Surgery for Obesity and Related Diseases 7 (2011) 644 – 651

Review article

Dietary intake and eating behavior after bariatric surgery: threats to

weight loss maintenance and strategies for success
David B. Sarwer, Ph.D.a,*, Rebecca J. Dilks, R.D., L.D.N.a,
Lisa West-Smith, Ph.D., L.C.S.W.b
a
Department of Psychiatry, Center for Weight and Eating Disorders, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
b
Bariatric Behavioral Health Services, Lifepoint Hospitals/Georgetown Community Hospital, Georgetown, Kentucky
Received September 28, 2010; accepted June 28, 2011

Abstract During the past decade, bariatric surgery has become an increasingly popular treatment option for
the growing number of individuals with extreme obesity. For most individuals, the size and
durability of the weight loss and improvements in co-morbidity and mortality have far surpassed
those typically seen with behavioral modification and pharmacotherapy. A significant minority of
patients, however, will experience suboptimal outcomes, including less than expected weight loss,
premature weight regain, and frequent vomiting and/or gastric dumping. The reasons for these
outcomes are not well understood, but likely involve both behavioral and physiologic processes. The
present review highlights current knowledge on the changes in dietary intake and eating behavior
that occur after bariatric surgery in terms of the potential threats these changes might pose to
long-term postoperative success. The paper also identifies several strategies from the nonsurgical
weight loss literature that might help optimize long-term weight maintenance after surgery. (Surg
Obes Relat Dis 2011;7:644 – 651.) © 2011 American Society for Metabolic and Bariatric Surgery.
All rights reserved.
Keywords: Dietary intake; Eating behavior; Behavior modification; Physical activity; Weight maintenance

Bariatric surgery is the most effective treatment of obe-
sity, producing greater and more durable weight loss than
typically seen with behavioral modification and/or pharma-
cotherapy. Within 12–18 months postoperatively, the pa-
tients typically lose 25–35% of their initial body weight
with Roux-en-Y gastric bypass (RYGB) and 20 –25% with
laparoscopic adjustable gastric banding (LAGB) [1– 4].
(The data reviewed in the present paper focused on the more
common RYGB and LAGB procedures; however, many of
the conclusions can be readily applied to other bariatric
procedures.) This weight loss is associated with significant
Supported, in part, by grants from the National Institutes of Health/
National Institute of Diabetes, Digestive and Kidney Diseases (grants
R01-DK080738 and R03-DK067885) to Dr. Sarwer.
*Correspondence: David. B. Sarwer, Ph.D., Department of Psychiatry,
Center for Weight and Eating Disorders, University of Pennsylvania
School of Medicine, Philadelphia, PA 19104.
E-mail: dsarwer@mail.med.upenn.edu
1550-7289/11/$ – see front matter © 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved.
doi:10.1016/j.soard.2011.06.016
improvements in obesity-related co-morbidities and mortal-
ity [1–5].
These impressive outcomes must be balanced by the
incidence of postoperative complications and suboptimal
weight loss. Early postoperative complications occur in
5–10% of patients, and late complications, including nutri-
tional issues, such as anemia and vitamin B12 deficiency,
have been reported in ⱖ25% of patients [6]. Also, approx-
imately 20 –30% of patients fail to reach the typical post-
operative weight loss or else begin to regain large amounts
of weight within the first few postoperative years [3,4]. As
seen in the Swedish Obese Subjects study, both gastric
banding and RYGB patients began to regain weight be-
tween the first and second postoperative year [3,4]. At 10
years postoperatively, approximately 10% of patients who
underwent RYGB and 25% of patients who underwent
gastric banding failed to maintain at least a 5% reduction in
their initial weight. The suboptimal results after RYGB and
LAGB are often attributed to poor adherence to the postop-
 D. B. Sarwer et al / Surgery for Obesity and Related Diseases 7 (2011) 644 – 651
erative diet or a return to maladaptive eating behaviors,
rather than to surgical reasons [7].
The present review begins with an overview of the cur-
rent knowledge on dietary intake and eating behavior after
bariatric surgery. Changes in dietary intake, dietary nonad-
herence, malnutrition and gastrointestinal-related events,
such as vomiting and gastric dumping, and maladaptive and
disordered eating behavior are presented in terms of the
potential threats they might pose to long-term postoperative
success. We also offer suggestions for strategies to improve
dietary intake and eating behavior after weight loss surgery
gleaned from the nonsurgical obesity treatment literature.
These include self monitoring, continued patient–provider
contact, and increased physical activity, well-established
factors central to weight loss and successful long-term
weight maintenance. We conclude with recommendations
for future research on these types of interventions to en-
hance the long-term weight control outcomes in bariatric
surgery patients.
Dietary intake and eating behavior after bariatric
surgery
In 2008, an American Society for Metabolic and Bariat-
ric Surgery committee published the Allied Health Nutri-
tional Guidelines for the Surgical Weight Loss Patient [8].
Before the publication of these guidelines, no uniform nu-
tritional guidelines were available to guide both providers
and patients. Although this document has the potential to
provide some degree of standardization across surgical
practices, its relatively recent publication suggests that such
standardization is likely years away. Thus, there is likely a
great deal of variability on the structure and content of the
postoperative diet across practices and patients. For exam-
ple, many programs recommend 60 – 80 g/d of total protein
intake (or 1.0 –1.5 g/kg ideal body weight) for the patient
without complications [8]. Although this is consistent with
clinical practice recommendations for medically supervised
protein fasting weight loss programs, the exact macronutri-
ent needs for the bariatric surgery patient are not yet de-
fined.
Dietary nonadherence
A number of reports have suggested that adherence to the
recommended postoperative diet is poor [9,10]. Caloric in-
take often increases significantly during the postoperative
period [3,10,11]. Brolin et al. [11] found that before surgery,
RYGB patients consumed 2604 ⫾ 1087 kcal/d, with 18% ⫾
6% of the calories from protein, 46% ⫾ 9% from carbohy-
drates, and 36% ⫾ 8% from fat. At 6 months postoperatively,
the patients consumed 890 ⫾ 407 kcal/d, with 20% ⫾ 7%
from protein, 48%% ⫾ 11% from carbohydrate, and 31% ⫾
11% from fat. During the next 2.5 years, the total caloric
intake increased to 1386 ⫾ 578 kcal/d, and the proportion of
645
intake from protein, carbohydrate, and fat remained stable.
Sarwer et al. [10] found similar changes in a more recent
study of RYGB patients. These increases in caloric intake
likely contribute to the weight regain, which often begins
during the second postoperative year [3]. Although this caloric
amount might not be great enough to promote weight regain, it
is important to note that individuals typically underestimate
their caloric consumption by approximately 40% on most
assessments of dietary intake [12].
Malnutrition
Although the total caloric intake typically increases dur-
ing the postoperative period, a subset of patients experience
malnutrition. There has been surprisingly little prospective
study of this issue. Micronutrient deficiencies are not only
important for overall health, but also help with long-term
weight maintenance, through their role in regulating appe-
tite, hunger, nutrient absorption, metabolic rate, fat and
sugar metabolism, thyroid and adrenal function, energy
storage, and glucose homeostasis. The risk of micronutrient
deficiencies is thought to be particularly great after RYGB.
It is unclear whether it results from inadequate dietary
intake or malabsorption of certain vitamins and minerals. In
addition, a lack of compliance with the recommended vita-
min supplementation and/or recommended follow-up visits
with the bariatric program (as discussed below) could also
contribute to malnutrition.
The most common and severe problems appear to be
deficiencies in vitamin B12 and iron [8]. Vitamin B12 defi-
ciency has been observed in ⱕ30% of adult patients 1 year
postoperatively, with the rate increasing over time [13,14].
Iron deficiency anemia has similarly been shown to increase
over time [15]. Vitamin D and calcium deficiencies are also
relatively common both pre- and postoperatively [16].
Adequate protein consumption can be a significant chal-
lenge for many postoperative patients. Strong evidence can-
not be found in the published data to support the theory that
the malabsorptive components of bariatric surgery alone
cause a protein deficiency. Protein malnutrition is usually
associated with the other circumstances surrounding bariatric
surgery, including anorexia, prolonged vomiting, diarrhea,
food intolerance, depression, fear of weight regain, alcohol/
drug abuse, socioeconomic status, or other reasons that might
cause a patient to avoid protein and limit intake [8].
LAGB can result in nutrient deficiencies related to de-
creased caloric intake. Because no alteration is made to the
pathway in which nutrients are absorbed, malabsorption
does not occur. Nutrient-dense foods, such as meat, and
high-fiber fruits and vegetables might not be well tolerated,
resulting in nutrient deficiency related to the decreased
intake of foods with high nutritional value [8].
646 D. B. Sarwer et al / Surgery for Obesity and Related Diseases 7 (2011) 644 – 651
Gastrointestinal-related events
Poor adherence to the postoperative diet can also result
in nausea and/or “plugging.” “Plugging” has been described
as the subjective experience of ingested food becoming
lodged in the gastric pouch, leading to pressure and/or pain
in the chest [17]. “Plugging” can occur from the overcon-
sumption of pasta, bread, or dry meat but also can occur
secondary to stricture formation. In a long-term follow-up
of RYGB patients, 43% reported “plugging,” which can
lead to reflexive or self-induced vomiting in an effort to
dislodge the food. One third to two thirds of patients have
reported postoperative vomiting, which occurs most fre-
quently during the first few postoperative months [17].
Frequent vomiting can occur several years postoperatively
and can be associated with malnutrition. Some patients
avoid foods that might trigger nausea, plugging, and vom-
iting, which can contribute to malnutrition and the potential
postoperative development of the “soft-calorie syndrome”
in which an excess of high-calorie soft or “melt-able” foods
or liquids are consumed.
Gastric dumping, which includes nausea, flushing, bloat-
ing, and extreme diarrhea, might be the most undesirable
postoperative event after RYGB. Dumping is believed to be
triggered by foods high in sugar and/or fat. Although dump-
ing in the early postoperative period might have the poten-
tial to promote dietary compliance (by “reminding” patients
to avoid these foods), continued dumping throughout the
postoperative period might be a marker of dietary noncom-
pliance. Studies suggest that dumping occurs in approxi-
mately 50 –70% of RYGB patients [17]. The frequency,
however, is not well documented. A recent study found that a
number of untoward gastrointestinal events (including loose
stool, diarrhea, and flatus) were more common in RYGB than
in LAGB patients [18]. In addition to serving as a trigger for
gastric dumping, the increased consumption of sugar might be
associated with less weight loss after RYGB [19].
Maladaptive and disordered eating behavior
The eating behavior of those with extreme obesity has
always fascinated the medical and lay communities alike.
Before the recognition of obesity as a “disease” within the
past decade, it was widely assumed that extreme obesity
was the result of profoundly atypical eating behavior, if not
overt pathologic eating. As we have developed a greater
understanding of the multiple genetic and physiologic con-
tributions to obesity, as well as the significant contribution
of the “toxic environment” to the obesity problem, we have
come to realize, primarily through clinical experience, that
some, but not all, individuals with extreme obesity have
maladaptive or problematic eating styles or have formal
eating disorders. However, the empiric research document-
ing the eating typical eating behaviors of those with extreme
obesity is still in its infancy.
Several studies have investigated the pre- and postoper-
ative eating behaviors of bariatric surgery patients. The
Eating Inventory [20], widely used in the obesity and eating
disorders data, measures 3 factors related to the regulation
of food intake. The first, cognitive restraint, refers to inten-
tional, chronic effort to limit food intake to lose weight or
prevent weight gain. The second, disinhibition, refers to the
tendency to lose control over food intake (often accompa-
nied by overeating or binge eating). Finally, the third, hun-
ger, captures the physical and psychological sensations re-
lated to hunger. Preoperatively, bariatric surgery candidates
have reported increased levels of disinhibition and hunger
compared with the norms of the measure [10]. Postopera-
tively, patients have reported increases in restraint and de-
creases in disinhibition and hunger [10]. These changes are
similar to those seen in those who lose weight with lifestyle
modification, with the increases in restraint and reductions
in disinhibition believed to be critically important to the
long-term regulation of food intake [21,22]. In contrast,
patients who fail to experience or develop restraint in the
face of environmental cues to eat and those who continue to
struggle to control their intake might be at greater risk of
weight regain.
Disordered eating, specifically binge eating and night
eating, are thought to be relatively common among candi-
dates for bariatric surgery. Binge eating disorder (BED) is
characterized by the consumption of an objectively large
amount of food within a brief period (i.e., 2 h) with the
patient’s report of a subjective loss of control during the over-
eating episode [23]. Bulimia nervosa describes those who
binge eat and subsequently engage in a compensatory behav-
ior, such as vomiting or laxative abuse [23]. Night eating
syndrome (NES) is characterized by a circadian delay in the
pattern of eating, defined by the core criteria of evening hy-
perphagia (i.e., the consumption of ⱖ25% of the total daily
caloric intake after the evening meal) and/or ⱖ2 nocturnal
ingestions per week (i.e., waking during the sleep period to eat)
[23].
The rates of disordered eating among bariatric surgery
patients appears to vary as a function of the method used to
assess their presence, as well as the specific definitions of
the disorders of interest [23–26]. For example, using the
Eating Disorder Examination Questionnaire, a question-
naire- based on the structured interview widely considered
the reference standard for the assessment of eating pathol-
ogy, de Zwaan et al. [26] found that 15% of RYGB candi-
dates met the diagnostic criteria for BED, and 24% reported
features of the disorder but did not meet the full diagnostic
criteria. In contrast, a more recent study by Allison et al.
[27] found that ⬍5% of patients met the full diagnostic
criteria for BED and the proposed diagnostic criteria for
NES. Similarly, only 3.5% of bariatric surgery patients have
been found to meet the diagnostic criteria for bulimia ner-
vosa [24]. Thus, the formal eating disorders do not occur in
large numbers of candidates for surgery. However, a sub-
 D. B. Sarwer et al / Surgery for Obesity and Related Diseases 7 (2011) 644 – 651
stantial number of these patients have endorsed problematic
behavior that, although they might not meet the formal
diagnostic criteria for an eating disorder, still represent a
challenge to the patients’ compliance with the postoperative
dietary and behavioral recommendations.
Several studies have investigated the relationship be-
tween disordered eating before surgery and the postopera-
tive outcomes. Two studies by Hsu et al. [28,29] found that
although patients did not report any objective binge epi-
sodes postoperatively, a significant minority reported feel-
ings of a loss of control consistent with BED. Kalarchian et
al. [30] observed no binge episodes in the 4 months after
surgery. However, 46% of patients reported either objective
or subjective binge eating during later follow-up [31]. Binge
eating might be related to smaller weight loss or weight
regain within the first 2 postoperative years [28 –32]. These
suboptimal outcomes might be attributable to stretching of
the gastric pouch, which would allow for increased energy
intake over time. Patients who engaged in night eating
before surgery have been found to continue the behavior
postoperatively [33]. At least 1 study has found that more
frequent nocturnal eating after bariatric surgery was asso-
ciated with a greater body mass index and less satisfaction
with surgery [34]. Colles et al. [35] suggest that LAGB
patients with preoperative binge eating disorder might be at
risk of becoming grazers postoperatively, which might
prove to be another potential contributing factor to the
suboptimal outcomes.
In summary, a small, yet substantial, minority of adults
who present for bariatric surgery have recognized eating
disorders. Although the restrictive components of the oper-
ations limit the consumption of excessive amounts of food,
those who binge eat before surgery appear, from the pre-
liminary reports, to be at risk of less weight loss or prema-
ture weight regain. The effect of night eating on the post-
operative outcomes has received less attention. The
behavior seems to persist, and its relationship to the surgery
outcomes warrants additional study.
Strategies to improve dietary intake and eating
behavior after bariatric surgery
As noted, there is little denying the success of bariatric
surgery in terms of the magnitude of weight loss and the
subsequent effect on the medical and behavioral co-morbid-
ities. This is particularly true in the first few postoperative
years. However, the limited amount of longer term data
currently available suggests that a substantial minority of
patients experience significant weight regain and a return to
maladapative eating behaviors within the first 5–10 years
after surgery [36]. Thus, a need exists to identify the dietary
and behavioral changes necessary for long-term success
after bariatric surgery and to develop and implement strat-
egies to help patients achieve these successful long-term
outcomes.
647
Lifestyle modification, which targets changes in diet,
eating behaviors, and physical activity, is the cornerstone of
nonsurgical obesity treatment [37]. In trials conducted at
academic medical centers, those who consumed a 1200 –
1500 kcal/d diet, combined with a comprehensive program
of lifestyle modification, lost approximately 7–10% of their
initial weight within 20 –26 weeks [38]. These interventions
can be delivered either in person or remotely (using the
telephone or Internet), which, in some studies, appears to be
as effective as interventions delivered in person (particu-
larly when the interventions incorporate some personalized,
tailored feedback to the patients) [39 – 43].
The sizable data that have investigated lifestyle modifi-
cation for weight loss provide a wealth of information on
the specific behavioral and dietary strategies critical to suc-
cessful weight loss and long-term weight maintenance.
However, the lessons learned from these data are often
prematurely dismissed when compared with bariatric sur-
gery, likely because of the smaller weight loss seen with
behaviorally based treatment. However, a number of valu-
able lessons can be gleaned from these data that have the
potential to improve the long-term outcomes of bariatric
surgery patients. These include self-monitoring of dietary
intake and weight change, ongoing patient–provider con-
tact, and increased levels of physical activity.
Self-monitoring
The self-monitoring of food and beverage intake is the
cornerstone of behaviorally based weight loss treatment. It
might be the most important skill to help patients identify
problematic food choices and behaviors and subsequently
modify those behaviors in the days and weeks after surgery.
Self-monitoring provides patients with feedback on their
targeted behaviors, such as average daily caloric consump-
tion, and provides patients with an opportunity to modify
these behaviors as appropriate.
Traditionally, patients self-monitored their caloric intake
with paper-and-pencil methods, such as food journals, and then
needed to use books that listed the caloric content of the foods
to calculate their daily intake. In several studies, those who
regularly performed self-monitoring of food intake and weekly
weighing attained greater weight loss than those who did not
[44,45]. In our current electronic age, a number of programs
are available for the computer, on the Internet, and with
“smart phone”” capabilities. This has made recording food
intake and counting calories faster and more efficient than
before. These advantages might promote greater adherence
to self-monitoring, although this has to be confirmed. Al-
though self-monitoring strategies are frequently recom-
mended to bariatric surgery patients, it is unclear what
percentage of patients use them and how they affect the
long-term outcomes.
Another important self-monitoring strategy is regular
weighing on a scale. Experts differ in their recommenda-
648 D. B. Sarwer et al / Surgery for Obesity and Related Diseases 7 (2011) 644 – 651
tions regarding the frequency of weighing at home. Most
recommend a minimum of at least once a week, although
some experts have recommended daily weighing [46]. Mon-
itoring changes in weight provides patients with feedback
on their weight and, as with self-monitoring of caloric
intake, can allow patients to modify behaviors in the future
to reverse small amounts of weight gain. Studies have un-
derscored the importance of regular self-weighing as a strat-
egy for successful weight maintenance [45,47]. In addition
to providing patients with regular feedback on the changes
in their weight, self-weighing is believed to be associated
with greater dietary restraint and decreases in disinhibition,
critical skills associated with successful weight mainte-
nance.
Data from the National Weight Control Registry have
provided some of the most convincing information on the
value of self-monitoring skills. This voluntary registry in-
cludes individuals from throughout the world who have
maintained a minimum 13.5-kg weight loss for ⱖ1 year
and, by sharing their experiences of success with research-
ers, have helped identify the behavioral strategies critical to
long-term weight control.
Individuals in the Registry report eating a reduced calo-
rie diet (approximately 1400 kcal/d) that is low in fat and
high in carbohydrates [48,49]. This diet is quite similar, in
many respects, to the recommended diet for patients after
bariatric surgery. Registry members also report that they
regularly engage in a number of self-monitoring behaviors.
Almost one half (44%) reported weighing themselves at
least once a day, and 31% reported weighing themselves
once each week [49 –51].
Continued patient-provider contact
Clinical trials have identified additional strategies to im-
prove the maintenance of weight loss. One such strategy,
which appears to promote long-term weight control, is the
provision of ongoing, regular contact between the patient
and provider [52]. One of the best and most recent examples
of the importance of ongoing contact comes from the
Weight Loss Maintenance trial [53]. In that study, those
who lost ⬎4 kg in the initial weight loss phase were ran-
domized to 1 of 3 interventions: (1) a self-directed control
group; (2) a personal contact intervention that provided
brief monthly telephone or face-to-face contact; and (3) an
interactive technology intervention. Although the patients in
all 3 groups were able to maintain some of the weight they
had lost, those who received personalized contact main-
tained significantly greater weight loss compared with the
other 2 treatment groups 24 and 30 months later [53].
Despite the power of the tool that is bariatric surgery,
a long-standing belief exists that success after bariatric
surgery, just as with more conservative weight loss treat-
ment, requires regular follow-up. Patients who undergo
RYGB are recommended to return to the bariatric surgery
program at least every 6 months in the first 2 postoper-
ative years and annually thereafter (although this sched-
ule likely varies across programs) [6]. Adjustments of a
gastric band can require follow-up appointments as reg-
ularly as every 4 – 6 weeks in the first postoperative year
and quarterly through the first 3 postoperative years (al-
though no protocol for band adjustments has been widely
accepted) [54]. These postoperative visits can be used,
not only to monitor patients’ weight loss, but also to
counsel patients on issues related to dietary adherence
and eating behavior, which are often forgotten or ne-
glected after surgery [55,56].
Clinical reports have suggested that postoperative fol-
low-up with the bariatric surgery program is frequently
suboptimal and can negatively affect weight loss, in some
cases within the first postoperative year [55,57]. In recent
reports, only 40% of patients returned for each of their
first 4 annual follow-up visits with the surgeon. Those
who returned for all their annual follow-up visits lost
significantly more weight than did those patients who did
not return [58]. A more recent study suggested that those
who regularly participated in a monthly support group
experienced greater weight loss than did those who did
not attend the support group [59].
Physical activity
Another strategy identified in the behavioral weight
control data as central to long-term weight maintenance
is regular participation in physical activity [60,61]. For
example, in 1 study, participants in a behavioral weight
control trial who were asked to expend 2500 kcal/wk in
physical activity maintained significantly greater weight
loss at 12 and 18 months after the onset of treatment
compared with those who only expended 1000 kcal/wk
[62]. Less-intensive lifestyle activity (i.e., increasing the
number of steps taken daily) also can enhance weight
maintenance [63].
Although most bariatric programs recommend that pa-
tients increase their physical activity after surgery, few
studies have investigated the changes in physical activity
after bariatric surgery. In self-report surveys completed by
patients postoperatively, ⱕ80% reported participation in
some degree of physical activity [64]. The level of physical
activity has been associated with postoperative changes in
weight [64 – 66]. A recent study of RYGB patients found
that participation in 150 min/wk of at least moderate-
intensity physical activity was associated with greater
weight loss at 6 and 12 months postoperatively [67].
Similarly, those who did not increase their physical ac-
tivity from the baseline levels after LAGB more than
doubled their likelihood of not losing ⬎50% of their
excess body weight [68].
 D. B. Sarwer et al / Surgery for Obesity and Related Diseases 7 (2011) 644 – 651
Conclusion and future directions
During the past decade, bariatric surgery has become an
increasingly popular treatment option for persons with ex-
treme obesity. Patients who present for bariatric surgery
typically do so with poor dietary habits and problematic
eating behaviors. Some have formal eating disorders, such
as BED or the NES. These factors likely contributed to the
development of extreme obesity. Postoperatively, the ca-
loric intake typically decreases and the eating habits often
improve during the first postoperative year. The resulting
weight loss can be sizable and have been associated with
significant improvements in obesity-related co-morbidities
and psychosocial status.
Despite these impressive outcomes, a significant minor-
ity of patients experience suboptimal weight loss or prema-
ture and significant weight regain. Clinical observations and
a small number of studies have suggested that suboptimal
weight loss and other untoward outcomes (e.g., malnutri-
tion, vomiting, and dumping) are often attributed to poor
adherence to the postoperative diet and/or a migration to
maladaptive eating behaviors. Thus, the belief is growing
that sustained improvements in dietary intake and eating
behaviors are critical to long-term success after bariatric
surgery.
Postoperative dietary adherence and eating behaviors
have received only a modest amount of research attention to
date. We believe these behavioral issues represent perhaps
the greatest threats to successful long-term weight mainte-
nance after bariatric surgery. The well-developed data on
behavioral weight maintenance provide a numbers of strat-
egies that can be adapted and used with bariatric surgery
patients. These studies have identified a number of critical
behavioral targets for modification to successfully maintain
weight loss. However, the lessons learned from these data
are frequently ignored by the bariatric surgery community,
because they are believed to be associated with less weight
loss and poor long-term maintenance. Many of the strategies
used to improve the long-term outcomes of lifestyle modi-
fication, such as the use of continued patient–provider con-
tact, might play an important role in optimizing the out-
comes.
The provision of long-term patient–provider contact in
behaviorally based treatment underscores the belief that
obesity is a chronic disease and that the behaviors that
contribute to obesity (overconsumption of food and de-
creased physical activity) require chronic treatment. Pa-
tient–provider contact provide an opportunity for “guided-
mastery” in which the provider can reinforce the continued
practice of the positive behavioral changes that patients
made to facilitate weight loss. Maintenance sessions con-
ducted electronically (i.e., telephone or Internet) can over-
come some of the logistical barriers (i.e., commuting time,
lack of flexibility) to in-person visits and might be a viable
option for bariatric patients and providers [69,70]. The ef-
649
ficacy of these behavioral interventions with postoperative
patients awaits empiric study.
Another area in need of future study is physical activity.
Although members of the bariatric surgery team likely en-
courage patients to become more physically active postop-
eratively, little research has been done on the changes in
activity that occur after surgery. Most of these studies have
relied on the self-report of activity, rather than validated
psychometric measures or physical assessments. No study
of bariatric surgery patients, to our knowledge, has used an
objective measure of activity such as accelerometry. Thus,
the validity of the findings are limited. Also, it is important
to remember that there is a big difference between a health-
care provider telling a sedentary patient to become more
physically active (which the patient has likely heard repeat-
edly) and helping the patient to enroll in an exercise pro-
gram specifically tailored to that patient’s needs. Such phys-
ical activity interventions have been developed and tested
for a number of medical patients, such as cancer survivors,
but are only now in development for patients who have
undergone bariatric surgery.
Many of these programs promote lifestyle activity, in
which patients are encouraged to become as active as pos-
sible throughout the day by walking as much as possible
(i.e., parking farther away in parking lots when safe, taking
the stairs rather than the elevators). Lifestyle activity might
be a more appropriate strategy for the promotion of the
long-term maintenance of activity compared with struc-
tured, programmed activity (e.g., intensive cardiovascular
activity such as jogging), particularly among persons with
extreme obesity who might have physical conditions that
limit their ability to engage in high-intensity aerobic activ-
ity. Continued patient–provider contact could also assist
patients with maintaining greater levels of physical activity.
Regular postoperative follow-up also has the potential to
address the potential recurrence of problematic and disor-
dered eating. BED and NES can be conceptualized as a
function of an individual’s inability to self-regulate food
intake. These factors are typically targeted as a part of
behavioral modification interventions for weight control.
Such interventions have been effective in helping those with
BED lose weight and decrease the frequency of binge epi-
sodes, with the abstinence of binge eating believed to be
critical for long-term weight maintenance [71]. The treat-
ment of NES similarly focuses on impulse control and
alternative methods for decreasing the frequency of nega-
tive mood states that might lead to night eating. Postoper-
ative maintenance sessions for bariatric surgery patients can
help patients identify the potential triggers for binge and
night eating and control those impulses.
It is our hope that future research in the area of bariatric
surgery will continue to investigate dietary intake and eating
behavior and will begin to explore the dietary and behav-
ioral counseling strategies that could help enhance the long-
term outcomes of those who undergo bariatric surgery.
650 D. B. Sarwer et al / Surgery for Obesity and Related Diseases 7 (2011) 644 – 651
Disclosures
Dr. Sarwer has consulting relationships with Allergan,
BaroNova, Enteromedics, and Ethicon Endo-Surgery and is
on the Board of Directors of the Surgical Review Corpora-
tion. Dr. West-Smith has a consulting relationship with
Ethicon Endo-Surgery. Ms. Dilks reports no disclosures.
References
[1] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a
systematic review and meta-analysis. JAMA 2004;292:1724 –37.
[2] Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: Sur-
gical treatment of obesity. Ann Intern Med 2005;142:547–59.
[3] Sjöström L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and
cardiovascular risk factors 10 years after bariatric surgery. N Engl
J Med 2004;351:2683–93.
[4] Sjöström L, Narbro K, Sjöström CD, et al. Swedish Obese Subjects
study: effects of bariatric surgery on mortality in Swedish obese
subjects. N Engl J Med 2007;357:741–52.
[5] Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases
long-term mortality, morbidity, and health care use in morbidly obese
patients. Ann Surg 2004;240:416 –23.
[6] Fujioka K. Follow-up of nutritional and metabolic problems after
bariatric surgery. Diabetes Care 2005;28:481– 4.
[7] Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behav-
ioral aspects of bariatric surgery. Obes Res 2005;13:639 – 48.
[8] Aills L, Blankenship J, Buffington C, Furtado M, Parrott J, Parrott J.
ASMBS Allied health nutritional guidelines for the surgical weight
loss patient. Surg Obes Relat Dis 2008;4:S73–S108.
[9] Moize V, Geliebter A, Gluck ME, et al. Obese patients have inade-
quate protein intake related to protein intolerance up to 1 year fol-
lowing Roux-en-Y gastric bypass. Obes Surg 2003;13:23– 8.
[10] Sarwer DB, Wadden TA, Moore RH, et al. Preoperative eating
behavior, postoperative dietary adherence and weight loss following
gastric bypass surgery. Surg Obes Relat Dis 2008;5:640 – 6.
[11] Brolin RE, Robertson LB, Kenler HA, Cody RP. Weight loss and
dietary intake after vertical banded gastroplasty and Roux-en-Y gas-
tric bypass. Ann Surg 1994;220:782–90.
[12] Litchtman SW, Pisarska K, Berman ER, et al. Discrepancy between
self-reported and actual caloric intake and exercise in obese subjects.
N Engl J Med 1992;327:1893– 8.
[13] Xanathakos SA, Inge TH. Nutritional consequences of bariatric sur-
gery. Curr Opin Clin Nutr Metab Care 2006;9:489 –96.
[14] Provenzale D, Reinhold RB, Golner B, et al. Evidence for diminished
B12 absorption after gastric bypass: oral supplementation does not
prevent low plasma B12 levels in bypass patients. J Am Coll Nutr
1992;11:29 –35.
[15] Avinoah E, Ovnat A, Charuzi I. Nutritional status seven years after
Roux-en-Y gastric bypass surgery. Surgery 1992;111:137– 42.
[16] Alvarez-Lerte JI. Nutrient deficiencies secondary to bariatric surgery.
Curr Opin Clin Nutr Metab Care 2004;7:569 –75.
[17] Mitchell JE, Lancaster KL, Burgard MA, et al. Long-term follow-up
of patients’ status after gastric bypass. Obes Surg 2001;11:464 –78.
[18] Potoczna N, Harfmann S, Steffen R, Briggs R, Bieri N, Horber FF.
Bowel habits after bariatric surgery. Obes Surg 2008;18:287–96.
[19] Sugerman HJ, Starkey JV, Birkenhauer R. A randomized prospective
trial of gastric bypass versus vertical banded gastroplasty for morbid
obesity and their effects on sweets versus non-sweets eaters. Ann
Surg 1987;205:613–24.
[20] Stunkard AJ, Messick S. Eating inventory manual. San Antonio:
Harcourt, Brace Jovanovitch; 1988.
[21] Wing RR, Tate DF, Gorin AA, Raynor HA, Fava JL, Machan J.
STOP Regain: are there negative effects of daily weight? J Consult
Clin Psych 2007;75:652– 6.
[22] Niemeier HM, Phelan S, Fava JL, Wing RR. Internal disinhibition
predicts weight regain following weight loss and weight loss main-
tenance. Obesity 2007;15:2485–90.
[23] Stunkard A, Allison K, Lundgren J. Issues of DSM-IV: night eating
syndrome. Am J Psychiatry 2008;165:424.
[24] Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders
among bariatric surgery candidates: relationship to obesity and func-
tional health status. Am J Psychiatry 2007;164:328 –34.
[25] Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Binge eating in
bariatric surgery patients. Int J Eat Disord 1998;23:89 –92.
[26] de Zwaan M, Mitchell JE, Howell LM, et al. Characteristics of
morbidly obese patients before gastric bypass surgery. Compr Psy-
chiatry 2003;44:428 –34.
[27] Allison KC, Wadden TA, Sarwer DB, et al. Night eating syndrome
and binge eating disorder among persons seeking bariatric surgery:
prevalence and related features. Surg Obes Relat Dis 2006;2:153– 8.
[28] Hsu LKG, Betancourt S, Sullivan SP. Eating disturbances before and
after vertical banded gastroplasty: A pilot study. Int J Eat Disord
1996;19:23–34.
[29] Hsu LKG, Betancourt SP, Sullivan SP. Eating disturbances and out-
come of gastric bypass surgery: A pilot study. Int J Eat Disord
1997;21:385–90.
[30] Kalarchian MA, Wilson GT, Brolin RE, Bradley L. Effects of bari-
atric surgery on binge eating and related psychopathology. Eat
Weight Disord 1999;4:1–5.
[31] Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE,
LaMarca LB. Binge eating among gastric bypass patients at long-term
follow-up. Obes Surg 2002;12:270 –5.
[32] Hsu LKG, Benotti PN, Dwyer J, et al. Nonsurgical factors that
influence the outcome of bariatric surgery: a review. Psychosom Med
1998;60:338 – 46.
[33] Adami GF, Meneghelli A, Scopinaro N. Night eating and binge eating
disorder in obese patients. Int J Eat Disord 1999;25:335– 8.
[34] Latner JD, Hildebrandt T, Rosewall JK, Chisholm AM, Hayashi K.
Loss of control over eating reflects eating disturbances and general
psychopathology. Behav Res Ther 2007;45:2203–11.
[35] Colles SL, Dixon JB, O’Brien PE. Grazing and loss of control related
to eating; two high-risk factors following bariatric surgery. Obesity
2008;16:615–22.
[36] Mechanick JI, Kushner RF, Sugerman HJ, et al. American Associa-
tion of Clinical Endocrinologists, Obesity Society, American Society
for Metabolic & Bariatric Surgery, American Association of Clinical
Endocrinolgoists, the Obesity Society, and American Society for
Metabolic and Bariatric Surgery medical guidelines for clinical prac-
tice for the perioperative nutritional, metabolic, and non-surgical
support of the bariatric surgery patient. Surg Obes Relat Dis 2008;
5S:S109 – 84.
[37] National Institutes of Health/National Heart, Lung, and Blood Insti-
tute. Clinical guidelines on the identification, evaluation, and treat-
ment of overweight and obesity in adults: the evidence report. Obes
Res 1998;6:51S–210S.
[38] Wing RR. Behavioral treatment of obesity. In: Wadden TA, Stunkard
AJ, editors. Handbook of obesity treatment. New York, Guilford;
2002, p. 301–16.
[39] Donnelly JF, Smith BK, Dunn L, et al. Comparison of a phone vs
clinic approach to achieve 10% weight loss. Int J Obes 2007;31:
1270 – 6.
[40] Gold BC, Burke S, Pintauro S, Buzzell P, Harvey-Berino J. Weight
loss on the Web: a pilot study comparing a structured behavioral
intervention to a commercial program. Obesity 2007;15:155– 64.
 D. B. Sarwer et al / Surgery for Obesity and Related Diseases 7 (2011) 644 – 651
[41] Polzien KM, Jakicic JM, Tate DF, Otto AD. The efficacy of a
technology based system in a short-term behavioral weight loss in-
tervention. Obesity 2007;15:825–30.
[42] Tate DF, Wing RR, Winett RA. Using Internet technology to deliver
a behavioral weight loss program. JAMA 2001;285:1172–7.
[43] Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral
counseling on weight loss in adults at risk for type 2 diabetes: a
randomized trial. JAMA 2003;289:1833– 6.
[44] Wadden TA, Berkowitz RI, Womble LG, et al. Randomized trial of
lifestyle modification and pharmacotherapy for obesity. N Engl J Med
2005;353:2111–20.
[45] Wing RR, Tate DF, Gorin AA, Raynor HA, Fava JL. A self-regula-
tion program for maintenance of weight loss. N Engl J Med 2006;
355:1563–71.
[46] Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a
systematic review of the literature. J Am Diet Assoc 2011;111:92–
102.
[47] Linde JA, Jeffery RW, French SA, Pronk NP, Boyle RG. Self-
weighing in weight gain prevention and weight loss trials. Ann Behav
Med 2005;30:210 –16.
[48] Wing RR, Hill JO. Successful weight loss maintenance. Annu Rev
Nutr 2001;21:323– 41.
[49] Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. A descrip-
tive study of individuals successful at long-term maintenance of
substantial weight loss. Am J Clin Nutr 1997;66:239 – 46.
[50] Butryn ML, Phelan S, Hill JO, Wing RR. Consistent self-monitoring
of weight: a key component of successful weight loss maintenance.
Obesity 2007;15:3091– 6.
[51] Vanwormer JJ, French SA, Pereira MA, Welsh EM. The impact of
regular self-weighing on weight management: a systematic literature
review. Int J Behav Nurt Phys Act 2008;4:5–54.
[52] Perri MG, Sears SF Jr, Clark JE. Strategies for improving mainte-
nance of weight loss: toward a continuous care model of obesity
management. Diabetes Care 1993;16:200 –9.
[53] Svetkey LP, Stevens VJ, Brantley PJ, et al. Comparison of strategies
for sustaining weight loss: the weight loss maintenance randomized
controlled trial. JAMA 2008;299:1139 – 48.
[54] Favretti F, O’Brien PE, Dixon JB. Patient management after LAP-
BAND placement. Am J Surg 2002;184:S38 – 41.
[55] Madan AK, Tichansky DS. Patients postoperatively forget aspects of
preoperative patient education. Obes Surg 2005;15:1066 –9.
[56] Harper J, Madan AK, Ternovits CA, Tichansky DS. What happens to
patients who do not follow-up after bariatric surgery? Am Surg
2007;73:181– 4.
[57] Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren CJ. Impact of
patient follow-up on weight loss after bariatric surgery. Obes Surg
2004;14:514 –19.
651
[58] Gould JC, Beverstein G, Reinhardt S, Garren MJ. Impact of routine
and long-term follow-up on weight loss after laparoscopic gastric
bypass. Surg Obes Relat Dis 2007;3:627–30.
[59] Orth WS, Madan AK, Taddeucci RJ, Coday M, Tichansky DS.
Support group meeting attendance is associated with better weight
loss. Obes Surg 2008;18:391– 4.
[60] Phelan S, Wing RR, Loria CM, Kim Y, Lewis CE. Prevalence and
predictors of weight-loss maintenance in a biracial cohort: results
from the coronary artery risk development in young adults study.
Am J Prev Med 2010;39:546 –54.
[61] Dalle Grave R, Calugi S, Centis E, El Ghoch M, Marchesini G.
Cognitive-behavioral strategies to increase the adherence to exercise
in the management of obesity. Obesity 2011;34:82–93.
[62] Jeffery RW, Wing RR, Sherwood NE, Tate DF. Physical activity and
weight loss: does prescribing higher physical activity goals improve
outcome? Am J Clin Nutr 2003;78:684 –9.
[63] Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedome-
ters to increase physical activity and improve health: A systematic
review. JAMA 2007;298:2296 –304.
[64] Boan J, Kolotkin RL, Westman EC, McMahon RL, Grant JP. Binge
eating, quality of life and physical activity improve after Roux-en-Y
gastric bypass for morbid obesity. Obes Surg 2004;14:341– 8.
[65] Bond DS, Evans RK, DeMaria EJ, et al. Physical activity stage of
readiness predicts moderate–vigorous physical activity participation
among morbidly obese gastric bypass surgery candidates. Surg Obes
Relat Dis 2006;2:128 –32.
[66] Bond DS, Phelan SP, Wolfe LF, Evans RK, Meador JG, et al.
Becoming physically active after bariatric surgery is associated with
improved weight loss and health related quality of life. Obesity
2009;17:78 – 83.
[67] Evans RK, Bond DS, Wolfe LG, et al. Participation in 150 min/wk
of moderate or higher intensity physical activity yields greater
weight loss after gastric bypass surgery. Surg Obes Relat Dis
2007;3:526 –30.
[68] Chevallier JM, Paita M, Rodde-Dunet MH, et al. Predictive factors of
outcome after gastric banding: a nationwide survey on the role of
center activity and patients’ behavior. Ann Surg 2007;246:1034 –9.
[69] Harvey-Berino J, Pintauro SJ, Gold EC. The feasibility of using
internet support for the maintenance of weight loss. Behav Mod
2002;26:103–16.
[70] Gold BC, Burke S, Pintauro S, Buzzell P, Harvey-Berino J. Weight
loss on the Web: a pilot study comparing a structured behavioral
intervention to a commercial program. Obesity 2007;15:155– 64.
[71] Gladis MM, Wadden TA, Vogt R, Foster GD, Kuehnel RH, Bartlett
SJ. Behavioral treatment of obese binge eaters: do they need different
care? J Psychosom Res 1998;44:375– 84.