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Titre: ``When the honeymoon is over, the real work begins:'' Gastric bypass patients' weight loss trajectories and dietary change experiences
Auteur: Amanda Lynch
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Social Science & Medicine 151 (2016) 241e249
Contents lists available at ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
“When the honeymoon is over, the real work begins:” Gastric bypass
patients' weight loss trajectories and dietary change experiences
3103 Human Health Building, Health Sciences Department, Oakland University, Rochester, MI 48309, United States
a r t i c l e i n f o
a b s t r a c t
Received 3 April 2015
Received in revised form
1 December 2015
Accepted 16 December 2015
Available online 19 December 2015
To understand gastric bypass patients' experiences with managing food and eating for long-term weight
management, this study examined patients' self-reported dietary changes and weight loss patterns.
Thirteen women and three men between 15 months and 10 years post-gastric bypass surgery were
recruited in Upstate New York. They completed two qualitative, in-depth interviews about their weight
loss and dietary experiences. Using verbatim transcripts, researchers created timelines for each participant that summarized weight changes and the associated dietary behaviors. Constant comparative
analysis of the timelines and transcripts identiﬁed a common, initial rapid weight loss period followed by
weight stabilization, after which participants' weight loss patterns diverged into three possible longterm trajectories (Maintaining, Regained/Losing, and Regained) and one short-term trajectory (Losing).
Dietary management over the periods of weight loss involved six components: physical needs, hunger
and fullness, relationship with food, strategy use, habit formation, and awareness of eating. In the
“honeymoon period” weight loss was “easy” because “surgery does the work” in limiting appetite,
portion sizes, and interest in foods. As weight stabilized, “the work begins” as participants became
capable of eating a greater quantity and a wider variety of foods. Differences in weight loss trajectories
were associated with participants' abilities to maintain changes in relationship with food, dietary strategies and habits, and awareness of eating behaviors. Viewing weight loss outcomes of gastric bypass
surgery as trajectories that develop as the result of dietary transitions and changes in dietary management suggests that patients need to be counseled on a variety of cognitive and behavioral strategies.
© 2016 Published by Elsevier Ltd.
Major weight loss resulting from bariatric surgery loss has been
described as a “self-transformation” (Sutton et al., 2009). Drastic
changes in weight alter self-perceptions and body image, leading to
changes in identity, conﬁdence, and social interactions (Bocchieri
et al., 2002). The physical transformations happen quickly, as patients who undergo gastric bypass surgery can expect to lose
approximately 35% of their body weight in the ﬁrst year, with averages of approximately 95 pounds (Buchwald et al., 2004).
Long-term studies have reported that between 14% and 29% of
patients regain more than 10% of their weight loss (Freire et al.,
2012; Valezi et al., 2013), suggesting the cognitive and behavioral
changes needed to sustain weight loss are not always permanent.
Although the processes involved are not well understood, poor
weight loss outcomes (e.g. regain or inadequate loss) have been
E-mail address: email@example.com.
0277-9536/© 2016 Published by Elsevier Ltd.
associated with maladaptive eating behaviors such as grazing
(Colles et al., 2008), emotional eating (Mathus-Vliegen, 2006), and
loss of control when eating (Kofman et al., 2010). (Sarwer et al.,
2008). Factors which promote adequate and/or sustained weight
loss include avoiding maladaptive eating behaviors, compliance
with post-surgery dietary recommendations (Sarwer et al., 2008),
support group attendance (Livhits et al., 2010) and physical activity
(Welch et al., 2008).
Gastric bypass patients must also make dietary changes to
accommodate their permanently altered digestive tract. Gastric
bypass surgery promotes weight loss by reducing the size of the
stomach to between 15 and 25 ml and reconﬁguring the small intestine, whereby food does not pass through the duodenum and
proximal jejunum (Buchwald, 2005). Decreased intake is due to
limits on volume of food consumed and reduced hunger due to
changes in secretions of appetite hormones (Ochner et al., 2011).
Food selection frequently changes within the ﬁrst year. Patients
may avoid high fat foods (Thomas and Marcus, 2008) or reduce
A. Lynch / Social Science & Medicine 151 (2016) 241e249
protein intake (Moize et al., 2003) due to intolerances. Presumably
many changes are due to dumping syndrome, a variety of unpleasant gastrointestinal symptoms (e.g. diarrhea) and/or hypoglycemia that occurs after consuming high sugar or high fat foods,
and other side-effects of surgery (Overs et al., 2012), or alterations
in taste and craving (Behary and Miras, 2015). However, studies ﬁnd
that macronutrients and food selections return to pre-surgery
patterns in a year (Miller et al., 2014; Sarwer et al., 2008). Thus,
there remains a gap in our understanding of motives for dietary
changes and inﬂuences on the stability of these changes.
An integrated, grounded theory model of the food choice process (Sobal and Bisogni, 2009) provides a useful framework for
examining gastric bypass patients' long-term dietary management.
This model takes a social constructivist perspective (Charmaz,
2000) viewing individuals as actively constructing their thoughts,
feelings, and behaviors based on a variety of personal, social, cultural, economic, and environmental factors (Sobal and Bisogni,
2009). People develop personal systems of meanings and cognitive processes for making tradeoffs among conﬂicting food choice
values (e.g. health and taste), ways of classifying foods and situations (Blake et al., 2007), and scripts and routines for familiar situations (Blake, 2008).
From the life course perspective (Wethington, 2005), gastric
bypass surgery is a critical turning point with the potential to
permanently alter the path of one's food choices and dietary patterns, just as it alters one's weight and body. Studies examining
patients' experiences with food and eating post-surgery have uncovered changed relationships to food, challenges in dealing with
emotional eating, and an increased awareness of eating behaviors
(Benson-Davies et al., 2013; Wood and Ogden, 2015). Ogden et al.
(2006) found that after an adjustment period, patients felt they
had more control over their eating behaviors. In addition, Lynch
and Bisogni (2014) documented patients' intentional use of strategies to manage weight, promote health, and avoid negative reactions to eating. Although these studies highlight important
cognitive and emotional processes that shape patients' experiences
and behaviors, they generally focus on diet and weight as separate,
emergent themes. However, the two change concurrently. This
study aims to add to the literature by describing the experiences of
weight loss and the processes of changing dietary behaviors
simultaneously and providing a conceptual model to explain how
these occur together. Using a social constructivist perspective and
qualitative interviews, the researchers examined detailed information from patients regarding their experiences with dietary
changes and weight loss management after surgery.
Purposive sampling (Lincoln and Guba, 1985) was used to recruit
adult gastric bypass surgery recipients, who were a minimum of 12
months post-surgery. The researchers assumed that by one year,
participants would have experienced maximum weight loss
€ m et al., 2004), would have transitioned to new ways of
eating and managing weight, and would be able to reﬂect upon the
process of change and make comparisons between pre-surgery and
Sixteen participants (13 female, 3 male) were recruited from
three different bariatric support groups in Upstate New York. With
permission of the group leader, the researcher also observed the
support group meetings. The ﬁrst wave of recruitment in 2006
yielded ten participants from support groups associated with two
regional hospitals. Six more participants were recruited in 2009
from a third support group that met as part of a work-site wellness
program. These additional participants were recruited to conﬁrm
ﬁndings from preliminary analysis of the initial interviews and to
expand diversity of experiences. By the 16th participant, no new
information emerged that added to the existing categories and
themes. It was believed theoretical saturation was achieved and
recruitment efforts ended (Glaser and Strauss, 1967). All study
procedures were approved by Cornell University's institutional
review board. Study purpose, procedures, and risks/beneﬁts were
explained to the participants both verbally and through a written
consent form. Written informed consent was obtained prior to the
start of the ﬁrst interview.
Participant characteristics are summarized in Table 1. Participants ranged in age from 32 to 63 years. Fourteen participants lived
with spouses or partners, one participant lived with children, and
one participant lived alone. Time since surgery ranged from 14
months to 10 years, with an average of three years, eight months.
Fifteen participants had gastric bypass surgery as their ﬁrst bariatric surgery and one had a revision to gastric bypass due to
complications from a previous bariatric procedure. All participants'
surgeries were covered by insurance.
Semi-structured interviews were used to elicit detailed descriptions of participants' experiences. Interview questions were
developed using the Food Choice Process Model (Sobal and Bisogni,
2009) as a guide to uncover participants' present and past food
selection and eating behaviors and to understand the inﬂuences
and rationales for their decisions. Questions also covered the topics
of pre-surgery weight and dieting history, post-surgery weight loss,
health, and surgical experiences. Each participant was interviewed
twice, with approximately one month between interviews, to allow
time to review transcripts. The ﬁrst interview focused on dietary
behaviors and the second on weight and post-surgery experiences.
Two interviews allowed for in-depth, detailed exploration of topics
while reducing participant and interviewer fatigue. These multiple
contacts promoted rapport and provided the researcher with the
opportunity to clarify details and conﬁrm interpretations from the
The interview guide was pilot tested with an individual meeting
the criteria for the study. As no major changes were made to the
Lives with spouse/signiﬁcant other only
Lives with spouse and children
High school diploma
Graduate or Advanced Degree
Time since surgery
Less than 2 years (14e17 months)
2e4 years (2e3.75 years)
5e10 years (5e10 years)
One person did not report their income.
A. Lynch / Social Science & Medicine 151 (2016) 241e249
questions, this participant's interviews were included in the data
analysis. Interviews were conducted in mutually agreed upon locations between the participant and the researcher, including ofﬁces, bookstores, and participants' homes. Interviews lasted
between 50 and 150 min, were audio recorded, and transcribed
verbatim. Transcripts were de-identiﬁed (e.g. names of places and
people were changed) and participants were given pseudonyms.
Transcripts were coded using the constant comparative (Glaser
and Strauss, 1967) using ATLAS.ti 6.2 (ATLAS.ti.GmbH) to code text,
record memos, and organize codes into categories and themes for
easy retrieval. Initial coding focused on participants' descriptions of
pre- and post-surgery dietary and weight related thoughts, behaviors, and attitudes. These broad descriptions were broken down
into “meaning units” (Giorgi, 1997), or sections of the text that
described the same concept. Coding continued in an iterative
manner until no further emergent concepts occurred.
The next step in analysis focused on the descriptions of the postsurgery weight loss progression and current perspectives on
weight. Timelines depicting post-surgical weight changes were
drawn for each participant based on their detailed accounts of
rates, amounts, and patterns of weight loss. Sections of the timelines were annotated with participants' descriptions of his/her
initial rapid weight loss, weight plateaus (periods of weight stability between periods of loss), and weight stabilization (when
weight loss ended and weight remained consistent). Life events,
dietary and physical activity summaries, and other weightinﬂuencing factors were also marked on the timelines. As timelines were drawn, transcripts were reviewed and coded a second
time for participants' descriptions of inﬂuential factors and changes
in dietary behaviors over time These codes were categorized into
conceptual themes such as vigilance, dietary progression, relationship to food and habits.
Next, participants were grouped according to their self-reported
weight outcomes. Average pre-surgery weight for this group was
308 pounds (range: 234e424) with an average post-surgery weight
of 191 pounds (range: 115e330). Pre-surgery BMI was an average of
55.1 kg/m2 for the group with an average post-surgery BMI of
32 kg/m2. Four weight loss outcome groups emerged based on
post-surgical weight changes and current weight: Losing, Maintaining, Regained/Losing, and Regained. These groups are summarized in Table 2. The four Losing participants were either
approaching their lowest post-surgical weight or had been at their
current (lowest) weight for a maximum of three months. The ﬁve
Maintaining participants reported stable, personally acceptable
weights for at least ﬁve months without unwanted weight regain.
Members of the Regained/Losing group experienced unwanted
weight regain since achieving their lowest post-surgical weights,
but had either lost the weight or were in the process of losing it.
One regained 50 pounds, while three regained 15e20 pounds. All
three participants in the Regained group reported personally unacceptable amount of weight regain and no current weight loss
efforts. Their regain ranged from 45 to 68 pounds, or 25%e69% of
their initial weight loss.
In the last step of analysis, a matrix of cross-case displays was
created from the dietary and weight categories. to facilitate data
exploration and conceptual analysis (Miles and Huberman, 1994).
Each matrix row represented one participant while each column
represented a salient category related to weight or diet, along with
his or her self-reported weight outcome (e.g. Maintaining). Quotes
and summaries were placed in each cell allowing for researchers to
examine each participant as a “case” and assess all emergent
themes across cases. Participants' descriptions of dietary changes
were compared and contrasted to create a conceptual framework of
dietary progression following surgery and main areas of dietary
change. Timelines and weight categories were compared and
contrasted to create an overall framework to describe and explain
Techniques to establish trustworthiness were employed
throughout data collection (Lincoln and Guba, 1985). Credibility
was enhanced through prolonged engagement, which included
multiple contacts and support group observations, and examining
negative cases. Negative cases included one individual who reported returning to pre-surgery eating behaviors and another who
said she made no major changes in her beliefs, or attitudes towards
food and eating. Negative cases were compared and contrasted
with other cases and working frameworks were modiﬁed accordingly. Member checks were used during the interviews to conﬁrm
researchers' interpretations of participants' stories and explanations. Peer-debrieﬁng was achieved through regular meetings between the researchers to discuss emergent concepts, themes, and
processes. Quotes were selected based on conceptual ﬁt and how
well they captured the common experiences expressed by more
than one person. Quotes are presented verbatim to accurately
represent a lived experience.
3.1. Weight management periods
Despite differences in weight loss outcomes, participants
described a common sequence of weight management periods.
Following surgery, all participants experienced a “honeymoon”
when weight loss was drastic and rapid. Participants stated, “no
matter what you do, you will lose weight.” This Honeymoon period
began immediately after surgery and continued for six to 12
months, during which time participants reported losing between
80 and 150 pounds. Participants agreed that “the surgery does the
work of weight loss for you” during this period. The Honeymoon
Participants grouped according to self-reported weight status and time since surgery.
Self-reported weight outcomes at the time of study
Time since surgery
Less than 2 years
Cindy (15 mo)
Heather (15 mo)
Lynne (15 mo)
Pam (15 mo)
Zach (17 mo)
4 þ years
Ashley (2 yr)
Eleanor (2.75 yr)
June (2.5 yr)
Diana (3.75 yr)
Trevor (3 yr)
Dana (6 yr)
Marge (5 yr)
Vanessa (5 yr)
Courtney (5.5 yr)
Oliver (10 yr)
A. Lynch / Social Science & Medicine 151 (2016) 241e249
ended with weight “stabilization,” a period when weight loss
stopped or slowed to a few pounds a month. While not all participants believed they had reached their lowest weights, they all felt
they had reached the end of their Honeymoon period.
Following Stabilization, participants transitioned into “the work
begins” period, a time when cognitive and behavioral effort was
needed to manage weight. Weight management during this time
included accepting (and maintaining) the current lowest weight
(i.e. no desire to lose more weight), accepting small regains (e.g. a
ﬁve to ten pound “bounce back”), monitoring small weight ﬂuctuations, or addressing unwanted weight gain.
3.2. Dietary management phases
Phases of dietary management represented the changes in food
and eating that occurred as participants adjusted to their postsurgical bodies and weight loss. “My old habits,” or ways of
eating before surgery, were frequently compared and contrasted
with eating practices after surgery.
Existing dietary practices were immediately abandoned after
surgery to accommodate healing and gastrointestinal modiﬁcations. Post-operative diet progression followed the same pattern for
all participants: clear liquids, full liquids, pureed or blended foods,
soft solids, and ﬁnally “regular” foods. As participants progressed to
solid foods, they described a “trial and error” phase when they had
to “experiment” with food and eating and “learn how to eat all over
again.” Participants experienced unexpected food intolerances,
restrictions on the volume of food they could eat, and painful
consequences from eating too much or too fast.
Participants transitioned from the Trial and Error phase to a
Retraining phase, as they “retrained” and “re-taught” themselves
how to eat. Participants formed new strategies, modiﬁed food selections, and actively changed their thoughts about food and eating.
Participants viewed these changes as “setting myself up for success,” emphasizing the importance of “creating good habits” during
the Honeymoon period because it was “easy to be good.” Eating less
required little effort due to early satiety; intolerance of high sugar
and high fat foods made avoiding these foods easy.
As weight loss slowed and participants adjusted to the physical
changes of surgery, they became less strict about following “the
rules.” Participants were physically able to eat more and select from
a wider variety of foods. In addition, their motivation for change
decelerated as their lower weight became “normal” and the
“excitement” “wore off.” Participants now had to “work” to maintain changes (and weight) by “paying attention” to behaviors and
habits and making “conscious” decisions. The Making it Work
phase of dietary management required a shift in awareness and
renewed cognitive effort to maintain ways of eating and to deal
with the return of pre-surgery eating habits.
3.3. Weight outcome trajectories
Participants' current places along the continuum of weight
management periods and their ability to “make it work” differentiated their weight outcome trajectories, or the relatively stable
patterns of weight over time. The Losing trajectory was a shortterm, temporary trajectory currently at a lowest post-surgical
weight, which Losing participants hoped to maintain with minimal or no rebound. These participants were either “stabilizing” or
entering the Work Begins period. The longer-term weight outcome
trajectories that formed during the Work Begins period represented
participants' current weight outcomes: Maintaining, Regained/
Losing, or Regained.
Fig. 1 presents a theoretical representation of the weight management periods, dietary management phases, and weight
outcome trajectories. This ﬁgure illustrates the key common
themes and reference points that emerged from participants' explanations of their weight loss experiences and dietary change
3.4. Components of dietary management
Six components of dietary management emerged as participants
described their transitions between dietary management phases:
1) physical needs, 2) hunger and fullness, 3) relationship with food,
4) strategy use, 5) habit formation, and 6) awareness of eating.
Although the components were the same throughout, the challenges, barriers, and ease of management changed over the periods
of weight management.
Physical needs. Prior to surgery, participants had fewdif anydphysical needs they managed with diet, aside from individual
restrictions for diseases such as diabetes or hypertension. They
rarely considered the role of nutrients or foods in their health or
energy levels. As Heather stated, “I never thought about how what I
was eating affected my body.”
Managing physical needs initially focused on identifying “limits”
of a surgically altered digestive system. Surgery created a “forced
stopping point” leading all participants to reduce their intake to
“mouthfuls” or “tablespoons” to accommodate the smaller stomach. Overeating led to pain or discomfort. Food intolerances were
common, often severe, and unpredictable. Eating too fast, not
chewing well, or drinking while eating produced consequences
such as vomiting or pain. Many participants reconsidered their food
choices due to taste changes or new aversions to textures. These
physical needs were identiﬁed and attended to during the Trial and
Error phase of dietary management and integrated into the strategies developed during Retraining.
Physical health now motivated participants to make “good
choices.” Participants emphasized the importance of taking
vitamin, mineral, and protein supplements to offset malabsorption
and reduced intake of foods. Eating was an essential act to manage
“low blood sugar” or “low energy” and food was now described as
“fuel” and “necessary for health.”
By the time participants' weights stabilized, they were no longer
surprised at food intolerances and had identiﬁed how much food to
eat before becoming “too full.” Supplements continued to be the
main way of managing micronutrient deﬁciencies; most participants continued to drink protein supplements. In general, physical
needs were not the focus of the “work” of long-term dietary and
Hunger and fullness. A deﬁning aspect of post-surgical dietary
management was managing a drastically altered appetite. About
half of the participants stated they never felt hungry prior to surgery because they ate “all the time.” Others said they overate
because they were hungry all the time. Hunger was described as
“pangs” or a “desire” to eat, while fullness was frequently described
as being “stuffed,” and participants commented on the large
quantities needed to achieve a fullness sensation. Most participants
reported eating food “because it was there” and eating until it was
Following surgery, all participants noted immediate fullness
after a “sip” of beverage or “bite” of food. For some, this was the ﬁrst
time in years they “felt full.” During the Trial and Error phase,
participants quickly learned to “listen to my body,” and to stop
eating when they felt full. Due to the belief that they could “stretch
the pouch” over time by consuming large portions, many participants chose portion sizes they believed were in line with the size of
their post-operative stomach, and would not eat beyond that
Most participants said they did not “feel hungry.” If they did,
A. Lynch / Social Science & Medicine 151 (2016) 241e249
Fig. 1. Gastric bypass patients' post-surgery weight outcome trajectories and dietary management phases.
hunger signals were “feeling woozy,” having “low blood sugar,” or
feeling “low energy.” Lack of hunger raised participants' awareness
of habits that contributed to their obesity. For example, several
participants described “going through the motions” of opening the
refrigerator or kitchen cupboards immediately upon coming home
from work even though they were not hungry.
Finally, participants experienced increased satisfaction with
eating, saying “a little bit satisﬁes me.” They also described a lack of
“desire” for or “interest” in food. Participants were no longer
“triggered” by environmental cues, such as holiday cookies or the
smell of baking bread. Changes in hunger, satiety and desire to eat
appeared to act as a catalyst for participants to re-evaluate the role
of food in their lives and how they incorporated food and eating
into their daily schedules.
“Having the hunger change has kind of helped me keep a new
normal for me. Um, to eat healthier, to eat smaller amounts. Just
cause something tastes good, you know, doesn't mean I have to
eat the whole thing. That kind of mentality that you have before
it's like, well it tastes good, I'll ﬁnish it whether I'm full or not.
And now it's painful if you do [that].” Cindy
Reduced hunger persisted for over two years for some participants, while, for others it lasted only nine months. Similarly, the
desire to eat or try new foods returned for many participants between six and 12 months post-surgery. Thus, as weight stabilized,
participants reported “it takes more to get me full.” Cravings and
“looking forward” to eating began to challenge participants. Thus,
part of the Making it Work phase of dietary management included
ways of dealing with returning hunger, decreased satiety and
Relationship with food. Participants' relationships with food were
complex and inﬂuenced by decades of emotional eating and/or
feeling guilty for eating. Almost all participants said they were
“emotional eaters” prior to surgery with the “habit” of using food as
a “crutch” or coping mechanism. Participants usually described
eating in response to negative emotions, however, several also ate
for “every emotion” or used food as a reward or celebration. Many
described food as a “friend” because “it never let me down” and
“was always there.”
“Prior to that was my comfort. That was the one thing that
wouldn't say no to me, one thing that wouldn't judge me. The
one thing that what you know then, but you don't pay attention
to, is that it only gives you a very temporary feeling of happiness
or feeling of release,” Diana.
Beginning in the Honeymoon period, participants actively
modiﬁed their relationship to food, facilitated by reduced hunger
and desire to eat. Redeﬁning the role of food in their lives “takes
work” and “did not happen overnight.” Most participants stated,
“food is not my friend.” An exception was Eleanor who described
her relationship as “friendly” because it did not “control” her.
Changes in relationship to food complemented participants' views
of food for health and many explained, “I eat to live, not live to eat.”
During the Work Begins period, many participants noted more
frequent challenges to their new relationship to food. This ranged
from noticing an “urge” to emotionally eat to struggling with food
being “too much of a friend.” Many believed “I'll always be an
emotional eater” and worked to prevent emotional eating by
ﬁnding a “release” in other activities or through “willpower.” Most
participants also emphasized the need to understand why they
used food as a coping mechanism and many went to therapy. Some
came to this understanding prior to surgery, but for many, it was
part of the process of learning how to interact with food again.
Maintaining a new relationship to food and dealing with a reemergence of emotional eating was a critical component of the
Making it Work phase of dietary management.
Strategy use. Strategies were food and eating behaviors participants consciously planned and enacted to manage various aspects
of dietary and weight loss needs. Participants reported having few
dietary strategies, structures, or restrictions prior to surgery, eating
“whatever I wanted, wherever I wanted.” The exception was during
active weight loss attempts. Dieting strategies ranged from liquid
fasts to purchasing and eating pre-portioned foods. While effective
for weight loss, these strategies did not “train you how to eat right,”
A. Lynch / Social Science & Medicine 151 (2016) 241e249
and weight returned when strategies were abandoned.
Participants often referred to their post-surgery strategies as
“the rules” or “the plan,” which included eating protein ﬁrst,
measuring food, and limiting carbohydrates. Strategies were
created by “trial and error” and by following post-surgery dietary
instructions. Much of the cognitive and behavioral effort in the
Retraining phase of dietary management was devoted to developing strategies to manage physical needs, hunger and fullness, and
relationship to food. The Making it Work phase of dietary management involved enactment and continual evaluation of
Habit formation. Habits, as described by participants, were
routine behaviors or ways of thinking that were “second nature.”
These behaviors included meal and snack patterns, planning ahead,
reading food labels, and eating slowly. They also included repetitive
food choices which freed participants from “having to think” about
what to eat at meals and snacks.
Participants intended that many of the strategies they developed during the Honeymoon would become habits, making weight
management easier during the Work Begins period. They worked to
eliminate “bad habits” or “old habits” they associated with obesity
or weight gain such as grazing and “mindless eating.”
“I set so many good habits for myself that it's a lot easier for me
to follow, ‘the plan,’ versus somebody that doesn't take that time
and build in the good habits and try to push away the bad habits.
Because eventually those, eventually thosedsome of those, if
not all of those, bad habits will come back to haunt you.” Diana
Awareness of eating. Attending to physical needs and developing
new strategies and relationships to food required that participants
increase self-awareness of thoughts and behaviors. Participants
often stated, “I never paid attention” to food choices, eating behaviors, or quantity consumed prior to surgery. Paradoxically, participants also recalled that food was a “constant thought process” or
an “obsession;” several stated “food ruled my world.” After surgery,
participants no longer wanted their lives to “revolve around food.”
Some credited lack of hunger, which caused them to “forget to eat,”
others believed this change was a direct result of the surgery:
“It happened when the surgery happened and so I am more
conscientious of things yes, because I have to be. Um, but it was
like the surgery, the surgery did it, and I don't know if it is
because they were slicing and dicing in there and that, that
changed my receptors or whatever, I don't know, but I do not
obsess about food any more like I used to.” Dana
During the Honeymoon period, and particularly during the
Retraining dietary management phase, all participants monitored
everything they ate and drank, to ensure “I'm doing what I'm
supposed to.” They were “strict,” following diet progression
guidelines, weighing and measuring food, avoiding high calorie
foods, and timing their meals and drinks. Even as they developed
strategies and habits, participants believed they had to “constantly
think about food” or “be aware of everything I eat” in order to
manage weight and physical needs. This included planning meals,
tracking intake over the course of the day, and maintaining
awareness of eating motives. While requiring a great deal of mental
effort, most participants accepted it as “what I have to do to make
this work.” Table 3 depicts the six components of dietary management and how these components change over the course of the
weight management periods.
3.5. Explanations for weight maintenance and regain
Surgery is a tool. Regardless of their weight outcome trajectory,
participants all believed that unwanted weight regain occurred
when individuals did not want to put effort into dietary management. Surgery was viewed as a “tool” that only worked if individuals had the “will to work with it.” Explanations for regain
among the Regainers centered on the fact they had wanted the
surgery to “do all the work,” and were not “believers” that they
would be able to “gain it all back.” They recognized they had the
tool of surgery, but struggled to use the “tools” once hunger and
their ability to eat returned.
“Surgery is a tool. It's not like a, it doesn't ﬁx what, you know,
what made you, what brought you to these habits … I get full. I
get sick on certain things. I get full fast. You know, if I would just
like listen to those … you know, it's like shouting out, “[Courtney] stop!” You know if I would listen to those things, it would
work just ﬁne, you know? But I don't.” Courtney
Follow the rules. Participants consistently stated “you have to
follow the rules” or “you will fail at this surgery.” Participants
especially emphasized the importance of following the rules during
the Honeymoon period, while weight loss was easy, hunger was
reduced, and fullness was immediate and intense. Rules for success
varied among participants, but centered on maintaining structured
meal and snack patterns, eating protein ﬁrst, avoiding carbohydrates and high sugar foods, chewing food well, enacting portion
control, and not drinking while eating. Over time, participants
became more ﬂexible about some rules, particularly portion control
methods and foods to avoid; those in the Regained/Losing group
reported more lapses in their use of these strategies. When some
participants noticed weight regain they “went back” to stricter
levels of control or monitoring to offset regains, reactions not
mentioned by those in the Regained trajectory.
Vigilance. Three Maintainers were concerned that recent episodes of emotional eating or grazing might lead to future weight
regain and were taking preventative measures. They, like the rest of
the participants, emphasized the danger of reverting back to old
habits. Statements such as “You can't let your guard down,” “You
have to keep on top of it,” and “I have to watch myself for the rest of
my life,” were used to describe the belief that old habits did not “go
away” with the surgery.
“The things that brought you to weight loss surgery could do it
again. And we all ﬁght this, we all ﬁght. It's hard. You know, not
going to old habits. And I'm three years out.” Trevor
Participants explained that remaining “vigilant” was often
challenged by life circumstances that caused them to “lapse” into
behaviors that might (or did) result in weight gain. Deaths of family
members and getting married were two life events participants
related to a recurrence of emotional eating or a change in their
newly established eating patterns. Other life stressors included
marital problems, stress at work, holidays, and depression. Maintaining new dietary behaviors in spite of pressures from everyday
life was viewed as an important aspect of weight management
during the Work Begins period.
Long-term weight outcome trajectories. When examining the
long-term weight outcome trajectories of Maintaining, Regained/
Losing, and Regained, similarities and differences emerged. In
general, those in the Regained trajectory had not managed to
develop or maintain new relationships to food or new eating habits,
and they struggled with returning old habits. In addition, they
A. Lynch / Social Science & Medicine 151 (2016) 241e249
Changes in components of dietary management over the course of the three periods of weight loss.
Period of weight loss
Component of Before surgery
Physical needs Few physical needs attended to
Intolerances and taste/texture aversions; learning to
handle smaller stomach; trial and error eating
Rarely full or always hungry; eat beyond No desire to eat; lack of hunger; early satiety
point of fullness; ignore hunger or
Food as a “friend” or comfort; emotional Adopt a new relationship with food; deal with emotional
eating, “live to eat”
eating causes, “food is not a friend,” “eat to live”
Intolerances and aversions continue but no longer
unexpected; nutrient deﬁciencies surface
Hunger for some, fullness persists but is less intense;
desire to eat & appetite return
Maintain new view of food and new relationship with
food; work on emotional eating; for some return to
Strategy use primarily when dieting
Strategies based on post-operative counseling, managing Continue to follow “ the plan” and strategies; or, be
other aspect of eating; follow “the plan,” trial and error come more “lax” or abandon altogether
eating and retraining
Habitual overeating, habitual food
Begin repetition of certain behaviors, develop routines to Maintain new habits, continue to avoid old habits, or
choices, or no habits
make eating easier; work on extinguishing bad habits
go back to old habits
Become aware of eating, food choices; paying attention, High awareness continues or become less mindful
Rarely thought about food type or
quantity unless dieting; either deprived monitoring
or never controlled
experienced more hunger, less response to fullness, and did not
have daily eating structures that worked for them. Those in the
Maintaining and Regained/Losing trajectories had similar descriptions of their relationships to food, tailored their strategies and
habits, and maintained vigilance, acting on noticeable weight or
behavior changes. Differences between Maintaining and Regained/
Losing trajectories were mainly in the experiences of challenges to
the new eating habits, life stressors, and relationships to food.
Table 4 summarizes the components of dietary management for
each long-term weight outcome trajectory. As those in the Losing
trajectory were still developing dietary strategies and habits, they
were not included in the table.
This study aimed to gain conceptual understanding of gastric
bypass patients' construction of dietary behaviors related to weight
management using qualitative methods and a constructivist
approach. The researchers applied the life-course concept
(Wethington, 2005) to yield theoretical weight-loss outcome trajectories of gastric bypass patients that included weight management periods and phases of dietary management. Viewing gastric
bypass surgery as having weight outcome trajectories rather than a
ﬁxed weight at one point in time recognizes the individual and
dynamic nature of the patient experience, which may be a more
realistic way of viewing bariatric surgery outcomes than is
currently practiced. Most studies deﬁne weight loss success (arbitrarily) as a percentage of excess weight lost or a percentage of
weight lost kept off, as measured at a single point in time; participants below the cut-offs are considered failures. These static definitions may not accurately reﬂect the ups and downs of weight
management, nor do the averages or regression lines represent the
variety of potential outcomes. Instead, weight outcome trajectories
offer a ﬂexible and multidimensional way of portraying the process
of weight loss, capturing changes, and providing a way to identify
subtle changes that may signal unwanted weight regain.
The dietary management phases and components identiﬁed in
this study support the concept of an actively constructed personal
food system in the Food Choice Process Model (Sobal and Bisogni,
2009). The sequence of dietary management phases from Trial
and Error through Making it Work, provides support for a person's
intentional and individualized construction of beliefs and cognitive
processes for food decisions. The long-term experiences of gastric
bypass patients provides a unique context from which to examine
these processes, as these patients had to develop a whole new way
of thinking about and interacting with food in a comparatively
short period of time.
An interesting paradox that emerged was the discordant ways of
Summary of components of dietary management by type of weight outcome trajectory among participants 15 months or more post-surgery.
Weight outcome trajectories
Individual intolerances, taste and texture preferences, blood sugar management, nutritional deﬁciencies
Individual variations; hunger signals mainly low Individual variations; increased incidence of wanting Hunger between meals; do not eat only
when hungry; fullness short-lived; eat
to eat when not hungry; pay attention to fullness
energy; little desire to eat; do not eat beyond
Relationship with New relationship; “food is not my friend,” “food Aware of new vs old relationship with food; struggle Retain pre-surgery emotional relationship as
doesn't control me”
to maintain new relationship and develop strategies “friend,” “comfort,” “coping”
Strategies developed and consistently employed Strategies reﬁned, consistent enactment with some Few new strategies for weight loss
lapses in “compliance”
maintenance developed or consistently
Habit formation Strategies becoming habits
“Old habits” return and must be managed; most new Many pre-surgery habits returned, few posthabits maintained
surgery habits maintained
High awareness behaviors and weight
Awareness of eating behaviors, increased awareness Less aware of portion sizes, weight changes
of certain weight promoting behaviors
or eating behaviors
A. Lynch / Social Science & Medicine 151 (2016) 241e249
viewing pre- and post-surgery cognitive efforts devoted to thinking
about food. Participants' lives “revolved” around food prior to surgery. After surgery, participants also always thought about food and
eating. This was not what many expected, but was deemed
necessary. The difference in perceiving this cognitive effort as
positive or negative seemed to be related to whether participants
felt in control of the thoughts and actions related to food and
eating, or whether they felt controlled by the food. This was reﬂected in participants' shifting from “living to eat” to “eating to
live.” Ogden et al. (2006) found a similar paradox in their study,
with patients describing preoccupation with food prior to surgery
and a renewed sense of control over eating and their relationship to
food following surgery. This phenomenon deserves more attention
both in the areas of bariatric surgery and obesity. The inability to
fully transition the relationship to food or a subsequent loss of
control over the relationship may explain weight regain after bariatric surgery and more traditional weight loss efforts.
These ﬁndings add to a growing amount of literature on the
post-surgical dietary and weight loss experiences of gastric bypass
surgery patients. Sutton et al. (2009) described the post-surgery
dietary change process in 14 women in discrete stages (e.g. “immediate post-surgical period”, “the ﬁrst 6 months”). They described
immediate changes in hunger, decreased desire for food, and a
changing relationship with food during the ﬁrst 6 months. The
present study adds additional explanations for longer-term dietary
changes, such as habit development and the need to remain vigilant regarding dietary behaviors leading to weight regain. The
current study found similar themes of emotional eating, relationship to food, awareness, and avoiding old habits that have been
described previously (Benson-Davies et al., 2013; Bocchieri et al.,
2002; Ogden et al., 2006; Wood and Ogden, 2015). This speaks to
the idea that there may be commonalities in the way humans relate
to food and emotion and that these are difﬁcult to change and
manage. All of these investigations were conducted in different
countries with relatively small samples (ranging from 10 to 24), and
all (including the current one) emphasize the need to effectively
manage the cognitive and emotional dimensions of eating.
Regardless of their weight outcome trajectory, participants
consistently labeled surgery as a “tool” not a “cure.” This provides
further insight into the complexity of maintaining behavior
changes after surgery, as half the participants struggled at some
point post-surgery with their weight. Typical weight loss and
regain after gastric bypass surgery vary among studies with ﬁndings including regains ranging from 5% to over 50% of weight lost
(Courcoulas et al., 2013) to an average regain of 23% (Cooper et al.,
2015). The average BMI of the participants in this study, 32 kg/m2, is
also typical (O'Brien et al., 2006), thus the weight loss and weight
regain reported by patients in this study are comparable to the
Compared to the other groups, those who regained weight
described a return to old habits (e.g. grazing, lack of awareness of
portion sizes) and emotional eating and less success in maintaining
strategies or awareness of behaviors. The small sample size and
subjective nature of qualitative data analysis in this study prevent a
conclusion about the role these differences play in explaining
successful weight loss maintenance. Grazing and lack of awareness
of portion sizes or behaviors have been linked to weight regain
(Colles et al., 2008; Kofman et al., 2010) and emotional eating has
been found to negatively affect weight loss (Canetti et al., 2009).
Future investigations should focus on ways to identify who is at risk
for relapsing into behaviors such as emotional eating and grazing
and identify methods to combat these behaviors.
Limitations. This study's ﬁndings were based on participants'
self-reports of weight, thoughts, feelings, and actions. Their retrospective reports may have been selective or different than their
actual experiences and interpretations at the time, including their
reports of weight. However, participants' detailed descriptions and
commonality of distinct periods and phases across their reports
lends credence to this conceptualization. This analysis focused on
patients' constructions of dietary management across the phases of
their weight outcome trajectories. Other factors, such as physical
activity and social support, were likely involved. This study should
be followed with prospective studies that collect actual weight data
over time along with detailed data about dietary management and
This analysis is based on a small, purposively sampled group of
gastric bypass patients in one geographical region who were
accessible through support groups and interested in participating.
The ﬁndings cannot be extended beyond these participants; other
patients in different regions or who received care through a bariatric surgery center instead of a local hospital, may have different
experiences that were not captured here. Finally, the collection and
analysis of qualitative data was subject to the interpretations of the
researchers who brought their own perspectives to the study.
Though the researchers took careful steps to enhance the quality of
the data collection and analysis, other researchers may have elicited different perspectives from participants and/or interpreted
their descriptions in different ways.
In undergoing gastric bypass surgery, people embark upon a
dynamic and challenging path as they experience transitions with
weight and adjustments with how they manage food and eating.
This study emphasized the complex cognitive and behavioral aspects of dietary management and weight transitions as patients
adapt to the dynamic nature of this experience. Weight regain after
gastric bypass surgery is not simply a matter of non-compliance,
nor is weight maintenance simply occurring due to forced
changes of the surgery. Additional research is needed to further
understand how these transitions relate to long-term weight outcomes and how health professionals can better guide patients
through these experiences towards their goal of permanent weight
The author would like to acknowledge Dr. Carole Bisogni for her
assistance and guidance in data interpretation and in the writing of
The author would like to acknowledge Division of Nutritional
Sciences at Cornell University as the funding source.
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