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  1. 3 Top Reasons For Regain After Weight Loss Surgery Making the decision to have weight loss surgery is a very big deal. It seems obvious to say that when someone agrees to weight-loss surgery they're desperate for help to change the way they're living, or not fully living their lives. Everyone goes into the procedure ready and willing to surgically alter their anatomy hoping for a better future. So why is it that so many will fall short of losing the optimal amount of weight for their health and will actually regain within 3 years much if not all of the weight they lost? Some studies say 1/3 of patients will regain most of their weight post-surgery. I think the number is actually higher because many people who regain simply fall out of contact with their bariatric surgeon and support staff because they feel ashamed, so the statistics do not include these people. So, why do most people regain the weight? What can you do to help insure that you will be one of the successful long-term losers of your excess weight? By examining why people fail you can create a plan for how you will succeed. The government agency, National Institutes for Health (NIH) defines weight-loss surgery as "merely a tool that helps people get a new start toward maintaining long-term good health. The surgery alone will not help someone lose weight and keep it off. Together with a reduced-calorie and low-fat diet and daily exercise, surgery will help an individual lose weight and maintain the weight loss." Please read that a few times. That is how important this quote is! The surgery alone will not help someone lose weight and keep it off. We as weight-loss surgery patients have a history of seeking comfort, happiness and pleasure through food. We wouldn't be here if that weren't true. Me included. The process of surgically altering our anatomies does nothing to remove from us the tendency to seek comfort in familiar ways but assures there will be physical suffering if we do. Post-surgery we will still have the same brain that is used to comforting us with food, and we will still have the fingers and the arms that are used to lifting food to the same mouth to find comfort and pleasure. It is critically important that the WLS patient seek out new ways to soothe, comfort, and find pleasure in their world other than by eating. ONE main reason patients regain their weight is they search for ways to get around the surgery, still thinking of food as primarily a source of pleasure, not a source of fuel that can be pleasurable. This is often done relying on liquid calories, which may pass more easily, like high calorie coffee or juice bar drinks or alcohol. This is also done post-operatively by trying to maintain the presence of "trigger foods" in their lives. "Trigger foods" are often foods from the patient's past that helped cause obesity, do not satisfy hunger but instead create a craving. Many are high-calorie and highly processed, not nutritious. Trigger foods can include chocolate, chips, crackers, bread, cookies, ice cream, pudding, lattes, frapuccinos and alcoholic beverages. Really, any food can be a "trigger food" if there is so much pleasure in the "mouth-feel" or taste that repeating the pleasurable experience takes on more importance than actually feeding hunger. Very successful patients cultivate a mostly trigger-free post- surgical life. Bariatric surgeons know the most common reason for regain. The most common post- surgical complication is "noncompliance." Non-compliance is a fancy word that means the patient is not eating and exercising the way he/she agreed to before surgery. These people "talk the talk." The successful patient "walks the walk" after surgery and changes how they eat and move. A SECOND reason people often regain beginning in the second or third year post-op is that the "honeymoon" is over. The "honeymoon" generally encompasses the first 12 to 18 months post- surgery. During this time many patients will say, "I could eat all the chocolate and ice cream I wanted and still lose weight. I didn't have to try and the weight just came off." This is often true because the body has been through such a shock after surgery that it takes months for the body to reset itself and learn to function with its' new physiology. Patients who regain their weight often believe that this "honeymoon period" is the new way that it will always be and don't adopt healthy eating patterns. So when their "honeymoon period" ends as it will they believe that the surgery has somehow failed them. In reality they have failed their surgery! During the first 12-18 months post-op it is essential to develop healthy patterns around food and exercise. This is the time when it is actually easiest to do and to not do so wastes a once-in-a-lifetime opportunity to begin a great new life with positive momentum. A THIRD reason many patients regain much of their lost weight is a lack of support. Humans are social animals and we desire and need the support of each other throughout our lives. For thousands, if not tens of thousands, of years people coming together as a family or a community over food has been a way we connect with each other. Post-surgery, when the patient isn't able to eat what others are eating or in the quantities others are eating, or others are eating their 'trigger foods", life can feel very stressful and lonely. This can be compounded by being around unsupportive people or people who want to be supportive but don't know how. Patients fail by not surrounding themselves with supportive people in a safe environment where they also must be accountable for their actions and behavior with food and their bodies. It is key to have a community of professionals and non-professionals who understand the challenges and hardships faced by those carving a new life with a new anatomical structure. There are online and in-person support groups. Even patients who've gone abroad for weight loss surgery can often use the support services available with their local medical group's Bariatric department. Creating relationships that support and assist you in becoming a healthier person and that hold you accountable for making healthy choices are key. These are my top three. What would you add to this list? What plan will you create to deal with the items you add to this list? Who will support you on this journey of your life.....for your life *This comment is of particular interest:* As a family nurse practitioner in bariatric surgery care and podcaster of the Weight Loss Surgery Podcast I think you bring up some very important points. However, where I take exception is with the delicate matter of blame, aka “noncompliance” woven throughout your piece. You begin by asking, “…why is it so many fall short of losing the optimal amount of weight for their health and will actually regain within 3 years much if not all of the weight they lost.” When I read this sentences I wondered a few things: Who are you referring to when you state, “so many?" Who has made the decision of what is the “optimal amount of weight [lost] for their health?" And finally, who gets to decide on their “health” to begin with? I agree with you that weight regain happens, but your implication that any regain is problematic is simply not true and perpetuates misconception of success vs failure. There are numerous studies discussing weight regain, too many to highlight here. But for a summary on this issue, one needs only go to the ASMBS website to read the following regarding weight regain: ""As many as 50 percent of patients may regain a small amount of weight (approximately 5 percent) two years or more following their surgery. However, longitudinal studies find that most bariatric surgery patients maintain successful weight-loss long-term. ‘Successful’ weight-loss is arbitrarily defined as weight-loss equal to or greater than 50 percent of excess body weight. Often, successful results are determined by the patient, by their perceived improvement in quality of life. In such cases, the total retained weight-loss may be more, or less, than this arbitrary definition. Such massive and sustained weight reduction with surgery is in sharp contrast to the experience most patients have previously had with non-surgical therapies."” https://asmbs.org/pa...-misconceptions You go on to outline three main reasons people regain weight: 1) Eating around their surgery by consuming “trigger foods” that give pleasure but are not nutritious, 2) Lack of practicing appropriate weight-loss-sustaining behaviors in the first 12-18 months which then become habits and carry them forward after the “honeymoon” of rapid weight loss is over, 3) Lack of support. Regarding the first of your arguments, the truth is the biology of our eating behaviors is very complicated. Far way more complicated, in fact, than our conscious brain can control through willpower or skillpower. And even (often?) more complicated than our scientific ability to manipulate our anatomy through the surgical intervention of bariatric surgery. It could be that a person is driven to eat around their surgery because the hormones that drive hunger are stronger than the hormones that drive satiety and surgery did not fix that for them. I am not saying that it is ok to have trigger foods around simply because it’s ones biological imperative to eat pleasurable foods, nutrition and weight loss be damned, but I am saying that biology sometimes trumps all and blaming someone for their unconscious biological imperative does not help them, it only adds to their mounting shame. Unfortunately, we are in our infancy of understanding the hormonal regulations of hunger and satiety and how manipulation of the GI tract changes these hormones. If you are interested in learning more, then I refer you to the work of Dr Randy Seeley, PhD and and Dr Lee Kaplan. Regarding your second and third arguments, I honestly feel that number three, lack of support, drives many of the behaviors that result in peoples struggles after surgery including not practicing healthy behaviors as early as possible. When it comes to bariatric surgery, it takes a village. I firmly believe, that the center of that village needs to be the bariatric surgery practice; the village square if you will, where all gather to learn and connect. When I hear of someone who is struggling I wonder a number of things: Were they educated enough and appropriately by their surgical practice? Just because you can perform surgery on someone, does not mean they are ready. Did they have access to a support group before and after surgery? If they are struggling with anything, including weight regain, after bariatric surgery, did their practice create a culture of inclusiveness and non-bias that is welcoming to all their patients, not just the practices definition of successful patients? Were their family and friends on board and if not, did their bariatric surgery practice create an environment conducive to connection with a new community of support? When a patient struggles after bariatric surgery, in my opinion, it reflects more on the practice than on the person. I realize that is a controversial thing to say that I may catch some heat for, but I stand by my opinion. Sara, I know without a doubt you and I are on the same page when it comes to believing in and supporting bariatric surgery patients long term success, however that success is defined. What I worry about, however, is when we start distilling weight regain after bariatric surgery down to a few patient-centric elements without giving credit to how complicated these issues are; how we are early in our understanding of the science (and we have not even talked about weight regain due to surgical complications because let’s not forget, the surgeries can have their own shortcomings separate from human behaviors); and how much bariatric surgery practices bear the responsibility of patient selection, preparation, and support; what we inadvertently end up doing is what we have done a millions times before and to our patient's detriment- we take the easy way out by shifting the burden of blame back onto the person, the person who has a complicated and progressive disease known as obesity. Sincerely, Reeger Cortell, FNP http://www.bariatricpal.com/page/articles.html/_/support/3-top-reasons-for-regain-after-weight-loss-surgery-r520
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