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Typical early weight loss following bariatric surgery ranges from 47–80% of excess weight. However, typical weight regain is 15–25% of that lost weight. This can be very disheartening for patients and it is very important to manage expectations of weight following surgery. With more than 22,000 people undergoing bariatric surgery per year in Australia, it is becoming increasingly common for dietitians to see patients experiencing weight regain. Weight regain after surgery may be caused by a variety of factors (Table 1).

Table 1. Contributing factors to weight regain

Problems leading to weight regain	Common examples
Anatomical	Enlargement of the stomach pouch, enlarged stomach outlet
Physiological	Altered fat metabolism, resulting in easy fat storage and limited fat-burning; menopause
Psychological	Depression; lack of self-efficacy; difficulty in asserting for new behaviours
Behavioural	Inactivity; eating behaviours (eg processed foods, grazing, eating beyond satisfaction)

It is normal to see weight gain after bariatric surgery because patients still live in an obesogenic environment, and the individual’s or surgery’s ability to control all factors is limited. Body fat is also subject to metabolic pressures to regain lost weight.

There are several nutritional intervention strategies which dietitians can employ for addressing the common problematic eating behaviors seen to accompany weight regain (Table 2).

Table 2. Eating behaviours that may contribute to weight regain after bariatric surgery

Problematic eating behaviours	Description	Strategies
Chaotic eating	Lacks structure; no formal eating pattern	Create structure, including approximate eating times spaced throughout the day; prioritise eating within the day’s activities
Skipping meals	Going long periods without food, which can result in overeating later	Planning of meals, with suitable snacks or easy options for the individual’s situation
Poor food choices	Highly processed, fried and fast foods; falling back on previous habits that resulted in initial weight gain	Identification of easy food choices with less processing; encouraging patients to take an interest in food preparation and quality (eg cooking classes)
Grazing	Small portions of food eaten over an extended period of time; previous binge eating may be expressed in this way	Defined meals of appropriate volume at meal times to ensure satisfaction, limiting meal time to 30 mins.
Night eating	A significant proportion of calories are ingested after the evening meal	Ensure adequate and even food spacing throughout the day
Excessive portion size	Eating beyond ‘satisfaction’ resulting in ‘fullness’; this continues to drive excessive intakes	Reduce and maintain smaller portion sizes, ideally one-cup volume at meals
Alcohol intake	Alcohol is rapidly absorbed following bariatric surgery, resulting in disinhibited eating and lack of satiety from liquid calories	Introduce strategies to reduce alcohol intake; alcohol problems can develop after surgery in those who previously experienced no problems and all care team members should be alert
Inadequate protein intake	Protein is important for satiety but also for maintenance of muscle mass, which contributes to resting metabolic rate	Education on protein content of food along with strategies, recipes and ideas for inclusion
Mixing fluids and foods	This may stretch the capacity of the stomach and cause early gastric emptying	Avoid fluids in the immediate pre-meal period and for 30 minutes after

Other factors that represent an opportunity for modification include psychological barriers, physical activity, sleep quality, medications and exposure to endocrine-disrupting chemicals.

It is important for patients that we assess and address modifiable contributors to weight regain prior to enabling a further surgery, as problems may persist.

Amanda Clark is an experienced bariatric dietitian and creator of Portion Perfection for Bariatrics tools and visual portion guides available in the USA and Australia