Introduction

The World Health Organization [1] estimates that by 2025, around 167 million individuals, both adults and children, will experience declining health due to being overweight or obese. The highest rates have been reported in the Middle East and North Africa; for instance, in Saudi Arabia, about 70% of both genders are classified as overweight, and 35% are considered obese [1]. According to the survey executed by Al-Enazi and Al-Falah [2], Metabolic and Bariatric Surgery (MBS) is gaining popularity in Saudi Arabia. MBSis more effective than dietary changes for maintaining long-term weight reduction and enhancing general wellbeing and quality of life (QoL). The amount of weight lost following MBS differs from person to person. After reaching their minimum weight, the majority of patients tend to gain some weight [3–6]. According to previous research, the occurrence of weight regain in the bariatric population varies greatly. While other research findings, documented that 20–24% of patient populations have acquired back more than 15% of their body mass 5 years after gastric bypass or sleeve gastrectomy [7]; the Longitudinal Assessment of Metabolic and Bariatric Surgery research (LABS) demonstrates an average weight regain of about 4% of their body mass 3–7 years after surgery [8]. Whereas a distinction for measuring weight regain and identification of prevalence of re-occurrence is difficult to estimate [9,10]. Additionally, around 20% to 35% of patients encounter weight regain, influenced by factors such as surgical approaches and the time frame after surgery. Analysis following the nadir point demonstrated that this weight regain substantially affects the worsening of related health conditions, including hypertension and dyslipidemia when the greatest weight loss surpasses 20%, and diabetes when it exceeds 25% [11]. Furthermore, several elements contribute to post-operative weight outcomes and appetite control including heredities, a boost in gut hormones, i.e., glucagon-like-peptide-1 (GLP-1) and peptide YY (PYY), as well as a reduction in ghrelin secretion. Lost weight may be recovered due to post-bariatric hypoglycemia or anatomical failure associated with surgical operations like gastro-gastric fistula or dilated gastric pouch. Moreover, an inadequate diet, mental instability, hyperplasia, substance use, sedentary life and poor nutritional maintenance could stimulate weight regain after MBS [12]. Additionally, weight regain has been associated with several factors, including preoperative Body Mass Index (BMI). Heavier individuals tend to exhibit lower percentages of initial and excess weight loss, regardless of whether their BMI is above or below 60 kg/m². This effect was particularly noticeable after the initial 12-month rapid weight loss phase, during which less obese individuals (BMI < 50) continued to lose weight, while those with a higher BMI (BMI ≥ 50) experienced significant weight regain [13]. In addition to gender, advanced age, existing co-morbidities, as well as consistency and intensity of post-surgery follow-up [14–16]. Numerous studies have proposed medical, socio-demographic, and psychosocial factors to effect weight loss after MBS. Furthermore, the type of operation and procedure selected must be personalized for each patient based on their unique circumstances, which include, but are not limited to, BMI, medical considerations, and the presence of comorbidities [9,11,17].

A qualitative study shows that after surgery, patients either enjoy long-standing benefits of their surgery even after 10 years, or face difficulties in controlling their weight. Some patients dread regaining weight and usually view it as an individual setback [18]. Weight regain has proven to be a complex phenomenon. In order to provide adequate support to these patients, it is essential to understand the reasons and mechanisms behind weight regain, as well as the challenges associated with weight management after MBS. Therefore, conducting a qualitative research on patients’ insights may help identify the barriers and facilitators involved in this process. Consequently, this study aims to address the following question: “What factors do patients perceive as influencing weight regain after MBS?”

Methods

Findings and results

The objective of this qualitative study was to identify relationships that contest, complement, and develop each other through a series of interviews. The thematic categorization maintains its validity since the specified categories are founded on a framework that is consistent with the viewpoints of the participants.

Sociodemographic characteristics

The sample of this study was made up of 18 patients with a mean age of 32.78, who have undergone MBS, where, 6 (33.3%) of them were males, while 12 (66.7%) were females. 15 (83.3%) where the majority were university degree holder and employed (Table 1).

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Table 1. Patient characteristics.

https://doi.org/10.1371/journal.pone.0340120.t001

Discussion

This is the first qualitative research in Saudi Arabia to investigate the perspectives of these patients. Dietary patterns in Saudi Arabia have been moving towards a Western-style diet that is rich in fat, salt, and sugar, resulting in an increased obesity rate [21,22]. Social interaction in Saudi culture is based on food serving and food themes as gatherings, wedding celebrations revolve around food preparation and high-calorie food serving [21,22].

Five themes have resulted from the thematic analysis in this study, focusing on the lack of support, effect of emotional concerns, social influence, reduced physical activity, and economic challenges on weight regain after MBS.

The respondents had anticipated that having surgery would provide them long-term and control over their diet and weight. Patients anticipate that MBS would put an end to their battles with food and obesity. In this study, loss of control took the place of the early emotions of assurance and changes in dietary practices [23]. Respondents hypothesized that failure to follow dietary advice led to a decrease in managing their weight. Lack of dietary compliance, as seen by increased carbohydrate intake, higher fat consumption found in street food, and inferior nutritional quality, was found to be a major factor in weight gain after the recuperation from bariatric surgery. This was associated with economic challenges that the participants faced in obtaining more healthy and appropriate ingredients. Previous research has shown that variations in dietary compliance during the post-operative period may be linked to weight regaining in individuals who have undergone MBS [24]. The most obvious dietary factor linked to weight increase seems to be an increased carbohydrate intake. Although the origin of the carbs was not precisely characterized in all research, some have shown that a rise in the consumption of fluid calories and glucose from sources other than food were related to weight regain [25].

The participants in this study have reported episodes of binge eating due to stress and emotional distress after non-compliance. The feeling of “a twofold defeat”, originally being unable to sustain a healthy weight and then failing to attain a satisfactory post-operative outcome, exacerbated the psychological suffering that respondents felt after weight regaining. The guilt that individuals felt as a result of social weight stigma may have influenced ineffective coping mechanisms, including emotional eating, grazing, or limited eating, which are per research that links weight regain to unhealthy eating habits [26,27]. Instilled weight stigma and additional weight control challenges have been linked to poor self-esteem, unhealthy eating habits, drug use, and generalized poorer psychological adjustment. Even though bingeing or depressive symptoms appear to lessen following operation, our study found that issues with eating patterns and psychological health issues are the main causes of weight increase [28].

Due to the gastric constriction caused by bariatric surgery, an individual’s caloric intake increases through the ingestion of higher calorie-dense meals, fluids, or more meals that are regular. This illustrates that food patterns change gradually following bariatric operations instead of being constant, and some individuals might not be aware of the implications this will have on their long-term prognosis. In order to discover answers and solutions to the obstacles to sustaining compliance with dietary guidelines, individuals will likely need the continuing guidance and supervision of nutritionists and their bariatric team. Consequently, MBS by itself is not beneficial in the long run [29].

This false belief has been reflected by the testimonies of the participants, who they relied on the surgery, did not comply with the dietary guidelines, and did not engage in physical exercise. Surgery to lose weight may significantly increase movement and lessen the effects of osteoarthritis [30]. Individuals who are obese frequently claim having more physical activity than they actually do, as has already been shown in the literature [31]. A study found that only about 50 percent of patients committed average to intense exercise for some more than one period per week, which is lesser than the exercise of people in the overall similar demographic [32]. This is despite the fact that 89% of clients self-reported being consistently active at two years following surgery. Additionally, according to activity tracker measurements, only 11%16 of patients who have undergone MBSreally walk 10,000 steps each day, relative to 35%43 of the overall population. There are few studies on the relationship between physical exercise and weight gain, with the majority of publications citing that “reduced energy spending” was linked to obesity, despite the fact that there have been several studies on the influence of exercise on post-operative MBS results [33]. Additionally, it has been asserted that the recommended levels of exercise may be insufficient to avoid long-term weight retention following bariatric surgery. Nevertheless, it has been found that MBS patients are less physically engaged on a daily routine while having similar patterns of moderate to intense physical exercise to the general public [5].

Moreover, the participants in this study have reported lack of support from their family on top of the economic and work-related challenges, which have hindered their compliance with dietary instructions, and consequently weight regain. Recommendations for post-operative follow-up treatment with a bariatric crew have been developed by the American Society for MBS (ASMBS), which highlights the significance of follow-up management on a client’s development and results. Follow-up management assists in monitoring the patient’s development, ensuring that they listen to the advice of their medical provider, and providing tips for maintaining their weight and behavior [34]. Based on previous study, given that 50% of individuals who undergo MBS regain weight during two years following their procedure, it is not unexpected that 60% of these individuals did not obtain routine nutritional follow-up and 80% could not seek mental follow-up. In comparison, individuals who completed all of their post-surgical follow-up appointments were more effective in the longer run. In comparison to a client who was abandoned follow-up during the first year of the operation, follow-up sustained for a maximum of three years post-surgery led to an 18% greater weight reduction [35]. This finding may suggest a beneficial relationship between extended follow-up durations and enhanced health results. Following bariatric operations, the effects of support have been well researched, as shown by a number of comprehensive studies on the topic. Healthy familial, social, and medical bariatric support were found to be essential in ensuring long-term post-operative satisfaction from the client’s point of view. This provides crucial information into the viewpoints of the participants and the three main pillars thought to be essential to improve their long-term results [36]. According to these findings, a patient’s doctor and interpersonal circle, which may comprise family and friends, should urge them to attend follow-up visits and, preferably, be accompanied by those people. Encouraging the clients’ support networks to follow-up consultations could motivate them to sustain regular communication with one‘s post-operative team and also represent a reminder to clients of the favorable measures and habits addressed during discussions, which is helpful given that patients typically miss the details they have been instructed before surgery, which even farther exacerbates at one year after surgery [26].

Conclusion and recommendations

Following MBS, weight restoration was viewed as an unanticipated and challenging event that led to feelings of frustration, embarrassment, and dissatisfaction. Our findings suggest that factors both intrinsic and extrinsic, such as economic challenges, changes in hunger, lack of support and issues with physiological and psychological health, may play a role in the deterioration of weight management. Long-term post-surgical weight control may be facilitated by interpersonal support, self-care, and lifestyle measures. The results of this qualitative investigation may serve as a hypothesis starter for subsequent quantitative research.

Despite being successful, weight regain can still happen following MBS. In order to promote long-term weight loss sustainability, the results of this paper reinforce the idea that persons who have had MBS ought to be educated of the controllable variables linked with weight rebound. The avoidance of long-term weight rebound depends on frequent, systematic, and long-term follow-up with the bariatric specialists. Inadequate dietary compliance, behavioral problems, and lack of physical activity that affect long-term weight results can all be quickly addressed with follow-up care. Future studies should establish acceptable assessments and instruments that have been verified in the bariatric community as well as a consistent concept and standard for measuring weight regain following bariatric operation. In order to give healthcare workers a better comprehension of the kinds of food items to recommend limiting and the kinds of activities to enhance, future studies should also recognize the precise foods, eating regularity, and kind of physical exercise that may be most pertinent to individuals who have had bariatric surgical procedure. Finally, psychosocial assessments should be regularly applied to enhance the involvement of the social circle in the patients’ treatment.

Supporting information

Acknowledgments

The authors express their gratitude to Princess Nourah Bint Abdulrahman University Researchers Supporting Project number (PNURSP2026R386), Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia. The authors acknowledge the funding from the Deanship of Scientific Research at Zarqa University, Jordan