Think We Know What Predicts Weight Regain? Think Again

Veronica Hackethal, MD

April 11, 2019

A new study identifies several factors associated with weight regain after bariatric surgery. Other behaviors had less of an association than expected.

"Reducing sedentary behavior, avoiding fast food, addressing binge and loss of control eating, and other specific eating behaviors, such as eating continuously and eating when full, and promoting self-weighing at least weekly were indicated as the most important post-surgery behavioral targets," Wendy King, PhD, from the University of Pittsburgh Graduate School of Public Health, Pennsylvania, told Medscape Medical News.

King and colleagues published findings from the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study online April 4 in Annals of Surgery. The study is the largest long-term investigation to evaluate a large range of patient behaviors related to weight regain after bariatric surgery, the most effective treatment for severe obesity.

Surprisingly, these behaviors were linked to more weight regain than other eating behaviors thought to promote weight regain, such as frequent meals or eating out often in restaurants. 

To understand patient behaviors associated with weight regain after bariatric surgery, the researchers conducted a prospective cohort study that included 1278 adults who had undergone Roux-en-Y gastric bypass surgery at 10 hospitals between 2006 and 2009.

They evaluated the following factors before and every year after surgery: 21 weight control practices, 13 eating behaviors, three aspects of substance use, and four aspects of physical activity. Researchers measured weight a median of eight times during 6.6 years.

Eighty percent of participants were female and 86% were white, with a median pre-surgery age of 46 years and median pre-surgery body mass index of 46 kg/m2.

After adjustment for clinical site, maximum weight lost, and weight loss medication, post-surgery behaviors significantly linked to weight regain included sedentary time (P = .005), frequently eating fast food (P < .001), eating when full (P < .001), eating continuously (P = .04), and disordered eating such as binge and loss of control eating (P < .001).

Weighing oneself at least once weekly was linked to significantly less weight regain (P < .001).

"The behaviors that we identified as independently related to weight regain made sense," King said.

Patient characteristics independently linked to weight regain included younger age (P < .001), high fasting triglycerides (P < .001), venous edema with ulcerations (P = .04), worse physical functioning (P = .001), poor general health (P = .002), and more depressive symptoms (P < .001).

"Because we found that most individual patient characteristics at the time of surgery do not clearly identify those most at risk for poor weight loss maintenance after surgery, it is especially important that clinicians and programs engage with patients early and often after surgery about behaviors that can aid in limiting weight regain," senior author Anita Courcoulas, MD, University of Pittsburgh Medical Center, Pennsylvania, said in a news release.

Twelve weight control practices, including eliminating sugar sweetened beverages, eating fewer carbohydrates, and increasing fruit and vegetable intake, were not associated with weight regain.

The researchers identified few pre-surgical behaviors and mental health issues linked to weight regain. Eating seven or more meals per day before surgery was linked to more weight regain compared with eating once or twice per day before surgery. Surprisingly, eating when full more than once per week and using meal replacements regularly before surgery were not linked to weight regain.

Although surgical candidates are often screened for mental health issues, the results suggest these factors may not be good indicators of which patients will have trouble keeping the weight off.  

The study also provides the best evidence to date that staying active — even when it is not part of an exercise program or just household chores or gardening — is important for weight loss maintenance after surgery.  

The authors mention several limitations of the study, including the inability to account for the influence of genetics, environment, hormones, and metabolism on weight regain.

"Primary care physicians, who see patients much more than surgeons in the years following surgery, should regularly monitor weight and behaviors related to weight regain in patients with a history of bariatric surgery to help patients achieve successful weight loss maintenance," King advised.

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases, Columbia in collaboration with Cornell University Medical Center, University of Washington, Neuropsychiatric Research Institute, East Carolina University, University of Pittsburgh Medical Center, and Oregon Health & Science University. One or more authors report grants from Allurion Technologies, Shire Pharmaceuticals, and/or Stanford Profile.

Ann Surg. Published online April 4, 2019. Abstract

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