Evaluating & Addressing the Factors of Weight Regain After Bariatric Surgery

February 10, 2020

The most common WLS procedures of the Gastric Sleeve, Gastric Bypass, and Gastric Banding have occurrences of weight regain. Historically, the procedure with a better weight loss track record is the Gastric Bypass followed by Gastric Sleeve then the Gastric Band. However, we do see patients from all procedures returning with weight regain. It is important to understand the connection between obesity and weight gain.

Having performed thousands of bariatric procedures over the past 15 years at Las Vegas Bariatrics, we are now seeing more patients with weight regain that want revisional procedures. But when an individual presents to us with weight regain, there is a systematic approach and work-up. First, let’s review the crucial components of what can determine success when talking about weight loss after bariatric surgery.

Bariatric Surgery Program

A thorough evaluation of the candidate

Is the individual ready to make lifestyle and behavioral change? A psychological evaluation is always required to see if an individual is emotionally ready and without untreated psychological underlying issues. Eating disorders must be addressed.

Nutrition education

Understanding calories is crucial to successful weight loss. A good program and a great dietitian will teach their patients how to read food labels and the calories associated with fats, carbs, sugars, and protein. Without proper knowledge of nutrition, one can easily make mistakes. Understanding the diet before and after surgery is essential and the diet progression. Proper choices are key.

Support groups

This mirrors the support that one should get at home with family, friends, and loved ones. A good program will offer their patients support group classes before and after their planned procedures. This motivates and encourages patients to keep them engaged.

Follow-up visits

Routine scheduled follow-up is required. Patients sign a contract stating that they will adhere to a routine follow-up regimen. As there are different phases of weight loss right after surgery. The rapid period during the first few months, followed by a slower period, and episodes of plateau phases, then the maintenance phase. Patients need to understand that there will be constant challenges and changes that occur during their weight loss journey. And I do say "journey" because it is a journey that’s lifelong. Body dynamic changes, and it’s also good to have a relationship with an exercise physiologist, trainers, and coaches to assist. A good program will do routine lab studies on patients during their follow-up visits to assess the nutritional and metabolic health of their patients. Any nutrient deficiencies must be addressed with vitamin and supplement replacements. It is not unusual for patients to develop micronutrient deficiencies without experiencing any symptoms.

Patient Behaviors

Non-Compliance to a healthful diet

Following a healthy diet plan is very important to lose weight and maintain weight loss. The post-surgical diet is a slow progression from liquids to solids over a 6 to 8week period. Once an individual is back to eating regular food, the choices that they make is crucial. We focus on eating clean, eating fresh, unprocessed foods. Fresh fruits, healthy vegetables, and lean protein. Avoiding sweets, sweet drinks, and foods of low nutritional value. Not snacking when you are not hungry and prepping meals. Logging meals keep you mindful and present.

Skipping meals

Time and time again, patients tell me, ‘I don’t eat much. I only eat once a day’. But yet they’re overweight and can’t lose weight. What’s the problem then? I call it the starvation diet when an individual is in starvation mode all day, and then they eat a large meal late in the day. This is a set up for disaster. The idea is to spread your meal out throughout the day so that your body gets the proper nutrition throughout the day so that it can function right. Without the proper nutrients, the body slows down metabolism, goes into preservation mode, and saves fat.

Snacking or grazing

The classic grazer is one that consumes excessive calories throughout the day, not realizing how this impacts their weight. A typical example when I talk to patients is the handful of nuts or the small bag of nuts or trail mix. Just consuming 10 nuts alone can add up to between 50 to 100 calories depending on which nut it is. I always say that nuts are healthy in that there are healthy oils and fats; however, they are calorie-dense. One nut can be 5 to 10 calories. Constant snacking or grazing on items that are high in calories can sabotage weight loss. It’s best not to have these things around.

Environment

You have control over your environment to a certain degree. This means making sure that you have the food items that are healthy around you. So, outfit your home, pantry, and refrigerator with good healthy items. Don’t buy unhealthy items. Shop appropriately, stay on the outer isles of the supermarket where the fresh items are. Avoid processed items.

Lifestyle change

Habits can be hard to break. But to succeed, one must make better choices. An individual’s lifestyle does impact obesity. Meal prepping and knowing where your next meal is coming from is crucial to avoid eating the wrong foods. Especially when it comes to high calorie and rich foods. The number of times that an individual eat fast foods can also play a role with weight regain compared to individuals who prepped meals at home. When eating out more frequently, there’s less control of one’s caloric intake. I know that when I go out, it’s a more conscious effort to make the right choices. For instance, will I have the spaghetti alio olio or the fettuccine alfredo? Or the grilled chicken, vs. the chicken in a creamy mushroom sauce?

Overeating

I get clients who tell me that they don’t know when they’re full. This may seem hard to understand. Eating when one is full is a real way to increase weight gain. Once you’re desensitized to the feeling of satiety and don’t recognize it anymore, it’s challenging to lose weight. There is a mantra that Okinawans in Japanese perform before their meals. It’s an ancient Confucius saying “Hara Hachi Bu. “ The meaning is that one should stop eating when you are 80% full. The idea is to stop eating when you’re satisfied. Usually, when you’re full, it means that you’ve eaten too much already. Of note, Okinawa is one of The blue zones studied by Dan Buettner, author of the book “The Blue Zones of Happiness,” where people in these regions live into their 100s. In this book, he talks about the secrets to longevity. Simply put, eating moderately is more healthy than eating extravagantly. The concept of ‘I’m full’ vs. ‘I’m no longer hungry.’

Mindless eating

TV, socializing, parties, etc. At times we are faced with situations where we can over-indulge and munch mindlessly given the setting that we are in.

Anatomic

Gastric Pouch stretch Overeating and not paying attention when physical fullness can lead to pouch stretch. Increasing portion sizes. Clients are taught to measure meals and portions. Gastro-gastric Fistula This occurs with gastric bypass when the remnant stomach still is connected to the small gastric pouch and recanalizes or staple lines breakdown.

Weight regain after bariatric surgery is unfortunately common. However, working with an experienced and caring bariatric surgery program will give you an advantage in losing it and keeping regain off.

ABOUT THE AUTHOR Bernie Hanna, MD, FACS is an internationally recognized bariatric surgeon, and the founder and Medical Director of Las Vegas Bariatrics. He is the Medical Director of North Vista Hospital, a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited for excellence in patient care & safety. Dr. Hanna has practiced medicine in the Las Vegas Valley since 2000. Read more articles from Dr. Hanna!

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