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Before considering weight loss injections, patients experiencing suboptimal results after gastric sleeve surgery should explore alternative evidence-based strategies : Dietary optimisation remains fundamental: Protein prioritisation : Consuming adequate protein (commonly ≥60g daily, individualised by a bariatric dietitian) to preserve lean muscle mass and promote satiety Portion control : Using smaller plates and mindful eating techniques to prevent stomach stretching Avoiding liquid calories : Eliminating sugary drinks, alcohol, and high-calorie smoothies that can bypass restriction Regular meal patterns : Eating three small meals with planned snacks to maintain stable blood glucose and prevent grazing Nutritional counselling : Working with a specialist bariatric dietitian to identify and address dietary challenges Lifelong supplementation : Following BOMSS guidance on multivitamin/mineral, vitamin D/calcium, and B12 supplementation with periodic blood monitoring Physical activity enhancement : Resistance training : Building muscle mass to increase metabolic rate and improve body composition Cardiovascular exercise : Aiming for 150–300 minutes of moderate-intensity activity weekly, as recommended by UK Chief Medical Officers Behavioural activation : Increasing daily movement through lifestyle changes such as walking, gardening, or active commuting Psychological interventions : Cognitive behavioural therapy (CBT) : Addressing emotional eating, body image concerns, and maladaptive eating patterns Support groups : Participating in bariatric patient communities for peer support and accountability Stress management : Developing healthy coping strategies to prevent stress-related eating Medical review : Medication assessment : Identifying drugs that may promote weight gain (certain antidepressants, antipsychotics, corticosteroids) Endocrine evaluation : Screening for hypothyroidism, Cushing's syndrome, or polycystic ovary syndrome Sleep assessment : Addressing obstructive sleep apnoea, which can impair weight loss Anatomical assessment : Evaluating for sleeve dilation, reflux, or other structural changes that might warrant endoscopic or surgical revision These foundational strategies should be optimised before adding pharmacological interventions, as they address modifiable factors that commonly contribute to post-bariatric weight regain

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