Denise W.

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It has been so long since I have posted!! Since becoming pregnant, I feel like I am such a different page as everyone else.
In a nutshell, I am almost 9 months along, with 25 days to go. I have gained about 12-14 lbs for the pregnancy, and have managed to avoid going on insulin. Blood pressure actually dropped a bit about 2 months ago and hasn't gone up at all. Compared to my first pregnancy where my blood pressure required an early induction, and the diabetes required 10 shots of insulin a day, I am doing really well. The only issue that we are monitoring right now is that my amniotic fluid is low. I have my next ultrasound on Wednesday to see how it is going.

After the baby, I know I will be around a lot more as I work on getting back on track. My pre-pregnancy rules are three meals a day, no snacks, mostly protein. Due to pregnancy, that has all gone out of the window, and I am probably able to eat much more now than I should be if I hadn't gotten pregnant.

Vitamin levels seem ok, we check them frequently. Currently taking 2 prenatals a day, an iron supplement, 3 DHA, b12, folate, and of course, lots of calcium.

Feel free to message me if anyone is looking for pregnancy information. Hope everyone is doing well!

Maybe I can help you start over. YOU have to do it. One thing is to start
recognizing the physical portion of the disease. I could've told you that
you don't care about bfast, don't start eating til mid day and have trouble
slamming on the brakes at night. That is how our disease works.

We start out ok. Then as life starts smacking us down, the serotonin level
goes down. We eat food (carb) to raise serotonin level ( and label it
emotional eating, because it makes us feel better. DUH, it is a chemical
feeling). OUR serotonin level doesn't just go up to a nice comfy level, it
shoots thru the roof, then a lil later, KA THUD, back in the basement.
Repeat cycle. Hence, the more carb we get, the more we want (need) to try to
level out the serotonin, which cannot be leveled for us because it's broken.
Of course, this is taking the blood sugar on a wild ride as well. You can
see the cycle.

SOOOOOOO, you do protein drink (30g each, no added milk, fruit, juice) , small non-carb meal (well, complex carb on
the side is ok, once you get out of the binge cycle) 2-3 hrs later, protein
drink, "sensible meal". Protein drink (esp mid-day, about 2-3pm in a normal
person day) and protein snack. Yet another protein drink
before dinner to lower volume or prevent grazing while prep. About 2 hrs
after dinner, when the S level starts to plummet, stick in a protein shake,
followed by a protein snack. Maybe like meat & cheese with grain cracker or
bread. You'd have to experiment & see if it triggers you. If the craving is really bad, you can do another protein.

All meals are over in 15 min. You take your food on a plate to the eating
place. You can eat anything but milk or sugar & white carbs (right now),
preferably normal fat, not fat free. You can have a big fluffy salad, if
you want. With breaded chicken, with normal dressing--I don't care. What I
don't want is white bread or saltines with it. See?

And of course, start sucking water 30 min after eating and get as much as
possible.

Does it sound do-able?

Vites go (roughly) like so:
iron + C with the first non-dairy, non-caffeine protein or meal (no eggs or whole grains)

1 multi
2 calc (if mine)
1 A-25
1 D-5
1 E

with next protein drink or snack

1 multi
2 calc
1 A-25
1 D-5
1 zinc
1 E

with next protein drink or food
another pair of calcium (or use UpCal D in all shakes EXCEPT the one taken near iron)

B12 any time

If you take HSN or B-complex, it can go with either multi-grouping.

And another 2-3 calcium before bed

And the usual set of "rules",
64+ oz of water, as in water
no drinking with meals
distinct "meals", not grazing
limit sugars to 6 g per MEAL
try to avoid "white" things, like bread, potatoes, rice, pasta

Good snacks:
cheese
beef sticks
jerkies
tuna
chicken (don't care about skin)
smoked salmon
other meats or fish
some protein bars

Issue yourself a portion in a Ziploc bag to take to work or on the go. Control your portion in advance, before you are hungry

It's all about rhythm. Creating a system that keeps you in a "I'm doing the
right thing almost all the time" frame of thinking. That alone helps keep
the serotonin level closer to smooth, esp for US, with the 100# of guilt we
carry at any weight. Ditch the guilt to keep the S level from dropping. If
you fall off the wagon, then by the next meal, you get back on. One slap to
correct yourself and stand back up, do the next one right. Keep the
serotonin level smooth, not whacking all up & down like a yo-yo. You can
ALWAYS insert another protein in the trouble spots until you get a grip on
them.

It's really hard getting used to eating more after being able to eat so little in the beginning - like you're doing something wrong because you get more in then a couple ounces.

Here are some pictures of a one cup measuring cup versus a 1 ounce (2 TBS) meausring cup. As you know volume wise - there is going to be an obvious size difference.



Well - when looking at a measuring cup it doesn't really tell the whole story of what's happening inside of our new anatomy. Here is a visual of 8 ounces of white meat chicken breast versus 1 ounce of white meat chicken breast. 





In the very beginning your pouch is made on average 2 ounces in size. That is why you can only eat small amounts of food at one sitting. As time goes by a natural relaxation happens and makes us capable of eating more volume, usually between 6-10 ounces. Now understanding how what you eat impacts how your feel is vital to know how your man made pouch/stoma works. 

If you've had your RNY for any length of time you've started to understand your head hunger versus true physical hunger and how what you eat impacts how you feel. Well, as we get further along, being able to consume more at one sitting can be terrifying. I know it was for me. Finishing my first South Beach frozen meal almost gave me a panic attack. Well, what people told me was that things are going to be chewed down to a nice compact tightness, thus making me able to consume more - so it's important to make sure to have protein first to not consume too much of the really soft (pass through the stoma easily) foods.

That brings me to simple carbs. Simple carbs - crackers, chips, cookies, etc - are going to chew down to mush. Who here hasn't ever eaten a donut? Do you swallow chunks of donut after chewing it or is it pretty liquified before you swallow? There ya go. It's a matter of consistency. Here is a picture of 8 ounces of chicken versus 8 ounces of bread crumbs (which I figure is good enough to show the texture of simple carbs after consumption).

 

Notice how compact the chicken breast is on the plate. Notice how the breadcrumbs are spread out and sandlike. If you've ever seen breadcrumbs they are lightweight and airy. Although it looks like more volume on the plate it's actually less dense then the chicken - so 8 ounces of chicken breast versus 8 ounces of simple carb CAN NOT be considered the same on a satiety scale becasue it's all about texture and density. To get the same fullness from 8 ounces of chicken breast you would more then likely have to double the amount of simple carb - and double the calories, carbs, fats, etc. AND the chicken will stay in the pouch longer then a simple carb would because it has to be broken down to get through the stoma. Slider foods don't require as much work and can exit the pouch quicker then something dense making you hungrier sooner. So eating right is more then just avoiding simple carbs because they're "bad" for a diet. It's because they offer almost no satisfaction for anything but your tongue. And I'm all about fullness now that I want the most bang for my fullness buck.

So taking a look at the above pictures I wish I could see everyone who thinks they eat SOOOO much at one sitting raise their hands if they thought they could finish all 8 ounces of dry white meat chicken breast at a couple months out.  I think people think they're eating a lot but in reality they're not. At 15 months I'm able to eat the 8 ounces of chicken salad and usually a small salad or piece of fruit if I'm still hungry. Keep in mind that salad will chew down to nothing (if you don't believe me go throw a salad in a blender and whir it up). But compared to a Big Mac, large fry, 2 apple pies, and couple refills of Diet Coke - and still being hungry -  I am nowhere near my pre-op volume and likely never will be again. 

So thanks for letting me share this. I don't measure my food - never have. I just eyeball it. I really focus on the cardinal rules and let them guide my actions. But I know without a doubt if I sat down with a bag of Ruffles and french onion dip I will be consuming WAY MORE to get the same fullness I would from the chicken salad in the fridge. It's about choices and choosing to get the most satisfying volume for your caloric needs. You very possibly can eat too much - but not if you're eating the best options available! And this is something to remember for life - not just the first couple years.

Hope this helps people who think they eat too much!

Who Should do the 3 Day LPT?
1. If you have gotten off track (or just plain de-railed in your weight loss journey!), then the 3 day LPT is for you.
2. If you find that you are addicted to carbs, are eating junk food, are snacking and grazing, then the 3 day LPT is for you.
3. If you need to jump start your weight loss once again, then the 3 day LPT is for you.
4. For those who have no weight to lose and are not addicted to carbs, this is probably not necessary. Instead, you may want to check out Susan Maria’s Basic Bariatric Eating Plan to stay on track.

Before You Begin:
1. How many days will I do this program? Normally it’s done for 3 days. You may choose to continue for up to 5 days. Anything over this might be excessive.
2. Will I drink ONLY protein shakes or will I add a light supper? The choice is entirely up to you. If you are able to get rid of carb cravings by cutting back to eating a light supper (high protein), then you may want to stick with drinking shakes all day but a light supper at night. However, if you are overly addicted to carbs and need a more aggressive approach, the full liquid shake only approach may be the best for you.

Preparation for the Program:
1. Make sure you have plenty of protein shakes available – there’s nothing worse than to be in the middle of a program and run out of products! Stock up on high protein, low carb, low sugar and low calorie protein powders or ready to drinks. Bariatric Eating sells a wide variety of great tasting protein products.
2. Decarb your pantry – get rid of foods that you should not have (crackers, chips, cookies, high carb sugar free products) as these will be a stumbling block to you. Also, the purpose of the LPT is to get back on track and away from those items that cause you to fail. You don’t want to sabotage your own success by having these tempting products in the house. They do have a tendency to call your name at the most inopportune (usually your weakest) times!

How It's Done:
1. Drink a protein shake whenever you feel hunger (whether it be real body hunger or head hunger) – one person said they drink a shake every two hours. I figured that if a person would start at 6 am, drink a shake every two hours, this would allow them to drink up to 8 pm! (Sounds great)
2. Consume a minimum of 800 calories for the day
3. You may drink fluids after consuming protein shakes. The "30 minute wait period" before drinking after food does not apply in this case.

Keep in Mind:
1. Get off sugar products
2. Some people include a few additives in their shakes to help spice them up such as a little peanut butter, or sugar free Davinci syrups, or a little bit of fruit (although fruits do have carbs, so it depends on what your preference is). If the additive causes you to crave more, DON'T add it.
3. You may want to include thin soups with light vegetables, yogurts or custards as they are considered full liquids.
4. It has been suggested that if you are exercising, drink a protein shake right before your workout.

Transitioning Back to Normal:
1. If you are doing full liquids for 3 days, on the fourth day you will want to add a light supper. When comfortable, add a light lunch until you are back to your 3 meals a day. The LPT will help you to be more in tune with how food makes you feel. In other words, you will know when you are full on a meal. Stop there, do not overeat. Listen to your body and pouch when it says its full.
2. If you did liquid all day and a light supper at night during the 3 days, then just add your light lunch back into the routine.

I can anything I want, just never all that I want.

Some people want to say I'm "a success."  I dunno, maybe.  All I know is that so far today is OK; tomorrow might be different. 

a thought from Animal House: "Fat, drunk and stupid is no way to go thru life, son."

Exercise. It's not about hating it or loving it, it's just about doing it. Period.

Cool website

http://www.cockeyed.com/photos/bodies/heightweight.shtml

Hola lighties!!!!

Today is my 3 month anniversary, having had RNY surgery on January 7th. I know that I personally love to see the updates that everyone posts, because of COURSE I use them to chart my own progress. Yes, we aren't supposed to compare, but of course we all do.
Please keep your upates coming AND AND AND....if you are around 3 months, let me know how you are doing!!! We need to keep rootin' for each other!! *hugs*

Food
I am not tracking my calories, but I stick with 3 meals a day, no snacking. I measure/eyeball my portions to stay in the 1/2 - 2/3 cup range.
Typical daily menu is:
B - 1/2 c FF cottage cheese with 1T sf preserves, 1 scrambled egg/egg beaters with salsa
L - 1/2c FF turkey chili with cheddar cheese and FF sour cream
D - 3oz seared ahi tuna, couple bites of veggies

If something doesn't go down well, or comes back up, my next meal is usually a protein shake, just give my pouch a few hours to rest and find its happy place again. We eat out a TON, so when I get my plate, the first thing I do is portion off what I plan to take home and box it up, so that I don't continue mindlessly eating. This is doubly important since I still don't feel hunger/fullness.

Liquids
Water is getting easier and easier for me. I am well over 100 ounces a day now. I don't touch carbonation, juices, sodas, etc. I have 1 Diet Lipton Citrus Green Day a day to which I add all my powdered supplements.
I also use fluid loading before EVERY meal. I firmly believe this is one of the reasons I have been so successful so far. (This helps you eat less, and stay full for much much longer-details on my blog if you want it). I stop drinking about 5-10 minutes before I eat, and try not to drink for 90 minutes afterwards.

Supplements
My surgeon says my first set of labs will be at 6 months, so I feel like I am trying to hit a moving target while blindfolded. However, here is what I try to do everyday:
Calcium - 2650mg per day - 3 packets UpCal D, 1 T Life time liquid calc citrate, 1 citracal creamy bite (bought 12 boxes off ebay!)
Multi Vitamin - 1 baratric advantage multi with added A, D, K, 1 bariatric advantage B Complex, 2 centrum chewable multi
B-12 - 1 sublingual every day
Biotin - 5000 mg
Benefiber - 8 teaspoons a day
Colase stool softener - 4 per day
Miralax - 1 serving per day

I add the Benefiber, Miralax, and Biotin (open the caplet, dump the powder) to my Lipton Green Tea, this is my 'daily cocktail'.  I usually add the UpCal D to my water, or just pour it right on my tongue. 
 
Exercise
Definitely my weak area.
I have signed up for a couple races and a half marathon, just walked a 5k last month. But other than weekly cheer practice (which *is* intense), and our performances, I don't do much. This is an area I need to work on in a major way. I have my dumbells and strength bands in the living room so I can do reps throughout the day. I also downloaded a new running program to my ipod, now I just need to find the time. With a full time job (50 hrs a week), a 15 month old, husband, and cheerleading, it is really hard to get this in. However, as the fat melts away, the muscles I do have are becoming very apparent!!! When I was near this weight a couple years ago, I got there through massive exercise and weight lifting, and was down to a size 8. I think the lack of exercise is best reflected in my clothing size, since I am in a 12, while being 5 lbs less than my previous lowest.

Overall
I feel pretty well overall! I am in a size 12 now and have had to get into my box of skinny clothes that has been in the garage for the last two years. It is awesome getting back into my expensive jeans, though my size 6 Lucky's are still the goal :)
I am addicted to self tanners, right now using Nivea firming tanning lotion 2-3 times a week. You always look a couple lbs lighter when tan! My energy level when I do exercise is much better, I feel stronger and more capable.
 
And most important, I am off all meds. I had been on insulin injections and pills for 10 years, with sugars in the 400 and 500's. As of three weeks post op, I no longer take cholesteral, blood pressure, or diabetes medications. Lately I have been overly tired and a bit dizzy when I stand up, and I think it is perhaps an Iron issue. I just orderd an Iron supplement from VitaLady, and will pick something up at Walgreens today to hold me until it gets here.

Any type of Movement in the restroom is a cause for celebration, hence all the supplements towards that cause. Even with all that, I am averaging 1-2 times per week. I have had a couple upper GI's due to vomiting, but nothing was ever found. I am still struggling with taking small enough bites and chewing, which may have contributed to it. I think my pouch is a touch more sensitive than my surgeon expected, but again, I just try and eat slowly. And if I do anger the mighty pouch, I keep my next meal very soft and palatable.

I don't deprive myself of anything. This is not a diet, it is a lifestyle. So, I will definitely take a bite from my husband's dinner if I want to try it. But that one bite is sufficient to where I get to taste it, and I don't feel deprived and bitter.

I have not dumped, I try not to do anything that will cause my dump. I stay under 15grams of sugar at a meal. I have had some of the typical culprits - BBQ sauce, a bite of chocolate, etc - but in moderation with an eye towards the goals. Sugar alcohols make me nauseous. I tried a couple of the sugar free Oreos and felt SOOO horrid. Same with sugar free chocolate. I think this is malitol?? Excessive fat makes me nauseous too. I ate fresh crab, and the clarified butter made me very nauseous as well.

Short Term Goals
-Regular exercise program
-Stretching every day
-Measure/weigh my portions more consistently

Long Term Goals
I spend a lot of time reading the WLS Graduates board to see what people are struggling with so that I can try and incorporate the good habits now to avoid those issues. So of course my number one long term goal is to lose all my excess weight and keep it off for life. In order to do this, my long term goals/habits include:
-avoiding sugar, pasta, breads, soda, bad carbs
-measure my portions, and eat by those measurements, not try to eat until I am full
-don't drink with meals, continue fluid loading
-make exercise a daily part of life

I am sorry that this is so long! I have an appointment tomorrow with my surgeon, and writing this has helped me figure out what I need to talk to him about, and I now have a good record of what I am doing. I imagine that 1 year from now, this post will be very different.

Results
And for those of you that actually read all this, here are my results!


Inches Progress
Surgery day (bust/waist/hip) - 47/44.7/47
6 weeks out (bust/waist/hip) - 44/41.5/43
3 months out(bust/waist/hip) - 38.5/35.5/38.5 (RRIP b**bies)

Weight Progress
1st consult (9/2007) - 260lbs
Surgery day (1/7/2008) - 234 lbs
1 month out (2/8/08) - 207 lbs
2 months out (3/8/08) - 193 lbs
3 months out (4/7/08) - 180 lbs

80 lbs lost since first consult, and 54 lbs since surgery.

Before/After
  

Before/After

Before/After

(we are moving next week, so this was my farewell night out. Talk about a Buffet 'o Boys!)

 

Feedback

Postive? Negative? What else do I need to be doing? Any other great tips I should know? Something I have forgotten? Bring on the noodle lashings in the areas I deserve it. We are in the this together and for each other, so I welcome the feedback. I am still learning!

Thank you for taking the time to wade through all this. Again, it was personally really beneficial to write all this out!! So thank you!!!!

1st Mistake:  Not Taking Vitamins, Supplements, or Minerals

 Every WLS patient has specific nutritional needs depending on the type of surgery you have had. Not only is it a good idea to ask your surgeon for guidelines, but also consult with an experienced WLS nutritionist. Understand there is not a standard practice that all surgeons and nutritionists follow in guiding WLS patients. So, it is important to do your own research, get your lab tests done regularly, and learn how to read the results.  Some conditions and symptoms that can occur when you are deficient in vitamins, supplements, or minerals include:

Osteoporosis; pernicious anemia; muscle spasms; high blood pressure; burning tongue; fatigue; loss of appetite; weakness; constipation and diarrhea; numbness and tingling in the hands and feet; being tired, lethargic, or dizzy; forgetfulness, and lowered immune functioning.

Keep in mind, too, that some conditions caused by not taking your vitamins, supplements, or minerals are irreversible.

2nd Mistake:  Assuming You Have Been Cured of Your Obesity

A "pink cloud" or honeymoon experience is common following WLS. When you are feeling better than you have in years, and the weight is coming off easily, it's hard to imagine you will ever struggle again. But unfortunately, it is very common for WLS patients to not lose to their goal weight or to regain some of their weight back.

A small weight regain may be normal, but huge gains usually can be avoided with support, education, effort, and careful attention to living a healthy WLS lifestyle. For most WLSers, if you don't change what you've always done, you're going to keep getting what you've always gotten -- even after weight loss surgery.

3rd Mistake:  Drinking with Meals

Yes, it's hard for some people to avoid drinking with meals, but the tool of not drinking with meals is a critical key to long-term success. If you drink while you eat, your food washes out of your stomach much more quickly, you can eat more, you get hungry sooner, and you are at more risk for snacking. Being too hungry is much more likely to lead to poor food choices and/or overeating.

4th Mistake:  Not Eating Right

Of course everyone should eat right, but in this society eating right is a challenge. You have to make it as easy on yourself as possible. Eat all your meals--don't skip. Don't keep unhealthy food in sight where it will call to you all the time. Try to feed yourself at regular intervals so that you aren't as tempted to make a poor choice.  And consider having a couple of absolutes: for example, avoid fried foods completely, avoid sugary foods, always use low-fat options, or only eat in a restaurant once a week. Choose your "absolutes" based on your trigger foods and your self knowledge about what foods and/or situations are problematic for you.

5th Mistake:  Not Drinking Enough Water

Most WLS patients are at risk for dehydration. Drinking a minimum of 64 oz. of water per day will help you avoid this risk. Adequate water intake will also help you flush out your system as you lose weight and avoid kidney stones. Drinking enough water helps with your weight loss, too.

6th Mistake:  Grazing

Many people who have had WLS regret that they ever started grazing, which is nibbling small amounts here and there over the course of the day. It's one thing to eat the three to five small meals you and your doctor agree you need. It's something else altogether when you start to graze, eating any number of unplanned snacks. Grazing can easily make your weight creep up. Eating enough at meal time, and eating planned snacks when necessary, will help you resist grazing.   Make a plan for what you will do when you crave food, but are not truly hungry. For example, take up a hobby to keep your hands busy or call on someone in your support group for encouragement.

 7th Mistake:  Not Exercising Regularly

Exercise is one of the best weapons a WLS patient has to fight weight regain. Not only does exercise boost your spirits, it is a great way to keep your metabolism running strong. When you exercise, you build muscle. The more muscle you have, the more calories your body will burn, even at rest!

 8th Mistake:  Eating the Wrong Carbs (or Eating Too Much)

 Let's face it, refined carbohydrates are addictive. If you eat refined carbohydrates they will make you crave more refined carbohydrates. There are plenty of complex carbohydrates to choose from, which have beneficial vitamins. For example, if you can handle pastas, try whole grain Kamut pasta--in moderation, of course. (Kamut pasta doesn't have the flavor some people find unpleasant in the whole wheat pastas.) Try using your complex carbohydrates as "condiments," rather than as the center point of your meal. Try sprinkling a tablespoon of brown rice on your stir-fried meat and veggies.

9th Mistake:  Going Back to Drinking Soda

Drinking soda is controversial in WLS circles. Some people claim soda stretches your stomach or pouch. What we know it does is keep you from getting the hydration your body requires after WLS--because when you're drinking soda, you're not drinking water! In addition, diet soda has been connected to weight gain in the general population. The best thing you can do is find other, healthier drinks to fall in love with. They are out there.

 10th Mistake:  Drinking Alcohol

If you drank alcohol before surgery, you are likely to want to resume drinking alcohol following surgery. Most surgeons recommend waiting one year after surgery. And it is in your best interest to understand the consequences of drinking alcohol before you do it.

Alcohol is connected with weight regain, because alcohol has 7 calories per gram, while protein and vegetables have 4 calories per gram. Also, some people develop an addiction to alcohol after WLS, so be very cautious. Depending on your type of WLS, you may get drunker, quicker after surgery, which can cause health problems and put you in dangerous situations.

If you think you have a drinking problem, get help right away. Putting off stopping drinking doesn't make it any easier, and could make you a lot sicker.

The following is a list of things I think are real MUSTS for RNY post-ops who want to:
a) lose all the weight they want/need to lose
b) maintain that loss FOREVER.

Argue with me if you want to OR add to the list if you want to.  I'm just compiling information 
and putting it out there because I agree with it.  

Tips for Successful Weight LOSS and MAINTAINANCE for post-op RNYers  1. Attend all your follow-up appointments with your surgeon. 
             Your relationship with your RNY surgeon should be a life-long relationship.  Follow-up is not just for lab work-ups and/or to pad your surgeon’s pocket.
              Research has shown that patients who continue long-term follow-up care 
with their surgeon maintain substantially more of their weight loss than those that do 
not.  Differences in maintained weight loss become evident around 3 – 4 years. 
See below: 

	Post-ops Attending Every Scheduled Post-op Appointment (even 3 - 4 years out)	Post-ops Attending Only the 1st Year's Post-op Appointments Before Being Lost to Follow-up	Post-ops Who Were Lost to Follow-up During 1st Post-op Year
Excess Weight Loss at 1 Year Post-op	70%	65%	not stated
Excess Weight Loss at 3-4 Years Post-op	74%	61%	56%

Source:             http://www.soard.org/article/S1550-7289(07)00570-9/abstract 

2. Attend support group meetings regularly. 
            Regular attendance to monthly support group meetings produces MULTIPLE benefits: emotional support, practical advice/tips, continuing education and fellowship.  
But it also produces physical benefits as well.  
             Research has shown that regular attendance (>5 per year) to support group meetings has been linked to increased weight loss after RNY.  The difference in weight lost between post-ops attending or not attending support group meetings is seen after 
the initial 6 months post-op.  In addition, research has shown that an increase in the frequency of support group attendance has been shown to increase weight loss.  
See below:

Post-op Time:	Excess Weight Loss for RNYers attending support group meetings regularly	Excess Weight Loss for RNYers NOT attending support group meetings regularly
2 weeks	10.5%	11.3%
6 weeks	21.4%	21.8%
3 months	30.9%	31.8%
6 months	45.4%	41.3%
9 months	53.6%	45.2%
12 months	55.5%	47.1%

Source:             http://www.soard.org/article/S1550-7289(07)00087-1/abstract 
                        http://www.soard.org/medline/record/MDLN.9819086 

3.  Exercise regularly. 
            Regular exercise has many mental, emotional and physical benefits.  Not surprisingly, it is imperative to incorporate exercise into your life to increase your 
chances of getting to goal and staying there.  
             In fact, research has shown that 75% of patients who incorporate exercise 
into their life GET to their goal and STAY THERE.  Research also shows that the 
majority of patients who regain are consuming too high-calorie foods and beverages 
and don’t exercise enough.  
Source:             OH Magazine March-April 2008 
                        http://www.mayoclinic.com/health/gastric-bypass-diet/WT00007 

4.  Measure your meals (by volume).  Do not just eat until you are “full”.  
             It is unreasonable to expect an individual who has overeaten, in most cases, 
for years to:
1) identify a proper portion size for a “normal” person, much less a new post-op portion size 
2) know what “full” feels like, especially as a new post-op. 
            Research has shown that post-ops who measure their meals have a much 
higher success rate than those that eat until “full”.  If you are eating until you feel "full", 
you have eaten enough food to fill your pouch to capacity.  The problem with this is 
that, over time, it will take more and more to give you that "full" feeling.  This will lead 
to regain long-term and inadequate short-term weight loss in some cases. 
Source:             OH Magazine January-February 2008

5.  Do not eat and drink at the same time.  
            There is a reason that - despite VASTLY different post-op directions given to 
RNY patients regarding diet allowances, etc - 99.9% of surgeons agree that post-ops should not eat and drink at the same time.  Drinking with your meals can cause a 
wide range of issues, some directly affecting your health and weight loss chances.
            Drinking with your meals can:
a) lead to dumping, even in individuals not prone to dumping since the food is washed 
out of the pouch sooner than it should be
b) lead to malnutrition since a pouch that contains liquid in addition to solids can hold LESS solids (therefore less nutrient rich foods)
c) lead to inadequate satisfaction following a meal (since the food is almost immediately "washed out", leaving the pouch empty of protein rich foods that are most satisfying
d) stretch the stoma (since food needs time to slowly leave the pouch - it does not 
need to be pushed through the stoma by ingesting liquids too soon after meal).

6. Do not drink carbonated beverages. 

Pouch Rules

INTRODUCTION:
A common misunderstanding of gastric bypass surgery is that the pouch causes weight loss because it is so small, the patient eats less. Although that is true for the first six months, that is not how it works. Some doctors have assumed that poor weight loss in some patients is because they aren't really trying to lose weight. The truth is it may be because they haven't learned how to get the "satisfied" feeling of being full to last long enough.


HYPOTHESIS OF POUCH FUNCTION:
We have four educated guesses as to how the pouch works:

1) Weight loss occurs by actually "slightly stretching" the pouch with food at each meal or;
2) Weight loss occurs by keeping the pouch tiny through never ever overstuffing or;
3) Weight loss occurs until the pouch gets worn out and regular eating begins or;
4) Weight loss occurs with education on the use of the pouch.

PUBLISHED DATA:
How does the pouch make you feel full?

The nerves tell the brain the pouch is distended and that cuts off hunger with a feeling of fullness.

What is the fate of the pouch? Does it enlarge? If it does, is it because the operation was bad, or the patient is overstuffing themselves, or does the pouch actually re-grow in a healing attempt to get back to normal?

For ten years, I had patients eat until full with cottage cheese every three months, and report the amount of cottage cheese they were able to eat before feeling full. This gave me an idea of the size of their pouch at three month intervals. I found there was a regular growth in the amount of intake of every single pouch. The average date the pouch stopped growing was two years. After the second year, all pouches stopped growing. Most pouches ended at 6 oz., with some as large at 9-10 ozs.

We then compared the weight loss of people with the known pouch size of each person, to see if the pouch size made a difference. In comparing the large pouches to the small pouches, THERE WAS NO DIFFERENCE IN PERCENTAGE OF WEIGHT LOSS AMONG THE PATIENTS. This important fact essentially shows that it is NOT the size of the pouch but how it is used that makes weight loss maintenance possible.

OBSERVATIONAL BASED MEDICINE:
The information here is taken from surgeon's "observations" as opposed to "blind" or "double blind" studies,
but it IS based on 33 years of physician observation.

Due to lack of insurance coverage for WLS, what originally seemed like a serious lack of patients to observe, turned into an advantage as I was able to follow my patients closely. The following are what I found to effect how the pouch works:

1. Getting a sense of fullness is the basis of successful WLS.
2. Success requires that a small pouch is created with a small outlet.
3. Regular meals larger than 1 ½ cups will result in eventual weight gain.
4. Using the thick, hard to stretch part of the stomach in making the pouch is important.
5. By lightly stretching the pouch with each meal, the pouch send signals to the brain that you need no more food.
6. Maintaining that feeling of fullness requires keeping the pouch stretched for a while.
7. Almost all patients always feel full 24/7 for the first months, then that feeling disappears.
8. Incredible hunger will develop if there is no food or drink for eight hours.
9. After 1 year, heavier food makes the feeling of fullness last longer.
10. By drinking water as much as possible as fast as possible ("water loading"),
the patient will get a feeling of fullness that lasts  15-25 minutes.
11. By eating "soft foods" patients will get hungry too soon and be hungry before their next meal,
which can cause snacking, thus poor weight loss or weight gain.
12. The patients that follow "the rules of the pouch" lose their extra weight and keep it off.
13. The patients that lose too much weight can maintain their weight by doing the reverse of the "rules of the pouch."

HOW DO WE INTERPRET THESE OBSERVATIONS?

POUCH SIZE:

By following the "rules of the pouch," it doesn't matter what size the pouch ends up.
The feeling of fullness with 1 ½ cups of food can be achieved.

OUTLET SIZE:

Regardless of the outlet size, liquidity foods empty faster than solid foods. High calorie liquids will create weight gain.

EARLY PROFOUND SATIETY:

Before six months, patients much sip water constantly to get in enough water each day, which causes them to always feel full.

After six months, about 2/3 of the pouch has grown larger due to the natural healing process. At this time,
the patient can drink 1 cup of water at a time.


OPTIMUM MATURE POUCH:

The pouch works best when the outlet is not too small or too large and the pouch itself holds about 1 ½ cups at a time.

IDEAL MEAL PROCESS (rules of the pouch):

1. The patient must time meals five hours apart or the patient will get too hungry in between.
2. The patient needs to eat finely cut meat and raw or slightly cooked veggies with each meal.
3. The patient must eat the entire meal in 5-15 minutes. A 30-45 minute meal will cause failure.
4. No liquids for 1 ½ hours to 2 hours after each meal.
5. After 1 ½ to 2 hours, begin sipping water and over the next three hours slowly increase water intake.
6. 3 hours after last meal, begin drinking LOTS of water/fluids.
7. 15 minutes before the next meal, drink as much as possible as fast as possible. This is called "water loading,"
IF YOU HAVEN'T BEEN DRINKING OVER THE LAST FEW HOURS, THIS 'WATER LOADING' WILL NOT WORK.
8. You can water load at any time 2-3 hours before your next meal if you get hungry, which will cause a strong feeling of fullness.

THE MANAGEMENT OF PATIENT TEACHING AND TRAINING:

You must provide information to the patient preoperatively regarding the fact that the pouch is only a tool: a tool is something that is used to perform a task but is useless if left on a shelf unused. Practice working with a tool makes the tool more effective.

NECESSITY FOR LONG TERM FOLLOW-UP:

Trying to practice the "rules of the pouch" before six to 12 months is a waste. Learning how to delay hunger if the patient is never hungry just doesn't work. The real work of learning the "rules of the pouch" begins after healing has caused hunger to return.

PREVENTION OF VOMITING:

Vomiting should be prevented as much as possible. Right after surgery, the patient should sip out of 1 oz cups and only 1/3 of that cup at a time until the patient learns the size of his/her pouch to avoid being sick.
It is extremely difficult to learn to deal with a small pouch. For the first 6 months, the patient's mouth will literally be bigger than his/her stomach, which does not exist in any living animal on earth.
In the first six weeks the patient should slowly transfer from a liquid diet to a blenderized or soft food diet only, to reduce the chance of vomiting.
Vomiting will occur only after eating of solid foods begins. Rice, pasta, granola, etc., will swell in time and overload the pouch, which will cause vomiting. If the patient is having trouble with vomiting, he/she needs to get 1 oz cups and literally eat 1 oz of food at a time and wait a few minutes before eating another 1 oz of food. Stop when "comfortably satisfied," until the patient learns the size of his/her pouch.

SIX WEEKS:

After six weeks, the patient can move from soft foods to heavy solids. At this time, they should use three or more different types of foods at each sitting. Each bite should be no larger than the size of a pinkie fingernail bed. The patient should choose a different food with each bite to prevent the same solids from lumping together. No liquids 15 minutes before or 1 ½ hours after meals.

REASSURANCE OF ADEQUATE NUTRITION:

By taking vitamins everyday, the patient has no reason to worry about getting enough nutrition.
Focus should be on proteins and vegetables at each meal.

MEAL SKIPPING:

Regardless of lack of hunger, patient should eat three meals a day. In the beginning, one half or more of each meal should be protein, until the patient can eat at least two oz of protein at each meal.

ARTIFICIAL SWEETENERS:

In our study, we noticed some patients had intense hunger cravings which stopped when they eliminated
artificial sweeteners from their diets.

AVOIDING ABSOLUTES:

Rules are made to be broken. No biggie if the patient drinks with one meal - as long as the patient knows he/she is breaking a rule and will get hungry early. Also if the patient pigs out at a party - that's OK because before surgery, the patient would have pigged on 3000 to 5000 calories and with the pouch, the patient can only pig on 600-1000 calories max. The patient needs to just get back to the rules and not beat him/herself up.

THREE MONTHS:

At three months, the patient needs to become aware of the calories per gram of different foods to be aware of "the cost" of each gram. (cheddar cheese is 16 cal/gram; peanut butter is 24 cals/gram). As soon as hunger returns between three to six months, begin water loading procedures.

THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY:

1. Fill pouch full quickly at each meal

2. Stay full by slowing the emptying of the pouch. (Eat solids. No liquids 15 minutes before and none until 1 ½ hours after the meal). A scientific test showed that a meal of egg/toast/milk had almost all emptied out of the pouch after 45 minutes. Without milk, just egg and toast, more than ½ of the meal still remained in the pouch after 1 ½ hours.

3. Protein, protein, protein. Three meals a day. No high calorie liquids.

FLUID LOADING:

Fluid loading is drinking water/liquids as quickly as possible to fill the pouch which provides the feeling of fullness for about 15 to 25 minutes. The patient needs to gulp about 80% of his/her maximum amount of liquid in 15 to 30 SECONDS. Then just take swallows until fullness is reached. The patient will quickly learn his/her maximum tolerance, which is usually between 8-12 oz.

Fluid loading works because the roux limb of the intestine swells up, contracting and backing up any future food to come into the pouch. The pouch is very sensitive to this and the feeling of fullness will last much longer than the reality of how long the pouch was actually full. Fluid load before each meal to prevent thirst after the meal as well as to create that feeling of fullness whenever suddenly hungry before meal time.

POST PRANDIAL THIRST:

It is important that the patient be filled with water before his/her next meal as the meal will come with salt and will cause thirst afterwards. Being too thirsty, just like being too hungry will make a patient nauseous. While the pouch is still real small, it won't make sense to the patient to do this because salt intake will be low, but it is a good habit to get into because it will make all the difference once the pouch begins to regrow.

URGENCY:

The first six months is the fastest, easiest time to lose weight. By the end of the six months, 2/3 of the regrowth of the pouch will have been done. That means that each present day, after surgery you will be satisfied with less calories than you will the very next day. Another way to put it is that every day that you are healing, you will be able to eat more. So exercise as much as you can during that first six months as you will never be able to lose weight as fast as you can during this time.

SIX MONTHS:

Around this time, our patients begin to get hungry between meals. THEY NEED TO BATTLE THE EXTRA SALT INTAKE WITH DRINKING LOTS OF FLUIDS IN THE TWO TO THREE HOURS BEFORE THEIR NEXT MEAL. Their pouch needs to be well watered before they do the last gulping of water as fast as possible to fill the pouch 15 minutes before they eat.

INTAKE INFORMATION SHEET AS A TEACHING TOOL:

I have found that having the patients fill out a quiz every time they visit reminds them of the rules of the pouch and helps to get them "back on track." Most patients have no problems with the rules, some patients really struggle to follow them and need a lot of support to "get it", and a small percentage never quite understand these rules, even though they are quite intelligent people.

HONEYMOON SYNDROME:

The lack of hunger and quick weight loss patients have in the first six months sometimes leads them to think they don't need to exercise as much and can eat treats and extra calories as they still lose weight anyway. We call this the "honeymoon syndrome" and they need to be counseled that this is the only time they will lose this much weight this fast and this easy and not to waste it by losing less than they actually could. If the patient's weight loss slows in the first six months, remind them of the rules of water intake and encourage them to increase their exercise and drink more water. You can compare their weight loss to a graph showing the average drop of weight if it will help them to get back on track.

EXERCISE:

In addition to exercise helping to increase the weight loss, it is important for the patient to understand that exercise is a natural antidepressant and will help them from falling into a depression cycle. In addition, exercise jacks up their metabolic rate during a time when their metabolism after the shock of surgery tends to want to slow down.

THE IDEAL MEAL FOR WEIGHT LOSS:

The ideal meal is one that is made up of the following: ½ of your meal to be low fat protein, ¼ of your meal low starch vegetables and ¼ of your meal solid fruits. This type of meal will stay in your pouch a long time and is good for your health.

VOLUME VS. CALORIES:

The gastric bypass patient needs to be aware of the length of time it takes to digest different foods and to focus on those that take up the most space and take time to digest so as to stay in the pouch the longest, don't worry about calories. This is the easiest way to "count your calories." For example, a regular stomach person could gag down two whole sticks of butter at one sitting and be starved all day long, although they more than have enough calories for the day. But you take the same amount of calories in vegetables, and that same person simply would not be able to eat that much food at three sittings - it would stuff them way too much.

ISSUES FOR LONG TERM WEIGHT MAINTENANCE:

Although everything stated in this report deals with the first year after surgery, it should be a lifestyle that will benefit the gastric bypass patient for years to come, and help keep the extra weight off.

COUNTER-INTUITIVENESS OF FLUID MANAGEMENT:

I admit that avoiding fluids at meal time and then pushing hard to drink fluids between meals is against everything normal in nature and not a natural thing to be doing. Regardless of that fact, it is the best way to stay full the longest between meals and not accidentally create a "soup" in the stomach that is easily digested.

SUPPORT GROUPS:

It is natural for quite a few people to use the rules of the pouch and then to tire of it and stop going by the rules. Others "get it" and adhere to the rules as a way of life to avoid ever regaining extra weight. Having a support group makes  all the difference to help those that go astray to be reminded of the importance of the rules of the pouch and to get back on track and keep that extra weight off. Support groups create a  "peer pressure" to stick to the rules that the staff at the physician's office simply can't create.

TEETER TOTTER EFFECT:

Think of a teeter totter suspended in mid air in front of you. Now on the left end is exercise that you do and the right end is the foods that you eat. The more exercise you do on the left, the less you need to worry  about the amount of foods you eat on the right. In exact reverse, the more you worry about the foods you eat and keep it healthy on the right, the less exercise you need on the left. Now if you don't concern yourself with either side, the higher the teeter totter goes, which is your weight. The more you focus on one side or the other, or even both sides of the teeter totter, the lower it goes, and the less you weigh.

TOO MUCH WEIGHT LOSS:

I have found that about 15% of the patients which exercise well and had between 100 to 150 lbs to lose, begin to lose way too much weight. I encourage them to keep up the exercise (which is great for their health) and to essentially "break the rules" of the pouch. Drink with meals so they can eat snacks between without feeling full and increase their fat content as well take a longer time to eat at meals, thus taking in more calories. A small but significant amount of gastric bypass patients actually go underweight because they have experienced (as all of our patients have experienced) the ravenous hunger after being on a diet with an out of control appetite once the diet is broken. They are afraid of eating again. They don't "get" that this situation is literally, physically different and that they can control their appetite this time by using the rules of the pouch to eliminate hunger.

BARIATRIC MEDICINE:

A much more common problem is patients who after a year or two plateau at a level above their goal weight and don't lose as much weight as they want. Be careful that they are not given the "regular" advice given to any average overweight individual. Several small meals or skipping a meal with a liquid protein substitute is not the way to go for gastric bypass patients. They must follow the rules, fill themselves quickly with hard to digest foods, water load between, increase their exercise and the weight should come off much easier than with regular people diets.

SUMMARY:

1. The patient needs to understand how the new pouch physically works.

2. The patient needs to be able to evaluate their use of the tool, compare it to the ideal and see where they need to make changes.

3. Instruct your patient in all ways (through their eyes with visual aids, ears with lectures and emotions with stories and feelings) not only on how but why they need to learn to use their pouch. The goal is for the patient to become an expert on how to use the pouch.

EVALUATION FOR WEIGHT LOSS FAILURE:

The first thing that needs to be ruled out in patients who regain their weight is how the pouch is set up.

1) the staple line needs to be intact;
2) same with the outlet and;
3) the pouch is reasonably small.

1) Use thick barium to confirm the staple line is intact. If it isn't, then the food will go into the large stomach, from there into the intestines and the patient will be hungry all the time. Check for a little ulcer at the staple line. A tiny ulcer may occur with no real opening at the line, which can be dealt with as you would any ulcer. Sometimes, though, the ulcer is there because of a break in the staple line. This will cause pain for the patient after the patient has eaten because the food rubs the little opening of the ulcer. If there is a tiny opening at the staple line, then a reoperation must be done to actually separate the pouch and the stomach completely and seal each shut.

2) If the outlet is smaller than 7-8 mill, the patient will have problems eating solid foods and will little by little begin eating only
easy-to-digest foods, which we call "soft calorie syndrome." This causes frequent hunger and grazing, which leads to weight regain.

3) To assess pouch volume, an upper GI doesn't work as it is a liquid. The cottage cheese test is useful - eating as much cottage cheese as possible in five to 15 minutes to find out how much food the pouch will hold. It shouldn't be able to hold more than 1 ½ cups in 5 - 15 minutes of quick eating.

If everything is intact then there are four problems that it may be:

1) The patient has never been taught the rules;
2) The patient is depressed;
3) The patient has a loss of peer support and eventual forgetting of rules, or
4) The patient simply refuses to follow the rules.

1) LACK OF TEACHING:

An excellent example is a female patient who is 62 years old. She had the operation when she was 47 years old. She had a total regain of her weight. She stated that she had not seen her surgeon after the six week follow up 15 years ago. She never knew of the rules of the pouch. She had initially lost 50 lbs and then with a commercial weight program lost another 40 lbs. After that, she yo-yoed up and down, each time gaining a little more back. She then developed a disease (with no connection to bariatric surgery) which weakened her muscles, at which time she gained all of her weight back. At the time she came to me, she was treated for her disease, which helped her to begin walking one mile per day. I checked her pouch with barium and the cottage cheese test which showed the pouch to be a small size and that there was no leakage. She was then given the rules of the pouch. She has begun an impressive and continuing weight loss, and is not focused on food as she was, and feeling the best she has felt since the first months after her operation 15 years ago.

2) DEPRESSION:

Depression is a strong force for stopping weight loss or causing weight gain. A small number of patients, who do well at the beginning, disappear for a while only to return having gained a lot of weight. It seems that they almost on purpose do exactly opposite of everything they have learned about their pouch: they graze during the day, drink high calorie beverages, drink with meals and stop exercising, even though they know exercise helps stop depression. A 46 year-old woman, one year out of her surgery had been doing fine when her life was turned upside down with divorce and severe teenager behavior problems. Her weight skyrocketed. Once she got her depression under control and began refocusing on the rules of the pouch, added a little exercise, the weight came off quickly. If your patient begins weight gain due to depression, get him/her into counseling quickly. Encourage your patient to refocus on the pouch rules and try to add a little exercise every day. Reassure your patient that he/she did not ruin the pouch, that it is still there, waiting to be used to help with weight control. When they are ready the pouch can be used once again to lose weight without being hungry.

3) EROSION OF THE USE OF PRINCIPLES:

Some patients who are compliant, who are not depressed and have intact pouches, will begin to gain weight. These patients are struggling with their weight, have usually stopped connecting with their support groups, and have begun living their "new" life surrounded by those who have not had Bariatric surgery. Everything around them encourages them to live life "normal" like their new peers: they begin taking little sips with their meals, and eating quick and easy-to-eat foods. The patient will not usually call their physician's office because they KNOW what they are doing is wrong and KNOW that they just need to get back on track. Even if you offer "refresher courses" for your patients on a yearly basis, they may not attend because they KNOW what the course is going to say, they know the rules and how they are breaking them. You need to identify these patients and somehow get them back into your office or back to interacting with their support group again. Once these patients return to their support group, and keep in contact with their WLS peers, it makes it much easier to return to the rules of the pouch and get their weight under control once again.

4) TRUE NONCOMPLIANCE:

The most difficult problem is a patient who is truly noncompliant. This patient usually leaves your care, complains that there is no 'connection' between your staff and themselves and that they were not given the time and attention they needed. Most of the time, it is depression underlying the noncompliance that causes this attitude. A truly noncompliant patient will usually end up with revisions and/or reversal of the surgery due to weight gain or complications. This patient is usually quite resistant to counseling. There is not a whole lot that can be done for these patients as they will find a reason to be unhappy with their situation. It is easier to identify these patients BEFORE surgery than to help them afterwards, although I really haven't figured out how to do that yet. Besides having a psychological exam done before surgery, there is no real way to find them before surgery and I usually tend toward the side of offering patients the surgery with education in hopes they can live a good and healthy life.

"Dummies" version rewritten by Sally Perez
Original article written by:
Mason. EE, Personal Communication, 1980. Barber. W, Diet al, Brain Stem
Response To Phasic Gastric Distention.
Am J. Physical 1983: 245(2): G242-8 Flanagan, L. Measurement of Functional
Pouch Volume Following the Gastric Bypass Procedure. Ob Surg 1996; 6:38-43