By means of structured interviews via the phone, we ran a retrospective study on 399 bariatric patients to assess their dietary eating habits and reasons for poor compliance. Majority of the patients 98% had sleeve gastrectomy and only 2% received mini gastric bypass. The mean age was 35.21 ± 10.45, in which 178 (44.6%) were male, and 221 (55.4%) were female. Bariatric surgery is already known to be very effective. The “forced behavioral changes” in the first few months post-surgery leads to a rapid weight loss. But what about the long run? Gastric and intestinal adaptation are expected to occur two years following the surgery.[14] Freire et al. revealed some weight gain in the second year, second to the fifth year, and over five years to be 14.7%, 69.7%, and 84.8%, respectively.[15] It might be influenced by the reduction in the frequency of dumping symptoms, resolution of food intolerances, and return to preoperative eating and other lifestyle patterns that initially contributed to weight gain.[16]
In the present study, the final score of healthy eating assessment was relatively acceptable, as the majority 341 (85.5%) scored “good”, 50 (12%) scored “fair”, and none had scored “needs improvement”. General nutritional guidelines post-surgery prioritize protein intake, minimizing high carbohydrate and high fat foods, eliminating caloric beverages, and increasing the consumption of fruits and vegetables.[17] Fruits and vegetables provide the body with a wide range of nutrients.[18] In our study, the average intake of fruits and vegetables were “once daily” 1.51 ± 0.79, and 1.78 ± 0.76, respectively. These averages are lower than the recommended. Low consumption of fruits and vegetables has been reported in other extended follow up studies.[18, 19] Inadequate nutritive intakes may lead to haematological, metabolic, and neurological disorders.[20–22]
A high percentage of patients in our study had an obese family member 272 (68.2%) with an average of 2.42 ± 1.64 per family. Frequency of drinking sweetened beverages is “once daily” 4.28 ± 1.02. However, we did not measure the quantity of food/drink assumed thus, once daily can either be in high quantity affecting patients’ weight loss or in minimum to satisfy the apatite. Out of this large sample size eight patients scored “excellent” which represents 2% only. A comprehensive nutritional education should be delivered for all, both obese and non-obese, supporting those who need to make healthier dietary choices and to improve body health reaching maximum bariatric treatment’s efficacy.
“What keeps you away from eating healthier?” Well, 48.4% reported poor self-discipline as their main barrier. Loss of control over eating is a proxy for binge eating, as post-bariatric patients cannot consume large quantities of food in one sitting.[17] Saunders observed that many patients report feelings of loss of control over eating after bariatric surgery and, in some cases, weight gain after several years.[23] Changing the mindset over binge eating is quite tough and challenging. It necessitates big support from a dietitian, a psychologist, and a family member. Nevertheless, patient’s motivation and willingness to lose weight are important for the surgery to be effective.[24, 25] Diet adherence showed to be successful when patients are highly motivated.[26] Unfortunately, around thirty percent of our patients report a lack of motivation. More interestingly, a minority of patients, all were female, stated that they stopped being strict over their lifestyle not to lose more weight for their own perspective of body image, and preventing having excess skin.
An increase in physical activity after bariatric surgery is beneficial and effective for weight loss, maintaining lost weight, and improving body composition.[27, 28] It is highly recommended to start physical activity before and after the surgery to preserve lean body mass, boost cardiometabolic risk factors, and increase cardiovascular capacity as well as aerobic performance.[29, 30] It is advised to exercise at least 150 minutes per week.[31] Patients who exercise can lose on average 3.6 kg higher than the 1.5 kg of parallel meta-analysis study of non-surgical weight loss.[27, 32] In our study, only 55.9% obtained ≥ 30 minutes per day of physical activity, which is similar to what has been reported in other studies.[9, 15, 18] On the other hand, 47% of patients stated lack of time as their primary reason for not exercising regularly, followed by low self-discipline and weather, which counted for 38%, and 32%, respectively. In another study, the most commonly endorsed external barriers were time and weather.[33]
To conclude, 399 patients were assessed post bariatric surgery for dietary habits and reason of poor compliance. Majority scored “good” on the healthy eating assessment and while none had scored “needs improvement”, only 2% scored “excellent”. Poor dietary habits were found to be associated with fruits and vegetables. The main reasons for patient non-adherence were most commonly: low self-discipline, followed by a lack of motivation. When it comes to physical activity, a little more than half of the patients obtained ≥ 30 minutes per day of physical activity. Lack of time, low self-discipline, and weather were the primary reasons for not exercising regularly. As the surgical population is growing, a global drive should be taken to reduce the prevalence of obesity worldwide. We call for more randomized control trials headed to correct addressed reasons for poor adherence. We recommend the use of new technology to support and motivate patients through video appointments, group therapy, and smartphone applications. Hand in hand, toward outstanding results, future with fewer diseases, more self-satisfaction, and better quality of life.
Limitations
A limitation is a single-center and patient-report based study. Patients may have reported adherence in a socially desirable manner, and it may also involve recall bias. Yet, the large number of patients being interviewed and the patient-perspective reasons for difficulty adhering gives valuable information improving the long-term results of bariatric surgery.