Lindsay Parry The physical, psychological and financial benefits of weight loss following bariatric surgery are widely recognised across the literature. Weight regain is unlikely to be considered by individuals when first embarking on bariatric surgery. Accurately quantifying weight regain/unsuccessful weight loss is difficult due to a lack of clear agreed definitions. That said, around 20–30% of individuals will not achieve successful weight loss and 5–30% will regain weight. The consequences of weight regain can be devastating, both physically and psychologically, leading to the recurrence of pre‐existing co‐morbidities as well as deterioration in quality of life. Following bariatric surgery, the most significant weight loss tends to occur in the first 6–12 months with weight nadir being achieved by 12–18 months in most individuals. Thereafter, a period of weight stability, with weight regain, occurs from about 24 months onwards. Weight regain following surgery is multifactorial. It is not procedure specific and will differ from one individual to another. Karmali et al. conducted a systematic review and defined causative factors for weight regain as follows: More often weight regain results from a combination of these factors and in practice we recognise that environmental factors including living arrangements, finances and relationships are also contributing factors. This chapter focuses on the nutritional aspects concerning weight regain. Once an individual is deemed to have met eligibility criteria for bariatric surgery, a multidisciplinary weight management programme is recommended. This includes a detailed nutritional assessment from a registered dietitian. As well as looking at dietary intake, this assessment will encompass readiness to change, goal setting and behavioural, environmental, cultural and financial factors that may act as barriers to success. This is an opportunity not only to identify any nutritional deficiencies but also to recognise any gaps in nutritional knowledge and start to introduce the main principles of eating after bariatric surgery to maintain nutritional status and prevent nutritional complications. Expectations are explored and clarified at this stage. Maleckas et al. claim pre‐operative information may have an impact on an individual’s expectations and ability to resist weight regain. A study has shown only 10% individuals recall being informed about the possibility of weight regain after surgery. The idea of weight regain after surgery usually comes as a shock to individuals. It is important that patients are aware of this early on in the surgical pathway. Clear, uniform dietary guidelines are useful to keep messages consistent prior to and after bariatric surgery and will help improve understanding and awareness of physical versus psychological hunger. Recommended dietary guidelines should be based on guidance from national societies such as the American Society for Metabolic and Bariatric Surgery and the British Obesity and Metabolic Surgery Society. Regular meals will allow the variety and quantity of nutrients required, especially as appetite will be significantly reduced and satiety reached earlier after surgery. For example, protein‐rich foods tend to be more difficult to manage; therefore, only small amounts are tolerated in one sitting. Recommendations for protein after bariatric surgery are higher than normal (60–120 g per day) to preserve lean body mass during the period of rapid weight loss. More regular meals allow more opportunity to meet these requirements. Planning is essential to manage regular meals and allows for controlled and mindful eating. This can be helpful in managing portion control and also preventing spontaneous eating or ‘grazing’ behaviour that could in turn lead to an increased energy intake. Pizato et al. concluded there was consistent evidence that grazing behaviour leads to weight regain regardless of bariatric procedure. Individuals who do not eat slowly tend to get food stuck or regurgitate following weight‐loss surgery. If individuals do not allow adequate time for meals, a maladaptive eating pattern can begin to form and foods are chosen because they will go down easily (often referred to as ‘slider foods’) such as crisps, biscuits, chocolates and sweets that all have high energy density. This can lead to a ‘grazing’ style of eating. A systematic review and meta‐analysis by Robinson et al. that examined the effect of speed of eating on energy intake and hunger found evidence that indicated a slower eating rate was associated with a lower energy intake. The same review highlighted several mechanisms for this, including the effect of gut hormones, sensory exposure (how long the food/flavour is present in the mouth) and the number of sips/bites and chews. The effect on reported hunger however was less apparent. Many patients embarking on bariatric surgery are known to have maladaptive eating behaviours that are thought to lead in part to their obesity. A paper by Moore et al. described compulsive eating behaviour, characterised by habitual overeating, overeating to relieve emotional stress and overeating despite adverse consequences. These are behaviours often reported by individuals pursuing bariatric surgery. The paper likens the behaviours to those with alcohol and drug addictions. Although there is insufficient evidence for the type of treatment needed to address these behaviours, liaising closely with psychologist prior to and after surgery will be advantageous.
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Weight Regain
Introduction
Nutritional Considerations
Regular Meals and Planning (3–6 Small Meals per Day)
Speed of Eating
Overeating
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