For those planning to have weight loss surgery, as well as for those who have already done so, extensive patient education is required – or at least it should be. There’s the excitement of having made this life-changing decision, and the thrill of the weight coming off after surgery – for some, fast and furious, for others slower and more steadily. We call that the “honeymoon period,” when you can almost stand in front of a mirror and watch the changes take place. You’re excited, committed and compliant. And then a year goes by, and another, and before you know it, you’re three or four or five years post-op…with a whole new set of issues, or maybe some of the old ones resurfacing. Dr. Cunneen would like his audience to think about what “success” really means for weight loss surgery patients, how to achieve it and, most importantly, how to make it last.

1. What to do When the Honeymoon
is Over
Scott Cunneen MD FACS FASMBS
Director Center for Weight Loss
Ceadars-Sinai Medical Center
Los Angeles, CA
August 16, 2014

2. A recent study has found
that women who carry a
little extra weight live
longer than the men who
mention it.

3. Remember the day you
decided to have
weight loss surgery?

4. Remember the
honeymoon period
when the weight just
seemed to fall off?

6. It’s hard to argue with logic like
that, but there are a few other
reasons that this statement is
true...and especially frustrating
for weight loss surgery patients
who are “doing everything
right!”!””

7. Energy Balance & Set Point

8. Counterintuitive Nature of Obesity & Surgery
“The nature of obesity is that it’s in many ways
counterintuitive. And the way these operations work is
also counterintuitive. The notion that they work by
physiology and NOT by restricting how much you eat,
the notion that they change energy balance…that itself
is counterintuitive; however, it’s also very enabling to
the use of these operations that they work in such a
physiological way.”
7

9. Obesity & The Energy Balance Equation
8
“If we’re getting more obese
as a society, it must be the
case that our caloric intake
exceeds our caloric
expenditure. But I think the
vast majority of people who
think at all about this have a
very inaccurate version of
what that mismatch
between caloric intake and
caloric expenditure actually
looks like, and that they
view it as a situation where
patients are massively
increasing their caloric
intake to gain that weight.
But nothing could be
further from the truth.”

10. The Leptin Bathtub
9
“In this analogy, the
amount of water is the
same as the amount of
adipose tissue in your
body. Your body is paying
attention to the amount
of adipose tissue you
have. And that is the
defended parameter;
that is, when you try to
push the amount of
water, in this case the
amount of body fat, in
either direction, the
brain is going to fight
back by being able to
alter how hungry you are
and how rapidly you’re
burning calories.”

11. Defense Of A Set Point
10
“The end result of all this
regulatory activity on the
part of the body is to
defend a particular set
point for energy storage,
which turns out to
effectively be body
weight…On the left side
is why diets don’t work.
And this whole process is
determined
physiologically. ”
+ -

12. Energy Balance & Weight Management
11

13. The Myth Of Weight Management
12
“I think one of the durable
misconceptions in the area
of weight regulation and
obesity is that it results
from abnormal or
inappropriate behavior…
“You have to either engage
the body’s regulatory
system to make it want to
weigh less or you have to
fight it. So, this myth comes
from the fact that people
believe that the best way to
do it is to fight it.”

14. The Body’s Defense Of Set Point
13
“What weight you
defend is not a static
variable. It’s a variable
that can change over
time and over
circumstance. But just
because those animals
at the bottom hadn’t
ever been at that
weight, didn’t mean
that they didn’t know
they should be at that
weight and actively
work to defend it.”
Bernstein, IL. Proc Soc Exp Biol Med; 1975 Nov; 150(2): 546-8
The data presented in the above graph is from a study conducted on laboratory rats

15. The Body’s Defense Of Set Point
14
“Under different
dietary conditions, the
exact same signal of
leptin provides a
different response…
The point here is
things in our
environment are
changing the biological
signals that relate to
what weight the body
sees as appropriate.”
The data presented in the above graph is from a study conducted on laboratory rats

16. Environmental Changes Driving Obesity
Four Environmental Changes
• Altered Food Supply
• Decreased Physical Activity
• Stress and Distress
• Drugs
“Those four categories of changes in the environment are so profound that they
create the perfect storm for re-regulating energy balance, re-regulating set point, and
creating obesity.”
15

17. How Bariatric Surgery Works
16

18. Evidence for Physiological Mechanisms
“There are a variety of clinical observations that provide evidence that these
operations can’t work primarily by physical restriction or malabsorption of
ingested calories.”
Bariatric Surgery
Evidence for Physiologic Mechanisms
• Dramatic Effects on Hunger and Satiety
• Few Patients become Underweight After Surgery
• Transient Weight Gain During Pregnancy
• Little or no Weight Loss in Thin Patients or Animals
• Changes in GI Endocrine Markers-Gherlin, PYY, GLP-1 Amylin
• Increased Energy Expenditure (Bypass Procedures)
• Ability to Reverse the Effects of Surgery with Drugs and Genetic
17
Manipulation

19. Surgery Changes Set Point
“What surgery is doing is it’s changing the nature of these physiological
curves so that the control of appetite, or energy intake, is blunted in a way.
So as you lose body fat you end up with less of a rise in energy intake. And
as you lose body fat you see less of a conservation of energy expenditure.”
18

20. RYGB vs Dieting
19
“All of these physiological
changes are consistently
in the opposite direction
after surgery as compared
with dieting, and so what
that tells you once again is
that dieting engenders a
counter-regulatory
response that pushes you
back to your original set
point. Surgery, by having
the arrows go in the
opposite direction, must
be changing the
physiology.”
The data in the chart above are from multiple studies, presented here in aggregate.

21. Metabolic Effects of Vertical Sleeve
Gastrectomy
20

22. VSG Doesn’t Mechanically Restrict Intake
21
“Three weeks after the
surgery the animals
that got a VSG went
back to eating what
they were before. The
reason I point that out
is, ‘Where’s the
restriction?’ The
animals are capable of
consuming the same
amount of calories as
before. It’s not the
case that their
stomach is so small
that they aren’t
capable of consuming
sufficient calories.”
The data presented in the above graph is from a study conducted on laboratory rats

23. VSG Influences Food Choice
The data presented in the above graphs are from a study conducted on laboratory rats
“We give the animal a choice between a nutritionally complete high-fat diet (HFD) and a
nutritionally complete low-fat diet (LFD). Animals who haven’t had surgery prefer HFD. You
would too HFD tastes a little like sugar cookie dough. You look at an animal that’s had surgery
and that preference for HFD is almost entirely gone. The animal is choosing to make a change
in its behavior as a function of the biological changes of the surgery.”
22

24. Improving Post-Surgical Outcomes
23

25. Biological Factors Influence Outcomes
“We now have evidence that there are biological factors, including but not limited
to genetic factors, that have a great deal of importance in determining how much
weight you’re going to lose after any one of these procedures. And once you
recognize that, you recognize that the response to surgery is complex.”
24

26. The Role Of Genetics In Surgical Outcomes
25
“If you share all of your
genes with somebody,
your outcome after
bariatric surgery is going
to be very closely similar
to the person you share
your genes with. If you
share NO genes with
them, regardless of
whether you live with
them, you’re going to
have much less similarity
in the outcome. Taken
together this suggests that
there’s a very strong
genetic component and
some people are wired to
lose more weight than
others in response to the
same operation.”

27. Setting Expectations
26

28. Average Percentage of
EXCESS BODY WEIGHT LOSS
Gastric bypass 65%
Sleeve gastrectomy 60%
Lap Band 50%

29. Let’s try to redefine success…
• How has your overall health
changed?
• How has your energy level
changed?
• How do those achy knees, hips
and/or back feel these days?
• How does your accomplishment
make you feel?
• Do you ever get tired of hearing
“Oh, my GOD!” when you run into
people who haven’t seen you in a
while?
• Do you fit into those skinny jeans?
(Oh well, five out of six ain’t bad!)

30. What are some of the
benefits you’ve enjoyed by
losing weight?
• Lower cholesterol
• Lower blood pressure
• Lower risk of heart attack and
stroke
• Diabetes remission
• Back and joint pain reduction
• Resolution of sleep apnea
• Increased energy
• Probable increased life
expectancy!
Now...name some others!

31. The Rules!
1. Eat slowly and chew well
2. Limited or no alcohol.
3. Minimize liquid calories.
4. Vitamins and calcium are non-negotiable!
5. Small portions, balanced meals.
6. No aspirin/ibuprofen; limit caffeine.
7. 8 glasses of water a day.
8. 75 grams of protein a day.
9. Don’t drink while you eat.
10. Exercise, exercise, exercise. !

32. The dreaded truth about
exercise...here’s how it helps
to keep your weight off in the
long run:
• Burns more calories than
sitting on your couch
• Builds muscle which burns
calories more efficiently than fat
• Actually helps to control hunger
• Keeps you motivated to continue
making good food choices
WHAT ELSE???

33. Of course, there are other ways to
burn calories every day…
• Pick a parking spot far from your
destination.
• Take the stairs rather than the
elevator.
• A little mid-week gardening never
killed anyone.
• Walk the dog, walk the dog, walk the
dog.
• Find a little kid — or rent one — to
take to the park.
Any others???

34. At times, the lifestyle changes
you’ve committed to may
seem difficult...but
remember, what doesn’t kill
you makes you stronger!

35. Just remember…
...where you started!
...how hard you worked to get
where you are!
...you KNOW what to do, even if
you temporarily fall off the wagon!
— and especially —
...YOU’RE the ones who make us
surgeons look good, so remember
that we’re always in your corner!

36. Doctors have been trying to
answer this question for
decades...if anyone can
figure it out, please
let me know!
Any other questions?

37. Thank You
36

38. Metabolic Impact Of Surgery
37
“One of the most
remarkable things about
what we’ve learned
about bariatric surgery
over the last twenty
years is what a profound
impact it has on
metabolic disease.”
Kaplan, LM et al. Bariatric Times. 2012;9(7):12–14.

39. Surgical Effects Of Glucose Regulation
38
“Both surgeries,
despite the fact that
we’re doing them on
stomach and intestine,
have potent effects to
change what’s going
on in the pancreas…
“I think this provides
clear evidence that
these bariatric
procedures, including
VSG, have metabolic
impacts beyond what
you can imagine from
just weight loss alone.”
The data presented in the above graph is from a study conducted on laboratory rats

40. Just For Fun…
39
“They (the animals) don’t
have a registered dietician
who’s been telling them
about how to lose weight,
or how to count their
calories. They don’t show
up at the experiment
because the rat next door
made fun of them, or they
didn’t like what they saw
in the rat mirror.”

41. Genetic Markers
40
“There’s a region on
chromosome 15 where
the dots go very high…this
reproducibly shows that
this region of
chromosome 15, if you
have a particular version
of that gene, you’re going
to predictably lose more or
less weight.”

42. Classifying Surgical Failure
“We should think about surgical failure more as a
relative or subjective concept.
“And we should divide failure into primary failure,
which is the failure to lose an adequate amount of
weight or to improve comorbidities in direct response
to the surgery, versus…initial success but because of
weight regain or significant worsening of diabetes or
other comorbidities, you would call that secondary
failure.”
41