Bariatric Weight Loss Surgery Blog

Don't push the envelope.

In my years of working with weight loss surgery patients the best advice is to follow directions, especially in the first weeks and months after your surgery. I have seen people get themselves into trouble, and back into their surgeon's office, by advancing their diet too quickly. Guidelines for the diet progression vary greatly between surgery types and surgical practices. Even with these variations, I am certain you won't find any surgeon or dietitian allowing a sub sandwich on the way home from the hospital or pepperoni pizza three weeks postop.

Allow time for healing.

The diet progression is necessary to allow for healing of sutures and/or staple lines. You want to avoid any food that is going to cause retching, regurgitation, or vomiting because any of those reactions puts pressure on those sutures and/or staple lines. Your dietitian will give you diet steps and guide you through the progression until you are able to tolerate a regular diet.

The typical diet progression to a regular diet is

1. Clear liquids,
2. Full liquids,
3. Puree or smooth foods, and
4. Soft foods.

Yes, it can seem like forever before you can eat "normal" food again. But remember eating "normal" is what got you to weight loss surgery. It's time to develop a new normal as you work with your new tool. Even though a food may call your name, don't push the envelope.

Eat Smart…

Vicki Bovee, MS, RD, LD

www.simplysmartfoods.com

In the News...

After two trials published last month showed bariatric weight surgery leading to greater improvements in diabestes,  another study has found that bariatric surgery is a better diabetes treatment in obese patients than medical therapy, Italian researchers said, confirming results from other recent trials.

In a prospective cohort study involving 30 morbidly obese diabetic patients undergoing laparoscopic sleeve gastrectomy, compared with 30 similar patients receiving usual drug-based care, measures of diabetic control were improved far more with the surgical procedure, according to a group led by Nicola Basso, MD, of the University of Rome "Sapienza."

Patients receiving medical therapy showed modest improvements from baseline in major diabetic outcomes after 18 months -- fasting plasma glucose levels fell by more than 30 mg/dL and hemoglobin A1c values declined by one percentage point -- but diabetes was nearly eradicated in the surgical patients, Basso and colleagues reported online in Archives of Surgery.

However, after the New England Journal studies appeared last month, the Endocrine Society issued a statement cautioning against routine recommendations of bariatric surgery for obese diabetic patients.

The group noted that compliance with long-term lifestyle change is vital for patients undergoing bariatric surgery, and not every patient can handle it. Risks of surgery are also a consideration, the society said.

Read rest of story here at www.medpagetoday.com http://www.medpagetoday.com/Cardiology/Diabetes/32200

For National Stress Awareness Month - Can Stress Cause Weight Gain?  Yes!

Weight gain may be caused by many factors, some controllable, some not; but did you know that stress may contribute to weight gain?  There are several reasons why higher stress levels may cause you to gain weight or make it more difficult to lose weight.

Cortisol – a stress hormone

Cortisol is a stress hormone that is released by the body as a protective response causing a burst of energy, shifts in metabolism, rapid heart rate, increased blood flow and focus.  Whether it’s stress at work, home or other life crisis, prolonged stress periods may lead to weight gain as well as other serious health risks.

1. Slower Metabolism -- Too much cortisol released from stress can slow your metabolism which burns less calories and leading to weight gain, even if you still eat the same amount you did before.
    
2. Cravings for the bad stuff and more of it  - We’ve all been there.  Who wants to eat vegetables when you are stressed out?  Ice cream, chips, candy, alcohol and fast food sound much better; but of course, may cause weight gain if consumed too often.  Excess stress can also cause you to consume more than you normally would.  All of which means more calories in than out and equals weight gain.
    
3. Increased Fat Storage -- Increased levels of stress are linked to greater amounts of abdominal fat stored, which is also linked to greater health risks such as heart disease and diabetes.
    
4. Swinging Blood Sugar -- Prolonged stress may cause blood sugar levels to go up and down, causing mood swings, fatigue, and conditions like hyperglycemia. Too much stress has even been linked to metabolic syndrome, a cluster of health concerns that can lead to even greater health problems, like heart attacks and diabetes.  Eat short, small meals throughout the day to even out blood sugar levels.
    
5. Too Much Fast Food – It’s easy, it’s fast but we all know it leads to weight gain even if you order the salad – with all the dressing, croutons, nuts, cheese, etc.  Pizza anyone?  Taking the time to cook a healthy meal is not easy and you do have to plan ahead.  Grab a Subway sandwich if you have to eat fast food with just oil and vinegar or order a salad with low fat dressing on the side.
    
6. No Time for Exercise – It’s even more difficult to find time to exercise in our busy lives.  Before work, after work, during work or not at all if a deadline is looming.  Try to fit in little exercises here and there if you can.  Exercise is a wonderful stress reliever.

As part of your weight loss plan be sure to monitor the stress levels in your daily life and how it is affecting your eating habits.  B vitamins can also become depleted during stress and are important in reducing the affects of stress.  Taking a B Complex supplement  or a multivitamin with B Complex vitamins may help minimize the affects of daily stress and help with mental focus.

Learn more about controlling stress and some easy tips to relieve stress here and here.

For more information on National Stress Awareness Month visit http://stressawarenessmonth.com/

Guest post by Vicki Bovee, M.S., R.D., L.D., is a registered dietitian with over 25 years experience in weight loss, weight management, and specializing in bariatric nutrition since 2003.  www.chefdave.org

I recently met with a bariatric post-op patient and discussed what I see as a reoccurring theme with gastric bypass and adjustable gastric band patients, food getting stuck from not chewing it well enough, taking too big of bites, or eating too fast. So, what does this have to do with your dishwasher?

If it is filled with spoons you are most likely eating too many "slider", or soft foods, to reduce the risk of food getting stuck. Ice cream is a great example of a slider food. It melts and just slides right on down. You could still eat that carton of Ben & Jerry's, if you don't get dumping syndrome, without too much difficulty.

Liquids and Soft Foods at First
In the first few weeks or months after weight loss surgery, your surgeon or dietitian recommended you go through a diet progression of full liquids, smooth foods, and soft foods before you moved on to a regular diet, or your healthy diet for life. The reason we move you along through the diet stages is to allow the healing of sutures and/or staple lines. But when these have healed, it is time to move on to more solid foods. If you are more than six months post-op, you should be on a regular diet unless otherwise advised by your surgeon or dietitian.

After Six Months, Solid Food
Although eating soft, slider foods may prevent the pain and discomfort from food sticking, it's not in your best interest to eat this way. Typically you can eat more quantity, hence more calories, of slider foods than solid foods. I like to compare it this way. You could eat 2 cups of chicken soup because it will flow right on through the narrow opening. It would difficult to eat 2 cups of chicken because it is dense. You are likely to eat less quantity if you are eating more solid and dense foods. Think about which foods are more solid and dense. These would be protein foods and many fruits and vegetables, all healthier foods that need to be part of every meal.

Take Small Bites & Chew It!
Yes, you can eat many solid foods without having them get stuck. Take small bites, the size of the end of your little finger. Chew each bite 15-20 times. Some foods are problem no matter how many times you chew them and if you find you still have a lump of food in your mouth, don't swallow it. Watch out for fibrous fruit peels and vegetable stalks and dry, stringy meat. Chewing and slowing down eating takes practice to become a habit so keep working at it.

So, if you find you are eating more and still feeling hunger, check your dishwasher. If it's filled with spoons and bowls it's time to trade them in for knives, forks, and plates.

Eat Smart...
Vicki Bovee, MS, RD, LD

Guest Blog Post by Lynnda Shepherd Host of BariatricTV and bariatric weight loss surgery patient in 2003 Web Link: www.BariatricTV.com  Facebook Page www.facebook.com/BariatricTV 

You don’t wake up one morning and realize you’re fat. 

If you’re morbidly obese, you know that you’re morbidly obese.   There is probably not a minute of any day that goes by where you aren’t hyper focused on the fact that you are, in fact, fat.  You use every wish from falling stars, wishing wells, birthday candles hoping that one morning you will wake up and the weight will magically be gone.   And fat – real fat, not the 10lbs that your best friend is always saying she needs to lose because she is “Sooooooo fat”, is a demoralizer.  It rules your every thought and action.  You can be a successful CEO of a Fortune 100 company with a seven figure income, a loving spouse, picture perfect children and a vacation home in Belize and you will still feel that that you are a big, fat failure.

We've Tried Every Diet There Is - Anything...
Trying to lose weight is not easy no matter how successful you are in every other area of your life and no matter how you try to attack it.  Most morbidly obese people have tried every commercial diet on the market, online quick fixes and those diets that your sister’s boyfriend’s auntie lost 200lbs on by eating only cookies...  We will try ANYTHING to lose weight.  Inject ourselves with sheep urine on the promise that the pounds will drop?  Sure!  Sign me up.  Eat nothing but grapefruit with vinegar poured on top for a year?  Awesome!  As long as I can fit into those size 10s – I’m onboard. 

When you are morbidly obese, though, trying to drop 100, 200 or even 300lbs by eating grapefruit simply won’t work.   Oh.. You’ll drop some weight alright, but I guarantee that you will be sneaking pieces of pepperoni pizza by the two week mark to help “keep your strength up” and before you know it whatever  weight you managed to lose will have come back AND brought friends.
 

Exploring Weight Loss Surgery
For a lot of us, once we try (and fail) all of those fad diets and commercial diet programs we start to think about weight loss surgery.   It’s important to add that no one should ever lightly entertain the idea of rearranging your insides.  Weight loss surgery is not the easy way out... It is not for wussies.  And it is not for quitters.  If you are thinking of having weight loss surgery, you need to do your research and go into the operating room and under the knife with your eyes wide open (metaphorically speaking, of course).

You Must Go All In!
Once you have weight loss surgery you need to be “all in”.  You will have to commit to a lifestyle change.  A lifestyle full of eating protein first, moving your body and taking supplements every day for the Rest. Of. Your. Life.!

Supplements for After Bariatric Weight Loss Surgery
How many and what type of supplements is dependent on the type of weight loss surgery you have.  But the bottom line is that every type of weight loss surgery requires you to change your life.    It requires you to get your blood drawn yearly to make sure that the supplements you are taking are working.  And how often do you need to take those supplements?  If your answer was anything other than “Every day for Life” then you failed.    You don’t decide to have your guts surgically rearranged and then not follow through on the rest.  Oh.. you’ll lose the weight..  but 5 years down the line you will step off a curb and your ankle will snap because you aren’t getting enough calcium..  Your short term memory will go because you aren’t getting enough B vitamins.  You will be exhausted the moment you wake up each morning because your body is starving for what it isn’t getting.  

I Did It and You Can Too
I had weight loss surgery in 2003.  I did my research.  I changed my lifestyle.  I have kept off the weight that I lost.  My co-host on www.Bariatrictv.com, Toni Towe, had her surgery in 2004.  She did her research.  She changed her lifestyle.  She has kept her weight off.   We are success stories.  We follow the rules.  But that isn’t good enough for us.   We want to ensure that everyone knows that weight loss surgery is not the easy way out.  We want to make sure that no one joins our little club without having all the facts.  We don’t want anyone to fail.   In order to do that - we, along with Toni’s husband Mike, started a weekly internet video show back in 2008 that strives to educate while entertaining.  We think that weight loss surgery is a serious subject with a serious message but that people respond better to learning when they are laughing.  Everyone remembers the ‘one liners’ from their favorite movies without even trying.  That is what we want to do – we want the information to sneak up on you and stick with you while you are enjoying our show.  We want to make you laugh..   But mostly we want you to be successful.  To have a long, healthy life free from the fat, and health issues associated with that fat, that have held you back for so long. 

 
We tell our viewers to focus on SPEW after surgery.  Supplements.   Protein.  Exercise.  Water.
We also want everyone to stay connected to the people who are like them.  Never forget that you are a Surgically Altered Freak.    If you can do that then you will be successful.  And successfully losing 100, 200, 300 or 400 pounds and then keeping it all off will allow you to use all those birthday wishes for other priorities – like a trip to Paris (because you fit in the airline seats) or a whole new wardrobe (because you no longer have to wear those shapeless shirts and dresses from the past) or mountain climbing or surfing lessons (because you can!).

Once you lose the weight you will have a whole new list of wishes when you wake up each morning and that is what we, at www.Bariatrictv.com wish for you.

Thanks Lynnda, what a great post! 

A truly inspiring story!

By Sandi Henderson, Guest Blogger from BandedLiving and Bariatric Weight Loss Surgery Patient  www.bandedliving.com 

In January 2004 I sat in my doctor’s office fearing for my life, waiting for her to tell me that my blood pressure had gone down enough that I could go to the pharmacy and pick up my blood pressure meds and then go home. I was terrified. I was confused. I was morbidly obese and finally was scared into doing something about it.

Decision Time
In February 2004 I attended a weight loss surgery seminar at one of the local hospitals, and since I had done quite a bit of reading before I went I decided I wanted to visit with the surgeon and learn more about lap band surgery. I might be able to do this. If “it worked” maybe I would be able to lose some of this 424 pounds I was carrying around and help with some of my health issues. My visit with the surgeon confirmed my gut feelings that this could be “it” and before I knew it I was scheduled for surgery on May 28, 2004.

The Surgery
On that day I was prepared to die in surgery. I told my husband no “extreme measures” were to be taken. The anesthesiologist saw me in the pre-op area and gave me something to calm my nerves. I went out like a light and woke up in recovery. I was alive, hurting, disoriented and had a nurse telling me my sugar was too high and I needed a shot of insulin. All I could get out of my mouth were the words, “I don’t have diabetes”.  Five minutes, or 5 hours later, I have no concept of how long I was in recovery, I was brought up to my room and my husband. Now my new life truly began. Previous to this time, at 424 pounds I could barely walk across a room without stopping because of pain in my knee and having to catch my breath. I no longer went shopping. I created a list and gave it to my husband. My vacations were very restricted, my life was getting smaller and smaller as I got bigger and bigger. I had high blood pressure, sleep apnea, asthma, osteoarthritis in my right knee, and was on track at 55 years old to develop many more co-morbidities associated with morbid obesity. May 28,2004. That’s the day my new life began.

Post Weight Loss Surgery - A New Life
I followed ALL of the doctor’s instructions concerning protein, liquids, food progressions, vitamin supplements, support groups, regular visits to the office and within 2 years lost 250 pounds. I now weighed less than the amount of weight that I lost, and not to anyone’s surprise, as my body got smaller, my life got bigger and bigger. I could once again scuba dive, my grandkids could sit in my lap since I had one, I was swimming laps at least 6 times weekly and was in better health at 57 than I had been in the past 40 years.

I learned that I ate to live, I no longer had to live to eat. I could actually use food as medicine, as fuel for my body, the building blocks of muscle, and not as something that soothed the savage beast within me. I find it quite interesting that many of us who are overweight or obese are also malnourished. Add that to the food restrictions after weight loss surgery and you can have some folks in pretty poor shape. For me, as I lost weight my skin cleared, my eyes had a shine to them, my hair did NOT fall out, my energy levels increased, my depression, anger and negative outlook decreased, and I just felt good about life.

Take Your Vitamins and Supplements!
All of this did not come from simply losing weight. If that was the case, why did others I saw in support group lose hair, have really sickly looking skin, no energy, and increased depression and negative outlook? I can’t speak “scientifically” about this but I can say from the time I came home after surgery I began taking a good, chewable (because it was easy to take) multivitamin, my calcium, and as I added foods into my eating program, I strived to make healthy choices and balance my nutrition as much as possible. Within weeks of surgery it also became apparent that a good digestive aid was also necessary to keep things “moving along” on a regular basis. Any eating plan that is high in protein can easily create digestive issues.

Here I am now, over 7 years post-op doing the same things to stay healthy that I started on day 1 - Eating to live, taking a daily supplement of multivitamin and minerals, using a digestive aide, exercising regularly, and most important of all - participating in my life.

Please visit www.bandedliving.com for great information and a closed forum for support or Sandi's blog at http://sandisbandedliving.com/ and be sure to like Banded living on Facebook http://www.facebook.com/sandi.lapbandedliving.

Guest post by Vicki Bovee, M.S., R.D., L.D., is a registered dietitian with over 25 years experience in weight loss, weight management, and specializing in bariatric nutrition since 2003.  www.chefdave.org

Several years ago I attended the American Society for Metabolic and Bariatric Surgery (ASMBS) conference. Sometimes I find the most valuable information comes from the Q &A after the presentation.

Such was the case for one session. I wish I could give credit to the speaker, but I was busy scribbling my notes and failed to note the session. But what I did note was valuable information that I have passed on to patients regarding the predictors of success for after bariatric weight loss surgery. Though I cannot cite the reference, my experience tells me that successful weight loss maintainers fit the following criteria. Even if you have already had weight loss surgery, there are actions you can take to be successful.

1. Pre-op weight loss is important.
Very often patients are advised to lose weight before bariatric surgery. Typically, this is to help your surgeon in the operating room and reduce risk of complications. What it also does is give a jump start on your weight loss. Losing 5 to 20 or more pounds before surgery increases motivation to continue. If someone is eating "the last supper" right up until surgery, you have to ask how motivated are they to make those eating behavior changes long-term.

2. Eat ON TRACK the first 6 months.
The longer you stick to the rules, the longer you follow the guidelines from your bariatric health provider, the more likely you are to stay on track. For many people, that first bite of a food that is difficult to control is like opening a crack in Pandora's Box. When I have patients pushing the envelope with eating two months after surgery, I know there is trouble ahead. This is a lifelong commitment and it takes effort and dedication. Give yourself the time to establish those good habits before testing the waters with the old favorite foods that brought you to bariatric weight loss surgery.

3. Keep moving.
People who exercise 30 minutes or more daily do better. Period.

4. Attend support groups.
No man (or woman) is an island. Whether attending a support group in person or on the internet, having regular contact with other weight loss surgery patients is motivating. If you are struggling someone is there to give you a hand. And if you are on a roll, you can give someone else a hand. Buddy up.

5. Attend all follow-ups visits with your surgeon's office.
Keep every appointment and get your labs done every time they are ordered. Your providers know best and it's their job to keep you healthy. If you have gained weight back and are embarrassed to go back, you are not the first. They are there to help you so be sure to use their expertise.

Eat Smart...
Vicki Bovee, MS, RD, LD
www.chefdave.org

Now that January is over and the strength of New Year resolutions fades, here are some pointers to keep you focused on the positive, pro-actively seeking improvement and enjoying your lifelong weight loss journey.

by Kristi Merkling, Guest Blogger

Keep Learning
Make a deal with yourself to learn at least one small thing each day about your place along the bariatric weight-loss path ~ whether you research the surgeries themselves, if you’re still considering, or if you reference fun new ways to incorporate exercise into your post-surgery daily life, keep learning! 

From interesting new facts about how vitamins and minerals support your body’s functions, to practical ways of maintaining a positive attitude, there is always an abundance of things to learn about the new life you’ve chosen for yourself. Integrating those lessons and facts here and there will help bolster your interest, courage and enthusiasm, and keep you ahead on the positive curve!

Laugh Out Loud
It’s going to happen that some days are better than others.  Things related to your weight-loss surgery lifestyle and not related at all will come up to sabotage your positive outlook and bright focus.  On days you feel like staying in bed with the covers over your head, fight back with a dose of giggling, belly laughs, guffaws and snickers.  Laughter relaxes the whole body. A good, hearty laugh relieves physical tension and stress, leaving your muscles relaxed for up to 45 minutes after.  Just like a good massage!
 
Laughter really is the best medicine for all sorts of frustrations, and even a simple joke or two can do wonders to turn your mood right back to the positive, pro-active path that makes each struggle, each piece of work you do to succeed, that much more rewarding.

So learn something new and laugh out loud today!

Most weight loss surgery patients lose weight quickly during the first few months but then slow down.  This can be attributable to what you eat and drink to maintain your weight loss. You must know how many calories you are consuming each day. The best way to keep track of this is to keep a food diary because they do add up very easily!

Portion Control is Essential
Bariatric surgery reduces the size of the stomach in order to feel full on a smaller amount of food, thereby consuming less calories which results in weight loss.  However, some people who have had gastric bypass surgery still find ways to regain their lost weight. Eating until completely stuffed which stretches and enlarges the small pouch, eating high-calorie, high-fat foods and continuously eating all day long are all contributors to weight gain. 

There are important steps you must take to make sure your weight loss continues after surgery:

1. Know how big (or small) your new stomach is and how much food it can hold.
In the initial phases of gastric bypass surgery, your stomach is about the size of a thumb and can hold about ½ cup (4oz) of food at a time. If you have an adjustable band in place, the amount of food consumed varies until you reach the “sweet spot” or “right fit.” At this point, optimal food intake ranges from ½ cup to 1 cup (4-8oz) of food/meal or snack.

2. Eat slowly enough to recognize the feeling of fullness; stop eating just when you feel full - not overfull!
Each meal/snack should last 20-30 minutes. Chew each mouthful completely before swallowing.

3. Aim for satiety.
Satiety is the sensation of being full and satisfied after eating. Satiety is affected by many things including hunger, cravings, social situations, emotions, food choices, and eating habits.
High fiber foods slow down the rate at which food leaves the stomach, thereby creating a longer-lasting feeling of fullness. Incorporate beans/lentils, vegetables, fruits and high fiber (at least 5g fiber/serving) whole grain carbohydrates in your meals daily. High protein foods are also satisfying, so be sure to include lean meats, fish, poultry, low-fat or fat-free dairy and beans/lentils in your eating plan.
 
Feelings of satiety occur after a balanced, well-planned meal. Therefore, it is recommended to eat 3 small meals a day, adding a snack as needed (ask your dietitian), and avoid grazing. Grazing is a behavior common to people who are disappointed with their weight loss and/or who regain some or all of the weight lost after bariatric surgery. Ask yourself these questions:

•What time of day do I usually graze?
•What else am I doing when I graze? watching television, preparing a meal, studying, etc?
•What are you grazing on and how did you get it?
•What type of food do you crave when you graze or are tempted to graze: chewy, crunchy, sweet, salty?
•How do you feel when you graze or are tempted to graze: bored, tired, stressed, anxious, depressed, etc?

To further slow down the time it takes for food to empty out of your stomach, avoid drinking with meals and for approximately 30 minutes after meals. Also, avoid high calorie drinks because they do not satisfy. Instead, stick to calorie-free beverages and low-fat or fat-free milk between meals.

To make sure you are taking all of your essential supplements like calcium, iron and B-12 each day, be sure to write these down in your diary too.  Make them part of your daily routine like making coffee, brushing your teeth, washing your face, etc.  After about 2 weeks it will become a habit.

Vitamin B12 otherwise known as Cyanocobalamin, is an especially important vitamin for maintaining healthy nerve cells and it works with Folic Acid to regulate the formation of red blood cells and helps iron function properly in the body.

B12 also works with Folic Acid to produce S-adenosylmethionine (SAMe), a compound involved in proper immune function and mood regulation.1  As a specific neural precursor, and component of so many vital nervous and circulatory system processes, Vitamin B12 is especially critical to the overall health of weight loss surgery patients. In the case of malabsorptive surgeries,  B12 must often be administered as an independent supplement to offset the severe B12 deficiency in some patients. As B12 is a key contributor to the body's proper use of iron, a lack of B12 exacerbates any potential or existing iron deficiency.

Research has also shown that in general, people in phases of weight loss have higher requirements for B12 than those not currently losing weight.2  Also at risk for deficiency are vegetarians (red meat is high in B12) and older adults due to decreased absorption from food as we age.

Weight Loss / Bariatric Surgeries - Supplementation Critical
The severity and type of nutritional deficiencies experienced by post-op patients varies based upon the type of procedure performed. As can be expected, malabsorptive procedures cause the most impact to vitamin absorption and result in nutritional deficiencies much faster, while restrictive procedures limit food (and therefore nutritional) intake, but do not bypass any part of the intestine.

Vitamin and mineral supplements are still recommended for all procedures at the levels and frequencies specific to each patient's surgery type, loss rate, sex, age and medical history.
The incredible amount of physical and mental stress of obesity and the weight loss surgery journey may require daily fortification with sublingual B-12 or a robust B-Complex.

Each form of weight loss surgery requires specific individual monitoring for vitamin deficiencies, through the many years of each patients journey to better health.
 
Look for a sublingual liquid B12 supplement that can be put under the tongue with a dropper for optimum absorption through the membranes of the mouth. 

1. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Thiamine, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin
B12, Pantothenic Acid, Biotin and Choline. National Academy Press, Washington DC, 1998.
2. Dixon, JB, Dixon, ME, and O'Brien PE. Elevated homocysteine levels with weight loss after Lap-Band surgery: higher folate and vitamin B12
levels required to maintain homocysteine level. International Journal of Obesity 2001; 25. 219-227
3. Aasheim, Erlend et al. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch Am J Clin Nutr
2009; 90 15-22.

This post is by Kathy Stevens, RD and Fitness Expert.  Read her other blog posts here.

Congratulations! 
You made the decision to have the surgery and did it!  However, that's just the beginning. 

With the growing popularity of different types of bariatric weight loss surgery surgery, we must also realize that these procedures are not a complete solution to life long weight control. Many past patients have reported great weight loss with a gradual regaining of the weight regardless of the surgical intervention.  You may be asking yourself, how can this be? Or why would someone let that happen? But more importantly for those contemplating such weight loss measures; how can I prevent that from happening to me? 

It's all in the math (but easy!)
How it happens is basic metabolic math.  If you eat more than your body needs, even in small increments throughout the day, you will gain the weight back. For every 3500 calories of excess food you intake you gain one pound of fat.  Excess is any amount over your daily metabolic needs also referred to as you Maintenance Metabolic Rate (MMR).  Your MMR is a combination of the calories you burn at rest (Resting metabolic rate: see formula below) plus the calories you burn in activity throughout the day (step 2 formula below).

1) Resting Metabolic Rate (RMR) is the number
    of calories required for your  body to perform vital functions. 

•Estimate RMR by using the Harris-Benedict equation:
–Males = 66 + (6.3 x body wt in lbs) + (12.9 x ht in inches) – (6.8 x age in yrs)
–Females = 655 + 9.5 (4.3 x body wt in lbs) + (4.7 x ht in inches) – (4.7 x age in yrs)

2) Maintenance Metabolic Rate (MMR) is the number of calories required to maintain your body weight.

•Determine MMR by multiplying the RMR by the appropriate activity multiplier:
–Sedentary = RMR x 1.2 (little or no exercise, desk job)
–Lightly Active = RMR x 1.375 (light exercise/sports 1–3 days/wk)
–Moderately Active = RMR x 1.55 (moderate exercise/sports 3–5 days/wk)
–Very Active = RMR x 1.725 (hard exercise/sports 6–7 days/wk)
–Extremely Active = RMR x 1.9 (hard exercise/sports & physical job)

Be Active!
Inactivity can add to the problem because your body learns to be a great storage tank verses a lean moving machine.  When we are inactive, over long periods of time, we can lose vital muscle tissue due to disuse. That muscle tissue loss can result in a lowering of your resting metabolic rate, making it harder and harder to stay in the proper energy/caloric balance. Thus you must remember that, surgery is only a tool. You’ll need to continue doing the right things and making the right choices for any weight loss surgery to be effective over the long run.

Psychological Effect
The ‘whys’ are typically related to the unfortunate fact that old habits die-hard. Food is often used as a psychological fix.  Just because one loses the weight doesn’t mean they have lost the bad habits that may have contributed to their weight gain in the first place. In many cases the reason for eating has less to do with hunger than it does with emotions. Scientists have found that eating a meal alters your mood and emotions, typically increasing calmness and reducing irritability. Studies in Psychosomatic Medicine have confirmed that people with weight issues tend to consume food in order to self-medicate their feelings of anxiety, stress, boredom and depression.  Thus regardless of the reduction in appetite due to a surgical procedure, the need to eat for psychological reasons may still be there.

Why's
This brings us to the all-important question~ how to prevent this from happening to you, post surgery?  The first step is to find your most important ‘whys’.  Why did you want to lose the weight in the first place? What are your deepest and most meaningful or motivating reasons?  List them in order of priority:
1.
2.
3.

How's
Once you can recognize the ‘whys’ the ‘how to’ is much easier to accomplish.  Think about your list of important reasons every day.  Keep them in plain sight.  Better yet, post them right on your refrigerator or food cabinet. 

The next step is to change your eating habits.  It is not just about changing your food, but changing what your food means to you. To quote the author of the ‘The 10 Minute Total Body Breakthrough’, Sean Foy, “food is simply fuel”.  If you think of it as fuel your food choices become clear.  You wouldn’t want to fill your car up with the wrong fuel, the same way you don’t want to fill your body up with poor food choices.  And most importantly you need to release the association of food to the many reasons you might have eaten it in the past… to celebrate, to commiserate, to de-stress, to feel better.  These are not the reasons to eat.  Remember this simple truth,  ‘food is fuel’! 

Eat to function, eat to move, eat to keep your body healthy. 

Use It to Lose It!
Last but not least you need to move more!  Everyday, every way, it doesn’t have to be an organized exercise routine, or set time of day, you simply need to use your body as it was designed.  We are all movement machines, capable of an endless list of physical abilities.  I love the old exercise saying, ‘Use it or lose it’.  Specializing in the area of senior fitness for many years, I am constantly amazed at the difference exercise can make when it comes to maintaining ones functional ability.  On the other hand, you can also say that you have to ‘use it to lose it’.  This is because exercise is an important part of the energy balance equation. We know that those patients who have adopted a more active lifestyle that includes regular exercise burn off more calories per day and have an easier time keeping of the undesirable weight. 

So let’s sum things up: the best way to keep from being one of those people who gain fat weight back after surgery or dieting:

o Write down your ‘whys’
o See food as ‘fuel’
o And ‘move it’ …

Don’t forget to also include the right supplements,liquid calcium & vitamin D3, liquid multivitamin, liquid iron and B-12 sublingual liquid are all most important to help insure your body can function at it’s best.

This is a re-post of an article written awhile back by Kathy Stevens, author of our blog Health and Fitness for Life http://blog.wellesse.com/blog/health-and-fitness-blog 

Yes!  You can exercise before and after Bariatric Weight Loss Surgery - learn why & how to do it safely.

Asking a severely obese person (more than 100 pounds overweight) to exercise can be like suggesting a spicy meal to someone with a stomachache.  Obesity takes a toll on almost every system in the body from your heart and blood vessels to your organs, bones and joints.  This often leads to a vicious cycle of sedentary behavior; the less you move the more you gain ...the more you gain the less you feel like moving. When you spend years being inactive you lose important physical abilities and muscle properties that allow you to stay active for life. More and more people are turning to bariatric weight loss surgery as a solution when traditional diet and exercise are not working. This medical intervention can offer a fresh, new start but won’t be the full solution unless coupled with a healthier lifestyle, including proper nutritional and exercise habits. 

Research
Research studies on obesity and weight loss continue to support exercise as a key component to weight loss maintenance. A recent study done out of Brown Alpert Medical School and Miriam Hospital in Providence, Rhode Island found that of 199 patients who underwent gastric bypass, those who became more active after surgery lost more weight over one year than those who remained relatively inactive. (Bond DS, Phelan S, Wolfe LG, Evans RK, Meador JG, Kellum JM, Maher JW, Wing RR. Becoming physically active after bariatric surgery is associated with improved weight loss and quality of life. Obesity 2009;17:78-83.(2009).

Below is a three-phase approach to exercise for those considering or recovering from weight loss surgery.

Phase 1: Pre surgery (ideally 4 weeks)
Assuming you are currently inactive, the first step is to prepare for surgery by performing a pre-op ‘no sweat’ exercise program.  Now don’t let this phase scare you off, because I really mean ‘no sweat’.  This phase is simply to establish the ‘activity’ dream that lives deep down inside of your genes.  It is the preparation phase to the exercise program you will follow after surgery.  The main goal is to help you establish an exercise habit.  It starts with simply setting aside the time to exercise. It is ideal if you start this phase a month before surgery, but any amount of time will benefit you. 

Get a journal to track your progress - either a Weight Loss/Exercise specific journal or just a blank one.  Or use a tool online such as Spark People to track your progress.  There are many tools available to help.

Start with 10 minutes a day (most if not everyday of the week).  During those 10 minutes you can do whatever activity feels comfortable.  This might include limbering movements, light stretching, breathing exercise, chair exercise, contract and release muscle exercise, or simple closing your eyes and picturing yourself doing exercise. The key is to schedule the time like an important appointment and stick to your schedule.  It is not about the movement or exercise during this phase, it is about the commitment which will evolve into a new exercise habit in your post surgery lifestyle.  The more seriously you take this phase prior to surgery, the easier it will be to build upon it after weight loss surgery.

Phase 2: Post Surgery (typically 4 to 6 weeks)
You will be taking in far fewer calories directly following surgery, which can sometimes cause the body to react as you were on a starvation diet. This can signal the body to burn muscle instead of fat. This is the last thing we want in the long run because it leads to a downward turn in ones natural metabolism (ability to burn calories). Regular exercise alters the metabolism so that the body burns fat instead of muscle. This is why you want to get back to regular exercise as soon as possible. Initially post surgery you can get right back to your pre-surgery ‘no sweat’ workout commitment and only perform those movements or exercises that are easy to do without interrupting the healing process. This may be limited to light stretching, deep breathing and simple contract/relax exercises in your bed.

Start Slowly!
Once you have your doctor’s permission to exercise a bit out of bed you will want to add in some light walking on level surfaces. Start off slow and easy building up to 10 minutes non-stop. You may need to wait a good four to six weeks before you can get a bit more aggressive with your cardio routine.  Always check in with your physician for approval before increasing your workout intensity.  At this point you want to focus on extending your scheduled exercise time from 10 minutes to 30. Choose activities you like that will exercise your heart and lungs while burning additional calories.  Walking and non-jarring stationary equipment like a recumbent bike or elliptical trainer will feel the most comfortable. Water exercise may also be a good option but only after all incisions have heeled completely.

Phase 3: Beyond Recovery  (a life-time commitment)
Once you have been given the green light to engage in a more complete training program you will want to include some muscle strengthening work to your cardio routine.  This is one of the best ways to insure your body maintains it’s lean mass.  When you train your muscles they get the stimulation and nutrients they need to thrive. This contributes to stronger, healthier bones and joints.  An increase in muscle strength and mass will make all of the activities you do seem easier.  This in turn will increase your ability and desire to work harder.

So during phase 3 you will want to add muscle strengthening to your weekly workouts. You can continue with your 30 minutes of cardio, most if not all days of the week and simply add in the strength training exercises on 2 to 3 of the days (non-consecutive) extending those workouts to about 50 or 60 minutes; or you can alternate your workouts and spend 30- 45 minutes everyday in either a cardio or strength routine.  Below is a sample of a balanced strength routine:

Perform 8 to 15 reps of the following exercises (choosing a resistance that allows you to sense fatigue within the final few reps) 

1. Bench chest press
2. Bent over row or seated row 
3. Overhead press
4. Biceps curls
5. Triceps kick backs 
6. Squats
7. Hamstring/leg curls
8. Calf/heel Raises
(Perform 2 to 3 sets of exercise 1- 8)
9. Supine Abdominal (compression) press into the floor – avoid traditional abdominal curls until given doctors approval – see picture A below
10. Prone opposite arm and leg reach  – see picture B below

A. Hold for 3 to 5 breaths, repeating several times

B. Hold for 3 to 5 breaths, repeating several times one each side  

• Note: To maximize muscle growth be sure to include a nutrient dense diet with enough calories, calcium and protein to support muscle development – check with a physician or dietitian familiar with your condition for specific recommendations.

Breaking the Plateau
During a weight loss-training program you may find you occasionally hit a weight loss plateau.  To break a plateau try increasing the time you spend in each cardio session (moving towards 60 minutes) or increasing the intensity (moderate to vigorous). You can also choose to do a bit of both.

• Note extending your cardio workout time and or intensity will encourage faster weight loss.  If doing so be sure to stay properly hydrated by drinking a minimum of 4 oz. of water for every 20 minutes of vigorous exercise.

The good news is that the body is a miraculous machine when in comes to damage control. Given proper nutrition and physical motion it will rebuild itself. The damaged systems can become strong and vital again. 

Essential Supplements
You will need to take certain vitamin and mineral supplements for the rest of your life because your body will have a tough time absorbing certain nutrients.  Doctors recommend that you take a multivitamin supplement and calcium, iron, vitamin B-12 and vitamin D.  For example, when it comes to calcium and vitamin D supplements, these are typically quite big in pill form.  By opting for a liquid supplement, you can take them at any time during the day (just a few teaspoons worth at most).  Many physicians recommend liquid supplements for these reasons – they are convenient, fast absorbing and much easier for your digestive tract to handle.

When choosing a liquid calcium supplement, make sure it has calcium citrate and not calcium carbonate.  After weight loss surgery, the body cannot absorb calcium carbonate.  Calcium citrate is water soluble and can be easily absorbed, especially in liquid form.

Liquid supplements  are easier to swallow and fast absorbing.  The stomach does not have to "dissolve" the tablet or pill, making it a perfect choice for anyone who has had weight loss surgery or who has trouble swallowing pills.  Try a liquid calcium with vitamin D3 and take the liquid vitamin D3 for additional nutrition.  Doctors are now recommending 2,000 IU of vitamin D3 per day.

If you have had gastric bypass surgery or are planning to, please tell us your story and how it has affected your life.