Exploring Behavioral and Psychological Influences on Weight Regain and Weigh Loss After 3 Years Undergone Bariatric Surgery: In-Depth Exploration

doi:10.21203/rs.3.rs-4658634/v1

Download PDF

Research Article

Exploring Behavioral and Psychological Influences on Weight Regain and Weigh Loss After 3 Years Undergone Bariatric Surgery: In-Depth Exploration

https://doi.org/10.21203/rs.3.rs-4658634/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background: Bariatric surgery is often regarded as the gold standard treatment for obesity. However, the long-term success of this intervention depends not only on the procedure itself but also on subsequent behavioral and psychological adaptations.

Objective:This study aimed to in-depth explore the behavioral and psychological factors influencing weight gain or loss among participants three years post-bariatric surgery.

Methods: Employing a mixed-methods approach, the study combined descriptive quantitative and interpretative qualitative methodologies to achieve a comprehensive analysis. Data were collected through questionnaires for quantitative insights and in-depth interviews for qualitative exploration. This methodological integration allowed for a thorough examination of a wide range of variables affecting post-surgical weight management.

Results: The findings revealed a wide variance in the percentage of weight regain among participants, ranging up to 89.0% of the lowest weight achieved post-surgery. Almost half of the participants with obesity perceive themselves as overweight rather than with obesity. The majority of participants did not change their lifestyle after the surgery. Seventy-five percent are not following any nutritional or dieting programs, and only less than 12% engage in any physical activity, with a higher level of sedentary lifestyle.

Conclusion: These results revealed the complex interplay of factors that influence weight management after surgical intervention. The recurrence of obesity among the participants was primarily attributed not to the surgical procedures themselves but to insufficient postoperative behavioral changes, underscoring the necessity for integrated support systems focusing on lifestyle modifications and psychological support to enhance long-term surgical outcomes.

Bariatric surgery

obesity

weight regain

behavioral change

psychological factors

mixed-methods study

Long-term success post-bariatric surgery is heavily dependent on patients' ability to adapt their behavior, including dietary habits and physical activity, highlighting the need for comprehensive behavioral support programs post-surgery.
There is a significant variation in the percentage of weight regain among individuals’ post-surgery, indicating that the effectiveness of bariatric surgery can vary widely based on individual behavioral changes and psychological adjustments.
Effective postoperative care should integrate nutritional guidance, physical activity plans, and psychological counseling to support sustainable health improvements and prevent weight regain.

Metabolic/bariatric surgery is recognized as the most effective and long-lasting treatment for severe obesity, offering substantial weight loss. Additionally, it facilitates the improvement, prevention, or resolution of various comorbidities associated with obesity, including type 2 diabetes, heart disease, hypertension, sleep apnea, and certain forms of cancer [1, 2].

The American National Institutes of Health (NIH) aimed to comprehensively address the surgical treatments for severe obesity [1]. This included discussing the criteria for patient selection, assessing the efficacy and risks associated with these surgical interventions, and recognizing the need for ongoing research and epidemiological evaluation of these therapies [1, 2]. Among the key points outlined by the 1991 NIH Consensus Statement on the management of severe obesity are several critical recommendations: nonsurgical programs should be considered the initial therapy for severe obesity; patients should undergo a comprehensive selection process for surgery, involving evaluation by a multidisciplinary team; and post-surgical patients should receive lifelong medical surveillance[3]. This consensus statement has been widely adopted by healthcare providers, hospitals, and insurers as the standard for selecting candidates for bariatric surgery.

In addressing the issue of obesity thresholds, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) emphasize that BMI criteria commonly used to define obesity do not uniformly apply across different populations [1]. Notably, in Asian populations, clinical obesity is recognized at a BMI threshold of over 25 kg/m² [1]. Consequently, access to Metabolic and Bariatric Surgery (MBS) should not be denied based solely on traditional BMI risk zones. Furthermore, they recommend MBS under the following guidelines:

MBS is advised for individuals with a BMI over 35 kg/m², irrespective of the presence, absence, or severity of co-morbidities.

MBS is recommended for patients with Type 2 Diabetes (T2D) and a BMI over 30 kg/m².

MBS should be considered for individuals with a BMI of 30–34.9 kg/m² who do not achieve significant or lasting weight loss or improvement in co-morbidities through non-surgical methods.

Children and adolescents with a BMI greater than 120% of the 95th percentile with a major co-morbidity, or a BMI over 140% of the 95th percentile, should be evaluated for MBS by a multidisciplinary team at a specialized center.

In 2017, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) hosted a workshop under the National Institutes of Health titled "Developing Precision Medicine Approaches to the Treatment of Severe Obesity in Adolescents' [6]. The workshop focused on identifying opportunities to accelerate research that advances precision medicine strategies for treating severe obesity among adolescents. The conclusions drawn from the NIDDK workshop emphasized the need for further research to deepen understanding of the factors underlying severe pediatric obesity [6, 7]. This would aid in the development of more effective intervention strategies. The report specifically highlighted the necessity for additional research on metabolic and bariatric surgery (MBS) in adolescents, as well as how behavioral lifestyle interventions could be integrated to support these young individuals [6, 7].

However, In late 2022, the Saudi Council of Health Insurance introduced a new policy mandating that all private health insurance companies provide coverage for all types of bariatric surgery for individuals with a Body Mass Index (BMI) of 30 kg/m² or higher [4, 5]. The maximum coverage provided under this mandate is USD 5,000, with a deductible of 20% [4, 5].

Despite compelling evidence that post-operative adherence leads to better outcomes in weight loss, weight-loss maintenance, mental health, and overall quality of life, patients often struggle to consistently implement recommended lifestyle changes [8, 9]. These modifications include adopting a healthier diet, increasing physical activity, and managing psychological factors. The psychological challenges, which may include emotional eating, consuming high-caloric foods, night eating, and managing stress and depression, can ultimately contribute to weight regain, reduced quality of life, and increased risk of depression and anxiety [7–9].

To our knowledge, no study has extensively investigated the behavioral and psychological factors influencing weight regain or loss among individuals who have undergone bariatric surgery in Saudi Arabia. Therefore, the aim of this study is to in-depth explore the behavioral and psychological factors that affect weight gain or loss among participants post-bariatric surgery. The study specifically focuses on exploring change stages occurred after 3 years of having the operation.

Study Design:

A mixed-methods approach was employed, incorporating both descriptive quantitative and interpretative qualitative methodologies. This integration facilitated a comprehensive analysis and interpretation of data from multiple research perspectives, enabling the exploration of an extensive set of variables[10, 11]. Accordingly, data collection was conducted using two parallel techniques: questionnaires for quantitative analysis and in-depth interviews for qualitative exploration.

Participants and Instruments:

The inclusion criteria

The inclusion criteria for the study specified participants from both genders, adults only aged between 18 and 60 years, had undergone surgery at least 18 months prior to the study, Arabic speakers, and resided in any region of Saudi Arabia. Verbal consent was obtained prior to data collection, which was conducted quantitatively via telephone interviews and qualitatively through in-depth interviews using Zoom. All interviews were initiated and systematically recorded in the data collection system.

The Instruments Development

Qualitative

Instrument Design

This study employed a semi-structured questionnaire, meticulously designed to capture comprehensive insights into the participants' lives before and after bariatric surgery. The questionnaire was divided into two main sections.

Pre-Surgery Assessment

The first section focused on life before the surgery. It encompassed a broad range of topics including:

Lifestyle and Eating Behaviors: Participants described their dietary habits and eating behaviors such as fast-food eating, sweet and salted food consumption.
Obesity History: Inquiry into personal and family history of obesity.
Health and Mental Health Status: Assessments of overall health and mental well-being before the surgery, if the participants were feeling stigmatized due to their weight.
Previous Loss Weight Attempts: Exploration of any non-surgical or surgical attempts made to address obesity.
Motivations for Surgery: Participants discussed what motivated their decision to undergo surgery, who made that decision, including their perceptions of the causes of their obesity and reasons for choosing surgical intervention.
Physical Activity and Sedentary Lifestyle: participants were asked in general to assess their levels of physical activity and sedentary behaviors to understand their pre-surgery lifestyle dynamics.

Post-Surgery Assessment

The second section explored the participants' current lives, exploring how they have changed since undergoing surgery:

Eating Behavior Changes: This included changes in dietary habits and consumption.
Mental and Overall, Health: Assessment of mental health status and overall well-being following surgery.
Physical Activity and Sedentary Lifestyle: Current levels of physical activity and patterns of sedentary behavior.
Surgical Complications: Exploration of any complications that have arisen since the surgery.
Plastic Surgeries: Information on any subsequent plastic surgeries to enhance body shape or address issues such as sagging skin.
Weight Regain: Participants discussed instances of weight regain and their perceptions of the causes.

Pilot Testing

Prior to the main study, the interview guide underwent a rigorous pilot testing process with five volunteers who had undergone bariatric surgery in the past five years. The aim was to refine the questions to ensure clarity and relevance. Feedback from the pilot was used to make minor adjustments to the wording of questions to avoid ambiguity and to better prompt detailed responses.

Quantitative

In this study, the Sharik Diet and Health National Survey (SDHNS) was employed as the primary data collection tool, augmented with additional questions pertinent to bariatric surgery [12]. The questionnaire is comprised of multiple domains and subdomains, which are detailed as the following:

Demographic Variables: This section encompasses age, gender, marital status, and for female participants, an inquiry regarding current pregnancy status.
Health Status: This domain covers participants' self-rated health, current diagnoses and taking medications for managing chronic diseases and presence of food allergies.
Related to Bariatric Surgery: This domain assesses surgical details and outcomes, including the type of bariatric surgery undergone, time passed since surgery, weight prior to surgery, lowest weight achieved post-surgery, current weight, frequency of self-weight, wight reception, frequency of follow-up appointments in the last 6 months, any following surgeries (such as plastic surgery for body contouring or lifting and additional surgical and non-surgical procedures), obesity history, use of weight loss medications or injections and complications after the surgery.
Mental Health Assessment: This domain encompasses two main sub-sections:

Mental Health Risk Assessment: This sub-section evaluates the risk of mental health conditions, focusing specifically on depression and anxiety. The risk of depression is assessed using the Patient Health Questionnaire (PHQ-9), and the risk of anxiety is measured with the Generalized Anxiety Disorder (GAD-7) scale.
Eating related to phycological factors: This sub-section assesses behaviors associated with eating, including eating in response to feelings of stress, emotional eating; frequent thoughts about food; losing control over the quantity of food consumed; eating when feeling lonely; experiencing guilt associated with eating.

Anthropometric: Self-reported weight, time of last weight measurement, height. BMI then generated based on weight and height on three categories: 1) based on weight prior to surgery, 2) based on weight at the lowest achieved weight and 3) based on current weight.
Behavioral Assessment: This domain covers three main sub-dominos related to behavior such as:

Smoking Behavior: This sub-domain investigates the use of tobacco and related products, including cigarettes, waterpipes (shisha), and vaping devices.
Physical Activity and Sedentary Lifestyle: This sub-domain assesses physical activity levels, including the frequency of engagement in moderate and vigorous activities per week, as defined by the World Health Organization (WHO). Also, participants were asked if they have currently GYM membership. Additionally, it evaluates sedentary behavior by measuring the number of hours spent sitting, whether for office work during working hours or for leisure activities such as watching TV and playing video games. In addition, participants efforts to manage their current weight.
Dietary Behavior: This sub-domain assesses many sub-sections including:

Eating Consumption: This sub-section captures the dietary intake of various food items, including different sources of protein like red meat, chicken, fish. It also assesses the consumption healthy options like vegetables and fruits. Additionally, this section includes the intake of various drink types, ranging from canned and natural juices to carbonated drinks.
Eating Behavior: This sub-section assesses patterns in eating behaviors, focusing on the frequency of fast-food. It also examines the tendency to skip breakfast, the total number of meals consumed daily, and snacks intake. In Addition, eating while watching TV, nighttime eating habits, high consumption of sweets, pastries, and high-calorie foods, social eating contexts, and a lack of calorie monitoring.

These supplementary questions underwent linguistic validation to guarantee their clarity and relevance to the study's objectives. Subsequently, a pilot study involving 7 participants was conducted to test the final version to get final feedback on the clarity and understanding of the items.

Data Collection:

Quantitative :

In this phase of the study, cross-sectional design approach was employed for the quantitative phase of data collection. The data collection was automated and managed by the ZDataCloud® governance system, which operates without human intervention, thereby reducing sampling bias [13]. The utilization of ZDataCloud® ensured that there were no missing values in the research data [13]. Specifically, the Sharik Diet and Health National Survey (SDHNS) employs a structured telephone interview process conducted by trained interviewers [12]. Each interview was reordered for quality assurance. Additionally, the management of a participant database constitutes another key operation within the organization [14]. This function involves registering potential research participants and educating them on the importance of research participation, adherence to research ethics, and the significance of data quality[14]. Since its establishment in 2015, Sharik has maintained a growing database comprising now over 300,000 potential research participants, accurately reflecting the demographic composition of Saudi Arabia[14]. Moreover, the ZDataCloud system incorporates a data integrity validation feature [13]. This feature serves as a safeguard, designed to prevent erroneous data entry by data collectors and to minimize the incidence of missing data.

Qualitative:

In this phase of the study, a descriptive design was utilized for the collection of qualitative data, an approach well-suited to investigating specific situational issues. The data gathering process involved a semi-structured interview guide, initially developed and pilot tested with seven participants. Due to the minimal need for adjustments post-pilot, these participants were subsequently included in the main study sample.

Participants who had completed the survey was invited to participate to in-depth interviews. These in-depth interviews were conducted by a research team member, a female aged 37 with master’s degree in clinical nutrition and experience in qualitative research. The interviews were facilitated using Zoom®, a video conferencing tool, ensuring each session ranged from 45 to 60 minutes, thereby allowing for a thorough exploration of the topics [15]. Interviews were conducted until data saturation was achieved, evidenced by the repetitive emergence of findings across responses from participants in each province. The researcher employed descriptive notes during the interviews to record personal thoughts and perceptions, which informed the analytical process.

Data Analysis:

Quantitative

Data analysis was conducted using frequencies and percentages to delineate the variables under study. Statistical analyses were carried out using SPSS software, version 29. The presentation and communication of the results adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines specific to cross-sectional studies, ensuring a standardized and rigorous reporting process.

Qualitative

All interview content was methodically transcribed into text data verbatim by one independent researchers within 24 hours of recording. This process involved repeatedly listening to the audio recordings and integrating information from on-site notes. Each section of data was coded anonymously to maintain confidentiality. Following transcription, data analysis was performed iteratively using open coding techniques within the software atlas.ti 8. This method facilitated continuous reflection on the researchers' biases and assumptions. Codes were then systematically organized into themes and subthemes, employing constant comparison techniques to ensure methodological consistency throughout the study.

Ethical approval

The ethics committee of Imam Abdulrahman bin Faisal University approved this research project (Approval no. IRB-OGS-2024-03-352), according to the national research ethics regulations with registration number (HAP-05-D-003).

Quantitative

Forty participants successfully completed both the survey and the interview. Of these, 60% (24 participants) were female. The mean age of the participants was 37.13 years, with a standard deviation of 9.15, a median age of 37.5, an age ranges from 18 to 58 years and 67.5% were currently married. In addition, at the time of collecting data, none of the female were pregnant.

In terms of health self-assessment, the majority of participants rated their health as very good (40%), great (30%), and good (25%). Health conditions among these participants were relatively uncommon: hypertension was diagnosed in 4 participants (10%), hypercholesterolemia in 3 (7.5%), diabetes in 1 (2.5%), arthritis in 3 (7.5%), thyroid disorders in 2 (5%), and Polycystic Ovary Syndrome (PCOS) in 4 female (10%). Additionally, only three participants (7.5%) reported a food allergy, specifically to shellfish.

Regarding bariatric surgery, nearly all participants underwent Sleeve Gastrectomy, with the exception of one individual who underwent Gastric Bypass Surgery. Notably, 10% of the participants are currently using medications such as Ozempic (semaglutide) and Mounjaro (tirzepatide) to augment their weight loss efforts. The percentage of weight regain among participants varied widely, ranging from 1.69% to 89.36% from the lowest achieved weight. Approximately one-quarter of the participants (30%, n=12) experienced significant weight regain, defined as 20% or greater. Further details on participant characteristics can be found in Table 1.

Table 1: Participants characteristic post bariatric surgery. n=40

Characteristics	n (%)
Obesity History
Childhood	9 (22.5)
adolescence	15 (37.5)
Adulthood	5 (12.5)
One or more member of my family is with obesity	11 (27.5)
BMI Prior to Surgery based on self-reported weight and height
Weight - Mean, SD, (min - max)	120, 26.08 (85 - 173)
Obesity (BMI is 30.0 and above.)	40 (100)
BMI at the lowest achieved weight after surgery based on self-reported weight and height
Weight - Mean, SD, (min - max)	71.88, 14.25 (50 - 110)
Underweight (BMI is equal to or lower than 18.99)	1 (2.5)
Normal (BMI is 20.0 to 24.99.)	15 (37.5)
Overweight (BMI is 25.0 to 29.99.)	14 (35.0)
Obesity (BMI is 30.0 and above.)	10 (25.0)
Current BMI based on self-reported weight and height
Weight - Mean, SD, (min - max)	79.63, 18.48 (50 - 115)
Normal (BMI is 20.0 to 24.99.)	10 (25.0)
Overweight (BMI is 25.0 to 29.99.)	12 (30.0)
Obesity (BMI is 30.0 and above.)	18 (45.0)
Self-weight perception
Underweight	1 (2.5)
Ideal	10 (25.0)
Overweight	20 (50.0)
Obese	9 (22.5)
Self-weight
This week	21 (52.5)
Last 2 weeks	10 (25.0)
Last month	4 (10.0)
More than 1 month	5 (12.5)
Preformed Body Lifting orBody Contouring
No	37 (92.5)
Yes	3 (7.5)
Follow Up in the Last 6 Months
No	29 (72.5)
Yes irregularly	8 (20.0)
Yes regularly	3 (7.5)
Complication Post Bariatric Surgery
Sagging	17 (42.5)
Hair lost	11 (27.5)
Vitamin Deficiency	15 (37.5)

Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) with a cutoff score above 10, indicating risks of depression in 15% of participants. Anxiety was measured using the Generalized Anxiety Disorder-7 (GAD-7) scale, with a cutoff score above 10, indicating risks of anxiety in 17.5% of participants. Psychological factors are detailed in Table 2.

Table 2: Psychological Factors

Psychological Factors	n (%)
Depression- at risk	6 (15.0)
Anxiety - at risk	7 (17.5)
Stress Eating - Yes	6 (15.0)
Emotional Eating - Yes	8 (20.0)
Uncontrolled Eating- Yes	12 (30.0)
Passive Eating - Yes	8 (20.0)
Alone Eating - Yes	10 (20.0)
Eating-Related Guilt - Yes	7 (17.5)
Food-Related Pleasure - Yes	10 (25.0)
Food Preoccupation - Yes	11 (27.5)

In describing the lifestyle behaviors of the participants, only one reported smoking both cigarettes and waterpipe, whereas three participants indicated that they use vapes. More details about the behavioral lifestyle of these participants can be found in Table 3.

Table 3: Lifestyle Behavior Determines

Lifestyle Behavior	n (%)
Vigorous Physical Activity (VPA) - Meet 75 min/week.	4 (10)
Moderate Physical Activity (MPA) - Meet 150 min/week.	3 (7.5)
Combined Physical Activity - Meet both recommendation (VPA,MPA).	5 (12.5)
Sitting Office Work
Up to 4 hours	20 (50.0)
5 hours and more	20 (50.0)
Sitting Leisure Activities
Up to 4 hours	12 (30.0)
5 hours and more	28 (70.0)
Effort regard to the current weight
Nothing	6 (15)
Manage the current weight	10 (25.0)
Loss weight	24 (60.0)
GYM Membership
No	26 (65.0)
Yes, but I never go	11 (27.5)
Yes, and I go somedays	3 (7.5)

A significant proportion of participants, 75%, are not currently adhering to any specific nutritional or dieting programs. Furthermore, the majority fail to meet the recommended dietary guidelines for fruit and vegetable consumption. In terms of dietary attitudes, most participants reported behaviors such as night eating, eating while watching TV, and a complete lack of calorie monitoring. Table 4 provides additional details regarding dietary behavior among the participants.

Table 4: Dietary Behavior

Dietary Behavior	n (%)
Eating Consumption
Vegetables
Acceptable Vegetables level	2 (5.0)
Not Acceptable Vegetables level	38 (95.0)
Fruits
Acceptable Fruits level	3 (7.5)
Not Acceptable Fruits level	37 (92.5)
Fish
Acceptable Fish level	8 (20)
Not Acceptable Fish level	32 (80)
Red Meat
Acceptable Red Meat level	20 (50)
Not Acceptable Red Meat level	20 (50)
Chicken
Acceptable Chicken level	19 (47.5)
Not Acceptable Chicken level	21 (52.5)
Natural Juice
Never	21 (52.5)
1-3 time/week	15 (37.5)
4-7 times/week	4 (10)
Canned Juice
Never	27 (67.5)
1-3 time/week	10 (25.0)
4-7 times/week	3 (7.5)
Carbonated Drinks
Never	17 (42.5)
1-3 time/week	18 (45.0)
4-7 times/week	5 (12.5)
Fast Food Meals Per Week
Never	6 (15.0)
1-3 meals/week	10 (25.0)
4-7 meals/week	24 (60.0)
High consumption of pastry- Yes	9 (22.5)
High consumption of sweets - Yes	21 (52.0)
Eating Behavior
Eating while watching TV - Yes	21 (52.0%)
Night eating - Yes	21 (52.0)
Calorie Monitoring Behavior - Yes	8 (20.0)
Social Dining Frequency - Yes	15 (37.5)

Qualitative:

Four main themes emerged from the data analysis: Surgical Decision, Main Aims of Undergoing Surgery, Persistent Behavioral Patterns, and Weight Regain. Each theme is described in detail in the following paragraphs:

Surgical Decision:

The majority of participants reported that a family member, often a spouse, influenced their decision to undergo surgery. Surprisingly, doctors, who should ideally play a crucial role in such significant health-related decisions, were frequently not involved in the initial decision-making process. Participants noted that doctors generally approved the surgery within a few days without extensive consultation. Notably, participants also claimed that no educational materials or information were provided either before or after the surgery. Instead, they were encouraged to independently seek information by listening to and reading about other people's experiences. However, the information they found was often described as unhelpful, lacking in detailed explanations about the changes over time, and the adjustments necessary to adopt and adhere to a new lifestyle. Additionally, many participants reported this lack of support and information as the primary reason for not following up with doctors or healthcare professionals after undergoing the surgery.

Main Aims of Undergoing Surgery:

A significant proportion of participants reported that their primary motivation for undergoing surgery was to achieve a more fit appearance, facilitating the ability to find aesthetically pleasing clothes in smaller and available sizes.

"I want to be able to find clothing in my size without struggling."

Notably, only two participants identified improving their health as a primary goal, asserting that they were in good health prior to the surgery and had no substantial health concerns. Additionally, four female participants reported having Polycystic Ovary Syndrome (PCOS), which they mentioned as a secondary reason for seeking rapid weight loss. These women indicated that the successful outcome of the surgery, particularly the weight loss, assisted them in becoming pregnant within a year following the procedure.

Persistent Behavioral Patterns:

The majority of participants reported that no significant lifestyle changes were made in terms of dieting, adhering to a nutritional program, or increasing physical activity post-surgery. Specifically, participants noticed that consuming healthy foods such as vegetables and fruits frequently resulted in illness and indigestion.

"After the surgery, I haven't been able to eat salad or fruits, even years after the procedure. This might be because it makes me feel full for a long time and cause me discomfort."

They observed that although their eating behaviors did not change radically post-surgery, the quantity of food they consumed did change. Many were surprised by the amount of food they could tolerate or consume in a single meal, and some reported that even three years post-surgery, they struggled to control their portion sizes and tolerance levels. In addition, the majority of participants reported that their appetite for food did not change as much as their ability to eat.

"My biggest challenge, even after the surgery, is that I loss control whenever I ate, similar to before the surgery. I don't know when to stop and what the right portion or plate size should be. This leads me to eat whatever I want first, without considering healthier options".

In terms of protein intake, chicken was reported to be the most consumed type due to its ease of digestion compared to fish and red meat.

" I prefer to eat lamb or beef only when it's ground, because if it's not, I find it difficult to digest. That's why I often choose chicken, as it's easier and faster to digest."

Additionally, many participants reported a preference for consuming more sweets post-surgery, as they found these foods easier to digest compared to healthier options. Typically, sweets satisfied their hunger without inducing the discomfort associated with harder-to-digest, nutritious foods.

Recurrence of Weight Gain:

Weight regains was a prevalent phenomenon among the participants. Participants elaborate weight gain recurrence for the number of reasons. First, many participants reported attempting to lose weight while simultaneously acknowledging that they had not made significant lifestyle changes, such as increasing physical activity or adhering to a diet. Second, several participants expressed efforts to gain weight, dissatisfied with their current appearance and seeking a healthier look.

"Losing more than 43 kilos has left my body and face looking scrawny, which I dislike. For this reason, I am trying to gain weight."

Third, females reported that pregnancies occurring 1-2 years post-surgery contributed to weight gain, which they are now struggling to lose. However, almost all participants who experienced weight gain agreed that

"The social lifestyle nowadays Saudi Arabia, characterized by frequent fast-food consumption and a lack of exercise, are the main reasons for weight gain, whether intentionally trying to gain weight or not".

And finally, some participants reported that ceasing to weigh themselves regularly led to an increase in weight gain.

"Weighting myself makes me nervous and reminder me with old version of me".

This study explores behavior and lifestyle changes among individuals who underwent bariatric surgery after three years. We found that the obesity rate, in terms of BMI, decreased to 25% at the lowest achieved weight post-surgery, then increased to 45% among participants. Interestingly, only half of the participants who were with obesity identified themselves as such. A significant number reported that their obesity began in childhood (22.5%) or adolescence (37.5%).

Many studies have highlighted the challenge of maintaining weight loss over time following bariatric surgery, observing a tendency for individual to regain weight within two to three years post-surgery [7, 16, 17]. Despite claims positioning bariatric surgery as a "gold standard" or " permeant solution" in obesity treatment, a significant portion of individuals who undergo this surgery become with obesity again [18]. Usually, weight regain is associated with the performance of Gastric Bypass Surgery [17-19]. Many studies, including this one, have shown that approximately one in three participants regain at least 20% of their lost weight [17-20]. In a longitudinal study involving 300 Gastric Bypass patients, 37% experienced significant weight regain by the 7-year follow-up, defined as an increase of ≥ 25% from their lowest post-surgery weight [21]. A systematic review found that up to 76% of patients who underwent these surgery experienced significant weight regain by the 6-year follow-up mark [22].

The recurrence of obesity following bariatric surgery is not solely attributable to the ineffectiveness of the procedures for the individual characteristics of patients; rather, it is more frequently associated with a lack of behavioral changes post-surgery [17-19]. Adherence to dietary and lifestyle recommendations is crucial for achieving and sustaining optimal weight outcomes [16, 19]. This study revealed that only a minority of participants adhered to recommended levels of physical activity. Additionally, high levels of sedentary behavior were reported, associated with both leisure activities and occupational demands. These findings align with existing literature on weight management following surgery [19, 23]. In fact, a systematic review demonstrated that participants who have undergone bariatric surgery are less likely to engage in activities that require consistent commitment, such as regular attendance and active participation [23]. This suggests that without significant changes in physical activity, weight may begin to increase again. Consequently, planned physical activity for these participants should be designed to be more intense and sustained over time to maintain weight loss.

Despite the majority of participants reporting attempts to lose weight, 75% did not adhere to any structured diet plan. Additionally, this study reveals that dietary patterns showed poor adherence to healthy foods, with a marked preference for calorie-dense options such as sweets. Furthermore, behaviors such as night eating, inadequate calorie monitoring, frequent eating while watching TV, and regular engagement in social eating were prevalent. This phenomenon has been documented in the literature, showing that patients are most likely to adhere to food and lifestyle recommendations prior to surgery and in the immediate postoperative period. However, adherence tends to decline as more time elapses after the surgery[17, 19, 20].

The eligibility criteria for bariatric surgery are currently limited to BMI and the presence of comorbidities, without a thorough evaluation of an individual's overall health or preparedness for the procedure[24]. Although these surgeries may initially regulate hormones and slow the progression of related diseases, it is evident that these benefits frequently wane after three years, leading to a recurrence of conditions [25, 26]. In 2022, according to the Council of Health Insurance, individuals with a BMI of 30 with comorbidities and 35 without comorbidities are eligible for bariatric surgery, with insurance companies covering up to 70% of the total cost [27]. Before 2022, the majority of participants in this study reported paying for their surgery out-of-pocket. Despite the availability of these surgeries at government centers for obesity and bariatric surgery, there are typically lengthy delays before procedures can be scheduled, as participants often encounter extensive waiting periods.

Regardless, there is a risk that these surgeries may take on a commercial form, whereby individuals deemed eligible for the procedures are provided with minimal information about the significant lifestyle changes required and the potential struggles throughout the journey. Our interviews revealed a significant gap in the provision of information about the surgery and post-operative lifestyle changes. This insufficiency often resulted in participants not engaging in follow-up with their doctors. Several studies have shown Non-adherence to prescribed follow-up schedules can elevate the risk of complications and diminish the long-term efficacy of bariatric treatments. Furthermore, ineffective follow-up reduces the volume of data available for assessing the outcomes and risks associated with various bariatric treatment modalities [28, 29].

In this study, we observed that doctors and healthcare professionals were not involved in the initial decision-making stages for bariatric surgery. Individuals with obesity often approached obesity clinics with a pre-decided intention to undergo surgery, which doctors typically approved within a few days. Almost all participants reported that doctors did not discuss the necessary behavioral adjustments or suggest exploring nonsurgical interventions prior to proceeding with surgery. Instead, participants were often left to initiate these changes on their own, without structured guidance from their healthcare providers. The role of doctors should extend beyond the surgical procedure itself; they should also provide consultations and collaborate with psychiatrists and dietitians to prepare patients for significant lifestyle changes. This preparation should include both pre-operative and post-operative adjustments. Candidates for surgery should demonstrate a commitment to adopting and maintaining a new lifestyle and possess a thorough understanding of the modifications necessary to sustain these changes for long term.

Despite the extensive availability of bariatric surgery centers in Saudi Arabia and the fact that insurance companies now cover 75% of the costs, the obesity rate remains stubbornly high and continues to increase annually. This persistent issue raises ethical concerns not only about the criteria for selecting candidates for surgery but also about the overall success rates of these procedures. Current literature has not yet explored the ethical implications of bariatric surgeries comprehensively. In contrast, other countries often require that nonsurgical methods be tried extensively before surgery is considered, potentially reducing ethical dilemmas. Bariatric surgery is often touted as the "Gold Standard" for weight loss treatment; however, the definition of success remains debated. Despite using various criteria, it is clear that while many patients reach their target weight, others struggle or even regain weight after some time.

The 1998 FDA guidance clearly specifies that the standard efficacy criterion for approving a new drug typically involves conducting "at least two pivotal, adequate, and well-controlled trials," each maintaining a two-sided alpha level of 0.05. This requirement for two trials, often referred to as the two-trial rule, serves to provide independent confirmation of experimental findings. However, bariatric surgeries do not have a similar metric for assessing long-term benefits or approval rates. Without proper regulation and oversight, the practice of bariatric surgery risks becoming overly commercialized, potentially undermining the integrity of the healthcare system.

This study presents several strengths and limitations. It is, to our knowledge, the first in Saudi Arabia to explore the relationship between bariatric surgery and behavioral changes which include physiological and dietary factors.

This study presents both notable strengths and limitations that are important to acknowledge. Among its strengths, the use of a mixed-methods approach enriches the analysis by incorporating both qualitative and quantitative data, providing a comprehensive understanding of the phenomena under investigation. The inclusion of a diverse participant base enhances the generalizability of the results, while the employment of validated instruments ensures the reliability of data collection. Conversely, the study's limitations include a small sample size, which may limit the generalizability of the findings and underpower the study. There is also the potential for selection bias, which could affect the representativeness of the sample. The reliance on self-reported data may introduce response biases, and the cross-sectional nature of some data collection prevents the establishment of causality. These limitations necessitate a cautious interpretation of the study's conclusions and underscore the need for further research.

Ethical approval

Informed Consent Statement:

Informed consent was obtained verbally during the phone inter-view with the participants and recorded in the data collection system.

Conflicts of Interest:

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding:

This research received fund from Informed Decision Making (F-004).

Author Contribution

N.A.A., N.F.B., S.A.A ., and A.A participated in the conceptual design . All authors participated in the development and review of the manuscript. N.A.A., supervised and managed the data collection process. N.A.A. and N.F.B. analyzed the data. All authors have read and agreed to the published version of the manuscript.

Eisenberg, D., et al., 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. 2023, Springer.
Health, N.I.o. Bariatric Surgery. 2011 [cited 2024; Available from: https://www.nhlbi.nih.gov/events/2011/bariatric-surgery.
Brolin, R.E., Update: NIH consensus conference. Gastrointestinal surgery for severe obesity. Nutrition (Burbank, Los Angeles County, Calif.), 1996. 12(6): p. 403–404.
Insurance, C.o.H. Basic Health Insurance Policy. 2022 [cited 2024; Available from: https://chi.gov.sa/en/business/employer/healthinsurancepolicy/Updated%20Essential%20Benefit%20Package%20%20(%20effective%201%20October%202022).pdf.
Althumiri, N.A., et al., Comparative analysis of lifestyle behaviors and dietary intake among obese and non-obese individuals following bariatric surgery: a secondary data analysis from 2020 to 2022. Frontiers in Nutrition, 2023. 10.
Kelly, A.S., et al., Working toward precision medicine approaches to treat severe obesity in adolescents: report of an NIH workshop. International journal of obesity, 2018. 42(11): p. 1834–1844.
Misserian, M., et al., Adaptation of a standardized lifestyle intervention to maximize health outcomes in adolescent metabolic and bariatric surgery patients. Journal of Translational Medicine, 2024. 22(1): p. 197.
Bergh, I., et al., Preoperative predictors of adherence to dietary and physical activity recommendations and weight loss one year after surgery. Surgery for Obesity and Related Diseases, 2016. 12(4): p. 910–918.
Punt, S.E., et al., A semi-structured interview is associated with bariatric surgery outcomes. Journal of Behavioral Medicine, 2024: p. 1–9.
Sharma, L.R., et al., Exploring the mixed methods research design: types, purposes, strengths, challenges, and criticisms. Global Academic Journal of Linguistics and Literature, 2023. 5(1): p. 3–12.
Wasti, S.P., et al., The growing importance of mixed-methods research in health. Nepal journal of epidemiology, 2022. 12(1): p. 1175.
studies, S.A.F.R.A. Sharik Diet and Health Survey. 2019 [cited 2014; Available from: https://sharikhealth.com/attachments/article/89/diet-and-health-survey.pdf.
ZDataCloud. ZdataCloud. 2024 [cited 2024; Available from: www.zdatacloud.com.
Stidies, S.A.f.R.a. Database for Participants Registration. 2015 [cited 2024; Available from: .
Zoom. Zoom. 2024 [cited 2024; Available from: www.zom.com.
Hasan, N.A., et al., Effect of bariatric surgery on weight loss, nutritional deficiencies, postoperative complications and adherence to dietary and lifestyle recommendations: a retrospective cohort study from Bahrain. Sultan Qaboos University Medical Journal, 2020. 20(3): p. e344.
Reis, M.G., et al., Weight regain after bariatric surgery: A systematic review and meta-analysis of observational studies. Obesity Medicine, 2023: p. 100528.
Noria, S.F., et al., Weight regain after bariatric surgery: scope of the problem, causes, prevention, and treatment. Current diabetes reports, 2023. 23(3): p. 31–42.
Miller-Matero, L.R., et al., Post-surgical psychiatric symptoms, maladaptive eating patterns, and lifestyle behaviors associated with weight recurrence after bariatric surgery. Surgery for Obesity and Related Diseases, 2024. 20(3): p. 297–303.
Lobão, S.L., et al., Contribution of Ultra-Processed Foods to Weight Gain Recurrence 5 Years After Metabolic and Bariatric Surgery. Obesity Surgery, 2024: p. 1–7.
Cooper, T.C., et al., Trends in weight regain following Roux-en-Y gastric bypass (RYGB) bariatric surgery. Obesity surgery, 2015. 25: p. 1474–1481.
Lauti, M., et al., Weight regain following sleeve gastrectomy—a systematic review. Obesity surgery, 2016. 26: p. 1326–1334.
James, J.D., et al., A systematic review of interventions to increase physical activity and reduce sedentary behaviour following bariatric surgery. Physiotherapy, 2022. 115: p. 1–17.
surgery, a.s.f.m.a.b. Is Metabolic and Bariatric Surgery Right for You? [cited 2024 01/06]; Available from: https://asmbs.org/patients/is-metabolic-and-bariatric-surgery-right-for-you/#:~:text=Qualifications%20for%20bariatric%20surgery%20in,BMI%20%E2%89%A530%20kg%2Fm2.
Alnajjar, L.I., et al., The remission rate, metabolic changes, and quality of life assessment among patients with type 2 diabetes post-bariatric surgery in Riyadh, Saudi Arabia: A cross-sectional study. Saudi Medical Journal, 2023. 44(7): p. 694.
Aminian, A., et al., Late relapse of diabetes after bariatric surgery: not rare, but not a failure. Diabetes care, 2020. 43(3): p. 534–540.
Insurance, C.o.H. Updated Essential Benefit Package (effective 1 October 2022). 2022 [cited 2024 01/06]; Available from: https://chi.gov.sa/en/business/revenue-cycle-comp/healthinsurancepolicy/Updated%20Essential%20Benefit%20Package%20%20(%20effective%201%20October%202022).pdf.
Nurczyk, K., et al., Follow-up after bariatric surgery: are we effective enough? Videosurgery and Other Miniinvasive Techniques, 2022. 17(2): p. 299–302.
Gould, J.C., et al., Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surgery for Obesity and Related Diseases, 2007. 3(6): p. 627–630.

No competing interests reported.

Download PDF

Reviews received at journal
15 Sep, 2024
Reviewers agreed at journal
09 Sep, 2024
Reviewers agreed at journal
08 Sep, 2024
Reviewers agreed at journal
23 Jul, 2024
Reviews received at journal
23 Jul, 2024
Reviewers agreed at journal
22 Jul, 2024
Reviewers invited by journal
12 Jul, 2024
Editor assigned by journal
11 Jul, 2024
Submission checks completed at journal
09 Jul, 2024
First submitted to journal
29 Jun, 2024

You are reading this latest preprint version

Exploring Behavioral and Psychological Influences on Weight Regain and Weigh Loss After 3 Years Undergone Bariatric Surgery: In-Depth Exploration

Status:

Version 1

Abstract

Key Points

Introduction

Methodology

Study Design:

Participants and Instruments:

The inclusion criteria

The Instruments Development

Qualitative

Instrument Design

Pre-Surgery Assessment

Post-Surgery Assessment

Pilot Testing

Quantitative

Data Collection:

Quantitative :

Qualitative:

Data Analysis:

Quantitative

Qualitative

Results

Discussion

Declarations

Ethical approval

Informed Consent Statement:

Funding:

Author Contribution

References

Additional Declarations

Status:

Version 1