Right after gastric sleeve, patients usually report that weight drops off fairly easily. And while eventual plateaus are to be expected, it’s the last few pounds to “goal weight” that can be most frustrating. Many VSG patients can relate to Erica, who says, “I’m trying drop these last 20 pounds and it’s turning out to be the hardest thing I’ve ever done in my life.”

It’s not your imagination; science has repeatedly shown that the lower the scale goes, the harder it is to keep it heading in the same direction. Why? There are several reasons, actually.

1. Your body doesn’t like it. Our bodies are not a fan of change, especially when that change involves losing a significant amount of weight. Biologically, thin is dangerous. Our bodies don’t understand that too much food is more common (and dangerous!) than too little in modern societies.

2. You need fewer calories as your weight decreases. It takes much more energy to keep a 300-pound body going than it does a 150-pound body. As you lose weight, you need to take in fewer calories to maintain your body size, and fewer still to continue losing weight. You’ve (hopefully) developed a successful gastric sleeve diet along the way, and it can be disheartening to think about cutting caloric intake any further.

3. Boredom sets in. You’ve been doing everything right for months—maybe even years—at this point. And saying “no” to a cookie or handful of chips is getting old. Temptation is often more powerful as the journey goes on, not to mention when you feel like you’re not getting results no matter how “good” you are. At this stage, some vertical sleeve gastrectomy patients’ eating patterns are slipping because they have diet fatigue.

So how can you get the scale moving again? These ideas may help:

• Switch up your diet. “To break a long-time plateau, I did a 5-day Keto egg fast, with a 2-day transition,” says Linda. Changing things up once in a while can be a good thing when you’re trying to break through a plateau. Many people aren’t interested in doing keto over the long haul because it zaps their energy, but doing it for a set period of time may be worth it to help you break through.

• Up your water intake. Think you drink plenty of water and couldn’t possibly drink more? You’re probably wrong. Especially if you’re doing lower carbs than usual in order to shed those final pounds, you need even more fluids because your body is working harder. And if you’re restricting calories, drinking more water can help you feel full until your body adjusts to the new calorie levels.

• Erase temptation. You may be eating too much—or the wrong kinds of things—because you’re too tired to meal prep or cook after a long day. We’ve talked before about meal delivery services, but my patient, Brandon, has a twist on that idea: ordering meals in quantity from restaurant catering menus. Because most restaurant portions are too big for gastric sleeve patients, you’ll likely get two to four meals from a single order. Pick up several protein and non-starchy veggie meals at once from a trusted restaurant, freeze what you won’t eat in the next couple of days, and you’ll have no excuse to botch your gastric sleeve diet for the week.

• Add strength training. Women can be afraid to lift weights, fearing that they will “bulk up.” But the more muscle you have, the more calories your body burns even when you’re at rest. This may be particularly attractive if you feel like you can’t cut any more calories. Plus, strength training can help improve the appearance of loose skin that so many people struggle with after losing a lot of weight.

• Stop trying so hard. If you’ve gone back to basics on your water, protein, and exercise and still aren’t seeing the scale move, it may be time to trust that your body is where it wants to be. At least for right now. When we talk about plateaus, we usually mean a matter of weeks. But if you keep doing what you’ve been taught to do as a VSG patient, you may get a happy surprise a little farther down the road. Says Tracy, “I actually stalled for almost a year after my first 115 and now my body has lost another 15ish (pounds) in the last four months. Your body rests too.”

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“Changing lives…one sleeve at a time”