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Post-Surgery Weight Regain: Nutritional Factors

diet journalOne of the key reasons why bariatric surgery is so much more effective for treating severe obesity than non-surgical approaches, is because of its profound effect on food intake.

Thus, bariatric surgery significantly affects hunger and satiety and may even have important effects on “wanting” and “liking” of high-caloric foods.

However, this effect on ingestive behaviour is neither “guaranteed” not are these effects consistent between individuals.

As I tell my patients, “The surgeons operate on your gut, not your brain”.

Thus, it can only be expected that a certain proportion of patients will struggle to control their food intake despite surgery, thereby either losing less weight than expected or putting the weight back on.

In an article, published in Obesity Surgery, we systematically reviewed the published evidence on the role of dietary factors in this issue.

As may be expected, patients reporting “loss of control” of eating behaviour post-surgery lost less weight or had a higher risk of gaining back any weight they may have initially lost. Thus, individuals with self-reported “high-adherence” scores tended to lose and sustain greater weight loss than those who did not.

Given that bariatric surgery may limit the amount of food that can be eaten at a single meal, some patients resorted to grazing behaviours (defined as consumption of smaller amounts of foods over extended periods of time) leading to subsequent weight regain. In addition, it was reported that poor diet quality, characterized by an excessive intake of calories, snacks and sweets, as well as oils and fatty foods, was statistically higher in patients experiencing weight regain.

Interestingly, even short-term dietary “indiscretion” (or falling off) can result in very rapid weight regain. This is not surprising as, in this regard there is little difference between someone who has lost weight through surgery or simply through diet and exercise. Irrespective of how the weight is lost, the body appears to retain its ability to rapidly regain lost weight if allowed to do so.

Thus, as we discuss in our article,

“The existing literature strongly suggests that nutritional and lifestyle compliance is crucial to weight management post- bariatric surgery.”

“Comprehensive weight management programs must therefore provide improved patient education and promote adherence to post-bariatric surgery diets in order to ensure success. These programs must take action to support patients towards a long-term goal of healthy and appropriate dietary choices with active monitoring (journaling) and reinforcement (review of food records) strategies provided by a multidisciplinary health care team.”

As I have discussed previously, although bariatric surgery increases the chances of success, it is no magic bullet or easy way out – all patients have to work hard at learning to use their surgery as a tool to help them better control their food intake and will likely do better, the more they understand and comply with the post-surgical nutrition recommendations.

On the other hand, there may be very good reasons why certain individuals, despite best efforts, struggle to meet these recommendations.

I will discuss how neurohormanal and metabolic factors can make dietary compliance difficult in my next post.

Edmonton, Alberta
Karmali S, Brar B, Shi X, Sharma AM, de Gara C, & Birch DW (2013). Weight Recidivism Post-Bariatric Surgery: A Systematic Review. Obesity surgery PMID: 23996349




  1. Welcome back Dr. Sharma! We missed you at #obesitysociety ! Great series this week!

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  2. Great discussion! Also – a more severely impaired appetite regulation pre-surgery may be a symptom of a more severe underlying metabolic problem since appetite regulation is very complex with so many potential physiologic contributors- so rather than simply thinking that ‘behavior’ pre-surgery around nutrition may dictate post surgical ‘behavior’ – we also should explore the appetite regulating hormone contribution in patients with different levels of appetite regulation and ask ‘WHY’ do some people have impaired appetite regulation rather just ‘WHY’ are some people eating so much!

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  3. I’m looking forward to reading more about those “other” factors. I know your work well enough to know that you are not a “blame the patient” type of doctor, but there are oh, so many health professionals who jump right into that mindset when bariatric surgery patients present with regain. “Gee, you’ve been cheating. Get back on your diet!”

    Yeah, we’ve heard that before, docs. For quite a few of us, it isn’t any more true now than it was before surgery.

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  4. Thanks Dr. Sharma. After losing 100 lbs post bypass surgery in December it is a fear of mine to regain… I look forward to reading your upcoming articles. And thank you for starting the weight wise clinic in edmonton – I feel it saved me 🙂

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  5. I work at a VA that provides bariatric surgery for veterans. Included is free weight management programs, support group and 1:1 dietary and psych counseling. It amazes me that < 30% of post-surgical patients utilize these services.

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  6. People gain weight because their bodies have been in starvation mode and their metabolism drops. It’s amazing that people can go through extremely dangerous surgery for nothing. But hey, you doctors make a killing.

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  7. Hi Dr. Sharma,
    I was operated in Luxemburg in January 2006 with Roux-en-Y gastric bypass and I stopped 5 months afterwards with losing weight. I “just” hadt 246 lbs when I acceped the OP also knowing that I was born big girl, and I NEVER EAT too much, a lot of sports all my life, still muscles over normal with nearby 53. The bypass nearly killed me…. and nobody understodd….. till I went to Germany University clinic chief iProf. G. Gerken, one of the very high level gastro-enterologues and I said ” I HAVE A INTESTINAL DYSBIOSIS” already before the operation (antibiotics repeated from 0-4 years after my birth and Cortison YOU NEVER WILL HAVE A CHANCE THEN IN LIFE for a normal microbiome we know now) – My liver was before breaking down the Prof. said and I had (what a lot of gastric bypass patients have no more after some years….) normal values…… 10 pounds more in 3 days and I was on 500 kcal/day. Intolerances on nearly everything, JUST FAT did go …. one chance when whe look back.
    Nevertheless after 4 different antibiotics, all my organs crashed 5 months later…… I said the TOXINES and I directly went in alternativ medecine for desintoxication. Since then I mad researches worldwide to the whole theme, I write also medically and I could touch more doctors with the years. IT IS A LOT NO SO AS DOCTORS THINK, we could with tests as with DEXCOM Glucose Sensor (takes the glucose all 5 minutes 24/124 hours in the tissue, with calibration over blood suggar controls) show that DUMPINGS are not what medically said, I insisted on this since years and self tests. NOW the first study to this theme after bariatric operations will be brought to the word diabetic congress in Australia in November from Prof. Kristian Rett, diabetologue in Frankfurt/Sachsenhausen where the worldwide known bariatric operator Prof. Rudold Weiner is operating also (he made a surgery on me in April, as 4 cm hole and Stomach in the Mediastinum grrrrrr, 2 blindloops, 1 the “normal” years after most bariatric operations directly behind the anastomosys and one at the end ??? what nobody understood though operated by belgian Prof in Luxemburg which are the best bariatric in the world….. you never know finally what we have in our belly after OP. Result: DOUBBLE BLINDLOOP SYNDROM. That we all have a dysbiosis after some time, is worldwide know, that the “normal” intestinal dilation (blindloop) provides a “CANDY CANE SYNDROM2 we know also. What we now could show with the glucose sensor is that DUMPINGS (but different also without !!!!) are not only hypo-glycemias, but what I said since years HYPERGLYCEMIA. The bariatric surgery makes a DIABETES “FROM BEHIND” as I call it. You can’t see it in normal blood tests, like HbA1c as the peaks are not in it. I have a mutation for 50% diabetis risk, and in the study react as the only WITHOUT hypoglycemia. May be I am the only one (I know it is hard for the others) that will through the gastric bypass never become diabetes, but I had also none before operation as I don’t eat industrial food, no milk products, 50% vegetables and OFTEN SMALL PORTIONS. This ist absolutely correct in my case, as with the mutation the reserve is missing for insulin.
    The other point is what a searcher found in gastric bypassed mices in Magnet resonance, the duodenum is making an ENORMOUS INTAKE OF GLUCOSE out of all meal after 15 minutes !!!!!!!!!!!! This explains more the Dumpings, but also the SHOTS OF GLYCEMIA up/down. This is in our Dexcom sensor tests in study a real catastrophe sometimes. Half of the night a lot of patients are in hypoglycemia !!! And often during the day – you know the consequences, beside that they will easier become diabetis…..
    There is somewhere also an impact till now unknown over GLUT1-GLUT4

    In fact the body tries with ALL POSSIBILITIES he has, to get weight back….. even 5 years after bariatric operations he does. Nevertheless if you eat not what I call ADAPTED (and that can be for everybody other things we noticed in the tests) you get more “WRONG” intestinal bacterial or all is chaotic in the end when blindloops come also with the years.

    Personnally I wait for genetical tests an study on intestinal bacterias. We know now that we have 90% DNA from only intestinal bacterias, so we are only 10% human genetically….. or less, when taking all the other bacterias, viruses and so on in consideration. Fact is also so far, they have impact on our behaviour, not only on eating, but our whole personnality, even intelligence ! and the toxines of them have an impact of a lot of west civilisation health problems.

    So as I would like to have my gastric bypass again put back to normal – I said NO in April to the Prof. as too dangerous. But I HAVE LEARNED A LOT OF ME AND MY “BACTERIAS” and that I have to live with them, but also that I have not to wait any more when there is too much trouble with them. ALL IS THEN GOING WRONG IN MY BODY – I can be as hard with me as I want, tried event several days again after last days NOT TO EAT AT ALL, an nothing lost in weight !!! And that with 2 blindloops also taken out and whole bypass cut and put again together. He works now correctly, but no impact on my weight, AND FURTHER NO IMPACT ON THE METABOLIC SYNDROM !!! It is much more complex as thought from all doctors in the world. But we have to go an.

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  8. Welcome back! I was glad that you let yourself have a break. A cousin is among those who regained weight after surgery, and is heavier now than before. She also tends toward a very unhealthy diet, low in fiber and high in high in fats. There is a possibly somewhat related recent article in Science: Gut Microbiota from Twins Discordant for Obesity Modulate Metabolism in Mice. Among points: microbiomes of heavy and thin differed, and when allowed to war it out the thin one would win but ONLY with a healthy diet. With a high fat and low fiber diet the overweight microbiome won out.

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  9. In relation to MJ’s comment there also is an overview article in Science on microbiome transplants and on fecal transplants:

    Science, Vol 341, 30 August 2013, pp 954-957

    Honda at the University of Tokyo has had success with treating colitis and allergic diarrhea with a combination of 17 Clostridium species that tend to help with reducing inflammation (a comment which caught my eye because there might be a related veterinary application), and other studies and treatment results are also covered in the article as is a brief description of methodology and fascinating stories of treatment results.

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  10. I regained weight after a gastric bypass surgery in 2006 (or so.) I received surgery in Winnipeg at a clinic that was very early on in their provision of weight loss surgery. I lived in Kenora, Ontario, some 2 hrs from Winnipeg and was sent home thereafter with instructions post-surgery and one contact with a nutritional consultant. I was around 360 lbs. when I went in for surgery. I was normal weight as a child and into my 20’s I weighed 127 lbs at my lightest, 150 lbs. at my heaviest, but began to steadily gain weight in my mid-20’s when I met my husband to be, we bought a house, started new careers and overindulged with our friends. I was very active with aerobics, walking daily, bike riding etc. and considered myself to be quite strong and healthy. I got pregnant at 27 yrs. and ballooned to 212 lbs. I was 260 lbs. after my first child was born and worked hard at walking regularly with her and continuing aerobics at home. Nursing also helped me lose weight at a much faster rate then previously experienced. I was successful at getting back down to 206 lbs., where I stayed for approximately a year before gaining again up to 224 lbs. I was now living in a completely French speaking town in northern ontario, having given up my career and home community to move for my husband’s job….I started with a nutritionist/kinesthiologist after my first child’s birth which helped me to maintain a steady weight – but here I was introduced to low fat eating. We moved because of our social isolation to another small northern town, but English speaking, and I was able to work again. I began an exercise plan and stayed at or around 205-224 lbs. during this time. We moved again. I was pregnant during the move and weighed in at around 224 lbs. I worked at a job that required a one hour commute each day until my baby was due. When I had my second child, I weighed 280 lbs. I nursed for 3 weeks and despite my earlier experience, I ballooned to 340 lbs. I could not understand how I gained this much weight so quickly. I went back to work when she was 6 weeks, part-time. Lots of stresses occured during this time. I did join the gym and pool and worked out every day for 45 minutes to 1 and 1/2 hr. My weight went back down to 305 lbs. With multiple moves and stressors (I went through a stem cell transplant with my brother in 2002 – he had leukemia, I was the donor,) (I began working on an undergraduate degree in social work, worked full-time, moved to another town, had family issue and experienced a 10 month separation from my husband also at this time, had surgery for nodules on my vocal chords and broke my leg….to name a few things that happened….) My weight became so debilitating to me mentally, that I paid $17,000 for a lapband surgery as I felt it was the healthiest alternative to me at the time to address my weight issues. Imagine how I felt when the surgery was deemed a failure….the most weight I lost was when I lost 15 lbs. pre-surgery when I was drinking the shakes to get fat off my liver in prep for surgery. I did get down to 334 lbs., where I managed to stay for quite a while as my life stabilized somewhat. Within a few years, I had been laid off from a wonderful job and held a few contracts, which required an adjustment with each job. My husband’s job in forestry was becoming redundant and we agreed to move to southern ontario. I traveled once per week for a year by myself to have my saline checked at the weight loss clinic and to see a psychologist who was affiliated with the clinic, but whom I saw and paid for myself. I was, during that time, experiencing considerable tingling in my feet and fingers and was extremely fatigued and ended up being diagnosed as having fibromyalgia….I have moved to Belleville, Ontario with my husband and youngest daughter, with my oldest left behind to continue at the University of Manitoba on her own. 6 mos. into our move here, we suffered a huge personal trauma when a neighbour was caught watching from outside our house, my 14 yr. old daughter showering in the early morning. We actually moved again, lost money on our house and moved into town. I lived for almost 7 months with my mother-in-law before we sold one house and moved to the other so that my daughter and I didn’t have to be home alone while my husband worked shift work. So I basically lived in my car, travelling to and from school, to and from my home and mother-in-laws and other activities my daughter had, while trying to attend to my own health needs and gained almost 40 lbs. back after having lost almost 35 the previous 6 months. I am now around 360 lbs. (I think…) I have been to my doctor several times to ask for help, but it is obvious there is no help from family physicians, or anyone, for obesity issues. My health is very much in danger now and I am in constant pain. I have seen counsellors here, got acupuncture, paid for fitness training (which helped somewhat, but not really with weight loss…) and have attempted to shift my eating to anti-inflammatory and somewhat gluten-free to help with my pain. The shift from taking buproprion (that exacerbated my pain I believe,) to cipralex, in the past year, has contributed to food cravings that have also undermined my ability to cope and manage a weight loss mentality. I am so bereft of hope for myself I often think of just dying. I can’t because I have such lovely children, I would never do that to them….I NEED HELP. Please. I am scared of having a stroke and am embarrassed by my lack of mobility and overall self-isolation that is so obviously because I hate how I look right now and am ashamed of all that I lack to get me to where I need to go. I need help from someone else. I absolutely cannot do this myself and am ready to get this weight off. Even a contact for my doctor to follow up on….I appreciate your time and hope for your help 🙂

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  11. Hi Susan. Sorry to read about all your past troubles and current challenges. Ask your family doctor to refer you to the Weight Wise program in Edmonton. This program has been very helpful and supportive for me.

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  12. Thank you Michael. It has certainly been a long journey, but I haven’t given up hope. I have some work to do. Thanks for your advice. I made contact with a group down here in Southern Ontario and feel like it may be a great fit. All the best to you. Sue

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