Weight Loss Plateaus
Every patient stops losing weight after weight loss surgery and wonders why. Often they think their stomach has stretched. Often they just don’t know why they stop losing. But first let us define a true plateau. A plateau is when you have maintained your weight and your measurements for four weeks. If you are still losing inches, you are not on a plateau; you are simply redistributing the weight.
You will reach the plateau during the first few weeks after surgery
Some people find they weigh more when they come back from the hospital than when they went in. This is usually because a lot of the fluid we pumped in you is still in your tissues, so the first few pounds you lose are typically water weight. The first six weeks after surgery is a fun time, and it is common for patients to lose 10 percent of their weight during this time. This means that if you weigh 300 pounds you will lose 30 pounds or more. More isn’t bad. Some patients don’t have a scale or they are looking forward to the time when their scale can weigh them. You will sometimes lose inches before you lose pounds, as your body is changing where it is putting things. It is important to know where you are losing weight. That is why you should take your measurements—as well as your photograph—prior to going to the hospital. So, measure your neck, chest, waist, thighs, and arms before going to surgery, and keep watching those at least once a month.
Sometime during this first six weeks, the weight loss will stop for a while. Your body is readjusting—that is all. If your surgeon has placed you on a liquid diet, you will also notice that you can drink a lot more than you thought you could. No, you didn’t stretch it. It is just that liquids are able to flow passively through the stoma or the pylorus (if you had a duodenal switch). Sometimes you are left with a lot of hunger. In the beginning fluids will fill your pouch or stomach, and you will not have much of an appetite, but as you move forward, you will re-discover your appetite—not a bad thing. This is just one sign that it is time to move to more solid foods.
A readjustment period for the body is necessary. During the postoperative time, you not only lose weight from fat cells, but also from what we call “lean body mass.” That is, you lose weight also from muscles. You need this muscle mass for walking, moving around, breathing, and assorted other body functions. That muscle mass needs to be rebuilt, therefore we want you to start a walking program. The more you walk, the more lean body mass you will keep. If you don’t use muscle, you will lose it—so start walking.
The Carbohydrate Trap
Surgeons have their own version of a postoperative diet. Some surgeons do not want you eating any sugar-filled foods after surgery, and some surgeons do not mind for the first few weeks. Essentially, the first goal is to get your stomach working again and your body used to its new anatomy. Some items “go down” well, and a lot of things do not. If your surgeon is liberal the first few weeks after surgery, do not assume this is license to continue consuming these types of carbohydrates later on.
This is the carbohydrate trap: you begin to consume juices, yogurt, mashed potatoes—all items that have nutritional value, but also contain a fair bit of calories in the form of carbohydrates. As you transition out of your first few weeks and into “normal” eating, some of those foods should be put aside in favor of low fat, high quality protein foods. There is nothing wrong with yogurt, fruit juices, or even mashed potatoes. The trouble is that it is possible to consume them in large quantities, even with a small stomach. If your surgeon is liberal in the first few weeks after surgery, remember, these are just transitional “soft” foods; you should not consume them after the “soft” food phase of your diet.
The best example of this is the clear liquid diet. Even patients with diabetes are allowed a hospital clear liquid diet. Many of the approved liquids contain sugar. Immediately after surgery, patients with diabetes are allowed any clear liquid—as the affect of the sugar on their blood sugar will be minimal. However, when their stomach has fully regained function and they can consume larger quantities of liquids, the types of clear liquids are restricted. That is because if you consume enough of those sugar-filled liquids, you can raise your blood sugar. Again—small quantities of almost any food or liquid is fine. However, some patients find that they can consume vast quantities of these “soft” foods and it becomes a trap.
So, beware—as you transition from early post op period (the first 6-12 weeks) to the later period, you need to limit the “soft” high carbohydrate foods and move to a higher protein food.
High glycemic index carbohydrates
Every morning when you consider breakfast you have a choice. You can have the Pop-tart® or you can have an egg with a bit of fruit. Both have 25 grams of carbohydrates (not from the egg but from the fruit), but there is a difference. If you eat the Pop-tart, your blood sugar will quickly rise, which will cause you to produce more insulin, and in a couple of hours, you will be hungry again. If you eat the egg and a bit of fruit (an apple), your blood sugar won’t rise as fast, and your sense of “satiety” or fullness will last longer. Glycemic Index is a measure of how fast blood sugar rises after eating carbohydrates. A Pop-tart has a glycemic index of around 70, while an apple has about 28. The higher the glycemic index, the more that food is associated with obesity, diabetes, heart disease, and even cancer. Besides, the apple will have more fiber, more vitamins, and more other good stuff. Although the Pop-tart sounds good, you have the choice of eating what you want or gaining weight. The egg will have a bit of protein, and has a glycemic index of almost zero.
Carbohydrates are complex molecules of sugar. Some are put together in such a way that the body processes them differently and therefore, they are not associated with as much obesity. Naturally, anything you eat in excess can cause obesity (yes, even if you are on the Atkins diet you can still eat enough fat that your high school outfit will never fit). Carbohydrates that are less likely to cause obesity are vegetables, pulpy fruits (like grapefruit) and legumes. Those most often associated with obesity are breads, rice, pasta, and candy.
While counting carbohydrates is an easy way to lose weight—remember, those that have a lower glycemic index are far better for you and will keep you feeling full much longer than the higher glycemic index carbohydrates.
Weight Loss Surgery after the first six weeks...
If you have reached a plateau, you should check several things:
- Check the label and see how many carbohydrates and how much sugar your food contains. Certain foods will slow down and even STOP weight loss. Foods with sugar or high glycemic carbohydrates, including things you may not think about like fruits, fruit juices, condiments, potatoes, soft drinks, breads, and pastas.
- If you need a snack, make certain the snack is high in protein and not in carbohydrates or sugars. Snacking will slow down weight loss. A few extra bites of something contain a few calories you do not need.
- Do not skip meals. Meals are planned for, so it is easy to have nutritious food that has fewer calories (and lower glycemic index carbohydrates). If you skip meals, you will feel more like eating snacks, and snacks are filled with lots of dense calories. Skipping meals does not help to lose weight. In fact, the more you skip meals, the longer it takes you to get to your goal weight (a BMI of 22).
- Remember to eat three meals a day, not three hundred. Grazing will kill you. You can slowly consume a lot of calories by grazing. If a meal is taking you longer than 30 minutes to finish, you are grazing. The first few weeks you will need to eat a little bit at a time, but then you need to transition into three meals a day. This transition is difficult because you cannot believe that a two-inch square of salmon will fill you.
- Exercise. If you are not walking, the world is passing you by. Walk, walk, walk, and walk. When you are tired of walking, walk again. There is no excuse. If you need a new hip, knee, back, or other joint, then get involved in water aerobics. My favorite excuse is, “I walk a lot at work.” Essentially, if you are not dedicating some time to exercise, you are missing the boat. My suggestion—purchase a recumbent bike.
- Count carbohydrates. The more carbohydrates you consume, the harder it is to lose weight. Sixty grams a day should be MORE than enough. Check the carbohydrates you are eating and see where they fit on the glycemic index scale.
- Check the sugar content. Natural sugar and honey are still sugar and natural fruits contain sugar. Your body really doesn’t care if little elves, an organic mistress, or mom made the cake you eat. Just because it is natural does not mean your body won’t grab the calories. Believe me, your body loves sugar, and it will grab onto every molecule and hang onto it for dear life. If you don’t believe me, then you are not my patient.
- Check the calendar. For women, your cycle will affect your weight. During certain times of the month, you will retain more fluid and weigh more. There is a natural urge to snack more during these times. That is why you should keep a supply of sugar-free fudge sickles!
- Skip the Happy Hour. Alcohol contains calories. Wine and beer have a lot of carbohydrates, but alcohol has a lot of calories per serving. After surgery you will absorb alcohol quickly (you will become a cheap date).
—and back into the loss column: six months and beyond
You have two choices. Cut calories (and the most common source of these are with high glycemic index carbohydrates) or start walking. I love it when patients tell me they are going to the gym. Going to the gym does not mean exercise. Years ago, I went to a workout room at a hotel where I was staying. A woman came there dressed in appropriate workout clothes and walked around the room as if she was a priestess blessing the machines, and playing with them. There was no “work” out. She spent maybe five minutes on an exercise bike. But she could tell the world she went to the “fitness center” at the hotel.
Your body is a perfect calorie counter. It will measure what you take in and what goes out. You cannot fool it. Your body is not impressed that you took it to a gym. However, if you are stuck on a plateau, you need to work your way off of it. Just 45 minutes of sweating will do it. Watching a tape of some little ugly man swishing with old ladies does not cause you to lose weight.
You now have a tool that you never had before and dieting is a lot more successful because of this tool. Dieting before surgery didn’t work well, but it will now. It will work for one simple reason—you cannot eat as much as you used to. If you once had a 50-ounce stomach and now have a one-ounce stomach, you will be satisfied with a lot less. Even after a year or two, we see pouches stretch to ten ounces without the person regaining weight.
Before surgery, you had to eat a garden full of vegetables as well as half a cow in order to fill full. Now it takes a few ounces of tuna fish to satisfy you. The smaller stomach allows you to feel full with less, so you don’t have the urge to consume large quantities of food. The way to lose again is not to stop eating; it is to make healthier choices. You now have a tool that you dreamed about before surgery. Remember your skinny sister-in-law who preaches about self-discipline? Well, your body will now enjoy a discipline it couldn’t before, so make the choices.
Our goal is not just to get you to a BMI of 22, although that should be your goal and you can reach it. Those great before and after pictures you have seen, well—those are very dedicated patients. Their success was not the result of a specific surgery or surgeon; it was the result of a disciplined patient. Dieting may not have worked too well for you before the surgery, but after the surgery, dieting will work a lot better.
So, limit the carbohydrates to those that have a lower glycemic index, and start walking. You will get off the plateau, you will lose weight, and you will be surprised how well you can do this.
Finally—when thinking of the plateaus that you might be on, remember the commandments.
Dr. Simpson’s Ten Commandments
- Thou shalt learn the size of thy stomach and not over fill it
- Thou shalt eat protein first
- Thou shalt sip, not gulp thy liquids
- Thou shalt walk every day
- Thou shalt not smoke
- Thou shalt chew thy food
- Thou shalt take thy vitamins and supplements daily
- Thou shalt not covet thy neighbors or thy child’s plate
- Thou shalt limit snacks to two a day, and plan them
- Thou shalt not graze
Above all, bariatric surgery should not ever make your life miserable. It is simply a tool. There is nothing wrong with having some dessert, but if you are on a plateau and have not reached your goal, you might consider putting it aside for a little bit or walking it off later. Our goal is to provide you with a tool that will make a diet work well for you and help you get out of the morbid obesity category.