The “Skinny” on Drinking With Meals & Weight Loss After WLS​

I have heard many times from new patients to our Program that they have a friend, coworker or family member who has had weight loss surgery and were never told not to drink with their meals. My question is always, “How are they doing with their weight loss?” Although success with weight loss surgery is not achieved with just one behavior modification or diet choice, drinking with meals is a problematic behavior.Not drinking with meals and not drinking for 30 minutes following a meal is one of the best pieces of advice I could provide to a patient to help them lose weight, regardless as to if they have had bariatric surgery or not.

​Many of us are familiar with the famous Nathan’s Hot Dog Eating Contest every July 4th in which contestants compete to see how many hot dogs they can eat in a 10-minute period. These contestants not only train for this event, they have a strategy to win it. Although difficult for some of us to watch, you’ll find that that strategy includes soaking the hot dog and bun in liquid to allow for the faster transit of food and better compression of food into the stomach cavity. This is followed by a sip of liquid. Although the issue for postsurgical patients is not about compacting food, or getting food to pass quickly, (we’re talking about a ¾ cup of food not 61 hot dogs), the benefit of not drinking with the meal is two-fold and clearly a great tool for weight loss. Reasons For Not Drinking With Meals - Stay Full Longer! First, by allowing food to sit in the stomach longer, which happens when food is not mixed with liquid, the patient experiences more fullness and the signal is sent to the brain that it’s time to stop eating. Second, when liquid is added to solid food and mixes with stomach acids, the food literally liquefies faster and moves from the stomach down into the intestine at an accelerated rate. With the stomach emptying faster, and the feeling of fullness not being truly experienced, both physical and emotional hunger return more quickly. This begins the cycle of increasing the amount of food the patient is able to eat (physical) as well as the patient’s need to eat more (emotional), sabotaging a patient’s weight loss success. Not drinking with your meals is a good tool for all of us trying to lose weight. One of my patients shared with me that when she was preparing for weight loss surgery, her spouse asked how he could be supportive of her as she moved through the process. Her one and only request to him was that he also not drink with the meals they shared together. Because of their schedules, this generally meant just one meal a day. That said, during the six months of her preparation process, with just this one change at this one meal, he lost 10 pounds! Thankfully, she lost a few more pounds than he did as that might have been a sore subject, but I share this story often to demonstrate the importance of this one behavior change that can truly make a difference when trying to lose weight.

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Appetite Suppressants, Magic or Myth?  

​Appetite Suppressants, Magic or Myth? On occasion, I am asked about the need or use of appetite suppressants following weight loss surgery. Although a simple question, there are many variables that I would consider before providing an answer.For Gastric Band patients - In broad terms, I am much more inclined to endorse appetite suppressants with post-surgical Gastric Band patients then others, if they are following up for the adjustments and if they are being adherent to the guidelines and behaviors required to be successful with weight loss following gastric banding, (chewing food to applesauce consistency, eating protein forward meals, not drinking with their meals, allowing adequate time for the fullness signal to be experienced, and not grazing or eating without hunger). In these situations, the Gastric Band patient might need a little “jump start” to help them eliminate their feeling of hunger. In these cases, I think appetite suppressants are helpful. For Roux en Y (RNY) or Sleeve patients (I don’t do the Duodenal Switch) - For these patients who are experiencing weight gain, I am much more inclined to look for an answer outside of a medication. I want to make sure that the “tool” is intact and that there is not some breakdown or reversal in place to the operation that allows the patient to regain weight. I will order an upper endoscopy for measurements as well an upper GI swallow exam to better answer this question. If the Bypass or Sleeve is intact, then I want to make sure that the patient is working with the tool and not choosing behaviors to effectively bypass the anatomy such as eating poor food choices, eating without hunger, eating past hunger or grazing throughout the day

Your Relationship With Food Instead of Pills Let me share this experience that happened early in my career as an example. My wife and I were working with a young lady on a personal financial matter. One of the forms requiring our information asked our professions. As our discussion progressed, this woman inquired what type of a surgeon I was, and I told her that I was a general surgeon but 95% of my practice was weight loss surgery. She then shared with me that she had that surgery (RNY) and had gained all of her weight back. I asked what could she eat and she said that she ate “¾ of a pizza” last evening. I was convinced that she had a breakdown of her Gastric Bypass. I encouraged her to get me copies of her records and to make an appointment with me for further evaluation. She came to see me two weeks later. I ordered the upper GI and upper endoscopy. When the results came back, everything was perfect. I saw her back in the clinic the following week to discuss these results. I again asked if she really could eat ¾ of a pizza. When she answered yes, I asked, “Does it hurt?” “Oh, yes” she replied, “I get crushing chest pain up to my throat which lasts for three to four hours.” Now the picture was clear. She was able to eat this large amount by compressing and stacking the pizza up into her esophagus and throat. It was not until the pizza could move through the small Gastric Bypass pouch and be digested that her pain would resolve. For this woman, there is not a pill in the world that will help her to get back on track with weight loss. What was needed was behavioral counseling to relearn how to use the tool she had been given to lose weight. This was a prime and profound example for me of a patient’s need to reevaluate her relationship with food. That said, my standard plan of care for patients that have had either the RNY or Sleeve procedures with concern for weight regain and breakdown of their original procedure, is as follows. First, get an accurate weight history, acquire accurate accounting of their daily calorie/meals, inquire about maladaptive behaviors and evaluate the RNY or sleeve anatomy. In 9 times out of 10, the issue is not anatomical but, if it is, we proceed to revisional surgery to correct the problem. For everyone else, we work on helping the patient get back on track - to relearn the behaviors necessary for successful weight loss following weight loss surgery. Obviously, this is why it is so important for patients to have surgery first and foremost with an experienced surgeon who can perform these operations effectively to appropriately reduce the size of the stomach to allow for significant weight loss. Just as important is that the patient’s care is with a comprehensive bariatric program to ensure that they have the expertise and the support they might need if they do begin to struggle with weight regain. I have seen some crazy foreign operations for “WEIGHT LOSS”. What Is Your Best Approach? Weight loss, for Band patients, may involve appetite suppressants, but for most others, most likely will involve emotional support to get them back on track for weight loss. If indicated following RNY or Sleeve, a bariatrician would best direct this part of your journey into health.

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