Real Weight Goals by Dr. John Pilcher
Our patients have a lot of reasonable questions about weight loss goals and weight tracking after bariatric surgery. Questions like:
- Is surgery worth it (am I going to lose enough)?
- Will surgery make me too skinny, or ill?
- What weight should I be aiming for after surgery? That “Ideal Body Weight” seems pretty skinny.
- What if I’m just after better health, and I’m not worried about the pounds on the scale?
And after surgery:
- Am I on track???? Is this working?
- Am I doing a good job? (am I going to fail again?)
The “Ideal Body Weight,” then some real weight goals
Most medical weight loss programs set the Ideal Body Weight as the target weight goal for all their participants. This is not crazy, since Ideal Body Weight levels are actually derived from the weight at which people live the longest and healthiest when they grow up into that weight. BUT, when a person has been at a very heavy weight it turns out to be unhealthy to lose all the way down to the Ideal Body Weight. This seems to be because, when the body is much heavier, it takes on extra structure to support the weight (a bit of bone, skin, heart muscle, kidney, etc.). Then, when a person burns a lot of fat the body does not have a healthy way to get rid of that extra structure. So, if a formerly obese person loses from 340 pounds all the way to their Ideal Body Weight, they are cutting into some of their healthy body structure and they are actually unhealthy underweight. Weird, right?
Therefore, the Ideal Body Weight is a number that we use as a “reference point,” but we do NOT expect for our surgical patients to get down to that level and we don’t even want them to get there.
Instead, our best-case scenario is for our patients to lose down to a level that is 20-30 pounds above Ideal Body Weight, a level that can be translated into a Body Mass Index (BMI) of 27-29. We’re going to call this best-case scenario target the “Best Weight,” or when we’re playful we’ll call it the “Fairy Godmother Weight.” At this weight level, all the unhealthy fat has been eliminated.
As you can imagine, many patients can become much healthier without getting down to this practical goal that we’re calling the “Best Weight,” but at least we can help you set some realistic targets instead of believing you’re supposed to get down to “Ideal Body Weight.”
The cool thing is that if we help you get to a level that’s in the ballpark of your Best Weight, you will be much more healthy, with more energy, normal longevity, and normal appearance that is sustainable!
Estimating your likely weight loss from bariatric surgery
Does everyone get to the Best Weight? Of course not. The amount of weight that a person loses depends on a complex interplay of factors, and the amount of long-term weight loss that a person maintains depends on a different complex set of complex factors. This is a really important concept, so we’re going to give it to you in bullet format:
- Initial weight loss, up to one year from surgery, depends mostly on factors that were present on a physical level before surgery. You do not have much control over these factors.
- Long term weight loss, from one year for the rest of your life, depends mostly on your life habits and how you use your surgical tool.
So if we want to estimate how much weight you are likely to lose, we’re talking about where you’re likely to end up at the one-year mark (short term). There will be a lot more to say about long-term weight control and health, later in the blog.
Rule of Thumb: most patients lose roughly 70% of their excess weight, at one year after surgery, after either the Gastric Bypass or the Gastric Sleeve.
We’ll do some math on this 70% excess weight in a moment, but first here are some of the numerous pre-existing factors that would tend to cause more or less weight loss:
- Age – younger people lose weight better.
- Mobility – people with limited mobility (knee pain, back pain, etc) tend to lose less weight.
- Disease burden – the more medical conditions you have, and the more prescriptions you take, the less weight you will tend to lose.
- Muscle mass – more muscle mass = better weight loss.
- Starting weight – heavier people lose more pounds, but end up at a higher weight on average.
- Genetics – there is a fair amount of variation that we frankly don’t understand. Obesity is a disease that is caused by energy hormone imbalance and unhealthy hunger, and there are many different forms of these imbalances. Some of these respond very well to surgery and others notsomuch. There is active research on this, but it will take many years to tease out the details so we can make smarter predictions.
Notice once again, that none of the above factors is really under your control. Also notice that all of them move against you as time passes. Bottom line: if/when it becomes clear that your non-surgical weight loss plan is not working, then getting to surgery earlier works better than later.
Now, we’re ready to do some simple math to give you a pretty good idea about your one-year weight loss. We begin by calculating your Excess Body Weight.
- Current weight – Ideal Body Weight = Excess Body weight
For example, a person at 5’6” would have an Ideal Body Weight of about 140 pounds.
- So if they weigh 240 pounds today, they have 100 pounds of excess weight.
- If they weigh 340 pounds today, they have 200 pounds of excess weight.
Once we know the Excess Body Weight, the next step is to calculate the 70% of the excess weight a person is likely to lose.
- Our 240-pound person is likely to lose 70 of their 100 excess pounds, give or take. Their weight at one year would be in the ballpark of 170 pounds.
- Our 340-pound person is likely to lose about 140 of their 200 excess pounds. Their weight at one year would be roughly 200 pounds.
Again, heavier people lose more pounds but end up at a higher weight level on average.
I would say that the “Best Weight” for a person at 5’6” is around 165#, so both of our example patients are coming in above that level but both are likely to achieve substantial health and longevity benefits.
Also notice that our example patients are losing excess weight, because the hormonal effects of the surgery work to re-set the body’s fat storage level, rather than cutting into the body’s healthy structural tissues.
We’ve said a bit about practical and realistic weight loss goals, so now we’re ready to talk about checking your weight loss progress to be sure you’re on track. As you can see from this typical weight loss curve, the weight loss is pretty fast in the first 3 months, pretty steady from 3-6 months, then usually continues in fits and starts (we call these “plateaus”) up until about a year from surgery. Very often, there is a 10-15 pound regain between year 1 and 2 from surgery then most people remain stable for decades.
The key landmark for this discussion is the weight loss at 3 months. A pretty reliable rule of thumb is that, at 3 months, a patient will have lost about half of the weight they are going to lose. If we go back to our example of the 240# patient with the estimated weight endpoint of 170#, then at 3 months they will have lost about 35#.
At our practice, you’re going to have an appointment with the medical team at 3 months from your surgery, and this is an ideal time to check in and see if your weight loss is “on track.” The most common situation is that you are on track, and if so then our focus will be on optimizing your habits for long term success as well as checking to be sure there are not any early-stage vitamin deficiencies. Very rarely, a person is on track to lose too much weight. I mention this just to reassure some of you that we have a plan for that situation but we’re not going to dive any further into that for now.
About 1/3 of our patients are not losing as much weight as we’d like. Maybe they’re on track for losing that 70%, but as with our 340# patient the 70% excess weight loss is still going to put them significantly above the “Best Weight.” Or maybe they’re not on track to lose the 70% excess. Either way, if our 3-month weight loss trajectory does not lead to a satisfactory endpoint, it’s probably time to intensify our medical therapy for weight loss.
That’s where our awesome medical team partners come in. They will check first to see if there are any opportunities to improve your weight loss habits in terms of food plan, exercise plan, and vitamin intake (there are almost always some opportunities!). Once the lifestyle change is as good as it can be, they have a number of medical/pharmacologic tools they can use to boost the weight loss effects of the surgery to try to change the trajectory of weight loss. This is proactive approach is much better than waiting until one reaches the one-year mark from surgery, finds they are not at a happy weight level, then tries to lose another 20-30 pounds. At 3 months, medical interventions that change that weight loss trajectory are much more effective.
Is it all about the “pounds on the scale”?
At the end of the day, at the end of the weight loss, our goal for our patients is lasting health improvement more than a certain numerical goal. We’re going to wind up with some discussion about how to measure health improvement, and the potential adverse impact of chasing a difficult numerical weight loss goal.
As you lose weight after surgery, you should feel better energy and you should be more active in a way that feels natural. You’re very likely to feel less pain, and better breathing. Successful weight loss will lead to less need for prescription meds. You can shop in the typical-size clothing!
We can also measure success by reductions in visceral fat. This is the fat that infiltrates your vital organs (heart, liver, kidneys, etc.) and it’s the fat that correlates with medical disease. This is the fat that can make the belly big and round. The visceral fat can be measured using some fancy medical techniques, but it turns out that the neck and the upper chest can be a pretty good “window” into the visceral fat level. When the excess fat has melted away so that you can see your neck muscles and your collarbones, you can be pretty sure that the excess visceral fat has all melted away so that you have healthy non-fatty vital organs. A that point you will already have achieved your health goals! Very often, we can see these positive changes even at 3-6 months from surgery.
On the other hand, it’s almost impossible to lose all the “outside” fat, no matter how skinny you get. I’m talking about the normal fatty tissue underneath the loose skin. We do NOT expect to eliminate all of this outside fat through weight loss. That’s where plastic surgery comes in, once the weight is stable at its lower level.
Long-term weight loss attempts
What could be the harm in trying to lose more weight once your body reaches its “settling point” at a year or so out from surgery? There’s not any harm having a weight loss attitude, if the attitude leads to sustainable habits. You may be familiar with the concept that lifetime cycles of weight loss and weight gain can actually be harmful and can worsen weight gain, especially if the weight is lost with intense starvation diets, or if the exercise is so intense that it leads to injury. It appears that starvation-induced weight gain or exercise-induced injury can also be problems in the long run after bariatric surgery.
Instead of getting really intense and having “yo-yo” weight changes, let’s appreciate and cherish the weight that you’ve lost and the health that you’ve gained. Very often, the more sustainable and more beneficial approach will be to implement sustainable lifestyle changes that will help you maintain an “OK” weight for decades instead of distorting your life in unrealistic ways in hopes of losing that last 5-15 pounds. Our experience is that your one year weight loss depends mostly on the factors that pre-existed the surgery, but that long term weight loss depends much more on how you put the surgical tool to work.
While you have little control over your initial weight loss during the first year, you have a lot of impact over your long-term weight control. So at the same time we are working with you on assessing and adjusting your progress during that first year, we hope to teach you the sustainable lifestyle habits that will help you “nurture” your new metabolic balance to remain stable and healthy for decades to come.
With all that being said, a “practical and sustainable” amount of weight loss is almost always a really good amount of weight loss that leads to tremendous improvement in health and well-being. We are pleased and honored to work with you on your journey!