I found this is to be very interesting. Hope you guys enjoy it.....

One of the key reasons why bariatric surgery is so much more effective for treating severe obesity than non-surgical approaches, is because of its profound effect on food intake.

Thus, bariatric surgery significantly affects hunger and satiety and may even have important effects on “wanting” and “liking” of high-caloric foods.

However, this effect on ingestive behaviour is neither “guaranteed” not are these effects consistent between individuals.

As I tell my patients, “The surgeons operate on your gut, not your brain”.

Thus, it can only be expected that a certain proportion of patients will struggle to control their food intake despite surgery, thereby either losing less weight than expected or putting the weight back on.

In an article, published in Obesity Surgery, we systematically reviewed the published evidence on the role of dietary factors in this issue.

As may be expected, patients reporting “loss of control” of eating behaviour post-surgery lost less weight or had a higher risk of gaining back any weight they may have initially lost. Thus, individuals with self-reported “high-adherence” scores tended to lose and sustain greater weight loss than those who did not.

Given that bariatric surgery may limit the amount of food that can be eaten at a single meal, some patients resorted to grazing behaviours (defined as consumption of smaller amounts of foods over extended periods of time) leading to subsequent weight regain. In addition, it was reported that poor diet quality, characterized by an excessive intake of calories, Snacks and sweets, as well as oils and fatty foods, was statistically higher in patients experiencing weight regain.

Interestingly, even short-term dietary “indiscretion” (or falling off) can result in very rapid weight regain. This is not surprising as, in this regard there is little difference between someone who has lost weight through surgery or simply through diet and exercise. Irrespective of how the weight is lost, the body appears to retain its ability to rapidly regain lost weight if allowed to do so.

Thus, as we discuss in our article,

“The existing literature strongly suggests that nutritional and lifestyle compliance is crucial to weight management post- bariatric surgery.”

“Comprehensive weight management programs must therefore provide improved patient education and promote adherence to post-bariatric surgery diets in order to ensure success. These programs must take action to support patients towards a long-term goal of healthy and appropriate dietary choices with active monitoring (journaling) and reinforcement (review of food records) strategies provided by a multidisciplinary health care team.”

As I have discussed previously, although bariatric surgery increases the chances of success, it is no magic bullet or easy way out – all patients have to work hard at learning to use their surgery as a tool to help them better control their food intake and will likely do better, the more they understand and comply with the post-surgical nutrition recommendations.

On the other hand, there may be very good reasons why certain individuals, despite best efforts, struggle to meet these recommendations.

I will discuss how neurohormanal and metabolic factors can make dietary compliance difficult in my next post.

@DrSharma

Edmonton, Alberta

Karmali S, Brar B, Shi X, Sharma AM, de Gara C, & Birch DW (2013). Weight Recidivism Post-Bariatric Surgery: A Systematic Review. Obesity surgery PMID: 23996349

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Why Do Some People Regain Weight After Bariatric Surgery?

Posted: 11 Sep 2013 06:00 AM PDT

http://www.drsharma.ca/wp-content/uploads/sharma-obesity-bariatric-surgery21.jpgAlthough bariatric surgery is by far the most effective treatment for severe obesity, it is not a magic bullet and there are a significant number of patients, who either fail to lose a significant amount of weight or ultimately regain most of their weight.

In a paper published in Obesity Surgery, we conducted an in-depth review on the issue of post-surgical weight regain.

Following an initial screen of 2,204 titles and review of 1,437 abstracts, we found only 16 studies with meaningful information on this issue.

These studies included seven case series, five surveys and four non-randomized controlled trials, with a total of 4,864 patients for analysis.

There were a number of methodological issues with these studies as they varied widely in terms of duration and quality of follow-up, definitions of surgical failure or weight recidivism, as well as the actual surgical procedures, all of which had important implications for the interpretation of the data.

Thus, for example, inconsistent definitions of exactly what constitutes “excessive” weight regain or “insufficient” weight loss makes it virtually impossible to determine even exactly how often this treatment can be considered to have “failed”. (Remember, it is always the treatment that fails the patient and never the patient who fails the treatment!).

Nevertheless, it is clear that post-surgical weight regain is highly multi-factorial (like obesity itself), involving both patient and surgery related factors.

Overall, we identified five principle aetiologies representing nutritional indiscretion, mental health issues, endocrine/metabolic alterations, physical inactivity and anatomic surgical failure, each of which I will discuss in upcoming posts.

There is no doubt that the issue of post-surgical weight regain requires a systematic approach to patient assessment focusing on contributory dietary, psychologic, medical and surgical factors.

@DrSharma

Edmonton, Alberta

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Karmali S, Brar B, Shi X, Sharma AM, de Gara C, & Birch DW (2013). Weight Recidivism Post-Bariatric Surgery: A Systematic Review. Obesity surgery PMID: 23996349

Very true my dear, very true!

Here's another one I found.....

Your Body Is Happy To Wait For Your Weight To Come Back

Regular readers are well aware that losing weight is never a ‘cure’ for obesity – in fact, we know that any weight loss (by whatever means – perhaps with the exception of surgery) leads to hormonal changes that will facilitate weight regain. This is why conventional (diet and exercise) weight-loss strategies sooner or later tend to result in relapse or weight regain.

Just how pervasive and multi-faceted these long-term hormonal responses to weight loss are, is demonstrated by Priya Sumithran and colleagues from the University of Melbourne, in a paper published in the New England Journal of Medicine.

In order to examine whether or not changes in the circulating levels of several hormones involved in the homeostatic regulation of body weight persist over time, the researchers studied 50 overweight or obese individuals, who participated in a 10-week very-low-calorie-diet weight-loss program.

The 36 subjects, who completed the intervention lost about 14% of initial weight and were still well below initial weight (about 8%) 62 weeks after the start of the study.

This weight loss was associated with significant reductions in levels of leptin, peptide YY, cholecystokinin, insulin, and amylin, whereas levels of ghrelin, gastric inhibitory polypeptide, and pancreatic polypeptide increased – most of these changes were still clearly evident at 62 weeks.

In addition, subjective levels of hunger increased and remained significantly elevated at 62 weeks.

Thus, the authors note that:

“One year after initial weight reduction, levels of the circulating mediators of appetite that encourage weight regain after diet-induced weight loss do not revert to the levels recorded before weight loss.”

Given these profound and persistent hormonal changes that affect hunger, appetite, and metabolism, it should come as no surprise that maintaining weight loss is so difficult. It certainly seems like the homeostatic system is happy to wait for the weight to come back – even if this takes several months or even years.

As I have noted before, the challenge in obesity treatment is never how to lose weight – it is all about how to keep it off. This is why, I am never too enthusiastic about new diets or medications that promise to help lose weight – unless these diets or medications also counteract or effectively block the counter-regulatory responses seen in this study, chances are that they will be ineffective in the long term.

Or, as the authors put it:

“..successful management of obesity will require the development of safe, effective, long-term treatments to counteract these compensatory mechanisms and reduce appetite. Given the number of alterations in appetite-regulating mechanisms that have been described so far, a combination of medications will probably be required.”

We do not really need new treatments for weight loss – we do, however, need treatments for weight-loss maintenance or for keeping patients in ‘remission’.

Unfortunately, the regulators still do not appear to have a pathway for approving drugs that will help with the latter.

AMS

Edmonton, Alberta

Hat tip to Bill Colmers for pointing me to this article.

Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, & Proietto J (2011). Long-term persistence of hormonal adaptations to weight loss. The New England journal of medicine, 365 (17), 1597-604 PMID: 22029981

Excellent, Ms Skinniness. I posted the link in 5:2

MS - Thank you so much for sharing. Both articles are very good.

Here's another one I found.....

Your Body Is Happy To Wait For Your Weight To Come Back

We do not really need new treatments for weight loss – we do, however, need treatments for weight-loss maintenance or for keeping patients in ‘remission’.

Funny I *just* said this last week or so in another post. I have to think of my obesity being in "remission" because I know how quickly the weight can come back on!

This is so true! I forget about remission and constantly have to remind myself....

"Your Body Is Happy To Wait For Your Weight To Come Back"

It's not gonna have to wait long if I snack like I have today.