Pre-Gastric Sleeve Calorie Intake — Set Point Theory

Question Below Submitted By:  

Dana (a patient from New Orleans)

I am currently 260lbs and 5’3. Initially my husband had concerns about me having Gastric Sleeve surgery, but since I am determined to go through with it he is supportive. Of course he is still concerned about the general risk of elective surgery.

His next primary concern is “will this work” and what if it doesn’t work? He is concerned I will become despondent. He’s seen me struggle with my self esteem and scale obsession. He has watched me sink further and further into depression and isolation.

We’ve been together for 9 years…we met after I had lost 160lbs (low carb). I was 360lb and got down to 200lbs. I managed to keep it off for 6 years but in the last 5 years I have gained roughly 60lbs back. Nothing I tried worked — even though I have never reverted back to my old eating habits before my 160lb loss.

I have mostly stuck to a low carb diet. Rice, pasta, bread, potatoes are not a part of my everyday life. I just was not quite as strict– sometimes I would cheat a little but never full blown.

In the last year I have gone back to strict low carb. I could not lose a pound. If I did lose 2 pounds it came right back. It was just crazy.

Ok, so I thought maybe my body has become immune to low carb after 12 years. Maybe I need to mix it up a bit — I joined Weight Watchers. I DID NOT LOSE 1 POUND. I actually GAINED a few pounds. It has been a daily mental struggle.

This is where his concern comes in. He is worried that since I already watch carbs closely and limit calories (although of course not near as low as the 600 calories after the sleeve. More like 1200) that the surgery will not have much of an impact or shock to my system to be more than minimally successful. He’s concerned that I will have put myself at risk by having surgery,put myself at risk of serious complications and changed my entire life for minimal gain ( or loss in this case ).

I’m 49 so I know my metabolism has changed. I also take a ton of medications for MS, Lupus, HTN (who knows what the hell they do to body chemistry) and do have health issues that limits exercise but I feel like I have no other options. I feel like this surgery is my only hope to be able to live a fulfilling life.

Now, finally to my question. Can this surgery work for someone who has been doing 1200-1400 calories and low carb for a long period of time and who has been unable to lose weight?

I don’t have grand illusions. I don’t need to be thin. I’d be happy just to be labeled “overweight” instead of obese or morbidly obese. I’m 5’3″ and I would be ecstatic if I could get to 160 – I’d probably be on cloud nine. But now his concerns are starting to worry me and making me wonder too– will gastric sleeve work for me?

I told my surgeon these concerns — he told me this surgery actually causes the body to reset its “set points”. He did not go into much detail. I searched the internet and I really cannot find any information about that theory other than just the statement that it seems to reset the body’s set points. Anybody else know anything about that theory?

Sorry such a long post. Any insight would be very appreciated.


Expert Responses to the Question Above

Surgeon Response to "Pre-Gastric Sleeve Calorie Intake -- Set Point Theory"

by: John Rabkin, M.D., Pacific Laparoscopy


Rest assured that the sleeve gastrectomy (gastric sleeve surgery) will allow you to lose weight!

However, as with any of the weight loss surgery procedures that rely only on 'restriction' to effect weight loss, over time as the restriction lessens, a percentage of the patients who have undergone that procedure will regain some or all of the weight that they'd lost following the surgery.

In fact, the sleeve gastrectomy was initially intended to be a first part two-staged duodenal switch, with the malabsorptive portion of the procedure scheduled for 6 months to a year after the sleeve gastrectomy following substantial initial weight loss from the sleeve gastrectomy's restriction.

Consequently, if you begin to regain the weight that you'd lost after the sleeve gastrectomy, you could, at that time, consider undergoing the 'switch' portion of the duodenal switch, thus completing the second stage of a two staged duodenal switch.

The set point theory is just that... a "theory". No definitive science has evolved to support that concept which is one of many cited to explain the effects of weight loss surgery.

John Rabkin,
M.D. Pacific Laparoscopy

(click here for Dr. Rabkin's full bio & contact info)

DISCLAIMER: This educational advice is based on the depth of your question and the details provided. The above should never replace the advice of your local physicians as they have the ability to evaluate you in person.


Patient Responses to the Question Above

Gastric sleeve

by: Jennifer

Hi Dana My name is Jennifer and i had the gastric sleeve surgery just about two years ago.

let me give you a little background on me i am 29 and i have a two years old little girl and i have been married five years. After i had my daughter i weigh 280lbs and i had enough.

i was not ever stick thin but i was smaller in my ealrly highschool days.

i did the weight loss gimics and all the meds and weight watchers.

i would lose some and then gain some it was a viscous cycle.

when i first told my husband that i was interseted in this he was so supportive and helpful but deep down i think he was concerned too that it would not work or work the way i wanted it to.

with that being said this was the best decision that i made for myself my daughter and my husband is that i had the surgery and i that i am healthy.

the weight loss is fast in the begining and it is such a boost to your confidence.

This is a tool to help you for the rest of your life i dont think in any way would this be not a sucessful surgery for you.

our bodies change all the time.

i highly recommend this surgery it was so hard in the beginging but worth it in the end to set me right on the path to health ways of eating and exercising.

i hope that is somewhat helpful and i am here to help but as a person that has had the surgery i can tell you that it is a great tool.

good luck in your choice jennifer

Positive thoughts!

by: Waning

I do not proclaim to be a nutrition expert but I am a successful sleever just over 2.5 years out. Like you I had trouble losing weight with low carb although I had a lot of success with it in the past.

My morbidly obese self just couldn't find success with it or anything for that matter, so I decided on surgery. I rapidly lost weight and that in itself was a big motivator. As you o have a few medical issues, you will more than likely lose weight at a slower rate, but I think its doable. I'm maintaining a 160 pound loss and I really enjoy my new lifestyle. Instead of saying "what if it doesn't work?" say "what if it does?" What if it does and you have a wonderful new quality of life? Best Wishes, Waning Woman

More info about the set point theory and gastric sleeve surgery

by: Jeff

Hi Dana,

Here are a couple pages with a lot of information related to your post (click the links for each to go to the page):

1. Set Point Theory - How set-point relates to our increasing weight and working with your body’s set-point
2. Gastric Sleeve Surgery - full analysis of the procedure, including comparison with other procedures, risks and complications and life after.

Hope that helps!

Please continue to come back to this page and keep us posted by clicking the "click here to add your own comments" link below.

Take care,

Husbands fears

by: K

Hi Dana,

My husband had the same fears. I am 56 years old, 5'3" but my weight at the time of surgery was 378lbs (172kgs) I had my surgery 4 years ago and had limitations on my exercise due to injuries from a motor accident. The only exercise I can do that causes no intense pain is swimming. this is really hard for me because before my accident I was running a weight loss support and exercise group 6 days a week and working a full-time job as a nurse and I was 330lbs (150kgs) Now I only have access to a pool 6 months of the year. I was down to 217lbs (99kgs) but due to inactivity over winter am now back up to 264lbs (120kgs). That's ok I can deal with that.

I was doing the low carb 1200 calories a day thing before this surgery. Now I am doing limited carbs and 600 calories a day. If I have rice it is like a teaspoon same with pasta, a potato is about a quarter of a medium one. I live on protein and vegetables with the odd treat thrown in.

I guess what I am trying to say is that the surgery is only a tool. You still have to do the work and eat right to get to where you want to be. I know that come spring and the swimming season I will again lose what I have put on plus more.

I know if I work just a little harder this year and practice improved eating habits I can do it. I get lazy with my meals like a lot of people who have been obese. I skip meals because I am not hungry, I snack instead of making a nutritious meal. I think I do it because sometimes I just feel like it is too hard to manage.

My husband has also had to endure my depression but he stands fast by my side and supports me even when I am being a nasty depressed cow :)
Right now I am excited and getting ready for the swimming season which begins the first weekend in October so only five weeks to go.
The other thing Dana is only you can do this. You need to be positive and be proud to have made a decision to change your life.
My husband and I are happier than we have ever been in our relationship and I think that is just because I know he is always going to have my back and support me. It doesn't matter to him whether I am fat or thin.

I think if anyone was to ask me if I would recommend Vertical Gastric Sleeve Surgery I would have to say GO FOR IT!

So good luck whatever way you decide to go!

set-point theory

by: Ann

Hi Dana,

I had the gastric sleeve surgery 12 weeks ago (July 25, 2016), so I have no idea at this point whether the surgery will lower my set-point. I really hope it does. The surgery seems to have helped a couple of friends who had it a few years ago. But it doesn’t take much research on the web to see that some people regain a lot of the weight they lost following their surgery.

What I especially noted from your post is the emphasis you’ve placed on LOW CARB, and I'll discuss my experience with that in a moment. I’ve done several major diets since 2000, losing 160 lbs, 70 lbs, 50 lbs, 20 lbs, 17 lbs, 55 lbs, 80 lbs, 15 lbs – never reaching my “normal BMI” goal. My weight always creeps back up again. I got to within about 20 lbs of my 2000 weight by the end of last year. So I started dieting again, and I’m currently down 70 lbs, 40 lbs of which I’ve lost since the surgery.

I’ve kept detailed spreadsheets, weighing out everything I eat, using nutrition labels and USDA data to calculate calories, fat, saturated fat, carbs, fiber, sugar, protein, and sodium. My diet spreadsheet charts the weight I would expect to be based on my caloric intake and exercise expenditure, so I can compare this with my actual weight loss. I’ve collected a ton of data over the past 16 years, and have learned several interesting things about my body in the process.

The most important thing I’ve learned from my spreadsheets is that a 14000 calorie binge – which should cause a 4 lb weight gain – will result in a 20 lb weight gain in my body. However, by getting back on my program again, I’ll drop those 20 lbs in about 10 days, rather than the 10-20 weeks it originally took me to lose that weight. That knowledge encourages me. Before I learned this, I’d be so discouraged that I’d just quit. (The set-point theory suggests that our bodies will do whatever it takes to get us back to our set-point weight, including making us depressed and lethargic. So an extra 16 lbs of water weight may be one of the ways my body tries to break my will-power.)

Something I noticed this year is that I GAINED weight when my protein intake was above a certain level. Since my BMI was right at the cusp of having to pay an extra $400 for my surgery, I was shocked and upset that I was gaining weight. During the 3.5 weeks before the surgery, I averaged only 544 calories per day, but gained 6 lbs. When I reduced the protein a few days before the surgery, my weight quickly returned to the expected level, so I didn’t have to pay extra.

The last two of those weeks I was consuming a liquid diet consisting of high-protein shakes (this was the recommended prep for the surgery), and realized how easy it was to eat FAR MORE protein with protein powder shakes than when I consumed meat protein on my normal weight-loss diet. So I graphed out my protein intake (using the moving average feature in Excel to smooth out the data), comparing my protein intake with my weight chart. Sure enough, the high-protein period corresponded with the weight gain. Then I went back to the data from my 2013 diet, when I’d been persuaded to try “paleo” (or at least a very low carb diet) after losing 80 lbs on my usual weight-loss diet. The weight plateau during that very low carb experiment corresponded with a far higher protein intake than I’d previously averaged, even though my caloric intake remained constant.

(I recognize that the 544 calories per day mentioned above is considered extreme. In previous years, I stuck to around 850 calories per day while dieting. My spreadsheets indicate that my body is NOT in starvation mode. I’m losing weight exactly as predicted using 1944 as my estimate of my normal caloric need – pretty darn close to 2000 listed on nutrition labels.)

So for me, something similar to the Zone diet works better than low carb. (The Zone diet is 40% carbs, 30% protein, and 30% fat.) But I also noticed that the amount of protein I can eat without gaining weight or having a plateau has decreased in the past 3 years, perhaps because I’m getting older (61).

In any case, I’m hopeful that I’ll achieve something close to a “normal BMI”, and that the surgery will adjust my set-point closer to that weight. But I’m also working on the emotional stuff that triggers my binge eating, avoiding refined sugars and limiting foods made from grains. (I mostly cook whole grains such as bulgar wheat, rye berries, rolled oats, and barley, instead of eating bread, pasta, or pastries. I occasionally have brown rice.) The statistics that bariatric doctors quote indicate that most people maintain the loss of 60-80% of their excess weight, so I know that even if the surgery produces metabolic changes, I can’t count on my set-point dropping all the way to “normal.” Even with surgery, losing weight takes work.

You might be taking steroids for your lupus, and most people gain weight on steroids. And who knows what side effects your other medications and conditions cause. So I truly empathize with how much harder this journey probably is for you than it’s been for me (not that I’ve found it easy).

But since you specifically asked about the set-point theory, I can at least point you in right direction. The theory was proposed in the book “The Dieter’s Dilemma” by William Bennett M.D. and Joel Gurin. As Dr. John Rabkin responded above, it is just a theory. But definitive science is expensive – there are way too many variables (not just dietary content, but age, allergies, activity level, gender, genetic factors, geographic factors, stress levels, etc.). We’re all unique, so I’m skeptical of dietary advice, knowing that there’s little if any serious research behind it. The best we can do is study our own bodies. At the time the book was published (1982), the best suggestion for lowering one’s set-point was exercise. But after a year of doing Ken Cooper’s Aerobics program, I didn’t lose a single pound.

I wish you all the best on your journey, whether you choose surgery or not.

7 years out from VSG

by: Julie

I started this journey at 291 lbs at 5'9. My asthma was out of control. I could not walk across my living room without needing my inhaler.

I had been reading about gastric sleeve surgery being done in France for years but in the US it was only gastric bypass. I waited and soon I started reading about people getting a sleeve as the first part of a two part surgery for the super obese. I was too thin LOL to qualify. I did not want gastric bypass because of the medication restrictions and the dietary restrictions but the biggest fear was the weight regain I had seen in every bypass patient I knew.

I kept watching and I finally heard they had lowered the BMI to 50 to qualify. I had no idea what my BMI was at this point but I went to an orientation meeting just to see what was out there. At the meeting they said that it looked like the insurance companies were going to lower requirements to a BMI of 40 if you have comorbid conditions which FINALLY was me!!

I filled out the paperwork to start the process before I left the building. They called me and said I needed to wait 6 weeks to start because they were voting on November first to lower the BMI and after they voted I could pre-qualify. Nov 2nd I had my weigh in and met with the surgeon. The paperwork was sent to my insurance company and I got approval in 2 days.

I could have had surgery that next week but I chose to wait until after Christmas just in case things didn't go well. I had surgery 12-29 and went home 12-31. I felt absolutely fantastic when I woke from surgery. In fact I felt so good I thought they were unable to do the surgery because I am very hard to intubate and anesthesia does not work well in me. I went into the bathroom to lift the gown to make sure it was really done. I had no pain, no nausea, no issues at all. I went home to start my new life.

The only issue that came up was we found I am allergic to whey, soy and pea protein. I had food allergies before but never thought about protein supplements. So I was started on a soft diet long before most were off liquids. My weight did not fall off but it was a steady loss.

My son noticed my success and asked me about having the surgery also. He was 18 and tired of being fat. I told him he had to make the effort if he really wanted it. He called my surgeon the next day and got started.

On his 19th birthday and 6 months after me he had his sleeve. He started at 390 at 6'6. His weight fell off sometimes at 2 pounds a day. I was upset at first because I was losing about 2 pounds a week. But I stopped that destructive thinking and kept this my own journey.

It took me almost 2 years to take off 120 pounds. I stalled for almost 6 months when they discovered I had hypothyroid issues. Once I started the medication the last 30 pound fell off. My surgeon set a goal of 200 pounds as my end weight but I went to 170 without a lot of struggle. I had a bit of regain after having jaw surgery and I could not chew for a year. I am happy to say when I could get back to protein the weight came back off.

My son had a bit of an easier time at first. He dropped 160 pounds in less than a year. But he got careless and gained back 60. He went back to basics and a food journal and he is almost back to where he was. 15 more pounds to go.

We will both tell you this is the single best thing we ever did for ourselves. It took me longer to accept the new me. I kept waiting for the failure to come.... I waited 5 years to get rid of my fat clothes. I was panicked I would regain and I would not have clothes to wear.

I am now 7 years out I am happy with the weight. I could take off 30 more if I wanted to exercise like a fool but with RA and fibromyalgia with the chronic pain issues from my 12 jaw surgeries and 6 shoulder surgeries exercise is difficult. I walk daily and if I notice any weight creeping on I go back to a food journal and make sure I am getting my 100 grams of protein and gallon of water a day.

If I am hitting that I am not gaining when I fall off the wagon I know quick. It can be done if you look at this as a life changing event not a diet. You are changing the way you will eat, the way you look at yourself, they way the world sees you and it can be hard at times but the rewards are so worth it.

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