",isbn:"978-1-83881-922-4",printIsbn:"978-1-83881-921-7",pdfIsbn:"978-1-83881-923-1",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"dcfc52d92f694b0848977a3c11c13d00",bookSignature:"Dr. Fiaz Ahmad and Prof. Muhammad Sultan",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10454.jpg",keywords:"Agricultural Engineering, Technologies, Application, Sustainable Agriculture, Information Technology in Agriculture, Food Security, Renewable Energies, Precision Farming, Smart Agriculture, Farm Mechanization, Robotics, Post Harvest Technologies",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 25th 2020",dateEndSecondStepPublish:"December 23rd 2020",dateEndThirdStepPublish:"February 21st 2021",dateEndFourthStepPublish:"May 12th 2021",dateEndFifthStepPublish:"July 11th 2021",remainingDaysToSecondStep:"a month",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Ahmad is a researcher in the field of agricultural mechanization and agricultural equipment engineering, in-charge of Farm Machinery Design Laboratory at Bahauddin Zakariya University, with expertise in modeling and simulation. He applied for two patents at the national level.",coeditorOneBiosketch:"Renowned researcher with a focus on developing energy-efficient heat- and/or water-driven temperature and humidity control systems for agricultural storage, greenhouse, agricultural livestock and poultry applications including HVAC, desiccant air-conditioning, adsorption, Maisotsenko cycle (M-cycle), and adsorption desalination.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"338219",title:"Dr.",name:"Fiaz",middleName:null,surname:"Ahmad",slug:"fiaz-ahmad",fullName:"Fiaz Ahmad",profilePictureURL:"https://mts.intechopen.com/storage/users/338219/images/system/338219.jpg",biography:"Fiaz Ahmad obtained his Ph.D. (2015) from Nanjing Agriculture University China in the field of Agricultural Bioenvironmental and Energy Engineering and Postdoc (2020) from Jiangsu University China in the field of Plant protection Engineering. He got the Higher Education Commission, Pakistan Scholarship for Ph.D. studies, and Post-Doctoral Fellowship from Jiangsu Government, China. During postdoctoral studies, he worked on the application of unmanned aerial vehicle sprayers for agrochemical applications to control pests and weeds. He passed the B.S. and M.S. degrees in agricultural engineering from the University of Agriculture Faisalabad, Pakistan in 2007. From 2007 to 2008, he was a Lecturer in the Department of Agricultural Engineering, Bahauddin Zakariya University, Multan-Pakistan. Since 2009, he has been an Assistant Professor in the Department of Agricultural Engineering, BZ University Multan, Pakistan. He is the author of 33 journal articles. He also supervised 6 master students and is currently supervising 5 master and 2 Ph.D. students. In addition, Dr. Ahmad completed three university-funded projects. His research interests include the design of agricultural machinery, artificial intelligence, and plant protection environment.",institutionString:"Bahauddin Zakariya University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Bahauddin Zakariya University",institutionURL:null,country:{name:"Pakistan"}}}],coeditorOne:{id:"199381",title:"Prof.",name:"Muhammad",middleName:null,surname:"Sultan",slug:"muhammad-sultan",fullName:"Muhammad Sultan",profilePictureURL:"https://mts.intechopen.com/storage/users/199381/images/system/199381.jpeg",biography:"Muhammad Sultan completed his Ph.D. (2015) and Postdoc (2017) from Kyushu University (Japan) in the field of Energy and Environmental Engineering. He was an awardee of MEXT and JASSO fellowships (from the Japanese Government) during Ph.D. and Postdoc studies, respectively. In 2019, he did Postdoc as a Canadian Queen Elizabeth Advanced Scholar at Simon Fraser University (Canada) in the field of Mechatronic Systems Engineering. He received his Master\\'s in Environmental Engineering (2010) and Bachelor in Agricultural Engineering (2008) with distinctions, from the University of Agriculture, Faisalabad. He worked for Kyushu University International Institute for Carbon-Neutral Energy Research (WPI-I2CNER) for two years. Currently, he is working as an Assistant Professor at the Department of Agricultural Engineering, Bahauddin Zakariya University (Pakistan). He has supervised 10+ M.Eng./Ph.D. students so far and 10+ M.Eng./Ph.D. students are currently working under his supervision. He has published more than 70+ journal articles, 70+ conference articles, and a few magazine articles, with the addition of 2 book chapters and 2 edited/co-edited books. 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1. Introduction
New Urbanism and related studies recognize the traditional organization of the built environment as offering more appropriate solutions for a better urban life [1]. In contrast, the modern movement tends to focus on the suburban, automobile-based built environment, with homogenized land use, the diminution of a sense of place and community engagement, and the decline of the role of neighborhood units in the formation of urban environments [2]. The New Urbanism movement adopted certain qualities from traditional neighborhoods that were felt to be particularly positive and reflective of a more compact traditional urban tissue; key qualities included mixed land use, housing typologies, grid-like streets, and high densities. New Urbanism often expresses the need to, “rediscover the neighborhoods and sense of community through more human scale development” ([1], p.18), and conceives a better “public transit connectivity”, more walking among the community, and an increase in the social experience of a community [1]. Along with that, smart growth trend of urban planning seeks to improve the walkability of existing urban sprawl developments by retrofitting their physical environment [3]. In this regard, Talen explained that the retrofitting of sprawling existing developments is achievable through applying quantitative measures of physical environment that are validated by research. Thus, models of those quantitative models can predict, explain, justify, and achieve potential smart growth. However, she addressed a series of challenges that pertained to smart growth studies including “data sources, geographical scales, aggregation scales and spatial resolution” which all have primarily to do with the research outcomes [3, 4]. Moreover, Hillier [5] argues that architects predominantly rely on normative criteria for design and future developments. Nevertheless, master planning represents a strategic framework that comprises several aspects of a particular location, including its physical, social and economic contexts [6]; thus, it is a reality-pertaining activity as much as normative activity. Evidence-based practice (EBP) within planning has recently emerged as a method to link planning practice to research in order to inform decision makers and professionals within urban planning [7]. Thus, this study both suggests a model to improve the existing neighborhoods and also provides feedback to decision-makers around future developments concerning the current master planning of neighborhoods in Basra city (2010–2035).
It is worth mentioning, that the Master Plan is the only official intervention plan by the government of Basra city. The current Master Plan of Basra city, developed by a local firm, (Snafy company) was approved by government officials in 2015 [8]. The statement and criteria for the current Master Plan of Basra city (2010–2035) recognized a common problem in the significant shortage of both residential units and land for new development. Although the importance of neighborhood as a widely considered planning unit primarily concerned with people’s living environment, the existing residential land-use organizations of the current Master Plan applies the ‘residential quarter unit’ for future developments; this is approximately equal to four neighborhoods. Estimated residents in each quarter total 15,000. The units are classified into three types namely, high, medium, and low density housing units, where each type has a different percentage of the total quantity. Of the total area specified for each residential portion, high-density units will comprise 100-units/ha (10%), medium density will total 45-units/ha (25%), and low-density will amount to 35-units/ha (65%). Furthermore, the structure of the residential quarter includes two commercial centers (1 ha), retail space (1 ha), two religious centers (1 ha), health and social centers (1 ha), seven nurseries (2.5 ha), four primary schools (2.2 ha), four middle schools (3.8 ha), four secondary schools (4.4 ha), playgrounds (2 ha), local parks (3.5 ha), roads and open spaces (25.2 ha).
With regard to these aspects of the new Master Plan and further design considerations, is the subject of feedback from our study, which will be based on evidence concerning the walking minutes to occupational activities suggested by Al-Saraify and Grierson [9]. To support feedback, this work suggests a quantitative model adopting several urban design measures applicable to the physical environment at neighborhood scale. The authors explore structural and design differences within three neighborhoods of Basra city, namely Al-Saymmar, Al-Mugawlen, and Al-Abassya. Their buildings, streets, land uses, and edges were quantitatively measured to reveal differences with potential impacts on the walking activity of the residents. Moreover, the walking minutes outcomes of the residents are based on previous work using Q-GIS software and the Neighbourhood Walking to Occupational Activities NWOA model [9]. Then, the walking outcomes are statistically associated with the urban design qualities to explain the extent to which the differentiation of the physical environments may impact on walking.
2. Defining the case studies
The urban form of Basra city was significantly altered by different stages of interventions and this influenced the selecting of the case studies [10]. Also, socio-political conditions influence the formation of the urban form of Basra city over three distinct historical stages, including the Ottoman period (before 1916), the British colony and Iraqi Kingdome period (1916–1958), and Republic period (after 1958) [11]. No official planning system was applied after the old fence decayed. The inner organization of the traditional neighborhoods mostly still the same since it was founded before 1916 [12, 13, 14]. In the early 1950s Max Lock was hired by the Iraqi government to make the first Master Plan of Basra city [15]. This Masterplan had been embraced the automobile-oriented development, an orthogonal or grid-like or modern planning vision was applied to the city.
Three neighborhoods within Basra are considered by Al-Saraify [10] providing three distinct residential typologies of Basra City with varied potential impact on the physical activity of the residents. A visual comparison between the current status (Figure 1) and the proposed Max Lock’s master planning of the three neighborhoods (Figure 2) shows that the interventions have considerably altered the quality of the neighborhoods’ built environments. Figure 2 illustrates how land uses of the case studies were planned by Lock, however, the peripheral arterial streets around the neighborhoods imposed gridlines which are mostly now utilized as commercial land use that surrounding the residential blocks of the neighborhoods. Thus, this urban tissue systematically sampled for the application of the defined urban design measures of the physical environment.
Figure 1.
The current locations of the three neighborhoods located over the master plan of Basra City (authors based on Lock [15]).
Figure 2.
The targeted three case studies (three neighborhoods of Basra city): [10].
Within general consensus, the ‘walking distance’ offers a standard method to sample neighborhoods in behavioral studies, and the range of walking distance falls somewhere in the range between (0.4) and (0.8) kilometer radius [16, 17]. Similarly, health-built-environment studies depend on measuring Euclidian distance, 15-min radius or 30-min network distance that is 600-m radius [18]. Therefore, this study considers (400–600 m), that is, (10–15 min), as optimum ranges covering both the spatial definition of the neighborhood and the requirements of active living lifestyle. Accordingly, the sampled neighborhoods accommodate varied urban design qualities which are investigated in this study include; transportation roads, residential area, and commercial destinations. The centers of the selected neighborhoods were utilized to define the minimum (400-m) and maximum (600-m) ranges of the case studies. Moreover, following Al-Saraify [10] the cadastral maps of the three case studies are created depending on the systematic survey of the original maps and data of the government. The satellite images, PDF maps, and orthoimages were obtained from the Basra local government and georeferenced and geometrically corrected (orthorectified). Moreover, the images were spatially correctly located according to its georeferenced coordination points (N: 768546, S: 3376180, UTM-WGS 1984, 38 North) into the QGIS free source software by Google. AutoCAD Map 3D was utilized to create a shape file extension (.shp) of the neighborhoods in question that can be added into Q-GIS (Figures 3–5).
Figure 3.
Al-Saymmar neighborhood cadastral plan: [10].
Figure 4.
Al-Mugawleen cadastral neighborhood map: [10].
Figure 5.
Al-Abassya cadastral neighborhood map: [10].
3. Review of the measurement indicators of the urban physical environment
A proponent study by Cervero and Kockelman, addressed three dimensions that are considered responsible for moving demands of residents in the built environment; these include density, diversity, and design. The so-called ‘3Ds’ represent a general umbrella for the measurement of the physical dimension of the urbanism phenomenon. Their study showed how these three dimensions contributed to an increase in the number of walkable streets in San-Francisco [19]. Regarding the issue of density, the intensity of users in urban areas is associated with the concentration of built-up urban developments. Density influences how well human activity and place are related since it influences the availability of urban space. Moudon et al. demonstrated that density and walking are strongly associated and higher density areas are more vibrant and walkable [20]. Although the locations of destinations are defined by the distance factor, the density of the urban area is influenced by locations of activities. This is because the geometrical relationship among components of a higher density area imposes closer distances. Moreover, Frank et al. demonstrated that the residential typologies and their physical layouts could provide a conception of population density. For example, a high-density place could include multi-family housing, apartments, and small residential lots. Moreover, high density is suggested as >6 housing units per acre, and low density is defined as <3 units per acre, while a medium density falls between these values [21]. Therefore, density could be rather a parametric concept that abstractly defines the neighborhood typology. Although density is a reliable measurement in urban planning, there is no particular level of acceptance concerning density. It shifts according to different factors, such as social and cultural contexts. For example, what could be considered as high density in some Western countries could be seen as low density in China or India.
H is the total number of housing units and A is the total area measured by square hectare.
The mix of land use measure is the degree of difference between the land uses that occupy a certain urban area. In other words, this means the degree of proportionating between different types of land use areas within the total area. Similar to density, the mix of land uses is considered to be associated with the increase of walkers in urban areas. In other words, when a place has diverse facilities or destinations, this will encourage users to walk [19, 21, 22]. The impact of land use diversity on users is manifested in the way in which users associate themselves with their neighborhood or with the wider urban area of the city. This is because it provides them with more opportunities. Also, it facilitates their imagination, in accordance with the notion of a cognitive map, as posited by Kevin Lynch. Thus, diverse land use adds to the experience of people providing more motives and resolutions, which encourage walking. Furthermore, studies used a mix of land use as a criterion of the ‘3Ds’ to probe the quality of place in term of its walkability and transportation, and positive correlations were widely noted among several studies [17, 23, 24, 25]. The method to compute land use diversity is addressed by Frank et al. [21]. It adopts a mathematical equation to compute the entropy of land use division to a group of land usages, from a baseline of equality between the different portions [21, 26].
k is an individual category of land use, p is the proportion of total land use, and N is the total number of categories.
The design dimension based on Cervero and Kockelman [19] is the streets connectivity which is considered the third indicator in urban planning studies. It is based on the notion that a greater flow of movement highly depends on how easily people and cars can gain access within/through urban areas. Thus, more accessible attractions require more connectivity of streets and walkways. Their study outlined design dimension as the shape and number of streets and nodes. Streets could be a grid or curve-lined shapes, and the intersections are nodes of four or three legs. Regarding the quality of the streets, studies depend on street design criteria as a parametric measure to assess their contribution in terms of walkability and transportation [17, 20, 21]. Connectivity and smaller and denser blocks and streets decrease travel distances and encourage users to walk or cycle. Consequently, they increase place accessibility [27]. New Urbanism supported this finding, proposing that more connected and compacted urban form is generally more accessible and results in lower land consumption. Thus, the pedestrian-oriented areas designed with highly connected streets and a lower ratio of wasted land are not just more walkable but safer. As such these can also be considered as more sustainable areas [27, 28]. Both streets and intersections are useful tools for engineering urban tissue, which define its key urban characteristics. Moreover, many researchers emphasized the importance of these two components in measuring people’s movement [29, 30]. In this regard, several forms of measurement were addressed by different scholars, such as: (1) the intensity of nodes per area [21, 31]; (2) the external connectivity, which depends on the number of entrances (related to length in m) into a certain urban area [32]; and (3) the number of street segments normalized by the number of accommodated intersections [33]. However, the node density was more commonly used among urban planning measures of ecological models.
The density of intersections per area was considered a measure of the streets’ network connectivity, whereas the presence of three legs intersections or more indicate a greater connectivity, and thus more accessible place [19, 21]. However, different formulas were applied to measure the density of intersections. The first formula was by urban planners, and depends on the ratio of the aggregated number of three and four legs intersection to the total area in question [34].
N is the total number of T and X intersections and A is the total area measured by hectare.
Street density is the total length of streets included in a certain urban area, as normalized by the total area, was considered a measure of connective urban tissue [35, 36, 37]. Thus, the denser the streets per area, the more connected, and accessible, the place.
L is the total length to street segments and A is the total area measured in hectare units.
Other studies considered other indicators and the text below explains several reliable indicators that were considered in empirical studies and showed considerable association with walking, namely, external connectivity, Pedestrian Catchment Area (PCA), pedestrian route directness ratio (PRDR), the clustering coefficient of destinations, the quality of edges, and the enclosure ratio. The external connectivity is the ratio of Ingress/Egress (access) points of the neighborhood to the total length of peripheral streets reveal the extent to which the neighborhood is connected to external urban areas; thus, the greater the distance, the poorer the external connectivity [32].
L is the total length of peripheral boundaries of the neighborhood, and E is the total number of entrances into the neighborhood.
Pedestrian Catchment Area (PCA): The PCA is the accessible area via the street network, assesses the efficiency of the street network to serve certain destinations or built up urban areas within an acceptable Euclidean walking distance, such as a 200, 400, or 800-m radius, from a given point or important facility, like a transport station [37, 38]. Furthermore, the PCA ascertains that, measuring the extent to which the street network serves blocks, demonstrates a certain level of accessibility into the built-up area, as sampled by a circle (e.g., 200-m radius). The center of the circle is hypothetically considered as the pedestrian departure point and a 200-m radius ring is the proposed walkable shed. Thereby, the total accessible built-up area in a 200-m network distance is normalized by the total built-up area inside the circle, indicating the efficiency of the street network defined by the sampling circle. In some research this is referred to the ‘Pedshed ratio’ [37].
Eq. (7): Pedestrian Catchment Area equation (PCA) [37]
PCA=AAtot/AtotE7
AA is the total accessible area and A is the total built-up area.
Pedestrian route directness ratio (PRDR) concerns the proximity of the distributed destination in the urban area, which was frequently used in accessibility and transportation related research. This involves the distance, either aerial or real, between a resident’s house and the destination (calculated in walking distances, e.g., ¼ mile, ½ mile, and 1 mile). This was considered an influential factor in facilitating the activity of users, especially walking to the nearest destinations [17, 22, 23, 39, 40, 41]. Moreover, Randal and Baetz [42] developed the pedestrian route directness ratio (PRDR), which is the ratio between the aerial distance and the real distance. It is an expressive formula because it explains the ease or probability to access certain destinations located within a certain distance-range of residences. Thus, the higher ratios (up to 1) represent the best proximate relationships between origin and destination. In this study, the ratio was adopted to express the proximity caused by the street network design, and the number of destinations measure was considered in different measurement levels. The (PRDR) measure was considered on the neighborhood level of measurement, Eq. (8), and the numerical range of this ratio is ≤1. The 1 value represents an optimum relationship that has identical aerial and real distances, whereas a smaller ratio illustrates that the real route is longer than the aerial distance. In streets, network routes relate between two points, the user’s departure station and contextual locations or destinations; meanwhile, the Euclidian distance is the aerial distance between the two points. In this study, a certain number of destinations and one origin are defined for each case study, where the origin is the postulated departure point and the destinations are defined by the survey.
The clustering coefficient of destinations suggests that people perceive this as more than a single destination because each cluster provides a range of options. Thus, the cluster has a greater chance of meeting users’ needs than an individual destination [22, 43]. Thus, a cluster of destinations is a design process that serves the proximity by compromising the distance and geometrics of destinations; therefore, users maintain a cognitive map of the proximity of their houses to non-residential clusters. However, there is no study that validates any standard measures of a cluster; instead it is simply perceived as a group of destinations proximate to each other to which people take themselves. Each cluster accommodates a bundle of different types of uses instead of single type of land use. The depending bundle criterion was devised by Canter and Tagg, who defined how many clusters could serve a particular urban area [44]. The clustering coefficient is a graph-based measure, developed by Watts and Strogatz, to calculate social networks, which were considered ‘small world’ networks. If a group of destinations is represented as nodes and a graph was made through connecting the nodes by hypothetical links, then the clustering coefficient is the number of links between all the nodes divided by the total number of links that was postulated as a rational relationship among the nodes. Also, the coefficient represents the degree to which a group of nodes are clustered, by normalizing the number of observed Links to the number of possible Links among the same group of nodes. The implication of a small-world phenomenon, as defined by network theorists Watts and Strogatz [45], to measure the degree of proximities between a group of destinations is promising because there is no equivalent topological measure to represent the relationship among a group of proximate destinations. However, there is no available method to produce a standard measurement of accessibility from this coefficient. In this respect, van der Westhuizen [46] used the ratio of a number of realized links between destinations, normalized by the number of possible links, and reported the significant influence of walking.
The quality of edges: the studies of walking urban areas linked the quality of street edges with the number of walkers.1 Jacobs in [2] asserted the link between the quality of streets and street life. A street facilitates the interaction between people because it brings them together, even those who do not know each other. In a street, people do their favorite things: walking, watching, sitting, or choosing their favorite viewpoint. A good street has clearly designed edges, geometry and carefully delineated transparency [2]. The block frontage is an important component of block structure, which impacts on human perception, traffic and pedestrian flow [32, 47, 48, 49]. In this study, the method to assess the quality of street edges was adopted from Remali et al. [50], and depends on five factors to assess the quality of elevations. These factors are: the “number of visible units accessible from the street (S); visible diversity of function (F); openness to the public street (O); level of maintenance (M); and level of detail and quality of materials (D)”. The frontage quality index (SFOMD) method depends on a Likert scale of seven points, starting with (1), which is the lowest score of the assessment, and ending with (7), which the highest score of the assessment. The computing of the overall index was adopted from Gehl [51] and Hershberger [52], and combines the five indicators by totaling their raw scores. Thereby, the minimum score for the process is five points, which represents the poorest street quality, whereas, the highest score is 35 points which represents the best possible street quality [50].
Enclosure ratio: studies in urban design have developed different ideas on the relationship between human perception and street room. The enclosure notion defines the sense of place in connection with the relationship between street widths and adjacent building heights. From an architectural point of view, Cullen illustrated that enclosure is an important tool that influences the human perception of a place or the “hereness”. Accordingly, the quality of enclosure is defined as a highly-required dimension of a streetscape, because the street-building proportions represent the “outdoor room” of walkers. For example, Ewing et al. indicate that building height and other vertical elements are milestones to establishing well-defined outdoor spaces when they are proportionate with the width of the counter space, or street [53].
4. The measurement process of physical environmental attributes
The measurement of physical environmental attributes, which were addressed in the previous section, are applied to the case studies and discussed in this section based on the cadastral maps of the three case studies. The raw information concerning the essential structure of the case studies is elicited from cadastral maps which were in AutoCAD and QGIS formats (Figures 3–5), the numerical attributes were entered into an excel sheet and then SPSS software. Then, each individual indicator is computed based on its defined equation and coded in the SPSS based on their initial letters, either on 400-m radius or 600-m radius (Table 1). For example, the density indicator has three variables for each case study; thus, it was measured two times to produce six numerical values for three neighborhoods. The two scales are (400-m radius), and (600-m radius). Thus, the codes of the three density variables are DnS1 and DnS2, respectively; this coding is continued for the rest of the independent variables (Table 1). From this, independent variables for measures of the physical environment attributes are produced (Table 2). Twenty-two independent variables were developed in this study, which resulted from the application of the measured physical environment indicators to the case studies.
4.1 Block and housing units density
The area of the blocks was computed on the two scales 400-m radius and 600-m radius, and the density equations Eqs. (1) and (2) were applied with the assistance of Excel software. Although the block density indicator is computed on two scales, the housing unit density is computed on one scale. Thus, three independent variables were calculated for the densities, which are labeled as BDnSi i = 1, and 2, and HDnS1 (Table 1). Moreover, the block density has been measured on the two scales, for the block density on the 400-m radius scale, the highest density was found in Al-Saymmar (0.71), while in Al-Mugawlen and Al-Abassya differed slightly from (0.65) to (0.67), respectively. Furthermore, the block density on the 600-m radius scale was slightly degraded from Al-Saymmar (0.78) to Al-Mugawlen (0.77) to Al-Abassya (0.72) (Table 2). The intensity of housing units (HDnS1) was measured only on scale (400-m radius); however, a divergence was noted from Al-Saymmar (41.9) to Al-Mugawlen (25) to Al-Abassya (17.25), in light of the single-family housing per hectare (Table 2).
4.2 Mixed land use
The diversity of land use was computed by the entropy equation Eq. (3) and the variables used for that purpose were the different land uses measured by the area. From this, the equation was applied with the assistance of MATLAB software and the categories of land use, for instance, the retail shops and workshops, were entered as a variable of the equation (X1, X2, …, Xi) in the MATLAB format. Additionally, because the land use categories are not unified across the three case studies, they could have different nature of influence on residents’ lives. This study considers different combinations of land uses, or different type-based bundles. The first bundle involved all the commercial land uses, the second bundle involved the retail shops, which are the commercial land use without parking, workshops, and wholesale, and the third bundle included all the non-residential land uses, which are the commercial plus the civic buildings, such as mosques. Moreover, this indicator was applied to the two scales; 400-m radius, and 600-m radius. Thus, six independent variables were calculated for the land use diversity, which were labeled as LUDiv1S1, LUDiv1S2, LUDiv2S1, LUDiv2S2, LUDiv3S1, and LUDiv3S2, (Table 1). In terms of the commercial land use variable (LUDiv1S1), on a 400-m radius scale, the degree of diversity demonstrated a significant difference between the Al-Saymmar neighborhood (0.94) and the Al-Mugawlen and Al-Abassya neighborhoods, (0.7, and 0.79), respectively.
Moreover, the same variables, on a 600-m radius scale, had approximately a similar pattern of variance among the three case studies (0.94, 0.75, and 0.73), respectively. In terms of the variable for commercial land use without parking, workshops and wholesale (LUDiv2S1), on a 400-m radius scale the degree of diversity adequately differed between Al-Saymmar (0.98) and the other two neighborhoods, Al-Mugawlen and Al-Abassya, (0.67, and 0.68), respectively. Moreover, the same variable, on a 600-m radius scale, showed an approximately similar pattern of variance among the three case studies; Al-Saymmar brought about a 0.97 degree of variance, whereas, Al-Mugawlen and Al-Abassya each brought about 0.76 degree. In terms of the non-residential land use variable (LUDiv3S1), on scale 400-m radius, the degree of diversity adequately differed between Al-Saymmar (0.39) and the other two neighborhoods (0.56, and 0.52) for Al-Mugawlen and Al-Abassya, respectively. Moreover, the same variable, on a 600-m radius scale, had approximately shown a similar pattern of variance among the three case studies: Al-Saymmar brought about (0.45) degree of variance, whereas Al-Mugawlen and Al-Abassya each brought about (0.63) degree (Table 2). Thus, the land use diversity of Al-Saymmar, as measured by the six variables (Table 2), is significantly different from the other two case studies, namely the Al-Mugawlen and Al-Abassya neighborhoods.
4.3 Streets connectivity
The QGIS software was used to compute the number of segments, length of each segment, and number of nodes, and these were transferred to an Excel sheet. Moreover, the streets’ segments are represented as polyline between two adjacent nodes, or from a node to a dead-end street. The nodes are either X-intersection or T-intersection types. This procedure is conducted twice, on a 400-m radius scale and on scale 600-m radius. In this study, four indicators defined the connectivity, namely: intersections density, street intensity, link-node ratio, and external connectivity. Moreover, each indicator was applied to two scales, (400- and 600-m); however, the external connectivity was only applied to the 400-m radius scale because the 600-m radius scale did not define neighborhood boundaries, but instead the walking ranges. Thus, the total number of variables for this indicator is five namely, NodDnSi i = 1, 2, StDnSi, ExtConS1 (Table 1). Moreover, three equations were used to compute these indicators Eqs. (4)-(6).
The intensity of nodes (NodDnS1) on the 400-m radius scale in the Al-Saymmar neighborhood was (4.16), which is approximately double the number in for both Al-Mugawlen and Al-Abassya (2.89, and 2.03), respectively. Moreover, the node density (NodDnS2) on a 600-m radius scale showed a decline in the node intensity per hectare, from Al-Saymmar (3.36) to Al-Mugawlen (2.33) to Al-Abassya (1.8), (Table 2). The intensity of street lengths (StDnS1) on a 400-m radius scale showed a significant reduction in total street lengths, from 387 m/ha for Al-Saymmar to 324 m/ha for Al-Mugawlen and 267 m/ha for Al-Abassya. However, the intensity of street lengths (StDnS2) on a 600-m radius scale was the highest in Al-Mugawlen 368 at m/ha, while Al-Saymmar was slightly lower at 346 m/ha, and Al-Abassya illustrated the lowest street density in terms of length at 250 m/ha (Table 2). The external connectivity (ExtConS1) on a 400-m radius scale demonstrated an adequate reduction in the number of entrances per mile length, while the Al-Saymmar neighborhood showed the highest score with 28.1 entrance/mile, and the Al-Mugawlen neighborhood showed a moderate score at 20 entrance/mile; meanwhile, the lowest score was in the Al-Abassya neighborhood at 16 entrance/mile (Table 2).
4.4 Pedestrian catchment area (PCA)
To apply the PCA indicator, the center of each case study is the center of the 400-m radius, as sampled in the cadastral maps. Every single block was considered a destination that needs to be accessed from the center of the neighborhood within 10 min of walk along the street network. The QGIS Road-Graph tool was utilized to measure the shortest network distance between two spatial points, which are the center of the case study and each individual block falls within the 400-m radius. After the adjustment of the human speed to 5 km/h, only the blocks within a 10-min walk were considered in determining the total accessible area in each neighborhood. Thus, the accessible blocks in ≤10 min were added up, and the resulting total accessible block area was represented as percentage area out of the total block area within a 400-m radius. Thus, only one independent variable was noted in applying this indicator, PCAS1 (Table 1). Therefore, the PCA variable illustrates that, in the Al-Saymmar neighborhood, out of 356,135 m2 of built-up area, there was 219,635 m2 of accessible area in 10-min of network walking within the 400-m radius area; this is 61.67% of the total built-up area. In the Al-Mugawlen neighborhood, out of 326,500 m2 of built-up area, there was 219,635 m2 of accessible area in 10-min of network walking within a 400-m radius area; this is 73.18% of the total built-up area. In Al-Abassya neighborhood, out of 333,600 m2 of built-up area, there was 2235,600 m2 of accessible area in a 10-min network walk within the 400-m radius area; this is 70.4% of the total built-up area (Table 2).
4.5 Pedestrian route directness ratio (PRDR)
To apply the PRDR indicator, the center of each case study is the center of the 400-m radius, as sampled in the cadastral maps. The retailers are those that inhabitants want to access from the center of the neighborhood in 10 min of walk along street networks. In this regard, the shapefile maps were generated to create the blocks, blocks centroids, and streets networks on the 400-m radius and the 600-m scale. The QGIS Road-Graph tool was utilized to measure the shortest network distance between two spatial points, which are the center of the case study and each individual retailer within the 400-m radius and the 600-m radius. Moreover, because the indicator concerns how well the street network is connected between the destinations and residents’ houses, this study designed an approach to test the PRDR for 16 destinations within each case study on each scale. The approach divided the circles of the two scales into 16 sectors then the intersection point of the radiuses with the circles (for the 400-m and the 600-m radiuses) are defined; from this, the nearest destination to those points are considered to compute the indicator. Thus, two independent variables were addressed by the PRDR, which were labeled: PRDRS1, PRDRS2 (Table 1). Then, the specified PRDR equation Eq. (8) was utilized to compute the indicators, which must be ≤1. A value of 1 represents an optimum relationship that has identical aerial and real distances; whereas, the smaller ratio illustrates that the real route is longer than the aerial distance. In other words, the street network route distance between the two points relates the user’s departure station to the location of a contextual destination; thus, the shorter distance indicates the more accessible destination. The PRDR for the 16 destinations of each case study were averaged to determine how well the destinations of each case study are served by the street network. The PRDRS1 on the 400-m radius scale slightly differed among the three neighborhoods, at 0.73, 0.77, and 0.72 for Al-Saymmar, Al-Mugawlen, and Al-Abassya neighborhoods, respectively. Also, it illustrated similar differences for the 600-m radius scale, at 0.76, 0.79, and 0.76 for Al-Saymmar, Al-Mugawlen, and Al-Abassya neighborhoods, respectively (Table 2).
4.6 Clustering coefficient
The clustering coefficient indicator of the physical environment is measured by applying the equation of the clustering Eq. (9), and the major two components to run the equation are the observed number of links among the destinations and the possible number of links. However, there was no clear explanation about how to measure these two components in the reviewed literature; therefore, the criteria to measure these two components are designed by this study. In this regard, the first component of this equation is the observed links between destinations. It considered 5 min as the maximum walking distance between two destinations, which is a 200-m length. Thus, each destination has a potential relationship with all other destination in the 200-m radius. The reason for such an assumption is because, if the distance between every two destinations is not a complete journey for the walker but rather a sub-journey, then the minimum distances mean a better relationship. Based on this criterion, each destination was defined as a center and a straight line was drawn to all other adjacent destinations in the 200-m radius. The required information was elicited from the cadastral maps with the assistance of AutoCAD 3D map software; in this regard, the shapefile maps were generated to both the links and the destinations on the 400-m radius and 600-m radius scales. From this, the layers were added into QGIS software. The resulting total number of links was considered the observed links (numerator). The second component is the possible number of links, even if they did not exist, between the destinations; for this purpose, the equation used was: the number of possible links = (n2 − n)/2 (denominator), Eq. (9), where n is the total number of destinations. Thus, two independent variables resulted from this indicator, on the 400-m radius and 600-m radius scales. The two variables were labeled as ClsCofS1, ClsCofS2 (Table 1). Thereafter, on the 400-m radius scale, the clustering coefficient variable CICS1, indicated that the Al-Saymmar and Al-Abassya neighborhoods were identical, at 0.05 for each. Meanwhile, Al-Mugawlen was slightly different at 0.04. Moreover, on the 600-m radius scale, the clustering coefficient variable CICS2, indicated that the Al-Saymmar and Al-Abassya neighborhoods are identical at 0.04 for each. Finally, Al-Mugawlen was slightly different at 0.03 (Table 2).
4.7 Edges assessment
The method to assess the quality of street edges was adopted the frontage quality index (SFOMD) [50]: p.108. It depends on a Likert scale of seven points, starting with (1), which is the lowest score of the assessment, and ending with (7), which is the highest score. The application of the method depends on observations is conducted by a specialist team and criteria based sampling of the urban tissue. The computation of the overall index concerning the quality of the area was adopted from Gehl [51] and Hershberger and Clements [52], which combines the five indicators by totaling their raw scores. Therefore, the minimum score of the process is five points which represents the poorest quality streets, whereas, the highest score is 35 points, which represents the best possible quality. Thus, one independent variable was developed in terms of the edges assessment, namely: The Frontage quality index (SFOMDS1) on the 400-m radius scale (Table 1). Moreover, the principle of sampling the streets is an important issue to avoid bias and to validate the generalization of the results, therefore, this study depends on the selection of three streets segments based on the hierarchal level of the street. From the hierarchical street levels, they define the main street, a connector street, and a cul-de-sac from each case study. The information of the survey was transferred into Excel-sheets for the purpose of analysis. The individual survey sheets were summarized (Table 3). Accordingly, three variables were developed from this analysis, which were: the Frontage quality index of the main street (SFMODS1M), the Frontage quality index of the Connecting street (SFMODS1C), and the Frontage quality index of the Col-de-sac (SFMODS1CS) (Table 1).
Table 1.
The measurement indicators of the physical environment attributes.
Table 2.
The computed indicators of the physical environment attributes.
Table 3.
SFOMD index, analysis of the edges.
The SFOMD index in Al-Saymmar neighborhood demonstrated the lowest levels of frontage quality, at 21, 20, and 15 points for the variables SFOMDS1M, SFOMDS1C, SFOMDS1CS, respectively. The SFOMD index in Al-Mugawlen neighborhood demonstrated moderate levels of frontage quality, at 27, 23, and 22 points for the variables SFOMDS1M, SFOMDS1C, SFOMDS1CS, respectively. Finally, the SFOMD index in Al-Abassya neighborhood demonstrated the highest levels of frontage quality, at 30, 27, and 27 points for the variables SFOMDS1M, SFOMDS1C, SFOMDS1CS, respectively, (Tables 2 and 3). Therefore, the value of the SFOMD index increased in parallel with the increased grid structure among the street typologies. For example, the red level of the SFOMD index, brought about different scores across the three neighborhoods, 21, 27, and 30, for Al-Saymmar, Al-Mugawlen, and Al-Abassya respectively (Table 2).
4.8 Enclosure ratio
The enclosure ratio was measured for the sampled streets in Figures 6–8, Thus, three independent variables resulted from applying the enclosure indicator on the 400-m radius scale; these were coded as EnRBS1M, EnRBS1C and EnRBS1CS (Table 1). The variables required to apply the indicator are the width of the street and the heights of the adjacent buildings, which were measured directly in this study. Then, the function of the indicator was applied to the sections of all the sampled streets segments. In terms of the main streets (EnRBS1M), the three case studies have a broadly similar value of enclosure ratios, at 2.9, 2.7, and 2.7, for Al-Saymmar, Al-Mugawlen, and Al-Abassya, respectively. In terms of the Connecting streets with the green level of betweenness (EnRBS1C), the highest score was noted with the Al-Mugawlen neighborhood (1.7); Al-Abassya showed a moderate enclosure ratio level (1.3), and the lowest level was noticed within Al-Saymmar (1). In terms of the local streets and the blue level of betweenness (EnRBS1CS), the highest score was noted within the Al-Mugawlen neighborhood (1.7); Al-Saymmar showed a moderate enclosure ratio level (1.1), and the lowest level was noticed with Al-Saymmar (0.93) (Table 2).
Figure 6.
Al-Saymmar edges assessment.
Figure 7.
Al-Mugawlen edges assessment.
Figure 8.
Al-Abassya edges assessment.
5. The statistical analysis
The statistical analysis examines the extent to which the indicators of the physical environment are able to explain the variance among the walking outcomes of the individuals. The measured attributes of the physical environment were tested in terms of their predictability for the walking minutes. Thus, their variables are considered predictors (X), which need to be tested in terms of their predictability for the walking minutes (Y). In other words, this analysis tests whether the walking outcome variables can be individually predicted by the measured attributes of the physical environment. For such a purpose, the hierarchal regression analysis was chosen because of its flexibility to enter predictors in a split block with extra predictors. Moreover, the p-value (<0.05) indicates the significance of the models, while the determination coefficient (R2) explain the potential of the predictors to explain the variance of the outcomes. The hierarchical regression analyses were run to test the predictability of the physical environment indicators, which were individually tested with the walking minutes in one model for each indicator to determine the effect significance of the predictor on the outcome variable (p-value) and the (R2). Moreover, the SPSS software was utilized for the conducting all the required statistical analysis in this study.
5.1 Findings
The Block density, the predictability of the model was significant (F(173, 1) = 16.989, p < 0.001, R2 = 0.089). Thus, the singular model was able to explain 8.9% of the variance of the total walking minutes. Also, the test shows that the higher walking behavior outcome score was associated with higher block densities (b = 11.817, p < 0.001). In term of Housing Units density, the predictability of the model was significant (F(173, 1) = 26.231, p < 0.001, R2 = 0.132). Thus, the model was able to explain 13.2% of the variances of the total walking minutes. It was showed that the higher scores for walking behavior outcomes were associated with higher housing units densities (b = 0.040, p < 0.001).
Diversity of all commercial land use on a 400-m radius scale; the predictability of the model was significant (F(173, 1) = 11.145, p < 0.001, R2 = 0.061). Thus, the singular model was able to explain 6.1% of the variances of the total walking minutes. Furthermore, the higher walking behavior outcome scores were associated with a higher diversity of all commercial land uses (b = 2.478, p < 0.001). Regarding the commercial land use without parking, wholesale, and workshops variable on a 400-m radius scale, the predictability of the model was significant (F(173, 1) = 20.176, p < .001, R2 = 0.104). Thus, the model was able to explain 10.4% of the variances of the total walking minutes. Furthermore, the higher scores of walking behavior outcomes were associated with the higher diversity of commercial land use without parking, wholesale, and workshops (b = 2.390, p < 0.001). In term of the diversity of the non-residential land use on a 400-m radius scale, the predictability of the model was significant with the total walking minutes (F(173, 1) = 13.947, p < 0.001, R2 = 0.075). Thus, the model was able to explain 7.5% of the variances of the total walking minutes. Also, the higher of walking behavior outcomes scores were associated with a lower diversity of non-residential land use (b = −3.390, p < 0.001).
Regarding the connectivity indicators; the node (streets intersections) intensity on both scales 400-m and 600-m radius, the predictability of the model was significant (F(173, 1) = 26.940, p < 0.001, R2 = 0.135) and (F(173, 1) = 18.678, p < 0.001, R2 = 0.097), respectively. Thus, the models were able to explain 13.5 and 9.7% of the variances of the total walking minutes on the two scales, respectively. However, the higher walking behavior outcome scores were associated with the higher node intensities only on the 400-m radius scale in terms of the total walking minutes (b = 0.573, p < 0.001). In term of the street intensity on 400-m and 600-m radius scales, the predictability of the two models was significant for the total walking minutes (F(173, 1) = 27.071, p < 0.001, R2 = 0.135) and (F(173, 1) = 13.331, p < 0.001, R2 = 0.072), respectively. Also, the models were able to explain, 13.5 and 7.2% of the variances of the total walking minutes, respectively. Moreover, the higher walking behavior outcome scores were associated with a higher street intensity on a 400-m radius scale (b = 0.009, p < 0.001) and on a 600-m radius scale (b = 0.005, p = 0.001).
The Pedestrian Catchment Area (PCA) on a 400-m radius scale; The predictability of the model was significant with the total walking minutes (F(173, 1) = 14.914, p < 0.001, R2 = 0.079). Also, the singular model was able to explain 7.9% of the variances of the total walking minutes. Furthermore, the higher walking behavior outcome scores were associated with the lower value of the Pedestrian Catchment Area (b = −0.059, p < 0.001). Also, Pedestrian Route Directness Ratio (PRDRS1 and 2) on 400-m and 600-m radius scale; the predictability of the two models was nonsignificant for the total walking minutes were (F(173, 1) = 0.301, p > 0.05, R2 = 0.002) and (F(173, 1) = 0.142, p > 0.05, R2 = 0.001). Similarly, the models were inconsiderably explained the variances of the total walking minutes, at 0.2 and 0.1%, respectively. Also, the higher walking behavior outcome scores were not associated with the Pedestrian Route Directness Ratio (b = 1.231, p > 0.05). Regarding the Clustering coefficient of destinations on a 400-m and 600-m radius scales, the predictability of the two models were nonsignificant for the total walking minutes (F(173, 1) = 0.142, p > 0.05, R2 = 0.001) and (F(173, 1) = 2.288, p > 0.05, R2 = 0.019). Also, the models were able to explain, 0.1 and 1.9% on the two scales, respectively.
Frontage quality index of the streets on the 400-m radius scale: the predictability of the three models of the main, Connecting and col-de-sac streets was significant for the total walking minutes (F(173, 1) = 26.427, p < 0.001, R2 = 0.133), (F(173, 1) = 26.586, p < 0.001, R2 = 0.133) and (F(164, 9) = 4.374, p > 0.05, R2 = 0.211), respectively. However, the higher walking minutes were marginally associated with the lower frontage quality index of the main, the connecting and the col-de-sac streets (b = −0.110, p < 0.001), (b = −0.145, p < 0.001) and (b = −0.097, p < 0.001), respectively. Regarding the enclosure ratio of the streets on the 400-m radius scale, the predictability of the three models of the main and Connecting streets was significant for the total walking minutes (F(173, 1) = 20.840, p < 0.001, R2 = 0.108), (F(173, 1) = 49.636, p < 0.001, R2 = 0.223), respectively. While, in term Enclosure ratio of the col-de-sac street on the 400-m radius scale, the predictability of the model was not significant for the total walking minutes (F(173, 1) = 0.428, p > 0.05, R2 = 0.002). However, the higher walking minutes were marginally associated with the lower frontage quality index of the main, the connecting and the col-de-sac streets (b = 3.720, p < 0.001), (b = −0.615, p < 0.05) and (b = 0.103, p > 0.05), respectively.
6. Conclusions
In terms of optimizing livability through neighborhood sizes, the feedback from this study challenges the 25.02 ha suggested by the current Master Plan. Instead, it proposes 50.24 ha, which denotes a 400-m radius, or 10-min walking; that is based supported by other relevant urban planning literature. The walking outcomes and accessible amenities within a 10-min walk were highly associated and found to enhance pedestrian activity. In terms of the percentage ratio of retail space, the findings from this study disagree with the suggested proportion of ~1%. Instead, we propose that mixed types of commercial and retail activity should occupy up to 10% of the total land use. The findings suggest that the ratio should be separated into: food shops (~5%); consumer goods shops, selling items such as appliances or clothes (~2.5%); and general services, such as barbers, coffee shops, or maintenance workshops (~2.5%). In terms of health and religious centers, this study agrees with the Master Plan’s proposed approximate proportion of <1% for each. Meanwhile, open space was specified into playgrounds, local parks, roads and open spaces, and this study agrees with the approximate amount of 30% suggested by the Master Plan. However, more walking was observed in the traditional neighborhood (Al-Saymmar), which accommodates more and smaller open spaces. In terms of housing, the evidence from this study suggests 50% for the single-family housing residential typology; therefore it challenges the suggested high ratio of low-density housing within the Master Plan. Finally, no feedback is offered in terms of educational land use, since this depends upon relevant standardizations.
For other planning and design criteria, the indicators applied by this study suggest that the planning of new neighborhoods should, not only be confined to defining the densities and types of land use, but should also consider the topologic relationships, and streetscapes design, as these are important influences on walking. In this respect, further suggestions, in the form of both qualitative and quantitative recommendations, were made by this study. Based on evidence, the recommendations mostly focused on the organization of traditional neighborhoods (Al-Saymmar), which are considered more pedestrian-friendly environments than the more modern developments (Al-Mugawleen and Al-Abassya) because the increase in walking minutes were significantly associated with the higher scores in urban planning and design indicators tested. However, modern neighborhoods were found to be better in other respects than traditional neighborhoods; for example, commercial growth within the center of modern neighborhoods was far greater than in traditional neighborhoods, as was the permeability, and straightness of edges.
\n',keywords:"New Urbanism, smart growth, urban design, physical environment, neighborhood planning, walking",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/67907.pdf",chapterXML:"https://mts.intechopen.com/source/xml/67907.xml",downloadPdfUrl:"/chapter/pdf-download/67907",previewPdfUrl:"/chapter/pdf-preview/67907",totalDownloads:139,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,dateSubmitted:"April 18th 2019",dateReviewed:"June 3rd 2019",datePrePublished:null,datePublished:"December 16th 2020",dateFinished:"June 28th 2019",readingETA:"0",abstract:"Recognizing the importance of physical environments as a major product of an urban design process for the livability of the built environment, this study focuses on urban planning and design characteristics within three different neighborhood typologies of Basra City. The aim of the study is to support future urban developments in the city based on evidences from the association between the current qualities of neighborhood design and the computed walking minutes of residents. These characteristics are determined from reviewed literature in urban design as reliable physical environmental perceived or objectively measured qualities. The methodology of this study describes four steps of analysis such as: (1) the use of the cadastral maps of the case studies as a source of raw information for objective measurement; (2) the use of objective and subjective measures as defining indicators that are utilized from previous studies; (3) the application of defined indicators for the selected neighborhoods through a comparative analysis; and (4) the conducting of statistical analysis to reveal the influence of the defined indicators on the walking. The findings of this study have led to conclusions on the importance of design attributes to future master planning of neighborhoods especially those of the traditional neighborhood, such as the Al-Saymmar neighborhood in Basra city.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/67907",risUrl:"/chapter/ris/67907",book:{slug:"sustainability-in-urban-planning-and-design"},signatures:"Qaaid Al-Saraify and David Grierson",authors:[{id:"302327",title:"Dr.",name:"Qaaid",middleName:null,surname:"Al-Saraify",fullName:"Qaaid Al-Saraify",slug:"qaaid-al-saraify",email:"qaaid.alsaraify@gmail.com",position:null,institution:null},{id:"302328",title:"Dr.",name:"David",middleName:null,surname:"Grierson",fullName:"David Grierson",slug:"david-grierson",email:"d.grierson@strath.ac.uk",position:null,institution:{name:"University of Strathclyde",institutionURL:null,country:{name:"United Kingdom"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Defining the case studies",level:"1"},{id:"sec_3",title:"3. Review of the measurement indicators of the urban physical environment",level:"1"},{id:"sec_4",title:"4. The measurement process of physical environmental attributes",level:"1"},{id:"sec_4_2",title:"4.1 Block and housing units density",level:"2"},{id:"sec_5_2",title:"4.2 Mixed land use",level:"2"},{id:"sec_6_2",title:"4.3 Streets connectivity",level:"2"},{id:"sec_7_2",title:"4.4 Pedestrian catchment area (PCA)",level:"2"},{id:"sec_8_2",title:"4.5 Pedestrian route directness ratio (PRDR)",level:"2"},{id:"sec_9_2",title:"4.6 Clustering coefficient",level:"2"},{id:"sec_10_2",title:"4.7 Edges assessment",level:"2"},{id:"sec_11_2",title:"4.8 Enclosure ratio",level:"2"},{id:"sec_13",title:"5. The statistical analysis",level:"1"},{id:"sec_13_2",title:"5.1 Findings",level:"2"},{id:"sec_15",title:"6. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'PWK D, PIJ T. 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The Department of Architecture, The University of Basra, Iraq
The Department of Architecture, University of Strathclyde, UK
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1. Introduction
Bariatric surgery (BS) can achieve weight loss (WL), treat obesity-related metabolic disease and enhance the metabolic status by improving hypertension, type 2 diabetes mellitus (T2DM) and lipid profile, thereby decreasing the cardiovascular risk [1, 2]. Despite effective WL after BS, some patients do not achieve their target weight goals, and others regain a significant portion of their weight at long-term follow-up. Weight regain (WR) has a range of undesirable medical and psychological impacts [3, 4].
WR might occur after common BS procedures e.g. gastric bypass, adjustable gastric banding (LAGB), and sleeve gastrectomy (LSG), to different extents and at variable interval times [5]. The causes for WR are multifactorial, including patient- and procedure-specific factors [6, 7]. Interestingly, WR might occur despite the patients’ stated adherence to advised behavioral measures and absence of surgical anatomic causes. This suggests that various pre or post-operative demographic, physiologic or metabolic features could play a role. Given the complexity of the factors involved in WR, multimodal management strategies tailored to meet the individual needs of patients are essential.
2. Definitions of insufficient weight loss and weight regain
There is a distinction between two types of WL failure post BS: insufficient WL (IWL); and WR. The grouping of these two categories together should be discouraged. IWL is defined as excess weight loss (EWL%) of <50% at 18 months after BS [8], while WR is defined as regain of weight that occurs after achievement of an initial successful weight loss (defined as EWL% > 50%).
A range of definitions describe WR post BS [9, 10]. The lack of standard definition, consensus statements and guidelines leads to poor reporting and understanding of the significance of WR [3, 8, 10]. Moreover, clearer definitions will help to recognize when intervention is required and guide the intervention [8]. Available definitions include: regaining weight reaching a body mass index (BMI) >35 after successful WL [11]; an increase in BMI of ≥5 kg/m2 above the nadir weight [12]; > 25% EWL% regain from nadir [13, 14]; increase in weight of >10 kg from nadir [15, 16]; any WR [17]; any WR after type 2 diabetes mellitus (T2DM) remission [18]; or an increase of >15% of total body weight from nadir [19, 20]. The most common definition, an increase of ≥10 kg of nadir weight [15, 21], does little to define the clinical significance of the amount of WR in the affected individual. Therefore, a WR definition needs to be meaningful rather than arbitrary. It is important to note that multiple definitions affect the reporting of the prevalence of WR, and considerably change the reported outcomes. For instance, applying 6 different WR definitions to 55 patients 5 years after LSG led to WR rates ranging from 9–91% [10]. Similarly, the use of 5 continuous and 8 dichotomous measures among 1406 Roux en Y gastric bypass (RYGB) patients followed up for 5 years resulted in WR rates ranging from 44–87% [9]; and others reported rates between 16–37% WR 5 years post LAGB, LSG, and RYGB [19]. Therefore, more research is needed to define WR after BS in order to standardize its measurement.
3. Prevalence of WR and IWL after bariatric procedures
WR following BS varies by the type of BS performed, whether restrictive or malabsorptive as outlined below.
3.1 Laparoscopic gastric band (LAGB)
A large prospective multicenter study in Sweden found that 10 years post LAGB, patients regained 38% of the maximal weight they lost post surgery [1]. Likewise, research at 10 US hospitals that assessed weight trajectories among 2348 participants including 610 LAGB patients reported 1.4% WR 3 to 7 years after surgery [22] (Table 1).
Type of BS
Prevalence of WR
LAGB
1.4% between years 3 and 7 years [22] 38% at 10 years [1]
LSG
5.7% at 2 years [3] 39.5% at 5 years [23] 76% over variable follow-up periods ranging from 2 to 6 years [3]
RYGB
17.1% at 2 years [24] 22.5% at 3 years [9] 14.6%–26.8% at 5 years [9, 25] 3.9% between 3 and 7 years [22]
Table 1.
Prevalence of WR by type of BS.
LAGB: Laparoscopic gastric band; LSG: Laparoscopic sleeve gastrectomy; RYGB: Roux en Y gastric bypass.
3.2 Laparoscopic sleeve gastrectomy (LSG)
A systematic review of 21 studies reported WR rates post LSG ranging from 5.7% at 2 years to 76% over variable follow-up periods from (2 to 6 years) [3]. Other studies found that WR started three years after LSG [23]. At 5 years, WR (>10 kg) was observed in 39.5% of patients, where the EWL% decreased from 84.8% at one year to 57.3% after 5 years [23].
3.3 Roux en Y gastric bypass (RYGB)
Research among 1426 patients found that at 2 years, 17.1% regained >15% of their 1-year post-operative weight [24]. Others reported a 22.5% WR at 3 years and 26.8% at 5 years [9]. The Longitudinal Assessment of Bariatric Surgery (LABS) study observed 3.9% WR between 3 and 7 years post RYGB [22]. Others found that among 2965 patients, WR was 14.6% at 5 years post-surgery [25].
4. Causes of WR
Causes of WR following BS are multifactorial, and can be categorized into patient- and surgical-specific causes. The former includes hormonal causes and maladaptive lifestyle behaviors (e.g. dietary non-compliance and physical inactivity) [3, 7]. Other factors include the lack of follow-up support and mental health causes such as psychiatric conditions and maladaptive eating [3, 7]. Surgical-specific factors include e.g., enlargement of the gastric pouch or gastro-gastric fistula. Recognizing such underling etiologies is key to develop appropriate management strategies [26]. Figure 1 depicts the causes of WR.
Figure 1.
Summary of the causes, predictors and prevention and management strategies of weight regain.
4.1 Hormonal
Weight reduction following BS may be dependent to some extent on the ‘normalization’ of hormonal inputs. Furthermore, patients who fail to achieve WL post-BS or experience WR may have persistent hormonal ‘imbalances’ (e.g. high ghrelin, low peptide YY) which need to be addressed in order to accomplish WL.
Ghrelin is a hormone that is important in regulating food intake and energy balance. BS has a positive effect on ghrelin, where a significant decrease in both fasting and post prandial ghrelin is observed early after BS leading to decreased appetite and food intake [27]. However, research have found that among RYGB patients, subjects with WR had significantly higher pre and postoperative ghrelin levels compared to those who maintained or lost weight (722 ± 29 vs. 540 ± 156 pg/ml) [28]. Similarly, patients with WR 5 years post LSG had higher plasma ghrelin levels than their level at 1 year post surgery [16].
Peptide YY (PYY) is a 36 amino acid hormone that is released by the L-cells of the gastrointestinal tract after food intake to suppress appetite. Likewise, Glucagon-like protein-1 (GLP-1) is released after meals by L cells in the small intestine to stimulate insulin secretion, inhibit glucagon release, and delay gastric emptying [29]. Both these anorexigenic hormones display enhanced nutrient-stimulated secretion after BS, more so after RYGB than LSG [29]. However, the level of theses hormones was noticed to be lower in patients with WR. For instance, meal-stimulated gastric inhibitory polypeptide and glucagon-like peptide-1 (GLP-1) levels at 30 min were lower in 10 patients who had WR compared with 14 patients who successfully maintained WL post RYGB [30]. Whilst hormonal adaptation as a biological response to non-surgical WL has been examined [31], its influence on WR post BS is less documented in humans. For example, rodent studies showed that postsurgical WR was associated with failure to maintain elevated plasma PYY concentrations [32].
4.2 Nutritional non-adherence
Immediately following BS, caloric intake is reduced due to a smaller gastric capacity, diminished hunger, and increased satiety brought about by the anatomical and metabolic changes. Nevertheless, for some patients, caloric intake gradually increases over time which contributes to postoperative WR. In the Swedish Obesity Study, mean daily intakes of 2900, 1500, 1700,1800, 1900, and 2000 kcal/day were observed at baseline, 6 months, 12 months, 2 years, 3 years, and 4–10 years postsurgery respectively [1]. Such increase in food intake often begins in the second post-operative year, likely causing WR [1]. In addition, dietary non-adherence and the consumption of high-calorie foods and beverages contribute to the higher caloric intake leading to WR. A postoperative behavioral survey of 203 patients observed positive correlations between the magnitude of WR and evening or night consumption of large quantities of food, eating large amounts of high-fat foods, and eating out more frequently [33]. Equally, among 289 RYGB patients, 23% demonstrated dietary non-adherence and a continuation of pre-surgical eating patterns, leading to suboptimal weight loss and WR [34]. Such evidence substantiate the importance of diet quality and caloric intake as causative factors for WR after BS, and also highlight the importance of measuring and documenting the diet quality after BS [35].
Grazing behavior is the repeated episodes of consumption of smaller quantities of food over a long period of time accompanied by feelings of loss of control [36]. Those engaging in grazing nibbled continuously ≥2 days per week for a 6-month period, with an inability to stop or control their eating while nibbling [36]. Grazing contributes to poor weight outcomes post BS [37]. Although grazing and binge eating are similar as they involve subjective episodes of food consumption accompanied by a loss of control; however, grazing is physiologically more possible post BS than large binges. In 80% of patients with preoperative binge eating or grazing with loss of control, these behaviors returned 6 months post-surgery [36]. This suggests that preoperative binge eating may reemerge as postsurgical grazing in the context of a reduced stomach capacity [36].
Food indiscretion also contributed to WR. For instance, the follow up of 100 patients for 85 months after surgery revealed that poor dietary habits including consumption of excessive calories, snacks, sweets oils and fatty foods were statistically higher in WR patients [6]. This highlightes the importance of appropriate nutritional counselling for long-term weight maintenance. Lack of appropriate nutritional follow-up was also significantly associated with WR post BS [6]. For example, studies have found that among those with WR post-RYGB, 60% never maintained follow-up with appropriate nutritional consultants [38].
4.3 Physical Inactivity
Inadequate physical activity contributes to WR. Only 10–24% of BS patients met the guidelines regarding minimal physical activity for health promotion (i.e., ≥150 min/week or moderate-to-vigorous physical activity in bouts of ≥10 min) [39]. A meta-analysis of 14 studies and a literature review of 19 studies concluded that post-BS physical activity was significantly associated with greater WL [40]. Amongst 100 obese patients post-RYGB, those who performed physical activity had the lowest incidence of WR compared to those who were relatively inactive [6]. Barriers to exercise among bariatric patients such as health concerns, lack of proximity to a gym/park, or feeling self-conscious should be identified and addressed [40]. Such findings highlight the importance of measuring and documenting physical activity levels after BS [35].
Similarly, sedentary behavior, defined as ‘any waking behavior performed while in a sitting or reclining posture that requires very low energy expenditure’. The represents a risk factor for WR Sedentary behavior is associated with increased risk of obesity and related comorbidities [40]. Research have found that severely obese BS candidates are at high risk for SB [41]. In this study they found that BS candidates spent about 30% of their sedentary time watching television, suggesting that this is an important cause of sedentary behavior and should be a target for patient counseling [41].
4.4 Mental health
Mental health status prior to surgery is linked to WL following BS. Therefore, pre-operative psychological evaluation is important. Psychological factors might interfere with successful WL by undermining motivation, diet and exercise compliance, and other health behaviors critical to maintaining WL [42]. Among 60 adults who underwent RYGB or LAGB, 40% and 33.4% had single or multiple psychiatric diagnoses respectively, 47.5% stopped losing weight after 1 year, and 29.5% regained weight [43]. Furthermore, patients with ≥2 psychiatric conditions were 6 times more likely to either stop losing weight or regain weight relative to those with no or single psychiatric diagnosis [43]. Evidence supports the association between post-operative depressive disorders and poorer WL; however, the directionality of the relationship remains unknown [44]. More research is required to assess the long-term associations and directionality of depression and weight loss post BS.
Maladaptive eating patterns after BS have impact on weight and psychological outcomes [45]. One of these abnormal eating patterns is BE disorder which is defined as ‘the consumption of large quantities of food during a short amount of time without being in control of this behavior’, and is strongly associated with psychological distress [26]. BE disorder predicts poorer weight outcomes post BS, resulting in smaller BMI reductions as well as more WR [46, 47]. Despite the physical limitations of BS on stomach capacity, BE is not always abolished and many of those who had BE before BS still had feelings of loss of control when eating even small amounts of food post BS [37, 47]. Following RYGB, patients who regained >10% of their EWL% had significantly higher frequencies of BE and loss of control [46], and these maladaptive eating behaviors were significantly correlated with greater WR [46]. Follow up of 96 patients post RYGB two to seven years after surgery showed that binge eaters increased their BMI by 5.3 kg/m2 compared with 2.4 kg/m2 increase in non-binge eaters [48]. Likewise, among LAGB patients, the prevalence of eating disorder increased from 26.3% to 38.0% over one year post surgery, an increase that correlated with poorer WL outcomes [37].
4.6 Anatomic surgical failure
Each type of BS has its own potential mechanism/s of surgical failure that can lead to WR as outlined below.
4.6.1 Laparoscopic gastric band
LAGB success is correlated with appropriate follow-up, as saline adjustment of the band is essential for proper restriction and WL. Therefore, it is important to assess patients with WR after LAGB for potential pouch distension. Pouch distension is managed conservatively by complete band deflation, low calorie diet, reinforcement of portion size, and follow-up contrast study in 4–6 weeks, with success in more than 70% of patients [49]. On the other hand, premature removal of LAGB also causes WR. Studies have found that only 12% of patients with early band removal maintained their current weight [50]. Long term, LAGB removal rate is high, reaching 12% [51]. Moreover, after 14 years, the reoperation rate was as high as 30.5% with an average reoperation rate of 2.2% for every year of follow-up [51]. The main reason for LAGB removal was intolerance secondary to increased reflux type symptoms [52].
4.6.2 Laparoscopic sleeve gastrectomy
There are surgical causes of WR post LSG. The gastric sleeve may dilate over time leading to reduced restrictive effect and increase in gastric capacity, both associated with reduced satiety response and increased food intake resulting in WR [23]. For instance, among the 15.7% patients who had WR, CT scan volumetry showed that the mean gastric volume increased from 120 mL early after surgery to a mean of 240 mL at 3 years and to 524 mL at 5 years follow-up [23]. Several theories have been proposed as to the relationship of increased gastric volume and WR. One theory is that the physiologic dilation of the remnant stomach over time and the size of the gastric sleeve are linearly correlated with post-operative BMI [53, 54]. Another theory is the incomplete removal of the gastric fundus [55, 56], where in many cases, the dissection over the fundus, especially on the posterior aspect, may be difficult and technically demanding, notably in patients with the extreme obesity. Therefore, the success of LSG depends on the surgeon’s learning curve [55].
4.6.3 Roux-en-Y gastric bypass
RYGB produces WL through restriction of intake and malabsorption. In assessing WR post-RYGB, anatomical abnormalities are proposed to play a role. Dilatation of the gastric pouch or gastrojejunostomy (GJ) stoma outlet have been associated with loss of satiety with subsequent increase in food intake and WR [57, 58]. Among 205 RYGB patients who had upper endoscopy as workup for WR, dilation of the GJ was identified in 58.9%, enlarged gastric pouch in 28.8%, and both abnormalities in 12.3% of patients [57]. Multivariate analysis found that stoma diameter (>2 cm) was independently associated with WR [58], where among 28 patients following RYGB, WR was associated with dilated gastric stoma [59]. In this group, successful reduction in anastomotic size (<12 mm) with a sclerotic agent resulted in a mean 26-kg WL at 18 months [59].
Another anatomic change that reduces RYGB’S effectiveness is gastro-gastric fistula, an abnormal communication between the gastric pouch and the excluded stomach. This is thought to develop as a result of the breakdown of the surgical staple line. Although gastro-gastric fistulas are uncommon, with a 1.5–6% incidence rate [60]. Gastro-gastric fistulas have potentially significant effects as a complication after RYGB [60] as they may diminish the restrictive and malabsorptive components of RYGB leading WR [61].
5. Predictors of WR post BS
Knowledge of the preoperative predictors of WR post-BS can assist in identifying patients at risk for WR. The bariatric team can then offer such patients appropriate resources and counseling. Figure 1 depicts the predictors of WR.
5.1 Age
Age seems to be a predictor of WR, however, findings are inconsistent. Some smaller studies identified older age as a potential preoperative predictor of WR [62, 63]. Among 227 patients who underwent RYGB, older age (>60 years) predicted inadequate EWL% at 12 months [62]. While others found that younger individuals were more likely to have WR after RYGB [24].
5.2 Gender
Among post RYGB patients, male sex was associated with a worse weight trajectory [22] and suboptimal WL at 1 year after surgery [64]. Others found no effect of gender on weight loss outcomes [62].
5.3 Duration since surgery
Longer duration after BS predicted WR [24]. One study reported significant longer time since RYGB surgery in patients with WR (6 years) compared with patients who sustained their weight loss (3.3 years) [24]. Longer durations after surgery are probably associated with resolution of food intolerances, return to preoperative eating and other lifestyle patterns, anatomic surgical failure, or poor attendance of postoperative appointments [7, 65].
5.4 Preoperative BMI
Greater preoperative BMI was significantly associated with IWL [64]. A meta-analysis found that preoperative BMI and super-obesity were negatively associated with WL, where super-obese patients had 10.1 EWL% decrease [66]. Others observed that at 12 months post RYGB or LAGB, patients with baseline BMI ≥ 50 kg/m2 were more likely to have significant WR, but those with BMI < 50 kg/m2 were likely to continue losing weight [67]. Similarly, 80–100% of LSG patients with pre-surgery BMI > 40 kg/m2 had WR to BMI > 30 kg/m2 two years years after surgery; but only 3.6–38% of patients with lower pre-operative BMI (32.1–39.9 kg/m2) had BMI > 30 kg/m2 during the same time period [68].
5.5 Mental health
A presurgical BE disorder diagnosis predicted higher BMI. For example, studies found that among post-RYGB patients with 28.1 months mean follow-up, 79% reported WR and 15% regained ≥15% of their total weight loss [65]. The independent predictors of significant WR were lack of control of food urges (odds ratio, OR = 5.1), alcohol/drug use (OR = 12.74), lowest self-reported well-being scores (OR = 21.5), and lack of follow-up visits [65].
5.6 Presence of Comorbidities
Presence of T2DM predicts WR [22, 62, 63]. An assessment of 2348 bariatric participants in the Longitudinal Assessment of Bariatric Surgery (LABS) Study found that low HDL cholesterol and hypertension were also associated with an inferior weight trajectory [22].
6. Implications of weight regain
WR has important health consequences including recurrence of obesity related co-morbidities such as T2DM and deterioration in quality of life (QoL), thus contributing to socioeconomic and direct health care costs. This range of implications of WR is highlighted below.
6.1 Relapse of comorbidities
WR following BS is associated with and significantly predicted relapse of T2DM [12, 70]. At 10 year follow up, T2DM relapse was dependent on the extent of WR [70]. Patients with no WR had no relapse of their diabetes [70]. While, patients with mild regain (increase body weight > 5 kg from nadir) and severe regain (> 10 kg from nadir) had 5% and 17% relapse rates respectively [70]. Among 1406 RYGB patients with WR during the first year after reaching nadir weight, 25.8% and 46.2% of participants experienced progression of hyperlipidemia and hypertension respectively [9].
6.2 Quality of life
WR is significantly associated with deterioration in QoL [3, 9]. A study found that WR at 5 years after LSG was associated with a lower odds of satisfaction with surgery as measured by the Bariatric Analysis Reporting Outcome System (BAROS) score (incorporates weight loss, changes in medical conditions, health-related QoL, and reoperations) [3]. Others reported declines of physical and mental health–related QoL among 20.2% and 27.7% of patients with WR respectively [9]. Moreover, satisfaction with surgery also declined among 12.4% of patients with WR [9]. This decline was observed when the rate of WR was the highest, supporting a dose–response relationship (i.e., the less WR, the better) for physical health–related QoL [9].
7. Prevention of weight regain
Figure 1 summarizes the prevention strategies of WR. The foundation of prevention of WR after BS is aggressive behavioral interventions, similar to those utilized for medical weight management patients [33]. Behavioral modification components include commitment to regular structured physical activity, dietary control, nutritional optimization with substantive changes in eating practices and lifestyle habits [33, 71]. Other modulators include stress management, realistic goal setting, environmental control strategies, support systems, and cognitive restructuring [33, 71]. Close regular follow-up should start shortly after BS to reinforce nutritional and lifestyle instructions provided at discharge. Monitoring, education, and support should continue on the long term as the effectiveness of behavioral changes diminishes with time [33]. Self-monitoring with regular weight measurement, food records, and exercise diaries are essential tools for avoiding WR. These strategies increase patient’s awareness of eating patterns, and allow the bariatric dietitian to identify high-risk areas, such as nutritional inadequacy, food intolerances, poor food choices, or food dislikes that compromise weight loss and nutritional status [72]. In-person dietary counseling by a registered dietitian has an important role in prevention of WR post BS [73]. Structured physical activity is vital for weight prevention. An RCT demonstrated that a 5-month supervised exercise program post LSG resulted in reduction total body weight (TBW) and waist circumference with an increase in EWL% compared with the control group [74]. Conversely, stopping of the exercise program led to weight regain, with increased fat mass and decreased EWL% [74].
8. Management of WR
Figure 1 illustrates the management strategies of WR. WR after BS is complex and multifactorial [7]. Hence, management requires a holistic strategy addressing patient- and surgery-related factors that might contribute to WR. Dietary patterns, psychological disorders and physical activity levels should all be reviewed, as diet (25.3%), physical activity (21%) and motivational issues (19.7%) were the most common reasons among patients with WR [75]. Patients seeking BS often present with a range of mental health issues including mood, anxiety, addiction and personality disorders [7, 26]. Diagnosis and management of these conditions may improve outcomes following BS. As the patient undergoes psychological, dietary and physical activity counselling, it is critical to address the hormonal causes, and any anatomic/post-surgical changes that cause WR. Baseline anatomic studies include esophagogastroduodenoscopy or an upper gastrointestinal contrast to evaluate the GI tract [76]. These modalities provide essential data about the gastric remnant size, size of the gastrojejunal anastomosis, presence of gastro-gastric fistula, and location/integrity of the bands. Available treatment options include behavior interventions, WL-approved medications, endoscopic interventions and revision surgery to counter some of the factors that resulted in WR.
8.1 Behavioral
Psychological and behavioral factors that have negative impact on long term WL outcomes include life stressors that derail weight maintenance and decreased adherence to the recommended postoperative diet. This is likely due to lack of psychological skills to engage in long term healthy eating behaviors. This is particulalry important as the effects of surgery on appetite, hunger, and desire for food decrease. The aim is to address such challenges by behavioral therapy that is tailored to each patient’s need [77, 78]. Many patients with WR are lost to follow up; therefore, open, non-judgmental strategies that support the actions that patients are doing well are critical to motivate and involve patients in management [76].
A 6-week intervention of cognitive and dialectical behavior therapies among 29 RYGB patients (93% female) with WR of 37% of the initial WL, found that treatment completers had 1.6 ± 2.38 kg mean weight decrease compared with non completers [79]. Moreover, patients who completed behavior therapy treatment had improvement in their depressive symptoms with decreased grazing patterns (p ≤ 0.01), as well as subjective binge eating episodes (p ≤ 0.03) compared to non-completers [79]. Likewise, a 10-week behavioral intervention of psychological skills to mitigate WR among 11 patients after BS was feasible, acceptable (72% retention), and with high satisfaction among completers (4.25 out of 5.00)[80]. WR was stopped or reversed, with a mean 3.58 ± 3.02% total body WL% [80]. Similarly, the use of acceptance-based strategies and online or phone intervention delivery modes to enhance outcomes and reach more patients showed feasibility, acceptability (70% retention), efficacy, high satisfaction score of (4.7 out of 5.0), and reversal of WR with a mean 5.1 ± 5.5% total WL% at 3-month follow-up [81].
8.2 Dietary
Structured dietary interventions assist patients to improve WL. A randomized controlled trial (RCT) assigned post RYGB patients into two groups: a structured dietary intervention incorporating portion-controlled foods vs. a control group [77]. Both groups received behavioral WL instructions (one 60-min session followed by 4 coaching telephone calls at monthly intervals). The intervention group had significantly reduced calorie intake at 4 months (−108 vs. 116 Kcal) and increased WL% at 4 and 6 months compared to the control group (−4.56% vs. −0.13%, −4.07% vs. −0.14%, respectively) [77]. Another 16-week RCT among women who regained ≥5% of their lowest post-RYGB weight found that whey protein supplementation promoted WL and fat mass loss, with preserved muscle mass, compared to controls who gained weight (0.42 kg) and fat mass [82].
8.3 Pharmacological
Prior to 2012, the only FDA-approved WL drugs were orlistat, a modestly effective pancreatic lipase inhibitor with some side effects and phentermine, a sympathomimetic appetite suppressant approved for short-term use [83]. Since 2012, 4 other WL medications were approved [83]: phentermine-topiramate, bupropion hydrochloride-naltrexone hydrochloride, liraglutide and lorcaserin hydrochloride (withdrawn due to cancer risk [84]). Since then, anti-obesity medications have been increasingly used to manage WR post-BS. In an assessment of anti-obesity medications for WR/IWL among 319 patients (258 RYGB, 61 LSG), 54% lost ≥5% of their TBW, with many high responders (30.3% of patients lost ≥10%, and 15% lost ≥15% of their TBW) [85]. Of the 14 FDA approved and off-label anti-obesity medications, only topiramate showed statistically significant WL, where patients were 1.9 times more likely to lose ≥10% of their TBW [85]. Regardless of the postoperative BMI, RYGB patients were significantly more likely to lose ≥5% of their TBW with anti-obesity medications [85]. Another study of individual and combined anti-obesity medications for WR post RYGB reported that patients who received medications achieved significantly more WL compared to those not using anti-obesity medications [86]. Additionally, there was slower overall WR in the anti-obesity medications group during long term (11 year) follow up [86].
Among young adults post RYGB and LSG, topiramate, phentermine, and/or metformin led to 54.1%, 34.3% and 22.9% of patients losing ≥5% ≥10% and ≥ 15%, of their weight respectively [87]. Again, RYGB had higher median WL% than LSG (−8.1% vs. −3.3%), with no differences whether the anti-obesity medications were started at weight plateau or after WR [87]. In another study, phentermine was compered to phentermine–topiramate combination among RYGB or LAGB patients with WR and WL plateau [88]. The study showed that phentermine and phentermine–topiramate patients lost 6.35 kg (12.8% EWL%) and 3.81 kg (12.9% EWL%) respectively at 90 days post treatment [88].
Liraglutide, a GLP-1 analogue with central and peripheral actions, inhibits glucagon secretion, increases insulin secretion, decreases the gastric emptying rate, and promotes satiety [89]. In a recently published study, among 117 patients with WR after RYGB, LAGB and LSG, the use of liraglutide 3 mg over a 7 month period resulted in statistically significant WL (−6.3 ± 7.7 kg, P < .05) compared to baseline regardless of the type of surgery [90]. Moreover, the decrease in weight remained significant even after one year of liraglutide use [30]. In this study, nausea was the most prevalent side effect (29.1% patients) [90].
8.4 Surgical
Revision of a previous BS are carried out due to surgical complications e.g., development of intractable marginal ulcer, gastro-gastric fistula, severe gastroesophageal reflux, and malnutrition [91]. Recently, revisional surgery is increasingly utilized for the management of WR [91, 92].
8.4.1 After failed LAGB
In patients with WR or IWL after gastric band, the surgical options include band removal and revisional BS. A retrospective study evaluated the outcomes of revision of LAGB for inadequate weight loss to LSG or single anastomosis duodenal switch and found that patients who underwent single anastomosis duodenal switch had significantly greater weight loss than LSG in the first year post surgery, with excess BMI loss percentage of 66.7% versus 51.5% [93]. In the same study, at >12 months post revision, both single anastomosis duodenal switch patients and LSG patients had adequate WL (79% for single anastomosis duodenal switch versus 67.8% for LSG) [93]. A systematic review compared the WL outcomes of conversion gastric band to LSG or RYGB and showed significant increase in EWL% in RYGB and patients than LSG patients at 12 and 24 months after revision [94]. However, no statistically significant change was observed in terms of EWL% after 3, 6, or 36 months post revision [94]. RYGB was also associated with a higher rate of complications, readmission and longer operative time [94].
8.4.2 After failed LSG
Several surgical interventions can be considered for failed LSG including conversion to RYGB, biliopancreatic diversion with duodenal switch (BPD/DS), one anastomosis gastric bypass (OAGB) or single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). Among 43 post LSG patients who had revisional surgery for IWL/WR (25 patients converted to BPD/DS, 18 to RYGB), the median EWL% after 34 months was significantly greater for BPD/DS compared to RYGB (59% vs. 23%) [14]. However, short-term complications and vitamin deficiencies were higher in BPD/DS compared with RYGB [14].
Conversions of LSG to OAGB or RYGB are also utilized to manage WR. At 12 months, mean total WL percentage was significantly higher in OAGB compared to RYGB (15.8 ± 7.8% vs. 10.3 ± 7.6%), with no differences in readmission and complications between the two procedures, suggesting that OAGB is safe after failed LSG [95]. However, long-term follow up including the risk of malnutrition is needed for a complete evaluation of OAGB as a revisional BS. Another study evaluating the conversion of LSG to four different gastric bypass procedures including proximal RYGB, type 2 distal RYGB, long biliopancreatic limb RYGB and OAGB showed that the long biliopancreatic limb RYGB and OAGB resulted in significant EWL% at 3 years (33.8% and 33.2% respectively). However, the effect lasted only for 2 years in the proximal RYGB (EWL% of 23.1%) [96].
SADI-S is a relatively new procedure utilized as an alternative to the current duodenal switch (DS) [97]. Outcomes of SADI-S as a revision after LSG showed 20.5% weight loss and 9.4 units BMI change two years post revision with 93.7% T2DM remission rate [98]. Additionally, there were no mortality or conversions to open surgery, and postoperative early and late complication rates were low (5.3% and 6.4% respectively) [98].
8.4.3 After failed RYGB
There seems no standardized approach to revisional surgery after failed RYGB. A systemic review of revision of RYGB for WR (799 studies, 866 patients) assessed 5 revisions: conversion to distal RYGB or BPD/DS, or revision of gastric pouch and anastomosis, revision with gastric band or endoluminal procedures [92]. At 3-years after revision, mean excess body mass index loss percentage for distal RYGB was 52.2%, for BPD/DS was 76%, for gastric pouch or anastomosis revision was 14%, for gastric banding revision was 47.3%, and for endoluminal procedures was 32.1% [92]. Amongst these revisions, gastric pouch or anastomosis revision had the lowest rates for major complications (3.5%), while DRYGB had the highest rate for major complications (11.9%) and mortality (0.6%) [92]. A recently published study showed promising short and long term results as regards to the conversion of RYGB to long biliopancreatic limb RYGB for the management of IWL, where patients achieved an additional excess EWL% ranging from 40.0% at 1 year to 45.3% at 6 years [99].
9. Conclusions
Although BS is an effective treatment for weight loss and comorbidities resolution, however WR may occur on the long term. The lack of a standard definition and consensus on what constitutes clinically significance WR leads to poor reporting of this entity which requires further research. The underlying factors that contribute to WR are multifactorial, including hormonal and surgical causes, nutritional noncompliance, physical inactivity, and mental health issues. Therefore, patients with significant WR following BS should undergo comprehensive evaluations to determine the underlying etiology. Management should focus on preventive and treatment strategies delivered in a multidisciplinary approach to include dietary intervention, behavioral counseling, lifestyle modifications, pharmacotherapy and, if indicated, surgical revision. Future research should focus to identify the etiological factors and effective intervention strategies.
Acknowledgments
The publication fees of this chapter was funded by a grant from Novo Nordisk.
Conflict of interest
None.
Abbreviations
BMI
body mass index
BPD/DS
laparoscopic biliopancreatic diversion with duodenal switch
BS
Bariatric surgery
EWL
excess weight loss
FDA
food and drug administration
GI
gastrointestinal
GLP-1
polypeptide and glucagon-like peptide-1
IWL
insufficient weight loss
LAGB
Laparoscopic gastric band
LSG
Laparoscopic sleeve gastrectomy
OAGB
one anastomosis gastric bypass
QoL
quality of life
RCT
randomized controlled trial
RYGB
Roux en Y gastric bypass
SADI-S
single anastomosis duodeno-ileal bypass with sleeve gastrectomy
T2DM
type 2 diabetes mellitus
TBW
total body weight
WL
weight loss
WR
weight regain
\n',keywords:"bariatric surgery, weight regain, insufficient weight loss, causes, predictors, management",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/74559.pdf",chapterXML:"https://mts.intechopen.com/source/xml/74559.xml",downloadPdfUrl:"/chapter/pdf-download/74559",previewPdfUrl:"/chapter/pdf-preview/74559",totalDownloads:79,totalViews:0,totalCrossrefCites:0,dateSubmitted:"July 21st 2020",dateReviewed:"October 30th 2020",datePrePublished:"December 23rd 2020",datePublished:null,dateFinished:"December 23rd 2020",readingETA:"0",abstract:"Despite successful weight loss after bariatric surgery (BS), weight regain (WR) may occur on long term following most bariatric procedures, with 20–30% of patients either failing to reach their target weight goals or failing to maintain the achieved weight loss. Significant WR has important health consequences, including the reversal of the improved obesity-related comorbidities and psychological function leading to decreased quality of life. Given the challenges faced by these patients, there is a need for multidisciplinary approaches to deal with WR. This chapter addresses the issue of WR among bariatric patients. It starts with the various definitions of insufficient weight loss and WR and the prevalence of weight regain by type of bariatric procedure. The chapter then explores the underlying causes as well as the predictors of WR. It will also outline the behavioral and psychotherapeutic, dietary and exercise strategies employed in the prevention of post-surgery WR. The chapter will then highlight the non-surgical and surgical approaches used in the management of WR. The chapter will conclude with a summary of the findings emphasizing that WR is complex and multifactorial, requiring multidisciplinary and multimodal dietary, behavioral, pharmacological, and surgical management strategies tailored to meet the individual needs of each patient.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/74559",risUrl:"/chapter/ris/74559",signatures:"Wahiba Elhag and Walid El Ansari",book:{id:"9818",title:"Bariatric Surgery - From the Non-surgical Approach to the Post-surgery Individual Care",subtitle:null,fullTitle:"Bariatric Surgery - From the Non-surgical Approach to the Post-surgery Individual Care",slug:null,publishedDate:null,bookSignature:"Dr. Nieves Saiz-Sapena and Dr. Juan Miguel Oviedo",coverURL:"https://cdn.intechopen.com/books/images_new/9818.jpg",licenceType:"CC BY 3.0",editedByType:null,editors:[{id:"204651",title:"Dr.",name:"Nieves",middleName:null,surname:"Saiz-Sapena",slug:"nieves-saiz-sapena",fullName:"Nieves Saiz-Sapena"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Definitions of insufficient weight loss and weight regain",level:"1"},{id:"sec_3",title:"3. Prevalence of WR and IWL after bariatric procedures",level:"1"},{id:"sec_3_2",title:"3.1 Laparoscopic gastric band (LAGB)",level:"2"},{id:"sec_4_2",title:"3.2 Laparoscopic sleeve gastrectomy (LSG)",level:"2"},{id:"sec_5_2",title:"3.3 Roux en Y gastric bypass (RYGB)",level:"2"},{id:"sec_7",title:"4. Causes of WR",level:"1"},{id:"sec_7_2",title:"4.1 Hormonal",level:"2"},{id:"sec_8_2",title:"4.2 Nutritional non-adherence",level:"2"},{id:"sec_9_2",title:"4.3 Physical Inactivity",level:"2"},{id:"sec_10_2",title:"4.4 Mental health",level:"2"},{id:"sec_11_2",title:"4.5 Maladaptive eating: Binge eating (BE) disorder",level:"2"},{id:"sec_12_2",title:"4.6 Anatomic surgical failure",level:"2"},{id:"sec_12_3",title:"4.6.1 Laparoscopic gastric band",level:"3"},{id:"sec_13_3",title:"4.6.2 Laparoscopic sleeve gastrectomy",level:"3"},{id:"sec_14_3",title:"4.6.3 Roux-en-Y gastric bypass",level:"3"},{id:"sec_17",title:"5. Predictors of WR post BS",level:"1"},{id:"sec_17_2",title:"5.1 Age",level:"2"},{id:"sec_18_2",title:"5.2 Gender",level:"2"},{id:"sec_19_2",title:"5.3 Duration since surgery",level:"2"},{id:"sec_20_2",title:"5.4 Preoperative BMI",level:"2"},{id:"sec_21_2",title:"5.5 Mental health",level:"2"},{id:"sec_22_2",title:"5.6 Presence of Comorbidities",level:"2"},{id:"sec_24",title:"6. Implications of weight regain",level:"1"},{id:"sec_24_2",title:"6.1 Relapse of comorbidities",level:"2"},{id:"sec_25_2",title:"6.2 Quality of life",level:"2"},{id:"sec_27",title:"7. Prevention of weight regain",level:"1"},{id:"sec_28",title:"8. Management of WR",level:"1"},{id:"sec_28_2",title:"8.1 Behavioral",level:"2"},{id:"sec_29_2",title:"8.2 Dietary",level:"2"},{id:"sec_30_2",title:"8.3 Pharmacological",level:"2"},{id:"sec_31_2",title:"8.4 Surgical",level:"2"},{id:"sec_31_3",title:"8.4.1 After failed LAGB",level:"3"},{id:"sec_32_3",title:"8.4.2 After failed LSG",level:"3"},{id:"sec_33_3",title:"8.4.3 After failed RYGB",level:"3"},{id:"sec_36",title:"9. Conclusions",level:"1"},{id:"sec_37",title:"Acknowledgments",level:"1"},{id:"sec_40",title:"Conflict of interest",level:"1"},{id:"sec_39",title:"Abbreviations",level:"1"}],chapterReferences:[{id:"B1",body:'Sjöström L, Lindroos A-K, Peltonen M, et al. 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Obesity Surgery. 2014;24:1587-1594'},{id:"B22",body:'Courcoulas AP, King WC, Belle SH, et al. Seven-Year Weight Trajectories and Health Outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) Study. JAMA Surgery. 2018;153:427-434'},{id:"B23",body:'Braghetto I, Csendes A, Lanzarini E, Papapietro K, Cárcamo C, Molina JC. Is laparoscopic sleeve gastrectomy an acceptable primary bariatric procedure in obese patients? Early and 5-year postoperative results. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2012;22:479-486'},{id:"B24",body:'Shantavasinkul PC, Omotosho P, Corsino L, Portenier D, Torquati A. Predictors of weight regain in patients who underwent Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2016;12:1640-1645'},{id:"B25",body:'Baig SJ, Priya P, Mahawar KK, Shah S. Indian Bariatric Surgery Outcome Reporting (IBSOR) Group. Weight Regain After Bariatric Surgery-A Multicentre Study of 9617 Patients from Indian Bariatric Surgery Outcome Reporting Group. Obesity Surgery. 2019;29:1583-1592'},{id:"B26",body:'Kushner RF, Sorensen KW. Prevention of Weight Regain Following Bariatric Surgery. Current Obesity Reports. 2015;4:198-206'},{id:"B27",body:'Sundbom M, Holdstock C, Engström BE, Karlsson FA. Early changes in ghrelin following Roux-en-Y gastric bypass: influence of vagal nerve functionality? Obesity Surgery. 2007;17:304-310'},{id:"B28",body:'Tamboli RA, Breitman I, Marks-Shulman PA, et al. Early weight regain after gastric bypass does not affect insulin sensitivity but is associated with higher ghrelin levels. Obes Silver Spring Md. 2014;22:1617-1622'},{id:"B29",body:'Yousseif A, Emmanuel J, Karra E, et al. Differential effects of laparoscopic sleeve gastrectomy and laparoscopic gastric bypass on appetite, circulating acyl-ghrelin, peptide YY3-36 and active GLP-1 levels in non-diabetic humans. 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Postoperative Behavioral Variables and Weight Change 3 Years After Bariatric Surgery. JAMA Surgery. 2016;151:752-757'},{id:"B46",body:'Kofman MD, Lent MR, Swencionis C. Maladaptive eating patterns, quality of life, and weight outcomes following gastric bypass: results of an Internet survey. Obes Silver Spring Md. 2010;18:1938-1943'},{id:"B47",body:'Freire CC, Zanella MT, Segal A, Arasaki CH, Matos MIR, Carneiro G. Associations between binge eating, depressive symptoms and anxiety and weight regain after Roux-en-Y gastric bypass surgery. Eat Weight Disord EWD. 2020; Jan 2. doi: 10.1007/s40519-019-00839-w. Online ahead of print'},{id:"B48",body:'Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB. Binge eating among gastric bypass patients at long-term follow-up. Obesity Surgery. 2002;12:270-275'},{id:"B49",body:'Eid I, Birch DW, Sharma AM, Sherman V, Karmali S. Complications associated with adjustable gastric banding for morbid obesity: a surgeon’s guides. 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Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision. Gastrointestinal Endoscopy. 2007;66:240-245'},{id:"B60",body:'Cucchi SG, Pories WJ, MacDonald KG, Morgan EJ. Gastrogastric fistulas. A complication of divided gastric bypass surgery. Annals of Surgery. 1995;221:387-391'},{id:"B61",body:'Filho AJB, Kondo W, Nassif LS, Garcia MJ, Tirapelle R de A, Dotti CM. Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass. JSLS. 2006;10:326-31'},{id:"B62",body:'Al-Khyatt W, Ryall R, Leeder P, Ahmed J, Awad S. Predictors of Inadequate Weight Loss After Laparoscopic Gastric Bypass for Morbid Obesity. Obesity Surgery. 2017;27:1446-1452'},{id:"B63",body:'Paul L, van der Heiden C, Hoek HW. Cognitive behavioral therapy and predictors of weight loss in bariatric surgery patients. 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Loss and Regain of Weight After Laparoscopic Sleeve Gastrectomy According to Preoperative BMI : Late Results of a Prospective Study (78-138 months) with 93% of Follow-Up. Obesity Surgery. 2018;28:3424-3430'},{id:"B69",body:'Marek RJ, Ben-Porath YS, Dulmen MHM van, Ashton K, Heinberg LJ. Using the presurgical psychological evaluation to predict 5-year weight loss outcomes in bariatric surgery patients. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2017;13:514-521'},{id:"B70",body:'Capoccia D, Guida A, Coccia F, et al. Weight Regain and Diabetes Evolution After Sleeve Gastrectomy: a Cohort Study with over 5 Years of Follow-Up. Obesity Surgery. 2020;30:1046-1051'},{id:"B71",body:'Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obesity Surgery. 2004;14:1148-1156'},{id:"B72",body:'McGrice M, Don PK. Interventions to improve long-term weight loss in patients following bariatric surgery: challenges and solutions. Diabetes Metab Syndr Obes Targets Ther. 2015;8:263-274'},{id:"B73",body:'Swenson BR, Saalwachter Schulman A, Edwards MJ, Gross MP, Hedrick TL, Weltman AL, et al. The effect of a low-carbohydrate, high-protein diet on post laparoscopic gastric bypass weight loss: a prospective randomized trial. The Journal of Surgical Research. 2007;142:308-313'},{id:"B74",body:'Marc-Hernández A, Ruiz-Tovar J, Aracil A, Guillén S, Moya-Ramón M. Effects of a High-Intensity Exercise Program on Weight Regain and Cardio-metabolic Profile after 3 Years of Bariatric Surgery: A Randomized Trial. Sci Rep [Internet]. 2020 [cited 2020 Aug 29];10. A'},{id:"B75",body:'Thompson CC, Slattery J, Bundga ME, Lautz DB. Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain. Surgical Endoscopy. 2006;20:1744-1748'},{id:"B76",body:'Velapati SR, Shah M, Kuchkuntla AR, et al. Weight Regain After Bariatric Surgery: Prevalence, Etiology, and Treatment. Curr Nutr Rep. 2018;7:329-334'},{id:"B77",body:'Kalarchian MA, Marcus MD, Courcoulas AP, Cheng Y, Levine MD, Josbeno D. Optimizing long-term weight control after bariatric surgery: a pilot study. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2012;8:710-715'},{id:"B78",body:'Sarwer DB, Dilks RJ, West-Smith L. Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2011;7:644-651'},{id:"B79",body:'Himes SM, Grothe KB, Clark MM, Swain JM, Collazo-Clavell ML, Sarr MG. Stop regain: a pilot psychological intervention for bariatric patients experiencing weight regain. Obesity Surgery. 2015;25:922-927'},{id:"B80",body:'Bradley LE, Forman EM, Kerrigan SG, Butryn ML, Herbert JD, Sarwer DB. A Pilot Study of an Acceptance-Based Behavioral Intervention for Weight Regain After Bariatric Surgery. Obesity Surgery. 2016;26:2433-2441'},{id:"B81",body:'Bradley LE, Forman EM, Kerrigan SG, et al. Project HELP: a Remotely Delivered Behavioral Intervention for Weight Regain after Bariatric Surgery. Obesity Surgery. 2017;27:586-598'},{id:"B82",body:'Lopes Gomes D, Moehlecke M, Lopes da Silva FB, Dutra ES, D’Agord Schaan B, Baiocchi de Carvalho KM. Whey Protein Supplementation Enhances Body Fat and Weight Loss in Women Long After Bariatric Surgery: a Randomized Controlled Trial. Obes Surg. 2017;27:424-31'},{id:"B83",body:'Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. Oxford Academic. 2015;100:342-362'},{id:"B84",body:'Tak YJ, Lee SY. Anti-Obesity Drugs: Long-Term Efficacy and Safety: An Updated Review. World J Mens Health. 2020; Mar 9. doi: 10.5534/wjmh.200010. Online ahead of print'},{id:"B85",body:'Stanford FC, Alfaris N, Gomez G, et al. The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: A multi-center study. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2017;13:491-500'},{id:"B86",body:'Istfan NW, Anderson WA, Hess DT, Yu L, Carmine B, Apovian CM. The Mitigating Effect of Phentermine and Topiramate on Weight Regain After Roux-en-Y Gastric Bypass Surgery. Obes Silver Spring Md. 2020;28:1023-1030'},{id:"B87",body:'Toth AT, Gomez G, Shukla AP, et al. Weight Loss Medications in Young Adults after Bariatric Surgery for Weight Regain or Inadequate Weight Loss: A Multi-Center Study. Child Basel Switz. 2018;5'},{id:"B88",body:'Schwartz J, Chaudhry UI, Suzo A, et al. Pharmacotherapy in Conjunction with a Diet and Exercise Program for the Treatment of Weight Recidivism or Weight Loss Plateau Post-bariatric Surgery: a Retrospective Review. Obesity Surgery. 2016;26:452-458'},{id:"B89",body:'C Sudlow A, W le Roux C, J Pournaras D. Review of Advances in Anti-obesity Pharmacotherapy: Implications for a Multimodal Treatment Approach with Metabolic Surgery. Obesity Surgery 2019;29:4095-104'},{id:"B90",body:'Wharton S, Kuk JL, Luszczynski M, Kamran E, Christensen RAG. Liraglutide 3.0 mg for the management of insufficient weight loss or excessive weight regain post-bariatric surgery. Clin Obes. 2019;9:e12323'},{id:"B91",body:'Callahan ZM, Su B, Kuchta K, Linn J, Carbray J, Ujiki M. Five-year results of endoscopic gastrojejunostomy revision (transoral outlet reduction) for weight gain after gastric bypass. Surgical Endoscopy. 2020;34:2164-2171'},{id:"B92",body:'Parmar CD, Gan J, Stier C, Dong Z, Chiappetta S, El-Kadre L, et al. One Anastomosis/Mini Gastric Bypass (OAGB-MGB) as revisional bariatric surgery after failed primary adjustable gastric band (LAGB) and sleeve gastrectomy (SG): A systematic review of 1075 patients. Int J Surg Lond Engl. 2020;81:32-38'},{id:"B93",body:'Pearlstein S, Sabrudin SA, Shayesteh A, Tecce ER, Roslin M. Outcomes After Laparoscopic Conversion of Failed Adjustable Gastric Banding (LAGB) to Laparoscopic Sleeve Gastrectomy (LSG) or Single Anastomosis Duodenal Switch (SADS). Obesity Surgery. 2019;29:1726-1733'},{id:"B94",body:'Wu C, Wang F-G, Yan W-M, Yan M, Song M-M. Clinical Outcomes of Sleeve Gastrectomy Versus Roux-En-Y Gastric Bypass After Failed Adjustable Gastric Banding. Obesity Surgery. 2019;29:3252-3263'},{id:"B95",body:'Chiappetta S, Stier C, Scheffel O, Squillante S, Weiner RA. Mini/One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass as a Second Step Procedure After Sleeve Gastrectomy-a Retrospective Cohort Study. Obesity Surgery. 2019;29:819-827'},{id:"B96",body:'Kraljević M, Süsstrunk J, Köstler T, Lazaridis II, Zingg U, Delko T. Short or Long Biliopancreatic Limb Bypass as a Secondary Procedure After Failed Laparoscopic Sleeve Gastrectomy. Obes Surg. 2020; Jul 23. doi: 10.1007/s11695-020-04868-8. Online ahead of print'},{id:"B97",body:'Brown WA, Ooi G, Higa K, Himpens J, Torres A, IFSO-appointed task force reviewing the literature on SADI-S/OADS. Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS) IFSO Position Statement. Obes Surg. 2018;28:1207-16'},{id:"B98",body:'Zaveri H, Surve A, Cottam D, et al. A Multi-institutional Study on the Mid-Term Outcomes of Single Anastomosis Duodeno-Ileal Bypass as a Surgical Revision Option After Sleeve Gastrectomy. Obesity Surgery. 2019;29:3165-3173'},{id:"B99",body:'Kraljević M, Köstler T, Süsstrunk J, Lazaridis II, Taheri A, Zingg U, et al. Revisional Surgery for Insufficient Loss or Regain of Weight After Roux-en-Y Gastric Bypass: Biliopancreatic Limb Length Matters. Obesity Surgery. 2020;30:804-811'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Wahiba Elhag",address:null,affiliation:'
Department of Bariatric Surgery/Bariatric Medicine, Hamad General Hospital, Qatar
'},{corresp:"yes",contributorFullName:"Walid El Ansari",address:"welansari9@gmail.com",affiliation:'
Department of Surgery, Hamad General Hospital, Qatar
College of Medicine, Qatar University, Qatar
Schools of Health and Education, University of Skovde, Sweden
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Our business values are based on those any scientist applies to their research. The values of our business are based on the same ones that all good scientists apply to their research. We have created a culture of respect and collaboration within a relaxed, friendly, and progressive atmosphere, while maintaining academic rigour.
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Integrity - We are consistent and dependable, always striving for precision and accuracy in the true spirit of science.
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Openness - We communicate honestly and transparently. We are open to constructive criticism and committed to learning from it.
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Disruptiveness - We are eager for discovery, for new ideas and for progression. We approach our work with creativity and determination, with a clear vision that drives us forward. We look beyond today and strive for a better tomorrow.
\\n\\n
What makes IntechOpen a great place to work?
\\n\\n
IntechOpen is a dynamic, vibrant company, where exceptional people are achieving great things. We offer a creative, dedicated, committed, and passionate environment but never lose sight of the fact that science and discovery is exciting and rewarding. We constantly strive to ensure that members of our community can work, travel, meet world-renowned researchers and grow their own career and develop their own experiences.
\\n\\n
If this sounds like a place that you would like to work, whether you are at the beginning of your career or are an experienced professional, we invite you to drop us a line and tell us why you could be the right person for IntechOpen.
Integrity - We are consistent and dependable, always striving for precision and accuracy in the true spirit of science.
\n\n
Openness - We communicate honestly and transparently. We are open to constructive criticism and committed to learning from it.
\n\n
Disruptiveness - We are eager for discovery, for new ideas and for progression. We approach our work with creativity and determination, with a clear vision that drives us forward. We look beyond today and strive for a better tomorrow.
\n\n
What makes IntechOpen a great place to work?
\n\n
IntechOpen is a dynamic, vibrant company, where exceptional people are achieving great things. We offer a creative, dedicated, committed, and passionate environment but never lose sight of the fact that science and discovery is exciting and rewarding. We constantly strive to ensure that members of our community can work, travel, meet world-renowned researchers and grow their own career and develop their own experiences.
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If this sounds like a place that you would like to work, whether you are at the beginning of your career or are an experienced professional, we invite you to drop us a line and tell us why you could be the right person for IntechOpen.
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