Although bariatric surgery is obviously successful in ultimately causing fat loss, it’s harder to predict who will ultimately be unsuccessful in achieving their weight reduction goals, those whose weight may rise again to presurgical levels as well as beyond. Understanding the factors connected with worse outcomes with regards to sustained weight loss may help guide intervention. Studies in other dieting populations identify commonsense factors associated with sustained weight loss, including early weight loss, setting and reaching a predetermined goal weight, having a physically active lifestyle, keeping to a regular meal rhythm, overall healthy eating patterns, control of overeating, self-monitoring of behavior, social support, better coping strategies, and an capability to assume responsibility in life and handle life stresses. Clearly, some of those factors are markers of psychological strength and stability generally, and, unsurprisingly, the factors which could pose a risk for weight regain include eating in reaction to negative emotions or stress, passive reactions to problems, and dysfunctional eating behaviors such as for example disinhibited eating, binge eating, a history of weight cycling, and experiencing hunger.18 Studies of patients after bariatric surgery have found exactly the same commonsense association of improved results related to baseline cognitive restraint and adherence to the recommended diet postoperatively,19 whereas subjective hunger, nonhungry eating, and apparent symptoms of depression were of a lower percentage of weight loss.20 Overall, younger female patients have been obese before adult life and have good self-esteem, an effective marriage, high socioeconomic status, realistic expectations from the surgery, and undisturbed eating behaviors usually, but not always, obtain better results.21 On the other hand, patients who have been binge eaters ahead of surgery may become “grazers” postoperatively, eating small quantities almost nonstop. Although the caliber of these grazing episodes after surgery is clearly distinctive from the binges just before surgery, the continued sense of loss in control can lead to overconsumption and an unsatisfactory postoperative result.22,23 Behavioral change is difficult to sustain, and nearly all patients followed postoperatively in one single study reported noncompliance in one or more behavioral area, with exercise recommendations ignored by 41%, whereas 37% continued to snack.24 Patient expectations can also play a role in unsuccessful fat loss, particularly when patients choose bariatric surgery in the hopes that weight control will be easy, that they can not need to do the task implicit in the most common recommendations of diet and exercise. One series of interviews with patients who had been unsuccessful in maintaining weight loss after bariatric surgery found that some patients seemed insufficiently conscious that their very own effort could be needed to accomplish and maintain weight reduction postoperatively and indeed for the remainder of these lives.25 Although it might seem like depression and other psychiatric symptoms can result in a worse outcome, these factors have not been found to truly have a consistent affect outcome. Several studies have suggested that some patients who’ve more depressive or anxiety symptoms just before surgery do better with regards to weight loss than patients without such symptoms.26,27 It could be that such individuals experienced greater psychological stress from their obesity and thus are far more motivated to succeed in a weightloss program. Efforts to comprehend the behavioral and psychological impact of weight reduction and weight regain or cycling have generated somewhat contradictory findings. Overall, most studies report greater fat loss results in improved standard of living, enhanced self-esteem, and lower psychopathology,28 but there may be mixed consequences for some. One small study of Brazilian women who’d had bariatric surgery found that, although patients felt positive about the likelihood to be more socially accepted, their increased sense of femininity left them feeling more vulnerable. These patients’changed bodies also generated alterations in family balance and conjugal relationships, changes which were not always comfortable and sometimes generated discontinuation of treatment.29 Loss of weight can result in changed expectations in regards to work, school, and sexual or family function, expectations that may be problematic for someone to generally meet and sustain. Families that include multiple members in several generations who’re obese may overtly or covertly undermine efforts at weight loss. Studies in other populations are finding that small losses of weight can cause major improvements in body image and that continued fat loss is not related to further improvements in self-image, limiting motivation for more drastic change. Women with a history of obesity could have an increased amount of body dissatisfaction irrespective of their current weight30 and thus might not go through the sense of satisfaction from weight loss that will sustain change. The current presence of psychiatric disorders can complicate progress toward sustained fat loss in many ways, depending on the diagnosis. An individual with depression might have feelings of hopelessness, helplessness, or worthlessness that may lead to giving up on the job of weight reduction or weight maintenance. In a bipolar patient with mania, recommendations for a healthier lifestyle and appropriate eating could be ignored in support of excesses of types. It might be hard for an individual with panic attacks with agoraphobia to leave your house regularly, for appointments, exercise, or even food shopping. Patients with preoperative eating disorders, such as for instance bulimia, or personality disorders may act out round the opportunities for manipulation of those around them by disturbed eating postoperatively. Monitoring for substance abuse, particularly alcohol, might be important, as an eternity history of substance abuse is present in almost one third of patients undergoing bariatric surgery;31 changes in the metabolism of alcohol after bypass may enhance its effects.30 In addition, in the setting of decreased calorie consumption, increasing the proportion of calories obtained from alcohol can have significant nutritional and health risks. Thus, the interactions between psychological factors and weight loss or regain are complex and not easily characterized but certainly ought to be watched for and addressed to maximise outcome.