Weight regain (WR) is an important issue after the obesity surgery and may be considered a long-term complication because it can lead to recurrence of diseases associated with obesity and reduced quality of life. Weight loss is rapid in the first 2-3 months after the surgery, but decreases later. The lowest weight is achieved around 9 to 12 months after the surgery. During this time, about 70-80% and sometimes even 100% of the excess weight is lost. We first need to give a clear definition of two types of weight loss problems: IWL and WR.
Inadequate weight loss, or IWL, is defined as the percentage of excess weight loss, or EWL ٪ less than 50%, 18 months after the obesity surgery. WR is defined as gradual weight regain that occurs after successful initial weight loss is achieved. EWL> 50))
Weight regain following the obesity surgery varies depending on the type of surgery performed, whether restrictive or malabsorptive. Weight regain after the laparoscopic gastric sleeve surgery in long-term follow-up over 7 years was 27.8% (between 14% and 37%). On the other hand, weight regain in 3-7 years after the gastric bypass surgery is estimated at about 3.9%. Various factors such as lifestyle, lack of proper nutrition, physical inactivity, mental health issues, hormonal / metabolic imbalances, and postoperative technical issues (e.g., enlarged stomach sac, ostomy dilatation, or gastric fistula) may help to regain weight.
Lifestyle factors and mental health issues
Failure to follow a diet after the surgery may lead to increased calorie intake and subsequent weight regain. Snacks, sweets and fatty foods, as well as poor nutrition, significantly increase the risk of weight regain after the gastric bypass. Patients need to understand that the surgery does not offer a quick fix to their obesity problem, and that long-term adherence to dietary recommendations is the key to success. Proper training, diet counseling, and long-term follow-up by the surgeon are crucial. Preoperative patients should be evaluated for realistic goals, readiness for changes, and nutrition awareness. General post-operative dietary recommendations include consuming more protein daily (1.0-1.5 grams per kilogram of ideal body weight), limiting sugar (less than 5 grams per meal), and less than 30% of daily calories from fat. Foods with low glycemic index and long-term absorption such as fruits and vegetables should be preferred and the diet should include 4-6 meals a day. Physical activity increases among postoperative obese patients, however, only 10-24% of patients after the gastric bypass follow the minimum physical activity recommendations to promote general health. ASMBS recommends increasing post-surgical physical activity to at least 30 minutes a day. The International Association of the Obesity studies recommends moderate-intensity activity of 60 to 90 minutes or less on most days of the week to prevent weight regain.
Unknown and untreated psychiatric disorders as well as eating disorders may cause weight regain in some patients after the gastric bypass. Grazing is now considered an eating disorder that is defined as the unplanned eating of small amounts of food with a loss of control over these foods. Having two or more psychiatric illnesses increases the risk of improper weight loss or weight regain by up to six times after the gastric bypass. However, after the surgery, patients have a low rate of psychological follow-up, which does not allow them to diagnose psychological problems and receive adequate treatment in a proper time. Treatment of cognitive behaviors may be a treatment option in this group of patients, as it has been much more successful in treating maladaptive eating disorders than methods that do not focus on treating mental disorders.
Hormonal / metabolic imbalance
Patients after RYGB have decreased appetite due to reduced feelings of hunger and premature satiety with small meals, it seems that changes in intestinal hormones play an important role. Due to the small sac and direct contact with the small intestine, the intestinal epithelium is rapidly exposed to nutrients. This leads to changes in the secretion of glucagon-like peptide 1 (GLP-1), glucose-dependent tropical insulin polypeptide (GIP), ghrelin, and other digestive hormones. Gastric bypass is associated with suppressed ghrelin, and increased GLP1 levels that may help with weight-loss that happens due to surgery. However, hormonal changes do not appear to be the same in all bypass patients and may partly explain the phenomenon of weight regain.
Gastrointestinal hormone secretion varies between patients with satisfactory weight control and those with weight regain. In one study, there was no difference between baseline levels of GLP1, GIP, and ghrelin, but early release of GIP and GLP-1 after the food stimulation in patients with weight regain was lower than in those with successful weight loss. It was also found that patients with high preoperative ghrelin levels were at greater risk for early weight return. Another reason for weight regain after bypass may be reactive hypoglycemia. The mechanism of late postprandial hypoglycemia is thought to reflect excessive excretion of GIP and GLP1, which may lead to B cell proliferation and increased insulin excretion. Because glucose is known to be a major mediator of appetite, multiple portions of low glucose levels may stimulate appetite due to significant postprandial insulin secretion, leading to overeating and weight regain. Patients need to redesign their diet by eating low glycemic index foods and gelatinous proteins. The interval between meals should not be too long.
Surgical factors
Enlargement of the gastric bladder, dilatation of the ostomy and gastric fistula are some of the causes of weight regain after obesity surgery, which are less common and if they occur, reoperation is needed to eliminate it. This shows the importance of choosing an experienced and accurate surgeon to perform the surgery.
WR and IWL prevention and management strategies after the obesity surgery
Management begins with a comprehensive assessment that includes dietary patterns, level of physical activity, mental disorders, and motivation. Mental health issues such as mood swings, anxiety, addiction and personality disorders need to be addressed and managed effectively. If necessary, upper gastrointestinal and esophagus contrast studies (EGD) should be performed to evaluate the gastrointestinal tract and provide essential information about the gastric remaining parts, gastric anastomosis size, gastric fistula, and the location and integrity of the gastric strip. Having a proper sleep pattern is also one of the effective factors in maintaining a proper weight after surgery. Weight loss improves sleep quality and can reduce sleep disorders (such as sleep apnea). The most common causes of sleep problems after obesity surgery are insufficient sleep and circadian rhythm disturbances (such as night shifts) that should be avoided if possible.
Here are some of the most common eating disorders associated with weight regain and how to deal with them:
Eating Disorders:
Eating unstructured and without pattern. Build a structure for eating, prioritizing the approximate time of eating during the day and during the daily activities.
Eliminate meals:
Prolonged fasting without food is one of the mistakes that can lead to overeating later. Meal planning, with convenient snacks or easy options depending on the individual’s situation, can prevent this problem.
Poor food choices:
Highly processed, fried and fast foods and return to previous habits that lead to initial weight regain. To solve this problem, it is necessary to identify and choose the right and easy food with less processing.
Eating at night:
A significant portion of calories are received after an evening meal. To avoid eating at night, make sure of having enough and even intervals between food portions during the day.
Excess amount:
Eating after feeling full is one of the problems that leads to weight loss. Reduce and maintain the amount of your meals, the right volume is as much as the size of a cup per meal.
Alcohol consumption:
Alcohol is absorbed quickly after the obesity surgery, thus preventing food from being consumed and not being satisfied with liquid calories. Limit alcohol consumption; Problems with alcohol can occur after surgery in people who have not had a problem before.
Inadequate protein intake:
Protein is important for satiety as well as for maintaining muscle mass, which helps speed up metabolism at rest. Eat a high-protein diet for your meals.
Mixing liquids and foods:
This may increase the capacity of the stomach and cause premature emptying of the stomach. Avoid drinking fluids immediately before a meal and for 30 minutes afterwards.
When can the outcome of the surgery be considered good – when can you be satisfied with it?
Typically, the outcome of the bariatric surgery is considered good when the patient has lost 50% or more of their excess weight. However, sometimes even a 40% reduction in excess weight may mean a weight loss of 40 to 50 kg (in the case of high initial weight), which may be significantly more than any other alternative weight loss method. Success in the surgery should not be measured solely in terms of weight loss or weight regain. Changes in the health status and the quality of life should also be considered. A study examining the effect of the gastric bypass surgery on quality of life two years after the surgery found that the quality of life of 97% of patients improved after the surgery. Examples of positive changes include overall improvement in physical and mental fitness, increased self-esteem, higher energy levels, reduced physical pain, improved sex life, more successful social behavior, and improved emotional health.