After undergoing metabolic and bariatric surgery (MBS), such as a gastric sleeve or gastric bypass, many individuals experience significant weight loss and improvements in their overall health. However, a common concern among these patients is the possibility of weight regain. Weight recurrence after bariatric surgery is a real possibility, and it can happen for various reasons. Understanding why weight gain occurs after these procedures is crucial for long-term success.
Why Weight Regain Happens After Bariatric Surgery
People typically start gaining weight about a year after their surgery, and it can happen for a variety of reasons. It's important to recognize that "obesity is a chronic and relapsing disease, and while MBS provides a durable tool, patients need lifelong follow-up with their MBS program," according to metabolic and bariatric dietitian and doctor of healthcare administration Lillian Craggs-Dino, RDN, LD.
Changes in Eating Habits
In the initial period following surgery, individuals are often highly committed to their new dietary and exercise regimens. They diligently manage portion sizes, make healthy food choices, and maintain regular physical activity. However, over time, maintaining these habits can become challenging.
Gradually, individuals may start to:
- Tolerate a wider variety of foods
- Eat larger quantities
- Exercise less frequently
These changes can lead to a slowdown in weight loss, followed by a plateau and eventual weight regain. In some cases, individuals may revert to their pre-surgery eating habits without even realizing it.
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Metabolic Changes
"When you weigh more, you require more calories to function," Dr. Craggs-Dino explains. "After metabolic and bariatric surgery, your metabolism decreases. You need fewer calories as you lose weight. When you eat the same number of calories at 150 pounds that you did at 300 pounds, you’ll gain weight." This highlights the importance of adjusting caloric intake as weight decreases to maintain weight loss.
Dietary Factors
Most weight recurrence after gastric sleeve surgery boils down to eating habits, such as:
- Binge eating
- Eating even when you feel full
- Eating continuously throughout the day
- Eating high-fat, high-calorie foods
Other Contributing Factors
Sometimes, weight recurrence isn’t related to diet and exercise at all. Weight recurrence can happen with taking certain medications, or if the health of the patient changes. Pregnancy after MBS can also bring on weight recurrence.
Strategies to Prevent and Address Weight Regain
Weight recurrence following surgery is common. Some studies suggest that as many as 76% of people experience weight regain within six years. However, it's not inevitable. There are several strategies that can help prevent or address weight regain after gastric sleeve surgery.
1. Follow a Healthy Post-Surgery Diet
Gastric sleeve surgery can be a game-changer for people living with obesity. But as you probably already know, it’s not a magic wand. Developing long-term, healthy habits matters. Metabolic and bariatric surgery alone isn’t a permanent solution to obesity. It’s a tool for losing weight. After surgery, you need to eat well to maintain a healthy weight.
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“The ultimate goal is to eat a healthy and varied diet that’s centered on lean proteins, vegetables, fruits and whole grains. The MBS tool will help you reduce portions by allowing you to feel restriction,” Dr. Craggs-Dino clarifies.
Following the recommended nutrition plan diligently to ensure adequate nutrition and maintain muscle mass is essential. Opt for whole foods over processed ones, limit sugar intake, and avoid snacking or grazing, as it prevents feeling full and adds extra calories. Consider following a Mediterranean diet and consult with a registered dietitian to create a personalized plan.
2. Exercise Regularly
Exercising is critical to a healthy lifestyle after gastric sleeve surgery. It can help you maintain your muscle mass, keep hunger at bay, reduce your stress and more. If exercising didn’t play a big role in your life before surgery, it can be tough to know how to get started with a new routine.
Set yourself up for success by choosing exercises that fit into your life, rather than trying to plan life around your workouts. If you’re an early riser, start your day with a walk or jog around the block. Or a morning yoga session. If a midday workout fits better into your day, try hitting the gym at lunchtime. Or sign up for an after-work exercise class. Whatever you choose, commit to it fully.
“The goal is to include 300 to 400 minutes of exercise per week, including both cardio and strength training,” Dr. Craggs-Dino states.
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3. Care for Your Emotional Well-being
When you lose faith in yourself and your ability to overcome the disease of obesity, it’s harder to keep up with the habits that matter to managing your condition. You engage in emotional eating. When you gain weight, you blame yourself. When you blame yourself, you seek comfort in food and lose motivation to work out. And the cycle continues.
Obesity is a chronic, multifaceted condition that programs your body to gain weight. It’s not a moral failing, and it’s not your fault. But know that you have the power to manage it. Bumps on the road are likely to happen. But they don’t have to derail your progress entirely. “We say ‘Pick yourself up, dust yourself off and let’s start again,’” Dr. Craggs-Dino reinforces.
Caring for mental and emotional health is of utmost importance. If struggling with self-blame, guilt, or other feelings that are affecting the ability to maintain a healthy lifestyle, don’t hesitate to seek help from a mental healthcare professional.
4. Keep Your Team Close
Having regular visits with your metabolic and bariatric team can help keep your weight loss on track. If you notice that you start gaining weight, reach out to them. They can help you determine why it’s happening and find a route to success. They want you to succeed and may be able to offer new strategies to support you, like additional support, coaching or FDA-approved anti-obesity medications.
And the earlier the better. Weight recurrence is easier to manage in its initial stages.
5. Remember You’re Not Alone
Your bariatric surgery team is on your side. But so are lots of other people. And they can help support you in your journey. Join social networks and online forums for people who’ve had gastric sleeve surgery. They understand your experience and can offer advice and cheer you on.
Ask your team if they offer support groups or know of groups in your area. Or if they can connect you with a weight-loss mentor. Talk about your goals and involve your friends and family in your healthy habits. Invite a friend to take a walk in the park with you. Ask your partner to join an exercise class with you. Make them part of your efforts. It’s more fun that way, and more motivating.
Addressing Weight Gain After Gastric Bypass
Weight gain after gastric bypass is often called a “silent epidemic” because many people don’t know help is available. Gastroenterologist Ishfaq Bhat, MD, explains the challenge: “Most patients will be asked to do lifestyle modifications, which are important, but they will have difficulty trying to lose the extra weight. So they just live with it.” Some people feel embarrassed or think they’ve failed when the weight starts coming back. But it’s often caused by physical changes in your stomach, not because you lack willpower.
Why Weight Comes Back After Gastric Bypass
During gastric bypass surgery, your surgeon creates a small stomach pouch and connects it to your small intestine. Eventually, this pouch and the connection (called an outlet) may stretch.
“Over time the pouch, which was created at the first gastric bypass, becomes wider and bigger, and what we call ‘the outlet’ between the pouch and the small bowel becomes wider,” Dr. Bhat says. When that happens, you lose the feeling of being full quickly. You might notice you can eat larger portions than you could right after surgery.
How to Tell If You Need Help
If your body mass index (BMI) is 30 or higher, and you’re experiencing some of the symptoms below, it may be time to talk to your doctor about treatment options:
- You’re hungry more often.
- You don’t feel full as quickly.
- You can eat larger portions than before.
- You’re gaining weight.
- Health problems like high blood pressure or diabetes are returning.
- You have “dumping syndrome:” nausea, cramping or diarrhea after eating.
The Minimally Invasive TORe Procedure
A procedure called TORe (transoral outlet reduction) can help patients who experience weight gain after gastric bypass surgery. During the procedure, an endoscopist uses an endoscope (a thin, flexible tube with a camera) to narrow your stomach outlet.
“It’s a minimally invasive, same-day procedure,” Dr. Bhat says. “Most patients will have some nausea and discomfort for a day or so, a couple of days at the most, but they go home the same day.”
The procedure takes about an hour and is done while you’re under anesthesia. Here’s what happens:
- Your doctor uses an endoscope to look at your stomach.
- They apply a treatment to prepare the tissue.
- Stitches are placed to make the outlet smaller (about the size it was right after your original surgery).
- You go home the same day.
Research shows that people who have TORe typically:
- Lose 10 to 15 percent of their body weight within 12 months.
- Retain about 10 percent of their weight loss for five years.
“It’s not a huge weight loss, but it certainly adds to the lifestyle modifications, and in some situations, medications as well,” Dr. Bhat says. If needed, the procedure can be repeated in the future.
If you’re gaining weight after surgery, don’t wait to seek help. Early treatment works better than waiting until you’ve gained a lot of weight back. “The longer we wait for patients to have this procedure, the less robust outcome,” Dr. Bhat says. “So, the earlier we try to narrow that outlet, patients will have more weight loss.”
Revisional Bariatric Surgery
Weight loss from bariatric surgery requires a partnership between your surgeon and you. Your surgeon performs the surgery, but you also play a deciding role in whether you maintain weight loss. At Turnquest Surgical Solutions, they work with you to determine if revisional bariatric surgery is a good solution.
They discuss the types of revision surgery that would be good options for you. For example, if you had a sleeve gastrectomy previously, they may perform Roux-en-Y gastric bypass, where they create a small pouch in your stomach connected to your small bowel. Stomafix is a minimally invasive procedure that reduces stomach volume significantly. A lap band redo may be appropriate.
Additional Strategies for Long-Term Success
Dietary and Lifestyle Modifications
- Food Journal: Keep a food journal to document nutrition intake and identify triggers.
- Protein Intake: Consume about 80-100 grams of protein per day.
- Fiber-Rich Foods: Eat plenty of fiber-rich fruits and vegetables.
- Avoid Problem Foods: Avoid foods with high fat, sugar, and salt content.
- Hydration: Ensure adequate hydration (at least 64 fl oz of water daily).
- Sleep: Aim for 7-8 hours of sleep daily.
- Avoid Late-Night Eating: Avoid late-night eating, fast food, and convenience foods.
- Meal Planning: Practice meal planning and plan grocery shopping ahead of time to avoid purchasing trigger food items.
Exercise Regimen
A good exercise regimen is very important for long-term weight management. The ideal goal is to have 150 minutes of cardio and 2-3 days of strength training per week. Common cardio exercises include dancing, running, swimming, brisk walking, aerobics, kickboxing, skiing, surfing, and bike riding.
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. Starting weight loss medications after bariatric surgery should be an individualized decision. Semaglutide (Ozempic or Wegovy) has been shown to have robust weight loss for obese patients.
Conversion Surgeries
- Sleeve Gastrectomy 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. If the indication for conversion is due to weight regain/inadequate weight loss, patients can expect to lose 30-70% of the excess weight. With the weight loss, many patients have resolution of obesity related comorbidities. For RYGB with longer biliopancreatic limb (100-200 cm), recent studies suggest that the weight loss is better.
- Sleeve Gastrectomy 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. Then the small bowel is connected to this long gastric pouch. The biliopancreatic limb (150-200 cm) in OAGB is longer than the standard Roux-en-Y gastric bypass surgery (50 cm).
Other Considerations
- Gallstones: Are you a woman who’s overweight or obese? Do you have diabetes or high cholesterol levels? All of these are risk factors for gallstones.
- Acid Reflux: If your acid reflux has progressed to the point where you’re fearful of eating because pain usually follows a meal, it’s time for a new solution.