research paper on weight loss surgery

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Published: 06 July 2023

Bariatric Surgery

Associations between diet composition, dietary pattern, and weight outcomes after bariatric surgery: a systematic review

H. C. Cheung ORCID: orcid.org/0009-0007-4209-1720 1 ,
E. Strodl ORCID: orcid.org/0000-0002-7149-6395 2 ,
J. Musial ORCID: orcid.org/0000-0003-2086-9590 3 ,
H. L. MacLaughlin 1 , 4 ,
A. Byrnes ORCID: orcid.org/0000-0003-4069-4724 4 ,
C-A. Lewis 4 &
L. J. Ross 1

International Journal of Obesity volume 47 , pages 764–790 ( 2023 ) Cite this article

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Weight management

Introduction

Literature describing the impact of dietary intake on weight outcomes after bariatric surgery has not been synthesized. This study aimed to synthesize the evidence regarding any association between diet composition and weight outcomes post-bariatric surgery.

CINAHL, Cochrane, Embase, MEDLINE and Scopus were searched for adult studies up to June 2021 that assessed any association between dietary intakes (≥1-macronutrient, food group, or dietary pattern) and weight outcomes at 12-months or longer after bariatric surgery. Risk of bias and quality assessments were conducted using the Scottish Intercollegiate Guidelines Network checklists and the NHMRC’s Level of Evidence and Grades for Recommendations. Study findings were presented according to the time of post-surgery dietary intake assessment (≤12months, between 12 and 24 months, ≥24months).

5923 articles were identified, 260 were retrieved for full text screening, and 36 were eligible for inclusion (9 interventional including five randomized-controlled trials, and 27 observational cohort studies; sample sizes: 20–1610; total sample: 5065; follow-up periods: 1 year–12 years; level of evidence: II to IV, risk of bias: low to high). Findings on the association between long-term weight outcomes and dietary composition up to 24-months were mixed. After 24-months, studies consistently suggested no significant associations between weight loss and macronutrient composition or core food group patterns, or between carbohydrate, protein or food group patterns and weight recurrence. A single cohort study reported a weak association between diet quality score and weight-recurrence after 24-months.

There was no strong evidence to support significant associations between diet composition and weight outcomes post-bariatric surgery. The heterogeneity in study design and quality may reduce generalizability to external populations. Individualized dietary recommendations may be useful to support long-term post-surgery weight outcomes. More studies are needed to define and measure diet quality in this patient cohort.

Registration

PROSPERO (CRD42021264120)

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Rachel N. Carmody & Jordan E. Bisanz

Bariatric surgery is considered the gold-standard treatment for inducing significant weight loss, which can alleviate obesity-related complications in people with severe obesity [ 1 ]. In recent years, the demand for bariatric surgery has increased with the rising prevalence of obesity [ 2 ]. From 2011 to 2019, the total number of bariatric surgeries performed worldwide rose from 158,000 to 256,000 [ 2 ]. However, weight non-response (insufficient weight loss) or weight recurrence (weight regain) are reported in as many as 1 in 2 patients at 2 years, and 3 in 5 patients at 12 years after surgery [ 3 , 4 ]. These are associated with reduced quality of life, re-occurrence of obesity-related complications, deteriorated health, and ultimately, escalated health care costs and mortality [ 3 , 4 , 5 , 6 , 7 ].

Previous studies have explored the factors contributing to weight non-response or significant weight recurrence following bariatric surgery, and identified patients’ post-operative diet to be a key modifiable determinant of weight status post-surgery [ 5 , 8 ]. In addition, Zarshenas and colleagues’ systematic review reported poor diet quality among patients at least one year after bariatric surgery [ 9 ]. These findings highlighted the role of dietary intakes in the management of weight after bariatric surgery, and the importance of nutritional interventions to improve the long-term diets of patients post-surgery.

At present, nutritional management guidelines for patients after bariatric surgery either focus on the diet texture progression within the first month post-operatively, or have based their overall diet recommendations, after texture progression (10–35% or >60 g/d protein, 30–70% or >130 g/d carbohydrates, 20–35% fats, and 5 serves of vegetables a day), on extrapolated evidence from non-surgical populations and/or small studies with weak evidence [ 10 , 11 , 12 ]. As bariatric surgery leads to significant changes in patients’ anatomy, physiology, and tolerance of specific foods and food volumes, dietary advice intended for the general population may not be suitable for patients post-bariatric surgery [ 13 , 14 , 15 , 16 ]. Depending on individual needs, stomach capacity, surgical outcomes and time after surgery, there may be a change in macronutrient requirements over-time. More evidence is needed to drive consensus and inform dietary recommendations for the medium to long-term post-surgery [ 9 ].

Over the past decade, there have been several studies examining the potential influence of dietary intake on weight loss and/or weight recurrence post-bariatric surgery. Therefore, the aim of this systematic review was to synthesize the available evidence regarding associations between post-surgery dietary intake (macronutrient composition and food patterns) and weight outcomes at least one year and longer after bariatric surgery.

The protocol for this review is registered in PROSPERO (CRD42021264120) and was conducted and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist [ 17 ].

Search strategy

A systematic search was conducted in electronic databases: CINAHL, Cochrane, Embase, MEDLINE and Scopus for human studies published in English language from all years up to and including June 2021. The basic search strategy was (post OR after OR following) “Bariatric surgery” OR “weight loss surgery” OR gastric bypass” OR “gastric sleeve” OR “sleeve gastrectomy” AND diet* OR nutrition* OR eat* OR macronutrient* OR ‘postoperative diet’. The full search strategy and subject headings used for each database are available in Supplementary Material 1 .

Record screening and eligibility criteria

Title and abstract screening were conducted by HC. Full text screening was completed by members of the research team independently in groups of two (Group 1: HC and LR, Group 2: HC and ES, Group 3: HM and JM) using systematic review software, Rayyan (Rayyan Systems Inc., Cambridge) [ 18 ]. Any uncertainties around study inclusion were raised to the research team for discussion until consensus was reached. Eligible study designs were systematic reviews, meta-analyses, interventional and cohort studies of adults (18 years of age or above) without pre-existing life-threatening conditions who received bariatric surgery (any type). Outcomes included at least one post-surgery dietary variable (reported at least 1 macronutrient, food group or dietary pattern) that was compared to any post-surgery weight outcome(s). Studies were included if their analyses involved: (1) weight outcomes in response to a prescribed diet; (2) a comparison of weight change between participant groups and their concurrent diet; and/or (3) correlation analysis of association between weight outcomes and diet. Studies were excluded if: (i) any participants were pregnant or breastfeeding (ii) the participants were inpatients, (iii)a post-surgery progression diet (i.e. texture modified or less than 1 month post-surgery), (iv) measures of adherence to a specific diet or diet preferences without indicating the exact diet being followed, or (v) if intake analysis were limited to energy, micronutrients, test meals, single meals, or supplements only.

Data extraction

Data extraction was performed by HC and cross-checked by LR. Information extracted included country of publication, participant characteristics including pre- and post-surgery health parameters, assessment timelines, dietary assessment method, dietary intakes (energy, macronutrients, food/dietary patterns) and weight outcomes at any timepoint: excess weight loss, odds of reaching >50% excess weight loss, total weight loss, average monthly weight loss, initial weight loss, BMI loss, risk of obesity remission i.e. BMI < 30 kg/m 2 , presence of weight recurrence as defined by the study authors as exceeding a nominated percentage of weight gain after nadir weight (lowest weight post-surgery), odds of weight recurrence, risk of weight recurrence. Key findings were those regarding any association between dietary intake variables and weight outcome(s), and/or comparisons between intervention and control groups or groups of participants achieving/not achieving pre-defined weight outcome(s) and dietary intake. Statistical analysis results reported in studies were extracted, including correlation co-efficient, odds ratio, hazard ratio and 95% Confidence Interval and interpreted according to conventional standards established by Cohen [ 19 ].

Quality assessment

Individual studies were matched to the Australian National Health and Medical Research Council (NHMRC) levels of evidence and grades for recommendation guidelines depending on study design [ 20 ]. Studies were first assigned a level based on the potential of the study design to adequately answer the defined research question(s): with level I being the highest level of evidence, followed by II, III-1, III-2, III-3, and IV (lowest) [ 20 ]. The Scottish Intercollegiate Guidelines Network (SIGN) Risk of Bias checklists for cohort, case-control and controlled trial study designs were then used to determine the risk of bias (low risk, acceptable risk, and high risk) [ 21 ]. The level of evidence and risk of bias of each study were assessed by HC and cross-checked by LR independently with blinding.

Data synthesis

To synthesize reporting differences between studies, dietary and outcome data were treated as follows: Intake assessments reported over different timeframes were grouped and presented as three main post-surgery time-dependent categories: up to one year (≤12 months); between one and two years ( > 12 to <24-months); and two years or longer (≥24 months). Studies were then further categorised within each assessment timeframe according to the dietary variables reported (macronutrient composition or food pattern). Within these dietary categories, all associated weight outcomes were included regardless of follow-up timeframes (equivalent or longer than the dietary timeframes) and grouped as two main outcome categories: (1) weight loss (including excess weight loss (EWL), initial weight loss (IWL), total weight loss (TWL), body mass index (BMI) loss), and obesity remission (i.e. reaching a BMI of <30 kg/m 2 ); or (2) weight recurrence measures of odds ratio, hazard ratio, or presence of weight recurrence from nadir weight that had exceeded a study-specified percentage.

Data analysis

The bodies of evidence regarding the associations between post-surgery weight outcomes and individual macronutrients and food patterns were assessed and graded using the NHMRC Guidelines [ 20 ]. In accordance with these guidelines, the bodies of evidence were assessed based on five components, and each component has been graded based on a set of standard criteria [ 20 ].

Recommendations were then deduced from these bodies of evidence and graded based on the combined gradings from each graded component. The possible grades for recommendations were: Grade A (body of evidence can be trusted to guide practice); Grade B (body of evidence can be trusted to guide practice in most situations); Grade C (body of evidence provides some support for recommendation(s) but care should be taken in its application); and Grade D (body of evidence is weak, and recommendation must be applied with caution). The grading of evidence was conducted by HC, cross-checked by LR, then reviewed and achieved consensus with ES, JM, AB, and CL.

The screening process of this review is outlined in Fig. 1 . A total of 5923 records were identified and title/abstract screened after the removal of 1495 duplicates. A total of 260 records were retrieved for full text screening, and 36 papers were included in this review. Reasons for exclusion were listed in Fig. 1 .

Summary of the identified, screened, and included studies from databases and registers.

Study characteristics

The key characteristics of the 36 included studies are summarized in Table 1 [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ]. The retrieved study designs included nine intervention studies (5 randomised controlled trials, 3 non-randomized controlled trials, 1 pre-post-intervention) [ 29 , 32 , 34 , 36 , 37 , 47 , 52 , 53 , 55 ]. Interventions delivered typically consisted of lifestyle modifications with or without a prescribed diet plan, where participants’ dietary intakes (macronutrient composition and/or food group pattern) were recorded and compared against pre-intervention values and/or between study intervention or control groups. In total, 27 observational cohort studies (8 prospective and 19 retrospective) were included [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 30 , 31 , 33 , 35 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 48 , 49 , 50 , 51 , 54 , 56 , 57 ]. These studies compared the diets of participants grouped according to their weight status, and/or conducted direct tests of association between dietary variable(s) and weight outcome(s).

A range of bariatric surgery procedures were reported among the included studies, with some individual studies reporting more than one type. The most common procedures were Roux en Y gastric bypass (RYGB) ( N = 22 studies) [ 24 , 25 , 28 , 30 , 31 , 32 , 33 , 36 , 37 , 39 , 40 , 43 , 44 , 45 , 46 , 48 , 49 , 50 , 51 , 52 , 56 , 57 ] and sleeve gastrectomy (SG) ( N = 13 studies) [ 22 , 25 , 26 , 27 , 34 , 35 , 36 , 40 , 43 , 46 , 51 , 53 , 54 ]. Others included laparoscopic adjustable gastric banding (LAGB) ( N = 4 studies) [ 29 , 34 , 52 , 55 ], vertical banded gastroplasty (VBG) ( N = 3 studies) [ 38 , 41 , 47 ], gastric bypass (did not specify type) ( N = 3 studies) [ 23 , 38 , 41 ], gastric banding (did not specify type) ( N = 1 study) [ 38 ], and anastomosis gastric bypass (OAGB) ( N = 1 study) [ 25 ]. One study did not specify the type of bariatric surgery involved [ 42 ]. Dietary intake assessment tools (from most to least common) were food records (3–7 days), followed by 24-hour recalls, food frequency questionnaires, and other lifestyle or behavior surveys collecting dietary data as part of the tool [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ]. Sample size ranged from 20 to 1610 participants (total N = 5065) with drop-out rate from 0 to 61%. The reported mean age of participants ranged from 32.7 ± 1.6 years to 57.3 ± 8.7 years. The proportion of female participants totaled across all studies was 75% (excluding the single study where gender ratio was not reported) [ 54 ]. The majority of studies did not mention the proportion of participants with insulin resistance or type 2 diabetes mellitus (T2DM). Even though some studies did report on the percentage of participants with at least one co-morbidity, they did not specify the exact proportion of participants with T2DM [ 33 , 57 ]. Among studies that reported on them, the rate of participants with insulin resistance or T2DM mellitus ranged from 11.6%-52.5% [ 22 , 25 , 35 , 36 , 40 ]. Timepoint of measurement or assessment of post-surgery diets ranged from 6 months to 12 years. Significant post-surgery weight outcomes were reported in all studies from 1 to 12 years follow up.

The level of evidence and risk of bias outcomes are reported in Table 1 . There were no Level I studies, nine Level II studies [ 24 , 37 , 38 , 43 , 47 , 48 , 49 , 52 , 53 ], 22 Level III studies [ 22 , 23 , 25 , 26 , 27 , 28 , 29 , 31 , 33 , 34 , 35 , 36 , 39 , 40 , 42 , 44 , 46 , 50 , 51 , 54 , 55 , 56 ], and five Level IV studies [ 30 , 32 , 41 , 45 , 57 ]. Risk of bias assessment deemed 13 studies to be low risk [ 22 , 23 , 25 , 28 , 35 , 38 , 39 , 40 , 41 , 43 , 48 , 49 , 50 ], 14 studies were acceptable risk [ 24 , 26 , 27 , 29 , 30 , 33 , 34 , 36 , 37 , 44 , 45 , 46 , 51 , 57 ] and nine studies were high risk studies [ 31 , 32 , 42 , 47 , 52 , 53 , 54 , 55 , 56 ]. Studies’ level of evidence and risk of bias were both taken into consideration during quality assessment.

Study findings

Table 2 summarises the findings from individual studies, of which, 27 studies compared the concurrent diets of study groups (per intervention status or weight outcome) and 16 studies conducted direct tests of association between dietary variable(s) and weight outcome(s). The types of diet being assessed, key findings, and limitations for each included study. Study findings are presented according to the timeframe when dietary intakes were measured post-surgery ≤12-months, between 12 and 24 months, and ≥24 months.

Diet ≤12-months post-surgery and weight loss

Sixteen studies described diets up to 12-month and observed weight losses up to ten-years [ 24 , 25 , 27 , 29 , 30 , 34 , 36 , 38 , 39 , 40 , 47 , 48 , 49 , 52 , 53 , 54 ]. Regarding carbohydrate, significant inverse associations with weight losses were supported by three observational cohort studies (total N = 1888, up to 10-years follow-up) [ 30 , 38 , 40 ]. However, one RCT (prescribed protein enriched, low-carbohydrate diet vs prescribed normal protein and carbohydrate diet, with high reported adherence) and four observational cohort studies showed no significant associations (total N = 368, up to 8-years follow-up) [ 24 , 25 , 39 , 48 , 53 ]. Regarding protein, significant positive associations with weight loss was supported by five observational cohort studies (total N = 2232, up to 10-years follow-up) [ 30 , 38 , 40 , 48 , 49 ]. On the contrary, one RCT (prescribed protein enriched, low-carbohydrate diet vs prescribed normal protein- and carbohydrate diet, with high reported adherence), one pseudo-RCT (prescribed protein-enriched diet vs no prescribed diets, with poor reported adherence), and four observational cohort studies did not report significant associations with weight loss (total N = 444, up to 8-years follow-up) [ 24 , 25 , 27 , 29 , 39 , 53 ]. Regarding fat, significant inverse associations with weight losses were supported by two observational cohort studies (total N = 1799, up to 10-years follow-up) [ 38 , 40 ]. However, five observational cohort studies did not report any significant associations (total N = 400, up to 8-years follow-up). A single RCT that involved a lifestyle intervention did not result in any significant between-group differences in macronutrient intakes nor weight changes[ 52 ].

Food pattern, specifically fruit and vegetable intakes, were reported in three studies (one RCT, two non-randomized controlled trials) [ 34 , 36 , 47 ]. All studies reported significantly greater weight losses in intervention groups compared with controls after lifestyle interventions [ 34 , 36 , 47 ]. However, no significant differences in fruit and vegetable intakes were noted between intervention and control groups within the single RCT [ 47 ]. Although between-group intake differences were not measured within the two non-randomized controlled trials, both studies reported significant increases in fruit and vegetable intakes in their intervention groups when compared to pre-intervention intakes [ 34 , 36 ]. As both studies included a physical activity component, it was not possible to attribute outcomes to diet alone [ 34 , 36 ]. There was inadequate information provided on other food patterns including dairy, meat and grains, as they were not measured in the single RCT [ 47 ], whereas the two non-randomized controlled trials reported no significant changes in their intakes compared to pre-intervention [ 34 , 36 ]. Lastly, a single cohort study observed the effect of varying purine contents of the diet (exact food group intakes not reported), which did not show any significant association with post-surgery weight [ 54 ].

Diet ≤12-months post-surgery and weight recurrence

No studies examined weight recurrence during this period, presumably due to the short timeframe to enable observation of weight recurrence.

Diet between 12- and 24-months post-surgery and weight loss

Six studies described diets between 12- and 24-months post-surgery and observed weight losses up to five years post-surgery [ 31 , 37 , 41 , 51 , 52 , 55 ]. Diet was also described and compared with weight recurrence at two years post-surgery by a single cohort study [ 42 ]. Regarding carbohydrate, significant inverse associations with weight losses was supported by one observational cohort study (total N = 75, with up to 2-years follow-up), whereas a lack of association was suggested by one non-randomized controlled trial and one observational cohort study (total N = 290, with up to 5-years follow-up). Additionally, Lindroos et al. assessed the potential impact of different types of carbohydrate intakes and reported greater weight loss for participants with higher intakes of mono- or di-saccharides and lower intakes of polysaccharides, though the potential impacts of total carbohydrate intake was not assessed [ 41 ]. Findings for protein included one observational cohort study ( N = 75, with up to 2-years follow-up) suggesting positive associations [ 31 ], one observational cohort study ( N = 375, with up to 2-years follow-up) suggesting inverse associations [ 41 ], and two studies (one non-randomized controlled trial and one observational cohort) suggesting no significant associations with weight loss (total N = 290, with up to 5-years follow-up) [ 51 , 55 ]. Regarding fat, only one observational cohort study ( N = 375, up to two-years) [ 41 ] supported positive associations with weight loss whereas three studies (one non-randomized controlled trial, two observational cohorts) reported having no significant associations (total N = 365, up to 5-years) [ 31 , 51 , 55 ]. A single RCT that involved a lifestyle intervention did not result in any significant between-group differences in macronutrient intakes nor weight outcomes [ 52 ]. The relationship between post-surgery weight loss and food pattern was assessed by a single RCT [ 37 ], providing monthly home delivered meals with a personalized menu plan of 4 serves vegetables, 2–4 serves meat, and 1–2 serves grains per day. The intervention resulted in greater weight loss than a control group with no delivered meals or prescribed diet and may indicate some benefits for similar types of intervention or prescribed menu plans [ 37 ].

Diet between 12- and 24-months post-surgery and weight recurrence

Macronutrient composition, food pattern, and weight recurrence at up to 18-months post-surgery were described by a cohort study [ 42 ]. The findings of this study favored a diet with daily intakes of 3–5 fat, fruit, and vegetable exchanges for less weight recurrence, though the portion size of each food exchange was not reported [ 42 ].

Diet at ≥24-months post-surgery and weight loss

Fourteen studies described dietary intakes after 24-months post-surgery and weight loss up to 12 years post-surgery [ 23 , 26 , 32 , 33 , 35 , 39 , 43 , 44 , 45 , 47 , 50 , 51 , 56 , 57 ]. The absence of association was supported by 11 out of 11 observational cohort studies regarding carbohydrate and fat intakes (Total N = 1305, with up to 12-years follow-up) [ 23 , 26 , 33 , 35 , 39 , 43 , 44 , 45 , 50 , 51 , 56 ], and by 12 out of 12 observational cohort studies for protein intake (Total N = 1402, with up to 12-years follow-up) [ 23 , 26 , 33 , 35 , 39 , 43 , 44 , 45 , 50 , 51 , 56 , 57 ]. A pre-/post-interventional study of individuals who had experienced weight recurrence at 3 years post-surgery reported significant weight loss from a three-month diet with 45% carbohydrate, 35% protein, and 20% fat [ 32 ]. Despite high adherence, the researchers did not compare to pre-intervention intakes, and an incentivized physical activity component made attribution of results to diet alone impossible [ 32 ]. Regarding food pattern, the absence of association between weight loss and any core food group, except fruit and vegetables, was supported by 2 out of 2 observational cohort studies (total N = 147, with up to 5 years follow-up) [ 23 , 33 ]. A positive association between weight loss and fruit and vegetables was suggested by one RCT, where a lifestyle intervention resulted in significantly greater weight loss and concurrent significantly higher fruit and vegetable intakes in the intervention group compared to controls ( N = 30, with up to 3 years follow-up) [ 47 ]. However, the component of physical activity prevented the outcomes being attributed to diet alone [ 47 ]. Despite this, three cohort studies reported no associations between fruit or vegetable intakes with weight loss up to 9-years (total N = 244, with up to 9-years follow-up) [ 23 , 33 , 57 ].

Diet at ≥24-months post-surgery and weight recurrence

Eight observational cohort studies described dietary intakes after 24-months and observed weight recurrence up to 9 years [ 22 , 23 , 26 , 28 , 33 , 35 , 46 , 57 ]. For macronutrient intake composition, the lack of association between weight recurrence with carbohydrate and protein intakes was largely consistent across studies: Carbohydrate (6 out of 6 cohort studies, total N = 410, with up to five-years follow-up [ 22 , 23 , 26 , 28 , 33 , 46 ]); Protein (5 [ 22 , 23 , 28 , 33 , 57 ] out of 6 cohort studies [ 22 , 23 , 26 , 28 , 33 , 57 ], total N = 366 out of 403, with up to 9 years follow-up). The findings regarding fat intakes were mixed, though the absence of association was supported by 4 [ 22 , 23 , 28 , 33 ] out of 6 cohort studies [ 22 , 23 , 26 , 28 , 33 , 35 ] (total N = 269 out of 392, with up to 7-years follow-up [ 22 , 23 , 28 , 33 ]). Differences in the definition of significant weight recurrence across studies (i.e. >2% to >25% recurrence of weight [ 22 , 23 , 26 , 28 , 33 , 35 ]) may partially account for the mixed results. Notably, in the cohort study with the longest follow-up (7-years) and strictest criteria for Group 1 (>50% excess weight loss at first year and maintaining <25% weight recurrence until 7-years), higher fat intakes, in addition to total energy intake, were linked to a 4-fold increased risk of weight recurrence within a cox hazard regression model. Group 1 participants also reported significantly lower intakes of fat than Group 2 participants (>25% weight recurrence at 7-years).

Regarding food patterns, a lack of association between weight recurrence and any core food group was reported by 4 out of 4 observational cohort studies (total N = 326, with total follow-up of 8.9 years) [ 23 , 28 , 33 , 47 ], except for fruit, where 1 out of the 4 studies was suggestive of an inverse association between fruit intakes and weight recurrence [ 28 ]. Diet quality score, measured using the Brazilian version of the Healthy Eating Index, was assessed by one cohort study that showed a weak inverse association with the odds of weight recurrence with a higher diet quality score (achieved by having a balanced daily servings of grains, vegetables, fruits, beans, meats, dairy products, fats and oils, sugar and sweets, restricted intakes of saturated fats and cholesterol, and having a high variety of foods within the diet) [ 28 ].

Grading of evidence and recommendations

Tables 3 to 6 provide a summary of the results assessed using the NHMRC body of evidence framework [ 20 ].

The body of evidence for diet ≤12 months post-surgery and weight loss is summarized in Table 3 . Overall, the body of evidence was inconsistent regarding the presence or absence of any positive or negative associations between weight loss and macronutrient composition. While the findings for food group patterns appeared to be consistent, co-variables related to study design prevented the effect from being attributed to dietary intake alone. Therefore, no recommendations could be drawn.

The body of evidence for diet between 12- and 24-months post-surgery and weight loss and weight recurrence is summarized in Table 4 . The body of evidence was inconsistent regarding the presence or absence of any associations between weight loss and diet, and there was inadequate information to draw conclusions on whether, and in what way, dietary intakes were associated with weight recurrence. Therefore, no recommendations could be drawn.

The body of evidence for diet ≥24 months post-surgery and weight loss is summarized in Table 5 . The overall body of evidence was consistent for the absence of any significant associations between weight loss and all macronutrient intakes and food patterns. This body of evidence contributed to the recommendation that long-term diets post-bariatric surgery can be individualized with flexibility as to macronutrient and food pattern composition (Grade B –the body of evidence can be trusted to guide practice in most situations).

The body of evidence for diet ≥24 months post-surgery and weight recurrence is summarized in Table 6 . The body of evidence was consistent for the absence of any significant associations between weight recurrence and carbohydrate, protein, and food patterns. However, the study findings for the association between weight recurrence and fat intakes was inconsistent, and an inverse association with diet quality was reported by just one cohort study. Therefore, two recommendations can be made: long-term diets post-bariatric surgery can be individualized with flexibility to macronutrient and food group composition due to lack of association (Grade C); and that a high diet quality can be encouraged in long-term post-surgery diets for reduction of weight recurrence (Grade D).

Study findings for the dietary components not able to be graded

It was not within the scope of this review to have an in-depth analysis of the associations between energy intake and weight outcomes, due to not being included in the search term for systematic retrieval, and food patterns beyond core food group intakes due to not being consistently reported (e.g. specific food intakes like sandwiches, packaged foods or sweets that were defined differently across studies). These findings are presented as part of Table 2 .

To our knowledge, the current review is the first to systematically synthesize existing literature reporting on associations between macronutrient composition, food patterns and weight outcomes post-bariatric surgery. Our review found that current evidence is related to the assessment of diet in distinct timeframes: ≤ 12 months, between 12- and 24-months and ≥24 months after surgery. Relationships between macronutrient intake and weight loss up to 24 months were inconclusive due to inconsistent findings between several studies of varying quality. Very few studies reported on food patterns, where the lack of studies and poor study design also contributed to inconclusive evidence. However, at 24 months and longer the evidence was consistent across several study findings for no association between macronutrient intake or food group pattern and weight loss, and between carbohydrate, protein and food group pattern and weight recurrence. An inverse association between weight recurrence and diet quality was reported from a single cohort study. Therefore, the existing body of evidence, overall, does not support a specific macronutrient composition or food pattern for optimal weight outcomes after bariatric surgery.

Previous research has suggested or attempted to establish the best macronutrient composition to support post-surgery weight loss [ 9 , 40 ]. However, our review found the evidence base for associations with macronutrient composition and food pattern relied on less robust study designs and many contained confounding factors resulting in mixed results over different timeframes. The interpretation of association, therefore, was limited due to the lack of high-quality study designs. Despite this, the most notable phenomenon was that any relationship between macronutrients, food group pattern and weight outcomes, seemed to have lost significance after 24-months post-surgery, as studies that assessed dietary intakes after 24-months post-surgery found no associations whilst there was a mix of studies reporting the presence or absence of associations before 24 months [ 22 , 23 , 26 , 28 , 30 , 31 , 33 , 35 , 38 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , 50 , 51 , 55 , 56 , 57 ]. More well designed RCTs or prospective cohort studies are required to explore the potential associations between post-surgery weight outcomes with short- to medium- term dietary intakes (<24-months).

Although studies reporting on energy intake post-surgery were not systematically searched as part of this review, an inverse association with weight loss and positive association with weight recurrence was largely supported by those included studies that assessed energy intake [ 22 , 23 , 24 , 25 , 26 , 28 , 30 , 31 , 33 , 35 , 38 , 39 , 40 , 41 , 43 , 44 , 45 , 46 , 50 , 51 , 56 ]. Previous studies have debated the roles of long-term dietary restriction and food malabsorption in post-bariatric surgery weight outcomes [ 58 , 59 , 60 , 61 , 62 , 63 , 64 ]. However, there are known contributing factors that make it difficult to ascribe weight outcomes solely to energy intake, for example, the known prevalence of under-reporting dietary intakes among this population [ 59 , 62 , 63 ] and/or differences in energy balance as a result of individual basal requirements and physical activity levels [ 62 , 65 ]. In Novais et al., only those with >50% excess weight loss reported an energy intake that was significantly lower than their estimated energy requirements. Furthermore, Benson-Davies et al. [ 59 ]. found participants who maintained their weight loss achieved a 2100-kilojoule deficit in energy balance (through a combination of lower energy intake and higher step counts) when compared to participants who experienced weight recurrence. Similarly, Forbush et al. suggested energy expenditure, rather than energy intake alone, to be a predictor of weight loss [ 62 ]. Given the limited reporting of physical activity levels in this population [ 65 ], energy balance may be an important focus for future research and practice to support long-term weight loss/maintenance post-bariatric surgery.

For many, the ultimate goal of achieving and sustaining weight losses after bariatric surgery is to improve the management of obesity-related complications. With the modest direct associations between post-surgical weight and diet composition found in this review, it may be sensible to place higher emphasis on exploring the impacts of diet composition on non-weight parameters of health, and specifically, those that are associated with the management of obesity-related complications. In the current review, studies that have reported non-weight clinical parameters mostly focused on the associations between body composition, quality of life and protein intakes [ 29 , 37 , 49 , 53 , 55 ], due to protein’s role in muscle mass maintenance, believed to be beneficial for weight loss maintenance. However, the overall evidence from the current review is mixed and does not support a high-protein diet for weight loss outcomes long-term post-surgery. This finding aligns with those of two previous systematic reviews focusing on the associations of protein intakes and body composition, which resulted in inconclusive findings [ 66 , 67 ]. Larger and higher quality studies that place greater emphasis on obesity-related health parameters, in addition to weight, are required to explore how post-surgery diets may influence these parameters. Also, a recent study found no significant correlations between the extent of post-surgery weight loss and improvements in cardiovascular risk factors [ 68 ]. While this information was from a single study, it is apparent that future studies would benefit from placing additional emphasis on the relationship between post-surgery dietary intakes and clinical parameters, such as cardiometabolic health, in patients with or without weight non-response or recurrence at long-term post-bariatric surgery.

With the need to explore the relationships between obesity-related health parameters beyond weight, and in the absence of associations between weight non-response or recurrence with individual macronutrients and food groups, focusing on the overall quality of individuals’ diets may provide a more holistic approach to improving patients’ post-surgery eating pattern. In this review, Da Silva et al. was the only study retrieved that assessed diet quality in a systemic manner using an established tool, and suggested an ongoing weak association with weight re-occurrence after two years post-surgery [ 28 ]. Other identified studies that mentioned participants’ diet quality either did not use any established tool to measure diet quality [ 23 , 33 , 42 ], or did not adequately report participants’ dietary intakes [ 69 , 70 , 71 , 72 , 73 ], thus preventing comparisons across studies and, therefore, not included in the review as part of the data analyses for diet quality [ 23 , 33 , 42 ] or excluded for not meeting eligibility criteria [ 69 , 70 , 71 , 72 , 73 ]. Additionally, it is not known how useful or valid are established diet quality tools for use in this population [ 74 , 75 ]. At present, existing research undertaken to derive and validate diet quality indices does not specifically consider bariatric surgery population [ 28 , 70 , 71 , 72 , 73 , 74 , 75 , 76 ]. The potential changes in physiology and/or dietary needs after bariatric surgery may reduce the generalizability of diet quality indices from the general population to the bariatric surgery population. Without an accepted definition or measurement of high diet quality following bariatric surgery, it is not possible to compare the potential influence of diet quality on different obesity-related health parameters between studies and over-time. Future studies are needed to establish a consensus or criterion for the definition of a high-quality diet after bariatric surgery and to develop and validate a bariatric-specific diet quality measurement tool.

The differences in surgical procedure are often speculated as a contributor to different weight outcomes. Only one included study compared outcomes between different surgical types (SG versus RYGB), with no significant differences observed for weight outcomes and macronutrient composition [ 43 ]. Although findings for LAGB studies may not be generalizable across different surgery types, as they did not involve the resection of the gastro-intestinal tract, only 4 out of the 36 included studies involved post-LAGB patients. However, the differences in dietary intakes across surgical procedures were not the main interest of the current review. Since most of the included studies in this review reported single procedures only, and key findings did not differ across single or mixed surgeries or different surgery types, separate reporting of findings per surgery type was not attempted by this review. More studies may be needed to assess whether differences in surgical procedure can moderate the association between diet and post-surgery weight, and if so, whether such differences are significant enough to warrant separate dietary advice per surgery type. Another commonly speculated contributor to different weight outcomes is concomitant medications that may influence body weight (e.g. anti-depressants, corticoids, insulin) and the presence of T2DM, which may result in less weight loss than participants without T2DM [ 77 ]. In our review, only four of the included studies excluded participants taking these medications, but it was unclear whether the type(s) of medications considered in each study were the same [ 22 , 23 , 27 , 28 , 37 ]. Similarly, the rate of participants with insulin resistance or T2DM were only reported in a few studies and was often combined with other co-morbidities for assessment of the effects of number of co-morbidities on post-surgery weight [ 22 , 25 , 35 , 36 , 40 ]. The single study that assessed the potential impact of T2DM on excess weight loss reported no significant associations [ 25 ]. Another study reported higher rate of weight recurrence among those with insulin resistance, but acknowledged participants’ higher body fat percentage or BMI may have contributed in part to the results [ 22 ]. Future studies may need to clarify whether participants with medications or conditions that may influence participants’ weight are included in their statistical analysis, in order for higher confidence that the recorded weight changes are attributable to participants’ lifestyle.

The strengths of this review include the emphasis on long-term outcomes after bariatric surgery, and being the first review to systematically examine any potential associations between weight and dietary intakes after bariatric surgery. Limitations include the lack of inclusion of energy intake as a search criterion and the inability to discriminate the results by the type of surgery. The application, interpretation and generalization of results required subjective judgements to arrive at final recommendations. The retrieved studies were limited by a generally poor evidence base and poor consistency due to their methodological flaws and heterogeneity in study design, including different units of measure and different methods of assessment of association. Most studies did not account for dietary changes made before or after their dietary assessments, which may have played a role in weight status measured at time of study. Furthermore, the definitions used for post-surgery weight outcomes (weight non-response or weight recurrence) lacked standardization. These limitations align with the findings of a recent review that called for a research-derived definition of clinically significant post-surgery weight recurrence [ 78 ]. This lack of standardization limited comparisons between studies and the grading of evidence to support specific recommendations, particularly those assessing short-term dietary intakes (up to 24 months). The unknown contributors to weight outcomes such as physical activity, genetics and individual motivation, especially in studies with longer durations, were poorly reported within the included studies. Although the treatment of known confounders by the study authors were taken into consideration during risk of bias assessment, their interference on the potential clinical impact of the synthesized evidence was inevitable. Generalizability and applicability of studies to other bariatric contexts was also affected by individual study designs that may have incurred risk of selection bias, or contained inadequate information (e.g. adherence to prescribed diets, or dietary intakes prior to study intervention), to enable reproducibility of study outcomes to external populations. Moreover, the retrieved studies had a high proportion of female participants. Lastly, the results were prone to inherent limitations of dietary assessment methodologies such as recall bias and under-reporting. While there are standardized methods for excluding implausible reporting [ 79 ], only two studies in our review attempted to address the known risk of under-reporting by comparing two methods of self-report (a 72 h recall versus a three day food record) to evaluate compliance to prescribed diets, which reported high compliance and similar energy intakes [ 53 , 54 ]. The remaining studies simply acknowledged this limitation, but did not identify nor exclude potential under-reporters [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 55 , 56 , 57 ]. Even though one study hoped to use the Goldberg cut-offs to assess implausible intakes among their participants within 12-months post-surgery, said method assumes weight stability and was deemed unsuitable for use for patients who had yet to reach weight maintenance stage after surgery [ 29 ]. Importantly, there are no standardized energy intake cut-offs for this population to assist with assessment of implausible intakes, which further complicated the exclusion of implausible reporters. As this limitation was discussed by some of the included studies as a potential contributor to the lack of association found between dietary intakes and weight outcomes, future studies on patients post-bariatric surgery may benefit from including the assessment of implausible intakes using estimated energy requirements, supplementing food diaries with weighed food records or photographed pictures of participants’ meals, adjusting for total energy intake based on two methods (e.g. a food frequency questionnaire and three 24 h food recalls), or other standardized methods, to help improve accuracy of dietary assessments.

In view of the overall finding that there is a lack of evidence to support the strong association of any particular diet composition or pattern with weight loss or recurrence, it is not unreasonable to suggest that long-term dietary advice post-bariatric surgery can be individualized with flexibility as to the macronutrient and food composition, or that a focus on diet quality may be beneficial for the reduction of weight recurrence over the longer term. However, these recommendations should be taken with care until higher quality studies further confirm and strengthen these statements. Well-designed prospective trials with standardized reporting and monitoring of dietary intakes including energy intake/expenditure, coupled with the considerations of potential moderators of weight, such as the type of surgery, may be beneficial to help clarify the relationships between weight outcomes and dietary intakes.

Data availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. The search strategy of the current review is included as Supplementary Material 1 .

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Acknowledgements

The authors wish to acknowledge the Queensland University of Technology and the Royal Brisbane and Women’s Hospital for their support of this research.

This research was part of HC’s Doctor of Philosophy candidacy and has received no specific grant from any funding agency, commercial or not-for-profit sectors. Open Access funding enabled and organized by CAUL and its Member Institutions.

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HC, LR, ES, and JM contributed to the conceptualization of this research question and eligibility criteria. Literature search and abstract/title screening was completed by HC, where full text screening was completed by HC, LR, ES, JM, and HM. Quality and risk of bias assessments were led by HC and cross-checked by LR. Data synthesis and the drafts of the review were led and written by HC and reviewed by all authors. All authors have agreed with the final manuscript being submitted and declare that the manuscript has not been published elsewhere.

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Cheung, H.C., Strodl, E., Musial, J. et al. Associations between diet composition, dietary pattern, and weight outcomes after bariatric surgery: a systematic review. Int J Obes 47 , 764–790 (2023). https://doi.org/10.1038/s41366-023-01333-1

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Evidence-based weight loss interventions: Individualized treatment options to maximize patient outcomes

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1 Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana.
PMID: 32969147
DOI: 10.1111/dom.14200

Against the backdrop of obesity as a major public health problem, we examined three questions: How much weight loss is needed to benefit patients with obesity? How well do current therapies do in producing weight loss? What strategies can be used to improve patient outcomes using evidence-based studies. This paper reviews literature on the outcomes of lifestyle, diet, medications and surgical treatments for obesity using literature searches for obesity treatments. Current treatments, including lifestyle, diet and exercise, produce a weight loss of 5% to 7% on average. Despite continued attempts to identify superior dietary approaches, most careful comparisons find that low carbohydrate diets are not significantly better than low fat diets for weight loss. The four medications currently approved by the US Food and Drug Administration for long-term management of obesity are not as effective as surgery, adding about 5% on average to lifestyle approaches to weight loss. Two new medications that are under investigation, semaglutide and tirzepatide, significantly improve on this. For all treatments for weight loss, including lifestyle, medications and surgery, there is enormous variability in the amount of weight lost. Examination of this literature has yielded evidence supporting baseline and process predictors, but the effect sizes associated with these predictors are small and there are no prospective studies showing that a personalized approach based on genotype or phenotype will yield uniform success. Because obesity is a chronic disease it requires a 'continuous treatment model' across the lifespan.

Keywords: bariatric/metabolic surgery; comprehensive lifestyle programme; diet; medications for obesity; personalized obesity management.

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Diet, Fat-Restricted
Obesity* / therapy
Weight Loss*

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Weight loss from bariatric surgery compared to nonsurgical care for people with severe obesity

Researchers found that bariatric surgical procedures, including gastric bypass surgery and sleeve gastrectomy, led to significantly more weight loss than nonsurgical care for people with severe obesity—information that could help with treatment decisions. Although past research demonstrated that bariatric surgery leads to substantial weight loss, only a few long-term studies compared weight loss from nonsurgical care to that from surgery, and there has been less information on sleeve gastrectomy, though it is currently the most common bariatric procedure.

To better understand the effects of surgery, researchers analyzed electronic medical records and other data from women and men of diverse race and ethnicity with severe obesity in a large health care system, including 13,900 people who had sleeve gastrectomy (SG), 17,258 who had Roux-en-Y gastric bypass (RYGB), and 87,965 people who did not have surgery. Those in the nonsurgical group received usual medical care, which in general did not include specific obesity treatment. On average, 1 year after surgery, people in the RYGB group had lost 28 percent of their weight, and those who had SG lost 23 percent of their weight. At a similar time point, those in the nonsurgical group had lost 0.2 percent of their weight. Longer-term follow-up data were available for a majority of the people. At 5 years, the people who had surgery regained some weight, but those who had RYGB still maintained an average 22 percent weight loss, and those in the SG group still maintained 16 percent weight loss, or approximately 60 pounds and 43 pounds lost, respectively. Some regained enough weight to be within 5 percent of their initial weight, however, including 1 of every 10 people who had SG and 1 in 27 who had RYGB. Those who didn’t have surgery had lost approximately 2 percent of their weight, or about 6 pounds. At 10 years, those who had RYGB were still on average 20 percent below their pre-surgical weight, and those in the nonsurgical group had lost approximately 5 percent of their weight. (There were not enough data to analyze weight loss 10 years after SG.)

This study provides important information that people with severe obesity and their health care providers can use when considering bariatric surgery. The findings also suggest a need for additional care for people who experience weight regain after surgery. Future research could explore other long-term effects of bariatric surgery on health.

Arterburn DE, Johnson E, Coleman KJ, ...Haneuse S. Weight outcomes of sleeve gastrectomy and gastric bypass compared to nonsurgical treatment . Ann Surg 274: e1269-e1276, 2021.

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Weight-loss surgery yields long-term benefits for type 2 diabetes

At a glance.

Bariatric surgery helped people with type 2 diabetes better control their blood glucose years later compared to medical and lifestyle interventions.
The findings support the use of weight-reduction surgery for treating type 2 diabetes in people with obesity.

Doctor talking with an overweight patient in a wheelchair.

Diabetes affects more than 38 million people nationwide. It occurs when levels of blood sugar, or glucose, are too high. Over time, excess blood glucose can lead to serious health problems, such as heart disease, stroke, nerve damage, and eye disease.

Some people with type 2 diabetes—the most common type—keep blood glucose in check by making lifestyle changes, including diet and exercise. Medications can also help to control blood glucose. Clinical trials over the past few decades have found that bariatric surgery, or weight-control surgery, can also help control type 2 diabetes. But it had been unclear which of these interventions might have better long-term outcomes.

To learn more, NIH-supported researchers at four institutions drew on data collected from four previous clinical trials conducted between May 2007 and August 2013. These trials were single-center studies comparing the effectiveness of bariatric surgeries to medical and lifestyle interventions. The surgeries included sleeve gastrectomy, Roux-en-Y gastric bypass, and adjustable gastric banding. The medical and lifestyle interventions included nutrition counseling, self-monitoring of glucose, and medication to treat diabetes. By pooling data from the four clinical trials, the researchers had a larger, more diverse data set to analyze. Follow-up data was collected 7 to 12 years after the start of the original trials, through July 2022.

In total, 262 study participants agreed to long-term follow-up. All were between ages 18 and 65. Each had overweight or obesity, as measured by body mass index (BMI). Nearly 70% of participants were women, 31% were Black, and 67% were white. More than half (166) were randomized to receive bariatric surgery. The remaining 96 received diabetes medications plus lifestyle interventions known to be effective for weight loss. Results appeared in the Journal of the American Medical Association on February 27, 2024.

The researchers found that, seven years after the original intervention, 54% of those in the surgery group had an A1c measurement less than 7%. A1c is a blood test that measures a person’s average blood sugar levels over the previous two or three months. In contrast, only 27% of those in the medical/lifestyle group had similar A1c values.

In addition, 18% of those in the surgery group no longer had signs or symptoms of diabetes by year seven, compared to 6% in the medical/lifestyle group. The surgery group also had an average weight loss of 20%, compared to 8% in the other group. The differences between groups remained significant at 12 years.

No differences in major side effects were detected. The surgery group did have a higher number of fractures, anemia, low iron, and gastrointestinal events. These might have been due to greater weight loss and associated nutritional deficiencies. Sleeve gastrectomy and Roux-en-Y gastric bypass were both better than adjustable gastric banding at reducing A1c levels.

The surgeries appeared to be beneficial even among those with lower BMI scores, between 27 and 34 at study enrollment. That BMI range includes overweight and low-range obesity. Such people had typically been excluded from receiving bariatric surgery for diabetes. But this finding aligns with other recent data that support the use of surgery for some people with a BMI less than 35.

“These results show that people with overweight or obesity and type 2 diabetes can make long-term improvements in their health and change the trajectory of their diabetes through surgery,” says Dr. Jean Lawrence of NIH’s National Institute of Diabetes and Digestive and Kidney Diseases.

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A Bibliometric Analysis of the 50 Most Cited Articles on Body Contouring Surgery After Massive Weight Loss

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Body Contouring
Published: 12 February 2024

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Mario Alessandri Bonetti 1 na1 ,
Hilary Liu 1 na1 ,
Jeffrey A Gusenoff 1 ,
J Peter Rubin 1 &
Francesco M Egro ORCID: orcid.org/0000-0003-1536-7713 1

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Body contouring surgery after massive weight loss has emerged a safe and reliable option to improve self-esteem, social life, work ability, physical activity, and sexual activity, and it is considered as an essential step in the multidisciplinary approach to morbid obesity. In this study, we aim to provide a comprehensive overview of the current state of literature on body contouring after massive weight loss, identifying research trends and areas for future investigation.

The Web of Science Core Collection was used to identify the 50 most cited publications on post-massive weight loss surgery. Data collected from each article included: title, journal, publication year, total citations, average citations per year, authors, study type, study topic, country, and institution of origin.

The top 50 most-cited articles include 44 original articles and 6 review articles. The most cited article, published by Lockwood in 1991, received a total of 224 citations. The research areas included surgical outcomes and complications (n=19, 38%), psychological aspects such as body image, quality of life and desire for body contouring procedures (n=18, 36%), surgical techniques (n=11, 22%), an anatomical study (n=1, 2%), and a classification system (n=1; 2%). Plastic and Reconstructive Surgery journal published most (44%) of the papers identified. The University of Pittsburgh was the single institution that contributed the most (n=11; 22%).

This bibliometric analysis provides insights and research trends for clinicians interested in body contouring after massive weight loss, facilitating the understanding and evolution of post-bariatric surgery and elucidating the rationale behind current practice.

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Body Contouring Surgery Improves Weight Loss after Bariatric Surgery: A Systematic Review and Meta-Analysis

Rawan ElAbd, Osama A. Samargandi, … Sarah AlYouha

Investigating the Safety of Multiple Body Contouring Procedures in Massive Weight Loss Patients

Saad Mohamed Saad Ibrahiem

Comparing Bariatric Surgery Patients Who Desire, Have Undergone, or Have No Desire for Body Contouring Surgery: a 5-Year Prospective Study of Body Image and Mental Health

Liliana Buer, Ingela Lundin Kvalem, … Tom Mala

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Alhithlool AW, Al Qurashi AA, Halawani IR et al (2023) Top 50 highly cited publications in facelift surgery: a 50-year bibliometric analysis review. Aesthet Plast Surg. https://doi.org/10.1007/s00266-023-03752-x

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Department of Plastic Surgery, University of Pittsburgh Medical Center, 3550 Terrace Street 6B Scaife Hall, Pittsburgh, PA, 15261, USA

Mario Alessandri Bonetti, Hilary Liu, Jeffrey A Gusenoff, J Peter Rubin & Francesco M Egro

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Alessandri Bonetti, M., Liu, H., Gusenoff, J.A. et al. A Bibliometric Analysis of the 50 Most Cited Articles on Body Contouring Surgery After Massive Weight Loss. Aesth Plast Surg (2024). https://doi.org/10.1007/s00266-024-03854-0

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Published : 12 February 2024

DOI : https://doi.org/10.1007/s00266-024-03854-0

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Weight loss surgery has long-term benefits for people with diabetes, study finds

B ariatric surgery, also called weight loss surgery, leads to better blood sugar control and less medication use long-term in people with type 2 diabetes than non-surgical management with medications such as insulin and metformin, a new study found.

The study , published Tuesday in the journal JAMA, compared the blood sugar levels and medication regimens of 262 people who were randomly assigned to undergo weight loss surgery or non-surgical medical management, such as medication and lifestyle changes, for type 2 diabetes after seven to 12 years.

Participants who had weight loss surgery had significantly lower blood sugar levels and were on fewer diabetes medications than those who did not undergo surgery, the researchers, from University of Pittsburgh and other institutions, wrote. They were also more likely to achieve diabetes remission, which is defined as having non-diabetic blood sugar levels for at least three months without medication.

This research “provides the most robust evidence to date of the long-term efficacy of bariatric surgery for improving control of type 2 diabetes,” Dr. Thomas A. Wadden, a professor of psychology and former director of the Center for Weight and Eating Disorders at the Perelman School of Medicine at the University of Pennsylvania, wrote in an editorial that was published along with the research.

Weight loss surgery is a procedure in which the digestive tract is altered — typically, the size of the stomach is reduced — to help a person lose weight, according to the National Institute of Diabetes and Digestive and Kidney Diseases .

The resulting reduction in food intake and neurohormonal changes also lower blood sugar and thereby treat type 2 diabetes, Dr. Marilyn Tan, chief of the Endocrinology Clinic at Stanford Health Care, who was not involved with the research, wrote in an email to CNN.

“Though it’s a more invasive option than traditional diabetes medications and is a large commitment, it’s also an investment in long-term health,” Tan said.

Most health-care providers don’t currently recommend weight loss surgery for type 2 diabetes unless a person has a body mass index (BMI) of 35 or higher, and less than 1% of those people end up pursuing surgical treatment, according to the study.

However, Wadden said in an email to CNN that the new findings support the expanded use of bariatric surgery to those with a BMI less than 35 who have trouble controlling their blood sugar with medical management alone.

“I hope these results will encourage more insurers and payers to cover bariatric surgery for patients with type 2 diabetes and a BMI of 30 to 34.9,” he said. “It is a highly effective, long-term therapy for these individuals.”

Non-surgical medical management for type 2 diabetes involves lifestyle changes like reducing carbohydrate intake and increasing exercise, and using medications like metformin and occasionally insulin, Tan said. The goal is to lower hemoglobin A1c, the measure of average blood sugar levels over three months, below 7%.

“I’ve had multiple patients where despite hundreds of units of insulin a day, and despite their best efforts, they are unable to get their A1cs below 10%,” Tan said. “Then, after bariatric surgery, they can maintain A1c levels below the diabetes range without any medications. They also note that with the weight loss, they can be more active.”

Further research is needed to compare the clinical outcomes and cost efficacy of weight loss surgery and the new generation of anti-diabetes medications, such as Ozempic and Mounjaro, the editorial says.

The weight loss people have after surgery is key to improving diabetes outcomes as well as heart health, Tan said. Weight loss improves the body’s response to insulin, reduces inflammation and helps lower blood pressure and cholesterol. It can also improve arthritis so people can exercise more, she added.

The findings from this study also support the heart health benefits of weight loss surgery. People in the surgery group had significantly higher HDL or “good” cholesterol and lower triglycerides, a type of fat that can raise the risk of heart disease and stroke.

Despite the benefits, people are often hesitant to have weight loss surgery because it is invasive and comes with some risks, Tan said.

The study found that anemia (a lack of healthy red blood cells), bone fractures and gastrointestinal complications such as abdominal pain, nausea and vomiting were more common in people who had weight loss surgery.

These known complications result from nutritional deficiencies that can happen when the digestive tract is surgically altered. People who have surgery must change their diet and take vitamins regularly to avoid these problems, Tan said.

People who have the surgery can also gain back any weight lost, Tan added.

“Despite having the surgery, weight re-gain is possible if patients revert back to prior eating habits and quantities,” she said.

The study found that 51% of surgically treated participants achieved full remission of type 2 diabetes one year later, but only 18% maintained remission at seven years. This reduction in remission after surgery, which has been observed in previous research, is probably due to a combination of weight regain and the loss of insulin-producing cells over time, according to the editorial.

Even short-term diabetes remission has benefits in terms of reducing diabetes-related complications, such as eye, kidney and peripheral blood vessel disease, the editorial says.

Although bariatric surgery has a higher upfront cost than medical management — about $33,000 before insurance coverage — it is considered to be more cost-effective about five years after surgery, according to the editorial.

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Maintenance of lost weight and long-term management of obesity

Kevin d. hall.

1 National Institute of Diabetes & Digestive & Kidney Diseases

Scott Kahan

2 Johns Hopkins Bloomberg School of Public Health

3 George Washington University School of Medicine

Weight loss can be achieved through a variety of modalities, but long-term maintenance of lost weight is much more challenging. Obesity interventions typically result in early rapid weight loss followed by a weight plateau and progressive regain. This review describes our current understanding of the biological, behavioral, and environmental factors driving this near-ubiquitous body weight trajectory and the implications for long-term weight management. Treatment of obesity requires ongoing clinical attention and weight maintenance-specific counseling to support sustainable healthful behaviors and positive weight regulation.

Introduction

Robert is a 47 year old patient who initially weighed 270 pounds. He lost 85 pounds three years ago by carefully following your guidance to decrease his caloric intake to 1500 calories per day and exercise six days weekly. Today he comes in for his annual physical examination. You were excited to hear about his continued progress and see how much more he’s lost, but you felt immediately dejected to see that he had regained almost 60 pounds. “I don’t know what to do…the weight keeps coming back on. I keep trying, but there must be something wrong. I’m sure my metabolism is in the dumps. It feels like every moment of the day I can’t help but think about food – it was never like this before I lost the weight. And no matter how hard I try to stop eating after one serving, I just can’t seem to do it anymore.” Feeling defeated, he says “I don’t even know what’s the point of doing this anymore!” Frustrated, you remind him that he was able to do it just fine when he was losing weight initially, and he just needs to keep working hard at it. “I know it’s not easy, but I can’t help you unless you’re willing to help yourself. You just need to work harder and take control of this again.” You feel for him, but you know that you need to be stern to get him past this backsliding. Hoping to motivate him, you remind him how bad he will feel if he regains more weight, and you tell him to make a follow-up appointment for six months and warn him that if he doesn’t turn things around quickly he will have to restart his blood pressure medications .

Substantial weight loss is possible across a range of treatment modalities, but long-term sustenance of lost weight is much more challenging, and weight regain is typical 1 – 3 . In a meta-analysis of 29 long-term weight loss studies, more than half of the lost weight was regained within two years, and by five years more than 80% of lost weight was regained ( Figure 1 ) 4 . Indeed, previous failed attempts at achieving durable weight loss may have contributed to the recent decrease in the percentage of people with obesity who are trying to lose weight 5 and many now believe that weight loss is a futile endeavor 6 .

An external file that holds a picture, illustration, etc.
Object name is nihms904015f1.jpg

Average time course of weight regain after a weight loss intervention.

Data from Anderson JW, Konz EC, Frederich RC, et al. Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr 2001;74(5):579–584.

Here, we describe our current understanding of the factors contributing to weight gain, physiological responses that resist weight loss, behavioral correlates of successful maintenance of lost weight, as well as the implications and recommendations for long-term clinical management of patients with obesity.

Why is it so difficult to lose weight and keep it off?

The obesogenic environment.

Long term weight management is extremely challenging due to interactions between our biology, behavior, and the obesogenic environment. The rise in obesity prevalence over the past several decades has been mirrored by industrialization of the food system 7 involving increased production and marketing of inexpensive, highly-processed foods 8 – 10 with supernormal appetitive properties 11 , 12 . Ultraprocessed foods 13 now contribute the majority of calories consumed in America 14 and their overconsumption has been implicated as a causative factor in weight gain 15 . Such foods are typically more calorically dense and far less healthy than unprocessed foods such as fruits, vegetables, and fish 16 . Food has progressively become cheaper 17 , fewer people prepare meals at home 18 , 19 , and more food is consumed in restaurants 18 . In addition, changes in the physical activity environment have made it more challenging to be active throughout the day. Occupations have become more sedentary 20 and suburban sprawl necessitates vehicular transportation rather than walking to work or school as had been common in the past. Taken together, changes in the food and physical activity environments tend to drive individuals towards increased intake, decreased activity, and ultimately weight gain.

Physiological responses to weight loss

Outdated guidance to physicians and their patients gives the mistaken impression that relatively modest diet changes will consistently and progressively result in substantial weight loss at rate of one pound for every 3500 kcal of accumulated dietary calorie deficit 21 – 24 . For example, cutting just a couple of cans of soda (~300 kcal) from one’s daily diet was thought to lead to about 30 pounds of weight loss in a year, 60 pounds in 2 years, etc. Failure to achieve and maintain substantial weight loss over the long term is then simply attributed to poor adherence to the prescribed lifestyle changes, thereby potentially further stigmatizing the patient as lacking in willpower, motivation, or fortitude to lose weight 25 .

We now know that the simple calculations underlying the old weight loss guidelines are fatally flawed because they fail to consider declining energy expenditure with weight loss 26 . More realistic calculations of expected weight loss for a given change in energy intake or physical activity are provided by a web-based tool called NIH Body Weight Planner ( http://BWplanner.niddk.nih.gov ) that uses a mathematical model to account for dynamic changes in human energy balance 27 .

In addition to adaptations in energy expenditure with weight loss, body weight is regulated by negative feedback circuits that influence food intake 28 , 29 . Weight loss is accompanied by persistent endocrine adaptations 30 that increase appetite and decrease satiety 31 thereby resisting continued weight loss and conspiring against long-term weight maintenance.

Explaining the weight plateau

The overlapping physiological changes that occur with weight loss help explain the near-ubiquitous weight loss time course: early rapid weight loss that stalls after several months, followed by progressive weight regain 32 . Different interventions result in varying degrees of weight loss and regain, but the overall time courses are similar. As people progressively lose more and more weight, they fight an increasing battle against the biological responses that oppose further weight loss.

Appetite changes likely play a more important role than slowing metabolism in explaining the weight loss plateau since the feedback circuit controlling long-term calorie intake has greater overall strength than the feedback circuit controlling calorie expenditure. Specifically, it has been estimated that for each kilogram of lost weight, calorie expenditure decreases by about 20–30 kcal/d whereas appetite increases by about 100 kcal/d above the baseline level prior to weight loss 31 . Despite these predictable physiologic phenomena, the typical response of the patient is to blame themselves as lazy or lacking in willpower, sentiments that are often reinforced by healthcare providers, as in the example of Robert, above.

Using a validated mathematical model of human energy balance dynamics 27 , 31 , Figure 2 illustrates the energy balance dynamics underlying the weight loss time courses of two example 90 kg women who either regain (blue curves) or maintain (orange curves) much of their lost weight after reaching a plateau within the first year of a diet intervention. In both women, large decreases in calorie intake at the start of the intervention result in rapid loss of weight and body fat leading to a modest decrease in calorie expenditure that contributes to slowing weight loss. However, the exponential rise in calorie intake from its initially reduced value is the primary factor that halts weight loss within the first year. In contrast to the modest drop in calorie expenditure of less than 200 kcal/d at the weight plateau, appetite has risen by 400–600 kcal/d and energy intake has increased by 600–700 kcal/d since the start of the intervention.

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Mathematical model simulations of body weight, fat mass, energy intake, energy expenditure, appetite, and effort for two hypothetical women participating in a weight loss program. The curves in blue depict the typical weight loss, plateau and regain trajectory whereas the orange curves show successful weight loss maintenance.

These mathematical model results contrast with patients’ reports of eating approximately the same diet after the weight plateau that was previously successful during the initial phases of weight loss 33 . While self-reported diet measurements are notoriously inaccurate and imprecise 34 – 36 , it may be possible to reconcile such data with objectively quantified increases in calorie intake. It is entirely possible that patients truly believe they are sticking with their diet despite not losing any more weight or even regaining weight.

The patient’s perception of ongoing diet maintenance despite no further weight loss may arise because the physiological regulation of appetite occurs in brain regions that operate below the patient’s conscious awareness 37 . Thus, signals to the brain that increase appetite with weight loss could introduce subconscious biases such as portion sizes creeping upwards over time. Such a slow drift upwards in energy intake would be difficult to detect given the large 20–30% fluctuations in energy intake from day to day 38 , 39 . Furthermore, a relatively persistent effort is required to avoid overeating to match the increased appetite that grows in proportion to the weight lost 31 . For example, the model-calculated intervention effort for the simulated patient who experiences the weight plateau at six months followed by weight regain ( Figure 2 , blue curves) maintains more than ~70% of their initial intervention effort until the plateau. Perhaps self-reported diet maintenance before and after the weight plateau is more representative of the patients’ relatively persistent effort to avoid overeating in response to their increased appetite 31 . New technologies using repeated weight monitoring can be used calculate changes in calorie intake and effort over time 40 and help guide individuals participating in a weight loss intervention 41 – 44 .

Weight regain versus maintenance

From a purely calorie balance perspective, a patient who maintains lost weight after the first year of an intervention ( Figure 2 , orange curves) may be eating only about 100 kcal/d fewer than a patient who experiences long-term weight regain ( Figure 2 , blue curves). However, such a small difference in food intake behavior is somewhat misleading considering that prevention of weight regain requires about 300–500 kcal/d of increased persistent effort to counter the ongoing slowing of metabolism and increased appetite associated with the lost weight. The more typical pattern of long-term weight regain is characterized by a waning effort to sustain the intervention.

There are likely many factors that account for the ability of some patients to achieve and maintain large weight losses over the long term whereas others experience substantial weight regain. Unravelling the biological, psychosocial, educational, and environmental determinants of such individual variability will be an active area of obesity research for the foreseeable future 45 .

The role of diet composition

The laws of thermodynamics dictate that the energy derived from macronutrients being oxidized via the intricate biochemical pathways of oxidative phosphorylation inside cells can be equated to the values measured by combusting these fuels in a bomb calorimeter. However, this equivalence does not necessarily imply that “a calorie is a calorie” when it comes to diets with different macronutrient proportions differentially impacting weight loss.

Altering dietary macronutrient composition could theoretically influence overall calorie intake or expenditure resulting in a corresponding change in body weight. Alternatively, manipulation of diet composition can result in differences in the endocrine status in a way that could theoretically influence the propensity to accumulate body fat or affect subjective hunger or satiety. These possibilities do not necessarily violate the laws of thermodynamics since any change in the body’s overall energy stores (i.e. fat mass) must be accompanied by changes in calorie intake or expenditure. Therefore, it is theoretically possible that a particular diet could result in an advantageous endocrine or metabolic state that promotes weight loss. This promise provides fodder for the diet industry and false hope to the patient with obesity since it implies that if they simply choose the right diet then weight loss can be easily achieved.

In recent years, there has been a reemergence of low-carbohydrate, high-fat diets as popular weight loss interventions. Such diets have been claimed to reverse the metabolic and endocrine derangements resulting from following advice to consume low-fat, high-carbohydrate diets that allegedly caused the obesity epidemic. Specifically, the so-called “carbohydrate-insulin model of obesity” posits that diets high in carbohydrates are particularly fattening because they increase the secretion insulin and thereby drive fat accumulation in adipose tissue and away from oxidation by metabolically active tissues, and this altered fat partitioning results in a state of “cellular starvation” leading to adaptive increases in hunger, and suppression of energy expenditure 46 . Therefore, the carbohydrate-insulin model implies that reversing these processes by eating a low-carbohydrate, high-fat diet should result in effortless weight loss 47 . Unfortunately, important aspects of the carbohydrate-insulin model have failed experimental interrogation 48 and, for all practical purposes, “a calorie is a calorie” when it comes to body fat and energy expenditure differences between controlled isocaloric diets varying in the ratio of carbohydrate to fat 49 . Nevertheless, low-carbohydrate, high-fat diets may lead to spontaneous reduction in calorie reduction and increased weight loss, especially over the short term 50 – 52 . Meta-analyses of long-term weight loss have suggested that low-fat weight loss diets are slightly, if statistically, inferior to low-carbohydrate diets 53 , but the average differences between diets is too small to be clinically significant 54 . Furthermore, the similarity of the mean weight loss patterns between diet groups in randomized weight loss trials strongly suggests that there is no generalizable advantage of one diet over another when it comes to long-term calorie intake or expenditure 33 .

In contrast to the near equivalency of dietary carbohydrate and fat, dietary protein is known to positively influence body composition during weight loss 55 , 56 and has a small positive effect on resting metabolism 57 . Diets with higher protein may also offer benefits for maintaining weight loss 58 , particularly when the overall diet has a low glycemic index 59 . This might be partially mediated by dietary protein’s greater effect on satiety compared to carbohydrate and fat 55 , 56 along with the possibility of increased overall energy expenditure 60 . More research is needed to better understand whether these potentially positive attributes of higher protein diets outweigh concerns that such diets mitigate improvements in insulin sensitivity that are typically achieved with weight loss using lower protein diets 61 .

Whereas long-term diet trails have not resulted in clear superiority of one diet over another with respect to average weight loss, within each diet group there is a high degree of individual variability and anecdotal success stories abound for a wide range of weight loss diets 33 . Some of this variability may be due to interactions between diet type and patient genetics 62 , 63 or baseline physiology such as insulin sensitivity 64 – 67 . Such interactions offer the promise of personalized diets that optimize the patient’s chances for long-term weight loss success 45 , 63 . Unfortunately, diet-biology interactions for weight loss have not always been reproducible 68 , 69 and likely explain only a fraction of the individual variability.

It is certainly possible that the patients who successfully lost weight on one diet would have been equally successful had they been assigned to an alternative diet. In other words, long-term success with a weight loss diet may have less to do with biology than factors such as the patient’s food environment, socioeconomics, medical comorbidities, and social support, as well as practical factors, such as developing cooking skills and managing job requirements. Such non-biological factors likely play a strong role in determining whether diet adherence is sustainable.

Clinical recommendations for long term weight management counseling

Given the physiologic and environmental obstacles to long-term maintenance of lost weight described above, we offer the following recommendations for clinical practice and then present an alternative preferable depiction of the opening case example.

Long term benefits require long term attention

Long term behavioral changes and obesity management require ongoing attention. Even the highest quality short-term interventions are unlikely to yield continued positive outcomes without persisting intervention and support. Several studies show that ongoing interaction with healthcare providers or in group settings significantly improves weight maintenance and long-term outcomes, compared with treatments that end after a short period of time ( Figure 3 ) 70 , 71 . The importance of long-term intervention has been codified in the obesity treatment guidelines, which state that weight loss interventions should include long term comprehensive weight loss maintenance programs that continue for at least 1 year 72 .

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Weight management programs with a focus on maintenance of lost weight demonstrate improved long-term weight loss (red curve) compared to programs without maintenance visits (blue curve).

Adapted from Perri MG, McAllister DA, Gange JJ, et al. Effects of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol 1988;56(4):529–534; with permission.

With respect to the case study at the start of this paper, the physician should not expect ongoing weight loss without ongoing support and interaction. Rather than asking Robert to turn things around on his own, the physician has an opportunity to reengage with Robert to offer guidance and support in a more intensive and regular manner than sending him off on his own for six months, or if this is not realistic in a busy primary care practice, he could refer Robert to an obesity medicine specialist, registered dietitian, comprehensive weight management clinic, or recommend that he engage in a community weight management group, such as the Diabetes Prevention Program (now covered by Medicare for patients with prediabetes), or a commercial program, such as Weight Watchers.

Use weight maintenance-specific counseling/strategies

Behavioral strategies for initiation of weight loss are described elsewhere in this volume []. Weight-loss specific behaviors associated with long term success include: frequent self-monitoring and self-weighing, reduced calorie intake, smaller and more frequent meals/snacks throughout the day, increased physical activity, consistently eating breakfast, more frequent at-home meals compared with restaurant and fast-food meals, reducing screen time, and use of portion-controlled meals or meal substitutes 2 , 73 – 75 . Weight maintenance-specific behavioral skills and strategies help patients to build insight for long-term management, anticipate struggles and prepare contingency plans, moderate behavioral fatigue, and put into perspective the inevitable lapses and relapses of any long-term engagement.

Although the research is mixed, several studies show improved weight loss outcomes in patients receiving weight maintenance-specific training, compared with those who only receive traditional weight loss training 76 – 79 . Strategies are discussed below for weight maintenance-specific counseling.

Strengthen satisfaction with outcomes

People tend to focus on what they haven’t achieved, rather than what they’ve already accomplished. Unlike with weight loss, during which the external reward of watching the scale decrease and clinical measures (e.g., lipid levels) improve can increase motivation, the extended period of weight maintenance has fewer of these explicit rewards. To support motivation and make salient satisfaction with outcomes, call attention to patients’ progress, which often becomes overlooked. Providers can point to the magnitude of weight that has been kept off, putting it into context in terms of average expected weight loss (described below), as well as clinical improvements in risk factors, such as blood pressure and glycemic control. Additionally, showing patients “before and after” photographs of themselves and other tangible evidence of progress helps them to build awareness of and appreciate the benefits they have already achieved, which may improve long-term persistence with weight maintenance efforts.

Relapse prevention training

Anticipating and managing high-risk situations for “slips” and lapses helps patients minimize lapses, get back on track, and avoid giving up. This counseling often includes self-weighing and identifying weight thresholds that signal the need for reengaging with a support team or initiating contingency strategies; proactively developing plans and practicing strategies for managing and coping with lapses; problem solving to identify challenges, formulate solutions, and evaluate options; and building strategies for non-food activities and coping mechanisms, such as engaging in hobbies or mindfulness activities, to minimize counterproductive coping mechanisms, such as emotional eating.

Cognitive restructuring

Cycles of negative and maladaptive thoughts (e.g., “What’s the point…I failed again and I’ll never lose weight!”) and coping patterns (e.g., binge eating in response to gaining a few pounds) are counterproductive and demotivating. Helping patients to recognize and restructure the core beliefs and thought processes that underlie these patterns helps minimize behavioral fatigue and prevent or productively manage slips and lapses.

Developing cognitive flexibility

Many tendencies that promote initial weight loss are unrealistic over the long term. For example, many patients aim to make large, absolute changes in an “all-or-none” fashion via rigid rules, such as aiming for “no carbs” or very restrictive intake. Much as a sprinter can run all-out for a short race, but not for the entirety of a marathon, expecting strict, all-out efforts and clear-cut, black-and-white outcomes over the lifelong management of obesity is a recipe for frustration and failure. Instead, learning to accept that rigid expectations and “perfect” adherence to behavioral goals is unrealistic and building cognitive flexibility to take in stride when one’s plans do not go according to plan is a core competency for long term sustainable behavioral changes and weight management.

Appeal to patients’ deeper motivations

External, superficial rewards are unlikely to support the long term endurance needed for weight maintenance. For example, studies of financial rewards to incentivize behavioral changes, such as weight loss or tobacco cessation, yield initial benefits that invariably wane precipitously over time 80 , 81 . Whereas “white knuckling” and external, controlled motivations, such as directives from a spouse or healthcare provider, may lead to short-term weight loss, longer term sustained motivation is more likely when patients take ownership of their behavioral changes and goals, and engage in them because they are deeply meaningful or enjoyable 80 , 81 . As an example, compared with difficulty of sticking to a strict low-fat or low-carb diet, which are often arbitrarily prescribed and of little personal significance to the patient, and therefore difficult to maintain, countless millions throughout the world rigorously stick to comparably strict kosher, halal, or vegan eating patterns, which are aligned with their religious, ethical, or other deeply held beliefs and values. Similarly, prescribing daily gym visits to someone who hates the gym environment or gym activities is unlikely to be fruitful, whereas supporting patients to find more enjoyable physical activities, such as sports or group dance-exercise classes, increases the likelihood of continuing over time.

Manage expectations – both for patients and providers

Both patients and healthcare providers have wildly unrealistic expectations for weight loss outcomes. In one study, patients entering a diet and exercise program expected to lose 20–40% of their starting body weight - amounts that can only realistically be achieved by bariatric surgery 82 . Physician expectations are similarly inflated: in a survey of primary care physicians, acceptable behavioral weight loss was considered to be a loss of 21% of initial body weight 83 . In contrast, numerous studies show that diet, exercise, and behavioral counseling, in the best of cases, only leads to 5–10% average weight loss, and few patients with significantly elevated initial weights achieve and maintain an “ideal” body weight. From a cognitive psychology perspective, a waning intervention effort may be due to disappointment in the degree of weight loss actually achieved 82 leading the patient to conclude that the effort is not worth the achieved benefits 84 .

Although the published data is mixed on whether unrealistic outcomes will deter weight loss success, it stands to reason that excessive discrepancies between expectations and actual outcomes would be demoralizing and increase negative thoughts and self-blame (which itself is associated with numerous negative health outcomes 85 ), and may diminish long term persistence for continued behavioral change and weight loss maintenance. We recommend advising patients about the physiologic challenges of long term weight loss and the degree of weight loss that can be realistically expected from behavioral interventions. At minimum, there’s no known harm of offering this insight and being frank with patients about expectations, and it may help them navigate the minefield of unscrupulous diet programs and promises that promise miraculous outcomes.

Nonetheless, positive outcomes of behavioral counseling extend beyond weight loss. Despite the modest weight losses associated with behavioral interventions, small weight losses can lead to impressive health improvements and risk factor reductions. In the Diabetes Prevention Program, 7% weight loss over six months led to 58% reduction in development of diabetes, despite half the weight being regained over three years 86 . In the Look Ahead trial, 6% weight loss over eight years yielded improvements in a range of cardiovascular risk factors, including glycemic control and lipids, as well as less medication usage, and reduced hospitalizations and healthcare costs 87 , 88 .

While losing weight is important for improved health, people’s motivations for seeing the scale go down is all-too-often driven by cultural norms for thinness and healthcare provider-imposed weight loss directives. These external motivations can move the weight loss needle in the short-run, but they rarely lead to long-lasting determination. As described in the section above, long term management is improved when motivations are aligned with personal values and preferences. Helping patients shift their locus of motivation from weight loss alone to intrinsically meaningful areas, such as health improvement, can improve long term weight and behavioral outcomes 89 .

Escalate treatment as needed

For patients that do not achieve sufficient weight loss or health improvements with basic counseling in primary care settings, there are several opportunities to intensify therapy. Consider referral to a registered dietitian, obesity medicine physician, or comprehensive weight management clinic, as well as targeted specialists (such as a behavioral psychologist for patients with binge eating disorder or body dysmorphia). For patients with BMI greater than 30 kg/m 2 (or 27–30 kg/m 2 with obesity-related comorbid conditions), obesity pharmacotherapy leads to as much as 15% weight loss in responders, with weight loss being maintained in several studies for several years 90 – 92 . For patients with BMI greater than 40 kg/m 2 (or 35–40 kg/m 2 with comorbidities), bariatric surgery is a well-studied and valuable option that leads to large, sustainable weight losses in most patients 93 .

Using the principles discussed above, a more productive encounter in response to Robert’s presentation might go like this:

Physician: “I understand, and I know it’s challenging. It sounds like you’re feeling frustrated because you’ve worked so hard and you feel like you’ve got nothing to show for it.” He nods and says, “Exactly. What’s the point of doing this anymore.” Physician: “From my view, the evidence we have shows something different: You’re actually doing quite well in the scheme of things. I actually see quite a lot of progress for your efforts. You’re down 25 lbs, right? That’s almost 10% down from where you started…that’s impressive. Few people lose that much weight and keep it off for three years. Studies show that even under the best of circumstances with aggressive counseling, average weight loss is between 5–10% of starting body weight – so you’re doing better than most! You’ve been able to get off several blood pressure medications and you no longer take the pain medicine for your back and knees. And, we know from studies that losing just 7%, even if part of it is regained over the years, lowers the risk of diabetes by 60%!” His eyes widen. “Weight goes up and down, and our bodies fight back against weight loss, so this is never easy. Some regain and relapse is inevitable – just like in other areas of life.” He takes a deep breath and clearly seems more engaged and hopeful. ”So let’s figure out how we can move forward and keep getting the benefits, and I’ll be here with you to help along the way. Let’s agree on a couple of next steps, and we’ll meet again in a few weeks to see how it’s going. If we need, we can also consider additional strategies or treatments.”

The degree of weight loss and its maintenance should not be the sole metric of obesity treatment success. Rather, physicians should support and encourage patients to make sustainable improvements in their diet quality and physical activities if these behaviors fail to meet national guidelines 94 , 95 . Such lifestyle changes over the long-term will likely improve the health of patients even in the absence of major weight loss 96 .

Long-term maintenance of lost weight is the primary challenge of obesity treatment.
Biological, behavioral, and environmental factors conspire to resist weight loss and promote regain.
Treatment of obesity requires ongoing attention and support, and weight maintenance-specific counseling, to improve long-term weight management.
Realistic long-term weight loss magnitude is significantly lower than patient and healthcare provider expectations. However, even small amounts of sustained weight loss lead to clinical health improvements and risk factor reductions.

Acknowledgments

Funding: This research was supported by the Intramural Research Program of the NIH, National Institute of Diabetes & Digestive & Kidney Diseases.

KDH has received funding from the Nutrition Science Initiative to investigate the effects of ketogenic diets on human energy expenditure. KDH also has a patent on a method of personalized dynamic feedback control of body weight (US Patent No 9,569,483; assigned to the National Institutes of Health).

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Conflicts of Interest: SK has no relevant disclosures.

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Bariatric Surgery in Adults with Obesity: the Impact on Performance, Metabolism, and Health Indices
Introduction. Severe obesity, defined as a body mass index (BMI) of at least 35 kg m 2 [], is strongly associated with several health complications [2-4] along with significant impairments in physical capacity and overall fitness parameters [5-8].Bariatric surgery (BS) is emerging as an important option for those suffering from severe obesity when nonsurgical weight loss methods have been ...
Recent advances in bariatric surgery: a narrative review of weight loss
Methodology. We conducted a comprehensive narrative review to explore recent advances in bariatric surgery as a weight loss procedure. Our primary objectives were to identify and analyze the latest developments in bariatric surgery techniques, evaluate their efficacy, safety, and impact on patient outcomes and quality of life, and propose potential areas of future research to enhance the field.
Treatment of Obesity: Weight Loss and Bariatric Surgery
In contrast, the Swedish Obese Subjects (SOS) study reported weight loss following a variety of bariatric surgical procedures to be 17% 5 years following surgery, 16% in 15 years, and 18% in 20 years post-surgery 117. Weight was essentially unchanged in the usual care group matched for multiple clinical parameters.
Bariatric Surgery in Adults with Obesity: the Impact on ...
Severe obesity, defined as a body mass index (BMI) of at least 35 kg m 2 [], is strongly associated with several health complications [2,3,4] along with significant impairments in physical capacity and overall fitness parameters [5,6,7,8].Bariatric surgery (BS) is emerging as an important option for those suffering from severe obesity when nonsurgical weight loss methods have been exhausted.
Tirzepatide Once Weekly for the Treatment of Obesity
Finally, bariatric surgery results in weight reduction of approximately 25 to 30% at 1 to 2 years. 19,20 In the current trial, 36.2% of participants in the 15-mg tirzepatide group met the ...
Comparative Effectiveness and Safety of Bariatric Procedures for Weight
Background: There has been a dramatic shift in use of bariatric procedures, but little is known about their long-term comparative effectiveness. Objective: To compare weight loss and safety among bariatric procedures. Design: Retrospective observational cohort study, January 2005 to September 2015. (ClinicalTrials.gov: NCT02741674) Setting: 41 health systems in the National Patient-Centered ...
Long-term Study of Bariatric Surgery for Obesity: LABS
Purpose. The NIDDK funded the Longitudinal Assessment of Bariatric Surgery (LABS) observational study to research the risks and benefits of certain types of weight-loss (bariatric) surgery in adults—including gastric band and open or laparoscopic gastric bypass —and its impact on the health and well-being of people who have obesity with a ...
Weight loss is the major player in bariatric surgery benefits
Fig. 1. The effect on type 2 diabetes of weight loss achieved via diet or bariatric surgery. Full size image. Ever since the surgeon Walter Pories reported the rapid effects of RYGB on improving ...
A Systematic Review of Genetic Correlates of Weight Loss After
This systematic review synthesized research evaluating the relationship between genetic predictors and weight loss after bariatric surgery. Fifty-seven studies were identified that examined single genes or genetic risk scores. Uncoupling protein (UCP) rs660339 was associated with excess weight loss after surgery in 4 of 6 studies. The most commonly assessed genes were fat mass and obesity ...
Long-term durability of weight loss after bariatric surgery; a
Research Paper. Long-term durability of weight loss after bariatric surgery; a retrospective study. Author links open overlay panel Mohamad ... (6 yrs. −11 yrs) were recorded by a lot of research groups, with biggest sample-size mentioned before was by Abdellatif et al., [35] following 520 cases and displaying a steady weight reduction ...
Effectiveness of bariatric surgical procedures
3.3 Weight loss. All clinical trials showed significant weight reduction when compared with their baseline weight after receiving bariatric surgery in all 3 procedures (P < .05). Among the 3 surgical procedures, smallest treatment effect in terms of weight loss was observed in LAGB, while conflicting results were seen between RYGB and SG.
Associations between diet composition, dietary pattern, and weight
However, weight non-response (insufficient weight loss) or weight recurrence (weight regain) are reported in as many as 1 in 2 patients at 2 years, and 3 in 5 patients at 12 years after surgery [3 ...
The future of bariatric surgery research: A worldwide mapping of
The bariatric surgery (BS) research landscape is a continuous evolving. Since the first described procedure, numerous different techniques have been developed by surgical teams. ... (81% of RCTs) outcomes to be investigated are obesity-related diseases with the study of type 2 diabetes, followed by weight loss, quality of life, and surgical ...
Evidence-based weight loss interventions: Individualized treatment
Two new medications that are under investigation, semaglutide and tirzepatide, significantly improve on this. For all treatments for weight loss, including lifestyle, medications and surgery, there is enormous variability in the amount of weight lost.
Weight loss from bariatric surgery compared to nonsurgical care for
Longer-term follow-up data were available for a majority of the people. At 5 years, the people who had surgery regained some weight, but those who had RYGB still maintained an average 22 percent weight loss, and those in the SG group still maintained 16 percent weight loss, or approximately 60 pounds and 43 pounds lost, respectively.
The Ethical Work of Weight Loss Surgery: Creating Reflexive ...
In recent years bariatric surgery (a term used to denote operations designed to restrict the volume of the stomach, its absorption ability, or both) has become prevalent worldwide as a way to achieve weight loss for those who are medically diagnosed with "morbid obesity" (Buchwald and Oien 2013). Footnote 2 The surgery reduces an individual's body weight and consequently contributes to ...
Patients' Experiences of Weight Regain After Bariatric Surgery
Participants in our study had a pre-surgical mean BMI of 52 kg/m 2. Patients with a pre-surgical BMI of ≥ 50 kg/m 2 are more likely to regain weight, while a lower pre-surgical BMI has been associated with more successful weight loss outcomes 12 to 36 months after surgery [ 48 ]. These findings and the fact that our sample had a mean BMI > 50 ...
Once-Weekly Semaglutide in Adults with Overweight or Obesity
Weight loss of 10 to 15% (or more) is recommended in people with many complications of overweight and obesity (e.g., prediabetes, hypertension, and obstructive sleep apnea). 1,20,21,27 In the ...
JCM
Aim: Whilst bariatric surgery is the most effective treatment for severe obesity, the aim of this study was to evaluate whether postoperative weight loss is similar in patients with or without metabolic syndrome. Methods: We performed a 5-year observational retrospective comparative cohort analysis of bariatric surgery in 333 patients (72% women) without (Group A, n = 133) or with (Group B, n ...
Weight-loss surgery yields long-term benefits for type 2 diabetes
The surgery group also had an average weight loss of 20%, compared to 8% in the other group. The differences between groups remained significant at 12 years. No differences in major side effects were detected. The surgery group did have a higher number of fractures, anemia, low iron, and gastrointestinal events.
UTSW Research: Food allergies, weight-loss surgery, and more
Weight-loss surgery support offered for teens; Racial disparities found among pregnant patients with multiple sclerosis; Gestational age increased at start of COVID-19 pandemic ; Antibody treatment lowers risk for food allergies . Millions of children have food allergies, many of which can cause severe illness or death.
The Work behind Weight-Loss Surgery: A Qualitative Analysis of Food
2. Participants and Methods. This study used a qualitative research design, guided by a phenomenological approach, to investigate and describe the meaning and essence of experience of patients at least two years after bariatric surgery [9, 10].Phenomenological studies are primarily open-ended, searching for themes of meaning in participants' lives [].
Bariatric surgery better than weight-loss drugs for diabetics ...
At 12 years, the bariatric surgery group continued to have superior weight loss (19.3%) compared to the medical group (10.8%). "The magnitude of benefits of bariatric surgery is very large and ...
A Bibliometric Analysis of the 50 Most Cited Articles on Body
Background Body contouring surgery after massive weight loss has emerged a safe and reliable option to improve self-esteem, social life, work ability, physical activity, and sexual activity, and it is considered as an essential step in the multidisciplinary approach to morbid obesity. In this study, we aim to provide a comprehensive overview of the current state of literature on body ...
Weight loss surgery has long-term benefits for people with ...
The weight loss people have after surgery is key to improving diabetes outcomes as well as heart health, Tan said. Weight loss improves the body's response to insulin, reduces inflammation and ...
Wegovy's heart benefits are not just linked with weight loss, new study
GLP-1 drugs such as Wegovy and related medications are expected to top $164 billion in combined sales in 2032, according to consensus estimates from Visible Alpha, up from $37.9 billion in 2023 ...
Maintenance of lost weight and long-term management of obesity
Weight loss can be achieved through a variety of modalities, but long-term maintenance of lost weight is much more challenging. Obesity interventions typically result in early rapid weight loss followed by a weight plateau and progressive regain. This review describes our current understanding of the biological, behavioral, and environmental ...
How Tesla Planted the Seeds for Its Own Potential Downfall
29. Hosted by Katrin Bennhold. Featuring Mara Hvistendahl. Produced by Rikki Novetsky and Mooj Zadie. With Rachelle Bonja. Edited by Lisa Chow and Alexandra Leigh Young. Original music by Marion ...

Associations between diet composition, dietary pattern, and weight outcomes after bariatric surgery: a systematic review

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Completeness of intervention reporting of nutrition-focused weight management interventions adjunct to metabolic and bariatric surgery: effect of the TIDieR checklist

The effects of low-fat, high-carbohydrate diets vs. low-carbohydrate, high-fat diets on weight, blood pressure, serum liquids and blood glucose: a systematic review and meta-analysis

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Diet ≤12-months post-surgery and weight loss

Diet ≤12-months post-surgery and weight recurrence

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Diet between 12- and 24-months post-surgery and weight recurrence

Diet at ≥24-months post-surgery and weight loss

Diet at ≥24-months post-surgery and weight recurrence

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Evidence-based weight loss interventions: Individualized treatment options to maximize patient outcomes

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Weight loss from bariatric surgery compared to nonsurgical care for people with severe obesity

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Weight-loss surgery yields long-term benefits for type 2 diabetes

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A Bibliometric Analysis of the 50 Most Cited Articles on Body Contouring Surgery After Massive Weight Loss

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Body Contouring Surgery Improves Weight Loss after Bariatric Surgery: A Systematic Review and Meta-Analysis

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Weight loss surgery has long-term benefits for people with diabetes, study finds

Maintenance of lost weight and long-term management of obesity

Scott Kahan

Introduction

Why is it so difficult to lose weight and keep it off?

Physiological responses to weight loss

Explaining the weight plateau

Weight regain versus maintenance

The role of diet composition

Clinical recommendations for long term weight management counseling

Long term benefits require long term attention

Use weight maintenance-specific counseling/strategies

Strengthen satisfaction with outcomes

Relapse prevention training

Cognitive restructuring

Developing cognitive flexibility

Appeal to patients’ deeper motivations

Manage expectations – both for patients and providers

Escalate treatment as needed

Acknowledgments

How Tesla Planted the Seeds for Its Own Potential Downfall