Long Term Maintenance After Weight Loss Surgery at Advanced Surgical Associates

Years ago, zero-calorie natural and artificial sweeteners were considered a staple for those having undergone bariatric surgery. Recent research has brought new scrutiny on these compounds that include saccharin, sucralose, aspartame, neotame, acesulfame, and stevia.

The above sweeteners are approved by the FDA. These compounds are found in many of our everyday items including yogurt, vitamins, salad dressings, bakery items, and more. So, they must be safe, right?

Research suggests excessive intake of any added sweetener, can cause severe negative long-term health effects. While there is no definitive consensus on why this happens or what exactly strikes a good balance (moderation), there is plenty we do know.

What We Know About Sugar

Refined, added sugar is a bad carb. As a simple carb, sugar offers no nutrition and represents empty calories. Unfortunately, the modern palette has gotten used to added sugars and it’s getting harder to find anything without sugar added.

Sugar occurring naturally in many of the most nutritious foods we consume is not so bad. Even so, it is best to limit consumption. The problem is, we no longer find those naturally sweetened foods as palatable and we don’t eat enough of them.

The result has been an epidemic of added sugar consumption. Diabetes and obesity, two diseases linked, at least in part, to sugar consumption, are skyrocketing. Until recently, artificial sweeteners were the supposed cure for the epidemic.

What We Know About Artificial Sweeteners

The main benefit of artificial sweeteners is that they offer the sweet taste we crave without the calories. Drinking a diet soda versus the regular kind can save 140+ calories per bottle. Baking a cake with sucralose versus regular sugar can save thousands of calories. Seems like a win-win.

So, what’s the catch? There are a few and they’re biggies.

• There is a tendency to believe we can save calories by drinking diet soda in order to splurge on something else.
• New studies show that artificial sweeteners may be changing our palates to need sugar in to enjoy our food. This means that low-sugar items become less appealing. As our tastes change, so do the processed foods that cater to those tastes. The result? Intake of low-nutrition, processed foods that manage our cravings, but do not offer quality nutrition.
• Artificial sweeteners, much like sugar, may be addictive at least in animal studies. Just like every craving, over time we need more and more to keep us happy. You may have started with half a packet of sweetener in coffee, but a year later need a full packet. Trying to detox our bodies of such a powerful compound does not happen easily.
• Sugar substitutes may trick the body into believing it needs more calories, which it will crave from other sources.
• Even though there is some scientific consensus that many artificial sweeteners are not carcinogens in small amounts, they have become an ever-larger part of our diets. We do not know if these compounds could cause cancer in the quantities being consumed today

What About Other Natural Sweeteners?

There are many natural sweeteners out there, some that offer very compelling benefits. For example, being organic, derived from plants and zero- or very low calories. However, the negatives are the same. Extreme sweetness, regardless of the calories, can work against us, natural or not, for the same reasons mentioned above.

What’s the Takeaway on Sugar and Natural and Artificial Sweeteners?

To be sure there is a place for them, we must reduce our dependence on them. Just as we detox from a drug, removing added sugars and all forms of added sweetener from our lives will make us healthier and reduce those cravings that are so hard to resist.

OK, You’ve Told Me what NOT to Do, Now What Are My Options? 

• Understand that you will not be able to avoid all artificial sweeteners, especially right after bariatric surgery. Most protein shakes have it, but you can minimize your exposure to it.
  • Choose your products carefully by checking ingredients.
  • Avoid the consumption of non-essential foods and drinks like zero-calorie flavored drinks sweetened artificially.
  • Work with your nutritionist and support group peers to find new and interesting options.
• Get back to basics. What did our parents and grandparents eat and drink when obesity was not a national crisis? What portions did they find filling? How can we emulate that? Changing what a “treat” means (maybe instead of cake, we try fruit) and limiting portions (get the taste but not the quantity) can both help.
• Remember that healthy weight loss requires a combination of factors for long term success. Yes, diet is a very important component, but exercise and mental health are key to losing weight, too.
• Learn to love water again. For added flavor, you can place fruits and vegetables in the bottle – a little lemon, cucumber, mint or watermelon adds minimal calories and offers a more satisfying taste.

Drinking alcohol after a weight loss surgery procedure is not recommended. Both for weight gain and even in some cases, safety. 

Nutritional and Dietary Considerations

Regardless of the procedure you undergo, restricting calories is important after surgery to maximize weight loss. Alcohol is very high in sugar and calories. Even low-calorie drinks and mixes, that advertise themselves as diet-friendly, are too high in calories.

Alcohol can interfere with nutrition by causing problems absorbing key vitamins and nutrients.  Alcohol inhibits the pancreas’ ability to fully breakdown nutrients.  This can put bariatric patients at risk for nutritional deficiencies.

Alcohol is also diuretic and can cause dehydration.  Bariatric surgery patients may find it hard to stay hydrated while consuming alcohol.

Blood Sugar Considerations

After bariatric surgery, patients are placed on a high protein low carbohydrate diet.  This commonly results in low blood sugars.  Consuming alcohol can create a glycogen deficiency which in turn causes blood sugar levels to fall even further. Bariatric patients may experience symptoms including light headedness or even loss of consciousness.

Impairment and Overeating

Weight loss surgery reduces the size of the stomach.  Patients need to be careful to monitor not only their food intake, but alcohol consumption as well. The concerns are two-fold:

First, because of the phenomenon known as rapid gastric emptying, patients may experience heightened sensitivity to alcohol. Surgery results in the reduction of the stomach’s ability to metabolize alcohol. As a result, alcohol passes into the sensitive lining of the small intestine relatively undigested. This enhances inebriation and increases blood alcohol levels. This is especially true during the first six months to one year after bariatric surgery. As patients become more accustomed to life after bariatric surgery, they may be able to safely enjoy an occasional drink. Patients should wait ample time before driving and performing skilled tasks.

Too much alcohol may eliminate some necessary inhibitions surrounding food. This can make it possible for patients to overeat without thinking of the consequences. Over time, alcohol induced overeating can lead to stretching of the stomach pouch. There is a risk that the patient may revert to bad eating habits. A repeated cycle of drinking alcohol and consuming more food can eventually stretch the pouch permanently.

Alcohol Dependence and Transference

A possible consideration for bariatric patients is addiction transfer. Addiction transfer means substituting the comfort and dependence on eating (before surgery), for another addiction after surgery. Examples could be alcohol (or drugs, shopping, gambling, or any other compulsion). While addiction transfer rates vary, it may affect a significant number of bariatric surgery patients. Addiction transference for the bariatric patient may be managed with open and honest communication with loved ones and our office. Understanding the signs and risks and seeking help from a professional when these compulsions appear can help patients cope.

The Bottom Line

There will be times when you just want to have a small drink.  At this point, it is important to exercise appropriate restraint and caution. Much like anything else after bariatric surgery, the key is moderation.

Most importantly, do not drive or operate machinery having consumed alcohol recently, no matter how small the amount. You will not know your blood alcohol level or level of impairment. If you are drinking to cope or get through the day, seek professional help.

As always, we want you to enjoy your life after bariatric surgery and encourage you to bring up the topic of alcohol consumption either at your next follow-up appointment or at one of our monthly support group meetings.

Exercise is a critically important part of patient success. After surgery, bariatric patients who combine proper diet with a regular exercise program have been shown to achieve greater weight loss than patients who remain sedentary. Patients who exercise are not only healthier, but may be happier, too. Exercise releases chemicals in the body that stimulate happiness and mitigate depression and anxiety. Plus, exercise improves heart health and increases energy.

Patients should slowly build up the amount of time they spend exercising every day. Walking will be one of the most effective and easiest exercises to perform after surgery. Patients will likely be able to return to many activities and might finally be able to perform some that they haven’t in many years such as:

• Taking a long romantic walk with their spouse or significant other
• Playing (and keeping up) with their children or grandchildren
• Tying their shoes with no difficulty at all
• Fitting comfortably into a plane or movie theater seat
• Being able to perform and complete a cardiovascular workout
• Playing sports

Moderation in Exercise

With all activities and exercises, also comes risk. These risks usually revolve around overexertion and injury. Exercise should be started in moderation, slowly building up to greater and greater difficulty levels. Patients may also opt for low-impact activities as they lose wright, to minimize stress on their joints. Some beneficial low impact exercises may include:

• Swimming
• Cycling or spinning
• Ballroom dancing
• Yoga and stretching
• Pilates
• Rowing or kayaking
• Water aerobics
• Brisk walking

No matter what exercise is being performed it is important to remember that overexertion is not worth it. While you may be excited to see the next step in your routine, injuring yourself can set you back for weeks.

Staying Motivated to Exercise

One of the many challenges that patients face after surgery is staying motivated to exercise over the longer term. Workout routines can seem monotonous after a while. Here are some simple tips to get moving and keep motivated when you are cleared for all exercises.

First off, it is important to find enjoyable activities. Exercise does not have to be torture. In fact, we can come up with dozens of ways to entertain ourselves while exercising. Finding something fun – a walk in the park, riding a bike, swimming or rollerblading. If you enjoy winter weather you might try skiing, snowboarding, snowshoeing or cross-country skiing. They will all get your heart rate up, get you moving and that is the main goal. Participating in team sports can also be very fulfilling. Having others count on you to show up and play your best helps keep you motivated week in and week out.

Not into the outdoors? Even bowling counts as exercise! Or maybe join a gym and bring a buddy. Having someone to keep you accountable will encourage you on those days you really don’t want to exercise. Keep up with children - it will not only require plenty of exertion, but their excitement at playing with their parent or grandparent may offer motivation to keep going. Be creative – the need for exercise is never going away, so you may as well burn calories and shed those pounds doing something you enjoy.

Important reminder – always follow your surgeon’s instructions for exercise to avoid injury or surgical complications.

Remember exercise is a significant part of a successful surgery. Find activities that you really enjoy and relish the thought of finally being able to perform them to your fullest abilities.

There are many benefits to weight loss both medical and aesthetic. One of the most fulfilling benefits for many of our female patients is that they may begin to start ovulating and menstruating normally after surgery. This is as a result of the normalization of hormonal levels, especially estrogen and insulin.

Why Do Hormone Levels Matter?

The ovaries use the hormones in the body to regulate their natural cycles. Obesity however, interferes with hormonal balance and can cause irregular or missed ovulation, resulting in infertility. As a result of the more normal hormonal patterns, pregnancy is not only more likely, but complications and birth defects are less likely to occur. Further, it has been shown that children born to obese mothers have a higher likelihood of becoming obese themselves both at very young ages and through their adolescence.

When Can a Weight Loss Surgery Patient Get Pregnant?

It is important to understand that bariatric surgery causes disruption to the normal gastrointestinal and abdominal functions. Since pregnancy places an increased stress on your body and specifically your abdominal area, there is a potential for serious complications if a patient becomes pregnant within the first 16 to 24 months after weight loss surgery. Also, during the first year or two after surgery, patients will be losing a significant amount of weight and their diets and nutritional requirements will be changing as well. Becoming pregnant during that time can pose a risk to fetal development. We strongly advise that sexually active weight loss surgery patients begin taking effective birth control measures to avoid pregnancy within that time to not harm mother or child.

Effects of Obesity on Fertility

Obese women may have difficulty becoming pregnant as obesity may affect ovulation and fertility by altering the normal hormonal patterns that the ovaries need to function properly. It has also been shown that the risks of birth defects and adolescent obesity are increased in children born to women who were obese when pregnant.

Obesity affects fertility in several ways. Excess weight can alter hormonal production in the body, creating imbalances that can reduce the chances of getting pregnant. These imbalances can also alter ovulation patterns. Further, obesity can lead to type 2 diabetes which itself can cause problems with fertility.

Obesity can cause or worsen polycystic ovary syndrome (PCOS), a condition where the ovaries are enlarged and contain many small cysts, often causing fertility problems. Obesity can also interfere with the effectiveness of in vitro fertilization (IVF).

Risks of Pregnancy While Obese

A study published in the February 11, 2009 issue of the Journal of the American Medical Association analyzed clinical data from previous studies and concluded that indeed there is a link to birth defects when the mother is overweight or obese. Birth defects included: neural tube defects, spina bifida, cardiovascular problems and cleft lip.

While the risks of these birth defects were increased, their overall incidence is not widespread, so it is something to consider as obese women decide to conceive. Other data has shown that the risk of miscarriage increases with excess weight and obesity.

Studies have also shown that children born to women who have undergone successful weight loss surgery were less likely to be obese than siblings born presurgery. A 2006 study published in the journal Pediatrics compared 172 children – 113 born to obese mothers who had weight loss surgery to 45 similarly aged siblings who were born before surgery. The incidence of obesity in the post-surgical children was 52% lower and the incidence of severe obesity was over 45% lower than in pre-surgical births.

When can you get pregnant after bariatric surgery?

If you undergo bariatric surgery, there are limitations on when you can safely get pregnant. Depending on the procedure and how long you take to heal, you may have to wait up to 18 months after surgery before trying to become pregnant. Because pregnancy puts a strain on the abdominal area including the stomach and digestive system, it is very important you do not get pregnant until your surgeon declares it safe to do so.

Our office will be able to estimate when you can become pregnant safely based on the progress you make in healing. When you decide you would like to get pregnant, please let us know and we will be able to offer you guidance throughout the process.

If, after all your hard work and weight loss efforts, you notice that suddenly, the scale is going up instead of down, don’t panic. Virtually every bariatric surgery patient will contend with some weight regain, lack of weight loss and fluctuation throughout their post-operative journey. First, assess the situation and see if you can see an immediate and obvious cause. For example:

• Are your eating habits the same as before? If not, how have they changed?
• Have you been in one exercise routine for a long time?
• Has your exercise routine slowed down?
• Have you had an excess of salty foods recently?
• Has your stress level changed recently?

A change in eating habits, increasing or even decreasing calorie intake, can affect your weight loss or maintenance. Too much food can cause weight gain, but not enough food can trigger our bodies’ starvation mode and cause us to hold on to extra weight and water. A quick chat with your nutritionist can figure out any issues.

Slowing down your exercise routine or even simply staying at one difficulty level can also cause us to hit plateaus or put on weight. It may be time to change it up or even step up the intensity level just a bit. Talk to your exercise physiologist or your personal trainer for advice on how to take your workout to the next level.

Avoid salty foods and be sure to drink plenty of water. You’ve probably heard that a hundred times, but it’s true. Just a little excess salt can cause some powerful water retention and not consuming enough water can cause “head hunger,” water retention and low energy.

Stress and hormone levels can often affect our weight and ability to lose weight. Assess your current lifestyle. Have there been recent stress level changes or is high stress the norm in your life? If you said yes to either, stress relief exercises may help lower your levels, which will help bring those weight gaining stress hormones back in check.

• If you’ve assessed the situation and still can’t find the answer to the mystery weight gain, make an appointment with your surgeon. If lifestyle issues are ruled out, the reasons for weight regain after bariatric surgery can vary and include:
• Natural plateaus during the weight loss process
• The stomach may begin to stretch in response to increased food intake over time. This is perfectly normal if the weight regain is only moderate
• Gastric bypass patients may experience a widening or stretching of the stoma – this is the valve that was surgically created between the stomach and the small intestine
• The surgical procedure is not working ideally 

If no overt lifestyle reason can be determined, we may perform certain tests to verify the continued effectiveness of the primary bariatric procedure. For those that may have a physical or procedural reason for their weight regain, there are several minimally invasive (and even no-incision) options for restoring the procedure to its former effectiveness. This is called revisional bariatric surgery and represents an uncommon, but sometimes necessary solution to weight regain.

We encourage you to discuss your weight regain concerns with our team or consider bringing it up in support group to learn more about any possible underlying problems and to get more information on effective solutions.