"It's not a quick fix" : consequences of weight loss during life and experiences of weight regain after bariatric surgery

Sammanfattning: Maintenance of weight loss is challenging for most people who intentionally lose weight. Complex factors interact with each other and obstruct weight management. This thesis focuses on the consequences of weight loss and experiences of regaining weight. These results could be helpful in treatment recommendations for individuals who live with obesity. Studies I, II, and III were qualitative studies that analyzed data from semistructured interviews with participants living with obesity who had regained an average of 36% from the lowest weight point after bariatric surgery. All participants had undergone gastric bypass surgery. Study I focused on how participants experienced support from healthcare professionals, families, and friends during weight regain following bariatric surgery. The thematic analysis showed that participants felt lonely and abandoned during post-surgical weight management. In addition, shame and self-blame could further obstruct the search for medical support. However, participants described social support from healthcare and family members as desired and helpful for a healthier lifestyle and weight management. Our findings indicate the importance of an empathetic and non-judgmental approach towards patients and access to a multi-professional healthcare team for long-term support. In Study II, we investigated the experiences of patients who had undergone bariatric surgery and struggled with weight regain. Further, we aimed to understand the factors that might be of interest in improving post-bariatric care. Thematic analysis showed that weight regain was a complex and unexpected experience that induced a negative emotional response. In addition, post-surgery weight management became challenging due to multiple daily obstacles, alterations in appetite, and physical and mental health issues. Nevertheless, most participants experienced lasting benefits from gastric bypass surgery, despite regaining weight. To reduce the burden of weight management, participants wished to focus more on self-care and receive positive support from healthcare providers. In Study III, we explored patients’ experiences with food- and eating-related behaviors during weight regain after gastric bypass surgery. In the thematic analysis, we found that participants experienced overwhelming dietary challenges. They had not expected to need to struggle with dietary issues such as mealtimes, sizes of portions, and cravings. They also described emotional and disordered eating and drinking patterns. Participants experienced a lack of nutritional knowledge and support. They turned to restrictive eating and dieting behaviors to manage their weight. In a prospective cohort study, Study IV, we investigated the association between weight loss earlier in life and mortality outcomes, specifically for all-causes, cardiovascular disease (CVD), and cancer mortality. We followed 34,346 individuals from the Swedish National March Cohort for over two decades to assess mortality. To calculate Hazard Ratios (HR) and 95% confidence intervals (CI), we employed Cox Proportional Hazard Models, with age serving as the timescale. We adjusted for multiple confounders and found that individuals who had lost >10 kg or >5 kg on three or more occasions had higher mortality rates for all causes and cardiovascular diseases than those who had not lost weight. Furthermore, men who had lost more than 10 kg had higher mortality rates for all causes and cardiovascular disease than men who had not lost weight. We did not observe any associations between weight loss and cancer mortality. Study V was a cross-sectional study in which we examined whether weight loss earlier in life in adolescents and young adults with obesity before starting a medical obesity treatment program might be associated with self-esteem and eating behaviors. We used self-reported data from 224 participants to determine associations using linear regression models. Our findings showed that those who had lost 5-10 kg and >5 kg two times or more often had higher cognitive restraint eating scores than adolescents and young adults with obesity who had not lost weight. However, we did not find any association between weight loss, selfesteem, and other eating behaviors such as uncontrolled eating and emotional eating. In conclusion, existing post-surgical support was experienced as insufficient by participants who had regained weight after bariatric surgery. They may have had unrealistic expectations concerning postoperative weight management and eating behaviors. Various internal and external challenges may obstruct weight management and eating behaviors, contributing to emotional distress and feelings of personal failure. Our results show the need for an extended follow-up. Special focus should be directed toward those with difficulties in weight loss maintenance. Weight loss earlier in life may increase all-cause and cardiovascular mortality, particularly in men. Furthermore, previous weight loss attempts may affect adolescents and young adults with obesity, leading them to struggle to control their eating behavior to a high degree without sustained weight loss. Healthcare professionals should assess patients’ weight loss history and eating behaviors, and encourage healthy eating for sustained weight management, regardless of sex, throughout life.