The Effect of Mediterranean Diet Adherence and Physical Activity Level on Weight Loss after Laparoscopic Sleeve Gastrectomy

The Effect of Mediterranean Diet Adherence and Physical Activity Level on Weight Loss after Laparoscopic Sleeve Gastrectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Mediterranean Diet Adherence and Physical Activity Level on Weight Loss after Laparoscopic Sleeve Gastrectomy Havva BOZDEMİR, Esra USTA, Mevlüt PEHLİVAN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7176825/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Oct, 2025 Read the published version in Obesity Surgery → Version 1 posted 12 You are reading this latest preprint version Abstract Background Metabolic bariatric surgery is an effective method in the treatment of severe obesity; long-term weight loss success depends on the extent to which patients adapt to lifestyle changes. Mediterranean diet and physical activity are important lifestyle components for sustainable weight control. This study examines the effect of adherence to the Mediterranean diet and physical activity levels on weight loss in patients in the second year follow-up after Laparoscopic Sleeve Gastrectomy (LSG). Methods This cross-sectional and analytical study included 97 patients who underwent LSG surgery at a university hospital in Türkiye and reached the 24th-month follow-up. Data were collected using the Mediterranean Diet Adherence Screener (MEDAS) and the International Physical Activity Questionnaire-Short Form (IPAQ-SF). Weight loss efficiency was evaluated using percentage of excess weight loss (EWL%), total weight loss (TWL%), and body mass index (BMI). Results 60.8% of the participants had moderate-high adherence to the Mediterranean diet, and 18.6% had adequate physical activity levels. The EWL% and TWL% values of those with moderate-high adherence to the Mediterranean diet were statistically significantly higher at 3, 6 and 24 months (p < 0.01). The effect of physical activity level on TWL% was significant at 18th and 24th months. The rate of weight regain in the 18–24 months period was 26.8% and this rate was associated with low dietary adherence and physical inactivity. Conclusion Adherence to the Mediterranean diet and physical activity are determining factors in the maintenance of weight loss after LSG. A multidisciplinary, patient-centered case management approach may enhance long-term outcomes. Sleeve gastrectomy Mediterranean diet physical activity metabolic bariatric surgery weight loss multidisciplinary care Figures Figure 1 Figure 2 Figure 3 Highlights • Moderate-high adherence to the Mediterranean diet significantly increases postoperative weight loss. • Physical activity level gains importance in weight loss sustainability after 18 months. • At 24 months, the rate of weight regain was 26.8% and was associated with low dietary adherence and physical inactivity. Introduction Obesity is a global health concern, driven by its rapidly increasing prevalence and associated medical problems. Worldwide, adult obesity has more than doubled and adolescent obesity has quadrupled since 1990. According to World Health Organization data for 2022, 43% of adults are reported to be overweight and 16% have obesity problems ( 1 ). Metabolic bariatric surgery is one of the surgical procedures considered as an effective alternative for weight loss when traditional treatments for obesity are inadequate ( 2 ). Restrictive, malabsorptive and combined interventions are applied in the surgical treatment of obesity. According to the data of the International Federation for the Surgery of Obesity and Metabolic Disorders 2021, LSG is the most commonly performed intervention with a rate of 58.2% among all bariatric procedures ( 3 , 4 ). LSG has an increasing popularity due to its safety, efficacy and simpler technique compared to other procedures. Metabolic bariatric surgery aims to improve quality of life by providing weight loss and improvement in associated medical problems. The low early mortality and morbidity rates of LSG are an important advantage ( 5 , 6 ). In addition, improvement in associated medical problems and a decrease in drug use have been reported in mid-term follow-up after LSG ( 7 ). Meta-analyses comparing weight loss outcomes of LSG and laparoscopic Roux-en-Y gastric bypass (LRYGB) surgeries indicate that short- and mid-term results are comparable or in favour of LRYGB, while long-term outcomes generally in favour of LRYGB ( 5 , 8 , 9 ). Following LSG, the mean EWL% at 12 months has been reported as 67% ( 10 ), while long-term follow-up over 10 years indicates a decrease to 58% ( 11 ). However, revision or modification surgery rates due to insufficient weight loss and weight regain after LSG are between 6% and 20% ( 12 – 14 ). The postoperative lifestyle—encompassing healthy eating, regular physical activity, and reduced sedentary behavior—is a key determinant not only of initial weight loss but also of its maintenance in the medium and long term. The Mediterranean diet is one of the most well-known healthy eating patterns, characterized by high consumption of fruits, vegetables, legumes, nuts, whole grains, and olive oil; moderate consumption of fish and poultry; and limited intake of red and processed meats, sugar-sweetened beverages, and processed foods ( 2 ). High adherence to the Mediterranean diet is widely acknowledged to provide cardiovascular and metabolic benefits, reduce the risk of cardiovascular diseases and obesity, and lower overall mortality rates ( 15 – 17 ). There are a limited number of studies examining the effects of the Mediterranean diet in obesity surgery patients. Evidence from previous studies suggests that individuals with higher adherence to the Mediterranean diet during both short- and long-term postoperative follow-up achieve more favorable outcomes in terms of weight loss, weight maintenance, and improvements in lipid profiles, compared to those with lower adherence ( 18 – 22 ). Another important factor to be considered in the evaluation of lifestyle is the level of physical activity. Physical activity is essential for achieving and maintaining weight loss after surgery, as well as for promoting a healthy body composition ( 23 ). Short- and long-term follow-up study results show that the percentage of excess weight loss, lean body mass ratio and quality of life increase significantly as the physical activity level increases ( 24 , 25 ). Moreover, long-term studies have reported that higher levels of moderate-to-vigorous physical activity and greater daily step counts are negatively associated with weight regain rates ( 25 ). The literature contains a limited number of studies investigating the impact of lifestyle factors—specifically adherence to the Mediterranean diet and physical activity—on weight loss outcomes following surgery in patients who underwent the same surgical procedure performed by the same surgeon. In this study, we evaluated the effects of adherence to the Mediterranean diet and physical activity levels on weight loss in patients followed for two years after LSG. Methods Methodology and setting This cross-sectional and analytical study was conducted in the general surgery clinic of a university hospital in Türkiye with patients who underwent LSG surgery by the same surgeon. A total of 115 LSG procedures were performed at the clinic between 2022 and 2023. We analyzed the medical records and included patients aged 18–65 who underwent their first LSG surgery. We excluded patients who underwent revision or modification surgery, had previous alternative obesity procedures, or were diagnosed with eating disorders. There were 113 patients who met the criteria. Using the Slovin formula via the Raosoft program, we calculated the sample size based on a population of 113 patients. Assuming a 95% confidence level and a 5% margin of error, the minimum required sample size was determined to be 88 patients. A final analytical sample consisting of 97 patients was formed after excluding patients who could not be reached due to changes in contact information and who did not accept to participate in the study. Surgical Technique and Patient Follow-up All procedures were completed by five trocar laparoscopy under general anesthesia. A 36 Fr spark plug was used to calibrate the stomach volume. The first stapler was placed approximately 4 cm proximal to the pylorus. Resection along the greater curvature was performed using a green (Ethicon Echelon Flex Endopath, 60 mm) cartridge for the antrum and a blue (Ethicon Echelon Flex Endopath, 60 mm) cartridge for the corpus and fundus. Bleeding foci seen on the stapler line were controlled with clips. The plunger was pulled to the oesophagogastric junction and approximately 100 cc of methylene blue and saline was injected into the stomach to check for leakage at the stapler line. After the trocars were removed, the incisions were sutured. The multidisciplinary team in the clinic consisted of a surgeon, assistant doctors, nurses, and a dietitian. All patients underwent LSG performed by the same surgeon using a standardized technique, and the perioperative care, including nursing and dietary counselling, was delivered uniformly across all cases. The standard care and follow-up protocol in the clinic is as follows: Patients with adequate fluid intake, good general condition and stable vital signs are discharged on the first postoperative day. Upon discharge, patients were provided with a standardized graded diet plan and were advised to engage in at least 30 minutes of physical activity per day. Patients were scheduled for follow-up visits at 1, 3, 6, 12, 18, and 24 months postoperatively. During each visit, anthropometric measurements were recorded, and patients were counselled to adhere to a personalized healthy diet and to engage in at least 30 minutes of physical activity daily. Data Collection Method and Tools After obtaining ethics committee approval and institutional permissions, we contacted patients by telephone 24 months after their LSG surgery. Researchers E.U. and H.B., both of whom hold doctorates in surgical nursing and have extensive experience in the care of bariatric surgery patients, conducted the interviews. During the interviews, the participants' socio-demographic characteristics and chronic disease status, Mediterranean Diet Adherence Screener (MEDAS) and International Physical Activity Questionnaire-Short Form (IPAQ-SF) questions were asked and the responses were recorded. The interviews lasted approximately 15–20 minutes. Mediterranean Diet Adherence Screener (MEDAS) The scale consisting of 14 questions was developed by Martínez-Gonzalez et al. (2012) in the PREDIMED study ( 26 ). Its validity and reliability for the Turkish population was performed by Özkan Pehlivanoğlu et al. (2020) and Cronbach’s alpha reliability coefficient was found to be 0.829 ( 27 ). Each item in the scale is scored 1 or 0. A score of 0–6 on the scale indicates non-compliance with the Mediterranean diet (low), 7–8 points indicate compliance (medium), 9–14 points indicate strict adherence (high). International Physical Activity Questionnaire-Short Form (IPAQ-SF) It was developed by Craig et al. in 2003 to determine the physical activity level of individuals ( 28 ). Its validity and reliability for the Turkish population was performed by Öztürk (2005) ( 29 ). It consists of seven questions in which the time spent by individuals in sitting, walking and moderate intensity activities in the last week is questioned. The MET score is obtained by multiplying each activity by minutes, days and Metabolic Equivalent (MET; multiples of oxygen consumption at rest). Standard MET values were created for the activities (walking = 3.3 MET, moderate physical activity = 4.0 MET, vigorous physical activity = 8.0 MET). Physical activity levels are determined by summing the MET scores for walking, moderate physical activity and vigorous physical activity. They are classified as physically inactive ( 3000 MET min/week). Anthropometric Parameters In the clinic, we measured patients' height without shoes using a stadiometer, and body weight using a body composition analyzer (Tanita BC-418 model). We evaluated the effectiveness of weight loss using the percentage of excess weight loss (EWL%) and total weight loss (TWL%). EWL% = (initial weight - final weight) / (initial weight - ideal weight) x 100, with the ideal weight defined by a BMI of 25 kg/m 2 , TWL% = (initial weight - final weight / initial weight) x 100 ( 30 ). Statistical Analysis The researcher coded the data and transferred them to a computer for analysis. IBM SPSS Statistics 21.0 (IBM Statistical Package for the Social Sciences) was used to perform the statistical evaluation. Continuous variables were indicated by mean ± standard deviation and categorical variables by numbers and percentages. Normality of data distribution was evaluated by Shapiro-Wilk test, skewness and kurtosis values (± 1). Independent samples t-test and one-way ANOVA were used to compare differences between groups. Changes in EWL% and TWL% over time, as well as whether these changes differed according to levels of diet adherence and physical activity, were tested using two-way repeated measures ANOVA (Mixed Design). Categorical variables related to weight regain status were compared by Pearson's chi-square test and Yates' chi-square test. Post hoc analyses were performed with the bonferroni method to determine which category was the source of the difference in the chi-square test. The results were statistically significant at the level of p < 0.05. Ethical Consent We obtained ethical approval for this study from the XXXXXX University Non-Interventional Ethics Committee (decision date: April 1, 2024, decision number: 2024/64). We conducted the research in line with the principles of the Declaration of Helsinki. All patients were first provided with detailed information about the study during the telephone interviews and were included in the study on a voluntary basis. Results The mean age of 97 patients was 36.84±9.24 years and 79.4% were female. The mean BMI of the preoperative patients was 45.53±6.39 kg/m 2 . At 24 months postoperatively, 60.8% of the patients had medium-high adherence to the Mediterranean diet (≥ 7) and 18.6% had adequate physical activity (Table 1). The mean BMI of patients with moderate-to-high adherence to the Mediterranean diet was significantly lower than that of patients with low adherence at all time points, except at month 18 (Figure 1a). In contrast, changes in mean BMI across physical activity levels were not statistically significant at any time point (Figure 1b). There was a difference between the groups in the mean EWL% according to the level of adherence to the Mediterranean diet ( F =9.830, p=0.002, η² =0.094). The mean EWL% of those with medium-high adherence to the Mediterranean diet was significantly higher than that of those with low adherence at 3 months (48.96±12.96 vs. 39.56±13.98, p= 0.001), 6 months (72.49±15.68 vs. 61.93±18.03, p=0.003) and 24 months (86.23±16.76 vs. 70.35±25.85, p<0.001). At 12 months (84.29±15.43 vs. 77.22±21.13, p=0.080) and 18 months (84.67±17.02 vs. 78.46±23.56, p=0.135), there was no significant difference between the groups in mean EWL% (Figure 2a). The main effect of time on EWL% was statistically significant ( F = 196.532, p < 0.001, η² = 0.674). In within-time comparisons, there were significant increases in the 3-6 months ( F = 360.87, p < 0.001, η² = 0.792), 6-12 months ( F = 145.27, p < 0.001, η² = 0.605) and 18-24 months ( F = 23.01, p < 0.001, η² = 0.195) periods. Moreover, the time × group interaction for the 18–24-month period was statistically significant (F = 50.087, p < 0.001, η² = 0.345). In contrast, no significant interaction was observed for the 12–18-month period ( F = 0.61, p = 0.437, η² = 0.006). Overall, the time × group interaction was not statistically significant across all time points ( F = 2.889, p = 0.066, η² = 0.030) (Table 2). The mean TWL% significantly differed between groups according to their level of adherence to the Mediterranean diet ( F =6.369, p=0.013, η² =0.063). The mean TWL% of those with medium-high adherence to the Mediterranean diet was significantly higher than that of those with low adherence at 3 months (20.77± 4.80 vs.17.51± 4.97, p=0.002), 6 months (30.59± 4.71 vs. 27.54± 6.57, p=0.009) and 24 months (36.85± 7.24vs. 31.67± 10.88, p=0.006). At 12 months (35.76± 5.04 vs. 34.24± 7.04, p=0.256) and 18 months (36.09± 6.93 vs. 35.03± 9.00, p=0.540), there was no significant difference between the groups in mean TWL% (Figure 2b). The main effect of time on TWL% was statistically significant ( F = 209.118, p< 0.001, η² = 0.688). Within-time comparisons revealed significant increases during 3-6 months ( F =370.964, p < 0.001, η² = 0.796), 6-12 months ( F =167.696, p < 0.001, η² = 0.638) and 18-24 months ( F = 21.487, p < 0.001, η² = 0.184) periods. Furthermore, the time × group interaction was statistically significant for the 18-24 months period ( F = 54.163, p < 0.001, η² = 0.363). However, overall, the time × group interaction across all time points did not reach statistical significance ( F = 2.909, p = 0.067, η² = 0.030) (Table 2). There was no difference between the groups in mean EWL% according to physical activity level ( F = 0.443, p = 0.644, η² = 0.009) (Figure 3a). Regardless of group differences, the temporal change in mean EWL% was statistically significant ( F = 180.478, p < 0.001, η² = 0.658). In within-time comparisons, significant increases were observed at 3-6 months ( F = 319.054, p < 0.001, η² = 0.772), 6-12 months ( F = 130.463, p < 0.001, η² = 0.581), 18-24 months ( F = 7.203, p = 0.009, η² = 0.071), whereas there was no significant difference between 12-18 months ( F = 1.985, p = 0.162, η² = 0.021). When considering all time points collectively, the time × group interaction was not statistically significant ( F = 1.193, p = 0.302, η² = 0.025) (Table 3). There was a significant difference in mean TWL% between groups according to physical activity level ( F = 4.505, p = 0.014, η² = 0.087). No significant differences were observed in TWL% measurements at 3 months ( F = 2.357, p = 0.100, η² = 0.048), 6 months ( F = 0.983, p = 0.378, η² = 0.020), and 12 months ( F = 3.042, p = 0.052, η² = 0.061). However, significant differences were found at 18 months ( F = 4.941, p = 0.009, η² = 0.095) and 24 months ( F = 3.910, p = 0.023, η² = 0.077). Post hoc analysis revealed that these differences favored the group with an adequate physical activity level (Figure 3b). The main effect of time on TWL% was statistically significant ( F = 197.857, p < 0.001, η² = 0.678). Within-time comparisons showed significant increases between 3 and 6 months ( F = 332.624, p < 0.001, η² = 0.780) and between 6 and 12 months ( F = 153.653, p < 0.001, η² = 0.620), as well as significant decreases between 18 and 24 months ( F = 5.885, p = 0.017, η² = 0.059). Overall, the time × group interaction did not reach statistical significance across all time points ( F = 1.684, p = 0.164, η² = 0.035) (Table 3). We found that 26.8% of the participants regained weight after the 18th month of surgery. 55.3% of those with low adherence to the Mediterranean diet and 42.4% of those who were inactive regained weight (Table 4). Discussion The efficacy of the Mediterranean diet and compliance with physical activity on weight loss in overweight and obesity problem populations has been demonstrated in large-sample longitudinal studies. However, a very limited number of efficacy studies have been conducted in patients undergoing bariatric surgery. In this study, approximately 61% of patients at the two-year follow-up after LSG demonstrated moderate-to-high adherence to the Mediterranean diet. Patients with moderate-to-high adherence achieved statistically and clinically significant greater weight loss at both early (first 6 months) and long-term (24 months) time points compared to those with low adherence. The positive impact of adherence to the Mediterranean diet on weight loss aligns with existing literature. A positive correlation has been reported between increased adherence to the Mediterranean diet and weight loss at 12 months post-bariatric surgery ( 18 , 20 ). Furthermore, patients with high adherence to the Mediterranean diet at 24 months demonstrate greater weight loss compared to those with moderate or low adherence ( 31 ). In a long-term (5-year follow-up) follow-up study in which different metabolic bariatric surgery interventions were evaluated together, it was reported that the total weight loss of those with high adherence to the Mediterranean diet was 54% and that of those with low adherence was 32%, regardless of the type of surgical intervention ( 32 ). In our study, the main effect of time on %EWL and %TWL was substantial, with significant weight loss observed during the first 12 months post-surgery. However, a slight but statistically significant decrease in %EWL and %TWL occurred between 18 and 24 months. Consistent with previous research, the first postoperative year represents the period of maximal weight loss, after which patients face the risk of a weight loss plateau or regain ( 33 , 34 ). Notably, weight loss over time plateaued and showed limited sustainability in the group with low adherence to the Mediterranean diet. The Mediterranean diet is known to support weight loss due to its low glycaemic index, rich fibre content, high fruit and vegetable content, restriction of sugar-sweetened beverages, high anti-oxidant and anti-inflammatory components ( 2 , 35 ). Moreover, the diet’s sustainability and potential for long-term adaptation due to its high cultural adaptation as a lifestyle make it stand out as one of the factors that reduce weight regain ( 2 , 22 ). Approximately half of the participants in the second year follow-up after LSG had minimal physical activity levels. Generally, metabolic bariatric surgery patients tend to be less active, and adherence to postoperative physical activity recommendations remains poor. Ouelette et al. (2020) reported no significant change in physical activity level 6 months after surgery compared to baseline in patients undergoing bariatric surgery ( 36 ). Objective assessments during the first postoperative year indicate that patients’ physical activity levels increased; however, the majority remained classified as having low physical activity ( 37 ). Analysis based on physical activity levels revealed a significant difference in weight loss at the 18- and 24-month follow-ups among individuals with adequate physical activity levels. In a retrospective study, it was reported that there was more weight loss and improvement in body composition in individuals who increased their physical activity level compared to the baseline level two years after surgery ( 24 ). Similarly, a meta-analysis evaluating the effectiveness of exercise programs in bariatric surgery patients emphasized that increased physical activity levels are associated with greater weight loss and fat mass reduction ( 38 ) In contrast to these results, Gils Contreras et al. (2021) reported no significant difference in weight loss at 12 months post-surgery between individuals who increased their physical activity levels compared to those who maintained or decreased their activity levels relative to baseline ( 18 ). There are no evidence-based physical activity guidelines specifically for bariatric surgery patients. However, to maintain weight loss, prevent lean body mass loss, and improve body composition and physical capacity, it is recommended that patients engage in moderate aerobic exercise and strength training 2–3 times per week, aiming for at least 150 minutes per week initially, with a goal of reaching 300 minutes per week postoperatively ( 39 ). The rate of weight regain in the 18–24 month time period after surgery was 26.8%. While similar weight regain rates at two years following LSG have been reported in the literature ( 40 ), some studies have reported lower rates ( 41 – 43 ). Adherence to the Mediterranean diet and being physically inactive were the factors that played a significant role in weight gain. Similarly, a study by Schiavo et al. (2020) found that one-third of the participants who regained weight ate less fruit and vegetables, more pasta, bread, rice and potatoes, and had low levels of physical activity ( 22 ). Differently, studies are reporting that only diet quality affects weight gain ( 44 ), sedentary time and low physical activity are effective in the long term ( 25 ). While the physiological effects of surgery play a decisive role in the early postoperative period following bariatric surgery, behavioral factors become increasingly influential in the long term. These behavioral factors include low physical activity, consumption of hyper caloric foods and sweets, limited intake of fruits and vegetables, poor diet quality, emotional eating, and loss of control during eating ( 45 ). Therefore, sustaining the positive outcomes of surgery necessitates promoting lifestyle changes that enhance adherence to healthy dietary patterns and physical activity. In conclusion, this study offers a comprehensive evaluation of the impact of Mediterranean diet adherence and physical activity levels on weight loss following LSG. The results demonstrated that individuals with moderate to high adherence to the Mediterranean diet achieved significantly greater %EWL and %TWL. While physical activity had a limited effect on weight loss during the first 12 months post-surgery, its influence became more pronounced from the 18th month onward. Notably, during the 18–24 month period, the effects of both Mediterranean diet adherence and physical activity were particularly evident, with weight regain risk becoming increasingly sensitive to these factors. These results suggest that not only surgical intervention but also healthy lifestyle habits are indispensable to maintain long-term success after LSG. Encouraging patients to embrace a healthy lifestyle necessitates their active participation throughout the entire preoperative and postoperative process. Continuous engagement with a multidisciplinary healthcare team is essential. Nutritional counselling aimed at promoting adherence to the Mediterranean diet, and individual programs to promote physical activity should be integrated into interdisciplinary follow-up protocols. Adopting a patient-centered care approach is crucial to identify the biopsychosocial needs of each patient, tailor individualized care plans, and ensure coordination and continuity throughout the perioperative period and beyond. Given that multidisciplinary teams comprise health professionals with diverse objectives, implementing a case management approach—where specialist nurses serve as coordinators—may enhance team communication, cooperation, and overall care effectiveness. Limitations Our study has some limitations. First of all, the fact that the majority of the sample consisted of women reduces the power to represent the whole population. Only body weight values of the patients were analysed. The change of physical activity in body composition (muscle ratio, fat ratio, etc.) was not analysed. However, this study is the first study in our country to investigate the effect of adherence to the Mediterranean diet and physical activity level on weight loss and its sustainability in a sample of patients who underwent LSG and completed the 24th month. 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Romagna EC, Lopes KG, Mattos DMF, Farinatti P, Kraemer-Aguiar LG. Physical Activity Level, Sedentary Time, and Weight Regain After Bariatric Surgery in Patients Without Regular Medical Follow-up: a Cross-Sectional Study. Obes Surg. 2021;31(4):1705–13. Martinez-Gonzalez MA, Corella D, Salas-Salvado J, Ros E, Covas MI, Fiol M, et al. Cohort Profile: Design and methods of the PREDIMED study. Int J Epidemiol. 2012;41(2):377–85. Özkan Pehlivanoğlu EF, Balcıoğlu H, Ünlüoğlu İ. Akdeniz Diyeti Bağlılık Ölçeği’nin Türkçe’ye Uyarlanması Geçerlilik ve Güvenilirliği. Osman J Med [İnternet]. 2019 Apr 1 [cited 2025 May 24]; Available from: https://dergipark.org.tr/tr/doi/ 10.20515/otd.504188 Craig CL, Marshall AL, Sj??Str??M M, Bauman AE, Booth ML, Ainsworth BE, et al. International Physical Activity Questionnaire: 12-Country Reliability and Validity. Med Sci Sports Exerc. 2003;35(8):1381–95. Öztürk M. Üniversitede eğitim-öğretim gören öğrencilerde Uluslararası Fiziksel Aktivite Anketinin geçerliliği ve güvenirliği ve fiziksel aktivite düzeylerinin belirlenmesi [Yüksek Lisans]. [Ankara]: Hacettepe Üniversitesi; 2005. Brethauer SA, Kim J, El Chaar M, Papasavas P, Eisenberg D, Rogers A, et al. Standardized Outcomes Reporting in Metabolic and Bariatric Surgery. Obes Surg. 2015;25(4):587–606. Ruiz-Tovar J, Gonzalez G, Bolaños M de L, Lopez-Torre EM, Fernández-Contreras ME, Muñoz J, et al. Changes in Sexual Functioning in Women with Severe Obesity After Bariatric Surgery: Impact of Postoperative Adherence to Mediterranean Diet. Nutrients. 2025;17(4):605. Simpson T, Billy H. IBC-Ox22 Greater Adherence to Mediterranean Diet leads to longer term weight loss. Br J Surg. 2022;109(Supplement 8):viii11. Cantay H, Binnetoglu K, Erdogdu UE, Firat YD, Cayci HM. Comparison of short- and long-term outcomes of bariatric surgery methods: A retrospective study. Medicine (Baltimore). 2022;101(38):e30679. Garg H, Aggarwal S, Misra MC, Priyadarshini P, Swami A, Kashyap L, et al. Mid to long term outcomes of Laparoscopic Sleeve Gastrectomy in Indian population: 3–7 year results – A retrospective cohort study. Int J Surg. 2017;48:201–9. Bendall CL, Mayr HL, Opie RS, Bes-Rastrollo M, Itsiopoulos C, Thomas CJ. Central obesity and the Mediterranean diet: A systematic review of intervention trials. Crit Rev Food Sci Nutr. 2018;58(18):3070–84. Ouellette KA, Mabey JG, Eisenman PA, Shaw JM, Brusseau TA, Hatfield DL, et al. Physical Activity Patterns Among Individuals Before and Soon After Bariatric Surgery. Obes Surg. 2020;30(2):416–22. King WC, Hsu JY, Belle SH, Courcoulas AP, Eid GM, Flum DR, et al. Pre- to postoperative changes in physical activity: report from the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2). Surg Obes Relat Dis. 2012;8(5):522–32. Bellicha A, Van Baak MA, Battista F, Beaulieu K, Blundell JE, Busetto L, et al. Effect of exercise training before and after bariatric surgery: A systematic review and meta-analysis. Obes Rev [Internet]. 2021 Jul [cited 2025 Jul 8];22(S4). Available from: https://onlinelibrary.wiley.com/doi/ 10.1111/obr.13296 Busetto L, Dicker D, Azran C, Batterham RL, Farpour-Lambert N, Fried M, et al. Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management. Obes Facts. 2017;10(6):597–632. Kapała J, Maroszczuk T, Lewandowska J, Lech P, Dowgiałło-Gornowicz N. Weight Regain in the Second Year after Sleeve Gastrectomy Could Be a Predictor of Long-Term Outcomes? Medicina (Mex). 2023;59(4):766. Abdallah E, El Nakeeb A, Yousef T, Abdallah H, Ellatif MA, Lotfy A, et al. Impact of Extent of Antral Resection on Surgical Outcomes of Sleeve Gastrectomy for Morbid Obesity (A Prospective Randomized Study). Obes Surg. 2014;24(10):1587–94. Nocca D, Krawczykowsky D, Bomans B, Noël P, Picot MC, Blanc PM, et al. A Prospective Multicenter Study of 163 Sleeve Gastrectomies: Results at 1 and 2 Years. Obes Surg. 2008;18(5):560–5. Obeidat F, Shanti H, Mismar A, Albsoul N, Al-Qudah M. The Magnitude of Antral Resection in Laparoscopic Sleeve Gastrectomy and its Relationship to Excess Weight Loss. Obes Surg. 2015;25(10):1928–32. Da Silva FBL, Gomes DL, De Carvalho KMB. Poor diet quality and postoperative time are independent risk factors for weight regain after Roux-en-Y gastric bypass. Nutrition. 2016;32(11–12):1250–3. Athanasiadis DI, Martin A, Kapsampelis P, Monfared S, Stefanidis D. Factors associated with weight regain post-bariatric surgery: a systematic review. Surg Endosc. 2021;35(8):4069–84. Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 23 Oct, 2025 Read the published version in Obesity Surgery → Version 1 posted Editorial decision: Revision requested 05 Aug, 2025 Reviews received at journal 05 Aug, 2025 Reviewers agreed at journal 04 Aug, 2025 Reviews received at journal 03 Aug, 2025 Reviewers agreed at journal 03 Aug, 2025 Reviews received at journal 01 Aug, 2025 Reviewers agreed at journal 01 Aug, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers invited by journal 28 Jul, 2025 Editor assigned by journal 28 Jul, 2025 Submission checks completed at journal 28 Jul, 2025 First submitted to journal 21 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7176825","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":493926933,"identity":"e810fe4b-aba3-4135-b4ba-f4713991ade9","order_by":0,"name":"Havva BOZDEMİR","email":"","orcid":"","institution":"Kocaeli University","correspondingAuthor":false,"prefix":"","firstName":"Havva","middleName":"","lastName":"BOZDEMİR","suffix":""},{"id":493926934,"identity":"fdbca572-6fb5-4ff9-a848-a3cab5706b25","order_by":1,"name":"Esra USTA","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIie3RMUvEMBTA8VcKrUMg67vFfoUchaND5b7KO4S4dDsoN5WA0PVW/RiH4HwQqEvVNXIg535Dxo4GCzrl7CiY/xSS/MiDAIRCf7pUARzHpZgEENgegL4JTSFIEwnnzx82apuG35/mljY6g/T2EaPh3Utmdzc5Rq1GPFQ5Uq/ninU1Aq29RJgEHNkjHCqBq1ZGCquFI/7Jlq9dPLjBMHvr88GRpcpO54kAmbhXYhSGLdwr5UohO0/QyKSgFz3b9bIuqC+vWybXBUk/4dsuNrZu+OWTfjB2g1fbVO+MLf3kq/H4Yvz05Gfn19LjtHuhUCj07/oEATtMpZCk0WoAAAAASUVORK5CYII=","orcid":"","institution":"Yalova University","correspondingAuthor":true,"prefix":"","firstName":"Esra","middleName":"","lastName":"USTA","suffix":""},{"id":493926935,"identity":"d2bd0df0-9077-4be7-a5cf-2ae387e03620","order_by":2,"name":"Mevlüt PEHLİVAN","email":"","orcid":"","institution":"Duzce University","correspondingAuthor":false,"prefix":"","firstName":"Mevlüt","middleName":"","lastName":"PEHLİVAN","suffix":""}],"badges":[],"createdAt":"2025-07-21 11:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7176825/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7176825/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11695-025-08332-3","type":"published","date":"2025-10-23T16:17:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88193981,"identity":"1045308e-74b8-4ce6-bd95-e231f5e709be","added_by":"auto","created_at":"2025-08-03 15:33:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":224187,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea) \u003c/strong\u003eChanges in the mean BMI of the patients according to the level of adherence to the Mediterranean diet. \u003cem\u003eComparisons between groups were made by Independent samples t-test. \u003c/em\u003e\u003cstrong\u003eb) \u003c/strong\u003eChanges in in the mean BMI of the patients according to the physical activity level. \u003cem\u003eComparisons between groups were made by One Way Anova test. *p\u0026lt;0.05\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1ab.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7176825/v1/d6eee8513b2879e2e5482000.jpg"},{"id":88193131,"identity":"e6d06342-bfff-40e4-93f5-e0b35d5db760","added_by":"auto","created_at":"2025-08-03 15:09:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":249497,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in EWL% \u003cstrong\u003e(a) \u003c/strong\u003eand TWL% \u003cstrong\u003e(b) \u003c/strong\u003eaccording to the level of adherence to the Mediterranean diet. \u003cem\u003eComparisons between groups were performed with Independent samples t-test. *p\u0026lt;0.01\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2ab.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7176825/v1/565c2bfc914d28c531d26188.jpg"},{"id":88193508,"identity":"d0cebb1d-e35f-4aa7-8ef3-2c766f7c57e9","added_by":"auto","created_at":"2025-08-03 15:17:45","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":442078,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in EWL% \u003cstrong\u003e(a) \u003c/strong\u003eand TWL% \u003cstrong\u003e(b) \u003c/strong\u003eof patients according to physical activity level. \u003cem\u003eComparisons between groups were made by One Way Anova test. * p \u0026lt; 0.05\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3ab.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7176825/v1/704678dd444aa4e7d7d0853e.jpg"},{"id":94490375,"identity":"19931a55-34fa-4144-8725-24146dda7e83","added_by":"auto","created_at":"2025-10-27 17:09:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1454048,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7176825/v1/54ca94b8-9aef-44f5-ab29-cef4b5c5121a.pdf"},{"id":88193505,"identity":"67dd3c69-4ba8-4c4c-994e-0f489313e1d5","added_by":"auto","created_at":"2025-08-03 15:17:45","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":28324,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7176825/v1/610762938760435abf25199c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effect of Mediterranean Diet Adherence and Physical Activity Level on Weight Loss after Laparoscopic Sleeve Gastrectomy","fulltext":[{"header":"Highlights","content":"\u003cp\u003e\u0026bull; Moderate-high adherence to the Mediterranean diet significantly increases postoperative weight loss.\u003c/p\u003e\u003cp\u003e\u0026bull; Physical activity level gains importance in weight loss sustainability after 18 months.\u003c/p\u003e\u003cp\u003e\u0026bull; At 24 months, the rate of weight regain was 26.8% and was associated with low dietary adherence and physical inactivity.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eObesity is a global health concern, driven by its rapidly increasing prevalence and associated medical problems. Worldwide, adult obesity has more than doubled and adolescent obesity has quadrupled since 1990. According to World Health Organization data for 2022, 43% of adults are reported to be overweight and 16% have obesity problems (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Metabolic bariatric surgery is one of the surgical procedures considered as an effective alternative for weight loss when traditional treatments for obesity are inadequate (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRestrictive, malabsorptive and combined interventions are applied in the surgical treatment of obesity. According to the data of the International Federation for the Surgery of Obesity and Metabolic Disorders 2021, LSG is the most commonly performed intervention with a rate of 58.2% among all bariatric procedures (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). LSG has an increasing popularity due to its safety, efficacy and simpler technique compared to other procedures.\u003c/p\u003e\u003cp\u003eMetabolic bariatric surgery aims to improve quality of life by providing weight loss and improvement in associated medical problems. The low early mortality and morbidity rates of LSG are an important advantage (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In addition, improvement in associated medical problems and a decrease in drug use have been reported in mid-term follow-up after LSG (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Meta-analyses comparing weight loss outcomes of LSG and laparoscopic Roux-en-Y gastric bypass (LRYGB) surgeries indicate that short- and mid-term results are comparable or in favour of LRYGB, while long-term outcomes generally in favour of LRYGB (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Following LSG, the mean EWL% at 12 months has been reported as 67% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), while long-term follow-up over 10 years indicates a decrease to 58% (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, revision or modification surgery rates due to insufficient weight loss and weight regain after LSG are between 6% and 20% (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe postoperative lifestyle\u0026mdash;encompassing healthy eating, regular physical activity, and reduced sedentary behavior\u0026mdash;is a key determinant not only of initial weight loss but also of its maintenance in the medium and long term. The Mediterranean diet is one of the most well-known healthy eating patterns, characterized by high consumption of fruits, vegetables, legumes, nuts, whole grains, and olive oil; moderate consumption of fish and poultry; and limited intake of red and processed meats, sugar-sweetened beverages, and processed foods (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). High adherence to the Mediterranean diet is widely acknowledged to provide cardiovascular and metabolic benefits, reduce the risk of cardiovascular diseases and obesity, and lower overall mortality rates (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). There are a limited number of studies examining the effects of the Mediterranean diet in obesity surgery patients. Evidence from previous studies suggests that individuals with higher adherence to the Mediterranean diet during both short- and long-term postoperative follow-up achieve more favorable outcomes in terms of weight loss, weight maintenance, and improvements in lipid profiles, compared to those with lower adherence (\u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Another important factor to be considered in the evaluation of lifestyle is the level of physical activity. Physical activity is essential for achieving and maintaining weight loss after surgery, as well as for promoting a healthy body composition (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eShort- and long-term follow-up study results show that the percentage of excess weight loss, lean body mass ratio and quality of life increase significantly as the physical activity level increases (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Moreover, long-term studies have reported that higher levels of moderate-to-vigorous physical activity and greater daily step counts are negatively associated with weight regain rates (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe literature contains a limited number of studies investigating the impact of lifestyle factors\u0026mdash;specifically adherence to the Mediterranean diet and physical activity\u0026mdash;on weight loss outcomes following surgery in patients who underwent the same surgical procedure performed by the same surgeon. In this study, we evaluated the effects of adherence to the Mediterranean diet and physical activity levels on weight loss in patients followed for two years after LSG.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eMethodology and setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis cross-sectional and analytical study was conducted in the general surgery clinic of a university hospital in T\u0026uuml;rkiye with patients who underwent LSG surgery by the same surgeon. A total of 115 LSG procedures were performed at the clinic between 2022 and 2023. We analyzed the medical records and included patients aged 18\u0026ndash;65 who underwent their first LSG surgery. We excluded patients who underwent revision or modification surgery, had previous alternative obesity procedures, or were diagnosed with eating disorders. There were 113 patients who met the criteria. Using the Slovin formula via the Raosoft program, we calculated the sample size based on a population of 113 patients. Assuming a 95% confidence level and a 5% margin of error, the minimum required sample size was determined to be 88 patients. A final analytical sample consisting of 97 patients was formed after excluding patients who could not be reached due to changes in contact information and who did not accept to participate in the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurgical Technique and Patient Follow-up\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll procedures were completed by five trocar laparoscopy under general anesthesia. A 36 Fr spark plug was used to calibrate the stomach volume. The first stapler was placed approximately 4 cm proximal to the pylorus. Resection along the greater curvature was performed using a green (Ethicon Echelon Flex Endopath, 60 mm) cartridge for the antrum and a blue (Ethicon Echelon Flex Endopath, 60 mm) cartridge for the corpus and fundus. Bleeding foci seen on the stapler line were controlled with clips. The plunger was pulled to the oesophagogastric junction and approximately 100 cc of methylene blue and saline was injected into the stomach to check for leakage at the stapler line. After the trocars were removed, the incisions were sutured.\u003c/p\u003e\u003cp\u003eThe multidisciplinary team in the clinic consisted of a surgeon, assistant doctors, nurses, and a dietitian. All patients underwent LSG performed by the same surgeon using a standardized technique, and the perioperative care, including nursing and dietary counselling, was delivered uniformly across all cases. The standard care and follow-up protocol in the clinic is as follows: Patients with adequate fluid intake, good general condition and stable vital signs are discharged on the first postoperative day. Upon discharge, patients were provided with a standardized graded diet plan and were advised to engage in at least 30 minutes of physical activity per day. Patients were scheduled for follow-up visits at 1, 3, 6, 12, 18, and 24 months postoperatively. During each visit, anthropometric measurements were recorded, and patients were counselled to adhere to a personalized healthy diet and to engage in at least 30 minutes of physical activity daily.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection Method and Tools\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAfter obtaining ethics committee approval and institutional permissions, we contacted patients by telephone 24 months after their LSG surgery. Researchers E.U. and H.B., both of whom hold doctorates in surgical nursing and have extensive experience in the care of bariatric surgery patients, conducted the interviews. During the interviews, the participants' socio-demographic characteristics and chronic disease status, Mediterranean Diet Adherence Screener (MEDAS) and International Physical Activity Questionnaire-Short Form (IPAQ-SF) questions were asked and the responses were recorded. The interviews lasted approximately 15\u0026ndash;20 minutes.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMediterranean Diet Adherence Screener (MEDAS)\u003c/strong\u003e\u003cp\u003eThe scale consisting of 14 questions was developed by Mart\u0026iacute;nez-Gonzalez et al. (2012) in the PREDIMED study (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Its validity and reliability for the Turkish population was performed by \u0026Ouml;zkan Pehlivanoğlu et al. (2020) and Cronbach\u0026rsquo;s alpha reliability coefficient was found to be 0.829 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Each item in the scale is scored 1 or 0. A score of 0\u0026ndash;6 on the scale indicates non-compliance with the Mediterranean diet (low), 7\u0026ndash;8 points indicate compliance (medium), 9\u0026ndash;14 points indicate strict adherence (high).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInternational Physical Activity Questionnaire-Short Form (IPAQ-SF)\u003c/strong\u003e\u003cp\u003eIt was developed by Craig et al. in 2003 to determine the physical activity level of individuals (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Its validity and reliability for the Turkish population was performed by \u0026Ouml;zt\u0026uuml;rk (2005) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). It consists of seven questions in which the time spent by individuals in sitting, walking and moderate intensity activities in the last week is questioned. The MET score is obtained by multiplying each activity by minutes, days and Metabolic Equivalent (MET; multiples of oxygen consumption at rest). Standard MET values were created for the activities (walking\u0026thinsp;=\u0026thinsp;3.3 MET, moderate physical activity\u0026thinsp;=\u0026thinsp;4.0 MET, vigorous physical activity\u0026thinsp;=\u0026thinsp;8.0 MET). Physical activity levels are determined by summing the MET scores for walking, moderate physical activity and vigorous physical activity. They are classified as physically inactive (\u0026lt;\u0026thinsp;600 MET min/week), low physical activity level (600\u0026ndash;3000 MET min/week) and adequate physical activity level (\u0026gt;\u0026thinsp;3000 MET min/week).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAnthropometric Parameters\u003c/strong\u003e\u003cp\u003eIn the clinic, we measured patients' height without shoes using a stadiometer, and body weight using a body composition analyzer (Tanita BC-418 model). We evaluated the effectiveness of weight loss using the percentage of excess weight loss (EWL%) and total weight loss (TWL%). EWL% = (initial weight - final weight) / (initial weight - ideal weight) x 100, with the ideal weight defined by a BMI of 25 kg/m\u003csup\u003e2\u003c/sup\u003e, TWL% = (initial weight - final weight / initial weight) x 100 (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe researcher coded the data and transferred them to a computer for analysis. IBM SPSS Statistics 21.0 (IBM Statistical Package for the Social Sciences) was used to perform the statistical evaluation. Continuous variables were indicated by mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and categorical variables by numbers and percentages. Normality of data distribution was evaluated by Shapiro-Wilk test, skewness and kurtosis values (\u0026plusmn;\u0026thinsp;1). Independent samples t-test and one-way ANOVA were used to compare differences between groups. Changes in EWL% and TWL% over time, as well as whether these changes differed according to levels of diet adherence and physical activity, were tested using two-way repeated measures ANOVA (Mixed Design). Categorical variables related to weight regain status were compared by Pearson's chi-square test and Yates' chi-square test. Post hoc analyses were performed with the bonferroni method to determine which category was the source of the difference in the chi-square test. The results were statistically significant at the level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical Consent\u003c/b\u003e\u003c/p\u003e\u003cp\u003e We obtained ethical approval for this study from the XXXXXX University Non-Interventional Ethics Committee (decision date: April 1, 2024, decision number: 2024/64). We conducted the research in line with the principles of the Declaration of Helsinki. All patients were first provided with detailed information about the study during the telephone interviews and were included in the study on a voluntary basis.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age of 97 patients was 36.84±9.24 years and 79.4% were female. The mean BMI of the preoperative patients was 45.53±6.39 kg/m\u003csup\u003e2\u003c/sup\u003e. At 24 months postoperatively, 60.8% of the patients had medium-high adherence to the Mediterranean diet (≥ 7) and 18.6% had adequate physical activity (Table 1).\u003c/p\u003e\n\u003cp\u003eThe mean BMI of patients with moderate-to-high adherence to the Mediterranean diet was significantly lower than that of patients with low adherence at all time points, except at month 18 (Figure 1a). In contrast, changes in mean BMI across physical activity levels were not statistically significant at any time point (Figure 1b).\u003c/p\u003e\n\u003cp\u003eThere was a difference between the groups in the mean EWL% according to the level of adherence to the Mediterranean diet (\u003cem\u003eF\u003c/em\u003e=9.830, p=0.002, η² =0.094). The mean EWL% of those with medium-high adherence to the Mediterranean diet was significantly higher than that of those with low adherence at 3 months (48.96±12.96 vs. 39.56±13.98, p= 0.001), 6 months (72.49±15.68 vs. 61.93±18.03, p=0.003) and 24 months (86.23±16.76 vs. 70.35±25.85, p\u0026lt;0.001). At 12 months (84.29±15.43 vs. 77.22±21.13, p=0.080) and 18 months (84.67±17.02 vs. 78.46±23.56, p=0.135), there was no significant difference between the groups in mean EWL% (Figure 2a). \u0026nbsp;The main effect of time on EWL% was statistically significant (\u003cem\u003eF\u003c/em\u003e= 196.532, p \u0026lt; 0.001, η² = 0.674). In within-time comparisons, there were significant increases in the 3-6 months (\u003cem\u003eF\u003c/em\u003e= 360.87, p \u0026lt; 0.001, η² = 0.792), 6-12 months (\u003cem\u003eF\u003c/em\u003e= 145.27, p \u0026lt; 0.001, η² = 0.605) and 18-24 months (\u003cem\u003eF\u003c/em\u003e= 23.01, p \u0026lt; 0.001, η² = 0.195) periods. Moreover, the time × group interaction for the 18–24-month period was statistically significant \u003cem\u003e(F\u003c/em\u003e = 50.087, p \u0026lt; 0.001, η² = 0.345). In contrast, no significant interaction was observed for the 12–18-month period (\u003cem\u003eF\u003c/em\u003e = 0.61, p = 0.437, η² = 0.006). Overall, the time × group interaction was not statistically significant across all time points (\u003cem\u003eF\u003c/em\u003e = 2.889, p = 0.066, η² = 0.030) (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean TWL% significantly differed between groups according to their level of adherence to the Mediterranean diet (\u003cem\u003eF\u003c/em\u003e=6.369, p=0.013, η² =0.063). The mean TWL% of those with medium-high adherence to the Mediterranean diet was significantly higher than that of those with low adherence at 3 months (20.77± 4.80 vs.17.51± 4.97, p=0.002), 6 months (30.59± 4.71 vs. 27.54± 6.57, p=0.009) and 24 months (36.85± 7.24vs. 31.67± 10.88, p=0.006). At 12 months (35.76± 5.04 vs. 34.24± 7.04, p=0.256) and 18 months (36.09± 6.93 vs. 35.03± 9.00, p=0.540), there was no significant difference between the groups in mean TWL% (Figure 2b). The main effect of time on TWL% was statistically significant (\u003cem\u003eF\u003c/em\u003e= 209.118, p\u0026lt; 0.001, η² = 0.688). Within-time comparisons revealed significant increases during 3-6 months (\u003cem\u003eF\u003c/em\u003e=370.964, p \u0026lt; 0.001, η² = 0.796), 6-12 months (\u003cem\u003eF\u003c/em\u003e=167.696, p \u0026lt; 0.001, η² = 0.638) and 18-24 months (\u003cem\u003eF\u003c/em\u003e= 21.487, p \u0026lt; 0.001, η² = 0.184) periods. Furthermore, the time × group interaction was statistically significant for the 18-24 months period (\u003cem\u003eF\u003c/em\u003e= 54.163, p \u0026lt; 0.001, η² = 0.363). However, overall, the time × group interaction across all time points did not reach statistical significance (\u003cem\u003eF\u003c/em\u003e = 2.909, p = 0.067, η² = 0.030) (Table 2).\u003c/p\u003e\n\u003cp\u003eThere was no difference between the groups in mean EWL% according to physical activity level (\u003cem\u003eF\u003c/em\u003e = 0.443, p = 0.644, η² = 0.009) (Figure 3a).\u0026nbsp;Regardless of group differences, the temporal change in mean EWL% was statistically significant (\u003cem\u003eF\u003c/em\u003e = 180.478, p \u0026lt; 0.001, η² = 0.658). In within-time comparisons, significant increases were observed at 3-6 months (\u003cem\u003eF\u003c/em\u003e = 319.054, p \u0026lt; 0.001, η² = 0.772), 6-12 months (\u003cem\u003eF\u003c/em\u003e = 130.463, p \u0026lt; 0.001, η² = 0.581), 18-24 months (\u003cem\u003eF\u003c/em\u003e = 7.203, p = 0.009, η² = 0.071), whereas there was no significant difference between 12-18 months (\u003cem\u003eF\u003c/em\u003e = 1.985, p = 0.162, η² = 0.021).\u0026nbsp;When considering all time points collectively, the time × group interaction was not statistically significant (\u003cem\u003eF\u003c/em\u003e = 1.193, p = 0.302, η² = 0.025) (Table 3).\u003c/p\u003e\n\u003cp\u003eThere was a significant difference in mean TWL% between groups according to physical activity level (\u003cem\u003eF\u003c/em\u003e = 4.505, p = 0.014, η² = 0.087). No significant differences were observed in TWL% measurements at 3 months (\u003cem\u003eF\u003c/em\u003e = 2.357, p = 0.100, η² = 0.048), 6 months (\u003cem\u003eF\u003c/em\u003e = 0.983, p = 0.378, η² = 0.020), and 12 months (\u003cem\u003eF\u003c/em\u003e = 3.042, p = 0.052, η² = 0.061). However, significant differences were found at 18 months (\u003cem\u003eF\u003c/em\u003e = 4.941, p = 0.009, η² = 0.095) and 24 months (\u003cem\u003eF\u003c/em\u003e = 3.910, p = 0.023, η² = 0.077). Post hoc analysis revealed that these differences favored the group with an adequate physical activity level (Figure 3b). The main effect of time on TWL% was statistically significant (\u003cem\u003eF\u003c/em\u003e = 197.857, p \u0026lt; 0.001, η² = 0.678). Within-time comparisons showed significant increases between 3 and 6 months (\u003cem\u003eF\u003c/em\u003e = 332.624, p \u0026lt; 0.001, η² = 0.780) and between 6 and 12 months (\u003cem\u003eF\u003c/em\u003e = 153.653, p \u0026lt; 0.001, η² = 0.620), as well as significant decreases between 18 and 24 months (\u003cem\u003eF\u003c/em\u003e = 5.885, p = 0.017, η² = 0.059). Overall, the time × group interaction did not reach statistical significance across all time points (\u003cem\u003eF\u003c/em\u003e = 1.684, p = 0.164, η² = 0.035) (Table 3).\u003c/p\u003e\n\u003cp\u003eWe found that 26.8% of the participants regained weight after the 18th month of surgery. 55.3% of those with low adherence to the Mediterranean diet and 42.4% of those who were inactive regained weight (Table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe efficacy of the Mediterranean diet and compliance with physical activity on weight loss in overweight and obesity problem populations has been demonstrated in large-sample longitudinal studies. However, a very limited number of efficacy studies have been conducted in patients undergoing bariatric surgery. In this study, approximately 61% of patients at the two-year follow-up after LSG demonstrated moderate-to-high adherence to the Mediterranean diet. Patients with moderate-to-high adherence achieved statistically and clinically significant greater weight loss at both early (first 6 months) and long-term (24 months) time points compared to those with low adherence. The positive impact of adherence to the Mediterranean diet on weight loss aligns with existing literature. A positive correlation has been reported between increased adherence to the Mediterranean diet and weight loss at 12 months post-bariatric surgery (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Furthermore, patients with high adherence to the Mediterranean diet at 24 months demonstrate greater weight loss compared to those with moderate or low adherence (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In a long-term (5-year follow-up) follow-up study in which different metabolic bariatric surgery interventions were evaluated together, it was reported that the total weight loss of those with high adherence to the Mediterranean diet was 54% and that of those with low adherence was 32%, regardless of the type of surgical intervention (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our study, the main effect of time on %EWL and %TWL was substantial, with significant weight loss observed during the first 12 months post-surgery. However, a slight but statistically significant decrease in %EWL and %TWL occurred between 18 and 24 months. Consistent with previous research, the first postoperative year represents the period of maximal weight loss, after which patients face the risk of a weight loss plateau or regain (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Notably, weight loss over time plateaued and showed limited sustainability in the group with low adherence to the Mediterranean diet. The Mediterranean diet is known to support weight loss due to its low glycaemic index, rich fibre content, high fruit and vegetable content, restriction of sugar-sweetened beverages, high anti-oxidant and anti-inflammatory components (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Moreover, the diet\u0026rsquo;s sustainability and potential for long-term adaptation due to its high cultural adaptation as a lifestyle make it stand out as one of the factors that reduce weight regain (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eApproximately half of the participants in the second year follow-up after LSG had minimal physical activity levels. Generally, metabolic bariatric surgery patients tend to be less active, and adherence to postoperative physical activity recommendations remains poor. Ouelette et al. (2020) reported no significant change in physical activity level 6 months after surgery compared to baseline in patients undergoing bariatric surgery (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Objective assessments during the first postoperative year indicate that patients\u0026rsquo; physical activity levels increased; however, the majority remained classified as having low physical activity (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Analysis based on physical activity levels revealed a significant difference in weight loss at the 18- and 24-month follow-ups among individuals with adequate physical activity levels. In a retrospective study, it was reported that there was more weight loss and improvement in body composition in individuals who increased their physical activity level compared to the baseline level two years after surgery (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Similarly, a meta-analysis evaluating the effectiveness of exercise programs in bariatric surgery patients emphasized that increased physical activity levels are associated with greater weight loss and fat mass reduction (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) In contrast to these results, Gils Contreras et al. (2021) reported no significant difference in weight loss at 12 months post-surgery between individuals who increased their physical activity levels compared to those who maintained or decreased their activity levels relative to baseline (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). There are no evidence-based physical activity guidelines specifically for bariatric surgery patients. However, to maintain weight loss, prevent lean body mass loss, and improve body composition and physical capacity, it is recommended that patients engage in moderate aerobic exercise and strength training 2\u0026ndash;3 times per week, aiming for at least 150 minutes per week initially, with a goal of reaching 300 minutes per week postoperatively (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe rate of weight regain in the 18\u0026ndash;24 month time period after surgery was 26.8%. While similar weight regain rates at two years following LSG have been reported in the literature (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), some studies have reported lower rates (\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Adherence to the Mediterranean diet and being physically inactive were the factors that played a significant role in weight gain. Similarly, a study by Schiavo et al. (2020) found that one-third of the participants who regained weight ate less fruit and vegetables, more pasta, bread, rice and potatoes, and had low levels of physical activity (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Differently, studies are reporting that only diet quality affects weight gain (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), sedentary time and low physical activity are effective in the long term (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). While the physiological effects of surgery play a decisive role in the early postoperative period following bariatric surgery, behavioral factors become increasingly influential in the long term. These behavioral factors include low physical activity, consumption of hyper caloric foods and sweets, limited intake of fruits and vegetables, poor diet quality, emotional eating, and loss of control during eating (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Therefore, sustaining the positive outcomes of surgery necessitates promoting lifestyle changes that enhance adherence to healthy dietary patterns and physical activity.\u003c/p\u003e\u003cp\u003eIn conclusion, this study offers a comprehensive evaluation of the impact of Mediterranean diet adherence and physical activity levels on weight loss following LSG. The results demonstrated that individuals with moderate to high adherence to the Mediterranean diet achieved significantly greater %EWL and %TWL. While physical activity had a limited effect on weight loss during the first 12 months post-surgery, its influence became more pronounced from the 18th month onward. Notably, during the 18\u0026ndash;24 month period, the effects of both Mediterranean diet adherence and physical activity were particularly evident, with weight regain risk becoming increasingly sensitive to these factors.\u003c/p\u003e\u003cp\u003eThese results suggest that not only surgical intervention but also healthy lifestyle habits are indispensable to maintain long-term success after LSG. Encouraging patients to embrace a healthy lifestyle necessitates their active participation throughout the entire preoperative and postoperative process. Continuous engagement with a multidisciplinary healthcare team is essential. Nutritional counselling aimed at promoting adherence to the Mediterranean diet, and individual programs to promote physical activity should be integrated into interdisciplinary follow-up protocols. Adopting a patient-centered care approach is crucial to identify the biopsychosocial needs of each patient, tailor individualized care plans, and ensure coordination and continuity throughout the perioperative period and beyond. Given that multidisciplinary teams comprise health professionals with diverse objectives, implementing a case management approach\u0026mdash;where specialist nurses serve as coordinators\u0026mdash;may enhance team communication, cooperation, and overall care effectiveness.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOur study has some limitations. First of all, the fact that the majority of the sample consisted of women reduces the power to represent the whole population. Only body weight values of the patients were analysed. The change of physical activity in body composition (muscle ratio, fat ratio, etc.) was not analysed. However, this study is the first study in our country to investigate the effect of adherence to the Mediterranean diet and physical activity level on weight loss and its sustainability in a sample of patients who underwent LSG and completed the 24th month.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: EU, HB; Methodology: EU; Investigation: EU, HB; Resources: EU, HB; Formal analysis: EU; Writing - Original Draft: EU, HB, MP; Visualization: EU, HB; Writing - Review \u0026amp; Editing: MP\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Obesity and overweight [Internet]. 2024 [cited 2024 Jul 24]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGastaldo I, Casas R, Moiz\u0026eacute; V. Clinical Impact of Mediterranean Diet Adherence before and after Bariatric Surgery: A Narrative Review. Nutrients. 2022;14(2):393.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAngrisani L, Santonicola A, Iovino P, Palma R, Kow L, Prager G, et al. IFSO Worldwide Survey 2020\u0026ndash;2021: Current Trends for Bariatric and Metabolic Procedures. Obes Surg. 2024;34(4):1075\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuchwald H, Oien DM. Metabolic/Bariatric Surgery Worldwide 2011. 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Effect of a Lifestyle Intervention Program With Energy-Restricted Mediterranean Diet and Exercise on Weight Loss and Cardiovascular Risk Factors: One-Year Results of the PREDIMED-Plus Trial. Diabetes Care. 2019;42(5):777\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGils Contreras A, Bonada Sanjaume A, Becerra-Tom\u0026aacute;s N, Salas-Salvad\u0026oacute; J. Adherence to Mediterranean Diet or Physical Activity After Bariatric Surgery and Its Effects on Weight Loss, Quality of Life, and Food Tolerance. Obes Surg. 2020;30(2):687\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRueda-Galindo L, Zer\u0026oacute;n-Rugerio MF, Egea AJS, Serrancol\u0026iacute; G, Izquierdo-Pulido M. A Mediterranean-Style Diet Plan Is Associated with Greater Effectiveness and Sustainability in Weight Loss in Patients with Obesity after Endoscopic Bariatric Therapy. 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Surg Endosc. 2021;35(8):4069\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Sleeve gastrectomy, Mediterranean diet, physical activity, metabolic bariatric surgery, weight loss, multidisciplinary care","lastPublishedDoi":"10.21203/rs.3.rs-7176825/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7176825/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMetabolic bariatric surgery is an effective method in the treatment of severe obesity; long-term weight loss success depends on the extent to which patients adapt to lifestyle changes. Mediterranean diet and physical activity are important lifestyle components for sustainable weight control. This study examines the effect of adherence to the Mediterranean diet and physical activity levels on weight loss in patients in the second year follow-up after Laparoscopic Sleeve Gastrectomy (LSG).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis cross-sectional and analytical study included 97 patients who underwent LSG surgery at a university hospital in T\u0026uuml;rkiye and reached the 24th-month follow-up. Data were collected using the Mediterranean Diet Adherence Screener (MEDAS) and the International Physical Activity Questionnaire-Short Form (IPAQ-SF). Weight loss efficiency was evaluated using percentage of excess weight loss (EWL%), total weight loss (TWL%), and body mass index (BMI).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e60.8% of the participants had moderate-high adherence to the Mediterranean diet, and 18.6% had adequate physical activity levels. The EWL% and TWL% values of those with moderate-high adherence to the Mediterranean diet were statistically significantly higher at 3, 6 and 24 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The effect of physical activity level on TWL% was significant at 18th and 24th months. The rate of weight regain in the 18\u0026ndash;24 months period was 26.8% and this rate was associated with low dietary adherence and physical inactivity.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eAdherence to the Mediterranean diet and physical activity are determining factors in the maintenance of weight loss after LSG. A multidisciplinary, patient-centered case management approach may enhance long-term outcomes.\u003c/p\u003e","manuscriptTitle":"The Effect of Mediterranean Diet Adherence and Physical Activity Level on Weight Loss after Laparoscopic Sleeve Gastrectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-03 15:09:41","doi":"10.21203/rs.3.rs-7176825/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-05T07:30:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-05T07:26:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84365835248984230580348809722251136933","date":"2025-08-04T21:56:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-03T20:15:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37192782178971316214076468321792648388","date":"2025-08-03T16:47:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-01T13:56:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78897670715236449363569897070810338244","date":"2025-08-01T09:50:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247407475366646228774839848012749569479","date":"2025-07-29T07:42:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-28T20:22:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-28T18:21:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-28T13:24:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"Obesity Surgery","date":"2025-07-21T11:16:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c05c88e4-5ee6-41a9-b28a-ba76a0c05a4d","owner":[],"postedDate":"August 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:28:30+00:00","versionOfRecord":{"articleIdentity":"rs-7176825","link":"https://doi.org/10.1007/s11695-025-08332-3","journal":{"identity":"obesity-surgery","isVorOnly":false,"title":"Obesity Surgery"},"publishedOn":"2025-10-23 16:17:16","publishedOnDateReadable":"October 23rd, 2025"},"versionCreatedAt":"2025-08-03 15:09:41","video":"","vorDoi":"10.1007/s11695-025-08332-3","vorDoiUrl":"https://doi.org/10.1007/s11695-025-08332-3","workflowStages":[]},"version":"v1","identity":"rs-7176825","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7176825","identity":"rs-7176825","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}