How to Achieve Long Term Success with Weight Loss Surgery

According to the CDC, in 2015-2016, 93.3 million US adults (that’s roughly 40% of the US population) was considered obese (BMI of 30 or more). Because of the tremendous health issues and costs associated with obesity, the field of bariatrics has grown immensely. The American Society of Metabolic and Bariatric Surgery (ASMBS) is the main governing body and serves as a major resource for practicing physicians in the US. In an effort to combat the obesity epidemic of obesity, various medical and surgical options have evolved. At this time, bariatric surgery has been shown to be the most effective and durable treatment for morbid obesity.1 Surgery results in significant weight loss and helps prevent, improve or resolve more than 40 obesity-related diseases or conditions including Type 2 diabetes, heart disease, Obstructive sleep apnea and certain cancers.1 According to the ASMBS database, 228,000 bariatric procedures were performed in the US (this includes the sleeve, gastric bypass, duodenal switch, and revision surgeries). Unfortunately, this accounts for maybe 1% of the patient population that qualifies for surgery.

For those who do choose to undergo surgery, we have encouraging short term and long term data. We know that patients will generally reach their predicted weight loss from surgery within the first 12-18 months of surgery. And, as a general rule of thumb, the more aggressive the surgery, the more weight you will lose and keep off. In 2018, ASMBS performed a review of all available studies on the medium and long term durability of bariatric surgery.2 The study showed the following:

Prodedure 1 yr Excess Body Weight Loss 10-20 yr Excess Body Weight Loss
Laparoscopic Sleeve 75% 55-60%
Laparoscopic Duodenal Switch 85% 80%

As a bariatric surgeon, it not uncommon for my patients to experience weight loss plateaus and some weight regain after the 18 month mark (and sometimes sooner). It is important that I first explain that these things can occur and are not an indication of complete failure on part of the patient or surgery! After surgery, we always need to be looking ahead at the long game to ensure that all of your work as a patient is not lost. A study in 2005 in the American Journal of Clinical Nutrition showed that “successful losers” exhibited the following traits: 3

High levels of exercise (almost an hour a day)

Low calorie – low fat diet

Regularly eating breakfast

Consistent eating pattern on the weekdays and weekends

Self-monitor and kept food logs

Decreasing the effects of metabolic adaption

This study correlates well with what I have observed in my own clinic. Patients need to recognize that weight maintenance is lifelong and does not stop once you have met your goal weight. My most successful patients certainly have incorporated some, if not all, of the above mentioned traits. Exercise, keeping food logs, and having consistent eating patterns are key. But what exactly is the last point referring to….metabolic adaption? And how can it hinder weight loss?

As you lose weight, you have reduced energy needs. This is called metabolic adaptation. When we were cavemen, our bodies adapted to our changing diets. When we were able to eat plentiful, we grew stronger muscles and stored excess fat. However, in times of famine / lack of food, our bodies adapted by slowing our metabolism through a variety of digestive and hormonal pathways. This allowed our bodies to survive on LESS CALORIES. This same situation occurs when we diet or undergo weight loss surgery. We are causing our bodies to enter into a calorie or ENERGY DEFICIT. It is this prolonged energy deficit that causes our bodies to WANT TO REGAIN OUR FORMER WEIGHT through altered metabolic pathways! There are several studies that have looked at what we can do to decrease or halt the effects of metabolic adaption.

The Power of Protein

Any patient undergoing bariatric surgery will discuss the need for vitamin and protein supplementation after surgery. In fact, I have a lot of patients who have misconceptions as to why they need it and what happens if they don’t take it. If patients know why protein is so important and can find ways to incorporate it into their diet, they will be more likely to add protein to their daily routine.

WHAT DOES PROTEIN DO?

The building blocks of proteins, amino acids, are involved in almost every process in the body. They function as enzymes and are catalysts to numerous pathways in the body. There are some amino acids that cannot be synthesized by the body. These are called essential amino acids and must be ingested in order for your body to process them.

Proteins can be found, of course, in meat and dairy products. There are also plant based sources of protein as well, such as in beans, legumes, and soybeans. Every person, whether they have had bariatric surgery or not, needs 1 gm of protein per kilogram of body weight. So, if you weigh 140 lbs (which is about 70 kg), then you need 70 gms of protein daily. If you weigh 200 lbs (which is about 100 kg), then you need 100 gms of protein a day!

WHAT HAPPENS WITH LACK OF PROTEIN?

When patients begin to lose weight, it is important to keep up with protein needs because of how the body reacts to calorie deficits. The tendency is to not just utilize fat stores for energy, but to break down muscle as well. In an effort to minimize muscle wasting, it is critical for bariatric patients to maintain proper protein supplementation.

Muscle wasting is not the only potential complication from lack of protein. Patients can experience asthenia (weakness) and alopecia (hair loss). In fact, the most common causes for patients to have continued hair loss and thinning after surgery are iron deficiency, anemia and low protein. Patients who suffer from protein malnutrition can suffer from anemia related to iron, B12, folate, and/or copper deficiency. Deficiencies in zinc, thiamin (B1), and B6 are commonly found with a deficient protein status as well. In addition, catabolism of lean body mass and diuresis cause electrolyte and mineral disturbances with sodium, potassium, magnesium, and phosphorus.1

Muscle wasting, hair loss and vitamin deficiencies are not the only consequences of inadequate protein intake. Patients not ingesting protein can suffer from severe nausea and fluid build-up (edema) in their legs and tissues. Severe nausea can begin to occur as early as three weeks after surgery. The nausea can feel very similar to morning sickness. As it progresses, it makes it increasingly difficult for patients to swallow and tolerate foods. Often when a patient presents early after surgery with nausea and difficulty swallowing, I have to work them up not just for strictures (narrowings along the staple lines that obstruct food from passing) but for protein malnutrition as well. If patients have not been taking their protein supplementation for just a few weeks, they can typically be managed with oral medications to help with nausea as they begin to increase their protein intake. However, if patients have gone for longer periods of time without adequate protein intake and have significant nutritional issues, they may need supplemental nutrition in the form of TPN (IV nutrition) or a feeding tube.

HOW MUCH DO BARIATRIC PATIENTS NEED?

Bariatric patients need a DAILY MINIMUM SUPPLEMENT because you will not be able to meet your daily protein requirement simply by eating food. (A chicken breast is about 15 gm of protein. If you weigh 200 lbs, you need 100 gm of protein a day. You would need to eat 6 ½ chicken breasts to meet your protein requirement!) Since surgery restricts the total volume of food that you eat, you need to have an easier and LEANER way to reach your protein goals.

We recommend that gastric bypass and sleeve patients take in 60-80 gms of protein supplement a day. Duodenal switch and revision bypass patients are advised to take in 100-120 gms of protein supplement a day. You can choose protein shakes or protein bars.

IDEAS FOR PROTEIN SUPPLEMENTS

There are a variety of protein supplements on the market today. There is whey, soy, and other vegetable based protein powders. Patients can choose to make their shakes with water/milk or have a pre-made shake. Some ideas to improve the taste are as follows:

Add extracts to vanilla or chocolate shakes. Try cherry, vanilla, even root beer extract!

Add fruits such as blueberries, strawberries and bananas.

Try a peanut butter powder, such as PB2. A tablespoon of peanut butter is 100 cal and only a few grams of protein. Selecting a powder like PB2 gives you the peanut butter taste without all the calories.

Add unflavored protein powder (genepro.com, dochalenutrition.com) to tea, sugar-free lemonade or even a high protein milk like FairLife Milk. (I really like their 1% chocolate milk)! You can even make your own protein “shot” with unflavored protein powder. Genepro and Dochale only require a small amount of liquid to dissolve the protein. Use these in a ¼ cup to ½ cup of your favorite liquid (low sugar juice, etc) and bottoms up!
Mybariatricpantry.com has numerous high protein snacks, treats and foods to help maintain a high protein diet.

L. Aills, J. Blakenship, C. Buffington, M. Furtado, and Julie Parrott. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surgery for Obesity And Related Diseases, Sept-Oct 2008. 4(5) S73-S108.