Although bariatric surgery is actually successful in leading to weight reduction, it is more challenging 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 in terms of sustained weight loss may help guide intervention. Studies in other dieting populations identify commonsense factors connected with sustained weight loss, including early weight loss, 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 power 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 will pose a chance for weight regain include eating in a reaction to negative emotions or stress, passive reactions to problems, and dysfunctional eating behaviors such as for instance 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 symptoms of depression were associated with a lower percentage of weight loss.20 Overall, younger female patients who were 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 On the other hand, patients who were binge eaters prior to surgery could become “grazers” postoperatively, eating small quantities almost nonstop. Although the quality of these grazing episodes after surgery is actually different from the binges just before surgery, the continued sense of lack of control may lead to overconsumption and an unsatisfactory postoperative result.22,23 Behavioral change is difficult to sustain, and nearly all patients followed postoperatively in one study reported noncompliance in a minumum of one behavioral area, with exercise recommendations ignored by 41%, whereas 37% continued to snack.24 Patient expectations may also may play a role in unsuccessful weight loss, specially when patients choose bariatric surgery in the hopes that weight control will likely then be easy, that they will not need to do the task implicit in the most common recommendations of diet and exercise. One series of interviews with patients who’d been unsuccessful in maintaining weight loss after bariatric surgery unearthed that some patients seemed insufficiently aware that their particular effort will be needed to accomplish and maintain weight loss postoperatively and indeed for the remainder of these lives.25 Though it may seem as though depression and other psychiatric symptoms can cause a worse outcome, these factors have not been found to truly have a consistent effect on outcome. Several studies have suggested that some patients who have more depressive or anxiety symptoms ahead of surgery do better with regards to 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 far more motivated to achieve a weightloss program. Efforts to comprehend the behavioral and psychological impact of fat loss and weight regain or cycling have resulted in somewhat contradictory findings. Overall, most studies report greater weight loss results in improved standard of living, enhanced self-esteem, and lower psychopathology,28 but there might be mixed consequences for some. One small study of Brazilian women who’d had bariatric surgery discovered that, although patients felt positive about the possibility of being more socially accepted, their increased sense of femininity left them feeling more vulnerable. These patients’changed bodies also resulted in alterations in family balance and conjugal relationships, changes that were not necessarily comfortable and sometimes led to discontinuation of treatment.29 Lack of weight can cause changed expectations in regard to work, school, and sexual or family function, expectations that may be problematic for a patient to meet up and sustain. Families including multiple members in many generations that are obese may overtly or covertly undermine efforts at weight loss. Studies in other populations have found that small losses of weight can cause major improvements in body image and that continued fat loss is not associated 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 might not feel the sense of satisfaction from fat loss which may sustain change. The current presence of psychiatric disorders can complicate progress toward sustained weight loss in lots of ways, with regards to the diagnosis. An individual with depression may have feelings of hopelessness, helplessness, or worthlessness that can lead to giving up on the work of weight loss or weight maintenance. In a bipolar patient with mania, recommendations for a healthy lifestyle and appropriate eating could be ignored in favor 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 bulimia, or personality disorders may act out round the opportunities for manipulation of these around them by disturbed eating postoperatively. Monitoring for substance abuse, particularly alcohol, may be important, as a lifetime history of substance abuse is within 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 reduction or regain are complex and not easily characterized but certainly ought to be watched for and addressed to maximise outcome.

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