by Walter Medlin, MD, FACS

Winter 2013

To view a PDF version of this article, click here.

As I write this, it’s just one short week after the Your Weight Matters Inaugural Convention in Dallas. Many thanks to all the speakers and organizers; almost every talk gave a nugget of useful information for this article.

As a bariatric surgical patient (gastric sleeve 2008) and a surgeon myself, I get to look at this tough problem from multiple viewpoints. Being able to spend time in the clinic, in team review, and in giving information sessions gives me an opportunity to listen to all sorts of issues, lifestyles and struggles.

Valuable Resources

The community of surgeons has a vibrant dialogue and research is actively seeking out the particular advantages and limitations of various procedures, as well as structure of care pathways.

Medical and Allied Health Professionals
Medical and allied health colleagues (endocrinologists, dietitians, behavioral health professionals and nurses) all have unique and vital skill sets. It is a super lucky program that gets to share a single clinic space, so we can collaborate spontaneously.

Peer Group
The OAC peer group (you) just turbocharges that for me. Sounds like I am the luckiest patient in the world, right? All the resources, few distractions; how could Walt possibly struggle with his weight? Yet, I face these challenges too.

There is No Single Easy Answer

The only absolute truth all of these teachers have given me is this: While we share many human traits, each individual has a unique journey. We first have to listen and try to understand the parts and pieces of that life. Only then can we figure out which one of our many “tools” might be helpful. The old medical saying is often true, “If you listen well enough, the patient will give you the diagnosis and the solution.” So let’s break down those parts and pieces that can contribute to “failure” of weight-loss or regain. Remember that usually there is a combination of issues and that the mix can change throughout time.

Reality Check

Honestly, 90 percent of the time that I see someone for struggles, they are NOT doing it ALL right. Most commonly, they are not exercising regularly. Quite often, people are also eating very poorly. Their questions lead to deeper questions back:

      • “What are the barriers to you following lifelong program recommendations?”
      • “Are we overwhelming you with too many rules to reasonably sustain?”

If patients are not exercising regularly and have fallen off track with their nutrition intake, then our answer to patients is not the simple, “Just do everything right!” The more useful answer we as healthcare leaders can provide is, “Let’s find the keys to your journey, to your body and recognize that we all have limits to how perfect we can be on a given day.”

I do not live at boot camp and neither do you. Prioritizing means getting the important stuff done first. What is important to you? It isn’t just pounds on the scale, for sure! You have a life, and the parts have to fit. Bariatric surgery and metabolic health are far more than just pounds; therefore, I am not exclusively going to talk about minimizing your pounds.


Managing Hunger
(the magic part of bariatric surgery) Managing hunger has to be one of the most difficult challenges after surgery. As a patient, we do have some advantages.

The “Honeymoon” – As a surgery patient, we can get fullness at the end of a smaller meal and more time free from hunger between meals (satiety). The “honeymoon” of the first 6-18 months doesn’t last forever. Our use of the tool needs to adapt as our bodies change. Follow-up can be critical to understanding and adjusting habits.

Stay Connected – It is very tricky not to “blame the patient” for lack of follow-up, but we in the field know that value is not always obvious in your later visits. It is our challenge to deliver appropriate care and screening efficiently and effectively throughout your lifetime.

We can only help those who show up, though! Usually, regular visits help identify problems much earlier, and adjustments are far easier before 10 or 20 pounds are regained. Make a commitment to have some direct contact with your program every three months (support group is great) and at least one full evaluation every year (including labs and examination).

Avoiding Excess or “Invisible” Caloric Intake
There are several ways to slip into a dysfunctional pattern. Sometimes it’s old habit but often there is a new behavior. Grazing is very common with band patients whose bands are too tight, or gastric bypass patients with ulcer, stricture or pain. It is also common for comfort when there is significant emotional pain.

Alcohol, juice, mixers, cream/flavors in coffee– Liquid calories are “Kryptonite!” Be very careful (especially with liquid protein supplements). I have one patient who was getting more than 1,000 calories a day from her protein “shots.” Your body turns extra protein into fat.

Mixing fluids and solids – Most programs recommend no fluid 15-30 minutes before and 30-45 minutes after a meal. I will confess to you that I have to drink before – there’s just not enough time in the day to stay hydrated. If I wash down my food, the calories easily double, with no better satisfaction at all!

Keeping our Metabolism Stable
Hibernation/starvation mode creates huge frustration as we eat less, feel more fatigue and get grumpy! Each year, we are learning more and more about the role of genes in the body’s energy storage control systems (including fat). We don’t know enough yet to treat those variations though.

Sleep quality – You must get a follow-up sleep study before stopping usage of your Continuous Positive Airway Pressure machine (CPAP)! You may feel better without it, but the settings or mask may be seriously out of adjustment six to nine months out from surgery. Sleep disturbances can have major impact on post-op metabolism and hunger.

Medications – You need to take all medications as prescribed by your surgeon or other healthcare provider. Watch out for decreased effect of antidepressants as the dosage may need several adjustments throughout the first few years.

Thyroid, Estrogen and Testosterone – As we age, these can change throughout time. It is important to monitor them with your healthcare provider. The impact of other endocrine systems on weight and appetite vary by individual but can be severe.

Carbohydrate Intake – Carbohydrate intake can frequently be a challenge and a rollercoaster for your appetite. Get that cookie in at the end of a protein meal so it “hits bottom” for a while! You may also experience fatigue from iron deficiency anemia, Vitamin D deficiency, B12 deficiency. Get checked, get a pill organizer and give yourself a gold star!

Loss of Muscle Mass – This is the engine for your basal metabolic rate (BMR), which is 70 percent of your daily caloric need. BMR is what gets burned even when you are resting. We lose some muscle during the initial weight-loss but can hold onto more if regularly performing resistance work. The “natural” loss of muscle as we age depends a lot on inactivity (even in skinny people). Much of your BMR is built in for energy to your brain and organs to work, but muscle represents the largest modifiable portion.

Mindless Eating – You would not believe how many people don’t know what they eat. A food journal is my third most important tool. Honesty is empowering! My daily treat needs to be the only treat, and it’s easy to have another naughty moment later in the day if you didn’t write down the first treat. You can use your cellphone camera to take a picture and log it or simply write it down in a food journal. Do what works for you, and I bet you’ll be glad you did.

Managing Stress
It’s probably a safe bet that you have some type of stress in your life, such as your job, family, friends and the list continues. What’s important is that you do not let stress overtake and derail your weight-loss goals.

The word “should” is toxic. – It will make you beat yourself up and can cultivate a generally hostile attitude (very counterproductive). Often, the answer is to slow down when the world is telling us to speed up. Trying to do too much can lead to feelings of staleness and boredom. Surgeons are always saying in the operating room, “Perfect is the enemy of good.” That’s why we are all so mellow – ha!

Figuring out how to push yourself a little without turning harsh is not easy! Mindfulness training, counseling and support group/spiritual support can all be helpful. An attitude of self-care doesn’t eliminate problems; however, it can keep them from spiraling out of control and gives the true “comfort” that external sources never truly can.

Many patients do well until a life crisis throws them off track. Expect bumps in this life – the tool is still there! Many programs now offer a “back on track” pathway.

Body Image
Guess who the hardest critic is? You guessed right – it’s you. It is important when evaluating your body after bariatric surgery or any significant weight-loss to be fair to yourself and have realistic expectations.

Is your internal environment hostile or safe? – “Unreasonable expectations” is a term I probably use too often; however, to some extent, it is true. Bariatric surgeries usually give a compromise amount of weight change, and we are not a society of compromise. Average weight-loss is about 30 percent of starting total body weight. Sometimes excess skin is more annoying than excess weight. Give your body 12-18 months before major reconstruction, as skin often tightens throughout time.

At an early support group, I heard the phrase, “The same life in different sized clothes.” Did you expect to be a completely different person? Alternatively, were you afraid of losing some essential part of who you are? For many of us, “doing everything right” to have a healthy body includes honoring what can only be changed by a plastic surgeon or by having different genes! Usually, I see this as a problem from outsiders judging and not patients being hard on themselves. Inside the medical field, I often hear of someone “putting it all back on” when in reality, they are doing fine. Your friends and caregivers can forget where you started! Most often, true total weight regain comes from a broken tool.

Surgical Problems
Oh yeah, I almost forgot why we surgeons are an important part of that long term care team!

Guess what? Tools can stretch or break. – While trying to “retighten” things surgically or endoscopically is not always an answer, it can occasionally be quite powerful. More powerful yet, a completely broken tool can be found and fixed, such as eroded gastric band or failed staple lines on an older gastric bypass or gastroplasties (common in the 70’s-90’s). These problems basically undo the original operation so of course the appetite and weight return! Also common is an empty gastric band, either from a perforated component (usually tubing) or from intentional deflation because of reflux, vomiting or swallowing problems.

Revisional surgery is a highly individual issue, but we surgeons are learning more and more about it. While there is often more risk than the original operation, the benefits can be outstanding. As our surgical “toolbox” grows, we will have even more to offer, but beware that even a “better” tool is never a substitute for appropriate use of the tool.

The opposite problem concerns me also. How many people have a tool that has failed but never find out about it because they have shame or fear of being judged? Please remember – your team works for you! If they don’t, then get a different team, but don’t try to go on this journey alone. We started this journey to have a better, longer life – remember to have some fun doing it!

Final Words

Even though the premise of this article is that you are already exercising regularly, the truth is that most of us find regular physical activity to be by far the greatest challenge to sustain. A wise surgical mentor told me early on, “Walt, you will almost never find a patient with an intact operation who has regained more than 20 or 30 pounds if they are exercising more than 100 minutes a week. It just seems to be the KEY that makes the rest of it work.” In my personal and professional experience, he is 100 percent correct so far and that’s why it is my personal rule #1.


About the Author:
Walter Medlin, MD, FACS, is director of the Metabolic Surgery program at Billings Clinic in Montana and an OAC Advisory Board Member. He struggled with his weight since first grade. After performing hundreds of bariatric surgeries, he underwent sleeve gastrectomy in 2008, with outstanding results. Dr. Medlin is also a participating practice in the OAC Sponsored Membership Program where he gives each of his patients a one-year membership in the OAC and he is honored to be a longtime member of OAC. Dr. Medlin is also an avid user of Twitter; his handle is “@bonuslife.”