Bariatric surgery is a powerful tool for individuals with morbid obesity, offering the potential for significant and sustainable weight loss and improvement in related health conditions. Congratulations on your weight loss surgery! However, it's crucial to understand that surgery is just one step in a lifelong journey. Maintaining long-term weight loss requires commitment to lifestyle changes, including diet, exercise, and behavioral adjustments. This article provides a comprehensive guide to help you navigate the post-operative period and achieve lasting success.
Understanding Weight Regain After Bariatric Surgery
Metabolic and bariatric surgery (MBS) is an effective treatment for patients with morbid obesity and its comorbidities. Obesity is a chronic disease that results from a positive imbalance between energy intake and expenditure. As it is a pandemic-associated disease with comorbidities such as hypertension, diabetes, dyslipidemia, and cardiovascular disease, its effective treatment is urgently required. While metabolic and bariatric surgery (MBS) is considered the best treatment option for morbid obesity and its comorbidities, many patients experience weight regain (WR) after achieving their nadir weight. Establishing the definition of WR is challenging as postoperative WR has various definitions. Risk factors for WR after MBS include anatomical, racial, hormonal, metabolic, behavioral, and psychological factors, and evaluating such factors preoperatively is necessary. Long-term regular follow-up and timely treatment by a multidisciplinary team are important because WR after surgery is multi-factorial. Although lifestyle interventions that focus on appropriate dietary education, physical activity education or interventions, and behavioral psychological interventions are suggested, more well-designed studies are needed because studies evaluating intervention methods and the effectiveness of WR prevention are lacking. One possible cause of post-LSG WR is the gradual expansion of gastric volume, which attenuates the restrictive effect and eventually reduces satiety and increases food intake. This is due to the physiological distension of the remaining stomach over time and incomplete gastric fundus removal, which depends on the skill of the surgeon. Post-RYGB WR is associated with satiety loss due to anatomical abnormalities such as gastric pouch dilatation or gastrojejunal (GJ) anastomosis stoma outlet. Another cause is gastro-gastric fistula, which allows food to enter the bypassed stomach and reduces the effect of restriction and malabsorption during bypass surgery.
The Crucial Role of Diet
Prioritizing Protein Intake
Your diet should include a variety of lean proteins so you have energy and get crucial vitamins that build tissue and support muscle function. Try to include at least one serving at every meal and snack to help you feel full. You should eat between 60 and 100 grams of protein per day. Foods rich in lean protein preserve lean muscle mass while giving you energy and fuel. Plus, eating more protein leaves less room for sugary or starchy foods (which should be avoided). Getting enough protein is important for a couple of reasons. Protein also builds strong muscle. That’s important for preventing muscle loss as you lose weight.
Minimizing Sugar Intake
Try to eliminate sugar from your diet as much as possible. Look for it in sneaky sources such as condiments, cereals, yogurt and snacks. Don't drink juice, soda, caloric teas and coffee beverages or calorie-dense alcoholic beverages. Sure, sugary drinks might taste good. But they can also be a big source of unwanted calories.
Eating Mindfully
Take 30 minutes to eat your meal. Put your fork down in between bites to help you slow your pace. Another way to slow down while you're eating and to maintain weight loss after surgery is to chew your food well. You might also want to eat with your non-dominant hand to help you take your time. Eat and drink slowly. To avoid dumping syndrome, take at least 30 minutes to eat your meals and 30 to 60 minutes to drink 1 cup of liquid. Chew food thoroughly. The new opening that leads from your stomach into your small intestine is very narrow and can be blocked by larger pieces of food. Blockages prevent food from leaving your stomach and can cause vomiting, nausea and abdominal pain.
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Avoiding Snacking and "BLTs"
Eating throughout the day by nibbling on snacks can cause weight gain, particularly if you aren't tracking your food intake. It's easy for “BLTs" (bites, licks and tastes) to add up to hundreds of unwanted and unaccounted-for calories. It's recommended that people who have had weight loss surgery eat three meals a day.
Staying Hydrated
Aim for 48 to 64 ounces of low- or no-calorie beverages in the form of water, decaf tea and seltzers. Drink 64 ounces of water every day. Drinking enough water helps your body metabolize fats. To avoid dehydration, you'll need to drink at least 8 cups (1.9 liters) of fluids a day. Take small sips of water. Sip liquids between meals, not with meals.
Embracing Vegetables
Vegetables are chock-full of nutrients to give you energy, enhance healing and keep you full in between meals. Look for colorful vegetables to add to every meal and snack.
Post-Operative Diet Stages
Immediately following surgery, patients will be on a special diet explained by their bariatric surgery team. Most patients will start out on a liquid diet for some weeks, then will slowly start to take soft foods, and then eventually solid foods.
- Clear Liquids: For the first day or so after surgery, you'll only be allowed to drink clear liquids.
- Pureed Foods: After about a week of tolerating liquids, you can begin to eat strained and blended, or mashed up, foods. You can eat 3 to 6 small meals a day. Each meal should consist of 4 to 6 tablespoons of food.
- Soft Foods: After a few weeks of pureed foods, and with your doctor's OK, you can add soft foods to your diet. You can eat 3 to 5 small meals a day. Each meal should consist of one-third to one-half cup of food.
- Solid Foods: After about eight weeks on the gastric bypass diet, you can gradually return to eating firmer foods. Start with eating three meals a day, with each meal consisting of 1 to 1-1/2 cups of food. Depending on how you tolerate solid food, you may be able to vary the number of meals and amount of food at each meal. Try new foods one at a time.
The Significance of Exercise
It's suggested that you exercise 250 to 300 minutes a week to maintain weight loss. Aim for at least 30 minutes of exercise daily. Regular physical activity is another tool for maintaining lean muscle mass, and it can help boost metabolism. Exercise is always important for managing your weight, but after gastric sleeve surgery, it’s especially important, because physical activity also aids in digestion. When your stomach is smaller, you might have some unpleasant side effects, like nausea or heartburn (at least initially). You don't need to run a marathon or even join a gym. Some ways to get this exercise in could be a daily stroll at lunch, going for a 10-minute walk after dinner, taking your dog on a walk, following along with a fitness video or committing to a workout class at the gym.
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Incorporating Variety and Intensity
Consider changing your exercise routine by trying something new. If you feel comfortable with your treadmill workout, try switching to another piece of equipment, such as an elliptical or cycle. These tweaks to your routine can challenge your body in new ways and help maintain your interest in exercising. Workout variety also plays a significant role five to six months after bariatric surgery, when many patients experience a weight-loss plateau. As your fitness improves, you'll be able to increase the intensity, time or frequency of your exercise routine. One way to do that is through high-intensity interval training (HIIT). A HIIT workout alternates between short intense bursts of exercise and active recovery, which is like a "breather" with less intense exercise. Research shows that HIIT workouts are more effective for heart health, fat loss and strength gain than traditional cardio and strength training.
Muscle-Strengthening Exercises
As you plan your routine, focus on muscle-strengthening exercises at least three days a week, which will also improve your bone density and metabolism.
The Role of Vitamins and Supplements
After any weight loss surgery, patients will need to take over the counter vitamins and minerals for life. Your weight loss surgery healthcare team can advise you on the best vitamins to take daily to help with your healing and stay healthy. Each bariatric surgery program will instruct patients on how much to take. These typically include: a multivitamin, Vitamin B12, Calcium, Vitamin D, and Iron. Some patients will need chewable vitamins, but some can take pills if tolerated. After surgery your body won't be able to absorb enough nutrients from your food. Take recommended vitamin and mineral supplements. One of the best ways to avoid nutritional deficiencies is to maximize the nutritional value of your food.
The Importance of Lifestyle Adjustments
Managing Stress
Find healthy ways to manage stress that don't involve food. You're better able to manage food cravings when you're well rested. Manage stress.
Prioritizing Sleep
Sleep deprivation can be a risk factor for weight gain. Get 6 to 8 hours of sleep each night.
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Building a Support System
From family and friends to coworkers and your weight loss support group, having others to count on can help boost the likelihood that you'll stick with your weight maintenance goals.
Quitting Smoking and Limiting Alcohol
Patients who have chosen to undergo a major surgical procedure to make themselves healthier need to quit smoking for the rest of their life. Most bariatric surgery programs will require patients to stop all nicotine products before surgery. Alcohol use after bariatric surgery can have serious consequences. Alcohol is absorbed more quickly into the blood stream after surgery, and bariatric surgery patients will have higher levels of alcohol in their system for a longer period of time after drinking compared to before surgery.
Family Planning
Female patient should have a birth control plan before surgery and avoid pregnancy for 12 to 18 months after surgery. In order to reach their lowest possible weight and ensure that they have adequate nutrition should they want to become pregnant. In addition, bariatric surgery patients who had problems getting pregnant before can find that they have a much easier time after surgery.
Tracking Progress and Seeking Support
Keeping Detailed Records
Keep detailed records of your food and activity each day. Research has shown that people who track their food intake can lose up to twice as much weight. This can also help when you have your next dietitian appointment.
Regular Follow-Up Care
Early after surgery, patients will follow up every few months for the first year. They should have yearly visits with a bariatric specialist for life. These are important visits, since obesity is a chronic disease, and can continue or even return after surgery.
Addressing Weight Loss Plateaus
In fact, it's common for patients who’ve had bariatric surgery to experience “plateaus” in their weight loss. Many of my patients experience weight loss quickly after surgery and expect this to remain steady until they reach their weight goal. A pause in this weight loss can be discouraging or frustrating - and understandably so. Bariatric surgery reduces the size of the stomach and, in some cases, how the body absorbs nutrients. These changes trigger a cascade of biological responses to which the body must adapt. These digestive slowdowns are common and should be expected. Simply put, when we eat fewer calories, the body will initially try to slow down to use fewer calories. While plateaus are often the result of normal bodily responses, we work to support patients to follow their weight-loss plan and help to guide them if they’re struggling, especially if they are finding themselves eating more food than is recommended. When a patient comes to us with concerns about stalled weight loss, I first commend them for being proactive. Recognizing a plateau is the first step toward moving past it. Once we confirm that they're dealing with a plateau, we strategize our next moves.
Strategies for Overcoming Plateaus
- Pay attention to food intake. When you stick with your recommended diet plan, your body will adjust. If it's possible your food intake has crept up, commit to measuring and weighing everything you eat and drink.
- Prioritize protein.
- Drink 64 ounces of water every day.
- Aim for at least 30 minutes of exercise daily.
Addressing Psychological and Emotional Factors
In a meta-analysis encompassing 33 articles, including a total of 101223 patients who underwent MBS, depression was associated with WR[73]. A history of preoperative depression or antidepressant medication use can exacerbate postoperative depression, which is more prevalent among patients who regained postoperatively. Postoperative self-esteem and lack of social support also contribute to post-MBS WR[74]. In addition, eating disorders, such as emotional eating, night eating syndrome, loss of control, picking and nibbling, binge eating, and binge eating disorder, affect weight control after MBS[75]. Even if patients have problematic eating behaviors preoperatively, in most cases, these eating habits improve postoperatively. However, patients with higher emotional eating scores often experience depression and have a higher risk of insufficient WL after RYGB[76]. The occurrence of depression and anxiety symptoms is associated with WR in the long term[77]. A depressed mood is associated with emotional eating and low physical activity, worsens weight control, and is associated with WR[67,78]. A recent longitudinal study evaluating the relationship between different psychological factors and post-MBS WL has demonstrated that non-planning impulsivity is the principal factor that improves adherence to diet plans[79]. This study suggested that adherence to the nutritional plan and non-planning impulsivity are short-term predictors of WL.
Racial Disparities in Weight Regain
Several studies have demonstrated that African Americans (AAs) are more susceptible to WR than Caucasians[44,45]. A meta-analysis reported that AAs lose significantly less weight than Caucasians, with an 8.4% mean deficit in the percentage of excess WL[46]. Although the reason for this racial disparity remains unclear, biological, psychological, genetic, and socioeconomic factors may all play a role. Resting energy expenditure and aerobic capacity have been reported to be significantly lower in Black participants after WL[47,48]. Moreover, previous studies have demonstrated racial differences in the postprandial responses of appetite-regulating hormones, such as ghrelin and glucagon-like peptide 1 (GLP-1)[49,50]. AAs have less physical activity and a higher caloric diet than Caucasians, although several studies have not identified a significant difference in calorie intake and nutrition composition between the two groups[51,52].
The Multidisciplinary Approach
Clinical practice guidelines for patients undergoing MBS emphasize the importance of a team-based approach to patient care, including perioperative dietary and physical activity counseling, lifelong lifestyle support, and medical management[36,80]. Nutritional guidelines recommend regular food intake with adequate calories, no concentrated sweets, and sufficient protein and fiber intake[81]. Because eating disorders and related psychological problems affect the patient’s dietary habits, the presence of such problems should be assessed and appropriate interventions should be initiated.
Pharmacological Interventions
Anti-obesity drugs are useful adjuncts to diet and exercise for patients with obesity. They are also recommended for obese patients who experience post-MBS WR or have a poor postoperative response. A recent prospective study reported that patients who received a phentermine/topiramate extended-release (phen/top) combination lost more than twice as much weight preoperatively than the control group. This combination also produced a higher rate of excess WL (-18.2%; 95% confidence interval: -32.1 to -4.4) at 2 years postoperatively when consumed from 3 mo preoperatively up to 24 mo postoperatively in 15 patients.