Case study: What should I weigh? From Bariatric surgery to athlete

Case study: What should I weigh? From Bariatric surgery to athlete.

Many athletes are in sports that demand a specific weight. Other athletes strive to lose weight to (supposedly) help them perform better. Athletes often struggle to determine an appropriate weight goal. This case study addresses how to estimate an appropriate weight for an athletic person who had successfully lost a substantial amount of weight as a bariatric patient.

The subject, KS, is an atypical athlete. She is a 52-year-old woman who had never exercised regularly until she had bariatric surgery at age 49. She came to the initial nutrition consultation saying, “I had a gastric sleeve procedure done two years ago. My weight has dropped from 362 to 178 pounds (165 to 81 kg).  I feel fantastic! I would like to lose another 30 pounds. (13.5 kg), to take some weight off my knees and be able to exercise better.”

KS is 1.65 meters (65 inches) in height. She weighed about 91 kg (200 lbs.) in high school, and about 114 kg (250 lbs.) when she got married. Currently, her dream weight is 68 kg. (150 lbs.), a weight she has never seen as an adult.

KS currently exercises 1.2 to 2 hours at the gym (4:30 to 6:30 pm) four days per week. She had tried to exercise five to six days, but felt too tired. She enjoys her exercise classes (core, cardio, and strengthening) and does additional cardio on her own after the class. She is very interested in building lean mass; she meets with a personal trainer once a week for a weight lifting.  KS is very proud of her new muscles, reporting, “I have great guns!!!”

Regarding food intake, KS reports eating 1,700 to 1,800 calories a day, in the form of small meals every 2.5 hours. She follows the gastric sleeve protocol, which includes no fluids with main meals and frequent small meals. She reports no digestive concerns related to the gastric sleeve surgery.

KS consumes a high protein diet (130-140 g protein/day; about 1.7 g/kg), choosing protein powder, cottage cheese, lima beans or other bean, protein-fortified milk, and bone broth for her primary sources of protein. She restricts her carbohydrate intake to only 80 g carb a day  (~18% of total calories; ~ 1 g carb/ kg body weight). This low carb intake could explain, in part, her complaints about muscular fatigue. See Table 1. for a typical day’s food intake.

Table 1. Typical Day’s Food Intake

KS’s goal for the nutrition consult was to figure out how to lose more weight. “I have hit a plateau.” Her doctor suggested she reduce her intake to 1,300 calories a day. Yet, the previous summer, when she had hit a weight plateau, her trainer suggested she eat more. She added 400-500 calories (from 1,300 to 1,700-1,800 calories) and started losing weight again.

Like many weight-conscious athletes, she asked, “Do you think I should I eat more—or less—to lose these last 30 pounds?” The answer is elusive. To help assess the weight situation, I asked KS the following questions:

• How do you look compared to others in your genetic family? (leaner)
• Does your family think you should lose more weight? (No)
• Do you think you might see yourself as being fatter than you are? (Probably)
• Is what you consider “fat” actually just flesh and empty fat cells”? (Perhaps)
• What would your quality of life be if you were to eat less? (Hungry often)
• Should a random number that “sounds good “determine your goal weight? (No)
• Do you really want to struggle to lose weight that might be very hard to keep off? (Not really)
• Can you find peace at this weight—and enjoy feeling strong, powerful and fantastic? (Perhaps…)

After discussing the pros and cons of trying to lose more body fat, KS acknowledged, “Maybe my husband is right and I really don’t have more weight to lose.” She appreciated my help with guiding her to that conclusion.

In a follow-up consult one month later, KS reported. “I am a BEAST now when I work out. I am gaining strength and endurance daily. My overall energy is much better all day.” KS had increased to 2,200 to 2,400 calories a day, primarily by adding carbohydrate (200-250 g/day). This equated to about 2.8 g carb/kg body weight, an intake in keeping with improved performance. She had gained a little weight, and fluctuated between 180 to 184 lbs. (82-83.5 kg.) This concerned her, but her clothes still fit the same as before the weight gain. I suggested the change might be related to having more muscle glycogen, given her higher carbohydrate intake. (About 3 grams of water sets stored with each one gram of muscle glycogen.)

Teaching Points

When counseling weight-conscious clients, sports dietitians want to listen carefully to assess their client’s quality of life, energy level, hunger level, enjoyment of exercise, and feelings of deprivation. Next, they can discuss with the client the costs and benefits of a reducing program. The athlete can then estimate the best weight for his or her body—and that often is the “dream weight” but rather a realistic and sustainable weight.

Author

Nancy Clark MS RD CSSD has a private practice in the Boston-area and is author of Nancy Clark’s Sports Nutrition Guidebook (new 6th edition, 2019).