Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success

doi:10.1016/j.soard.2011.06.016

Surgery for Obesity and Related Diseases

Volume 7, Issue 5, September–October 2011, Pages 644-651

https://doi.org/10.1016/j.soard.2011.06.016 Get rights and content

Abstract

During the past decade, bariatric surgery has become an increasingly popular treatment option for the growing number of individuals with extreme obesity. For most individuals, the size and durability of the weight loss and improvements in co-morbidity and mortality have far surpassed those typically seen with behavioral modification and pharmacotherapy. A significant minority of patients, however, will experience suboptimal outcomes, including less than expected weight loss, premature weight regain, and frequent vomiting and/or gastric dumping. The reasons for these outcomes are not well understood, but likely involve both behavioral and physiologic processes. The present review highlights current knowledge on the changes in dietary intake and eating behavior that occur after bariatric surgery in terms of the potential threats these changes might pose to long-term postoperative success. The paper also identifies several strategies from the nonsurgical weight loss literature that might help optimize long-term weight maintenance after surgery.

Section snippets

Dietary intake and eating behavior after bariatric surgery

In 2008, an American Society for Metabolic and Bariatric Surgery committee published the Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient [8]. Before the publication of these guidelines, no uniform nutritional guidelines were available to guide both providers and patients. Although this document has the potential to provide some degree of standardization across surgical practices, its relatively recent publication suggests that such standardization is likely years away.

Dietary nonadherence

A number of reports have suggested that adherence to the recommended postoperative diet is poor [9], [10]. Caloric intake often increases significantly during the postoperative period [3], [10], [11]. Brolin et al. [11] found that before surgery, RYGB patients consumed 2604 ± 1087 kcal/d, with 18% ± 6% of the calories from protein, 46% ± 9% from carbohydrates, and 36% ± 8% from fat. At 6 months postoperatively, the patients consumed 890 ± 407 kcal/d, with 20% ± 7% from protein, 48%% ± 11% from

Malnutrition

Although the total caloric intake typically increases during the postoperative period, a subset of patients experience malnutrition. There has been surprisingly little prospective study of this issue. Micronutrient deficiencies are not only important for overall health, but also help with long-term weight maintenance, through their role in regulating appetite, hunger, nutrient absorption, metabolic rate, fat and sugar metabolism, thyroid and adrenal function, energy storage, and glucose

Gastrointestinal-related events

Poor adherence to the postoperative diet can also result in nausea and/or “plugging.” “Plugging” has been described as the subjective experience of ingested food becoming lodged in the gastric pouch, leading to pressure and/or pain in the chest [17]. “Plugging” can occur from the overconsumption of pasta, bread, or dry meat but also can occur secondary to stricture formation. In a long-term follow-up of RYGB patients, 43% reported “plugging,” which can lead to reflexive or self-induced vomiting

Maladaptive and disordered eating behavior

The eating behavior of those with extreme obesity has always fascinated the medical and lay communities alike. Before the recognition of obesity as a “disease” within the past decade, it was widely assumed that extreme obesity was the result of profoundly atypical eating behavior, if not overt pathologic eating. As we have developed a greater understanding of the multiple genetic and physiologic contributions to obesity, as well as the significant contribution of the “toxic environment” to the

Strategies to improve dietary intake and eating behavior after bariatric surgery

As noted, there is little denying the success of bariatric surgery in terms of the magnitude of weight loss and the subsequent effect on the medical and behavioral co-morbidities. This is particularly true in the first few postoperative years. However, the limited amount of longer term data currently available suggests that a substantial minority of patients experience significant weight regain and a return to maladapative eating behaviors within the first 5–10 years after surgery [36]. Thus, a

Conclusion and future directions

During the past decade, bariatric surgery has become an increasingly popular treatment option for persons with extreme obesity. Patients who present for bariatric surgery typically do so with poor dietary habits and problematic eating behaviors. Some have formal eating disorders, such as BED or the NES. These factors likely contributed to the development of extreme obesity. Postoperatively, the caloric intake typically decreases and the eating habits often improve during the first postoperative

Disclosures

Dr. Sarwer has consulting relationships with Allergan, BaroNova, Enteromedics, and Ethicon Endo-Surgery and is on the Board of Directors of the Surgical Review Corporation. Dr. West-Smith has a consulting relationship with Ethicon Endo-Surgery. Ms. Dilks reports no disclosures.

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The relationship between theoretically relevant psychosocial and behavioral variables and outcomes of metabolic and bariatric surgery remains unclear. Some studies have found that the presence of psychopathology, disordered eating, and impulsivity, either before surgery or during the early postoperative period, is associated with suboptimal postoperative weight loss. Other studies have not found these relationships.
Examine the relationship between psychopathology, disordered eating, impulsivity, and weight loss 24 months postoperatively.
Two large, urban university health systems.
Participant characteristics were collected using validated interviews, patient-reported outcome measures, and computerized assessment methods. Linear mixed effect models were used to test the association of the variables of interest on percent weight loss (%WL).
Three hundred participants were enrolled at baseline; weight data at 24 months were available for 227 participants; between 181 and 53 individuals completed other outcome measures. The mean %WL was 23.3 ± 9.9% at 24 months. Patients who underwent Roux-en-Y gastric bypass lost more weight than those who underwent sleeve gastrectomy. The presence of subjective binge episodes at baseline was related to a greater %WL at 24 months; there were no other baseline predictors. The presence of eating disorder diagnoses and disordered eating symptoms after surgery were associated with smaller weight losses over 24 months. Current and lifetime psychopathology and impulsivity were unrelated to %WL at 24 months.
Disordered eating after bariatric surgery was associated with a smaller %WL at postoperative year 2. Additional monitoring of these symptoms in the early postoperative period is recommended. Psychotherapeutic and/or dietary interventions may promote more optimal weight loss outcomes.
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Citation Excerpt :
Gastric acid secretion is almost absent in the small stomach pouch after metabolic surgery, which is harmful to iron absorption [38,39]. Fourth, after BS, patients dramatically decrease caloric intake with accompanied by changes in eating habits, including intolerance for meats and dairy products [40]. Study showed that 39% of patients who had undergone BS experienced emesis after consuming high-fiber meats [41].
Several studies have recently conducted to investigate the link between anemia and bariatric surgery (BS). The results from these studies, however, were inconsistent. Therefore, a meta-analysis was conducted to determine whether BS for weight loss is a risk factor for anemia.
Studies were identified relevant papers published a cutoff date of May 2022 for meta-analysis by searching four electronic databases (PubMed, EMBASE, Web of Science and Cochrane Library). Pairs of authors conducted title and abstract, full-text assessment, data extraction and risk of bias assessment, and quality of articles. Random-effects models were used to estimate the pooled effect size and evaluated the overall quality of evidence. The sources of heterogeneity were assessed with I². The Newcastle-Ottawa scale (NOS) was used to assess the methodologic quality of selected studies. The publication bias was assessed using funnel plots and Egger's test statistics.
In all, eight studies comprising 3150 patients were finally included in the final study analysis. Of these, pooled analysis of eight studies detecting association between anemia and BS for weight loss yield a statistically significant correlation (SMD −1.12 (−1.46—−0.78, I² = 93%). Subgroup analyses were performed according to postoperative follow-up time and operation method. Before 24 months postoperatively, no patient had a significant decrease in hemoglobin. More than 24 months after BS, patients show a significant reduction in hemoglobin. In addition, the hemoglobin level was not changed after sleeve gastrectomy (SG) and adjustable gastric banding (AGB) (SMD −0.19 (−1.04—0.67, I² = 0% for SG; SMD −0.30 (−0.82—0.22 for AGB), but the hemoglobin level was significantly reduced after Roux-en-Y gastric bypass (RYGB) (SMD −1.19 (−1.52—−0.87, I² = 94.2%).
This current meta-analysis found that at 24 months after RYGB, the patient's hemoglobin level was significantly reduced, increasing the risk of anemia. Therefore, attention should be paid to the occurrence of anemia after BS. A large, placebo-controlled, multi-center study is needed to clarify the role of BS for weight loss in this patient anemia.
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Little research has taken individual variability in weight loss into account. Furthermore, physical activity (PA) and eating style (ES) have been linked only sporadically to weight loss longitudinally.
Identify and describe latent classes of weight loss, change of PA, and change of ES up to 5 years after surgery and investigate whether these trajectories are interrelated.
Multicenter outpatient clinic.
This is a retrospective study of data collected during standard treatment before and up to 5 years after surgery. Latent class growth analysis was used to identify trajectories of weight loss (percent total weight loss), PA (Baecke questionnaire), and ES (Dutch Eating Behavior Questionnaire).
A total of 2785 patients were included. Follow-up rate was 84% at 1 year and 34% at 5 years. Analyses revealed 5 weight loss trajectories. Most patients followed an average, fairly stable weight loss trajectory (48%) or an above-average partial-regain trajectory (36%). Other patients followed a low-responder trajectory (9%), a rapid weight loss and weight regain trajectory (6%), or a continued weight loss trajectory (2%). Patients in the most favorable weight loss trajectory were more likely to also follow the most favorable ES trajectories. Patients following the most unfavorable weight loss trajectory were never also in the PA trajectory with an initial great increase in PA.
This study distinguishes demographic and behavioral factors that may influence long-term weight loss trajectories after bariatric surgery. Trajectories varied mainly in magnitude and less in the pattern of weight loss over time, suggesting that very deviant patterns are rare.
Are eHealth interventions for adults who are scheduled for or have undergone bariatric surgery as effective as usual care? A systematic review
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This systematic review aimed to evaluate the effect of eHealth-delivered interventions for adults who undergo bariatric surgery on postoperative weight loss, weight loss maintenance, eating psychopathology, quality of life, depression screening, and self-efficacy. Six electronic databases were searched, with 14 studies (across 17 reports) included, involving 1633 participants. With substantial heterogeneity, qualitative descriptions have been provided. Interventions were delivered via an online program or internet modules (n = 2), telephone (n = 2), text messages (n = 2), videoconferencing (n = 3), mobile application (n = 1), and audiovisual media (n = 1). Three studies included a combination, including internet modules and telephone (n = 1), wireless fidelity scales, emails, and telephone (n = 1), and a combination of online treatment, weekly emails, and access to a private Facebook group (n = 1). All the eHealth interventions, except for one, implemented behavior change techniques, including self-monitoring, problem solving, social support, goal setting, and shaping knowledge. Both eHealth intervention and control groups lost weight across the included studies, and eHealth was found to be as effective as or more effective than the control for weight loss. Two studies measured weight loss maintenance; both eHealth and control groups regained weight in the longer term. The interventions showed significant improvement on assessment measures for eating psychopathology. In conclusion, when bariatric surgery patients have limited or no access to healthcare teams or require additional support, eHealth may be a suitable option. Future studies implementing eHealth interventions would benefit from reporting intervention components as per the behavior change techniques taxonomy and further consideration of delivering eHealth in a stepped care approach would be beneficial.
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Eating disorders are associated with significant medical morbidity and mortality and serious psychological impairment. Individuals seeking bariatric surgery represent a high-risk group for evidencing disordered eating and eating disorders, with some patients experiencing the persistence or onset of disordered eating postsurgery. This review synthesizes the available literature on problematic or disordered eating in the bariatric field, followed by a review of measurement and conceptual considerations related to the use of eating disorder assessment tools within the bariatric population.
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Most patients who undergo bariatric surgery experience significant weight loss and improvements in obesity-related co-morbidities in the first 6–18 months after surgery. However, 20%–30% of patients experience suboptimal weight loss or significant weight regain within the first few postoperative years. Psychosocial functioning may contribute to suboptimal weight loss and/or postoperative psychosocial distress.
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: Supported, in part, by grants from the National Institutes of Health/National Institute of Diabetes, Digestive and Kidney Diseases (grants R01-DK080738 and R03-DK067885) to Dr. Sarwer.

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Review articleDietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success

Abstract

Section snippets

Dietary intake and eating behavior after bariatric surgery

Dietary nonadherence

Malnutrition

Gastrointestinal-related events

Maladaptive and disordered eating behavior

Strategies to improve dietary intake and eating behavior after bariatric surgery

Conclusion and future directions

Disclosures

Surg Obes Relat Dis

Surg Obes Relat Dis

Compr Psychiatry

Surg Obes Relat Dis

Behav Res Ther

Surg Obes Relat Dis

J Am Diet Assoc

Am J Clin Nutr

Am J Surg

Surg Obes Relat Dis

Am J Prev Med

Am J Clin Nutr

Surg Obes Relat Dis

Surg Obes Relat Dis

J Psychosom Res

Bariatric surgery: a systematic review and meta-analysis

JAMA

Meta-analysis: Surgical treatment of obesity

Ann Intern Med

Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery

N Engl J Med

Swedish Obese Subjects study: effects of bariatric surgery on mortality in Swedish obese subjects

N Engl J Med

Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients

Ann Surg

Follow-up of nutritional and metabolic problems after bariatric surgery

Diabetes Care

Psychosocial and behavioral aspects of bariatric surgery

Obes Res

Obese patients have inadequate protein intake related to protein intolerance up to 1 year following Roux-en-Y gastric bypass

Obes Surg

Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass

Ann Surg

Discrepancy between self-reported and actual caloric intake and exercise in obese subjects

N Engl J Med

Nutritional consequences of bariatric surgery

Curr Opin Clin Nutr Metab Care

Evidence for diminished B12 absorption after gastric bypass: oral supplementation does not prevent low plasma B12 levels in bypass patients

J Am Coll Nutr

Nutritional status seven years after Roux-en-Y gastric bypass surgery

Surgery

Nutrient deficiencies secondary to bariatric surgery

Curr Opin Clin Nutr Metab Care

Long-term follow-up of patients' status after gastric bypass

Obes Surg

Bowel habits after bariatric surgery

Obes Surg

A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters

Ann Surg

Eating inventory manual

STOP Regain: are there negative effects of daily weight?

J Consult Clin Psych

Internal disinhibition predicts weight regain following weight loss and weight loss maintenance

Obesity

Review article
Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success

Evidence for diminished B₁₂ absorption after gastric bypass: oral supplementation does not prevent low plasma B₁₂ levels in bypass patients