Clinical Pearls for Weight Maintenance Following Bariatric Surgery

| November 1, 2016 | 0 Comments

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Course Overview: Long-term weight maintenance and management following bariatric surgery remains a very difficult challenge both for the patient and the multidisciplinary team members working in bariatrics. This article will focus on weight maintenance as the multidisciplinary authors share their expertise to help patients achieving long-term weight maintenance.

Course Description: This educational program is designed to educate, through independent study, multidisciplinary clinicians who care for the postoperative bariatric surgical patients on contributing factors and behaviors that promote long-term weight maintenance.

Course Objectives: Upon completion of this program, the participant should be able to:
1.    Identify common, modifiable behaviors that can lead to weight gain following bariatric surgery.
2.    Explain the benefit and role of long-term follow up after bariatric surgery.
3.    Discuss the role of Physical Activity (PA) and weight maintenance after bariatric surgery.
4.    List prescribed medications that may contribute to weight gain.

Completion Time: This educational activity is accredited for a total of 1.0 contact hour.

Provider: This educational program is provided by Matrix Medical Communications. Provider approved by the California Board of Registered Nursing, Provider Number 14887, for 1.0 contact hour.

About the Instructors: Leslie J. Heinberg, PhD, is Professor, Cleveland Clinic Lerner College of Medicine, Section Head for Psychology, Department of Psychiatry and Psychology, BMI Director of Behavioral Services, Cleveland Clinic, Cleveland, Ohio. Jessie Fernandez, RD, LD, is Bariatric Coordinator, Corpus Christi Medical Center- Bay Area, Corpus Christi, Texas. Holly F. Lofton, MD, is Director of the Medical Weight Management Program at NYU Langone Medical Center and Assistant Professor of Medicine and Surgery at NYU School of Medicine, New York, New York. She is also a diplomate of the American Board of Obesity Medicine. Katelyn Castro, ACSM-CPT, is Fitness Coordinator for Wittgrove Bariatric Center, La Jolla, California, and a dietetic intern with University of CA San Diego Medical Center, San Diego, California. Tracy Martinez, RN, BSN, CBN, is Program Director, Wittgrove Bariatric Center, La Jolla, California. Disclosures: The instructors report no conflicts of interest relevant to the content of this article.

Support for this educational activity is provided by Ethicon

Provider Contact Information: Angela M. Saba, Matrix Medical Communications, 1595 Paoli Pike,Suite 201, West Chester, PA 19380; E-mail: [email protected]

Complimentary Continuing Education Course: Clinical Pearls for Weight Maintenance Following Bariatric Surgery

by Leslie J. Heinberg, PhD; Jessie Fernandez, RD, LD; Holly F. Lofton, MD; Katelyn Castro, ACSM-CPT; and Tracy Martinez, RN, BSN, CBN

Tracy Martinez, RN, BSN, CBN, is Department Editor:
Integrated Health Continuing Education, Bariatric Times; Program Director, Wittgrove Bariatric Center, La Jolla, California. Dr. Heinberg is Professor, Cleveland Clinic Lerner College of Medicine, Section Head for Psychology, Department of Psychiatry and Psychology, BMI Director of Behavioral Services, Cleveland Clinic, Cleveland, Ohio. Ms. Fernandez is Bariatric Coordinator, Corpus Christi Medical Center- Bay Area, Corpus Christi, Texas. Dr. Lofton is Director of the Medical Weight Management Program at NYU Langone Medical Center and Assistant Professor of Medicine and Surgery at NYU School of Medicine, New York, New York. She is also a diplomate of the American Board of Obesity Medicine. Ms. Castro is Fitness Coordinator for Wittgrove Bariatric Center, La Jolla, California, and a dietetic intern with University of CA San Diego Medical Center, San Diego, California.

This article, authored by specialists working in the multidisciplinary bariatric setting, will focus on the following areas related to weight maintenance in the post bariatric surgery patient: 1) behavioral health, 2) nutrition, 3) obesity medicine, 4.) exercise, and 5) nursing. The multidisciplinary authors share their expertise to help patients achieve long-term weight maintenance. Here, they share their clinical pearls and case studies for success in preventing weight regain and achieving long-term weight maintenance.

Bariatric Times. 2016;13(11):10–16.

Morbid obesity is a chronic disease for which we have no cure. However, bariatric surgery remains the most effective and powerful intervention currently known in medicine. After bariatric surgery, a lifelong threat of weight regain exists and will be seen by every practitioner in every program.
There have been many articles, presentations and book chapters written about the prevalence of weight regain and how to manage it following bariatric surgery; however, there are limited articles on how to prevent and maintain a healthy weight postoperatively.

Long-term weight maintenance and management following bariatric surgery remains a very difficult challenge both for the patient and the multidisciplinary team members working in our specialty.
This article will focus on weight maintenance as the multidisciplinary authors share their expertise to help patients achieve long-term weight maintenance. The durability of bariatric surgery from both the weight and co-morbidity standpoint is important not just for the patient, but also for our specialty’s reputation as a successful intervention in the fight against one of the most life threatening diseases of our time—severe obesity. Therefore, every effort should be made to prepare, educate and reinforce to our patients tips to prevent weight regain and achieve long-term weight maintenance.

By Leslie Heinberg, PhD
Weight regain remains a common yet unresolved problem. A number of anatomical and biological factors have been examined; however, the majority of putative factors within the literature relate to psychological factors, eating, adherence, and physical activity. A better understanding of these factors can help guide prevention and intervention into what may predict poorer long-term outcomes.

The bariatric outcome literature has shown that pre-surgical rates of psychopathology—which are common in bariatric surgery candidates[1]—appear to be risk factors for less weight loss[2–3] and post-surgical depression may be associated with less weight loss and/or more weight regain.[4] Stabilization of mood prior to surgery and ongoing monitoring and treatment of psychopathology postoperatively may improve outcomes with particular attention to altered pharmacokinetics which may occur as a result of malabsorptive surgeries.[5]

A number of studies have examined the influence of increased food intake over time[6–7] and disordered eating patterns. A history of binge eating or binge eating disorder prior to surgery is very common in bariatric surgery candidates and has been shown in a number of studies to be associated with less weight loss post-operatively, although this finding has been inconsistent.[8–9]. However, a growing literature has examined the reemergence of “loss of control” eating (since eating binges cannot be objectively large after surgery) as a more important predictor of weight regain.[10–11] Other abnormal eating behaviors may negatively impact bariatric surgery outcomes. For example, night eating syndrome may be associated with greater weight regain[12] as may be “grazing,” wherein patients eat a great deal of food over a long period of time.[13] Early, brief intervention for disordered eating behaviors has been shown to relate to improved early weight loss[14] and post-operative interventions for disordered eating and regain show promise.[15–16]

Beyond dietary change, physical activity plays an important role in altering energy balance post-weight loss surgery.  A recent review that examined physical activity in bariatric surgery patients has revealed that patients who exercised lose significantly more than those that did not.[17] Promoting walking has been recommended as a mode of physical activity that is efficacious and may deliver health benefits, facilitate weight loss, and is generally well tolerated by bariatric surgery patients.[18]

Research on weight loss interventions for non-surgical obese patients may also help illuminate options for post-bariatric surgery weight regain. Studies from the National Weight Loss Control Registry of successful long-term maintainers implicate a number of predictors which may be helpful as well for those who have had surgery as well: eating breakfast regularly, physical activity averaging approximately 60 minutes/day, self-monitoring of weight and a consistent eating pattern across weekdays/weekends.[19]

Behavioral Health Case Study

By Jessie Fernandez, RD, LD
Nutrition is just one of the many important components for a patient’s long-term success after weight loss surgery. Patients start out at all different levels of knowledge when it comes to food and nutrients, so it is important to assess a patient’s understanding of nutrition and use that as the starting foundation to build upon. The main role of the dietitian in post-bariatric care is to help patients create a sustainable nutrition plan that is effective yet realistic in maintaining long-term weight loss.

The main area I suggest patients focus on is meal composition. Even patients with only a basic understanding of food groups are able to have success using this method. I recommend that patients composite their plate in the following way: 50 percent lean protein, 30 percent vegetables, and 20 percent or lesscomplex carbohydrate. I also advise patients to eat in a ratio of 2 to 3 bites of their lean protein per one bite of the other items on their plate. This helps patients to keep protein a priority, while still maintaining a variety in their diet. Although it is true that calorie deficit, regardless of the macronutrient ratio, will result in weight loss, research has shown that keeping a higher percentage of protein to carbs versus the opposition will result in an increased loss of fat mass while minimizing the loss of lean mass.[1] Prioritizing protein, and in turn maintaining muscle mass, will help patients improve their metabolic rate, which will make it easier to sustain a long-term weight loss.[2] It is also known that a diet high in protein compared to carbohydrates can help patients with feeling more satisfied between meals.[3] I find that the first year after surgery patients do not report feeling hungry as often, but as they progress further out, appetite is something that can become more difficult to control. Emphasizing patients stay on a higher protein diet will help them to have more appetite control even after the honeymoon effect of surgery wears off. It is important to monitor a patient’s body fat percentage throughout their weight loss to ensure they are losing fat and not muscle.

A common acclaim in the field of bariatric nutrition is to recommend that patients eat their protein first; however, over the years, I have watched patients struggle with this suggestion. As with any fad diet, patients complain that the sustainability of eating protein first is not realistic because they often fill up so quickly on protein that they aren’t able to eat anything else in their meal. This is problematic as lack of variety is not only detrimental from a physiological standpoint, but it may also affect a patient’s long-term adherence to their meal plan. It’s important to help patients find a balance between meeting proper protein needs while still keeping their daily diet interesting.

Once patients are following the basic meal distribution mentioned above, you can then work to build on their knowledge of healthy cooking methods and more nutrient dense food choices. This should be assessed individually to take into account personal preferences and cultural demands. It’s important that we help patients create a healthy relationship with food so they can learn to indulge without guilt and stay committed to healthy eating habits for the long haul.

by Holly F. Lofton, MD
Providers who care for patients after bariatric surgery, whether in primary care or in the field of bariatrics, have undoubtedly faced the frustrated patient who has regained a noticeable amount of weight beginning months to years postoperatively. While there have been many symposia and articles aimed at treating postoperative weight gain, proactive measures to avoid weight regain should be considered more frequently.

After bariatric surgery a patient can expect to gain 3 to 5 percent of the maximum weight he or she has lost.[1] However, to avoid further weight gain, the work starts PRIOR to the operation. Preoperative nutrition education is of utmost importance. Patients should be informed that many patients regain more weight than expected, usually starting as an insidious gain 12 to 16 months postoperatively, but this can be avoided by close postoperative follow-up.[2,3]

The nutrition consult prior to surgery should include investigation to determine the patient’s individual “trigger foods”. These foods/ behaviors should be avoided postoperatively. In addition, training on keeping a food diary, and enlisting support either via live or online groups should be discussed at this consult. Those who are determined to have potential to eat in response to strong emotions or with a history of binge eating or other disordered eating should consult with a therapist for food and weight related issues prior to surgery. These will serve as the first line of treatment if subtle postoperative weight gain occurs and can be initiated even before the follow-up visit with the surgeon, dietitian, or another provider.[4]
Eating a more liberal diet after surgery is the most frequent cause of postoperative weight gain.[5] Thus, patients should be informed of the importance of eating protein postoperatively. Avoidance of high-glycemic, high-fat, and carbohydrate-rich foods should be emphasized. Most bariatric programs stress the use of liquid protein supplements after surgery in the early postoperative period and also to “reset” the nutrition plan if weight has plateaued early or is increasing faster than desired.  Low-calorie diets (1000–1200 calories a day for most women or 1200–1600 calories for most men) with protein supplements can be used for these reset diet plans. These supplements should be rich in protein of high biologic value to minimize risk of protein deficiency. Most bariatric programs recommend 60 to 80 grams of protein daily after bariatric surgery, though exact needs have yet to be defined.[6]

Of course, physical activity while actively losing weight is highly encouraged. Increasing activity slowly as weight is lost is more tolerable than a sudden increase. Patients can wear pedometers to track activity. Non-exercise activity thermogenesis, for example, walking three minutes of out every hour during an eight eight-hour work day, is important as is meeting physical activity guidelines. Cardiovascular activity should be combined with resistance training to increase lean body mass, which ultimately helps maintain a basal metabolic rate conducive to more weight loss long term without severe caloric restriction. The American College of Sports Medicine recommends 240 to 300 minutes of moderate physical activity weekly to lose weight and 150 minutes weekly to maintain weight (Table 1).[7]
As with any patient trying to avoid weight gain, screening for the situations which make one prone to weight gain is essential BEFORE significant weight gain occurs. This should include dietary recall of liquid calories, assessment of energy expenditure via indirect calorimetry, and possibly psychological/ behavioral counseling. In addition, a thorough review of social history is in order. Bariatric/metabolic surgery patients should be screened for recent negative life events, new societal pressures, and symptoms of eating disordered thinking or behavior, substance abuse, or depression.[7]
Finally, consideration of how medical conditions may influence a patients’ weight gain potential is essential to his/her overall care. Patients should be reminded to follow any medical orders they have been given to maximize his/her weight loss. This may include meeting fluid goals (usually 0.5 oz per pound of ideal body weight), and, for some wearing continuous positive airway pressure (CPAP) mask nightly. Patients should be coached to ask ALL providers about the weight gain potential of any new medications or supplements which are prescribed after bariatric/ metabolic surgery. If a medication has weight gain potential, then the benefit of the medication to the patient should be compared to the potential risk of weight gain for the patient. If the new medication is deemed essential, then early consideration of a low-calorie reset diet or FDA approved medication for weight loss is appropriate. In fact, if during any period after bariatric surgery a patient begins to experience increase in appetite associated with weight gain or notices subtle gain weight loss, medications should be considered if the patient meets criteria for such.

Obesity Medicine Case Study

PART 4: Exercise
By Katelyn Castro, ACSM-CPT
Achieving long-term weight maintenance post-metabolic surgery often requires a multidisciplinary approach. One of the key components for sustained weight maintenance and weight regain prevention post-surgery is physical activity (PA). It is essential to the patient’s success that they are educated on the importance of exercise peri-operatively. Aside from physiological challenges the patient with obesity may exhibit, physical challenges, such as joint and body pain, osteoarthritis, and breathing problems may contribute to the difficulty of adopting a PA program. However, promoting a stance of PA being a health benefit, rather than a performance tool, helps initiate the exercise dialogue with the bariatric patient.[1]

As weight loss occurs during the postoperative period of bariatric surgery, significant decreases in lean body mass (LBM) may also be apparent. When losses in LBM occur, decreased metabolic rates result, thus increasing opportunity for weight regain. When exercise is performed following minimum recommended guidelines (~150 min/week moderate intensity), fat loss can be maximized while LBM losses decrease. Additionally, earlier comorbidity improvement is seen with adherence of general exercise recommendations.[2]

The use of behavior-modified PA helps patient adherence with general exercise recommendations peri-operatively. While 150 mins/week of moderate intensity decreases comorbidities, long-term weight maintenance is achieved through 200 to 300 mins/week of moderate intensity exercise, especially when more than 10 percent total body weight has been lost prior to 24 months.[3] Suggested modalities of exercise include cardiorespiratory endurance training through implementation of a walking regimen or other aerobic activities, and resistance training through weights or calisthenics.
Cardiorespiratory training serves as the main modality for weight loss and weight maintenance, however, focusing on resistance training two to three times per week increases LBM and prevents muscle losses from occurring. Although weight training does not issue the same caloric deficits as aerobic exercise during active sessions, there is evidence that supports increased 24-hour energy expenditure due to LBM accumulations; therefore, aerobic and anaerobic exercise prescription should be considered. If resistance training is prescribed to the bariatric patient, additional recommendations of protein intake may also be warranted; simply due to adequate storage needs for energy, appropriate recovery, and muscle protein synthesis.
While exercise recommendations can be prescribed to bariatric patients pre- and postoperatively, follow up should be considered in determining adherence and assisting with patient motivation. Postoperative PA seems to be reflective of pre-operative PA in that insufficient levels of PA prior to bariatric surgery continue after as well. It is suggested that a behavioral component to PA peri-operatively may enhance adherence to PA recommendations.

Bond et al[4] demonstrated this in a randomized controlled trial called Bari-Active that tested the efficacy of a preoperative PA intervention (PAI) versus standard presurgical care (SC) for increasing daily moderate-to-vigorous PA (MVPA) in bariatric surgery patients. They found that the PAI group achieved a five-fold increase in the amount of PA duration completed postoperatively versus those in the SC program.

PAI application validity is enhanced by SF-36 scores that were measured between PAI and SC groups pre- and postoperatively. Results indicated that preoperatively patients tended to have low health-related quality of life (HRQoL) scores amongst both PAI and SC participants. When surveys were completed postoperatively, it was seen that PAI participants on average had significantly greater improvements on all but one of the SF-36 scales, after controlling for baseline differences.[5] It may be assumed that HRQoL scores increased based on PAI application, but surgical intervention must also be considered as well. Ultimately, the use of a certified exercise professional within the bariatric healthcare team may help the patient improve motivation and understanding in adopting general exercise recommendations, thus increasing clinical outcomes and preventing weight regain as positive attitudes and beliefs towards PA is enhanced.

The role of a fitness coordinator within a bariatric healthcare team can be composed of various components. Preoperative exercise program design and PA counseling to initiate behavior change is the best time to develop coordinator and patient relationships. Speaking to patients regarding realistic expectations pre- and post-op is essential in overall program compliance. Providing an outline of exercise progression postoperative allows the patient to understand how to achieve their goals in an adequate manner without being overwhelmed. For example, 30 mins/day moderate intensity prescription can be split up into three, 10 minute bouts of movement until endurance progresses. Participation in support group activities with occasional presentations continues to facilitate the coordinator/patient relationship.

In conclusion, the role of exercise, aerobic and anaerobic, in long-term weight maintenance and weight regain prevention starts with the bariatric candidate and fitness coordinator relationship, and continues throughout the surgical process and into the weeks, months, and years postoperatively. Developing exercise as a lifestyle behavior is a process that the fitness coordinator is able to initiate by educating and motivating the bariatric patient. Therefore, allowing the patient the confidence and ability to make the decisions to adopt such behaviors and continue on their journey of wellness.

By Tracy Martinez, RN, BSN
Nurses commonly have frequent interactions with the patient postoperatively. We are often the one who monitors the patient’s progress in routine follow-up appointments. Since we are in the best position to pick up on early warning signs that a patient may be getting off track, we can intervene early. Consistent questioning and monitoring is the first step in the recognition of this tracking process.  The repetitiveness reinforces the postoperative guidelines and emphasizes the importance of them.  Although all of our team members interact with the patient pre and postoperatively, I feel my role is to monitor the progress of the patient and refer patients to other disciplines as needed.

Preoperatively, I educate our patients on what the data tells us about behaviors that contribute to weight maintenance or conversely, weight regain. I don’t “sugar coat” anything.

In one study, despite satisfactory results in excess weight loss, patients did not maintain the weight loss mainly at five years.  Major factors of weight gain were poor diet, sedentary lifestyle, and lack of nutritional counseling.[1] Karmali et al[2] conducted a systematic review of 2,204 titles, and 1,421 met exclusion criteria. Sixteen studies were included in this analysis: seven case series, five surveys, and four non-randomized controlled trials, with a total of 4,864 patients. The authors found that weight gain was multifactorial and overlapping, and related to duration of follow up, behavioral health issues, and dietary choices.

Another retrospective study looked at 197 patients who had undergone RYGB and found that 22 percent gained weight starting at two years following surgery. This population demonstrated low physical activity, low self-esteem, and maladaptive eating behaviors.[3]

Soares et al[4] found dietary indiscretions were the most common cause of weight gain and, if it did occur, the vulnerable time is 12 to16 months after surgery. Contributing dietary change went from 2 to 3 meals per day to a “grazing pattern” and macronutrient composition changes from protein to more carbohydrates. Predominate intake was carbohydrates, sugars, and fats, and low consumption of proteins, fruits and vegetables.[4]

Another study states that individuals who have severe obesity, with a BMI of 40kg/m2 or greater, are five times more likely to have experienced depression compared to healthy weight individuals.[5] Therefore, patients who have been identified during the pre-operative consultation or diagnosed during their behavioral health evaluation with depression should have ongoing behavioral health follow up to address their depression or any other psychological issues. Numerous studies have shown that patients attending psychotherapeutic interventions or support groups following bariatric surgery were found to have greater weight loss and maintenance.
Physical active (PA) is important during rapid weight loss to preserve muscle mass[6] and PA is equally important for weight maintenance.[7] Muscle mass preservation is fundamental for maintaining optimal basal metabolic rates. The American Society and Metabolic Surgery (ASMBS),The Obesity Society (TOS), and the American Association of Clinical Endocrinologists (AACE) state that 30 minutes of accumulated daily exercise is a healthy behavior for optimal body weight and improves body composition postoperatively.[8]

I incorporate all the data as well as my observational experience and include them in every follow up appointment. Postoperative clinical pathways should include regular scheduled follow up appointments. In our practice we see the patient monthly for the first four months postoperatively then again at months 6, 9,12, and bi-annually, at a minimum. Patients are educated on this expectation preoperatively.  Frequent follow-up appointments allow the team to emphasize the important lifestyle changes necessary to build and maintain a balance in exercise, nutrition, and stress management as well lab surveillance. Repetitive questioning, educating long-term follow up plays a role in reinforcement of the behaviors that maintain health and weight maintenance in both short and long term following bariatric surgery. Our templated follow up forms ensure that we assess the aspects that the research shows are important in maintaining weight loss postoperatively.
I apply the above research into our program’s postoperative follow up process and incorporate the following take-home messages (nutrition, physical activity, and follow up) to patients:

• Nutrition
•    Eat real foods. Eat foods that rot and limit packaged foods. Focus on lean proteins first.
•    Omit all processed, sugar and simple carbohydrate foods. I explain the role that sugar and carbohydrates play in increased hunger by the glycemic index. (Figure 1)
•    No snacking (grazing), be aware of mindless eating. I stress that snacking is a saboteur of the surgery.
•    6 to 8 glasses of water daily and separate fluids from meals.

• Physical Activity
•    30 minutes of exercise daily —both aerobic and anaerobic. (minimum 200 minutes weekly).
•    Walk as an alternative to driving, other creative ways to incorporate exercise. I stress that patients should take stairs, park the car far as able from the destination, and walk as an alternative to driving when possible. We have a walking club and Fitbit Facebook page to help get patients engaged.

• Follow up
•    Regular follow up and support group attendance. I educate the patient that these are helpful tools in weight maintenance among another benefits.
•    Assess medications. I assess medications that may have been prescribed that have been shown to lead to weight gain, such as antidiabetics, antipsychotics, antidepressants, antiepileptics, steroids, and antihistamines.
•    Schedule appointments before the patient leaves the clinic. I always make the patient’s next follow-up appointment before they walk out the door.
•    Encourage and document attendance at our monthly multidisciplinary support group meetings.
•    Make mutual goals. Create goals with the patient and brainstorm ways in which to focus on them.

Nursing Case Study

Bariatric surgery is the best intervention in medicine today for treating severe obesity and related health conditions. All programs have experienced some patients who have regained weight following bariatric surgery. This can be frustrating for the clinicians and painful for the patient. This article’s aim was to encourage readers to reflect on their current practice and educate them with the research that highlights behaviors that impact weight regain and, more importantly, can help prevent it. Remember, no patient wants to regain weight following bariatric surgery. Pre and postoperative education, long-term follow up, and an integrated multidisciplinary team can make an impact in preventative measures to help reduce weight regain.

PART 1: Behavioral Health
1.    Mitchell JE, Selzer F, Kalarchian MA, Devlin MJ, Strain GW, Elder KA, Marcus MD, Wonderlich S, Christian NJ, Yanovski SZ. Psychopathology before surgery in the longitudinal assessment of bariatric surgery-3 (LABS-3) psychosocial study. Surg Obes Relat Dis. 2012;8(5):533–541.
2.    de Zwaan M, Enderle J, Wagner S, Mühlhans B, Ditzen B, Gefeller O, Mitchell JE, Müller A. Anxiety and depression in bariatric surgery patients: a prospective, follow-up study using structured clinical interviews. J Affect Disord. 2011;133(1-2):61–68.
3.    Júnior WS, do Amaral JL, Nonino-Borges CB. Factors related to weight loss up to 4 years after bariatric surgery. Obes Surg. 2011;21(11):1724–1730.
4.    Herpertz S, Kielmann R, Wolf AM, Hebebrand J, Senf W. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res. 2004;12(10):1554–1569.
5.    Roerig JL, Steffen K. Psychopharmacology and Bariatric Surgery. Eur Eat Disord Rev. 2015;23(6):463–469.
6.    Freire RH, Borges MC, Alvarez-Leite JI, Correia MITD. Food quality, physical activity, and nutritional follow-up as determinant of weight gain after Roux-en-Y gastric bypass.  Nutrition. 2012; 28:53–58.
7.    Sarwer DB, Wadden TA, Moore RH, Baker AW, Gibbons LM, Raper SE, Williams NN. Pre-operative eating behavior, post-operative dietary adherence, and weight loss after gastric bypass surgery. Surg Obes Relat Dis. 2008; 4:640–646.
8.    Wadden TA, Faulconbridge LF, Jones-Corneille LR, Sarwer DB, Fabricatore AN, Thomas JG, Wilson GT, Alexander MG, Pulcini ME, Webb VL, Williams NN. Binge eating disorder and the outcome of bariatric surgery at one year: A prospective, observational study. Obesity. 2011;19:1220–1228.
9.    White MA, Mashed RM, Rothschild BS, Burke-Martindale CH, Grilo CM. The prognostic significance of regular binge eating in extremely obese gastric bypass patients: 12-month postoperative outcomes. J Clin Psychiatry. 2006;67:1928–1935.
10.    White MA, Kalarchian MA, Masheb RM, Marcus MD, Grilo CM.  Loss of control over eating predicts outcomes in bariatric surgery patients: A prospective, 24-month follow-up study. J Clin Psychiatry. 2010; 71:175–184.
11.    Meany G, Conceição E, Mitchell JE. Binge eating, binge eating disorder and loss of control eating: effects on weight outcomes after bariatric surgery. Eur Eat Disord Rev. 2014;22(2):87–91.
12.    Allison KC, Wadden TA, Sarwer DB, Fabricatore AN, Crerand CE, Gibbons LM, Stack RM, Stunkard AJ, Williams NN. Night eating syndrome and binge eating disorder among persons seeking bariatric surgery: Prevalence and related features. Obesity. 2006;14:77–82.
13.    Colles SL, Dixon JB, O’Brien PE. Grazing and loss of control related to eating: Two high-risk factors following bariatric surgery. Obesity. 2008; 16:615–622.
14.    Ashton K, Heinberg LJ, Windover A, Merrell J. Positive response to binge eating intervention enhances weight loss. Surg Obes Relat Dis. 2011;7(3):315–320.
15.    Kalarchian MA, Marcus MD, Courcoulas AP, Cheng Y, Levine MD, Josbeno D. Optimizing long-term weight control after bariatric surgery: a pilot study. Surg Obes Relat Dis. 2012;8(6):710–715.
16.    Himes SM, Grothe KB, Clark MM, Swain JM, Collazo-Clavell ML, Sarr MG. Stop regain: a pilot psychological intervention for bariatric patients experiencing weight regain. Obes Surg. 2015;25(5):922–927.
17.    Egberts K, Brown WA, Brennan L, O’Brien PE. Does exercise improve weight loss after bariatric surgery? A systematic review. Obes Surg. 2012; 22: 335–341.
18.    Bond DS, Phelan S, Wolfe LG, Evans RK, Meador JG, Kellum JM, Maher JW, Wing RR. Becoming physically active after bariatric surgery is associated with improved weight loss and health-related quality of life. Obesity. 2009;17:78–83.
19.    Wing RR, Phelan S.  Long-term weight loss maintenance. Am J Clin Nutr. 2005;82(1)(suppl):222S–225S.

PART 2: Nutrition
1.    Layman DK, Evans EM, Erickson D, et al. A moderate-protein diet produces sustained weight loss and long-term changes in body composition and blood lipids in obese adults. J Nutr. 2009;139(3):514–521.
2.    Krieger JW, Sitren HS, Daniels MJ, Langkamp-Henken B. Effects of variation in protein and carbohydrate intake on body mass and composition during energy restriction: a meta-regression 123. Am J Clin Nutr. 2006;83(2):260–274.
3.    Westerterp-Plantenga MS, Lemmens SG, Westerterp KR. Dietary protein—its role in satiety, energetics, weight loss and health. Br J Nutr. 2012;108 Suppl 2:S105–S112.

PART 3: Obesity Medicine
1.    Still CD, Wood GC, Chu X, et al. Clinical factors associated with weight loss outcomes after Roux-en-Y gastric bypass surgery. Obesity (Silver Spring). 2014;22(3):888–894.
2.    Soares FL, Bissoni de Sousa L, Corradi-Perini C, et al. Food quality in the late postoperative period of bariatric surgery: an evaluation using the bariatric food pyramid. Obes Surg. 2014;24(9):1481–1486.
3.    Nicolau J, Ayala L, Rivera R, et al. Postoperative grazing as a risk factor for negative outcomes after bariatric surgery. Eat Behav. 2015;18:147–150.
4.    National Heart, Lung, Blood Institute Practical Guide to the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. 1998; 25-29
5.    Soares FL, Bissoni de Sousa L, Corradi-Perini C, et al. Food quality in the late postoperative period of bariatric surgery: an evaluation using the bariatric food pyramid. Obes Surg. 2014;24(9):1481–1486.
6.    Allied Health Sciences Section Ad Hoc Nutrition Committee, Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS Integrated Nutritional Health Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008;4(5 Suppl):S73–108.
7     Jakicic JM, Clark K, Coleman E, Donnelly JE, Foreyt J, Melanson E. ACSM position stand: Appropriate intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2001;33(12):2145–2156.

PART 4: Exercise
1.    Thompson WR, Bushman BA, Desch, J, Kravitz L. (eds.) ACSM’s Resources for the Personal Trainer. (3rd ed.). Baltimore, MD: Lippincott Williams & Wilkins: 2010.
2.    Shang E, Hasenberg T. Aerobic endurance training improves weight loss and body composition. Surg Obes Relat Dis. 2010 ;6(3):260–266.
3.    Donnelly JE, Blair SN, Jakicic JM, et al. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain in adults. Med Sci Sports Exerc. 2009;41(2):459–471. Erratum in Med Sci Sports Exerc. 2009;41(7):1532.
4.    Bond DS, Vithiananthan S, Thomas JG, et al. Surg Obes Relat Dis. 2015;11(1):169–177.
5.    Bond DS, Thomas JG, King WC, et al. Exercise improves quality of life in bariatric surgery candidates: Results from the Bari-Active trial. Obesity (Silver Spring). 2015;23(3):536–542.

PART 5: nursing
1.    Freire RH, Borges MC, Alvarez-Leite JI, Toulson Davisson Correia MI. Food quality, physical activity, and nutritional follow-up as determinant of weight regain after Roux-en-Y gastric bypass. Nutrition. 2012;28(1):53–58.
2.    Karmali S, Brar B, Shi X, Sharma AM Weight recidivism post-bariatric surgery: a systematic review. Obes Surg. 2013;23(11):1922–1933.
3.    Livhits M, Mercado C, Yermilov I, et al. Patient

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Category: Past Articles, Review

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