Weight loss following bariatric surgery, such as a gastric sleeve, is not always a straightforward process. It's common for patients to experience plateaus or even weight regain after the initial period of rapid weight loss. While this can be disheartening, it's important to understand the potential causes and strategies to get back on track.
The Reality of Weight Loss After Bariatric Surgery
Weight loss after bariatric surgery does not always follow a straight path. Sometimes, the number on the scale goes up after weeks of following the bariatric eating plan, which can be disheartening. There’s no need to panic, but weight gain after bariatric surgery should be an indicator to make adjustments to your eating and exercise habits. It's important to remember that bariatric surgery is a tool, not a magic bullet.
Why Weight Loss Might Stall or Reverse
Several factors can contribute to stalled weight loss or weight regain after a gastric sleeve. These can be broadly categorized as dietary, lifestyle, psychological, and surgical factors.
Dietary Factors
- Excessive Carbohydrate Intake: Consuming too many processed foods or complex carbohydrates can hinder initial weight loss and lead to weight regain.
- Poor Food Choices: Processed foods, junk food, and high-fat/high-sugar items can sabotage weight loss efforts. If moderation didn’t work for you before surgery, it is not going to work for you after surgery.
- Grazing: Repeatedly consuming small quantities of food over a long period can lead to increased caloric intake and hinder weight loss.
- Large Portion Sizes: Even with a reduced stomach size, consistently eating larger portions than recommended can lead to weight gain.
- Night Eating: Consuming calories late at night, especially while inactive, can contribute to weight gain.
- Inadequate Protein Intake: Protein is crucial for preserving muscle mass and promoting satiety. Insufficient protein intake can lead to increased hunger and cravings.
- Sweetened Beverages: Drinks like juice, soda, tea, and cocktails lack nutrition but contain high amounts of sugar and calories.
- Salty or Sweet Snacks: Salty or sweet snacks, very greasy foods, and meals with “empty” calories make it difficult for the body to obtain the right nutrients and lose excess weight.
- Processed Protein Shakes and Bars: Patients need to avoid processed protein shakes, food bars, and packaged meals.
Lifestyle Factors
- Inadequate Exercise: Regular physical activity is crucial for maintaining muscle mass, boosting metabolism, and burning calories.
- Sedentary Lifestyle: Inadequate PA and sedentary lifestyle also contributed to WR post-RYGB, where the incidence of WR was higher among patients who remained relatively inactive compared with patients who performed PA
- Insufficient Water Intake: Drinking enough water helps your body metabolize fats.
- Lack of Sleep: You're better able to manage food cravings when you're well rested.
- Poor Meal Planning: Failing to plan meals can lead to impulsive, unhealthy food choices.
Psychological Factors
- Stress Eating: Using food as a coping mechanism for stress can lead to overeating and weight gain.
- Depression and Anxiety: These conditions can affect eating habits and motivation to maintain a healthy lifestyle.
- Binge Eating: Binge eating may persist or remerge after BS despite the physical limitations of BS on the capacity of the stomach.
- Lack of Support: The BMI team is here to help you identify the underlying causes of stress eating, why you turn to food or self-sabotage.
- Unrealistic Expectations: Surgery alone won't lead to sustainable weight loss. But if you keep up with your healthy diet and lifestyle habits, you can succeed.
- Lack of Nutritional Follow-Up: Likewise, the lack of post-BS nutritional follow-up was significantly associated with WR [51], where 60% of patients with WR never maintained nutritional follow-up [56].
Surgical Factors
- Enlargement of Gastric Pouch: After LSG, dilation of gastric pouch is correlated with postoperative BMI [70, 71], where dilatation leads to the loss of restriction resulting in reduced satiety, increased food intake, and subsequent WR.
- Stoma Dilatation: After RYGB, the dilatation of the gastric pouch or gastrojejunostomy (GJ) stoma outlet was associated with increased food intake and WR [73, 74].
- Gastrogastric Fistula: Surgical mechanisms are also implicated in WR, e.g., enlargement of gastric pouch, stoma dilatation, or gastrogastric fistula.
Strategies to Get Back on Track
If you're experiencing stalled weight loss or weight regain, it's crucial to take action and address the underlying causes. Here are some strategies to consider:
Re-evaluate Your Diet
- Return to Basics: Get out your manual and start again. Remember what worked after surgery. Utilize the recipes.
- Prioritize Protein: You should eat between 60 and 100 grams of protein per day.
- Focus on Whole Foods: Once you’re in the lifetime eating stage, your diet should be comprised of real, whole foods.
- Limit Carbohydrates: Be aware of carbs. Excessive carbohydrate intake through processed foods or too many complex carbohydrates will slow initial weight loss and lead to weight regain.
- Avoid Processed Foods and Junk Food: Processed foods and junk weren’t your friends before surgery, and they aren’t your friends now.
- Control Portion Sizes: Avoid grazing and unhealthy portion sizes.
- Eliminate Sweetened Beverages: Sweetened drinks like juice, soda, tea, and cocktails lack nutrition but contain high amounts of sugar and calories.
- Avoid Salty or Sweet Snacks: Salty or sweet snacks, very greasy foods, and meals with “empty” calories make it difficult for the body to obtain the right nutrients and lose excess weight.
Implement Lifestyle Changes
- Increase Physical Activity: 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.
- Stay Hydrated: Drink 64 ounces of water every day. Drinking enough water helps your body metabolize fats.
- Get Enough Sleep: Get 6 to 8 hours of sleep each night. You're better able to manage food cravings when you're well rested.
- Manage Stress: Manage stress. Maintain realistic expectations. Focus on the positive.
- Plan and Prep Meals: Plan and prep your meals. If you fail to plan, then you plan to fail. Planning ahead for meals is your best weapon against impulse eating.
Seek Professional Support
- Consult Your Bariatric Team: Reach out to the BMI team. The BMI team is here to help you identify the underlying causes of stress eating, why you turn to food or self-sabotage.
- Consider Weight Loss Medications: In addition to dietary and lifestyle modification, the use of weight loss medications should be considered for patients with weight regain after sleeve gastrectomy.
- Explore Revisional Surgery: It's important, too, to consider the benefits of revisional surgery against the possible risks.
Monitor Your Progress
- Keep a Food Journal: Keep a food journal. If you bite it, you write it.
Long-Term Success
Bariatric surgery is not a diet or magic pill - it’s a lifestyle. The Bariatric & Metabolic Institute offers physical and mental support for life when managing obstacles such as weight regain after surgery. Remember that maintaining weight loss after gastric sleeve surgery requires a long-term commitment to healthy habits.
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The Role of Revisional Surgery
In some cases, revisional surgery may be an option for patients experiencing significant weight regain due to surgical factors.
- Conversion to Roux-en-Y Gastric Bypass (RYGB): During the conversion surgery, the stomach is divided, and a small pouch is created, then the small bowel is connected to this small pouch.
- Conversion to One Anastomosis Gastric Bypass (OAGB): Conversion of sleeve gastrectomy to OAGB is performed by creating a long gastric pouch (much longer than the standard Roux-en-Y gastric bypass) first.
Understanding Weight Regain and Insufficient Weight Loss After Bariatric Surgery: A Scoping Review
Some patients experience weight regain (WR) or insufficient weight loss (IWL) after bariatric surgery (BS). It is important to mention that WR is associated with the deterioration of the quality of life and the reappearance or worsening of obesity-associated comorbidities, e.g., hypertension and type 2 diabetes (T2D) which necessitate close monitoring and appropriate management.
Definitions of Weight Regain and Insufficient Weight Loss
In order to answer the first research question, there is a need to have a clear differentiation between two types of weight loss failure: IWL and WR. Insufficient weight loss is defined as excess weight loss percentage (EWL%) of < 50% 18 months post-BS [16]. WR is defined as progressive weight regain that occurs after achievement of an initial successful weight loss (defined as EWL>50%) [16].
Prevalence of Weight Regain and Insufficient Weight Loss
In terms of the second research question, WR following BS varies by the type of BS performed, whether restrictive and/or malabsorptive. A large prospective multicenter Swedish study found that 10 years after laparoscopic adjustable gastric banding (LAGB), patients regained 38% of the maximal weight they lost at 1 year [32], and WR after laparoscopic sleeve gastrectomy (LSG) was 27.8% (range 14-37%) at long-term follow-up (≥ 7 years) [33].
Mechanisms Contributing to Weight Regain
As regards the third research question, several mechanisms contribute to WR following BS (Table 2). These include hormonal mechanisms, nutritional non-adherence, physical inactivity, mental health causes, and maladaptive eating [3, 37].
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- Hormonal Imbalances: After RYGB, gastric inhibitory polypeptide and GLP-1 were lower among WR patients compared with patients who successfully maintained WL [43].
- Nutritional Non-Adherence: Among RYGB patients, 23% demonstrated dietary non-adherence and continuation of their pre-surgical eating patterns, leading to suboptimal weight loss, WR, or both [50].
- Physical Inactivity: Although many patients increase their PA, most remain insufficiently active.
- Mental Health Causes: Psychological factors might undermine WL by impeding motivation or hindering the compliance with diet, PA, and other behaviors that are critical to maintain WL [62].
- Maladaptive Eating: Grazing is defined as repeated episodes of consumption of smaller quantities of food over a long period of time, accompanied with feelings of loss of control [53, 54].
Preoperative Predictors of Weight Regain and Insufficient Weight Loss
In terms of the fourth research question, very few studies have addressed the preoperative predictors of IWL after BS.
- Higher Preoperative BMI: For instance, higher preoperative BMI was associated with WR and a worse weight trajectory, where patients with baseline BMI ≥ 50 kg/m2 were more likely to have significant WR, while those with BMI < 50 kg/m2 were more likely to continue losing weight at 12 months post-surgery [76].
- Age: Age seems to be another preoperative predictor of WR and IWL, but findings are inconsistent.
- Mental Health Conditions: Mental health conditions represent another preoperative predictor of WR and IWL.
- Presence of Comorbidities: The presence of comorbidities predicts WR and IWL.
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