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How You Can Improve Your Outcome From Weight Loss Surgery

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I often tell patients, “The surgery does what the surgery does.” What I mean by this is that weight loss surgery almost certainly will affect how much food you can eat, but may do little to change what you eat. Weight loss surgery does not make you suddenly crave healthier and less caloric food. You have to make those choices for yourself. Additionally, while losing weight may make it easier for you to adopt a more active lifestyle, surgery itself will not make you suddenly fall in love with exercise. So making health behavior changes in addition to having surgery remains critical. So what specific health behavior changes have been shown to improve outcome?

1. Document what you eat – Many people strongly dislike writing down what they eat but there is evidence that this helps people after weight loss surgery as it does with non-surgical approaches. The reason is likely that documenting what you eat gives you valuable information about your behavior and allows you to make changes when necessary. Consider that your actual weight is the end product of what you eat, so weighing yourself gives you the results, but not the information necessary to make changes. For many, weighing themselves is a pass-fail exam. Either I’m a good boy or a bad boy. Consider that you can’t actually change your weight…you change what you eat and/or exercise, and that is what helps change your weight.

Many people seem to have little or no objection to weighing themselves so why do so many people despise writing down what they eat? Writing down what you eat is the truth teller. It forces you to acknowledge what you are doing. To avoid seeing the truth, you can either change what you eat or stop writing it down. Unfortunately, many people choose the latter. The good news is that in the smartphone era, there are literally dozens of apps and other technological devices that can make documenting your food and activity level extremely easy. If you do a little research you can find one that is right for you.

2. Exercise – You probably saw this one coming as well because it makes sense. Regular exercise is a way of burning calories and losing weight that does not involve changing what you eat. Given how difficult it is to lose weight and keep it off, it would be silly not to take advantage of one of the few methods known to work. Ironically, it might not work the way you would expect. Many people who lose weight through exercise notice that it helps them not just by burning off calories, but also by affecting their food choices. In other words, when you discover how difficult it is to burn off 250 calories on a treadmill, you may think twice before having that chocolate bar afterwards. Not everyone finds this effect, but for those who do, it can make a big difference.

When deciding what form of exercise to do, consider that you don’t need to become an Olympiad or a marathon runner. Many of the positive effects of exercise have been documented with just walking 30 minutes 3-4 times per week. If rigorous exercise is enjoyable for you, that’s great. But any time spent engaged in activity is beneficial...especially if you would otherwise be sitting on the couch watching all of those tempting food advertisements on television!

3. Stress Reduction – An increasing amount of research has documented a relationship between stress and weight gain. The obvious connection is that many people use food as a means of comforting themselves from distress, commonly called “emotional eating.” An interesting new discovery is that is that some people who report high levels of stress gain weight even when their calorie intake is unchanged. How is that possible? There is the suggestion that stress hormones and other chemicals may affect how our body metabolizes food and stores food. So even if you’re eating the same foods and the same number of calories, what your body does with those calories can vary.

If you’re going to be successful in reducing stress, you need to begin by discovering what “pushes your buttons” and take steps to change. One first step could be to document the things that you find to be stressful. Sometimes just writing down your problems makes them less frightening now that they’re just words on a page. For other people, writing their sources of stress naturally leads them to write what they might do about them. Another good idea is to investigate some simple stress management techniques. Many refer to them as relaxation or meditation exercises. As discussed earlier, there are a number of excellent smartphone apps and other technology-based methods of relaxation that you can explore. No one is better than the rest so just find one that works for you and begin to incorporate relaxation/meditation into your daily routine. If reducing your stress requires more than practicing relaxation techniques, consider speaking to a psychologist or other mental health professional to get the help you need.

4. Get some sleep – Here’s another suggestion that you’ve probably seen in the media recently. There is growing consensus of an obesity-sleep connection. Like exercise, the benefits of sleep are more than meets the eye. The obvious connection is that if you’re up longer, you become hungrier and are likely to eat late at night. This interpretation is not wrong, however, new research suggests that people who get 7 or more hours of sleep tend to maintain lower weights even when people with fewer hours of sleep consume the same amount of calories. How is that possible? Again, it’s not just how many calories we eat…but what our bodies do with those calories. Unfortunately, an increasing number of people are so busy between their work and social lives (not to mention all those tempting television shows) that sleep is not a priority. Just know that making sleep the last priority comes at a cost.

Consider how we train children to sleep. We create a nighttime ritual to ease kids to bed. There’s dinner, wind down time, then bath time, maybe reading a story or two in bed, and then lights out. Many adults however have a terrible routine. Eat a big dinner at 9pm, catch up on emails and pay bills, watch television for an hour or so and then fall asleep on the couch and stumble into bed at 2AM only to have to wake up three or four hours later. Try to change your sleep habits by changing your nighttime ritual. Eat an earlier dinner. Try to pay bills and check your emails at another time. Use the evening as wind down time. Rather than fall asleep on the couch, watch a set amount of television or Internet time and then turn it off and “put yourself to bed.” Begin by trying to go into bed a half-hour early every night for a week and see how you feel. If you notice some improvements in your level of energy, mood, appetite or other factors, see if you can make it permanent.

5. Join a Support Group – Some research has demonstrated that patients who participate in support groups lose and maintain more weight than those who don’t. Of course it may depend on the content of the group and who attends, but adding a social element to your weight loss and weight maintenance goals seems to help. This may relate to the accountability factor discussed earlier. If “we’re all in it together,” there may be more of a commitment to stick to your goals to help out the group. Or perhaps it motivates you not to be the one group member who is falling behind. Either way, participating in support groups seems to have benefits both in terms of weight loss as well as emotional well being after surgery.

There are other suggestions of course, such as improving your diet by reducing carbohydrates in favor of lean protein and a more plant-based diet. However, for many people, changing their diet can push all of those emotional “diet” buttons; so before you make those changes (or in addition to making those changes), strongly consider some of the changes recommended above. There is evidence that the benefits are additive. For example, many people find that when they exercise, they sleep better and in turn these changes help them manage stress better. The key is to acknowledge whether or not some of the factors above are problem areas for you and to begin making small changes. Sometimes small changes can lead to big results!

1b. Be HONEST about what you're documenting. Lying to yourself about those little nibbles here and there will only be disastrous to the bottom line. Also, if you aren't weighing and measuring CORRECTLY, you could be grossly underestimating your totals.

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Of course there are lots of people that don't weigh or measure anything with great success. It's the ones that are forced to weigh and measure everything to get through a stall that I'm speaking in reference to.

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Excellent article.

This is the first place I've read that stress can cause weight gain even without additional calories. So I did some googling and lo-and-behold, the studies are out there.

Why is this not front-page news? Stress caused by financial insecurity is at Depression-era levels, as obesity rates soar.

The fact that stressful events and depression alter how we metabolize food (not just what we choose to eat, or how often we move) is BIG. As long as we pretend the problems of obesity are individual not systemic, we'll be chasing the wrong solutions.

My story in brief: I was a 10-pound baby and grew up chubby but healthy. Gained 20 with children and post-partum depression, then lost a friend to suicide and put on 35, very quickly. I lost that 35 with hard work and low carbs, but a series of stressors occurred that left me with little appetite or energy. Yet within two years, I gained 55 pounds.

I am not a binger. I eat sensibly and am moderately active (I walk, bike, swim, hike). I don't drink soda, eat very little sugar, and stay away from carbs. I honestly thought my doctor's scale was broken. She figured it was my genes kicking in (my parents are large), and no doubt suspected me of lying about my diet and activity levels.

The big takeaway for me?

Even after WLS, stress will effect how I metabolize food. Looks like stress-reduction will be just as critical to my success as keeping track of food and exercise.

I'll plan to add "cushion time" on MyFitnessPal to log daily meditation. It may burn more calories than one thinks. And join a support group! I suspect the cortisol-lowering effects of being with sympathetic people are just as critical if not more so than the "accountability" factor.

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