For some patients, complex internal and external factors contribute to weight regain following bariatric surgery.

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Although clinical studies have shown that bariatric surgery is superior to other treatments for maintaining long-term weight loss and improving overall health and QOL, weight loss following these operations varies between individuals.

“Obesity surgery leads to sustained weight loss and long-term health for most patients,” says Liisa Tolvanen, RD, PhD candidate. “However, some patients regain a significant amount of lost weight, which can lead to the return of health risks relating to obesity. To date, little is known about patients’ experiences of weight recurrence.”

Seeking a Better Understanding of Weight Regain Perceptions

Since weight regain after bariatric procedures is a complex phenomenon, qualitative research on patient perceptions may foster a better understanding of barriers and facilitators during weight regain. For a study published in Obesity Surgery,  Tolvanen and colleagues sought to understand how patients perceived weight regain. “By understanding our patients’ situation, we can better support them throughout their care,” Tolvanen says. “Our goal was to increase understanding of how people with weight regain experienced it and how they describe challenges with weight management.”

Investigators recruited 16 adults (four men, 12 women) at an obesity clinic in Sweden. Semi-structured individual interviews were conducted, and transcribed recorded interview data were analyzed with a thematic analysis. Eligible participants had a BMI of 35 kg/m² or higher, were aged 18 and older, and had a weight regain of 10% or more after sleeve gastrectomy or gastric bypass surgery.

Complex Internal & External Factors Contribute to Weight Regain

On average, participants had undergone gastric bypass surgery 10 years prior to the study and regained 36% of their weight from their nadir. “Our main findings indicated that complex internal and external factors contribute to weight regain after bariatric surgery,” says Tolvanen. “Varying psychosocial factors, changes in appetite, and mental and physical health problems may contribute to weight management difficulties.” Loss of control and focus and reducing the burden of weight management were identified as two major themes regarding patients’ experiences of weight regain after bariatric surgery (Figure).

Importantly, the study also showed that participants responded to weight regain with emotional distress, particularly with hopelessness, discouragement, shame, and frustration. “Many patients were unprepared for weight recurrence, which caused emotional distress,” Tolvanen notes. “Participants blamed themselves for not following dietary advice and described feelings of shame and guilt about their weight recurrence. However, increased social support and assistance with self-care may facilitate long-term weight management, according to the participants.”

Coordinated Efforts Needed for Effective Long-Term Follow-Up Care

The study highlights the need for multi-professional, individualized, and long-term follow-up after bariatric surgery, especially for patients with comorbidities and high BMIs, explains Tolvanen. “Patients with weight regain after bariatric surgery may experience shame due to prevalent weight stigma,” she says. “Experiencing stigma may contribute to non-functional coping strategies that lead to further weight gain. For a satisfactory treatment alliance, healthcare professionals need to have an empathic approach toward patients and actively work to reduce experiences of weight stigma.”

Some study participants reported increased feelings of hunger and decreased satiety over time, according to Tolvanen. “This indicates that changes in hormonal and metabolic factors may affect weight management approaches,” she says. “Our study also suggests that difficulties with eating behavior and mental health are essential factors to consider at postoperative follow-up. For example, research shows that mental health problems can contribute to increased alcohol consumption after gastric bypass surgery, and some participants in our study reported these same difficulties. For some patients, mental health problems can contribute to further difficulties with weight management. Theories of addiction transfer have also been raised, but these concepts are still being investigated.”

Tolvanen notes that the findings cannot be interpreted as generalizable to the entire population. “For example, patients who receive gastric bypass might have different experiences about weight regain than those undergoing sleeve gastrectomy,” she says. “Among bariatric surgery recipients, there is a need for future research on how to prevent weight regain and optimally treat patients affected by weight regain among bariatric surgery recipients.”