By David Okolica, MD FACS FASMBS


One of the most challenging and feared issues which can occur on a long-term basis after bariatric surgery is weight regain. Soon after uncomplicated bariatric surgery, regardless of the procedure performed, the patient develops good restriction, less hunger, and possibly intestinal malabsorption. Over the first year, the patient easily loses weight as the body’s metabolism changes and dietary habits are forced to accommodate to the reshaped stomach that was created during the surgery. This is referred to as the ‘Honeymoon Period’. Physiologically, it is the period when weight loss is most rapid due to gastric restriction, appetite suppression and intestinal malabsorption. However, once this period is over, some patients go back to their old dietary and lifestyle habits, and they can regain weight that was lost in the first post-operative year.


In these ensuing years, the patient accommodates to the bariatric surgery, and hunger increases, restriction decreases somewhat, and the patient tolerates a more varied diet in larger portions. The patient may return to maladaptive eating habits, including unplanned snacking, which can be tolerated better more than a year after the surgery, or larger portions, which may stretch the stomach pouch or sleeve to some degree. Poor lifestyle habits may reappear, which includes smoking, alcohol use or lower exercise levels.


Weight regain that takes place several years after bariatric surgery due to a surgical complication is unusual, but it is important to speak with the bariatric surgeon and to undergo testing if appropriate. Normally, the stomach pouch or sleeve is evaluated with an upper endoscopy or upper GI X-ray series to check the stomach for size and patency. Chronic abdominal pain and nausea after bariatric surgery also can prevent the patient from maintaining a lower weight, and the gallbladder may need to be evaluated for gallstones and gallbladder disease.


Once surgical issues are ruled out, weight regain is usually addressed with dietary counseling, medical evaluation, weight-loss medications, and lifestyle modification. It is important to be evaluated by the dietitian, where dietary habits, protein supplementation, portion sizes, and food journaling can be discussed. Sometimes, a psychological evaluation can be helpful to address behavioral habits which promote weight regain, like emotional eating, and smoking or alcohol use. Exercise habits are also important to discuss and monitor, as many patients do not maintain an active lifestyle with daily exercise years after bariatric surgery. There can also be medical issues which need to be addressed by the primary care physician to maintain a lower weight, such as thyroid deficiency, anemia, and vitamin deficiency. Weight loss drugs are also available to assist with weight regain, as they suppress appetite and decrease intestinal fat absorption. 


Obesity is a life-long disease, and patients must realize that surgery is only a tool to help them lower their weight and improve their health which must be used properly over the long term. After the honeymoon period is over, patients must be even more vigilant about their lifestyle habits to prevent weight regain and other nutritional problems.