Weight Gain after RNY

Congrats! You can do it!!

I haven't had surgery yet but I'm on the diet given to me from my Dr. to get ready. It's been 2 weeks and I've lost 16lbs. IT's a lot of hard work but so worth it! I've just started my journey and your the master so go for it!

Honesty is the first step to get you back on track. It will be hard but worth it. You may have to cry and sweat it out a lot to make it where you want to be, but as before it is worth it. You are worth it!  Stay honest with yourself and your journey. Best wishes.

Thank you for sharing this!  I have gained 20 pounds since July 2013 when I got pregnant.  I want to shed these 20 pounds and reading your journey truly helps me know that I, too, can do it!

Troy congrats on getting back on track.  This is NOT an easy journey.  There have been MANY MANY times over the past 11 yrs that I have felt like throwing in the towel.  It's such a difficult road and unless you have traveled it, you cannot understand it.  When I gained some weight back about five yrs ago, I got so scared and depressed, I thought I would just die.  Then I said to myself, "wait you have this amazing tool, start using it."  So I removed all sugar from my diet, all bread, pasta, rice, etc. and went with protein, veggies, and fruit, and amazingly enough, I lost what I had gained plus.  I am grateful to have celebrated my 11 yr anniversary weighing 101 lbs less than I did on 7/21/2004!  Sometimes when I pass myself in a window or mirror, I still cannot recognize who I am.  You CAN DO THIS!!  Use this forum for support and remember, you have a fabulous tool to help you along.

Best of luck to you!

JA

Congrats on getting back on track, Troy, and your approach (esp low carb) sounds good.  I'm going to take the unpopular view, but I'm convinced it is correct -- there is no doubt but that the weight loss effects of RNY greatly diminish after the first 2-3 yrs.  Anybody who has experienced this and can't acknowledge it is in denial about reality.  Just remember back to your first year after surgery.  It was impossible to gain weight and was just a question of how fast you lost.  I was able to eat all the carbs I wanted to in the first two years.  Now I'm at the same weight, my goal, but I have to really torture myself to stay at it (extremely low carbs, drastic lifestyle measures).

Don't get me wrong, I'm very glad I had the surgery.  But I take a realistic and scientific view of things.  For the first year, the surgery is a true cure of the disease that causes obesity, call it what it is.  For the 2nd-3rd year, this hard cure changes gradually to a soft remission.  Then after year 3, it morphs into more of a weight loss aid.  Hopefully in time, scientists will learn what changes over time.  We do know some things that it is not; for example, it is not that we malabsorb less because it is a total myth that proximal RNY patients malabsorb calories to begin with or that malabsorption has anything whatsoever to do with RNY weight loss, and it is not because the pouch stretches or similar ideas based on outdated and disproved theories.

Researchers still do not know exactly what mechanisms cause RNY weight loss in the sort term, much less why the effect consistently diminishes (and it does in studies, even in lab animals) in the long term.  The only thing known for certain is that RNY surgery greatly increases energy expenditure (aka metabolism) in response to food intake, and that this is a primary reason for the weight loss.  But it is not known precisely how this mechanism operates.  Some research has suggested it has to do with increased serum bile acids activating the farnesoid X (FXR) receptor to greatly amp up metabolism, but studies are equivocal on this at present.  All scientists know for certain is that RNY weight loss has virtually nothing to do with restriction or malabsorption as had once been thought long ago.  Yes, you were fed obsolete garbage information during your sales pitch indoctrination lectures!  The surgeons are brilliant at surgery, but don't expect them to be up on the research into the mechanisms because one has little to do with the other.

Personally, I think it is better to face reality than beat up on ourselves.  It does get harder, and a lot harder, for most RNY patients after the first 2-3 yrs, to maintain their weight loss, and this is because the advantage from the surgery diminishes.  Knowing that reality allows patients to prepare to get more strict on the carbs and avoid self-defeating guilt when faced with the inevitable regain challenge.  Telling yourself it wasn't the surgery that changed but that you failed in your diet is just re-engaging in the same idiotic self-flagellation that fat people are taught to practice.  We don't encourage people with cancer to blame themselves, but for some reason people almost universally do this with the disease of obesity.  

It was never your fault you got fat.  You had a metabolic disease, pure and simple.  Because of RNY, in the long term you may end up struggling just as much with your weight as before -- but the result of this same struggle will be a weight that is 100 lbs less (give or take).  In addition, your blood pressure, blood sugar, cholesterol, triglycerides, and cardiovascular health will greatly improve almost from day one after surgery and irrespective of your weight loss -- and many of these benefits (e.g., cholesterol and triglycerides) likely will be for life.  This is the big-picture, long term, bottom line on RNY surgery for those contemplating it.

Sorry, but I have to disagree with a number of things you wrote.  

First of  all, MOST people do not get obese because of a metabolic disorder.  It drive me insane when people, for example, blame their weight on their thyroid even though they're taking medication and their thyroid levels are normal.  Yes, there are physical conditions (and heredity) that contribute to obesity, but the VAST majority of people who are obese are that way because they eat too much food and make poor food choices.

Second, what you are basing your assertions about malabsorption on?  What you have put forth is not supported by even the recent medical research I have seen.  The temporary caloric malabsorption, while not as significant as many patients believe, is well documented (as is the body's ability to adapt).  I would sincerely be happy to read any medical studies you can cite... BUT for you to say that weight loss after RNY has nothing to do with restriction, though, is complete bull****  It has also been well documented that people *****turn to old eating habits and regain a signifciant amount of weight also frequently experience a return of their previous issues with blood sugar levels, cholesterol levels, etc..

What we know without question that the biggest thing that contributes to regain is people returning to the same eating behaviors and food choices that made them obese in the first place.  Too many carbs and calories will do it every time, and I personally think that you do people a huge disservice to come here and tell them that they are obese solely because of a metabolic issue and that they lose weight because of something magical and unknown that happens after surgery rather than because of a change in what --  and how much --  they eat.

Lora

I admire your commitment to this forum and respect your views and background, but you could not be more wrong on the science.  And unfortunately, your stating things confidently is not a substitute for being right.  Your views on the mechanism for weight loss after RNY, as well as the mechanisms responsible for morbid obesity and even fundamental mammalian weight regulation, are outdated and discredited.  In addition, the psychological construct that humans have "free will" over their food intake on a long term basis, though admittedly popular, is also discredited by years of research.

Below is just a sampler of the reams of science that have thrown out the old malabsorption and restriction theories of RNY weight loss.  But it should be intuitively obvious that caloric malabsorption (of which there is virtually none after proximal RNY) could not cause weight loss, since malabsorption-only surgery does not cause significant weight loss (eg, the diabetes surgery popular in Europe).  In addition, simply implanting a sleeve in the first portion of the duodenum that RNY bypasses produces profound weight loss without caloric malabsorption and with metabolic improvements (from day 1) that all work via the same primary mechanism as RNY, ie metabolic effects.

- Roux-en-Y Gastric Bypass Enhances Energy Expenditure

       [Ground-breaking Harvard study that first figured out the primary means of RNY weight loss.]

"It has been widely perceived that GIWLS works by mechanical means, i.e., food restriction and/or malabsorption...A growing body of evidence suggests that profound changes in body weight and metabolism resulting from GIWLS, and particularly RYGB, cannot be explained by simple mechanical restriction or malabsorption (7–27)." [note that is a reference to 21 additional scientific studies in support of this fact.]

Overall caloric malabsorption % (incl fat, protein, carbs) after RNY was only 4% -- virtually inconsequential.

http://onlinelibrary.wiley.com/doi/10.1038/oby.2009.207/pdf

- Mechanisms Responsible for Excess Weight Loss after Bariatric Surgery

"It was initially thought that bariatric surgery results in weight loss only due to restriction of caloric intake and malabsorption...later studies argue that malabsorption and inflammation are not the primary mechanisms explaining weight loss after bariatric surgery."

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208891/

- Increased Postprandial Energy Expenditure May Explain Superior Long Term Weight Loss after Roux-en-Y Gastric Bypass

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjourna l.pone.0060280

- Resting energy expenditure and energetic cost of feeding are augmented after Roux-en-Y gastric bypass

http://www.ncbi.nlm.nih.gov/pubmed/22416083

- Trends in Weight Regain Following Roux-en-Y Gastric Bypass (RYGB) Bariatric Surgery

"Weight [re-]gain is a common complication following RYGB surgery. Despite the percentage of weight loss over the first year, all cohort patient groups regained 21-29 % of lost weight."

http://www.ncbi.nlm.nih.gov/pubmed/25595383

-Myths, Presumptions, and Facts about Obesity

[New England Journal of Medicine]

"Myth #1: - Small sustained changes in energy intake or expenditure [diet or exercise] will produce large, long-term weight changes."

http://www.nejm.org/doi/full/10.1056/NEJMsa1208051

- Probability of an Obese Person Attaining Normal Body Weight

Odds are in excess of 1 in 200 for people losing and keeping off even 5% excess weight through diet and exercise.

http://ajph.aphapublications.org/doi/10.2105/AJPH.2015.30277 3

I started out the same as you and everyone else on ObesityHelp, believing the stuff I was fed about malabsorption and restriction, and that is was all my fault I became morbidly obese.  But I have over 1100 studies I've read and have on my computer related to bariatric surgery, and I can tell you without a doubt that initial primitive intuition has long since been debunked and replaced with more sophisticated physiological energy-related, hormonal, and neurological mechanisms that are responsible for RNY weight loss.  

Likewise, the old, simplistic intuition that people become morbidly obese because they chose to eat too much has been replaced with an appreciation for the complex physiological mechanisms by which the mammalian body regulates energy balance and dietary intake.

Believe me, I know the overwhelming majority of those on ObesityHelp hold these same outdated views and that I'm not going to influence many with mere science -- and that's okay with me.  But truth is not a democracy, and the science could not be more at odds with the many myths people cling to with respect to weight loss and bariatric surgery.  Hopefully, I will influence one person to question some of these faulty assumptions or beliefs.

And it is mentally healthier to be congruous with reality than to cling to these outdated beliefs.  Yes, it might on the surface seem healthy to believe you have complete "free will" over your weight and your food intake.  But in reality it is akin to holding your breath.  You can choose to hold it, just not for very long.  The same is true with food intake, which is why over 97% of diets fail.  In fact, there is an interesting study showing that will power becomes weaker the more it is taxed.  By contrast, low carb is somewhat effective because it has some physiological basis in reducing food intake and increasing energy expenditure, esp. for those with the morbid obesity disease.  This is not to say you are powerless.  You took the most important step and had bariatric surgery (which I consider to be RNY, VSG, or DS -- not the band), and that surgery is actual medicine to treat the actual physiological problem.  In addition, you continue the same heroic efforts you had undertaken before your surgery to combat weight re-gain, because the surgery is unfortunately not a full cure.

Your world view that it is the morbidly obese patient's fault, besides being scientifically invalid, leads to extreme self-blame, guilt, and shame, and is just one reason so many obese people develop depression.  The correct understanding leads to self-forgiveness and to focusing on those measures (e.g., bariatric surgery, low-carb diet) that actually work.

Morbid obesity is the leprosy of modern times.  Just as people used to blame the disease of leprosy on sin, people now blame the disease of morbid obesity (aka diabesity) on the sin of gluttony.  In both cases, it is an actual disease process.

Please don't misunderstand my factual tone for being in any way mean-spirited toward you -- far from it, as I said at the onset.  I just could not disagree more with you on the science and facts.

I appreciate you posting the articles. Unfortunately, based on the first three articles, I don't fidn any compelling evidence to support your statements and I stand behind my original statements.  My comments:

Article 1: First of all, this is a study on rats, not on human beings, and additionally 1) they were normal weight rats and the obesity was induced in order to use them for the study (which is significantly different than human beings who are already obese for whatever combination of reasons), and 2) The rats are not responsible for what they eat, they only eat what they are fed, and -- as far as I know -- there is no study that indicates that rats, under normal cir****tances, eat for emotional or other psychological reasons.

Second, this article is filled with statements of potentiality: "it is possible that the rearrangement of the G.I. anatomy... may significantly change neuroendocrine function"; "physiological changes, including altered neuroendocrine signaling, may be important mediators of the outcome of RYGB".  

Third, the premise of this article is that the primary mechanism of weight loss in the rats is increased "energy expenditure" (metabolism). I have never seen or heard of a single study that indicates that people who undergo gastric bypass surgery have an increased metabolism. On the other hand, I have seen several studies indicating that, due in part to the severe caloric deficit during the months following surgery, metabolism may be permanently lowered in some people undergoing WLS. 

Article 2: I didn't even read this whole article, because 1) it contains the same potential indicators throughout, 2) information in the abstract clearly indicates that they are looking for additional contributing factors beyond the malabsorption and restriction, not in place of them ("it is now clear that caloric restriction, per se, does not explain all the reduction in stored fat mass after surgery"; "A number of gastrointestinal hormones… can play roles and energy homeostasis and could be involved in bariatric-surgery-related weight loss and weight maintenance"; "Vagal innervation may play a role."; "this review discusses the possible roles of these hormonal mechanisms…. To help elucidate the potential mechanisms at play in short term and long term post bariatric surgery weight loss.", and 3) the sections on malabsorption and caloric restriction make it clear that these ARE primary components of weight loss!  These authors are NOT maintaining -- as you are -- that these things as not responsible for weight loss.  They are maintaining that they are not the only things responsible.  Many studies have shown contributing factors and I believe that most surgeons accept this as well. They simply don't attempt to explain it to the average potential patient coming in off the street.

The last article is simply a general study on people attempting non-surgical approaches to weight loss.  It simply supports one of the primary reasons for having WLS: your chances of getting the weigth off and keeping it off without surgery are quite small, and get smaller the larger you are.  This has nothing to do with the mechanisms of WLS.

I will look at the other things you cited later, because if there is solid evidence of something that I (Nd the surgeons I work for) am not aware of, I absolutely want to know about it.

I will also say that, as a Psychologist, I can tell you that -- based on your comments above -- you are significantly underestimating the role of psychological and behavioral issues on the development of morbid obesity and on the ability to maintain weight loss. These things significantly influence what we put in our mouths (and why), and I still believe that your "it isn't your fault" position does a huge disservice to people struggling with their weight.  That victim mentality will do nothing but keep them from accepting responsibility for the portions of their weight issues that they can control. That mentality is essentially the "victim "mentality, which does nothing but keep people victims.

I believe that we will simply have to agree to disagree.

I'm so glad to see you write this Lora because I'm not always the sharpest knife in the drawer but the way I read all these articles is that the OP took the possibilities and the maybes rolled them into facts and tied them up with a current research bow and called it truth. When in fact the studies were all at least 2 yrs old except the last one and those people were NOT WLS patients just regular people. The way I read them they all agreed with what he calls myths, in other words saying what we believe is indeed correct. One of them was even about myths and the myths were what he said not what you said. So I guess I'm alot sharper than I thought because I agree totally with you!

Isn't this the same guy that was on several different forums awhile back putting out this same kind of false drivel and saying he was everything from a doctor to a physical trainer to I don't remember all the careers he supposedly had but he would have to be 110 yrs old to have that many degrees! This guy is dangerous to newbies because they will believe him and think they don't have to do anything but have surgery and the rest will take care of itself. PLEASE PEOPLE don't buy the manure this guy is touting he is not to be trusted, he is very shady to say the least!

Ok, while watching the baseball game, I have been looking at the rest of the articles you cited. My original comment about the limitation of studies in rats from before also applies to these.

Article 3: I think this statement in the article sums it up well: "Until recently, it was thought that body weight loss after gastric bypass was mainly caused by the combination of mechanical restriction and malabsorption [40]. However, there is a growing body of evidence supporting that other mechanisms such as reduced hunger [10], [12], [41], increased satiety [10], [12], altered taste [42], [43], as well as reduced preference for high caloric dense foods [14], [44]–[46] are responsible for weight loss induction and maintenance after gastric bypass." 

The increased satiety, and (to a lesser extent, because there are also other factors) the decreased hunger are direct results of the physical restriction, and the "reduced preference" for high calorie foods is not a magical post-op distaste for high calorie foods... it is a conscious choice to avoid those foods since that was what made us fat in the first place. 

Article 5: I'm not sure whe you cited this article.  No one is disputing that re-gain is an issue after RNY (or any of the other WLS procedures, including (but in much smaller numbers) after the DS).  There are MANY potential factors that can contribute to regain after RNY: the loss of the majority of the caloric malabsorption and the ability to eat larger portions than during the early post-op period are just two, and in my personal and professional experience they aren't even necessarily the two BIGGEST contributors. That honor goes to people returning to their old eating habits (which is same reason that people who lose weight without WLS regain).  I have met a couple of people who have regained significant amounts of weight because they started taking medication that results in increased appetite ( even most meds that "cause" weight gain don't do it by altering the metabolism or by magic... they generally increase the appetite and people eat too much, plain and simple), but even among people seeking WLS revisions, when people honestly log what they are eating as part of the revision approval process, the issue is often not a surgical failure, but is a compliance failure.  People don't just magically start gaining weight if they continue to eat small portions and limit calories and carb consumption.

 As far as your analysis of the psychological aspects... I agree with you that it is psychologically healthier to operate within reality.  We just don't agree at all on what "reality" is.  I don't agree with your categorization of people accepting responsibility for the effects of what they choose to put in their mouths as blaming people in a judgmental way.  You cannot change a problem until you recognize that it IS a problem, and whether you choose to acknowledge it or not, except in very rare instances, obesity IS a direct result of what people put in their mouths.  I agree that there is a lot of unfair judgment of obese people as lazy or gluttonous, but it is ridiculous to correlate obesity to leprosy.  

I work with people all the time who are depressed.  Sometimes the depression is a contributor to the weight and sometimes it is a result of the weight.  Most often it is both.  Self-blame is psychologically destructive, to be sure, but there is a difference between accepting the role of one's thinking and behavior in regard to a problem with a positive attitude (as displayed by the original poster of this thread) -- and therefore identifying ways in which one realistically can and cannot control the problem -- and in allowing self-blame to cause further psychological issues.  Most people who suffer from the type of destructive self-blame that you describe already have very negative self-images, and most of the time it isn't primarily because of their weight.  The weight is a symptom of the larger problem.  I am in no way judging people for the psychological components of their obesity.  It is my job to try to help them overcome those things.  That requires compassion and empathy, but it also requires honesty.

The bottom line is that you are attempting to remove all responsibility for obesity from the individual and blame it on a concrete physical disease that does not exist.  I, on the other hand, fully acknowledge that there are metabolic, hereditary, and other physical contributors to obesity, but the bottom line is that the only way to control weight is to control food intake and that the vast majority of people who are obese simply take in too many calories.  It may be because they have a true clinical food addiction, because they use food as a coping or comfort mechanism (the percentage of obese adult women who were the victims of childhood abuse is significantly higher than in the normal weight population), or because they never learned how to eat properly and are just repeating the eating patterns they learned growing up, etc.. It may be a combination of those things, and it absolutely may be PARTLY because of the genes they inherited or because of medications they take or some say unknown factor that predisposes people towards obesity.  

The indisputable fact is that, despite the fact that I inherited most of my physical traits from my father's side of the family (where the women tend to be much shorter, muscular, bustier, darker complected and fatter than the women from my mom's side of the family who are tall, thin, and blue-eyed), I got to 300+ pounds because I ate too much (for a variety of reasons).  If I had spent my entire life eating the way I do now (even eating larger portions than what I am able to eat as a RNYer), and not eating as a coping mechanism, I would never have had a BMI of over 50.  I wouldn't have been thin like my mom, but I wouldn't have been SMO. Even now, 8 years after RNY, when I stick to my normal eating plan and a normal amount of daily activity, I can maintain my weight, but when I get complacent or just inattentive and eat too many carbs or calories for too long, the weight creeps up.  

Every single successful "vet" here will tell you the same thing. They will also testify to the number of unsuccessful WLS patients we have seen who expected WLS to be a magic cure and/or refused to take personal responsibility for what they are eating (the number of people *****fuse to even measure and track their food for a week (to see if their assertion that they aren't eating too many calories and haven't allowed their portion sizes to creep up is actually true) is astounding. 

I did not mean for this to be so long, but I have seen too many people fail at weight loss even after surgery because it is easier to whine "what am I doing wrong?" (and then ignore any response that isn't hand patting, reassuring them that they ant doign anything wrong) than to make sure they are making good chocies and controlling their portion sizes, and I am very bothered by someone coming here and replying to an EXCELLENT post by someone who decided to actually look critically and responsibly at the role that his food choices played in his regain with an "it isn't your fault" and your surgery doesn't even work the way you were told it did message (when even the sources you cited are NOT saying that... They are saying that there are other things that also contribute).