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Bariatric Surgery

How to Be a Successful "Loser" After Weight-Loss Surgery

Self-Monitoring and Personal Accountability
Portion Control
Diet and Nutrition
Physical Activity
Vitamin and Mineral Supplements

We also provide some Recommended Reading.

Obesity is a chronic disease. Although there is no cure for it, treatment does exist. Your treatment may include bariatric surgery; however, this is no cure for obesity. Surgical intervention is successful when used in addition to healthy eating and exercise, not a replacement for healthy eating and exercise. Weight loss surgery is a tool that you must learn to use properly.

Body weight, in part, is determined by the ratio between "calories in versus calories out." One pound of body fat represents 3500 calories that were consumed, but never used. Therefore, in order to lose one pound per week, 500 calories/day must be subtracted from the "calories in" side, or 500 calories/day must be added to the "calories out" side of the ratio. There are many different types of diets and exercise programs that can facilitate such a calorie deficit. Bariatric surgery is one method of producing such a calorie deficit.

Much can be learned from people who have lost a significant amount of weight and kept it off for long periods of time, both surgically and non-surgically. The National Weight Control Registry is an ongoing study investigating the common characteristics and behaviors of people who have lost at least 30 pounds and kept it off for a minimum of a year. Most people in the registry have lost approximately 70 pounds and maintained that weight loss for 5-6 years. These registrants have achieved weight loss through various methods: professional/medical help, commercial programs like Weight Watchers, healthy eating habit adjustments on their own, surgery, etc. Research is continually performed to determine the optimal path for success for weight loss surgical patients. In addition, numerous books have been published to aid surgical weight loss patients in their journey to a healthier body. One book in particular, The Success Habits of Weight Loss Surgery Patients, written by gastric bypass patient Colleen Cook, is a helpful tool for anyone considering bariatric surgery.

Some of the most common success habits shared between people who have lost and maintained a significant amount of weight have to do with self-monitoring behaviors and personal accountability, portion control, healthy eating habits, physical activity, and vitamin/mineral supplements, which are of critical importance to the weight loss patient.

Self-Monitoring and Personal Accountability

1. Weigh yourself
Approximately 75% of the National Weight Control Registry (NWCR) participants weigh themselves at least once a week. Keeping track of weight fluctuation once a week is ideal: more often can become obsessive, less often makes it too easy to slip.

Be consistent about weighing yourself. Weigh yourself on the same day of the week, same time of day, on the same scale, in the same amount of clothing.
Have a weight loss goal in mind and record progress on a weight chart or graph. Ask yourself these questions to decide what a good goal is for you:
- If you've ever felt good about your weight, what was it?
- Talk to your doctor or a registered dietitian about what a healthy weight range or BMI (body mass index) would be for you.
- At what weight do you think you'd be comfortable?
- What size do you think is right for you based on your height and your body type? Do you know anyone else who is of a similar height and frame as you? What size do they wear and what do they weigh?

2. Keep a food diary
Approximately half of the NWCR participants document what they eat and drink to maintain their weight loss. They know how many calories they are consuming. The best way to keep track of this is to keep a food diary.

Portion Control

One of the main goals of bariatric surgery is to drastically reduce the size of the stomach in order to feel full on a smaller amount of food. Despite this, some people who have had gastric bypass surgery find ways to regain their lost weight. This is accomplished in many ways, three of the main culprits being: eating until stuffed, thereby stretching and enlarging the small pouch; eating high-calorie, high-fat foods; and grazing throughout the day versus planning meals/snacks. Therefore, steps must be taken to ensure the preservation of the built-in portion control mechanism.

1. Know how big (or small) your new stomach is and how much food it can hold.
In the initial phases of gastric bypass surgery, your stomach is about the size of a thumb and can hold about ½ cup (4oz) of food at a time. If you have an adjustable band in place, the amount of food consumed varies until you reach the “sweet spot” or “right fit.” At this point, optimal food intake ranges from ½ cup to 1 cup (4-8oz) of food/meal or snack.

2. Eat slowly enough to recognize the feeling of fullness; stop eating when comfortable.
Each meal/snack should last 20-30 minutes. See your handout on "Addressing Your Eating Habits" for more tips on change the pace of each eating episode.

3. Aim for satiety.
Understand that hunger is what you feel when your stomach growls - it is a true physiological need for nourishment. Appetite is simply a desire for food - what you feel when driving past your favorite restaurant or when you smell your favorite food cooking. Satiety is the sensation of being full and satisfied after eating. Satiety is affected by many things including hunger, cravings, social situations, emotions, food choices, and eating habits.

High fiber foods slow down the rate at which food leaves the stomach, thereby creating a longer-lasting feeling of fullness. Incorporate beans/lentils, vegetables, fruits and high fiber (at least 5g fiber/serving) whole grain carbohydrates in your meals daily. High protein foods are also satisfying, so be sure to include lean meats, fish, poultry, low-fat or fat-free dairy and beans/lentils in your eating plan.

After meals, your stomach wall should be slightly distended, or stretched, which also creates satiety. This stomach wall distention is not experienced after a grazing episode. Feelings of satiety occur after a balanced, well-planned meal. Therefore, it is recommended to eat 3 small meals a day, adding a snack as needed (ask the dietitian), and avoid grazing. Grazing is a behavior common to people who are disappointed with their weight loss and/or who regain some or all of the weight lost after bariatric surgery. Ask yourself these questions when conquering your grazing habit:

What time of day is grazing most likely to occur?
What else is happening while grazing: watching television, preparing a meal, studying, etc?
What are you grazing on and how did you get it?
What type of food do you crave when you graze or are tempted to graze: chewy, crunchy, sweet, salty?
How do you feel when you graze or are tempted to graze: bored, tired, stressed, anxious, depressed, etc?

To further slow down the time it takes for food to empty out of your stomach, avoid drinking with meals and for approximately 30 minutes after meals. Also, avoid high calorie drinks because they do not satisfy. Instead, stick to calorie-free beverages and low-fat or fat-free milk between meals.

Healthy Eating Habits

1. Limit calorie intake.
Even people who have had bariatric surgery have to be cognizant of their calorie intake. Your small stomach pouch helps you to do this, as long as you do not stretch it or graze all day. One National Weight Control Registry (NWCR) study compared and contrasted the behaviors and characteristics of people who lost weight with surgery versus a nonsurgical approach, and both groups had an average caloric intake of only 1,460 calories per day, which is considered a low calorie diet.

The NWCR reported that people use a variety of ways to limit their calories. The most common approach is to limit the intake of certain types of food such as: sweets and “junk” foods, fast food, refined and processed carbohydrates, and high calorie drinks such as soda and juice.

2. Eat "nutrient-dense" foods.
When your stomach size is severely reduced and can only fit approximately ½ cup (4 ounces) of food in it at a time, you must make every bite count. Foods that are nutrient-dense include lean meats, poultry, and fish; low-fat or fat-free dairy products; fruits and vegetables; and high fiber carbohydrates. Read the Nutrition Facts panel to find carbohydrates with at least 5 grams of fiber per serving and the first ingredient as whole grain. Ask the dietitian for help if needed. Generally, sweets, snack foods, fried foods, refined and processed carbohydrates, soda and juices are not considered nutrient-dense, just calorie-dense!

3. Ensure adequate protein intake.
Adequate protein intake is critical for bariatric patients. There should be at least 2 to 3 ounces of a high protein food eaten at all meals/snacks. The high-protein portion of the meal should be eaten first before consuming any other food group. Your protein intake goal after surgery will be 60 to 80 grams per day. (Adjustments will be made by the dietitian on an individual basis as necessary.) The 60 to 80 g/day goal is not difficult to reach, as long as protein is the focus at each meal/snack.

There are two different kinds of protein: complete and incomplete.

Complete protein is also known as high biological value protein and most commonly is found in foods that come from animals. It is called "complete" protein because it has all of the essential amino acids in it. Low-fat foods that are excellent sources of high biological value (HBV) protein and should be included in your eating plan include:

White meat chicken and turkey (not fried)
Fish and shellfish (not fried)
Eggs, egg whites and egg substitutes
Lean cuts of beef (round, sirloin, flank, tenderloin, rib/chuck/rump roasts)
Lean cuts of pork (fresh ham, Canadian bacon, center loin chop, tenderloin)
Buffalo (bison)
Veal or lamp chops and roasts
Venison, duck and pheasant
Lean deli meats (turkey, ham (not chipped), roast beef)
Low-fat or fat-free cheese
Low-fat or fat-free cottage cheese, ricotta cheese, and yogurt
Low-fat or fat-free Greek yogurt
Skim or 1% milk, low-fat soy milk, lactose-free (Lactaid®) milk

Though good sources of complete protein, the following foods are high in fat and calories and should be eaten on a severely limited basis:

Bacon and sausage
Spareribs
Kielbasa
High-fat cuts of beef (ribeye, prime rib, T-bone)
Regular cheese (American, cheddar, Swiss, etc)
Bologna, salami and pepperoni
Hot dogs
Any fried meat, chicken, or fish

Incomplete protein does not contain all of the essential amino acids, and is usually found in plant-based foods. Incomplete protein counts toward your total protein intake for the day though more emphasis should be placed on the HBV protein. Sources of incomplete protein include:

Beans and lentils
Nuts (unroasted, unsalted should be chosen)
Peanut butter (natural version should be used)
Vegetables
Carbohydrates (whole grain, high fiber [5+ grams per serving] are the best choices)

Soy is one exception! Soy foods are great sources of complete protein, even though soy is a plant food. Go ahead and include soy milk, tofu, tempeh, soybeans, soy cheese and other soy-based foods in your diet regularly and count them as high biological value proteins.

Keep in mind that protein supplements should only supplement your food intake. Focus on food sources of protein first, and then add a supplement only in emergency situations. Always be mindful of the first ingredient in your protein supplement. If it does not state, “whey protein isolate” or “soy protein isolate” as the first ingredient, do not use it. Also keep in mind that protein bars may be more filling and satisfying than a protein shake, because liquids can be consumed quickly and easily. The same first ingredient rule applies to bars as it does to shakes.

4. Eat breakfast!
Approximately 78% of NWCR participants eat breakfast seven days a week, and 90% of them eat it at least four days a week. Remember, most of these participants have lost 70 pounds and have kept it off for at least 5 to 6 years. Breakfast should be eaten within 1 to 2 hours after waking. Talk to the dietitian about healthy breakfast options.

Physical Activity

Physical activity is a critical component in their ability to maintain significant weight loss. Research demonstrates consistent correlations between physical activity, self-monitoring behaviors and maintenance of weight loss. It's been proven time and again that people who exercise, weigh themselves regularly and keep track of what they eat tend to maintain their weight loss.
The biggest risk of exercise is to not start. Any activity is better than none at all. Start with 20 to 30 minutes, three or four days a week, and take time to build up to 30 to 60 minutes, five to seven days a week. Explore a variety of activities to find something you enjoy so that you don't get bored. Confront your reasons for not exercising and overcome them.

If you are having trouble motivating yourself, try one of these tricks:

Choose a place on the map you'd like to visit and find out how many miles away it is. Then, theoretically, walk there. Every mile you walk counts as one more mile toward your destination.
Write down ten different rewards on ten pieces of paper and put them in a bag. If you meet your exercise goal(s) at the end of the week or the month, pick one reward out of the bag. Keep in mind, though, that food should never be part of any reward.
Activity Bank: Place $1 in a bank every day that you meet your exercise goal(s). Do not place any money in the bank on the days that you do not meet your exercise goal(s). At the end of the month, use the money to treat yourself to a facial, manicure, tickets to a sporting event, etc.