The results pointed out that eating behavior, QOL and weight regain were interconnected in the women studied. Weight stabilization is expected to occur between 12 and 18 months after surgery, and it is natural that there is a recovery of part of the lost weight [14, 15]. However, more than half of the sample presented weight regain, with the average proportion of this regain greater than 20%, which is considered significant in Brazilian studies [5, 16].
Emotional eating was the most present and it was also the highest score in the group without regain. When comparing the score of eating patterns between groups based on weight regain, there was no difference between them, as showed in the study by Silva et al. [5], performed with 80 patients after 24 months of RYGB. A hypothesis that needs to be tested in future studies is the possibility of cognitive restriction could do the individual vulnerable to emotional eating behavior [13], which demonstrates the relationship between the domains, in which one dysfunctional behavior can lead to another, explaining even the highest cognitive restriction scores and emotional eating found in the group with no weight regain in the present study.
There was a significant correlation between weight regain and uncontrolled eating. Some studies did not find these results [17, 18], though, they were carried out up to 2 years after BS. Engström et al. [12], on the other hand, found that the group with uncontrolled eating had a reduction in emotional eating 1 year after BS, but in 2 years it returned to the same level as the preoperative period. The group that did not present uncontrolled eating had a reduction, over two years, of emotional eating and increased cognitive restriction. There is still no single pattern of eating behavior in patients who underwent BS, which suggests the need for further studies, especially with a qualitative methodology.
Functional capacity and limitation due to physical aspects were the domains of QOL with the highest scores, indicating a better function on these aspects by the participants. Other studie suggested that BS is able to improve the perception of QOL in the individual, since the significant reduction in weight allows achievements both in the physical and emotional spheres that were previously made impossible by overweight [12, 19, 20].
Women without weight regain had higher scores on physical components in general, functional capacity, limitation due to physical aspects and social aspects. This result is in line with that of Perdue et al. [21], that the differences in SF-36 were significant in the domains of vitality, mental health and summary of emotional components, all of which were smaller in women who still considered themselves obese, which may mean that BS and weight loss as a result of it are processes that are too fast for the brain and they have an identification of themselves as obese even if the body no longer corresponds to this.
It was observed that pain was the domain with the lowest score, demonstrating impairment of activities due to pain. The study by Høgestøl et al. [22] found that a considerable part of the patients who underwent RYGB after 5 years of the surgery still had abdominal pain and this interfered with the perception of QOL. In the study by Laurino Neto and Herbella [23], using the SF-36, it was found that in the short-term postoperative period there was an improvement in pain, however, in 7 years the score for this domain decreased again. The authors list the possible explanations: weight regain, aging and presence or recurrence of comorbidities.
The time of surgery was correlated to weight regain increases, decreasing the excess weight loss and the perception of QOL. After all, the more weight the person regains, the more difficulties are reported. The relationship between time of surgery and weight loss was also found in a survey that evaluated 50 adults (72.5% women) in 1 and 5 years after sleeve and found a significant weight regain average in the fifth postoperative year when compared to the first year, in which the average % EWL decreased [24].
There are many factors that work simultaneously influencing weight loss and maintaining the success of BS [25]. In the first 2 years after BS, the patient is more likely to follow nutritional recommendations, the reduction in the amount of food eaten is greatly influenced by anatomy and physiological changes, there is an increase in the feeling of well-being and a decrease in possible psychopathologies. Nonetheless, after this period, new changes in behavior occur, with a tendency to recover lost weight [15, 16]. That is, the time of surgery and the poor quality of food can be predictive factors for regain after 24 months of surgery [5, 26], though they can also influence weight regain a practice of physical activities and anatomy and physiological changes [5], besides psychological, metabolic, hormonal issues and even complications arising from the surgical procedure [27]. The study by Rocha, Hociko and Oliveira [16] found that the factors most associated with regaining weight were inadequate nutrition, lack of physical activity and lack of nutritional monitoring in the postoperative period.
The increase in lack of control eating seems to increase weight regain and to decrease the perception of QOL components. Devlin et al. [7] found that the lack of eating control was associated with lower weight loss and long-term weight regain (7 years) in people undergoing RYGB, which could compromise the results of the surgery. Wiedemann, Ivezaj, and Grilo [28] pointed out that the presence of uncontrolled eating and emotional eating may be predictors of worse results related to postoperative weight, though, the instrument used by them was not the TFEQ-21 and they analyzed only patients submitted to the sleeve less than one year after the surgery.
There was also an inverse relationship between weight regain and the perception of physical components of QOL. In a systematic review and meta-analysis including 82 studies in which QOL was analyzed (the most used was SF-36) before and after BS, inverse and significant relationships were found between BMI and QOL [29]. This result reinforces that even with improvements, the mental / social components are always below the physical components. Probably the improvement in QOL occurs due to weight reduction and remission of associated diseases.
This study has limitations such as the small sample size, the lack of a specific questionnaire for the targeted public and also the failure to monitor the women studied. Therefore, it is not possible to generalize these results. Despite the limitations, the study is relevant to contribute scientifically to the understanding of the processes that permeate weight regain and eating pattern in women submitted to long-term BS and the influence on their QOL.