Maintaining weight loss after bariatric surgery is the result of "staying on track" with diet and lifestyle modification. It has been shown that weight gain can begin two years after surgery. In the case of the post-Roux-en-Y gastric bypass (RYGB) patient, this is when "dumping syndrome" can taper off and sugary foods are more tolerated without negative effects. In both RYGB and LAP-BAND® patients, old food habits can return when there is a higher caloric intake. Failure to lose weight and weight regain within the first two years indicate poor adherence to diet.

Six main activities are important for success after surgery:
1. controlling portions
2. eating right for good nutrition
3. setting personal goals
4. exercising
5. reducing stress
6. participating in support groups

Portion control helps maintain the balance between calories in and calories out. Initially following surgery, patients need to measure their fluids and foods consumed. This helps them focus on portion control by estimating how many calories are consumed during the day. Since the small stomach pouch can hold one ounce or two tablespoons, all food measurements should be in fluid ounces (using measuring cups or measuring spoons instead of weighing foods on food scales). Long-term, each meal should be approximately one cup and each snack should be approximately one-half cup.

Good nutrition after surgery includes the right balance of protein, carbohydrates and fats. Protein is the main nutrient; the goal is to consume 70 grams of protein per day between foods and fluids. Including a complete protein source (e.g., lean meat or meat alternative, poultry, fish, eggs, milk products, or tofu) at each meal helps achieve the protein goal. Good protein snacks should not exceed one-half cup in volume. Some examples are: low-fat cheese (no more than 5-6 grams of fat per serving), hard-boiled egg, light yogurt, low-fat cottage cheese, lean ham or turkey and cheese roll-up, tuna salad (light mayonnaise) or chicken salad.

Supplements such as protein shakes or protein bars should be used if you cannot meet these needs with solid foods. Protein drinks should contain approximately 200 calories and 20 grams of protein per 12-ounce drink. Solid foods will maintain satiety longer than liquids, including protein drinks. Furthermore, drinking protein drinks with excess calories instead of eating solid foods can cause weight gain.

After bariatric surgery, you may ask, "To carb or not to carb?" Carbohydrates in the form of fruits, whole grains, legumes and vegetables are important to meet your daily fiber goal. These foods contain vitamins and minerals that you cannot get from protein foods alone. Fructose in the form of whole fruits will generally not cause dumping syndrome, though cutting out specifically concentrated juices from the diet will lower overall caloric intake and possibly help with dumping syndrome after RYGB. The general recommendation for fiber is 20-35 grams per day. A fiber supplement, such as Benefiber® or Sugar-free Metamucil® powder, mixed with a sugar-free fluid, may be used as needed. The key is to limit foods with added sugars. Avoid sucrose, dextrose, dextrin, glucose, maltose and crystallized sugar as noted on the food product ingredient label. Other forms of sugar to avoid are invert sugar, raw sugar, brown sugar, corn sweetener, (high fructose) corn syrup, maple or malt syrups, honey, molasses, rice syrup and fruit juice concentrates.

Healthy fats recommended in the diet include olive oil and canola oil used sparingly for cooking. Omega-3 fatty acids from eating oily fish, e.g., salmon or tuna, twice a week, are a great option. Milled and ground flaxseed and organic flaxseed oil also contain Omega-3 fatty acids; the recommendation is 1 tablespoon per day, if desired. Milled and ground flaxseed also contain fiber and protein, whereas flaxseed oil does not. Flaxseed should be refrigerated to preserve freshness. Note that the use of flaxseed is not recommended during pregnancy or lactation. Fluid intake should be at least 64 ounces each day. Sugar-free drinks such as Crystal Light or other caffeine-free, non-carbonated beverages are recommended. Caffeine interferes with absorption of calcium, which is a major mineral at risk for deficiency after RYGB: 300-400 milligrams of caffeine per day may reduce absorption of calcium and increase risk of bone fracture over time. Also, in larger amounts, caffeine can cause dehydration. Carbonated beverages may cause abdominal discomfort or belching. Finally, avoiding alcohol is recommended for at least one year after bariatric surgery. In the case of RYGB, the segment of the intestine where fluids enter from the small pouch has a large surface area for absorption; therefore, alcohol is absorbed more quickly after surgery. Also, there is less of the enzyme that metabolizes alcohol (alcohol dehydrogenase), which increases the intoxicating effects after a small amount of alcohol is consumed. This can impair judgment and increase the potential to overeat.

For long-term optimal nutrition, daily vitamin and mineral supplementation is required to prevent micronutrient deficiencies. A daily chewable multivitamin is needed after LAP-BAND surgery, whereas additional supplements, including iron, calcium, folic acid and vitamin B12, are needed after RYGB due to malabsorption issues that occur after surgery. The post surgery RYGB patient will need specific forms of supplements in higher dosages.

Setting personal goals is very important after bariatric surgery. Short-term behavioral goals of diet modification and commitment to exercise are necessary to meet and maintain the long-term weight loss goal. Keeping a daily plan is highly beneficial; the goal at mealtime should be to find the balance in recognizing "fullness." Eating three meals per day and including a good protein source at each meal are important. Solid foods help maintain satiety, as does waiting 30-60 minutes before and after meals to drink fluids. Keeping a food journal will show you how much you are eating and whether your protein and fluid goals are being met. If you have physical or emotional reactions to specific foods, you can write them down as well. Self-monitoring has been shown to be an important factor in the success of weight management.

Exercising on a regular basis is a key factor in weight maintenance. After surgery, aerobic activity of moderate intensity for at least 30 minutes per day, five or more days per week, is recommended. This can help when weight "plateaus" present a challenge for a patient. Increasing exercise duration and intensity can increase calorie expenditure and, if maintained, continue weight loss. Further, exercise is a natural stress reducer.

Remember that you decided upon surgery for self-improvement. Get a massage, take time to read a good book, relax or enjoy a favorite activity. Stress is a trigger for overeating; recognize your triggers for food temptations. Adequate sleep also reduces stress, so aim for eight hours of sleep each night. Spend time with family and friends, as their support is critical to your ongoing success. You can network with other patients at regular support group meetings. During these meetings, patients share personal journeys and experiences, ask questions, and receive education regarding various areas of interest after surgery (plastic surgery, nutrition, psychology, exercise, cooking). A safe atmosphere is created; patients can bring a spouse or friend and address concerns or share success stories.

Jennifer Naples, MS, RD, LD, is a clinical dietician at Houston's Methodist Hospital, specializing in bariatrics. She has appeared on the Learning Channel's Big Medicine series.