Weight Regain Following Obesity Treatment is not Only Common, it’s Expected

| August 1, 2019

by Christopher D. Still, DO, FACN, FACP

Co-Clinical Editor of Bariatric Times; Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity Research Institute at Geisinger Medical Center in Danville, Pennsylvania.


Dear Friends and Readers,

By now you know that one of my favorite and most frequently used take-home messages to my patients is the importance of having realistic expectations through all stages of their weight loss journey. Though some might find it disheartening to accept the possibility weight regain, we have a responsibility to give them the facts; research shows that weight regain is not only common, it is expected following nearly all obesity treatment modalities.

We know from multiple studies we can expect the following mean weight loss percentages according to the various treatment modalities:

  • Diet, Exercise, and behavior modification: 3–5%
  • Diet, exercise, and behavior modification plus Pharmacotherapy: 9-15%
  • Endoscopic interventions: >15%
  • Gastric bypass or sleeve gastrectomy: >30%

Step 1: Encourage accountability and follow-up. Bariatric surgery patients are likely to experience a weight gain of approximately 5-10 percent from their lowest weight, and so patient education is important. One way in which we can help patients prepare for weight regain is by encouraging continued accountability and follow-up, which leads to a greater chance for early intervention. With technology literally at our fingertips, keeping track of diet, physical activity, and weight on a day-to-day basis has never been easier. Apps like Geisinger’s free Get-2-Goal app can be customized to patients. The Get-2-Goal app provides personalized weight goals and displays trends of expected weight loss over time. It assists current, future, and prospective patients with weight loss expectations following Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass Surgery (RYGB). It even calculates the individual’s probability resolving Type 2 diabetes mellitus.

Step 2: Anticipate when weight regain is likely to occur. Another major factor of preparation is anticipating the “when” of weight regain. Weight regain usually occurs 9 to 12 months following a surgical intervention.

Step 3: Investigate the “why.” Just because we are expecting to see weight regain doesn’t mean we should dismiss it as solely a case of patients “falling off the horse” in terms of diet/exercise regimen adherence. Weight regain is multifactorial and usually diagnosed by evaluating a patient’s medical history and weight over time. There are multiple possible causes of weight regain, some of which require further attention. The following discusses the different categories that might contribute to weight regain:

Dietary intake. Dietary “indiscretion” is the most common cause of weight regain following bariatric surgery. Between 12 to 16 months postoperative, patients often change from eating 2 to 3 structured meals per day to more of a “grazing” pattern. Moreover, the macronutrient composition changes from predominately protein to more carbohydrates and soft calories that may increase appetite. 

Exercise and physiologic influences. Like diet, patient’s adherence to their recommended physical activity may tend to dwindle in the postoperative months/years. Exercise is a crucial part of weight maintenance. Following rapid weight loss patients can experience decreases in muscle mass, and resultant, decreased resting energy expenditure.  Physical activity helps maintain muscle mass which, in turn, maintains ones resting energy expenditure.  An individual’s weight is influenced by several factors, including genetics, environment, and hormonal regulation.  There are several physiologic factors that our body possesses to maintain one’s adiposity and regain weight.  This “set point” or weight range in which our bodies are programmed to function optimally. When weight is reduced by dieting or other means, hormone levels and adipocytes signal the brain to increase appetite. Because of these processes, it is often difficult for people to maintain a significant weight loss over a long period of time without some weight regain.

Depression. Depression is another cause of weight regain that can occur in the immediate postoperative period (~6-8 months). It can cause some patients to “self-medicate” with food, especially carbohydrates, often falling into the grazing eating pattern.  It’s important to screen patients for depression using an objective depression inventory.

Medications. Another consideration for weight regain are medications. It is important to take a thorough medication history to ensure that the medications that patients are taking are not causing weight gain or inhibiting weight loss.

Anatomical. Though uncommon, some patients experience more rapid weight gain following surgery due to an anatomical change. For instance, a gastro-gastric fistula may be present after a RYGB causing reflux symptoms and weight gain. There may be an overly dilated anastomosis, or a larger than expected sleeve following months after a SG. Anatomical defects can often be detected using upper gastrointestinal (UGI) or computed tomography (CT) scan with contrast. These should be reviewed by a bariatric surgeon who are familiar with bariatric procedures.

In summary, weight regain is common following all weight loss modalities. Due to genetics and physiological pathways that our bodies possess to maintain weight, weight regain is not the FAULT of the patient. Like other chronic, relapsing diseases, consideration for adjunctive pharmacologic treatment with anti-obesity medications is warranted and can be very effective.  Early intervention is key and therefore education about weight regain and continued accountability provides the greatest chance for long-term success.

Sincerely,

Christopher D. Still, DO, FACN, FACP 

Source: Still CD. The Why: Exploring the Medical Side of Weight Regain. Presented at Your Weight Matters Convention & EXPO 2019. Orlando, Florida. August 2, 2019  

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