How to Evaluate Post-pandemic Weight Regain

| July 1, 2021

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 Colleagues,

With the pandemic hopefully in our rearview mirror, we are left with most patients emerging with varying degrees of weight gain. Though we find it disheartening to accept, research shows that weight regain is not only common, it is expected following nearly all obesity treatment modalities. Especially after being “locked in” for the last 16 months! I have provided a stepwise framework that might be helpful when evaluating weight gain, primarily in surgical patients, but some apply to medical management patients as well.

Step 1. Encourage accountability and follow-up. Patients who undergo bariatric surgery are likely to experience a weight gain of approximately 5 to 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 such as 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 might increase appetite.

Exercise and physiologic influences. Like diet, patient’s adherence to their recommended physical activity might 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 one’s 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 is a “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 might be present after a RYGB, causing reflux symptoms and weight gain. There could 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) scans 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 a patient’s genetics and physiological pathways that our bodies possess to maintain weight, weight regain is not the FAULT of the patient or what he or she is doing or not doing. 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.

Be well,

Christopher D. Still, DO, FACN, FACP

References

  1. Still C, Benotti P, McShea S, Zubair F. Care of the Post-Bariatric Surgery Patient. In Kushner R, Bessesen D, Gilden A. Primary Care: Evaluation and Management of Obesity. Wolters Kluwer, New York, 2021

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