajectories since 2 years prior to starting the
intervention are shown in Fig. 4.
All treatment completers were assessed at 3-month follow- Based on food record data, treatment completers who pro-
up. Weight losses were maintained, with an average additional vided calorie data from pre- and post-treatment (n = 8) re-
weight loss of 0.6 ± 2.7 % from post-treatment to follow-up. duced their average daily calorie intake from 1364.5 ± 342.7
Total average weight loss from pre-treatment to 3-month fol- to 1227.1 ± 69.6 (Mchange = 137.4, SD = 245.9, t(7) = 1.58,
low-up was 5.7 ± 6.1 %. p = .16); however, this difference did not reach statistical
significance. Self-reported caloric expenditure (based on the
Paffenbarger physical activity questionnaire) did not improve;
Process Variable Outcomes
in fact, average calories expended per week evidenced a small
and statistically insignificant decrease from 4048.1 to
Changes in acceptance-based process variables from pre-to
3834.8 kcal/week (M c h a n g e = 213.3, SD = 2513.9,
post-treatment were generally large, in the expected direction
t(9) = 0.27, p = .80).
and supported hypotheses (Table 2). However, acceptance of
Due to our small sample size, we were not able to conduct
general internal experiences did not evidence improvement.
formal mediation analyses. However, exploratory analyses
Significant and generally medium to large improvements in
were conducted to identify potential mediators. Correlations
eating-related variables were also observed (Table 2).
between residualized changes in process measures from pre-
In addition to the changes in scores on these validated
to mid-treatment and residualized change in weight from pre-
measures, changes were also observed on items from our graz-
to post-treatment were conducted. Pre- to post-treatment
ing questionnaire. In particular, the percentage of participants
weights were used for these analyses rather than mid- to
who endorsed problematic grazing decreased from 36.4 to
post-treatments because the majority of weight loss seen in
9.1 % from pre- to post-treatment. In addition, items from
weight control interventions often occurs towards the begin-
the EDE-Q revealed that average frequency of loss of control
ning of the intervention. Residualized changes in several of
eating episodes decreased from 4.3 times to 0.9 times within
our hypothesized mediators were strongly correlated with
the previous 4 weeks (M = 3.36, SD = 6.04, t(10) = 1.85,
residualized changes in weight including defusion
p = .09). In addition, the percentage of participants who en-
(r = −0.58, p = 0.06), disinhibition (r = 0.55, p = 0.08), reac-
dorsed loss of control eating episodes decreased from 63.6 to
tivity to internal cues (r = 0.71, p = 0.02), eating in response to
27.3 % pre- to post-treatment.
depression (r = 0.63, p = 0.04), food cravings (r = 0.54,
p = 0.09), and food-related acceptance (r = −0.50, p = 0.12).

Discussion

The current study provides preliminary support for the use of a

Fig. 3 Percent weight change from pre- to post-treatment by participant
remotely delivered acceptance-based behavioral intervention
for weight regain after bariatric surgery. Specifically, our pilot
study supported the feasibility, acceptability, and preliminary
efficacy of this novel 10-module online program.
Overall, the program proved to be feasible and acceptable,
with the vast majority of participants rating the program as
OBES SURG

Table 2 Pairwise comparisons of

process measures from pre- to Baseline Post-treatment Paired t test (df = 10)
post-treatment
M SD M SD t p d
EI disinhibition 8.3 4.2 5.6 2.8 2.9 0.02* 0.75
EI cognitive restraint 12.4 3.2 17.6 2.3 −4.08 <0.01** 1.84
EI internal 4.4 2.6 2.3 1.7 3.0 0.01* 0.95
EI external 2.3 1.8 1.7 1.3 1.60 0.14 0.35
EES anger 22.9 9.4 20.6 7.1 1.24 0.25 0.27
EES depression 14.2 7.0 11.0 4.8 1.93 0.08 0.53
EES anxiety 23.3 8.3 18.9 5.1 2.92 0.02* 0.64
FCQ-T 121.5 36.7 100.9 30.7 1.66 0.13 0.61
PHLMSacceptance 31.5 6.8 31.6 7.7 −0.11 0.92 0.03
DDS 27.5 11.8 35.7 6.7 −2.91 0.02* 0.86
FAAQ 38.9 7.7 52.6 10.6 −3.90 <0.01** 1.47
PAAQ 45.6 13.6 54.3 11.7 −2.22 0.05 0.69

EI Eating Inventory, EES Emotional Eating Scale, FCQ-T Food Cravings Questionnaire-Trait, PHLMS
Philadelphia Mindfulness Scale, DDS Drexel Defusion Scale, FAAQ Food-Related Acceptance and Action
Questionnaire, PAAQ Physical Activity Acceptance Questionnaire
*
p < 0.05 ; ** p < 0.01

very helpful, easy to use, and engaging. It is noteworthy that
despite the reported technological difficulties, acceptability
ratings remained high. This result parallels data from other
recently completed trials of remote treatments, which also
suggest that technological problems using these formats tend
not to qualitatively disrupt the user’s experience [45, 71].
We predicted that delivering this program remotely would
mitigate the poor enrollment and retention seen in this popu-
lation. Program initiation and retention, however, was not op-
timal. Only 18 % of individuals who indicated initial interest
in a postoperative intervention (via survey and recruitment
postings) enrolled in the program. Of the 20 participants that
did enroll, 11 completed the treatment in its entirety. These
results indicate that there are likely more barriers than logisti-
cal ones to engaging patients in postoperative treatment and
that the use of technology to deliver interventions is only part
of the solution. More work is therefore needed to increase
engagement in postoperative behavioral programs such as this
one. Recruiting those who are actively regaining weight may
be especially difficult, as they may be experiencing decreased
motivation due to the challenges they have experienced. It
may be useful to emphasize the amount of time patients would
be required to directly interact with the intervention (which is
less than standard in-person treatments) as well as the poten-
tial effectiveness in halting and/or reversing weight regain.
However, it should be noted that of those participants who
actually began the program (i.e., interacted with the first mod-
ule), nearly 70 % completed the intervention and all treatment
completers were retained at 3-month follow-up. This relative-
ly high retention rate combined with the high ratings of the
program further indicates that the program was acceptable and
feasible.
In addition to proving to be acceptable and feasible, this
program proved effective: weight regain was halted or re-
versed in all but one case. Moreover, average weight change
(i.e., −5.9 kg) was almost double the amount (−3.3 kg) expe-
rienced by participants in a 6-month post-surgery standard
behavioral intervention [32]. Importantly, weight losses were
maintained at 3-month follow-up. Notably, mean weight
losses reached 5 %, a clinically significant weight loss shown
to improve obesity-related comorbidities in non-surgery sam-
ples [72]. This degree of weight loss may have similar effects
in bariatric surgery patients who have regained weight; how-
ever, more research is necessary to confirm this hypothesis.
The weight loss demonstrated in the current sample is also
notable, given that patients at this point post-surgery are on a
weight regain trajectory [1]; in fact, these particular partici-
pants’ postoperative weight losses decreased from 26 to 20 %
in the 2 years leading up to the start of the intervention. In
addition to significant weight losses, this intervention was
successful in producing medium to large improvements in
eating-related variables that have been implicated in post-
surgical weight regain. These changes mirrored improvements
seen in the in-person version of this program [29], including
decreased grazing, loss of control eating, food cravings, and
particularly large effects for decreased disinhibition and inter-
nal responsivity to food cues. The current study results, com-
bined with the favorable results from the in-person group ver-
sion of this program [29], highlight the potential benefit of
incorporating acceptance-based skills when treating post-
surgery weight gain.
The goal of this acceptance-based treatment was to empha-
size engaging in goal-directed behaviors that are in line with
one’s values in spite of non-preferred internal experiences,

such as those that lead to dietary inadherence. The interven-
tion provided participants with acceptance skills that aimed to
increase the capacity to experience less desirable internal
states (e.g., hunger, wanting of food, food cravings) and there-
fore better allow participants to engage in valued behaviors.
There were, in fact, significant changes in self-reported utili-
zation of acceptance-based variables, including increased use
of defusion and increased food-related and physical activity-
related acceptance. Although exploratory analyses indicated
strong associations between changes in proposed process
measures and weight change, with the small sample size and
without formal mediation analyses, it is impossible to con-
clude that the integration of specialized psychological strate-
gies were responsible (or necessary) for the observed weight
outcomes.
Results of this pilot study also highlight the potential effec-
tiveness of remotely delivered interventions in the post-
bariatric surgery population. The effectiveness of this program
is particularly robust when considering the amount of time
participants were actively engaged with the intervention.
Participants spent an average of 26 min on weekly modules
and 17 min every other week with a program coach, which is
significantly less time than required by traditional in-person
groups or individual sessions (i.e., 60–120 min weekly).
These data support the efficiency and potential cost-
effectiveness of this program. Bariatric programs may there-
fore be able to reach a wide number of patients (regardless of
location) using minimal resources by using a program such as
this. In addition, highlighting the minimal amount of time
necessary to engage with the program may increase the enroll-
ment and retention of future patients (as most of our lost par-
ticipants dropped out prior to engaging with the intervention).
This intervention specifically targeted those who have ex-
perienced weight regain after the initial weight loss phase.
Several participants recommended that this program be of-
fered at the start of the bariatric surgery process (possibly prior
to undergoing surgery), in order to build skills at the outset
that would prevent weight regain from occurring in the first
place. However, one participant noted that it was helpful for
him to struggle on his own in order for him to realize that he
needed the additional help and to be diligent with adherence to
weight control behaviors. In fact, previous research with this
population indicates that patients are less likely to utilize a
behavioral intervention if it is offered pre-surgery compared
to post-surgery [73]. Other research has shown minimal ef-
fects of a behavioral intervention implemented during the first
4 months after surgery [33], with no differences in weight at
follow-up between 12 and 24 months post-surgery. The espe-
cially strong physiological effects of surgery during the initial
weight loss phase may be one of the reasons for this lack of
significant effect of behavioral treatment.
This study has several limitations. The open trial design,
while appropriate to evaluating the first remotely delivered,
OBES SURG
interactive ABT intervention, means that observed outcomes
cannot be definitely attributed to any particular aspect of our
intervention. As discussed earlier, the intervention contained a
number of nonspecific and behavioral components (e.g., self-
monitoring) that may have effects independent of the psycho-
logical strategies delivered. It may be that standard cognitive-
behavioral strategies would work just as well as ABT strate-
gies in this population. The effects of the phone coach calls are
also unknown (i.e., they may have accounted for much of the
effects, or they may not have been necessary). The relatively
short follow-up period (i.e., 3 months) represents another lim-
itation; a greater follow-up time is needed to determine the
longer-term effects of this intervention. Also, weights were
self-measured using home scales, rather than by trained asses-
sors using a medical-grade, laboratory scale. However, as not-
ed previously, self-reported weights in bariatric surgery pa-
tients have been shown to be accurate [53]. It should also be
noted that because treatment acceptability was assessed at
post-treatment, acceptability ratings might be confounded
with treatment response. In addition, the generalizability of
our results may suffer due to our small sample size and the
fact that we recruited individuals mostly living in close prox-
imity to the Philadelphia area (and many who received surgery
from the same hospital).
As discussed above, future research is necessary to provide
additional support for the acceptability and efficacy of this
intervention, including trials with more participants who are
drawn from a variety of surgery centers. In addition, future
research is needed to better understand which aspects of the
remote intervention are necessary. For example, it may be that
having an online platform for self-monitoring is sufficient to
produce weight loss, or that receiving psychological skills and
interactions with phone coaches enhance outcomes. It may
also be useful to compare remote interventions that provide
opportunities for interaction within modules (as was present in
this study) compared to those that do not allow of interaction
(e.g., viewing presentations delivered online with text and
voiceover).
Conclusions
This study is a meaningful addition to this area of research,
indicating feasibility and acceptability of a remotely delivered
acceptance-based behavioral intervention targeting weight re-
gain in postoperative patients. Preliminary effectiveness was
also supported, with clinically significant weight losses ob-
served. Continuing to improve and refine interventions
targeting weight regain in bariatric surgery patients is imper-
ative, given the significant health consequences of weight re-
gain. It will be especially important to continue to refine re-
cruitment and retention techniques as attrition continues to
remain a significant barrier in the bariatric surgery population.
OBES SURG
Compliance with Ethical Standards
Conflict of Interest D. B. Sarwer is a consultant for BAROnova,
Covidien, and Ethicon and received consulting fees from these organiza-
tions during the time of the study. J. G. Thomas received research grants
from Weight Watchers International, Inc. and is a consultant for Applied
VR, KetoThrive Corp, and Medtronic and received consulting fees from
these organizations during the time of the study. The remaining authors
have no commercial associations that might be a conflict of interest in
relation to this article.
Ethical Approval All procedures performed in studies involving hu-
man participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical stan-
dards. The study was approved by the Institutional Review Boards of the
University of Pennsylvania and Drexel University.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
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