By means of structured interviews via phone, we ran a retrospective study on 399 bariatric patients to assess their dietary eating habits and reasons for poor compliance. Bariatric surgery is already known to be very effective. The “forced behavioral changes” in the first few months post-surgery lead to rapid weight loss. However, the results may not last long since gastric and intestinal adaptation are expected to occur two years following surgery. 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. It might be influenced by the reduction in the frequency of dumping syndrome symptoms, resolution of food intolerances, and return to preoperative eating and other lifestyle patterns that initially contributed to weight gain.
In the present study, the final healthy eating assessment score was relatively acceptable, as the majority 341 (85.5%) scored “good”, 50 (12%) scored “fair”, and none 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. Fruits and vegetables provide the body with a wide range of nutrients. In our study, the average intake of fruits and vegetables was “once daily”, 1.51 ± 0.79 and 1.78 ± 0.76, respectively. These averages are lower than recommended. Low consumption of fruits and vegetables has been reported in other extended follow-up studies.[18,19] Inadequate nutritional intake may lead to hematological, metabolic, and neurological disorders.[20-22]
A high percentage of patients in our study had 272 obese family members (68.2%), with an average of 2.42 ± 1.64 per family. The frequency of drinking sweetened beverages was “once daily” 4.28 ± 1.02. However, we did not measure the quantity of food/drink consumed; thus, once daily can either be in high quantity, affecting patients’ weight loss, or at minimum to satisfy the appetite. Out of this large sample, eight patients scored “excellent”, which represents only 2%. A comprehensive nutritional education should be delivered for all, both obese and nonobese individuals, supporting those who need to make healthier dietary choices and to improve body health, reaching maximum bariatric treatment efficacy.
Forty-eight percent reported poor self-discipline as their main barrier for not eating healthier. Loss of control over eating is a proxy for binge eating, as postbariatric patients cannot consume large quantities of food in one sitting. 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. Eating disorders necessitate substantial support from a dietitian, a psychologist, and a family member. Nevertheless, patient motivation and willingness to lose weight are important for surgery to be effective.[24,25] Diet adherence was shown to be successful when patients are highly motivated. Approximately thirty percent of our patients report a lack of motivation. More interestingly, a minority of patients, all of whom were female, stated that they stopped being strict over their lifestyle, not losing more weight in order to maintain their own perspective of body image and prevent having excess skin.
An increase in physical activity after bariatric surgery is beneficial and effective for weight loss, maintaining weight loss, and improving body composition.[27,28] It is highly recommended to start physical activity before and maintain it after the surgery to preserve lean body mass, benefit 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. Patients who exercise can lose on average 3.6 kg more than the 1.5 kg observed in a parallel meta-analysis study of nonsurgical weight loss.[27,32] In our study, only 55.9% of subjects achieved ≥ 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 accounted for 38% and 32%, respectively. In another study, the most commonly endorsed external barriers were time and weather.
To conclude, 399 patients were assessed post-bariatric surgery for dietary habits and reasons for poor compliance. The majority scored “good” on the healthy eating assessment, and while none had scored “needs improvement”, and only 2% scored “excellent”. Fruits and vegetables were found to be consumed less than advised. The main reasons for patient nonadherence were most commonly low self-discipline, followed by a lack of motivation. In regard to physical activity, slightly more than half of the patients achieved ≥ 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 grows, a global drive should be undertaken to reduce the prevalence of obesity worldwide. We call for more randomized control trials aiming 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.
A limitation is that this is a single-center, retrospective cross-sectional, and patient report-based study. Patients may have reported adherence in a socially desirable manner, and this study may also involve recall bias. Assessment of physical activity was limited, as only one question was used. However, the large number of patients being interviewed and the patient-perspective reasons for difficulty adhering provide valuable information for improving the long-term results of bariatric surgery.