Before undergoing bariatric weight-loss surgery, it’s hard to imagine that we could become one of “those people” who gain weight after losing it with the help of surgery. Unfortunately, at some point, most patients who have gastric surgery as a last hope for weight loss eventually gain some weight back. It can happen quickly and without fanfare. Here are three red flags to watch out for that can lead to weight regain:

1. Eat soft carbohydrate snacks. Over the past 10 years, countless bariatric patients have told me: “At first it seemed harmless to eat a few pretzels (crackers, chips, cookies, etc.), but pretty soon I was eating them all day and the weight started to come back.” This is a common mistake weight loss surgery patients make that eventually leads to regaining some of the weight previously lost with weight loss surgery. We turn to soft carbohydrates because, in most cases, they are comfortable in the stomach pouch, taste good, and are readily available. Unfortunately, soft carbohydrates shut down the function of the stomach pouch. When we eat a meal rich in lean protein and plant-based carbohydrates, the food stays in the stomach pouch and we feel a feeling of fullness or tightness that tells us to stop eating. Soft carbohydrates, on the other hand, pass quickly through the bag and the feeling of satiety is not achieved, so we can eat soft carbohydrates seemingly all day. The first rule of weight loss surgery is “Protein First” and rule number three is “No snacking.” Remembering these rules will help us refrain from snacking on bland processed carbohydrates, a habit that can lead to weight gain in bariatric patients.
2. Drink liquid with meals. Generally speaking, bariatric patients are instructed to stop consuming fluids 30 minutes before and 30 minutes after eating. Also, they are told to refrain from drinking beverages with meals. Fluid restrictions are intended to keep the focus of mealtime on a high-protein diet of lean animal, dairy, and vegetable proteins. Protein-rich food fills the gastric pouch and maintains satiety better when there is no fluid. When we consume beverages with our lean protein meal, the food washes out through the gastric pouch before being fully digested. Nutrients are lost as food is eliminated and hunger returns more quickly. As we move forward after weight loss surgery, we tend to relax fluid restrictions because it is not comfortable to eat food without liquid and dinner conversation is difficult with a dry mouth. An occasional small sip of water with meals may be acceptable and is unlikely to cause weight gain. However, returning to full drinking with meals almost always leads to a weight loss plateau or eventually weight gain.
3. Avoiding the Scale. During the first weeks and months after weight loss surgery, patients frequently weigh themselves because it is exciting to measure our weight loss on the bathroom scale. In fact, for some patients who are losing weight, the relationship with the scale becomes almost an obsession. Unfortunately, as lifelong dieting bariatric patients intuitively know when the pendulum has swung from weight loss to weight gain. Avoiding the bathroom scale is a strong red flag that weight gain is imminent. This is understandable, we have worked hard to lose weight and avoiding the scale allows us to deny or ignore what we already know: we are getting fat. Patients who establish a weekly ritual of weighing in on the same day each week at the same time and place tend to be more responsible for weight gain and are more likely to correct behaviors that lead to weight gain early. Patients who avoid the scale are encouraged to participate in a self-assessment to identify the cause of weight gain and correct behaviors quickly.

Before weight loss surgery, we are told that gastric bypass, adjustable gastric banding (gap band), or gastric sleeve procedures are just a weight loss tool. We are instructed to adopt a lifestyle that includes modifications in diet and physical activity. This new lifestyle must be followed for the rest of our lives to maintain weight loss and achieve better health. Just as surgery is a tool, we humans are prone to the ups and downs we call life. Red flags are also tools – warning tools – which, when observed, give us the opportunity to make a correction and move in a favorable direction.