Long-term Weight Loss After Bariatric Surgery

Lori Liebl, PhD, RN, CNE Assistant Professor of Nursing University of Wyoming Maintaining Weight Loss After Bariatric Surgery: A qualitative study Weight Loss Maintenance Within one year of nonsurgical weight loss Overweight adults regain ~ 50% of weight lost Past 1 year- regain of all or more of the weight lost Within 2 to 5 years of nonsurgical weight loss 92% will regain most or more of the weight lost Within 2 to 5 years of bariatric surgical patients 20% will regain >50%EWL < 5% will regain all of weight loss Obesity Treatments: Surgical Types Roux-en-Y gastric bypass (RYGB)- Criterion Standard 15.34 reduction in BMI Laparoscopic sleeve gastrectomy (LSG) 11.87 reduction in BMI Laparoscopic adjustable gastric band (LAGB) 7.05 reduction in BMI Background Pre- and post-surgical interventions Psychological screening Nutrition, behavior, exercise support

Support groups & exercise classes Percent & rate of weight regain - estimated 20% of the time Within 2 to 5 years Review of Literature & Gaps Factors &Traits oriented Long-term does not consider bariatric surgical patients (pts) Initial weight loss (12 to 18 mo) Minimal weight loss maintenance (>24 mo) Caucasian females 25 to 55, urban locations Quantitative: Quality of life; self-efficacy r/t behavior changes, self-regulation, self-talk, goal setting, support systems, behaviors. Qualitative: New identity clashing with old Loss, shame, anger, frustration, fear, joy, excitement, support systems, coping mechanisms Behavior change theories Banduras Social Cognitive Theory Minimally studied with bariatric surgical pts Theoretical Underpinnings Banduras behavioral change theory Social Cognitive Theory Triadic reciprocal causation model Broad assumptions used as framework Semi-structured interview guide open minded yet mindful

of the preconceptions (Sandelowski 2010,p. 80) Lasting change is dependent on reciprocal interaction of intrapersonal, behavioral, and environmental influences Purpose Statement The purpose of this qualitative descriptive study was to describe the experiences of adults who were successful and those who were unsuccessful at maintaining weight loss AT LEAST 2 YEARS after a bariatric surgery. Interview Guide Semi-structured questions were asked to allow the participant to answer and freely discuss their postsurgical experience. Question Examples: Prior to surgery, why did you believe your goal weight to be realistic? Why do you believe you have been able to maintain your weight loss? Tell me about the lifestyle changes have you made since your surgery? Tell me about the people who have supported you throughout this journey? Probing questions were used during the interview in order to keep participants on topic or to help the participant find a place to start or transition. Probing Question Examples: Has anyone helped you in your efforts to make these changes? What makes it difficult to choose healthy diet options? What type of activities do you do now? Are you satisfied with your current weight? Inclusion Criteria 1. Adult >19 years of age 2. > 24 months after a laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, or laparoscopic adjustable gastric band surgery 3. Able to speak, read, and understand English Success defined: > 50% of excessive weight loss (EWL) Unsuccessful: < 50% of EWL EWL: (preoperative weight minus postoperative weight) / (preoperative weight minus ideal body weight) 380 250 / 380 155 = 57% EWL

Recruitment results 20 adults agreed to participate 14 Successfully maintained weight loss 3 more recruited did not participate 6 Regained weight At least 6 more adults were recruited but did not participate Findings: Successful Participant Interviews M=82 minutes, between 60 and 117 minutes Upbeat and very willing to share information Participant did the majority of speaking, with minimal use of probing questions Demeanor and outlook on life were positive Awakened to a new life that came with a healthier weight Successful Participant Description Participant Age Gender Race Marital Status Education Employment Residence 1

48 Female Cauca Divorced College Part time & Self Rural 2 52 Male Asian Married College Full Time Suburban 3 38 Male Cauca

Married S. College Unemployed Suburban 4 40 Female Cauca Separated S. College Unemployed Suburban 5 46 Female Hispan Married S. College Part time

Urban 6 29 Female Cauca Married College Other Urban 7 60 Female Cauca Divorced College Unemployed Rural 8 29

Female Cauca Married College Other Suburban 9 73 Male Cauca Married College Retired Urban 10 40 Female Cauca Divorced

College Full Time Suburban 11 46 Female Cauca Married Tech Full Time Suburban 12 56 Female Cauca Married Tech Part time Rural

13 57 Female Cauca Married College Retired Suburban 14 43 Female Af. Am Single College Full Time Urban Successful participant surgical & weight information Participant Surgery Type

Months PostSurgery Highest Presurgical Weight & BMI Lowest Postsurgical Weight & BMI Current Weight & BMI Successful Weight & Ideal Body Weight 1 RYGB 30 386 / 62.3 180 / 29 195 / 31.5 270 / 144 3 RYGB 157 412 / 41.7

245 / 32.3 255 / 33.6 293 / 174 5 39 482 / 60.2 275 / 34.4 295 / 39.6 332 / 182 6 RYGB RYGB 29 225/ 38.6 110 / 18.9 115 / 19.7 182 / 138 7 RYGB 28

256/ 42.6 110 / 18.3 164 / 27.3 199 / 141 8 RYGB 129 297 / 56.1 136 / 25.7 136 / 25.7 213 / 129 9 RYGB 148 500 / 91.4 235 / 43 275 / 50.3 316 / 132 10

RYGB 52 301 / 55 118 / 21.6 143 / 26.2 219 / 137 12 LAGB 65 300 / 38.5 220 / 28.2 235 / 30.2 248 / 195 14 RYGB 46 238 / 43.5 116 / 21.2 131 / 24

188 / 137 15 LAGB 73 225 / 36.3 162 / 26.1 175 / 28.2 185 / 144 16 31 248 / 40 138 / 22.3 189 / 30.5 196 / 144 17 LSG LAGB 65 207 / 37.9

115 / 21 122 / 22.3 170 / 132 18 LAGB 79 298 / 49.6 163 / 27.1 195 / 32.4 220 / 141 Awakening: Major Themes Taking My Life Back Theres no way I could've lived and enjoyed life in general the way I was then as compared to how I am New Lease on Life now. Without Supportive People Around You, Youre Lost I Do Not Like Focusing on the Negative The Void

Food Demons I decided it's my responsibility to Finding the Happy take care of it and that's just how it Ripple Effects is. Taking My Life Back My goal is to take my life back I cannot be 72 and pass away because I didn't take care of myself. So she was really the reason why I was like Oh my goodness I can't be my mom. To participate more with my kids to be active in their lives. New Lease on Life Energy Physical ability Family life Confidence Appreciation Life now as I know it, I love life! I wasn't happy, fat, and I'm happy now and it makes a lot of difference in your life emotionally and physically. My oldest daughter now she says Mom stop stealing my pants! I love it! If I drop something I enjoy bending over to pick it up because I can. I'd probably still be sleeping 10 to12 hours a day because I didn't have energy or just sitting around the house because I couldn't move, I was so sore. Now, I'm never home. Without Supportive People Around You, Youre Lost Encouraging Youre not alone Honest professionals Without supportive people around you, youre lostI think if I didn't have those people in my life my success would be minimal.

I know that theyre gonna be very honest with me and do things not just from a friend perspective but from a nursing perspective and from someone whos been a patient perspective. I Do Not Like Focusing on the Negative He didn't really want me to have it. He would say Your This is something for me fine the way you areWere not together anymore. Shedding the negative Not the support I needed The boyfriend at the time, who I had been together with for seven years, was not so supportive. I had lost about 100 pounds, and he decided he didn't want to be together anymore. If I was still was with the same old guy, he would be asking if I wanted ice cream at night because he thought that was the way you took care of each other, you fed each other. The Void Those first two or three weeks after surgery it sets in very quickly that you had an addiction and youre going through detox and its hell. Food is an addiction Filling the void with another addiction I've been through the gamete of the different things that you can be addicted to. Center of my life I just have never been big on taking care of myself, its always everybody else.I've just never been okay with that. I'm getting ok with that. Food Demons I had to change my way of thinking. How I eat, why I eat, what I eat. Cravings

Negotiating with food demonsThere are times I'll get Magnum ice cream bars and I'll want to Distractions How, why, and what I eat eat three of them, right off the batThat never goes away. Tuning into your mind and body I can eat half a burger and throw it awayAnd before I didnt eat half of something and throw it away. Surgery doesn't fix everything and you have to always pay attention to it. Finding the Happy WeightScary weight is 175168 is happy weight. I feel good about myself. I feel good about my size. I couldn't believe I was that skinny and Id still see myself as fat though. I like my weight best at 140, that's where I'm happiest, and I wasn't too skinny, I wasn't too fat, I'm comfortable in that skin. Probably about 145 pounds, people said Your face looks a little bit gaunt Ripple Effects I think theyre probably more conscious about making good choices than they would have been if I had not had the surgery, because I wouldn't have been conscious about it. With the kids, we want to make sure they are instilled with good healthy values so that they don't have to go through what we did. If I don't eat it, the rest of the family doesn't really get it either. We don't really do the whole in-house fitness or going to the gym or whatnot. But we go out swimming. We go

camping, hiking, a lot of cardio, ride our bikes, stuff like that. Findings: Unsuccessful Participant Interviews M=54 minutes, between 40 and 70 minutes Hesitant to share details Reserve and a sadness resonated Multiple probing questions were used to extract information Somber but hopeful outlook on life Not ready to give up on their weight loss efforts Unsuccessful Participant Description Participant Age Gender Race Marital Status Education Employment Residence 2 62 Male Cauca.

Single Masters Full Time Suburban 4 54 Male Cauca. Married S. College Self Suburban 11 43 Female Cauca. Married H. School Self

Suburban 13 55 Male Cauca. Divorced S. College Other Urban 19 44 Female Hispan. Widowed S. College Full Time & Self Urban 20 55

Female Cauca. Married College Part Time Rural Unsuccessful participant surgical and weight information Participant Surgery Type Months PostSurgery Highest Presurgical Weight & BMI Lowest Postsurgical Weight & BMI Current Weight & BMI Successful Weight & Ideal Body Weight 2 RYGB 87

329 / 45.9 190 / 26.5 269 / 37.5 254 / 179 4 RYGB 45 430 / 55.2 260 / 33.4 317 / 40.7 313 / 195 11 LSG 44 263 / 39.3 165 / 32.8 197 / 32.8 193 / 150 13

LAGB 102 496 / 62 340 / 42.5 445 / 55.6 348 / 200 19 RYGB 28 276 / 44.5 207 / 33.4 214/ 34.5 216 / 155 20 LAGB 74 298 / 49.6 196 / 32.6 238 / 39.6

224 / 150 Not Giving Up I wanted it so bad and I wanted the surgery for so long and I had read all about how it wasn't successful for some people and I said I will not be one of those people and two years later I feel like I am one of those people. To Be Healthy and Active Lasting Changes I Failed the Surgery Im Working On It Support Systems The surgery was a success, yes but I failed the surgery Giving up is a big thing. I don't think there's anything they can do to help me change. I have to do it. To Be Healthy and Active I had high cholesterol and was having some knee pains andmy mom has had both of her knees replaced. I didn't wanna end up like her. I just wanted to do what I could to try and be proactive. I couldn't walk to the mailboxAll I did was stay around the house and go to the store and at the store I'd need one of those carts. That was always embarrassing. Lasting Changes Im very aware of what I eat and what I'm doingI'm more aware of what I'm buying and why I'm buying it. What and how much I eat The way I eat Increase in activity I get out a lot more. I get exercise. I go to the gym and exercise, and I can walk on my paper routeI'm just more activeIts more fun because I can ride my bike and go to the gym and lift weights, and I can just be more mobile.

Now, I am much more focused on three planned meals a day I used to eat whenever I wanted. I Failed the Surgery I feel ashamed, I feel embarrassed that I got the surgery. In the beginning Sabotaging my stomach Im struggling I quit exercising Old eating habits resurfaced Emotional eating Love of food Poor food choices Mindless eating Anger I'll try something, and I don't just try a couple bites, I usually try like a big piece of somethingThen I really do feel sick which makes no sense. That's just stupid. I started dating a guyand I have changed my diet a lot since he's been in my life. I feel the need to take care of peopleI think that hopefully over time Ill find that right balance. Balance Social, Work and Home The fault is mine I'm disgusted and madmad at myself.

I still choose French fries and the bread on a sandwich instead of getting fruit and a salad...It's all about poor decision-making. It's so hard to have control in so many areas. Right now, I'm struggling with how to change and not lose everything. Im Working On It I just need to try to forgive myself and say Well I got to do better and start over. I'm responsible for my own actions. Eating is my own action. If I eat too much lasagna I am responsible for that. Support Systems Support groups Family Non-judgmental support Health care support Co-workers I go out and look at my motorcycle sitting thereI gotta do something, or I'm gonna end up selling my bike and I'm never gonna be able to get another one. I'm gonna prioritize things in my life. I need to make healthy eating and exercise and spending quality time with my kids. I think he was happy that I was losing weight but he never says anything about my weight or that I didn't look good after I had my surgery or anything. When you're really, really down and then you think I'm

going to quit and not do it anymore and then you think well what did they tell me in the support group My husband would get on me and say like my plate looks like a mans plate. I felt a little bit alone. Conclusions: Reciprocal Determinism Previous studies focus initial weight loss Long-term challenges Reciprocal Determinism: Interaction between intrapersonal, behavioral, and environmental influences Individuals ability to interact, modify, and alter their environment to regulate their behavior Successful - identify negative attitudes, influences, and behaviors then modified their environment to support healthy behavior Unsuccessful failed to modify or alter their environment to support healthy behaviors Discussion: Confirmed & Expanded Intrapersonal influences Self-efficacy to make lasting changes (diet & physical activity (PA)) Behavioral influences Self-regulate healthy behaviors (seeking support, dietary, & PA) Follow-up meetings, exercise classes Coping strategies disturbed eating patterns Overcoming replacement addictions Support groups (NA, AA, OA)

Environmental influences Support systems- seek out models & emulate Discussion: Inconsistent Reciprocal determinism Vulnerability, ill-prepared Now I can, so I will vs. Now I can, so I should Paradoxical anger, fear, or frustrations with others perceptions Further out, not discussed Behavioral & Intrapersonal influences Motivated to lose weight and make lasting healthy lifestyle choices Obtainable realistic goals High self-efficacy to make lasting changes Implications for Practice & Future Research Therapeutic education & counseling Changes in relationships Communication techniques Negativity Support groups Different stages Sponsors Weight fluctuations Comfortable and maintainable weight Guilt, shame, anger, and frustrations Questions & Comments Thank you for your time!

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