Patients may often feel embarrassed or guilty when there is a sudden weight gain or when a plateau occurs. These feelings and the reactions they cause can impact and/or put health, weight loss, and nutritional status at risk. Patients who regain more than 22 pounds (10 kilograms) from the lowest weight reached after surgery should contact their surgeon and nutritionist for immediate assessment and to further prevent weight gain. It is important to not underestimate the significance of post-surgical weight regain which should be medically and nutritionally assessed.
If you are suddenly able to tolerate a much larger meal, experience an increased frequency of hunger, or develop new acid reflux, it may be an anatomical problem. This will need to be evaluated with an upper GI series or endoscopy.
Anatomical possible causes of weight regain are different to each surgery, these may include:
• Pouch dilatation
• Anastomotic dilation
• Adjustable gastric band system failure (balloon leak, hole in tubing, port disconnection, etc)
• Staple line breakdown
Common medical causes related to weight regain are:
• Thyroid issues
• Adrenal issues
• Certain medications
• Heart or kidney problems
Anatomical and medical causes of weight gain are rather uncommon. In the absence of anatomical complications or medical causes, dietary habits, nutrition quality, and lifestyle behaviors will need to be evaluated.
Typically, at 12 to 18 months post-surgery, patients may experience some weight regain. Although the number in the scale might alarm some, this weight gain may be due to muscle gain. In this case, it should not be of concern. On the contrary, the muscle is the only active tissue that helps to burn fat further promoting weight loss. To properly evaluate weight regain first measure current body fat and compare it to initial body fat (your nutritionist or surgeon will most likely have this information). There are many ups and downs before weight stabilizes two years after surgery; the most important indicator to evaluate a healthy weight is body fat.
A healthy weight is proportional to a healthy body fat percentage. For most women fat percentage should range between 21 to 30% and for most men, it is 8 to 18%. Body fat should be measured every two weeks, never daily, with an adequate scale (i.e. Fitbit Aria).
To be successful in long-term weight maintenance you will need to have great communication with your nutritionist or dietitian to continue receiving optimal education and counseling on how to use and make the most of your surgery. Feel safe to share your struggles early on before you regain a significant amount of weight. It is extremely helpful if you prepare a food journal, consisting of at least two weekdays and one weekend’s food intake information. Have this ready before your consultation.
The 10 most common dietary causes of weight regain after bariatric surgery are:
- Skipping meals: We recommend planning 5 meals and trying your best to stick to the scheduled mealtimes. Patients who skip meals miss out on the nutrition and protein that that particular meal could have offered. People tend to overeat at their next one because of this, enlarging the pouch and overtime being able to eat more. Rather than skipping a meal, replace it with a protein shake.
- Eating solids and drinking liquids at the same time: Once solid foods are flushed down by liquids, hunger kicks in a lot sooner and leads to grazing. Avoid drinking liquids 5 minutes before your meal and resume drinking at least 30 minutes after. Avoid having a glass of any liquid next to your meal.
- Grazing, mindless munching and nibbling pack calories without you being aware of it. Common snack foods tend to have more calories and fewer nutrients than main meal foods. People who snack a lot are often unaware of the extra food they tend to consume while preparing meals, cleaning the kitchen, sitting at a meeting, attending a social event, or standing in a checkout line. It is best to establish an eating pattern and stick to it.
- Drinking calories: This is the surest way to add up calories without nutrients. Avoid calorie filled liquids such as natural and commercial juices, sports drinks, energy drinks, gourmet coffees, V8 vegetable juices, vitamin and protein waters, among much more. Drink water, infusions, tonics, or herbal teas (without added sugars). Keep in mind that alcohol sabotages all weight loss and weight control efforts.
- Eating the wrong carbs: Filling your body on “empty carbs” such as refined flour, bread, and pasta limit the stomach's capacity for nourishing foods. These foods usually lack nutrients that stimulate the body's ability to work on fat burning. Be aware of protein bars, fruit juices, and alcohol, as these are a concentrated form of carbs.
- Not taking specialized bariatric supplements: Bariatric supplements fill the nutritional gap left from low-calorie diets and help provide your cells nutritional elements necessary to fuel metabolism.
- Not meeting protein needs: Ideally weight loss should come from fat tissue, not muscle. If daily protein intake is not enough, your body will use your own muscle as a protein source further reducing its capacity to burn fat. Therefore it is crucial to reach your individual protein needs.
- Eating processed food: These increase toxic load, add burden to the liver and make it hard to metabolize the extra fat. Needless to say, chemicals, colorings, and additives alter gut function, therefore, nutrient absorption necessary for overall metabolism.
- Pureed food syndrome: foods with a pureed consistency (e.g. puddings, mashed potatoes, or creamy soups) tend to empty your pouch much faster, shortening the duration of satiety and making you feel hungry sooner. Put an effort into chewing solid foods properly and preferably from lean protein sources and produce.
- Sleeping less than 8 hours a day and being sedentary. Sleeping is a physiological need. Studies have shown that people who sleep less than 6 hours will most likely have excess weight. Last but not least being sedentary greatly impacts weight as our body needs to move and exercise to eliminate toxins, regulate hormones, burn fat, and build muscle. All these activities are extremely relevant for weight control.
a. Most of the weight comes off during the first five months after surgery; this is your main window of opportunity to burn fat. To take advantage of this and jump onto this initial fat burning wave, it is best to do exercise, mainly cardio like walking, using the elliptical machine, or stationary bike. Cardio steers weight loss from muscle to fat.
b. Resistance training: during the first months there will be extreme weight loss and some muscle loss is also expected. To regain some of this muscle mass, resistance training, known for its muscle building properties, should be included. Light weight lifting at 2 months post-surgery is recommended, likewise combining cardio and resistance later on.
Patients who have had the band and have regained a significant amount of weight may want to consider a sleeve revision. Please contact your surgeon or a qualified bariatric center to further evaluate and determine if you can be a candidate to switch procedures.
Obesity is a chronic disease that is not cured by surgery. It should be accompanied by the necessary lifestyle changes to promote long-term weight loss and overall health. Although it is one of the best tools, bariatric surgery should not be confused for a magical weight fix. Addressing nutritional issues and an early intervention will make it possible to prevent weight regain and establish a permanent and healthy weight.