**6. Behavioral, dietary, lifestyle, and psychological factors**

According to different authors [10, 23, 36, 43], there are four eating and lifestyle habits, independently associated with greater probability of post-surgical WR - **Table 1**. Those four types of post-bariatric surgery patients are called: a "sweet-eater," a "grazer," lifestyle habit as sedentarism, and patients consuming more daily calories or alcohol. A "sweet-eater" is someone who eats 50% or more of carbohydrates or consumes only simple carbohydrates. A "night eater" is defined as someone who three or more times per week consumes ≥50% of daily calories after 7 PM, who had difficulty sleeping, and who reports not being hungry at breakfast. Alcohol consumption is important and has been determined as independent factor for weight regain. Those patients are categorized in two groups: those drinking alcohol ≥2 times per week vs < 2 times per week. Sedentarism as definition describes the habits related to an inactive lifestyle, which can cause health problems such as Obesity in some people. There is another disorder, known as Binge eating Disorder (BED). That type of disorder led to implementation of one anastomosis Gastric bypass in Asia first and then on other continents, and it is associated with food culture of population in different countries. One of the definitions of BED describes it as eating substantially large amounts of food within short periods of time, accompanied by a sense of loss of control and feelings of disgust, guilt, and/or depression after binge episodes [34]. Approval of one anastomosis gastric bypass as accepted by IFSO standard weight loss surgical procedure significantly increased the number of patients with binge food disorders as candidates for B/MS. Their number varies from 10 to 40% according to available published officially results on Bariatric Registers. However, that inclusion criterion did not increase or propose an algorithm for a robust preoperative investigation of those patients or adequate screening results for outcome after bariatric surgery. Therefore, we "branded" a proportionally huge number of


#### *Predicting Factors for Weight Regain after Bariatric Surgery DOI: http://dx.doi.org/10.5772/intechopen.108715*

#### **Table 1.**

*Morbid obese patients with known eating and lifestyle habits and WR.*

patients as those with "binge food disorder," who qualify for a weight loss procedure. But those patients aren't diagnosed or treated for BED before surgery. They probably have certain aspects of the disorder (e.g., loss of control about food and eating), and they may emerge post-surgery, potentially resulting in negative long-term weight loss outcomes or weight regain [36]. The conclusion is that we need beforehand preoperative assessment of patients with BED by experienced behavioral health professionals. The process of diagnosis and management of patients with BED, candidates for B/ MS is critical, as the underlying dynamics of the disorder usually will persist after surgery [27]. Effective treatment for BED or maladaptive eating before surgery potentially will predict outcome of surgery. Such treatment will help the patient to cope successfully with depression, anxiety, or trauma after weight loss surgery. The process of long-term management must include nutrition counseling, medical care, and follow-up to 5 years after surgery. Outcome of patient's treatment as individual or in a group with similar patients plus involvement of family therapy is a significant predicting factor for WR after one anastomosis gastric bypass [44]. The absence of such a multidisciplinary approach to treatment is a potential risk for the eating disorder to persist or morph into another form of eating disorder as grazing. According to most definitions, available on Intranet, "grazer" is a person who eats snacks or small food portions several times a day, without consuming a primary meal. Grazing

is a more serious behavioral health disorder, as it can develop a higher risk of vomiting and gastrointestinal symptoms. According to some Bariatric surgeons, dysphagia and dumping after weight loss surgery can teach the patients to change their eating habits. Unfortunately, that statement is wrong. Regular vomiting postoperatively can cause nutritional deficiencies, dental caries, esophagitis, and gastric ulcers, all of which can further impact food choices and intake [43]. The misperception among some patients that frequent vomiting helps to prevent WR should be corrected and noticed by responsible Dietitian and surgeon on follow-up clinic reviews immediately and negative effects of the condition to be explained and treated accordingly. Even patients who lack a formally diagnosed eating disorder can lose control over their eating habits after B/MS and that loss of control might increase around the 2-year point [26, 33]. Literature review confirms that loss of control overeating or appearance of grazing after surgery is associated with less excess weight loss, greater WR, and decreased perceived quality of life [23]. It is known that patients who engage in grazing behaviors two or fewer times per week after surgery have poorer percentage of excess weight loss and larger weight regain than those who had not has such a problem.

There are also so-called: "Other Maladaptive Eating Behaviors." Dietitians and Nutritional specialists have found that maladaptive eating behaviors may also develop in some patients. It is explained that attempts to avoid vomiting after B/MS are linked to the development of food aversion, protein malnutrition, and micronutrient deficiencies. Unfortunately, those maladaptive disorders also influence long-term weight loss outcomes and quality of life [45]. There is another group of patients with eating disorders. They generally avoid solid foods and eat softer, high-calorie foods such as chocolate, candy, and ice cream. The consumption of excess calories, particularly from refined carbohydrates and saturated fats, is another objective predictor of WR in such patients. Maladaptive eaters among patients with weight loss surgery consider easier to swallow soups, crackers, and cheese than solid foods. Overconsumption of softer, calorie-dense foods ("soft food syndrome") provides inadequate nutrition and decreased satiety. Another condition, which ultimately contributes to excessive energy intake and weight gain. There is also another group of patients who prefer fully to engage in restrictive model of eating, failing to consume adequate calories due to an intense fear of stretching the stomach pouch and regaining weight. There is a psychological factor in those patients: preoccupation with weight and body image, but that condition can lead to macro- and micronutrient deficiencies and eventual WR [33]. Bariatric surgery developed another restrictive eating disorder. It is known as: "post-surgical eating avoidance disorder" or PSEAD. The disorder is described as eating very little to avoid WR or experience of an almost "phobic" reaction to food. Healthful eating habits should be reinforced months before surgery. Active role of Dietitian and engagement of patient are mandatory to prevent the onset of maladaptive eating patterns, gastrointestinal distress, and WR. The Dietitian should be certain that candidates for weight loss surgery have made significant behavioral changes involving nutrition and food as eating slowly and exercising portion control. The use of cognitive behavioral strategies to encourage mindful eating and appropriate food choices is another successful part of the game about the process of teaching [26]. The regular follow-up from multidisciplinary team members will recognize early maladaptive eating behaviors or food aversions, expressed by patient, and will encourage him to maintain adequate lifelong nutrition, and not rely on BS alone to improve their weight loss outcomes and health benefits. The early changes in total energy intake and macronutrient composition during the first 6 months after surgery are found to be

a predictor of long-term success with 10 years follow-up [21, 25]. Data confirm that eating 100 additional daily calories is associated with a 30% increase in odds of WR 3–4 years after BS.

It is known that preoperative physical activity levels and eating style do not correlate with maximum weight loss. However, there is a negative correlation between preoperative physical activity levels and external eating and a positive correlation between physical activity levels and restrained eating [22]. According to a paper, presented at IFSO 22nd World Congress; August 29–September 2, 2017, in London: "There was a less weight regain in patients who reported more [physical activity] after RYGB. Eating style does not seem to affect weight regain" [3]. A study from 2021 confirms that low level of physical activity and longer sedentary time have occurred more frequently in those with high WR and longer time since weight loss surgery [28]. Mental health conditions are common among bariatric surgery patients. Abnormal eating patterns, binge eating disorder in particular: depression, alcohol and drug addiction are reported as predictive factors of weight regain after BS [23, 24]. Psychological assessment and identification of those patients preoperatively are a major contributing factor for good long-term results after Bariatric/ Metabolic Surgery. Unfortunately, the limitations of funding for weight loss surgery and the whole process of preparation of a patient for such type of treatment are an ongoing problem in Europe and all over the world. Patients who choose BS must be educated to understand that Obesity is a chronic disease! Bariatric/Metabolic surgery is only one of the tools, which can effectively help the patient to achieve significant weight loss, but inadequate postoperative adherence to recommendations can override that tools' efficacy, leading to weight regain.
