Prevention and Treatment of Weight Regain After Bariatric Surgery: A Team Approach

This column is dedicated to covering a variety of topics relevant to the multidisciplinary care of the bariatric surgical patient.

Column Editor: Karen Schulz, RN, APN
President of the Integrated Health Section of the ASMBS; Clinical Nurse Specialist, University Hospitals of Cleveland, Cleveland, Ohio.

This month: Prevention and Treatment of Weight Regain After Bariatric Surgery: A Team Approach

by Bernadette Aquavella, MS, RN, CCDC

Ms. Aquavella is from Upper Chesapeake Bariatric Surgery at Hartford Memorial Hospital, Havre de Grace, Maryland.

Bariatric Times. 2012;9(9):34–35

Introduction
Many patients with obesity have experienced weight loss and weight regain before bariatric surgery. Patients often arrive at their initial bariatric consultation expressing a fear that after surgery, they will again experience regaining of lost weight. At Upper Chesapeake Bariatric Surgery at Hartford Memorial Hospital, Havre de Grace, Maryland, we care for patients using a multidisciplinary approach, which we have found to be especially helpful in preventing and treating weight regain. Prevention begins during the initial pre- operative visit and continues through both short- and long-term follow-up postoperative appointments.

The multidisciplinary bariatric team comprises the surgeon, nurse/director, behavioral counselor, nutritionist, exercise specialist, and mid-level provider, such as an APN (advanced practice nurse) or PA (physicians assistant). Each member of the team plays a specific role in the bariatric patient’s weight loss journey. During a patient’s preoperative visit, members of the bariatric team explain to the patient the possibility of weight regain. Although an exact percentage of patients who experience weight regain following bariatric surgery does not exist, some studies show that it is a common occurrence.[1,2]

How Common is Postoperative Weight Regain?
Some studies have been able to offer snapshots of the likelihood of weight regain in patients following certain types of bariatric procedures. For instance, Odom et al1 conducted a survey of patients who had undergone Roux-en-Y gastric bypass (RYGB) and were at least one-year postoperative. Of 203 eligible respondents in their study population, 160 (79%) reported experiencing some weight regain from nadir (i.e., lowest point of weight loss).

In another study of patients following RYGB, Friere et al[2] found that among 100 patients, weight regain was seen in 56 percent of patients, and 29 percent of the patients reported regaining over 10.1 percent of the minimum weight reached postoperatively. The researchers also discovered that weight regain increased significantly with time after surgery and that patients did not maintain lost weight, especially at five years postoperative.

Causes of Weight Regain
Studies have shown different possible causes of postoperative weight regain in patients, including physiological makeup,3 mechanical complications of the surgery (i.e., gastro-gastric fistula, staple line breakdown, tubing or balloon leak, pouch or stoma dilatation, poorly constructed bypass with short limb, or poor pouch construction),4 and patients’ nonadherence to lifestyle changes (dietary, exercise, and other behavioral changes).[1,5–8]

Intervention
Mechanical complications of surgery can often be corrected, but sometimes require a revision or conversion to another operation.[4] The surgeon typically assesses the patient for mechanical complications.

When weight regain occurs in patients, the bariatric team can often intervene to assist the patient in getting back on track. Each team member might meet with the patient individually or the staff may choose to meet with the patient as a group. If the patient is emotionally fragile, the staff will often choose not to meet as a group since this could prove to be too overwhelming for the patient. Whether meeting with the patient individually or as a group, the setting is supportive, nonconfrontational, firm yet empathetic. The team approach affords the opportunity for strategically devising a comprehensive plan of care.

The dietitian asks the patient what he or she is eating during a typical day and reviews daily vitamin supplements and fluid intake. Along with the patient’s input, the dietitian updates the nutrition plan to meet the needs of the patient while following the program guidelines. The exercise specialist asks for an accounting of the patient’s daily/weekly exercise routine. Again, along with the patient’s input, the exercise specialist revises the exercise plan in order to diminish the patient’s weight gain. The mid-level provider might review and update medical and medication changes.

In our program, we teach seven key behaviors to which patients should commit for a lifetime in order to be successful in achieving and maintaining weight loss. These behaviors include the following:
1.    Healthy food choices
2.    Portion control
3.    Zero-calorie drinks
4.    Vitamin supplements
5.    Exercise
6.    Support group attendance
7.    Follow-up/aftercare.

The behavioral counselor evaluates the patient’s commitment and adherence to the key behaviors, nutrition, and exercise plans. The patient’s support system, overall mood, relationship issues, and commitment to plan of care are assessed. The behavioral counselor then strategizes with the patient to develop a plan to implement the key behaviors. A referral for counseling and/or evaluation of psychotropic medications, developing healthy new or renewed interests and/or hobbies, and involvement in social activities might be indicated.

In addition to medical evaluation of the patient, the surgeon may also review behavioral changes that can help prevent and/or weight regain.

Other behavioral changes, similar to the seven key behaviors mentioned previously, suggested to a patient may include the following:
1.    Healthy food choices (protein first)
2.    Portion control
3.    Daily exercise
4.    Proper hydration (i.e., drinking plenty of water but not with meals)
5.    Eating breakfast daily
6.    Meal planning
7.    Use of food and exercise journals
8.    Getting the proper amount of sleep
9.    Utilizing a healthy support system (support group meetings and on-line support).[9]

Conclusion
The interventions presented here are merely an outline of the in depth educating, assessing, evaluating, and treating performed by each member of an integrated health team. Although each team member has a distinct role, there is a degree of overlap in services. This repetition can prove useful in patient learning. With the input of all members of the bariatric team an individual comprehensive plan of care for each patient can be developed and updated. The patient can then be assured that if he or she chooses to follow the plan, there should be no unusual weight regain. If the patient has already regained the weight, the team can assist the patient in getting back on track.

References
1.    Odom J, Zalesin KC, Washington TL, et al. Behavioral predictors of weight regain after bariatric surgery. Obes Surg. 2010;20(3):349–356. Epub 2009 Jun 25.
2.    Freire RH, Borges MC, Alvarez-Leite JI, et al. 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. Epub 2011 Aug 31.
3.    Sarzynski MA, Jacobson P, Rankinen T, et al. Associations of markers in 11 obesity candidate genes with maximal weight loss and weight regain in the SOS bariatric surgery cases. Int J Obes (Lond). 2011;35(5):676–683. Epub 2010 Aug 24.
4.    Champion JK. Videoscopic Institute of Atlanta PC. “Dealing with Weight Regain after Bariatric Surgery.” n.p., July 29, 2010.
5.    Faria SL, de Oliveira Kelly E, Lins RD, Faria OP. Nutritional management of weight regain after bariatric surgery. Obes Surg. 2010;20(2):135–139. Epub 2008 Jun 25.
6.    Sarwer DB, Dilks RJ, West-Smith L. Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success. Surg Obes Relat Dis. 2011;7(5):644–651. Epub 2011 Jul 13.
7.    Kalarchian MA, Marcus MD, Courcoulas AP, et al. Optimizing long-term weight control after bariatric surgery: a pilot study. Surg Obes Relat Dis. 2011 May 23. [Epub ahead of print]

8.    Peacock JC, Zizzi SJ. Survey of bariatric surgical patients’ experiences with behavioral and psychological services. Surg Obes Relat Dis. 2011 Dec 8. [Epub ahead of print]
9.    Stapleton C. Eat It Up! Bloomington, Indiana: Transformation Media Books; 2009.

Funding: No funding was provided in the preparation of this manuscript.

Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.

Category: Hot Topics in Integrated Health, Past Articles