If you’ve had bariatric surgery, you should care about your blood sugar.

You see, your cells run on glucose, a simple sugar obtained form the food we eat.  Not to mention, your body works hard to ensure the amount of glucose in the blood is kept at just the right level.  At no surprise, high blood glucose is often associated with weight issues and diabetes.  

But chronically elevated blood sugar also has other effects such as accelerated aging and chronic inflammation. These underlie every major chronic illness. Additionally, insulin is manufactured in the body and is used to regulate glucose.   Which also has to be considered after bariatric surgery. 

In my opinion, blood sugar balance is one of the most important things anyone can do to manage your health and weight. To further explain, Type 2 diabetes is a disease where blood sugar levels are consistently elevated.   It’s where the body either doesn’t produce enough insulin or it resists insulin. Unfortunately, there’s an estimated 462 million people world wide that are affected by blood sugar imbalances. 

But what happens to your blood sugar after bariatric surgery?

Bariatric surgery does a fabulous job influencing blood sugar balance positively.  So much so that many patients leave the hospital in remission.

In fact, early on it was touted as a “cure” for diabetes.  But like so many things when it comes to health, the reoccurrence of blood sugar imbalance remains a problem after surgery. 

For example, a study published in 2020 “Comparing the 5-year diabetes outcomes of sleeve gastrectomy & gastric bypass”, a cohort study in 34 US health systems on 9,710 patients found the reoccurrence rate to be…

Regardless of the reoccurrence rate.  The fact remains that 60-70% of bariatric patients still maintain blood sugar balance 5 years later.  Except if you’re in that 30-40% where you’re needing blood sugar medications again.  You might be quite disappointed. 

Here’s the thing, you have choices. You can take control of your health and do something about it. Especially when you have the awareness and tools to keep blood sugars better balanced after bariatric surgery. In reality, there is no set formula that works for every bariatric patient.  Given that there are genetic components influencing how YOU respond to different foods. The key is to be proactive.  Actually, to have a prevention mindset is even better. 

So first things first, understanding the tests necessary to evaluate where you are.  This will help guide you into understanding how to help yourself. 

Blood sugar tests

There are a few simple test that can monitor and evaluate how your body is regulating your blood sugar.

1. Hemoglobin A1C(HgbA1c)- gives a rough estimate of glucose levels over a 3 month window.  Anything between 5.7 to 6.4 is considered pre-diabetes.  Above 6.5 is consistent with a diagnosis of diabetes.  A healthier range is between 4.6-5.3. 
2. Fasting glucose- this measures the amount of glucose in your blood stream after a 8-12 hour fast.  Any value between 99-126 is indicative of pre-diabetes.  Above 126 indicates diabetes.  For more optimal levels <100, but more ideally between 70-80. 
3. Fasting Insulin- it can help detect early signs of insulin resistance that contribute to dysregluated blood sugar.  Research shows a fasting insulin level over 7 as being associated with a significant increase in future risk of metabolic syndrome & type 2 diabetes.  If you’re looking to optimize your insulin I would strive to keep it between 2-5. 

So as you can see, there are healthier references ranges to follow.  And test results provide feedback to help you navigate your choices or decide if you need to add support. But also further, let’s discuss the things that can influence blood sugar balance after bariatric surgery. As you can realize, there are many factors that can influence your actual blood sugar level.  And they’ll typically fall into a few categories. 

These include….

• Diet
• Inactivity
• Gut bacteria
• Hormones
• Genetics

How your diet influences your blood sugar after bariatric surgery

Most are aware of the connection between food choices and blood sugar control.   In fact, consuming foods with added sugar and non-fiber filled carbohydrates increase the risk for elevated blood sugar levels.  But it’s not always linear.   For example, a study published in 2018 found a protective effect from honey against metabolic syndrome.  Although natural, honey is still sugar but as you can see not all “added” sugar provides the same blood sugar response. 

Most are familiar with carbohydrate foods influencing blood sugar balance.  As a matter of fact, carbohydrates actually turn into sugar.  So it’s easy to see how it can alter your blood sugar. A recent study published in 2022 found that those following a low-carb high protein diet had better blood sugar balance and overall weight loss.  So being intentional about the types of carbohydrates you choose matters.  Furthermore, Low-carb doesn’t mean No-carb.  Don’t misinterpret these claims.  Your body needs fiber-filled carbohydrates daily. 

How inactivity impacts blood sugar balance after bariatric surgery

Physical activity can help lower your blood sugar up to 24 hours or more after your workout making your body more sensitive to insulin.  Not moving your body consistently will set you up for higher blood sugar levels.  With and without bariatric surgery.  It’s a human thing. 

Now, that doesn’t mean you have to run a marathon.  Being intentional about moving your body daily should be the biggest take away.  In fact, studies show walking after a meal can blunt the glucose spike.  This is why finding a routine with intentional movement is important. But, let’s dig into some areas that can influence blood sugar balance beyond your control if you don’t enlist parameters to keep it in check. 

Gut bacterias influence on blood sugar

A study published in 2020 found gut bacteria regulate glucose balance.  Additionally, another study published in 2020 also reports “Glucose alters the symbiotic relationship between gut microbiota and host physiology”.   For example, people with diabetes have dysbiosis.   In fact, dysbiosis increases lipopolysaccharide levels and gut permeability.  This results in mucosal inflammation, endotoxemia, systemic inflammation, insulin resistance and poor glucose control. 

Not to mention, one study found a positive and negative relationship exists between the types of gut bacteria and type 2 diabetes. To clarify further, Bifidobacterium, Bacteroidetes, Faecalibacterium, Akkermansia and Roseburia were negatively associated with type 2 diabetes.  Whereas, Ruminococcus, Fusobacterium, and Blautia were positively associated with type 2 diabetes. 

But we also realize gut bacteria can be influenced.  In fact, a study of 3,400 participants was able to demonstrate the potential of using dietary interventions to influence the gut microbiome to improve health.  Including blood sugar balance. 

Hormones and blood sugar after bariatric surgery

When it comes to blood sugar balance, the hormone estrogen plays a role.  In fact, the reduction of estrogen in post-menopausal women accelerates the development of insulin resistance and type 2 diabetes.  So, if you’re a female going through menopause or have gone through menopause you may’ve noticed your fasting blood sugar and HgbA1c slowing increasing during this time. This is where knowledge is power.  Understanding that this season of life may require a different approach to negate the effects of hormone changes. 

You may need to make different carbohydrate choices, different exercises, restore gut bacteria balance and optimize liver function.  This will allow you to have better control over your blood sugar.  Maintaining a healthy response. 

Genetics influence on blood sugar

The way insulin and glucose do their job is determined by certain genes, as well as by other factors such as diet, lifestyle, gut bacteria and hormones as we’ve discussed. To further elaborate, there are seventeen genetic SNPs either directly or indirectly associated with blood sugar balance. 

For example, the genetic SNP ADIPOQ(Adiponectin C1Q and collagen domain).  The GG genotype was associated with high insulin and triglyceride levels, compared to A allele carries and is associated with a higher risk of insulin resistance and metabolic syndrome. 

The genetic SNPs include…

• ADIPOQ
• ADRB2
• APOA2
• CETP
• DIO2
• FABP2
• FOXO1
• FOXO3
• FTO
• IRS1
• PPARA
• PPARG
• PPARGC1A
• SLC2A2
• TCF7L2
• TNFA
• UCP2

Additionally, a very recent study published in 2022 on “How the timing of dinner and genetics affect individuals blood sugar control” . The found eating dinner close to bedtime, when melatonin levels are high, disturbs blood sugar control.  Especially in individuals with a genetic variant in the melatonin receptor MTNR1B.  Which has been linked to an elevated risk of type 2 diabetes.

The high melatonin levels and food intake associated with late eating, impairs blood sugar control in carriers of the MTNR1B genetic risk variant through a defect in insulin secretion. So as you can see, your genes can make you more susceptible to more imbalances in your blood sugar. But here’s the thing, having genetics SNPs that predispose you to imbalanced blood sugars is not a death sentence or a guarantee they will be expressed.  

In fact, your genes load the gun, but your epigenetics pull the trigger.   Meaning you have the ability to influence your genes either positively or negatively by your behaviors and choices. So now that you understand why your blood sugar balance might be influenced after bariatric surgery.  Let’s dig into ways

What can you do for better blood sugar regulation after bariatric surgery?

1. Stay low-carb
2. Quality carbs(fiber, resistant starch)
3. Get adequate Omega-3, magnesium & vitamin D
4. Move your body consistently
5. Consume a higher protein diet
6. Add apple cider vinegar with meals
7. Restore gut bacteria balance to increase SCFA production
8. Consider Berberine
9. Consider continuous glucose monitor 

Stay Low-carb

Most studies find that maintaining a low-carb, high fiber diet to be advantageous for better blood sugar control.   

But what qualifies as low-carb? This is where many get confused.  Especially with the explosion of the ketogenic diet.  A keto diet where you consume 20 grams or less of carbohydrates.  But overtime you can remain in ketosis while consuming up to 50 grams of carbs for some. Unfortunately, this is where so many bariatric patients “feel” they should be with their carb intake.  I’ve recorded a podcast on this very topic.  

Although I remain neutral on this type of diet, I do find it difficult for most to sustain long-term. As a matter of fact, I find that a carb intake between 75-125 grams is more sustainable.  And achievable life long.  Which is important.  Not only do you have to consider sustainability, but your gut bacteria need fiber.  And fiber comes from carbohydrates. So dialing in your carbs and recognizing how you feel at different gram levels is a great experiment you can do yourself.   Get the blood work completed first.  Then for the next three months implement a carb intake consistently.  At that point you can retest.  This will provide feedback letting you know if that dose of carbs works for you. 

The next thing to consider is the type of carbs. 

Quality carbs

As you may be well aware, not are carbs are equal.   If you’re consuming 75-125 grams of carbs daily you will want to consider fiber-filled carbohydrates. 

In fact, carbohydrates can be broken down into two categories…

• Simple 
• complex carbohydrates. 

The body breaks down simple carbohydrates quickly.  Whereas, complex breaks down at a slower rate.   In addition, complex carbohydrates contain fiber. 

You see, consuming fiber-filled carbohydrates actually improve blood sugar regulation.  So including foods that contain soluble, insoluble and resistant starch positively impact your blood sugar. 

In fact a study published in the Journal of Nutrition found the replacement of digestible starch with resistant starch resulted in significant reductions in blood sugar after a meal and your insulin level. 

Adequate Omega-3, magnesium & vitamin D

This is where choosing nutrient dense foods become important.  

A meta-analysis in the Journal of Metabolites 2021 found that Omega-3 supplementation can improve blood sugar balance and lipid profiles of patients with type 2 diabetes. One study found that Omega 3 poly-unsaturated fatty acids had an effective role in improving lipid and hormonal profile, reducing blood glucose, weight gain in PCOS rats. Magnesium insufficiency is associated with an increased risk of type 2 diabetes.  Yet magnesium supplementation improves insulin sensitivity and blood sugar control. 

And then a study published in the Journal of the North American Menopause Society found when 25(OH) Vitamin D was less than 30, blood glucose levels were >100. Therefore lower serum 25(OH) vitamin D concentrations appear to be associated with a high blood glucose level. Your body does better with food first and then supplements second.  If you’re unable to meet your needs through your diet then adding a supplement is necessary. 

Move your body consistently

This may seem obvious, but it’s not always easy to implement.  This is where I recommend baby steps.  Pick one activity that you enjoy and set out on a mission to implement a routine.  You may want to start with one day a week and get good at that for a few months.  Then challenge yourself to increase to 2-3 days. In fact, a study published in 2016 found that walking for just 30 minutes a day reduces the risk of type 2 diabetes by approximately 50%. 

When it comes to exercise consistency is key.  So jumping into an intense routine may not be effective.  You want this to be life long not a few months. 

Consume a high protein diet

The reality is, most bariatric patients already consume a high protein diet.  This is second nature for most.  The reality is a high protein diet does help you stay more satiated, but also improves blood sugar balance. In fact, a study in the Journal of Nutrition found a protein intake of 20-30% of total calories is best for optimizing type 2 diabetes management. Continuing to make protein first a priority not only benefits weight loss, but blood sugar regulation as well.  This should be a life long strategy for all bariatric patients. 

Add apple cider vinegar

More and more studies are discovering the impact of apple cider vinegar and its beneficial effects on blood sugar balance. A study published in 2020 found the results to clearly show that the daily consumption of vinegar can reduce the rise in blood sugar and lipid profile induced by a high calorie diet in rats. An additional study in the Journal of Clinical Nutrition 2019 reported daily vinegar in the amount of 2-6 tablespoons appear to improve the glucose response to a carbohydrate-rich meal. 

So if you’re struggling with blood sugar control.  Adding a few tablespoons with meals may be an option to consider. 

Restore gut bacteria balance

The evidence is plentiful on how gut bacteria influence blood sugar regulation.  There are many ways to approach this, but first and for most working with a provider like myself can help you get to the root of your gut health.  The good news is gut bacteria can be influenced.  You just have to discover what is causing your imbalance and correct it.  You may find value in starting with boosting your beneficial gut bacteria. 

Consider berberine

Berberine is an herbal supplement that is a bioactive compound found in various plants. 

Several animal studies suggest berberine may help lower blood sugar levels in a variety of ways…

• Increasing insulin sensitivity
• Promoting insulin production
• Regulating metabolism
• Reducing glucose production in the liver
• Slowing carbohydrate absorption from the gut

Although they’re animal studies, you can see there are many benefits to consider. So even natural alternatives can help lower blood sugar levels.  And Berberine is one of them.  A study published in 2019 found berberine and metformin can modulate the composition of the gut microbiome and reduce body weight, blood glucose levels and intestinal inflammation in mice. 

Additionally, this study found berberine effective in lowering glucose at varying doses.  Also improving weight loss. 

Consider continuous glucose monitor

Lastly, if you’ve implemented many of these strategies and are not seeing improvements.  It may be helpful to consider a continuous glucose monitor.  There are several direct-to-consumer options.  These include…

Nutrisense

Signos

Levels

This allows you to take control of your health and dial in the specific foods that may be influencing your blood sugar balance. 

Conclusion

Hopefully, you can see the importance of maintaining blood sugar control after bariatric surgery.  Although bariatric surgery influences your blood sugar positively, it’s not guaranteed to maintain it life long. This is why it’s so important to take control of your own health and discover new ways to help lower your blood sugar with tools like berberine, omega 3, vitamin D, magnesium, continuous glucose monitors, apple cider vinegar and restore gut bacteria balance.  Sometimes you may have to go beyond a low-carb diet and exercise.