Weight Regain After A Gastric Sleeve

Weight Regain After The Sleeve Gastrectomy

Referred to as the new operation on the block the laparoscopic sleeve gastrectomy has seen a rapid rise globally with patients choosing this over the gastric bypass and gastric band as a first choice treatment option. Currently there isn’t enough long term data on the sleeve compared to the other operations and the most recent long term study showed significant weight regain with a return of the comorbidities.

The study led by Andrei Keidar, MD, at the Beilinson Hospital in Israel and his researchers reviewed 443 cases of LSG from 2006 to 2013 by the same surgery team and found that within 5 years, the percentage of excess weight loss declined from 77% to 56%, and “complete remission of diabetes was maintained in only 20% of patients.”

They also found that remission of hypertension was only maintained in 45.5% of patients and there were significant differences in levels of high-density lipoprotein cholesterol levels and triglyceride levels. The results of the study were published in JAMA Surgery in August 2015.

Anita P Courcoulas MD, MPH from the University Of Pittsburgh School Of Medicine wrote in an accompanying editorial that caution should be urged in interpreting the findings stating that answers about the effectiveness of bariatric surgery will not be easy to come by.

“It will take time, patience, and a willingness to avoid a rush to judgment,” she wrote. “In the meantime, clinicians and prospective patients will need to discuss and weigh the evidence in a dynamic exchange driven not always by final conclusions but by the most current available data.”


In the beginning the laparoscopic sleeve gastrectomy was performed as an intervention for high risk patients before they underwent a gastric bypass or performed as the first step of a biliopancreatic diversion duodenal switch. However Dr’s soon realised that the sleeve could be done as stand-alone procedure and since then it has grown in popularity. However, according to Keidar and his colleagues there are still relatively few studies on the long term effects of the sleeve.


Obesity specialist; Craig Primack MD from the Scottsdale Weight Loss Centre in Arizona, wrote in an email that doctors may be surprised at the lack of quality, long-term data for LSG.

“If I am going to let a surgeon cut out my stomach (especially as many now consider this procedure the procedure of choice) I would sure like to know what will happen to my weight and other comorbidities down the road,” he wrote.”

gastric sleeve

In the latest study, Keidar and colleagues looked at how patients fared at one, three, and five years after surgery. More than 1,000 patients underwent bariatric surgery during the time frame that the researchers looked at, and less than half underwent LSG.

The definition of remission of diabetes was defined as a normal fasting glucose level (<100mg/dL) with no use of insulin or oral medications. The definition of partial remission was defined as a reduction of medication dosage or cessation of medication use despite abnormal laboratory results. Complete data were not available for a relatively high number of patients: at one year, complete data were available for 241 of the patients (54.4%), at three years for 128 of 259 patients (49.4%), and at five years for 39 of 56 patients (69.6%).

The mean preoperative body mass index was 43.9, noted the authors. At one year, the percent of excess weight loss was 76.8%. It was 69.7% at year three and 56.1% at year five.

Before undergoing surgery, 82 of the patients had been diagnosed with type 2 diabetes, 65 with impaired fasting glucose, 110 with hypertension, 155 with hypercholesterolemia, 109 with hypertriglyceridemia, and 55 with hyperuricemia. At one year, 64.5% of the patients stopped taking medications for type 2 diabetes, at three years 48.3% stopped, and at five years 55.5% stopped.

Courcoulas wrote that there are gaps in the knowledge about how effective LSG is. “These critical gaps in knowledge pose a significant problem for people considering a potential surgical option to treat severe obesity,” she wrote. “Contributing to these deficits are the paucity of comparative trials, incomplete follow-up, a lack of standardized definitions for changes in health status (e.g., diabetes mellitus remission), and the tendency to a rush to judgment in favour of surgical treatment options.”

Many of the studies done on LSG use different end points, wrote the authors, making it difficult to compare. In addition, the term “partial remission” is used to mean different things in the studies.

“In our opinion, the presence of obesity-related comorbidities should play a major role when choosing the appropriate procedure for a specific patient,” wrote the authors. “For example, performing an operation that yields a low resolution rate of hyperlipidaemia translates into lifelong medical treatment in a young patient with significant hyperlipidaemia. In that case, a malabsorptive procedure might be more beneficial than an LSG procedure.”

The study was done at a single site and the results may not be generalizable. Also, many of the patients were lost to follow-up, which may have led to a bias, noted the authors. The small sample size at five years precluded conclusions about the changes in comorbidities, and the follow-up was not continuous for all of the patients.


Journal References:

Anita P Courcoulas, MD MPH No Rush to Judgment for Bariatric Surgery JAMA Surgery August 2015 DOI: 10.1001/jamasurg.2015.2222

Andrei Keidar, MD et al. Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy. JAMA Surgery, August 2015 DOI:10.1001/jamasurg.2015.2202




The Decision To Have A Gastric Band or Gastric Sleeve

Gastric Band versus Gastric Sleeve


Having made a life changing decision to embark on weight loss treatment with bariatric surgery you need to consider your options as well as the pros and cons of the various operations. We are going to do a comparison between the gastric sleeve and the adjustable gastric band.


Each person is different and when you are considering having surgery it is best to do as much research as possible and take some time to learn about the options to help you decide which one is best suited to your personal situation. Set up an appointment with a bariatric surgeon to discuss your weight loss journey and to ask any questions and to address any concerns that you may have, they normally work with a team so you can also speak to one of the members who will have a wealth of experience working with patients like yourself.


The two operations we are going to look at are the laparoscopic adjustable gastric band (LAGB), which is an operation that involves placing a medical device around the top of the stomach to control hunger and eating, and the laparoscopic sleeve gastrectomy (LSG), also called the gastric sleeve, this is an operation which surgically removes a greater part of the stomach to limit food intake.


So, let’s look at each operation in detail starting with the sleeve gastrectomy.

This a restrictive procedure which limits the amount of food that can be eaten and reduces feelings of hunger. The stomach is reduced in size as, 60-80% of the stomach is physically removed leaving a very narrow tube resembling a sleeve.


During the weight loss phase in the first 1-2 years patients are on 600-800 calories a day which increases to 1000-1200 once patients have reached their target goal weight.


Patients are advised to eat protein-rich foods, avoid high fat and high calorie foods, drink 6-8 cups of water a day and avoid carbonated drinks. Patients are also recommended to eat five small meals a day, avoid snacking and not to eat and drink at same time. They must chew their food thoroughly and not lay down or rest horizontally after eating. It is also recommended that patients take a multi vitamin supplement as well as calcium and vitamin B12.


The operation itself is performed through keyhole surgery and on average takes one hour with an average hospital stay of 2-3 days. Patients need to take 2 weeks off work and the recovery period is 3-4 weeks. Although there is no implanted device the disadvantages of this procedure are that it is not adjustable or reversible and carries general surgical risks which includes blood clots, bleeding, infection, and pneumonia. There is also a risk of leakage at the suture/staple edge line of the stomach and a risk of newly diagnosed reflux disease. Patients are required to make a lot of effort for initial weight loss.


The advantages are that it does not require a medical device implant into the body, the pyloric valve and small intestine are kept intact. The gastric sleeve reduces hunger because the portion of stomach that produces Ghrelin; the hunger stimulating hormone has been removed. Patients have few food intolerances and therefore there is a low risk of malnutrition. The sleeve is an option for patients who do not qualify for band or bypass and can be converted to a gastric bypass for additional weight loss.


In terms of expected weight loss there is a faster rate of weight loss compared to the band. The short term results have been primarily favourable, especially in low BMI patients (BMI 35 – 45). The expected weight loss is an average of 55% of excess weight at 2 years. At the moment long term results are not yet available




Now let’s take a look at the gastric band procedure:


The band is also a restrictive procedure which slows down digestion therefore limiting the amount of food that can be eaten and creating a feeling of fullness earlier with less food. The anatomy is not changed in any way and during the operation a new small stomach pouch is created by placing an adjustable silicone band around the top part of the stomach and the access port is placed just under the skin to enable the clinic to access the port to perform adjustments.

Band Pic

The dietary requirements for gastric band patients are 800 calories per day during weight loss period (2-3 years) then 1000-1200 calories per day, once their goal weight has been achieved. It is recommended to eat protein-rich foods and avoid fibrous, dry, or doughy foods as they can get stuck in the stoma of where the band is situated around the stomach. It is wise to avoid high fat, high calorie foods and carbonated drinks and to drink 6-8 cups of water a day. Gastric band patients need to eat 3 small meals a day, avoid snacking and not drink at the same time as eating. One of the golden rules is to eat slowly and chew their food thoroughly. In terms of supplementation they are advised to take multi vitamins and calcium.


The actual operation is performed by keyhole surgery and takes approximately an hour, in some cases the surgery is done as a day case otherwise it is an overnight stay. Patients need to take a week off work and recovery time is 2 weeks. The band is adjustable and the operation is fully reversible.


The disadvantages of the gastric band are the normal general surgical risks including infection. A band slippage (<5%), band erosion (<1%), or port problems. If inappropriate foods are eaten the stoma can become obstructed causing discomfort and pain. On the weight loss journey the band needs to be filled and adjusted in the clinic by either a surgeon or specialist nurse. Patients need to make an effort to eat in the prescribed way for the initial weight loss to occur.


The advantages of the gastric band are that the operation is simple and relatively safe. It is reversible and adjustable and does not remove or alter any part of the stomach or intestines. The hospital stay is short with a quick recovery period. There is a low risk of malnutrition as well as a low rate of major complications. There is an excellent App called the Bioring Gastric Band which helps to both support and educate the patient on their weight loss journey and is very user friendly.


In terms of weight loss with a gastric band it occurs at a slow and steady rate settling at the final goal weight 2-3 years after surgery. Patients can lose 40-50% after 1 year and 55% after 5 years, there is excellent long term data on gastric banding.


When you are considering your weight loss options remember to keep in mind that surgery is only a tool to help you lose weight and that regardless of which procedure you choose you need to make an effort to change your lifestyle and eating behaviours to be successful.




Prevent Childhood Obesity- Measure Babies BMI

Early Childhood Obesity May Be Predicted by An Infant’s BMI


Following a recent study scientists say that an infant’s BMI could be a predictor which children are more likely to be obese by the age of 6 years.

Dr Allison Smego, study lead investigator and paediatric endocrinology fellow at Cincinnati Children’s Hospital Medical Centre said, “Our study shows that growth patterns in children who become severely obese by 6 years of age differ from normal weight children as young as 4 to 6 months of age”.


big baby 1

Normally the BMI tool isn’t routinely used on children younger than 2 years old but the researchers are hoping that their study will change that mind-set.

For the study the children all had a BMI above the 99th percentile. The researchers examined electronic health records of 480 severely obese children between 2 and 6 years in the Cincinnati area.

Children are considered overweight when the BMI is at or above the 85th percentile for their age and gender. Those with a BMI at the 95th percentile or higher are considered obese.

The records of nearly 800 kids between 2 and 6 years old who were at a healthy weight and had a BMI between the 5th and 75th percentiles were also analysed by the researchers.

The study noted that most of the obese children were black and from low-income households and that BMI began to shift in different directions among infants in the two groups as early as 4 months old.

To confirm their findings, the researchers repeated their study in a third group of nearly 2,650 children in Colorado. This trial, which involved more Hispanic children, showed that a BMI above the 85th percentile at least tripled the likelihood that a child would struggle with severe obesity by the age of 6 years.

The study authors concluded that a BMI above the 85th percentile at 6, 12 or 18 months of age was a strong predictor of severe obesity by the age of 6 years.

The study’s findings were expected to be presented Friday at the Endocrine Society’s annual meeting, in Boston. Until published in a peer-reviewed medical journal, data and conclusions presented at meetings are usually considered preliminary.

In a news release from the Endocrine Society Smego said, “Based on our findings, we recommend that paediatricians routinely measure BMI at infant well-child assessments beginning at 6 months, identify high-risk infants with BMI above the 85th percentile, and focus additional counselling and education regarding healthy lifestyle toward the families of these children,”

Smego also added, “It might take the paediatrician a minute to look at BMI, yet it gives them a wealth of knowledge about how their patient is growing.”


Reference: BMI Trajectory of Severely Obese Children Diverges from Normal Weight Children During Infancy

Authors: Smego A, Woo J G, Klein J et al

OR 07-5 Presented at ENDO 2016 in Boston, April 1-4


Can A High Protein Diet Improve Sleep?

Improve Your Sleep While You Lose weight On a High Protein Diet


In a study published in the American Journal of Clinical Nutrition overweigh and obese adults who are losing weight on a high protein diet are more likely to sleep better according to researchers from Purdue University.


Wayne Campbell, a professor of nutrition science said “Most research looks at the effects of sleep on diet and weight control, and our research flipped that question to ask what are the effects of weight loss and diet — specifically the amount of protein – on sleep.”


“We found that while consuming a lower calorie diet with a higher amount of protein, sleep quality improves for middle-age adults. This sleep quality is better compared to those who lost the same amount of weight while consuming a normal amount of protein.


“The paper’ ‘Higher-protein diets improve indexes of sleep in energy-restricted overweight and obese adults: results from 2 randomized controlled trials’, focuses on a pilot study found that in 14 participants, consuming more dietary protein resulted in better sleep after four weeks of weight loss.


In the main study, 44 overweight or obese participants were included to consume either a normal-protein or a higher-protein weight loss diet. After three weeks of adapting to the diet, the groups consumed either 0.8 or 1.5kgs of protein for each kg of body weight daily for 16 weeks. The participants completed a survey to rate the quality of their sleep every month throughout the study. Those who consumed more protein while losing weight reported an improvement in sleep quality after three and four months of dietary intervention.

Diet and sleep

A dietitian designed a diet that met each study participant’s daily energy need and 750 calories in fats and carbohydrates were trimmed per day while maintaining the protein amount based on whether they were in the higher- or normal-protein group. The sources of protein used in the two studies varied from beef, pork, soy, legumes and milk protein.


“Short sleep duration and compromised sleep quality frequently lead to metabolic and cardiovascular diseases and premature death,” said Jing Zhou, a doctoral student in nutrition science and the study’s first author. “Given the high prevalence of sleep problems it’s important to know how changes to diet and lifestyle can help improve sleep.”


Campbell’s lab also has studied how dietary protein quantity, sources and patterns affect appetite, body weight and body composition.


“This research adds sleep quality to the growing list of positive outcomes of higher-protein intake while losing weight, and those other outcomes include promoting body fat loss, retention of lean body mass and improvements in blood pressure,” Campbell said. “Sleep is recognized as a very important modifier of a person’s health, and our research is the first to address the question of how a sustained dietary pattern influences sleep. We’ve showed an improvement in subjective sleep quality after higher dietary protein intake during weight loss, which is intriguing and also emphasizes the need for more research with objective measurements of sleep to confirm our results.”


Reference: The American Journal of Clinical Nutrition


AMJ Clin Nutr: March 2016 Vol 103 no3 766-774 doi:10.3945/ajcn 115-124669


Title: Higher-protein diets improve indexes of sleep in energy-restricted overweight and obese adults: results from 2 randomized controlled trials’


Authors: Jing Zhou, Jung Eun Kim, Cheryl Armstrong, Ningning Chen and Wayne Campbell