One of the greatest fears of patients seeking weight-loss surgery is the fear of weight regain. This is understandable considering that virtually every patient that has undergone weight-loss surgery has at some point been a “Yo-Yo Dieter” during their weight-loss journey.

It is not uncommon for a surgical candidate to relate stories of losing 10 pounds, 20 pounds, sometimes even 50-100 pounds with dieting attempts, only to see it return over time.

The good news is that with weight-loss surgery, the weight-loss seen post-operatively can maintain throughout a long period of time. However, it is important that patients keep in mind that obesity is a chronic disease that is not cured by surgery. Surgery provides a powerful tool for significant weight-loss, but without proper care “the tool” can lose its effectiveness, leading to weight regain.

There are several causes of weight regain after weight-loss surgery, most of which if addressed properly, results in a loss of the gained weight and resumption of weight maintenance. In this article, I would like to share with you my thought process in dealing with the patient who experiences weight regain.

Keys to Prevention of Weight Regain
The key to prevention of weight regain is education and follow-up. Both before and after weight-loss surgery, patients need to be taught how to use their surgery to optimize their success. The optimal education should involve counseling in dietary, behavioral health and exercise issues.

I believe one of the most important things that a program can do to promote long-term weight maintenance is to create an environment in the clinic where a patient feels comfortable coming, not only when they are doing well, but also when they are struggling. By creating an environment where patients feel safe to share their struggles, we can often intervene early-on before the patient regains a significant amount of weight.

When I initially see a patient who regained some weight, I congratulate them for having the courage to come in to see me. My main focus of the visit is to begin to get an understanding of whether their weight regain is due to an anatomical problem (something wrong with the surgery), a medical problem or a behavioral problem (returning to old habits). It is extremely helpful if the patient brings a food journal to the visit.

I find the following questions to be quite helpful when sorting out the issue of weight regain:

1. How many times a day do you eat?
2. How many times a day do you get hungry?
3. Do you ever feel full and if so, how long does it last?
4. How much can you eat in one sitting?
5. Are you having heartburn or reflux?
6. Have you started any new medicines?
7. How has your energy level been? Your sleep?
8. Are there any new or ongoing stressors in your life?
9. Why do you think you are regaining weight?

If a patient is suddenly able to tolerate much larger meals, experiences an increased frequency in the sensation of hunger or develops new or recurring acid reflux, then I am much more concerned that I am dealing with an anatomical problem (something wrong with the surgery). Anatomic problems are best diagnosed with an upper GI series or an upper endoscopy. The following are some anatomic causes of weight regain:

Anatomic

• Pouch dilatation
• Anastamotic dilatation
• Adjustable gastric band system problem (balloon leak, hole in tubing, port disconnection, etc.)
• Gastric-gastric fistula due to staple line breakdown

There are certainly some medical conditions that can lead to weight regain as well. I have listed some common ones below. Most of these will be diagnosed with a good medical history and blood work.

Medical

• Pregnancy
• Thyroid issues
• Adrenal issues
• New medications
• Kidney and/or heart problems

In my experience, anatomic and medical causes of weight regain after weight-loss surgery are rather uncommon, but they certainly should be considered. In the vast majority of patients, weight regain is the result of the patient slipping back into old, unhealthy habits.

The good news is that by intervening early and addressing the particular patient’s issues, we can often prevent the patient from regaining a significant amount of weight.

About the Author: 
Lloyd Stegemann, MD, is a private practice bariatric surgeon with New Dimensions Weight Loss Surgery/Weight Wise in San Antonio, TX. He was the driving force behind the Texas Weight-Loss Surgery Summit and in the formation of the Texas Association of Bariatric Surgeons (TABS) where he currently serves as President. He has been very active in the Texas state legislature trying to increase patient access to weight-loss surgery. Dr. Stegemann is a member of the American Society for Metabolic and Bariatric Surgery (ASMBS) and the OAC Advisory Board.