Back on Track: Confronting Post-Surgical Weight Gain

Abstract

The battle against obesity is a lifelong journey. Surgery can be an effective intervention; however, many patients experience post-surgical weight regain. At a large, urban health care system in Virginia performing bariatric surgeries, it was determined that a focused intervention was needed to target this weight regain in many patients. Thus, an 8-week pilot group therapy intervention was implemented to help these patients get “Back on Track.” Groups combined cognitive-behavioral therapy and motivational interviewing to address the specific needs of these participants. Fourteen female Roux-en-Y gastric bypass surgery patients who were at least 18 months post surgery completed the 8-week program in two separate groups. Participants reported difficulty coping with the return of food cravings and challenging eating behaviors after a period of relative relief following surgery. Participants rated peer support as a highly valuable component of group and reported significant behavioral changes, enhanced motivation and confidence, and weight loss as a result of participating in group. Results provide preliminary support for the use of this type of group in long-term post–bariatric surgical patients. Further, participant feedback suggests that earlier intervention may be warranted. Themes that arose in the groups and future directions for implementing and evaluating this type of intervention are discussed.

Introduction

Prevalence of obesity (i.e., a Body Mass Index [BMI] of ≥30.0 kg/height in m²)¹ has risen dramatically in both developed and nondeveloped countries around the world. Obesity is associated with significant health consequences, including dyslipidemia, insulin resistance, certain types of cancer, type 2 diabetes, hypertension, coronary heart disease, stroke, gallbladder disease, and osteoarthritis.² In addition to these health concerns, overweight and obese persons become disabled at a younger age than their nonobese peers, have greater absentee rates at work, retire earlier, and go into nursing homes at younger ages than persons with healthy body weight.² Bariatric surgery can be an effective tool for facilitating weight loss and ameliorating weight-related comorbidities.³ Patients are typically considered candidates for surgery when they have a BMI > 40 or have a BMI > 35 with obesity-related health comorbidities.¹

The most frequently performed surgery today is the Roux-en-Y gastric bypass (RYGBP).⁴ Patients who have RYGBP on average lose 60% of their excess body weight within 2 to 3 years post surgery and experience dramatic improvements or complete resolution of health conditions such as diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea.⁵ Unfortunately, however, up to 30% of patients begin to regain weight beginning as early as 18 months to 2 years after their procedure,⁶ and evidence is accumulating that improvements in health dissipate with weight regain.⁵

One possible cause of this weight regain is the finding that daily caloric intake increases over time in many patients.⁵ The physiological and psychological mechanisms of this increase in calorie intake are not well understood at this time; however, recurrence of disturbed eating patterns such as binge eating may be one explanation. In this population where stomach size is restricted post-operatively, binge eating may be better defined as a “recurrent sense of loss of control over eating” rather than by quantity consumed⁷ (p. 114). Some researchers have also hypothesized that binge eating in the post-surgical population may appear more as “grazing” pattern eating where small portions of food are consumed continuously throughout the day.⁸ Surgery is often associated with short-term improvement in challenging eating patterns, but for some patients, these benefits begin to erode around two years after surgery.⁷ Because some patients appear to become physically able to consume more calories in the long-term post-surgical period, maintenance of weight loss may depend largely on their ability and willingness to behaviorally adapt to a new lifestyle. Clinical attention to post-surgical weight gain and research investigating the physiological and psychological mechanisms that contribute to the recurrence of disturbed eating patterns are needed to determine appropriate intervention and prevention strategies.

The current study

Patients at a large, urban health care system in Virginia have access to a large monthly support group both before and after bariatric surgery. In these groups, post-surgical weight regain had become a frequent topic of discussion, and we determined that a focused, small-group intervention would be helpful in addressing the challenges faced by long-term post-surgical patients. Commercially available programs offer structured “Back on Track” and “Kick Start” education and support groups based on “success habits” derived from their work with long-term bariatric surgery patients. Support groups associated with surgical programs, however, tend to focus more intensively on the pre- and immediate post-surgical period.⁹ The current intervention was intended to fill in this “gap” in our surgical program and was conceptualized using a combination of cognitive-behavioral therapy and motivational interviewing. The current study seeks to add to our understanding of the psychological mechanisms of weight regain following bariatric surgery by exploring psychological themes that emerged during a group clinical intervention.

Materials and Methods

Recruitment

The group was advertised through the monthly newsletter distributed by mail and by the bariatric surgery listserv maintained by the bariatric surgical group. This newsletter is distributed to patients of the bariatric surgery program at the Virginia Commonwealth University Health System who have signed up for the program's support group. Interested participants were instructed to e-mail or call study personnel to indicate their interest and were offered entry into the group on a first-come, first-served basis. The group was limited to a maximum of eight members in each group, and interested participants exceeding the group limit were put on the wait list. Any patient who was 18 months or longer post bariatric surgery in this university hospital's bariatric surgery program was eligible to enter the group. No exclusion criteria were used. This study was approved by the Institutional Review Board of Virginia Commonwealth University.

Participants

Two cohorts were completed, with a total of 14 females enrolled in the “Back on Track” program. One participant withdrew from the group after the first session due to family medical issues. Participants ranged in age from 32 to 67, three participants were African American, and 10 were Caucasian. All participants had surgery at least 18 months prior to entering the group.

Group methods

The 8-week group was designed as a treatment for long-term (≥18-month) post–bariatric surgery patients who had been experiencing difficulty with weight regain. During the initial session, participants were asked to generate a list of content areas they wanted to cover in group. These content areas were addressed using cognitive-behavioral strategies that emphasize the interconnected nature of thoughts, feelings, and behaviors. Motivational-interviewing (MI) strategies were also used to enhance participants' readiness for behavior change. MI is a client-centered, directive clinical style used to explore and resolve ambivalence about behavior change.¹⁰ Patients who are considering making health behavior changes typically experience some level of ambivalence, as they are able to see both advantages and disadvantages to changing their behaviors. MI promotes behavior change by helping patients explore and resolve this ambivalence. Participants in both groups reported a strong desire to learn how to cope with emotional eating. Additional topics included goal setting, stress reduction, and the development of specific coping strategies.

Participants attended group therapy one evening per week for 8 weeks; each session was 90 minutes long. The groups were led by advanced doctoral students in psychology and were supervised by a postdoctoral fellow and a licensed clinical psychologist. Each session consisted of a specific topic for education and discussion as well as unstructured time for open discussion. Participants were assigned “homework” specific to their personal goals (e.g., increasing exercise, monitoring food intake, and recording thoughts and emotional experiences) each week. Because feedback from group 1 resulted in modifications to the second group, specific content varied slightly between the groups. Table 1 provides a general guideline to topics addressed each week. During their final weekly session, participants in the first group suggested that weekly weigh-ins might be a beneficial addition to group. As a result, the second group was asked to weigh each week at the beginning of each meeting. Each member weighed privately, and their weights were not recorded.

Table 1.

Topics Covered in 8-Week Back on Track Group

Week	Topic
1	Introductions and brainstorming ideas for what group members wanted to gain from being in group. Learn SMART goal-setting strategy—goals should be specific, measurable, action oriented, realistic, and time limited.
2	Motivational interviewing activity—review benefits of staying off track versus getting on track.
3	Discussion of emotional eating—learning the cognitive triad (thoughts-emotions-behaviors related to challenging eating situations).
4	Review of common cognitive distortions, keeping an automatic thought record, and strategies for restructuring maladaptive thinking.
5	Discussion of emotional triggers, learning to differentiate physical from psychological hunger by rating each separately on a scale of 1–10, and reviewing alternative strategies for coping with emotion.
6	Proactive behavior—discussion of challenging situations. Learning strategies for staying on track and making home environment conducive for healthy eating.
7	Review of cognitive triad, and discussion of strategies.
8	Feedback forms, discussion of progress, and plan for maintaining new behaviors.

Participants completed a brief 14-item feedback form at the last session that allowed them to rate the success of the program, to evaluate the effectiveness of specific elements of the program, and to suggest additional content for future groups. Items from this form are listed in Table 2. Results from feedback forms and qualitative data from group sessions are presented below.

Table 2.

Feedback Questions for “Back on Track”

1. Please rate how “on track” you were at the beginning of group (1–10, with 1 being completely off track and 10 being completely on track).

2. Please rate how “on track” you are today, using the same scale.

3. Can you describe in a few sentences how you think this change (if any) has occurred?

4. Before group, did you weigh yourself regularly?

5. If not, have you now begun to weigh yourself?

6. Have you noticed any signs of making weight loss progress (e.g., clothes fitting looser, or have you lost weight? If so, how many pounds?)?

7. Have you noticed any behavior change (e.g., decreased intake of candy, improved portion control, and/or increased exercise)? Please describe.

8. How confident are you that you can maintain these changes (please rate on a scale of 1–10, with 1 being not at all confident and 10 being completely confident)?

9. Before group, were you keeping yearly appointments with your surgeon?

10. If not, do you think you will go now after group?

11. What parts of group were most helpful to you (please rank them from 1 to 8 with 1 being the most helpful): getting support from others; charting my thoughts, emotions, and behavior; rating my physical and emotional hunger; meeting with the nutritionist; learning about emotional eating and food obsessions; practicing stress management and deep breathing; learning how to make SMART goals; and/or other (please describe)?

12. Were there topics covered in group that you think should receive MORE attention?

13. Were there topics covered in group that you think should receive LESS attention?

14. What other topics do you think would be useful to cover in a group like this?

15. Please write any additional comments you may have about the group.

Results

Quantitative findings: Feedback forms

Six group members in the first group completed feedback forms during their final session. Members in the second group were asked to complete feedback via e-mail. Two members of group two e-mailed blank forms back and did not respond to requests to resend their forms. Therefore, quantitative data reflect only the six members from the first group. Members reported an average rating of 2 on a scale of 1–10 (with 1 being completely off track and 10 being completely on track) when rating how “on track” they were at the beginning of group. They reported that this had increased to a mean rating of 7 by the end of group. Three participants indicated they had not weighed themselves regularly prior to group, and two of these participants reported that they were now weighing after group. They reported an average total weight loss of 4 pounds (range 0–6 lbs.). All six members also reported at least one specific behavioral change. Examples of behavior changes reported included keeping less “junk” food in the house, reducing portion sizes, counting calories, increasing physical activity, and decreasing sugar intake. They reported a mean rating of 8 out of 10 for confidence that they would be able to maintain these changes. Five of the six participants had either scheduled appointments to return to yearly follow-up appointments with their surgeons or reported intentions to do so. Getting support from others/knowing that other RYGBP participants are experiencing the same problem was the most frequently cited benefit of participating in group (four of six participants ranked it as the most beneficial component of group). Four participants suggested follow-up meetings after the completion of group.

Themes that emerged during group were collected from group notes and the recollection of the group therapists. Themes from both groups were subjectively determined and are summarized and discussed below.

Return of pre-surgical eating disturbance

Group members described a number of behavior changes that occurred over time that contributed to increased food intake and weight regain. They reported subjectively that the 18–24-month period after surgery seemed to be a period of relief from their struggles with eating. They described a relative lack of interest in food and said they could “take it or leave it” during that time. Many had thought that their difficulty controlling their eating was over for good, and they described deep disappointment and frustration that food again began to “call to them” as they experienced increased hunger, stronger food cravings, greater desire to eat, and greater difficulty controlling food cravings. Several of our participants described developing what could be called “grazing” pattern eating in that they were continuously consuming small portions of highly energy-dense foods (goldfish crackers, M&Ms, etc.) throughout the day.

Participants also described a number of behavior management strategies that had worked for them initially after surgery, and acknowledged that they had, over time, begun to relax their use of these strategies. Most had abstained from sugar altogether in the short term due to fear of dumping syndrome. Several patients had tried sugar and found that they were able to eat it with minimal or no side effects. One participant described anger at a woman she had met after her surgery who had told her that she would probably be able to eat sugar again, because she wished she had never known it was possible.

Avoidance of reminders of weight regain

Participants shared their frustration and embarrassment over their weight regain. A number of participants were avoiding any feedback that would remind them of their weight gain to include weighing, shopping for new clothes, and attending yearly follow-up appointments with their surgeons. Participants encouraged each other to think of these feedback opportunities as tools in their journey toward getting back on track. Feedback forms completed at the end of group showed that only one participant had not begun weighing regularly at group completion. All but one of our participants planned to resume their yearly follow-up appointments with their surgeons.

Social impact of living with obesity

Participants discussed experiences with how nonobese people perceive and react to persons with obesity. Group members shared experiences of discrimination and how they felt that their weight had impacted their interactions with others. All of our participants were women who worked outside of the home, and they sometimes felt that obesity had impacted their professional reputations. They also described changes they noticed in other people's reactions toward them as they lost weight. They discussed how some people had taken more interest in them socially after they lost weight, and how this made them feel objectified.

Participants also discussed how their weight had provided them with some degree of social protection. Some participants believed that avoiding unwanted sexual attention had likely played a role in their initial weight gain and reported feeling uncomfortable at times with increased attention as they lost weight. One participant was surprised to learn that she could no longer blame her weight when a relationship failed. This forced her to consider that perhaps there were other things about her character that needed development. She experienced this as a challenge, and ultimately perceived this to be a benefit of losing weight; however, other patients may not cope as well with this surprising realization.

Struggling with obesity had also impacted their intimate relationships. Some patients described that although their partners were supportive of their desire to lose weight, they often did not understand the emotional challenge of doing so. Some participants reported that they felt tempted or pressured to overeat when with their spouses or family members. Family members often unwittingly modeled permissive attitudes toward overeating in their attempts to be supportive, or even directly pressured participants to overindulge.

Strategies for coping with emotional eating

Emotional eating was a central theme of the group. Each session included a didactic on coping strategies based on cognitive-behavioral therapy, which focuses on the interrelations between thoughts, feelings, and behaviors (see Table 1 for a description of weekly topics). These didactics served as “jumping-off” points for group discussions in which participants discussed a wide range of situations they found challenging. They also brainstormed, discussed, and modeled coping strategies for one another.

The workplace was one of the most frequently discussed sources of stress and eating temptations. Conflict with coworkers or anxiety over work responsibilities frequently triggered stress and the desire to eat. Some described using snacks as a strategy to avoid unpleasant work tasks. Easy access to vending machines and office snacks increased the challenge in these situations. Participants generated numerous alternatives to emotional eating using cognitive and behavioral strategies. One such strategy was restructuring thoughts about food and its function (e.g., “Eating this cookie will make me feel better” was replaced with “Eating this cookie will distract me for a moment, but the feeling will still be there when I'm done”). Another strategy included changing their environments to reduce exposure to tempting foods (e.g., not taking change to work so they cannot use the vending machine, asking coworkers to keep snack foods in a different location, and walking a different route to the bathroom to avoid smelling brownies in the conference room). Participants also explored the role of food as avoidance of emotional experience (e.g., learning to use rating scales of physical versus psychological hunger, and stopping during a food craving to ask, “What is the emotion I feel right now?”). Finally, participants also worked together to generate replacement behaviors (taking a walk in the sunshine, calling a friend, taking a relaxing bath, etc.)

Importance of peer support

Participants discussed why peer support was such an important part of this program. Participants were relieved to find that other participants had experienced similar challenges after losing weight with RYGBP. They felt that it was important that they be able to discuss their emotional struggle with food and their disappointment that these struggles seemed to return after a period of relative relief. They talked about how family and friends often had difficulty understanding their struggles with eating, and that sharing with others who did understand helped them to feel less alone in their struggle. They also felt encouraged by each other's successes, and supported each other through their challenges.

Participants also modeled the cognitive-behavioral strategies they were learning in group for one another. Participants frequently noted when another participant was thinking negatively about a “setback” situation. When a participant made a statement such as “I was terrible this week,” others provided more realistic and supportive statements such as “You can't always be perfect” or “You'll do better next time,” and encouraged her to think about what was learned from the “setback.” In their feedback, participants rated peer support as the number one benefit to participating in group, and both groups decided to exchange e-mail addresses so that they could continue to meet informally after completing the group. This suggests that group format is highly desirable among this particular subset of RYBGP patients.

Discussion

The purpose of this study is to describe participant feedback from pilot groups targeting weight regain in bariatric surgery patients. Overall, participants provided rich detail about a number of challenges they face in their effort to maintain their weight loss after RYGB surgery, which can help inform future intervention efforts. Many had battled lifelong difficulties with eating and weight, and they found themselves relatively free of these difficulties during the early period following surgery. When they found that their emotional eating habits were returning, they felt discouraged and alone. Some began avoiding feedback about their weight such as weighing, following up with their surgeons, and trying on clothes. Working with other patients and learning strategies for coping with emotional eating provided a valuable service to these participants. They learned that they were not alone in their struggles and found other women with whom they could share their concerns. They also reported specific behavioral changes, confidence that they would be able to maintain these changes, increased motivation to get “Back on Track,” and between 0 and 6 pounds of weight loss during the 8-week group. These results suggest that offering groups such as “Back on Track” benefits patients both physiologically and psychologically, and could become an important contributor to long-term success for bariatric surgical patients.

Limitations and future directions

Limitations must be noted. The sample for this pilot was small, with a low participation rate in completing the feedback forms. All six forms came from participants in the first group who completed the form during their last session. Participants in the second group were asked to return their feedback via e-mail, and this was not a successful approach in obtaining feedback. Future groups will return to the in-session feedback format for this reason. Further, group participants were self-selected and thus potentially represent a select group of post-surgical RYBGP patients who may have been more motivated to get back on track than patients who did not enroll. The participants in these groups may also represent a subset of patients who prefer group format intervention. Alternative intervention formats may be preferable to other patients.

Results from these two groups provide preliminary support for the use of cognitive-behavioral therapy and motivational-interviewing techniques in enhancing motivation and developing skills for coping with emotional eating. A number of issues remain that must be studied to more vigorously evaluate the effectiveness of this intervention. Additional groups will need to be conducted to increase sample size. The current study did not include pre-group evaluation or a control group. Future groups could benefit from individual evaluation to include full psychosocial history, screening for mood and eating disorders and other psychopathology using validated measures, prior experience with therapy, and evaluation of specific subtypes of pre-surgical eating disturbance. Participants may have had greater levels of psychopathology or disordered eating than they may have revealed in a group format. This would allow for the evaluation of group effectiveness with patients who have different types of eating disturbance and the development of strategies that target specific eating problems. Evaluation could also include food journals and weight monitoring before, during, and after group to enhance accuracy of patient self-reported behavioral changes and weight loss. Time since surgery should also be recorded to better assess the best timing for post-surgical intervention. Post-group follow-up would also be beneficial in determining the long-term success of the group. Dose–response relationship curves could be determined by conducting a series of studies examining groups of different lengths with varying frequency of long-term follow-up.

Overwhelmingly, the current participants reported feeling unprepared for the possibility that their pre-surgical eating habits could return in the long-term post-surgical period. It is possible that post-surgical weight regain was not emphasized as a potential challenge during the time that they were having surgery. Although current surgical candidates likely receive more education about this than previous patients, it is possible that earlier intervention would enhance long-term success. Focused small-group sessions with a psychologist on emotional eating prior to surgery and booster sessions as patients approach the 18-month post-surgical period may be warranted.

Despite the pilot nature of this study and the above limitations, we provide preliminary support for group intervention to help patients get “Back on Track” as they confront weight regain after bariatric surgery. Clinical and research attention to this weight regain is needed to improve surgical outcomes and optimize patient health.

Disclosure Statement

No competing financial interests exist.

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