EXPLANATION OF BARRIERS TO WEIGHT LOSS AFTER BARIATRIC SURGERY

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Although bariatric surgery is clearly successful in resulting in weight loss, it’s more difficult to predict who will ultimately be unsuccessful in achieving their weight reduction goals, those whose weight may rise again to presurgical levels or even beyond. Understanding the factors related to worse outcomes with regards to sustained fat loss may help guide intervention. Studies in other dieting populations identify commonsense factors associated with sustained weight loss, including early weight reduction, setting and reaching a predetermined goal weight, having a physically active lifestyle, keeping to a typical meal rhythm, overall healthy eating patterns, control of overeating, self-monitoring of behavior, social support, better coping strategies, and an ability to assume responsibility in life and handle life stresses. Clearly, some of those factors are markers of psychological strength and stability generally speaking, and, unsurprisingly, the factors that may pose a risk for weight regain include eating in a 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 discovered 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 who have been obese before adult life and have good self-esteem, a reasonable marriage, high socioeconomic status, realistic expectations from the surgery, and undisturbed eating behaviors usually, but not at all times, obtain better results.21 In contrast, patients who have been binge eaters ahead of surgery can become “grazers” postoperatively, eating small quantities almost nonstop. Although the grade of these grazing episodes after surgery is actually distinctive from the binges just before surgery, the continued sense of loss in control can result in overconsumption and an unsatisfactory postoperative result.22,23 Behavioral change is difficult to sustain, and nearly all patients followed postoperatively in a single study reported noncompliance in at least one behavioral area, with exercise recommendations ignored by 41%, whereas 37% continued to snack.24 Patient expectations can also may play a role in unsuccessful weight loss, particularly when patients choose bariatric surgery in the hopes that weight control will likely then be easy, that they will not want to do the work implicit in the usual recommendations of diet and exercise. One number of interviews with patients who’d been unsuccessful in maintaining fat loss after bariatric surgery discovered that some patients seemed insufficiently aware that their very own effort could be needed to reach and maintain weight loss postoperatively and indeed for the rest of their lives.25 Although it might seem like depression and other psychiatric symptoms can cause a worse outcome, these factors haven’t been found to truly have a consistent affect outcome. Several studies have suggested that some patients who have more depressive or anxiety symptoms prior to surgery do better in terms of weight loss than patients without such symptoms.26,27 It might be that such individuals experienced greater psychological stress from their obesity and thus are more motivated to succeed in a weightloss program. Efforts to know the behavioral and psychological impact of weight loss and weight regain or cycling have led to somewhat contradictory findings. Overall, most studies report greater weight loss contributes to improved quality of life, enhanced self-esteem, and lower psychopathology,28 but there can be mixed consequences for some. One small study of Brazilian women who’d had bariatric surgery discovered that, although patients felt positive about the chance 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 that have been not always comfortable and sometimes led to discontinuation of treatment.29 Loss in weight can cause changed expectations regarding work, school, and sexual or family function, expectations that may be hard for someone to meet and sustain. Families offering multiple members in many generations that are 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 connected with further improvements in self-image, limiting motivation for more drastic change. Women with a history of obesity might have a higher level of body dissatisfaction aside from their current weight30 and thus may not go through the sense of satisfaction from weight reduction that will sustain change. The current presence of psychiatric disorders can complicate progress toward sustained weight reduction in lots of ways, with regards to the diagnosis. Someone with depression could have feelings of hopelessness, helplessness, or worthlessness that can result in giving through to the job of weight reduction or weight maintenance. In a bipolar patient with mania, recommendations for a healthier lifestyle and appropriate eating might be ignored in favor of excesses of types. It may be burdensome for an individual with panic attacks with agoraphobia to leave the house regularly, for appointments, exercise, or even food shopping. Patients with preoperative eating disorders, such as for example bulimia, or personality disorders may act out around the opportunities for manipulation of the around them by disturbed eating postoperatively. Monitoring for substance abuse, particularly alcohol, may 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 Furthermore, in the setting of decreased calorie consumption, increasing the proportion of calories obtained from alcohol may have significant nutritional and health risks. Thus, the interactions between psychological factors and fat loss or regain are complex and not easily characterized but certainly should be watched for and addressed to maximise outcome.

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