It's very important to specify that not just any B12 works for us.  We must take METHYLcobalamin, and NOT the CYANOcobalamin.  We absorb methlycobalamin much more readily.  Just got off the phone with my nutritionist and she said I should be taking CYANOcobalamin.....Bariatric Advantage B-12 is CYANOcobalamin so I will continue to take it.  I specifically asked her which kind I should take and the CYANO...was her answer.

Many RNYers must take monthly B12 injections to be sure their levels remain high enough. Sublingual methylcobalamin is okay, but sometimes insufficient.

It is important to add that we don't just become ANEMIC without B12.  We develop what is called pernicious (or "deadly") anemia, which is significantly harder to treat than your garden variety anemias - hence the name.  Also, with a deficiency in any B vitamin, serious and sometimes irreversible neurological damage can occur - this can include coordination problems, cognition problems, and memory loss.


There are four areas where vitamin B12 benefit’s the human body:

1. Vitamin B12 is essential to helping the body convert carbohydrates, fats and proteins into energy.

2. Vitamin B12 can help prevent heart disease by helping to keep red blood cells healthy.

3. Vitamin B12 helps the white blood cells which as a result helps prevent disease through a healthy immune system.

4. Vitamin B12 is required to form a protective shield around nerve cells which is especially important in the brain. If there is an absence of B12 and this protective shield isn’t maintained then brain malfunction can occur.

Anemia can result if a person doesn’t have sufficient levels of vitamin B12 in their system. A lack of B12 causes a reduction in red blood cells which leads to anemia. Kids who are not fed properly will develop anemia. In addition, if a persons body doesn’t have a sufficient intrinsic factor to help B12 be absorbed by the body then anemia can result.

If a person is a vegetarian then they should take B12 supplements. To help babies grow in the womb, pregnant women should also take extra B12 supplements. The intrinsic factor in the body is decreased in people over fifty years of age so they may have problems absorbing large amounts of B12. For this reason people over fifty should consider B12 supplements so that they can reduce their chances of developing anemia and other health problems.

B-12: Gross deficiency in B-12 can lead to anemia and can, over time, cause permanent damage in the nervous system. Marginal deficiencies in challenged individuals lead to psychological, neurological, cardiovascular and immunological vulnerabilities. Certain groups, including people over age 50 who generally have reduced stomach acid, are more vulnerable to B-12 deficiency because B-12 requires adequate stomach acid and complete digestion to be usable by the body. In addition to older adults, people taking antacids, or who have chronic GI problems, such as celiac disease or irritable bowl syndrome, probably will be functionally deficient in B-12.

Everything I have read states B12 is a water soluable vitamin excess is excreted by Kidneys and there are 'no reports' of b12 toxicity.
What is the health risk of too much vitamin B12?
The Institute of Medicine of the National Academy of Sciences did not establish a Tolerable Upper Intake Level for this vitamin because Vitamin
B12 has a very low potential for toxicity. The Institute of Medicine states that "no adverse effects have been associated with excess vitamin B12 intake from food and supplements in healthy individuals" [7]. In fact, the Institute recommends that adults over 50 years of age get most of their vitamin B12 from vitamin supplements or fortified food because of the high incidence of impaired absorption of B12 from animal foods in this age group [7].
REF:
[7]ute of Medicine. Food and Nutrition Board. Dietary Reference Intakes:
Thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. National Academy Press. Washington, DC, 1998.
http://ods.od.nih.gov/factsheets/vitaminb12.asp#h11
~~~~~~~~~~~~~~~~~
Water-soluble vitamins. Vitamin C, biotin and the seven B vitamins - thiamin (B-1), riboflavin (B-2), niacin (B-3), pantothenic acid (B-5), pyridoxine (B-6), folic acid (B-9) and cobalamin (B-12) - dissolve in water
(water-soluble) and aren't stored in your body in any significant amounts.
Surplus water-soluble vitamins are simply excreted in your urine.
http://www.mayoclinic.com/invoke.cfm?id=NU00198
~~~~~~~~~~~~~~~
Vitamin B12 Toxicity
Vitamin B12 has a very low potential for toxicity. The tolerable upper intake level (UL) for vitamin B12 from dietary sources and supplements combined has not been determined. This does not mean that there is no potential for adverse effects resulting from high intakes. Because data is limited, caution should be used when supplementing.
 

World's Healthiest Foods ranked as quality sources of: dietary fiber
Food	Serving Size	Cals	Amount (g)	DV (%)	Nutrient Density	World's Healthiest Foods Rating
Cinnamon, ground	2 tsp	11.8	2.48	9.9	15.1	very good
Turnip greens, cooked	1 cup	28.8	5.04	20.2	12.6	excellent
Basil, dried, ground	2 tsp	7.5	1.20	4.8	11.5	good
Coriander seeds	2 tsp	9.9	1.40	5.6	10.2	very good
Oregano, dried, ground	2 tsp	9.2	1.28	5.1	10.1	very good
Raspberries	1 cup	60.3	8.34	33.4	10.0	excellent
Thyme, dried, ground	2 tsp	7.9	1.08	4.3	9.8	good
Mustard greens, boiled	1 cup	21.0	2.80	11.2	9.6	excellent
Rosemary, dried	2 tsp	7.3	0.92	3.7	9.1	good
Romaine lettuce	2 cup	15.7	1.90	7.6	8.7	very good
Cauliflower, boiled	1 cup	28.5	3.35	13.4	8.5	excellent
Collard greens, boiled	1 cup	49.4	5.32	21.3	7.8	excellent
Broccoli, steamed	1 cup	43.7	4.68	18.7	7.7	excellent
Cloves, dried, ground	2 tsp	14.2	1.52	6.1	7.7	very good
Celery, raw	1 cup	19.2	2.04	8.2	7.7	very good
Swiss chard, boiled	1 cup	35.0	3.68	14.7	7.6	excellent
Cabbage, shredded, boiled	1 cup	33.0	3.45	13.8	7.5	very good
Spinach, boiled	1 cup	41.4	4.32	17.3	7.5	very good
Chili pepper, dried	2 tsp	25.5	2.64	10.6	7.5	very good
Black pepper	2 tsp	10.9	1.12	4.5	7.4	good
Fennel, raw, sliced	1 cup	27.0	2.70	10.8	7.2	very good
Green beans, boiled	1 cup	43.8	4.00	16.0	6.6	very good
Eggplant, cooked, cubes	1 cup	27.7	2.48	9.9	6.4	very good
Cayenne pepper, dried	2 tsp	11.2	0.96	3.8	6.2	good
Cranberries	0.50 cup	23.3	1.99	8.0	6.2	very good
Strawberries	1 cup	43.2	3.31	13.2	5.5	very good
Bell peppers, red, raw, slices	1 cup	24.8	1.84	7.4	5.3	very good
Winter squash, baked, cubes	1 cup	80.0	5.74	23.0	5.2	very good
Kale, boiled	1 cup	36.4	2.60	10.4	5.1	very good
Split peas, cooked	1 cup	231.3	16.27	65.1	5.1	very good
Summer squash, cooked, slices	1 cup	36.0	2.52	10.1	5.0	very good
Carrots, raw	1 cup	52.5	3.66	14.6	5.0	very good
Lentils, cooked	1 cup	229.7	15.64	62.6	4.9	very good
Brussel sprouts, boiled	1 cup	60.8	4.06	16.2	4.8	very good
Asparagus, boiled	1 cup	43.2	2.88	11.5	4.8	very good
Black beans, cooked	1 cup	227.0	14.96	59.8	4.7	very good
Green peas, boiled	1 cup	134.4	8.80	35.2	4.7	very good
Pinto beans, cooked	1 cup	234.3	14.71	58.8	4.5	very good
Cucumbers, slices, with peel	1 cup	13.5	0.83	3.3	4.4	good
Lima beans, cooked	1 cup	216.2	13.16	52.6	4.4	very good
Turmeric, powder	2 tsp	16.0	0.96	3.8	4.3	good
Flaxseeds	2 tbs	95.3	5.41	21.6	4.1	very good
Kiwifruit	1 each	46.4	2.58	10.3	4.0	very good
Wheat, bulgur, cooked	1 cup	151.1	8.19	32.8	3.9	very good
Tomato, ripe	1 cup	37.8	1.98	7.9	3.8	very good
Oranges	1 each	61.6	3.13	12.5	3.7	very good
Kidney beans, cooked	1 cup	224.8	11.33	45.3	3.6	very good
Barley, cooked	1 cup	270.0	13.60	54.4	3.6	very good
Apricots	1 each	16.8	0.84	3.4	3.6	good
Blueberries	1 cup	81.2	3.92	15.7	3.5	very good
Onions, raw	1 cup	60.8	2.88	11.5	3.4	very good
Garbanzo beans (chickpeas), cooked	1 cup	269.0	12.46	49.8	3.3	good
Papaya	1 each	118.6	5.47	21.9	3.3	good
Apples	1 each	81.4	3.73	14.9	3.3	good
Grapefruit	0.50 each	36.9	1.69	6.8	3.3	good
Beets, Boiled	1 cup	74.8	3.40	13.6	3.3	good
Navy beans, cooked	1 cup	258.4	11.65	46.6	3.2	good
Figs, fresh	8 oz-wt	167.8	7.48	29.9	3.2	good
Rye, whole grain, uncooked	0.33 cup	188.7	8.22	32.9	3.1	good
Pear	1 each	97.9	3.98	15.9	2.9	good
Soybeans, cooked	1 cup	297.6	10.32	41.3	2.5	good
Yam (Dioscorea species), cubed, cooked	1 cup	157.8	5.30	21.2	2.4	good
Sweet potato, baked, with skin	1 each	95.4	3.14	12.6	2.4	good
Avocado, slices	1 cup	235.1	7.30	29.2	2.2	good
Mustard seeds	2 tsp	35.0	1.08	4.3	2.2	good
Spelt grains, cooked	4 oz-wt	144.0	4.40	17.6	2.2	good
Prunes	0.25 cup	101.6	3.02	12.1	2.1	good
Buckwheat, cooked	1 cup	154.6	4.54	18.2	2.1	good
Shiitake mushrooms, raw	8 oz-wt	87.2	2.49	10.0	2.1	good
Olives	1 cup	154.6	4.30	17.2	2.0	good
Plum	1 each	36.3	0.99	4.0	2.0	good
Crimini mushrooms, raw	5 oz-wt	31.2	0.85	3.4	2.0	good
Oats, whole grain, cooked	1 cup	147.4	3.98	15.9	1.9	good
Miso	1 oz	70.8	1.86	7.4	1.9	good
Banana	1 each	108.6	2.83	11.3	1.9	good
Corn, yellow, cooked	1 cup	177.1	4.60	18.4	1.9	good
Pineapple	1 cup	76.0	1.86	7.4	1.8	good
Cantaloupe, cubes	1 cup	56.0	1.28	5.1	1.6	good
Potato, baked, with skin	1 cup	133.0	2.93	11.7	1.6	good
Sesame seeds	0.25 cup	206.3	4.24	17.0	1.5	good

You first need to know what your "ideal" weight is... and ...  what your "goal" weight is. 

Ideal Weight -- this is the number your surgeon is using to determine your excess body weight.  It's usually the number that will put you in the middle of the BMI scale or the number of the Met Life Weight Chart.  For instance, my "Normal BMI" has a weight range of 115 to 154.  So the middle of that range is 134.5.  That's the number my surgeon uses for my ideal weight.

Goal Weight -- I'll never see 134 in my life!  For me a more realistic weight would be around 150-160.  My goal is to hit 160 first and see what happens after that. 

SO..... once you know those two numbers you can do some calculations.  The percentage for the Ideal Weight number will be what your surgeon uses to turn in for statistical purposes to the ASMBS and other survey organizations.  The percentage for Goal Weight is for your own personal use, it's not scientific or official.

Starting Weight - Ideal Weight = Excess body weight (EBW)
Mine:  241.5-134=107.5
Now divide to get the percentage...

pounds lost so far   -divided by-   EBW  = percentage of EBW lost
Mine:  20/107.5 = 18.6%

I keep my weekly weigh-in chart on an Excel Spreadsheet and that formula is formatted into the cells.  That way when I input the new weekly number, the percentage automatically calculates.  I keep track of both my Ideal Weight Percentage and my Goal Weight Percentage.  

Vitamin & Mineral Schedule & Shopping List

for Proximal RNY

 

The following is NOT to be construed as medical advice.  This proposed schedule has been known to work for many Proximal RNY Patients

 

The prices listed are to assist in calculating your monthly budget for basic vitamin and mineral supplementation.  Prices are based on prices current at time of printing and do not include shipping handling costs or sales and are subject to change with out notice.

 

Schedule:

 

AM:      **          1 Vitamin C                                           Evening:           1 Vitamin B-1

See note below 1 Polysaccharide Iron or 6 Tender Iron                            1 Vitamin E

                                                                                                            2 Calcium

                                                                                                            1 Multi-Vitamin

Mid-Day:           1 Vitamin A                                                                   1 Vitamin D-3

                        1 B-12                                                                           1 Zinc

                        2 Calcium

                        1 B-Complex                                         Bed Time:         2 Calcium

                        1 Vitamin E                                                                   1 Magnesium Citrate

                        1 Multi-Vitamin                                                              1 Vitamin C

            1 Vitamin D-3

 

Qty.                  Item                                                                 Price    Will Last      Cost/Day

1          Vitalady Tender Vitamin A (25,000IU)      100 cap                        4.49      100 days           .04

1          Superior Source Vitamin B-1 (100mg)     100 cap                        4.99      100 days           .05

1          Vitalady Tender Vitamin D-3 (5,000IU)     100 cap                        7.59      50 days                        .15

1          Vitalady Tender B-12 (1000mcg) 100 tab             14.99    100 days           .15

1          Vitalady Tender B-Complex 55               90 tab               10.99    90 days                        .12

1* **      Kirkland Vitamin C (1,000mg)                 500 tab             17.99    125 days           .14

1          Vitalady Tender Vitamin E (400IU)           250 cap                        26.99    125 days           .22

1*         Nature’s Science Calcium Citrate (500mg)240 cap           16.99    40 days                        .42

1* **      Cypress Polysaccharide Iron (150mg)     100 cap                        24.99    100 days           .25

1*         Kirkland Multi-Vitamin/Mineral                 500 tab             18.99    250 days           .08

1*         Puritan Pride Zinc (50mg)                       250 tab             8.49      250 days           .03

1          Vitalady Tender Mag Citrate (140mg)      90 cap              8.49      90 days                        .09

                                    Average cost for 30 day month = $52.20           Per Day            1.74

 

* If Chewables are desired we can substitute

1          Kirkland Chewable Vitamin C (500mg)     500 tab             15.99    250 days           .10

1          Bariatric Advantage Calcium (400mg)     270 tab             34.99    45 days                        .78

1          Vitalady Tender Iron (25mg)                   400 tab             15.99    66 days                        .24

1          Kirkland Chewable Multi-Vitamin             300 tab             19.88    150 days           .13

1          Vitalady Zinc Lozenge (23mg)                60 loz               7.49      60 days                        .12

                                    Average cost for 30 day month = $66.60           Per Day            2.22

 

** Iron and Vitamin C should be taken together, alone for at least an hour with fruit, vegetables,

meat but not dairy, caffeine, eggs and whole grain or any other medications, vitamins or minerals.

Pouch Rules for Dummies

September 24, 2007 by Traci  
Filed under Post-Op: Staying on Track

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Here are the basic pouch rules, including misconceptions about what the pouch does and doesn’t do. These rules have been circulated around the web for quite a while, and posted on several email groups I’m on.  I’ve copied and pasted it in it’s entirety here, including any and all credits.

Pouch Rules for Dummies

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 1/2 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 awhile.
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 1/2 cups of food can be achieved. OUTLET SIZE: Regardless of the outlet size, liquidy 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 1/2 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 1/2 hours to 2 hours after each meal.
5. After 1 1/2 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 pre-operatively 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 1/2 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 1/2 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 1/2 of the meal still remained in the pouch after 1 1/2 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: 1/2 of your meal to be low fat protein, 1/4 of your meal low starch vegetables and 1/4 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 1/2 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 awhile 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 NON-COMPLIANCE: The most difficult problem is a patient who is truly non-compliant. 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 non-compliance that causes this attitude. A truly non-compliant 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. This rewrite was done exclusively for the people of this spotlight obesity support group

. It should not be sold for any reason.  “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. Physiol 1983: 245(2): G242-8 Flanagan, L. Measurement of Functional Pouch Volume Following the Gastric Bypass Procedure. Ob Surg 1996; 6:38-43  Rosemurgy, A.

I, too, started questioning myself right before surgery....I would say to myself...."Do you really want your insides rearranged?"  I've lost a little weight, why can't I continue and do this on my own???  Then, I thought back at all my "attempts", my numerous attempts and said..."Marsha, how is this working for ya????  Well, it never worked for me and why was I to think it would work this time if I tried again.  I also was scared to death of being diabetic and that was where I was headed.  For me, 1.  diets for me have never worked and why was I to think a diet would now magically work? 2.  I am going to be diabetic unless something drastic happens and I lose weight.......That did it.  I was fine with my choice. 

You have to access where you are, is that where you want to be, how can you realistically get to where you want to be.....then, do whatever it takes to get there.

Three week out, feeling good, 18 lbs lost....I have a lot more work to do but now I am confident that I can do it with the tool my doctor gave me.

Her are her suggested labs with the targets on the last page.
Gina
Not to be construed as medical advice, this list includes labs we have had performed as gastric bypass patients. The first group, every 3 to 6 months for life, as we are able. The second group, annually, as long as the results were comfortably within normal limits for more than 2 years in a row.  
1^st Group 
  *80053          Comprehensive Metabolic profile: (sodium, potassium, chloride, glucose,BUN, creatinine, calcium, total protein, albumin, total bilirubin, alkaline phosphatase, aspartate aminotransferase) (10231)
* 84134          Pre-albumin:
* 7600            Lipid profile: (cholesterol, HDL, LDL, triglycerides, chol/HDL ratio)
* 10256          Hep panel: includes ALT (SPGT) & GGT)
* 84100          Phosphorous – Inorganic: (718)
* 83735          Magnesium:
* 84550          Uric Acid: (905)
* 7444            Thyroid panel: (T3U, T4, FTI, TSH) (84437; 84443; 84479; 84480)
* 85025          Hemogram with platelets: (1759)
* 7573            Iron: TIBC, % sat
* 83550          Ferritin: (457)
* 84630          Zinc: (945)
* 84446          Vitamin A: (921)
* 82306          Vitamin D: (25-hydroxy)   (680)
* 84052          Vitamin B-1: (Thiamin) (4052)
* 84207          Vitamin B-6: (Pyridoxine)
* 7065            Vitamin B-12 & Folate: (82607; 82746)
* 83970          Serum intact: PTH
* 83937          Osteocalcin:
* 84597          Vitamin K:
* 85610          PT:
* 85730          PTT:
* 86141                     C Reactive Protein  
2^ND GROUP  
* 593              LDH:
* 31789          Homocysteine, Cardio:
* 83921          MMA:
* 367              Cortisol:
* 84255          Selenium:
* 84590          Vitamin E:
* 82525          Copper:    

For diabetics:
*496 - HEMOGLOBIN A1C  
   
    POSSIBLE DIAGNOSIS CODES    
269.2              Hypovitaminosis
269.8              Vitamin D deficiency
275.40            Calcium deficiency
266.2              Cyanocobalamin deficiency (B12)
281.1             other B12 deficiency anemia
281.0              Pernicious anemia
280.9              Iron-deficiency anemia
281.2              Folate deficiency anemia
285.9              Anemia, unspecified 
269.3              Zinc deficiency
244.9              Hypothryoidism
250.0              Diabetes 
401.9              Hypertension
276.9              Electrolyte and fluid disorders
272.0              Hypercholesterolemia
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 
*579.3             Surgical malabsorption* 
*579.8             Intestinal malabsorption *  
* Bands or sleeves should not use these codes as they are not accurate.

 *Some insurance companies will not pay for any procedure that uses these codes.

This is NOT medical advice, just my own targets for the main blood levels I watch.  
  Protein:           7's
Albumin:         4's
Pre-Albumin: 20-30's  
Iron:                80-100
Ferritin:        200-300
HGB:              12+
HCT:               36+  
Vit A:               60- 80
Vit D:              80-120   
Calcium:        9.0-9.4
PTH:               20-40  
Vit B1:              Mid to top of range
Vit B6:             Mid to top of range
Magnesium: Mid range (but also go by if we have leg/foot cramping) Zinc:                Mid range  
Vit B12:          1000 +
Folate:           Top of range  
AST (sgot):    Below 40
ALT (sgpt):     Below 40  

We usually want to "meet or beat" pre-op levels. In some cases, higher is better, and in other cases (Cholesterol, PTH for example), lower is better.   The only things *I* don't mind being on the high end of out of range are Ferritin and B12. But that applies to ME.    My doctors don't show interest in any of these until I am out of range. *I* am interested when I begin heading that direction.

Probiotics help gastric-bypass patients lose weight more quickly, Stanford study shows

STANFORD, Calif. — New research from the Stanford University School of Medicine and Stanford Hospital & Clinics suggests that the use of a dietary supplement after Roux-en-Y gastric bypass surgery can help obese patients to more quickly lose weight and to avoid deficiency of a critical B vitamin.

In a study published in the July issue of the Journal of Gastrointestinal Surgery, John Morton, MD, associate professor of surgery at the medical school, showed that patients who take probiotics after the gastric-bypass procedure tend to shed more pounds than those who don't take the supplements. Probiotics are the so-called "good" bacteria found in yogurt as well as in over-the-counter dietary supplements that help in the digestion of food.

"Surprisingly, the probiotic group attained a significantly greater percent of excess weight loss than that of control group," said Morton, who wrote the paper with lead author Gavitt Woodard, a third-year medical student, and five other medical students at the Surgery Center for Outcomes Research and Evaluation in Stanford's Department of Surgery. Morton has performed more than 1,000 of these bypasses at Stanford Hospital & Clinics.

The researchers followed 44 patients on whom Morton had performed the procedure from 2006 to 2007. Patients were randomized into either a probiotic or a control group. Both groups received the same bariatric medical care and nutritional counseling, as well as the support of weight-loss study groups. Both groups also were allowed to consume yogurt, a natural source of probiotics. In addition, the probiotic group consumed one pill per day of Puritan's Pride, a probiotic supplement that is available online and in many stores. Morton has no financial ties to the company that makes the supplement.

The study showed that at three months, the probiotics group registered a 47.6 percent weight loss, compared with a 38.5 percent for the control group.

The study also found that levels of vitamin B-12 were higher in the patients taking probiotics — a significant finding because patients often are deficient in B-12 after gastric-bypass surgery. The probiotics group had B-12 levels of 1,214 picograms per milliliter at three months, compared with the control group's levels of 811 pg/mL.

Morton said he now recommends probiotic supplements to his patients, and he plans to continue to look for ways to enhance the outcomes from the procedure.

Roughly 15 million Americans are morbidly obese, and bypass surgery is becoming an increasingly common treatment for the problem. Some 150,000 Americans who have a body mass index of more than 40 — who are typically at least 100 pounds overweight — have the procedure each year.

Morton said the study was prompted by the fact that some patients have problems eating after gastric-bypass surgery. "For some reason, the food doesn't go down right," he said. When no anatomical reasons could be found for blockages, he hypothesized that a build-up of bacteria in the intestine — bacterial overgrowth — might be the culprit.

"Bacterial overgrowth can be bad in that it changes your motility, how you empty," Morton said. "A lot of people aren't aware that we all carry about a lot of bacteria in our intestines and that they're extremely helpful in aiding digestion. And I thought, 'Well, if we give these patients probiotics, then maybe we can improve these symptoms.'

"Part of the obesity puzzle may be due to the kind of bacteria you have in your intestine," he said.

###

There was no outside funding for the study.

The Stanford University School of Medicine consistently ranks among the nation's top 10 medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit http://mednews.stanford.edu. The medical school is part of Stanford Medicine, which includes Stanford Hospital & Clinics and Lucile Packard Children's Hospital. For information about all three, please visit http://stanfordmedicine.org/about/news.html.

Stanford Hospital & Clinics is known worldwide for advanced treatment of complex disorders in areas such as cardiac care, cancer treatment, neurosciences, surgery, and organ transplants. Consistently ranked among the top institutions in the U.S. News and World Report annual list of "America's Best Hospitals," Stanford Hospital & Clinics is internationally recognized for translating medical breakthroughs into the care of patients. For more information, visit www.stanfordhospital.com.

PRINT MEDIA CONTACT: Diane Rogers at (650) 723-3900 ([email protected])

Lots of gastric folks have leg and or feet  cramps. Mine were horrible , wasnt potassium although that is the first thing we think of.  Broccolli had way more than a banana though,,,however, my Dr said to go to Wal mart or somewhere and get some Magnesium 250 mg.  ( A  VITAMIN) Take one at night before bed , you might need 2 but start with one as it also helps out if someone has constipation..  Worked like a charm ofr me and boy did i suffer with cramps before in calves and feet EVERY NIGHT ,
Good luck
Shirley G.

Post Date: 9/14/09 8:17 pm

Your doing great and yes your weight loss may be slower than those with higher BMIs, try looking at it as a % of weight loss and you'll find you are on even ground.  Also you will run into stalls especially early out.  Here is a copy of post that explains why this happens:

When you magically drop x pounds per day or x pounds in the first week, two weeks, three weeks, etc. after surgery, it feels like a dream come true.

But: IT. WILL. STOP. Because it is NOT fat. It is WATER. This is what is happening, courtesy of Diana Cox, who is a molecular biologist Ph.D. and taught stuff like this in medical school. She makes me look smart :-).

Our bodies use glycogen for short term energy storage. Glycogen is not very soluble, but it is stored in our muscles for quick energy -- one pound of glycogen requires 4 lbs of water to keep it soluble, and the average glycogen storage capacity is about 2 lbs. So, when you are not getting in enough food, your body turns first to stored glycogen, which is easy to break down for energy. And when you use up 2 lbs of glycogen, you also lose 8 lbs of water that was used to store it -- voila -- the "easy" 10 lbs that most people lose in the first week of a diet.

As you stay in caloric deficit, however, your body starts to realize that this is not a short term problem. You start mobilizing fat from your adipose tissue and burning fat for energy. But your body also realizes that fat can't be used for short bursts of energy -- like, to outrun a sabertooth tiger. So, it starts converting some of the fat into glycogen, and rebuilding the glycogen stores. And as it puts back the 2 lbs of glycogen into the muscle, 8 lbs of water has to be stored with it to keep it soluble. So, even though you might still be LOSING energy content to your body, your weight will not go down or you might even GAIN for a while as you retain water to dissolve the glycogen that is being reformed and stored.