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The RNY Rules

 

These "rules" are already posted throughout my blog here somewhere ... but I figured I'd put them all together in one post to make it easier to find them. I formatted these as handouts for my support group, so they look all fancy and stuff.

A month or so ago I shared these with the director of my bariatric center and I just found out last week that she printed a bunch of copies and has them available in the waiting room at my surgeon's office for other patients to read. What an honor, huh?

The RNY Rules

Preparing for Surgery

Why We Don't Drink with Meals

Understanding the Pouch

Where are Nutrients Absorbed?

Will I Change After Surgery?

Breaking a Stall / Plateau

As of April 22, 2009

2 week pre-op liquid diet = 15.4
Month 1 = 18.4
Month 2 = 9
Month 3 = 8.5
Month 4 = 11
Month 5 = 8.5
Month 6 = 6.1
Month 7 = 8.4
Month 8 = 5
Month 9 = 4.5
Month 10 = 5.2  (hit 100lbs lost mark)
Month 11 = 1.2
Month 12 = 2.4
Month 13 = 0.6
Month 14 = 3.4
Month 15 = +.6
Month 16 = 2.9 
Month 17 = +.7
Month 18 = +.2
Month 19 = 2.6  (this "month" isn't complete yet, there are only 3 weeks in this tally)

Total weight loss to date:  112 pounds or 68% of excess body weight

*** These "months" are based on a 4 week "month" rather than an actual calendar month.  So since I'm only 17.5 months post-op the above tally might look a bit off, but this is how I chose to keep track of my monthly totals.

Side Note:  You'll notice that it it has taken me about 9 months to lose 12 pounds once I hit the 100lb mark. 

I haven't lost any weight since Christmas -- 2 months.  I lost 2 pounds on December 23rd, but for the 6 weeks before that, I hadn't lost any weight either.  Basically I'm losing about 2 pounds every 6 weeks or so since August.  Of course I'm frustrated. 

I posted on a thread today some of my thoughts on the matter.  Figured I'd copy them here so I don't lose my mental ramblings.

-----
I'm 190-ish right now (189-191).  I'm wearing a size 16 jeans and a large or medium top.  I have a pair of size 12 stretchy jeans that I can put on and zip up .... but I can't breath.  LOL!  So I don't think they count yet. 

I know I'm not working hard enough at the gym.  But I really hate the gym.  I'm an outdoor girl and I want to feel my feet hitting dirt on a trail that winds through the woods and runs along the river.  I want to feel sunshine on my face and breath fresh air and hear birds cheering me along as I sweat my butt off.  I don't want to look at other sweaty people pumping iron or reading magazines on the elliptical machine or being bored on the treadmills or goofing off with the free weights -- it goes against my grain and I resent the time I spend cooped up inside.  So I don't go to the gym as often as I should ... and I know it's been hurting my progress with the scale. 

It's still cold here in Michigan (13 degrees today).  I'm registered for a 5k race this weekend and I know I'll freeze my butt off, but at least I'll be outside.  Registered for another race on March 22nd and another on April 11th.  Even if I get frostbite, I swear I'm getting back outside and on the trails.  And I'm going to push myself to try running too!  The massive weight loss has affected me just like everyone else -- I'm freezing all the time! -- but right now, it's more important that I get back to my workouts than not be cold, so I'll suffer for a while until spring officially comes.  Because really... I can't bear the thought of being in the gym anymore.  I'll still go, but it will no longer be my primary workout location.

The scale will move eventually. 
Maybe this is God's way of teaching me patience so that I can once again have hope. 
Romans 5:3-4 --- ... but we glory in tribulation, knowing that tribulation worketh patience; And patience, experience; and experience, hope

~Pam

When they say it's "everything in one" .... be wary.  It's not.  Just because a manufacturer slaps the word "Bariatric" on the label doesn't mean it's the right brand for bariatric patients.  And just because the drug reps are really good at marketing and pulling the wool over surgeon's eyes, doesn't mean it's the right vitamin for us.  Everyone is trying to make a buck these days and I'm afraid Bariatric Fusion is one of those companies. 

So when you combine the information that Bariatric Fusion provides on their website about the ingredients in their vitamins and some basic research in the medical and scientific community about vitamins, their interactions with each other and how our RNY bodies handle certain vitamins.... we know that:

Wrong Kind of Calcium --- it's calcium carbonate combined with citrate.  Carbonate is the wrong kind of calcium after RNY - we dont' absorb carbonate.  Bariatric Fusion fully acknowledges that we don't absorb calcium carbonate, but uses it anyway.  They have an explaination on their website why they use a combination of different calciums and their lame excuse is that it helps make the pills smaller.  My bones are more important than pill size.

Not Enough Calcium -- even if it was all the right kind of calcium, it'd still not be enough.  In 4 pills daily you get a total of 1200mg of calcium.  Figure half of that is the wrong kind/not absorbed, so only about 600mg calcium citrate per day.  According to the ASMBS, we need 1500-2000mg calcium citrate per day in addition to the calcium we get from food.

Iron and Calcium Together -- It is well established in the medical and scientific community that iron and calcium use the same cell receptors in the body for absorption and that calcium always wins and iron always loses.  It has also been established that the upper limit of combining the two that 300mg of calcium is when that interferance begins.  So the 7.5mg of iron per pill may very well be unused by the body because of the amount of calcium per pill.  PLUS, Bariatric Fusion says on their website that it's alright if you take 2 pills at once... which means 600mg calcium is beating out 15mg of iron.  And let's not even talk about the other heavy metals (zinc, copper) that are also competing with the calcium.

Not Enough B12 -- After RNY we no longer have intrinsic factor to extract B12 from foods and supplements.  This is why we need to use sublingual B12 or injections.  There is some evidence that we are able to passively absorb 2-3% of B12 from oral supplements, but in order to get an adequate amount of B12 in that way, we need to take mega doses (2500mcg/day).  Bariatric Fusion contains a mere 560mcg per daily dose.

If you're looking for a bariatric specific vitamin.  Look at Bariatric Advantage or Celebrate.  After researching those two brands... I'm more comfortable recommending them.  Personally, I use Centrum Adult Chewable Multi-Vitamins

JMHO
Pam

After RNY our pouch no longer produces gastric acid (scientifically known as hydrocloric acid).  And after surgery most surgeons have their patients take a proton pump inhibitor for several weeks/months after surgery to "kill of" any remaining acid producing cells that might cause ulcers.  I took Prevacid for 12 months post-op. 

The diagnosis for lack of gastric acid in a patients stomach is called Achlorhydria.  This disorder is often seen in elderly patients, but since WLS has become increasingly popular, doctors have recognized that RNY patients need the same alternative treatment as elderly patients who have the same diagnosis.  

Calcium carbonate requires gastric acid in order to break down and be used by the body.   It does not break down in a neutral pH environment -- meaning it is not water soluable, it requires a highly acid environment to be bioavailable.

Calcium citrate is water soluable and dissolves quickly and easily in a neutral pH environment.  No acid is required.  In fact, a calcium citrate supplement tablet will dissolve in plain water in about 5 to 10 minutes.

In 1985 R. R. Recker published a study in the New England Journal of Medicine that showed the absorption rates of calcium carbonate vs. calcium citrate in patients with normal stomach acid vs. patients with achlorhydria.  Patients with achlorhydria absorbed calcium carbonate at a rate of 4% and absorbed calcium citrate at a rate of 45%.  Patients with normal hydrochloric acid levels absorbed calcium (either type) at about the same rate with no significant difference in absorption.

So what does all this mean?

It means that after RNY we must use calcium citrate as our calcium supplementation.  Calcium carbonate does not dissolve and is not used by our body after WLS.  The ASMBS Guidelines for Bariatric Nutrition recommends we take 1500-2000mg of calcium citrate supplement per day in addition to whatever calcium we get from food.  It is common knowledge among the medical community that doses of calcium must be no larger than 400-500mg at a time, spaced at least 2 hours apart.

Tums, Viactiv, Caltrate and the generic versions of all these brands..... all are calcium carbonate.  Stay away from them.  Look for Citracal, Bariatric Advantage, UpCalD, TwinLabs Calcium Citrate and others. Read the label carefully not only for the type of calcium, but also for the serving size.  Many calcium citrate brands require 2 pills per dose, so do the math according to your daily requirements.  For instance, Citracal Petites have 200mg calcium per pill... so to get 2000mg of calcium per day you'll need 10 pills in 5 doses throughout the day. 

My mom had RNY 5.5 years ago.  She was never taught the difference between calcium carbonate and calcium citrate.  She was simply told to "take calcium" -- not even told a certain amount per day, just to take the supplement.   She took calcium carbonate.  This past year she was diagnosed with osteoporosis with an 18.1% bone density loss in her spine.  She is only 54 years old and faces a very difficult road ahead with brittle bones, fractures and dental problems.  I preach about calcium so passionately because I don't want any other WLS patient to be faced with the same fate.

~Pam

It seems like I've been copying / pasting this a lot lately, so I'm going to stick it here for easy reference.  For the past few weeks I've been making delicious protein hot cocoa for my morning commute or for a late night snack.  It's so yummy!


I have a few different recipes I use:

OPTION 1
1 scoop chocolate protein powder
1 cup hot water
1 splash milk or sugar free coffee creamer

OPTION 2
1 scoop protein powder (vanilla or chocolate works)
1 envelope Swiss Miss Diet Hot Cocoa Mix
1 splash milk or sugar-free coffee creamer 
1 cup hot water

OPTION 3
1 scoop chocolate protein powder
1 squirt sf chocolate syrup (like Hershey's)
1/3 c. evaporated powdered milk
1 c. hot water
(I use powdered milke because the real stuff spoils before I can drink it, and mixed into shakes, you can't taste the difference with powdered milk.)

Two ways to mix it:

1)  Throw everything into the blender and mix on low until it's smooth and lump-free.  

2) The tried and true way when you don't have a blender:

Add dry ingredients to mug (protein powder, cocoa mix, milk, whatever).  Add the splash of milk or a little bit of cold water.  Mix like crazy until you have a smooth paste with no lumps.  Add a small amount of hot water and stir like crazy.  Add a little more hot water, stir like crazy ... you get the point.  This method helps to avoid the lumps that often happen when you mix hot water and protein powder straight.

Some people will claim you can't use water over 130 degrees, or coffee-pot-hot.  Personally I only ever use boiling water from the tea kettle.  Heating protein powder will not harm the protein, or cause it to disintegrate -- that's a myth. 

ALSO -- this same method works for protein coffee  or protein hot chai tea.  

 Here are the basic interaction rules when figuring out when to take your vitamins:

Calcium and Vitamin D are Friends --- take them together, they help each other absorb better.  Your body can only deal with 500mg at a time, so split up your doses into 3 or 4 doses per day to reach your 1500-2000mg daily goal.  Calcium tends to absorb better when taken with a meal, so schedule it that way if you can.

Iron and Vitamin C are Friends ---  Iron needs an acid environment to break down and Vitamin C does that job so make sure they are in your tummy at the same time.  Iron does not like food, so take it on an empty stomach.  However, if you get an upset tummy because of the iron, pick a non-dairy snack.  

Iron and Calcium are Enemies --- iron and calcium fight for the same cell receptors in the body and calcium is bigger and badder and always wins.  Which means the iron is simply excreted from the body and not used at all.  Keep iron and calcium at least 2 hours apart from each other. 

Vitamin B's are a Family --- they work together as a team and are best taken at the same time.  Your Multi-Vitamin has many B's in it, so take it together with your biotin, B12 and B-complex if you're taking those too.

EDITED 12/29/08 -- Nope, this vitamin schedule doesn't seem to be working.  I don't like taking my  iron with the rest of my vitamins and I need to figure out how to fit another dose of calcium in to get a true 2000mg/day.  So I have a new schedule I'm trying.  I posted about it on my blog here.

---

Right before surgery, during the nutrition class, my bariatric center gave new patients an hour-by-hour schedule for meals and drinking water.  I've adapted that schedule to fit my own daily timeline.  Even now, a year out from surgery, I still use this schedule to keep me on track with my meals, drinking enough water and getting in all my vitamins.  I now have just a single schedule that I use for everything.  Vitamins are absorbed best when taken with food, so I try to coordinate my supplements with my meals.

I've recently added Vitamin A (because my labs shows I was near the bottom of the normal range) and Iron/Zinc/Copper (because my labs are trending low) .... so I'm still playing around with where to insert those additional supplements. But for now, here's my daily schedule.

7:00 a.m. --- Breakfast #1 -- Calcium +D
8:30 a.m. --- Water
10:00 a.m. - Breakfast #2 -- Multi-Vitamin, Vit A, B-50, Fish oil, Colace
11:00 a.m. --Water
1:00 p.m. --- Lunch -- Calcium +D
2:30 p.m. --- Water
4:30 p.m. --- Snack -- Calcium +D
5:00 p.m. --- Water
7:30 p.m. --- Dinner -- Calcium +D
8:30 p.m. --- Water
11:00 p.m. -- Bedtime (no food) -- Multi-Vit, B-50, Fish oil, Colace, Iron/Zinc/Copper, Vit C, B-12 (2x/week)

There are some things on my schedule that are programmed into my cell phone because I tend to forget. Breakfast #2, 11am Water, 2:30 Water, 8pm Water ... those are all things I need to be reminded about so the alarms help me stay on track.  

Yes, I do eat 2 breakfasts each day.  #1 is usually on my commute to work and is either a protein shake or protein bar or oatmeal while I'm driving.  Then #2 is something smallish and eaten at my desk at work.  

There's a long stretch between the afternoon snack and dinner (7:30 pm is my dream dinner time, often it's an hour later than that).  Sometimes I will have a second snack between the 4:30 snack and dinner if I have something going on after work (which is most days) and I won't be getting home until late.  

Because I eat all my meals and snacks on the road or at work, I try really hard to eat dinner at home every evening.  Sometimes I meet friends for dinner or can't make it home early enough to cook, but about 80% of the time I eat at home because it's so important to me.  Before surgery it ws pretty common for me to hit the drive-thru and just eat on the run ... but now I would rather wait and eat very late just so I can have a home-cooked dinner. 

As I type this my cell phone alarm is going off to remind me to get a glass of water for my last 20 ounces for the evening.  So I'm off to obey the alarm.  :-)

Pam

I was asked to share my story of weight loss and exercise in the next edition of our employee newsletter.  Thought I'd share the final version of the article that will be published early next month.

--------------------

Journey to a Healthier Me

 

On November 13, 2007 I had Rouex-n-Y gastric bypass surgery.  This is the story of my journey to health. 

 

With a diagnosis of Polycystic Ovarian Syndrome (PCOS) which created insulin resistance and a hormonal imbalance, my body simply would not allow me to lose the weight I tried so hard to lose.  After years of failed dieting, exercise that made little difference and the advice of my ill-informed doctor to “just try harder,” I was at the end of my rope.  I consulted with a bariatric surgeon and realized I needed medical intervention and that there was a real option for me to get healthy. I made the agonizing decision to undergo gastric bypass surgery. The approval process took nearly two years which gave me plenty of time to be 110% sure it was the right option for me. 

 

After a quick recovery from surgery the real work began.  Imagine suddenly having the stomach of a newborn infant and needing to learn how to drink, chew and swallow food as if you were a baby.  Calling it a lesson in humility and experimentation is an understatement. 

 

The Rouex-n-Y (RNY) Gastric Bypass Surgery is a complex rearrangement of my digestive system.  My stomach was remade into a pouch that can hold about 6-8 ounces of food – compared to a normal stomach that can hold up to 16 cups of food.  A portion of my small intestine was bypassed so I no longer absorb all the calories I eat.  Of course, this also means that I no longer absorb all the vitamins and minerals contained in food, so I am on a strict regimen of vitamins and supplements.  The restriction of a smaller stomach and the malabsorption of a bypassed intestine along with following a strict diet and exercise program is what cause the weight loss after RNY. 

 

Within 6 weeks after surgery I was off all medications for high blood pressure, asthma and allergies.  I was finally able to sleep through the night, my chronic back pain vanished and the symptoms of my PCOS were slowing going away too.

 

Three months after my surgery I hesitantly signed up for the 20-week Crim Fitness Foundation Training Program which included completing the 10-mile Crim race in Flint and the 13.1 mile Brooksie Way Half-Marathon race held in October.  I signed up with a huge doubt hanging over my head.  “How can a morbidly obese person ever hope to finish a half marathon?”  But even with the doubts, I just put one foot in front of the other and transformed myself into Walker Girl. 

 

I was walking an average of 40 miles every month and slowly the hesitation about my ability to walk a half marathon grew into a confidence that the finish line was squarely within my realm of reality.  And yes, I crossed the finish line at Meadow Brook Hall along with members of my training group.  We celebrated after the race with steaks at Applebee’s in Rochester. 

 

I’ve recently joined the Powerhouse Gym in Waterford and am starting a new phase of my workouts with weight training and yoga.  Walker Girl will be back again in the spring when the snow melts. 

 

To me this journey has always been about more than just losing weight.  Being skinny was never the goal.  Being healthy and having the opportunity to live a longer, happier life has been my main focus.  I have set many other “life goals” that have nothing to do with the number on a scale or how many miles I can walk or what size jeans I can fit into.

 

Shortly after my surgery I attended a 10-week class for weight loss surgery patients where we each developed a Comprehensive Holistic Wellness Plan.  I set goals that focused not only on my physical health, but also my emotional, spiritual, financial, intellectual and vocational health and the health of my relationships and overall character.  Having a written plan for all areas of my life has helped me stay focused on what is really important to me and what I want to achieve.

 

A great benefit of having weight loss surgery that I didn’t anticipate is the friendships I have developed along the way.  I attend three different support group meetings each month where members of the weight loss surgery community gather to help each other through the struggles and celebrate the triumphs of the journey.   In one of the groups the members asked me to be their new leader, so now I’m able to help new surgery patients find their way and encourage the old timers to stay on track.  The bonds of friendship are strong in the community and I’m a better person for having these people in my life.

 

One of the tools that has helped me stay on track and remain accountable is writing.  I started an online blog about my weight loss journey on the day I decided to have surgery.  Over the last two years I’ve written about the good days and the bad days, the struggles and the victories, the detailed nutritional research I dig up, advice and guidance for those coming behind me, healthy recipes, my exercise challenges, my life goals and the triumphs I’ve experienced along the way.  You can visit Journey to a Healthier Me at www.pamtremble.blogspot.com.

 

So here I am a year after my surgery, and I’ve lost 110 pounds so far.  I still have a little ways to go before I hit my goal weight, but when I look at all the other goals I have achieved I know that I am already a success.

 

If you are interested in learning about weight loss surgery, I would be happy to answer any questions or help in any way I can.  If you have had surgery and would like to drop me a note, I’d love to hear your story too.

 
November 13th was my one year anniversary since surgery. I spent the day enjoying the sunshine of Florida and remembering how far I've come in such a short period of time. 

The picture here was taken the day before I left for vacation by my new friend Kimberly ofCoombs Photography. Can you believe the transformation I've gone through over the past year. Remember the photo collage that shows my face pictures for the first 6 months of my journey (I'll have to update this with the full 12 months worth of pictures). I'm a new person!

But it's more than just the physical transformation that I see in pictures. I've seen so many other changes in my life too. I'm more confident. I'm happier. I'm more outgoing. I'm more satisfied with myself and the way I come across to other people. I've learned to be more selfish and realize how imporant it is to take care of myself rather than scurrying around doing stuff for everyone else out of guilt or so-called obligation. I'm healthier and more active.  
Heck! I can walk 13 miles and still breath - who would have thought? I'm smarter about my body, nutrition and how to live a healthy life. I pay closer attention to what my body and mind is telling me and how I can "feed" myself with something other than food. I am seeking out new friends and experiences and trying to make the changes in my life that I want to see.

There are WoW moments still happening in my life. Just the other day as I was searching through my jewelry box for some earrings, I came across my high school class ring and tried it on. It fit! I just stood there in my bedroom looking down at my hand and grinning like a fool. Silly, small things like that can just make your day, can't they?

So my official weight loss is a total of 107 pounds. I'm currently stuck at about 192 pounds and the scale keeps teasing me ... up and down with the same 2 or 3 pounds. But I know the scale will move again soon. My tight-ish clothes are fitting looser these days and I'm in the continual mode of packing more things away for charity that don't fit anymore.

So what about my goal weight? I'm getting close! It's exciting to be so close, actually. 

My original weight goal is "160-ish" -- which means that as soon as I hit 169, I'll be at goal. That's a mere 23 pounds away. My surgeon's goal of 135 still seems pretty unrealistic to me, but even that is only 58 pounds away. I doubt I'll go all the way down to 135, but once I hit that 169-mark I'll most likely come up with a new goal weight. My initial inclination is leaning toward the 150-mark. But we'll see...

I have good days and bad days when it comes to eating and exercise. Vacation was not a free-for-all, but I certainly didn't follow my eating plan religiously. Now that I'm back to real life and on a routine, I'm doing much better. I'm seriously slacking in the exercise department and need a swift kick in the butt to get back on track. I want to join a gym and do weight training and maybe take a yoga class. There are a myriad of excuses and reasons that I haven't done it yet... but I need to stop procrastinating and get it done.

I do fairly well with my vitamins and supplements most days. Weekends are still tough for me and following a strict routine on Saturday and Sunday is difficult. I need to buckle down and figure out a way to make weekends work better for me. I also need to figure out how to get that 4th dose of calcium in every single day instead of only about 50% of the time. There's definitely room for improvement, but overall I do pretty well.

There are still some areas of my "health" that I want to work on. Remember that Comprehensive Holistic Wellness Plan? I've got some things to work through with those goals. I'd like to sit down with my journal and figure out which goals I've met and which ones still need work. Going back to college in January is a major goal I plan to hit, but I need to get my act together or I'll miss the registration deadline again. Updates on that to come...

I'm truly amazing and feel so blessed to have to many new friends and avid supporters in the bariatric community. I checked my blog statistics earlier today and I was amazed at the traffic this site gets. So many people read what I say --- I assume that ya'll are reading anyway. LOL! The support and encouragement I get from my friend on http://www.obesityhelp.com/ and from the support groups I attend is truly inspiring to me. How does anyone make this WLS journey without such a strong and faithful circle of friends? I am blessed.

Thank you all for being here to cheer me on. You mean the world to me!
~Pam