beckyvee
Still Hanging in There
May 24, 2009
May 2009
It's been nearly three years since I've posted. I did gain some weight, but I'm back on the right track. I'm getting ready for my 30th high school reunion, which will be a year from now. If you will read my story and the ups and downs post, you will see that something really bad happened to me when I was about 1.5 years out of surgery (May 2005). At that point, I completely lost my focus and you don't see another post for a full year.
From this point on, my focus will be on taking care of myself and getting the rest of my weight off and I will NEVER lose my focus again.
Becky
0 comments
It's been nearly three years since I've posted. I did gain some weight, but I'm back on the right track. I'm getting ready for my 30th high school reunion, which will be a year from now. If you will read my story and the ups and downs post, you will see that something really bad happened to me when I was about 1.5 years out of surgery (May 2005). At that point, I completely lost my focus and you don't see another post for a full year.
From this point on, my focus will be on taking care of myself and getting the rest of my weight off and I will NEVER lose my focus again.
Becky
Making Progress
Nov 08, 2006
I've now lost a total of 12 pounds since I started exercising five days a week and eating right. It's coming off slowly but surely.
The Ups and Downs of the Past Few Years
Nov 08, 2006
Thanksgiving, 2004
Hello Everyone! Happy Thanksgiving! Today is my one year anniversary. I am so thankful for my new life at 110 pounds lighter. I've been working with a personal trainer and I'm getting stronger and healthier every day. Hopefully, I will continue to lose weight and be closer to goal this time next year. For those of you on your way to Ensenada, you are in very good hands. Please read our profiles and then email us or post your questions to Dr. A's message board. We are all rooting for you--even when we are too busy to respond right away. For those of you who have come before me and who have journeyed with me, thank you so much for your patience and support. Isn't life great? God Bless you all.
November 7, 2004
I wish you all could have gone to the reunion in Las Vegas. Twenty-seven Dr. A. patients were there to celebrate our successes and to honor Dr. Aguirre. The combined total loss of all these attendees was over 3000 pounds! Dr. A. was so overwhelmed and choked up. He was thrilled to see us all healthy and in great spirits. Grace, Vicky, and Rachel were excellent hostesses. Charlotte raised over 500 dollars running the silent auction. Kat Ryan delivered a speech about our experience that, in my opinion, is worthy of a Pulitzer (or at the very least, publication). All the committee members did a great job and all the attendees lent a hand as well. If you are a pre-op, please check out the scrapbook that we put together for Dr. Aguirre. It should be in his office by now. Oh, by the way, we had a blast too!
October 2, 2004
I've finally broken my plateau and I'm now down 106 pounds after a little over 10 months. I'm looking forward to the reunion in Vegas and I've been very busy on that front. Life is good!
How do you break a plateau? Exercise and drink fluids all day. For one day, I had nothing but protein shakes, soup, and water. It works!
What about vitamins? I recommend either Bariatric Advantage (the multi and calcium) or Vista Vitamins. In addition, you either need to get Vitamin B-12 shots or use the sublingual spray.
What do I eat? I basically eat 3 small meals a day, focusing on lean proteins and vegetables. For a mid afternoon snack, I enjoy fruit or cheese and crackers. I avoid bread, rice, pasta, and starchy foods. I drink water constantly. And unfortunately, I do drink tea and coffee as well. I still can't eat spaghetti or rich desserts, but I don't miss them either.
I'm down another three pounds. I've been working hard these last two months. During the week, I work out with my friend Sandra every morning. We get in thirty minutes of cardio, weights, and situps. It's hard work, but I have got to get this weight off. I'd like to be less than 250 pounds by Christmas and less than 200 pounds a year from now. I've also improved my diet.
August 18, 2006
I've omitted refined carbs, popcorn, crackers, and bread (even the whole grains). I have a protein, fruit, and fiber shake every morning and eat lean proteins, veggies, and fruits the rest of the day and I'm down SEVEN pounds in two weeks--I have so much more energy. I've also been detoxing--I found a great product online called Colonix.
I'm still not able to work out much due to the hot Texas sun, but hope to workout and swim this weekend.
August 6, 2006
I'm now up 25 pounds since my surgery. I weighed as much as 269 lbs., but that is still a far cry from 360 lbs. where I started.
One thing that I'm going to try is to workout more regularly and stay positive. I also need to stay away from processed carbs. Starting today, I'm going to eat lean proteins, veggies, fruit, and drink lots of water, and continue taking my vitamins. I'm also looking for a workout buddy. I posted something on the Texas board.
I feel like my family is disappointed too.
I'm actively looking for an extreme workout partner in the Cedar Park/Round Rock area.
Here is the deal. I belong to the 24 hour Fitness near the Lakeline Mall (Lake Creek). I am looking for someone to work out with me most Saturday and Sunday mornings for 1-3 hours (one or both days). Don't worry about the guest fee, because I have a VIP pass.
Please look at my profile below to determine if we would be a good match. My favorite things to do at the club include: weight machines, the elliptical, situps, and swimming. If you are interested, shoot me an email at [email protected].
I am very committed to this, and I need a workout buddy who is also committed. Please don't respond unless you are serious.
BECKY
April 17, 2006
Can you believe that it has been a year now? I've had many ups and downs this year. In late May 2005, something really awful happened at my job and I've been in intensive therapy as a result. I've also been job hunting. My teaching job is fine; the problem is with the advising position. I just can't take the politics in this office. I am no longer the cute fat doormat that I was three years ago and they just don't get that.
Anyway, my personal life is good. My husband and daughter are both still wonderful and supportive. And I'm closer than ever to my mom and dad. We now have two Yorkies--Muffin and Joey! Anyway, I'm meeting with a personal trainer later this week and hopefully she can help get me back exercising again and the scale will start going in the right direction again.
At one point, I was over 260 pounds; now I'm at 257. My goal is to get below 200 pounds, so I still need to lose at least 60 more. When I get depressed about my lack of progress, I remind my self that three years ago I weighed 360 pounds. Without this surgery, I probably would be dead or near death.
To all of you who have just had the surgery--you can gain this weight back if you are not careful.
BTW, I did pass my comprehensives, so I am now ABD (all but dissertation).
Becky
April 10, 2005
I am so happy right now. My daughter, Tina, is going to be confirmed (in the Catholic Church) next month. She is very active in church and school. Right now, she is in the top 5 percent of her high school class. Next weekend, she will perform in a dance recital and the two of us are going with a bunch of my students to see Thoroughly Modern Millie at the Bass Concert Hall. Although she is just a freshman, she has announced her intention to study art at Rice, NYU, or some other top 50 school, so we need to keep working!
Oscar, my hubby, is playing a lot of golf, gardening, and making home repairs. This summer we have plans to see friends in D.C. and New Jersey (and to visit NYC as well). Christina and I will definitely be in Houston swimming in that gorgeous pool with grandma and grandpa. This Christmas, we are hoping to spend time with friends in Alamogordo when we rent a cabin in Cloudcroft, New Mexico.
I have finished my doctoral classes and have just started my comprehensives. If all goes as planned, I'll have my doctorate by the end of next year. I've been volunteering at the Crossings, a spiritual retreat about a mile from my house on the lake. I just love it! I began volunteering after a holistic doctor there cured me of my migraines. I haven't lost any weight in a while, but I am firming up, so it looks like I've dropped some more. In total, I've lost over 120 pounds. I am certain that I can still lose another 20-40 pounds--it's just going to take time. Meanwhile, I am obsessed with living well (the new Whole Foods in central Austin is paradise!), getting physically and spiritually fit, and wearing fun clothes right now (yikes--too much money!).
I know that I do not post often, but every single one of you (pre-ops, post-ops, and lurkers) are always in my thoughts and prayers. I look forward to seeing you all this fall in San Antonio.
Christmas, 2004
Happy Holidays! I'm still on a grand plateau, but I've been working with a personal trainer and I feel that I will soon be losing again. I've really enjoyed the holidays this year. I took some additional time from work and concede that I truly needed some R and R. I must admit that my mood has been strange. I've been feeling more depressed than usual lately. That is why I've been seeing a therapist as well. In addition, I've scheduled an appointment with a psychiatrist in January to see about changing my depression medication.
Pouch Rules for Dummies
Nov 05, 2006
POUCH RULES FOR DUMMIES
I copied this from Princess Splenda's website.
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 over-stuffing 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 ozs., 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 1.5 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 sends 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 one 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 1.5 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 one 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 1.5 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 1.5 hours to two hours after each meal.
5. After 1.5 to two hours, begin sipping water and over the next three hours, slowly increase water intake.
6. Three hours after last meal, begin drinking LOTS of water/fluids.
7. Fifteen 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. Practicing 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 six 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 1.5 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 protein 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 ozs. 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 out on 3000-5000 calories and with the pouch, the patient can only pig out on 600-1000 calories, maximum. The patient needs to just get back to the rules and not beat himself/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 calories/gram; peanut butter is 24 calories/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 1.5 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 1.5 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 15-25 minutes. The patient needs to gulp about 80% of his/her maximum amount of liquid in 15-30 SECONDS. Then just take swallows until fullness is reached. The patient will quickly learn his/her maximum tolerance, which is usually between 8-12 ozs.
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 re-grow.
URGENCY:
The first six months is the fastest, easiest time to lose weight. By the end of the six months, 2/3 of the re-growth 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 anti-depressant 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 5-15 minutes to find out how much food the pouch will hold. It shouldn’t be able to hold more than 1.5 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 re-focusing 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 re-focus 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 that 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.
THE GASTRIC BYPASS DIET
~~McFarland Clinic, PC
~~Ames , IA
Gastric Bypass surgery assists in weight lo by restricting the amount of food that can be eaten at one time. In order for this procedure to be a success, you must abide by the limits of the amount of food allowed per hour, coupled with good nutritious choices. Because you are limiting the amount of food and fluids you have at a time, it is important to drink enough water to prevent dehydration, by having some every hour you are awake.
Following surgery, no oral intake is allowed until bowel activity resumes and some healing of the pouch occurs. During this time, your fluid requirements are met with I.V. fluids.
GUIDE FOR MEASURING FOODS:
1 Cup = 240 cc = 8 ounces
1/2 Cup = 120 cc = 4 ounces
1/4 Cup = 60 cc = 2 ounces
2 Tablespoons = 30 cc = 1 ounce
1 Tablespoon = 15 cc = 1/2 ounce
THE FIRST STEP IS WATER
About day 3-4 post surgery, you will begin taking water in sips of 50 cc per hour.
Sip this 50 cc slowly, and stop if you feel uncomfortable. Limits are placed on the hourly amounts taken to avoid stretching or rupturing the small gastric pouch. Early after surgery, the emptying of the pouch may be slow. The feeling of fullness may be different from the feeling you had before surgery. Get to know what this feels like. A sheet for recording your water intake will be provided. Record the amount you take accurately to help gauge your tolerance.
CLEAR LIQUIDS
After tolerating 24 hours of water, the diet is advanced to clear liquids, at a rate of 75 cc per hour.
The following foods are provided on a clear liquid tray in the hospital.
~~Water
~~Broth
~~Diet Gelatin
~~Tea
~~Coffee (caffeine-free)
~~Clear juice (diluted)
You may have the clear liquid tray for two hours. Choose foods from the tray so that you can eat 75 cc each hour for the two hours. The tray will have more on it than you can finish. Once the two hours are up, put the food tray away and switch back to having water at the rate of 75 cc per hour.
FULL LIQUIDS
After a day of tolerating clear liquids, the diet is advanced to full liquids at the rate of 100 cc per hour. Once again, meals last two hours, with water taken in between meals.
The following foods are provided on a full liquid tray at the hospital:
~~Cream of Wheat
~~Soups (strained, creamed soup, broth)
~~Desserts (custard, diet gelatin, sugar-free frozen yogurt, sugar-free pudding)
~~Beverages (coffee, tea {caffeine-free})
~~Seasonings (salt and flavorings in moderation)
~~Pureed fruits
~~Sugar substitutes
~~Skim milk
~~Juices (diluted)
**********By now you should be tolerating 100 cc per hour of full liquids.
**********Patients usually go home after tolerating a day of full liquids.
**********Be sure you plan ahead and think of foods in this category that you can have at home.
**********Again, be sure to drink 100 cc per hour of water in between meals. Do not exceed the 100 cc per hour limit. If you take sips of water during mealtimes, count the amount sipped in your 100 cc per hour total.
SAMPLE MENU FOR TWO WEEKS AT HOME:
Breakfast:
~~100 cc NSA Carnation Instant Breakfast (made with Double Milk) (OR)
~~1/4 Cup SF/NSA yogurt (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk)
Lunch:
~~1/4 Cup cream soup (made with Double Milk) (OR)
~~100 cc NSA Carnation Instant Breakfst (made with Double Milk) (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk)
Supper:
~~1/4 Cup cream soup (made with Double Milk) (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk) (OR)
~~2 Tbsp. puree fruit
**********Double Milk Recipe**********
1 Cup FF Skim milk
1/3 Cup non-fat powdered milk
Drink a total of at least 1000 cc (4 cups) of water, broth, diet soda, unsweetened tea or coffee during the day, between meals. Stick to the restriction of 100 cc per hour of full liquids for three weeks after surgery.
PUREED DIET
This diet begins three weeks after your operation.
Take 15-20 minutes to eat one ounce of food. STOP DRINKING 30 MINUTES BEFORE EATING AND WAIT 45 MINUTES AFTER EATING THE MEAL BEFORE HAVING WATER AGAIN. Chew foods well. Be sure to have protein foods at each meal.
PUREED MENU EXAMPLES:
Breakfast:
~~1 scrambled egg (OR)
~~1/4 Cup cereal (OR)
~~1/4 Cup yogurt
Lunch:
~~1/4 Cup pureed meat (OR)
~~1/4 Cup mashed potatoes (OR)
~~1/2 Cup cream soup (made with Double Milk)
Supper:
~~1/4 Cup pureed meat (OR)
~~1/4 Cup pudding (made with Double Milk) (OR)
~~100 cc NSA Carnation Instant Breakfast (made with Double Milk)
To puree meat:
1/4 Cup broth
1/4 Cup meat, poultry or fish, cut against the grain
Blend in this small amount to achieve desired consistency.
Clean blender after each use to avoid food borne illness. (Use within 24 hours, unless frozen.)
Freeze:
Place extra blended food in plastic freezer ice cube trays. When frozen, transfer to freezer bags and write date on the bag. Use within two months, or throw away.
MECHANICAL SOFT DIET
This diet begins four weeks after surgery. Be sure to chew well and take 15-20 minutes to eat one ounce of food.
Begin to slowly add soft foods, such as:
~~Fat free or 1% cottage cheese
~~Low-fat cheese
~~Scrambled eggs
~~Hard cooked eggs
~~Unsweetened dry cereals
~~Crisp toast
~~Non-fat crackers
~~Tuna salad (water packed)
~~Baked fish
~~Ground chicken or turkey
~~Low-fat refried beans
~~Canned vegetables
~~Baked potato
~~Watermelon
~~Bananas
~~Low-fat casseroles
SOFT DIET MENU EXAMPLES
Breakfast:
~~1 scrambled egg (OR)
~~1/4 Cup cooked cereal (OR)
~~1/4 Cup low calorie yogurt
Lunch:
~~1/4 Cup baked fish (OR)
~~100 cc NSA Carnation Instant Breakfast (made with Double Milk) (OR)
~~1/4 baked potato
Supper:
~~1/4 Cup ground meat (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk) (OR)
~~1/4 Cup fruit
GENERAL DIET
Begin this diet after tolerating a soft diet. Add foods gradually and remember to chew well.
GENERAL MENU EXAMPLES:
Breakfast:
~~1 scrambled egg (OR)
~~1/4 Cup fresh fruit (OR)
~~1/2 slice toast, SF jelly
Lunch:
~~1/4 Cup tender meat (OR)
~~1/4 Cup yogurt (OR)
~~1/4 Cup cooked vegetable
Supper:
~~1/4 Cup tender meat (OR)
~~1/4 Cup raw vegetables or salad (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk)
DO NOT EAT BETWEEN MEALS. DRINK ONLY NON-CALORIC FLUIDS.
THINGS TO REMEMBER:
Be careful eating red meat for the first four months.
Be careful with white bread for the first four months, unless toasted.
PROBLEM FOODS TO TRY WITH CAUTION:
Beef, orange membranes, skins and seeds of fruit and vegetables, corn, celery, sweet potatoes and fresh breads.
PROBLEM FOODS
The ability to tolerate certain foods depends on teeth condition and thoroughly chewing the food. Keep a written (or mental) list of foods difficult to eat.
Some problem foods are:
**********Tough meats, especially beef. Buy lean hamburger, marinate meats, use a tenderizer.
**********Membranes of oranges. Remove membrane, used canned sections or canned mandarin oranges.
**********Skins and seeds of some fruits and vegetables. Peel and seed fruits and vegetables.
**********Fibrous vegetables (corn, celery and sweet potatoes). Blend, puree, mince or strain to break down fiber.
**********Fresh bread. Toast white bread; use day-old whole grain wheat bread.
FLUID INTAKE
**********Fluids will be provided through an I.V. (intravenous feeding) after surgery. The I.V. will be continued until adequate fluids are taken by mouth.
**********Do not drink fluids with meals. Avoid drinking fluids 30 minutes before meals and 45 minutes after meals.
**********Sip beverages slowly. Let them linger in your mouth before swallowing.
**********Select no-calorie beverages, such as water, tea, SF Kool-Aid or SF lemonade.
**********Limit use of fruit juices to 1/2-1 cup per week.
**********Pay attention to signals of fullness.
**********Drink 4-6 cups of no-calorie fluids daily.
**********Drink a total of 7-9 cups of fluid per day.
**********Drink enough water to urinate four cups per day.
PROTEIN INTAKE
It is important to eat protein at each meal. In order to get 40-60 grams of protein each day, eat the protein foods first, and have skim milk or yogurt daily.
SIGNS OF INADEQUATE PROTEIN:
~~Hair loss
~~Brittle nails
~~Slow healing
INCREASING PROTEIN
**********Use Double Milk
**********Add low-calorie Nestle Quik, low-calorie cocoa, Alba or low-calorie instant breakfast to skim milk.
**********For Lactose intolerance~~~Put Lactaid or Dairy Ease in milk or use soy milk if lactose intolerance is a problem.~~~Choose lactose-free low-fat milk available in the dairy case of most grocery stores, If not available, ask for it to be stocked.
**********Eat an omelet, scrambled egg or low-calorie fruit-flavored yogurt.
**********Combine cottage cheese with canned fruit.
**********Spread tuna or chicken salad, made with low-calorie mayonnaise, on low-fat crackers.
FAT INTAKE
Keep total fat intake below 30-40 grams per day.
**********Read labels~~~To identify hidden fats.~~~To identify unrealistic portion sizes.
**********FAT-FREE is not CALORIE-FREE.
**********Too many calories, no matter the energy source, will slow weight loss.
Calorie per gram of energy nutrients comparison:
Carbohydrate = 4 calories/gram
Protein = 4 calories/gram
Alcohol = 7 calories/gram
Fat = 9 calories/gram
CHEWING
Swallowing food without chewing adequately causes pain, discomfort, nausea, or vomiting. It is possible to stretch the pouch and disrupt the staple line.
Guidelines are:
**********Do not skip meals.
**********Take 30-60 minutes to eat every meal. At first, take longer.
**********Chew each bite 20-30 times until the food is of pureed consistency.
**********Use a dessert spoon or long-handled baby spoon to better control bite size and speed of eating.
**********Savor the flavor and texture of each bite of food.
**********See the dentist, if your teeth are in poor condition.
**********Explain the reason for eating slowly if asked.
VITAMIN AND MINERAL SUPPLEMENTS
Vitamin and mineral deficiencies of iron, calcium and B-12 can occur following a gastric bypass surgery (Roux-en-Y). To avoid this complication, discharge recommendations are chewable Tums to provide 1000 mg elemental calcium (2-5 tablets, depending on amount per tablet) and chewable multiple vitamins daily. Daily supplements of B-12 (500 mcg) and iron are necessary after your first post-op visit. Tums will be replaced with Calcium Citrate at your six week post-op visit.
Calcium and iron should not be taken at the same time (at least four hours apart). Take iron with high vitamin C foods (citrus fruits, strawberries, tomatoes, mango and papaya, kiwi, cantaloupe and cabbage family vegetables), but not with milk or antacids. Do not take with yogurt, cheese, tea or coffee. Do not crush or chew extended release iron preparations. If a dose is missed, do not double the dose.
Use one bottle of chewable multiple vitamins with iron, then use any brand multiple vitamin with iron. If using large Centrum-type, break in half.
Do not eat rhubarb and spinach, or bran and whole grain cereals, when taking a calcium supplement. These foods contain oxalic acid or phytic acid and may interfere with calcium absorption.
CONSTIPATION
It is typical to have a bowel movement every 2-3 days following a gastric restriction procedure. Constipation sometimes occurs after surgery. If constipation occurs, include high fiber foods in your diet.
Additionally, increase no calorie fluids from six to eight 8-ounce glasses daily. Colace, an over-the-counter stool softener, is available if high-fiber foods and fluids do not relieve constipation. Metamucil may be used to increase finer intake.
High Fiber Food Examples:
~~1/4 Cup Kellogg's All Bran (with extra fiber)~~7 fiber grams
~~1/4 Cup Fiber One~~7 fiber grams
~~1/4 Cup Nabisco 100% Bran~~5 fiber grams
~~1/2 Cup Prune juice~~3 fiber grams
~~2 Tbsp. Mashed Peas, Pinto beans or Kidney beans~~1 fiber gram
~~2 Tbsp. Fresh fruits/Vegetables~~
How to break a plateau
#1 - Do this for 10 days to break a plateau
#2 - Drink 2 quarts of water a day
#3 - You must have 45 grams of protein supplement and all your vitamins/minerals supplements each day
#4 - You may consume up to 3 oz of the following high protein foods, 5x a day
beef
pork
chicken
turkey
lamb
fish
eggs
low fat cheese
cottage cheese
plain yogurt or artificially sweetened (?)
peanut butter
beans/legumes
You may also have:
sugar free popsicles
tea or coffee
sugar free soda
sugar free jello
broths/bullion (sp?)
crystal light drinks
#5 - If it's not on the list, you can't have it for 10 days!!!!
#6 - Keep a food diary and try to get up to 30 mins of exercise daily
First Stage of Post Op
HIBERNATION SYNDROME
After WLS, you may be feeling tired and become depressed. When you are several weeks post op, and are either on a liquid diet or you are eating many fewer calories than you were pre op, this depression and inactivity can become more pronounced.
All you want to do is sleep, you may have crying spells, you may begin to believe that the surgery was a mistake, or you may think 'what in the world have I done to myself?
All these feelings are completely normal and, to a certain extent, are to be expected. The low number of calories you are eating produces what many of us call the 'hibernation syndrome' and your depression and feelings of despair,are a direct result.
During the weeks immediately following surgery, our body starts to notice that we are not taking in enough calories. It doesn't know we've had WLS, or that it's the year 2004. Our body is missing food, thinks this is a famine, and struggles to conserve our energy. The human body reacts like it always has in a famine; it makes us depressed--so we don't have the motivation to do anything, and it makes us tired--so we don't have the energy to do anything. In this way, we will conserve as many calories as possible and remain alive.
You can see the practical value of this as our bodies have been living through famines, snowstorms, and other periods of unstable food supply for centuries.
This stage can last several weeks. Our discomfort is compounded as we are, at this same time, trying to recover from major surgery, adopt new eating habits, and deal with a liquid or soft diet. To get out of this stage, our body has to say to itself 'gee, this famine is lasting a bit too long. If I keep conserving my energy with inactivity, I will starve to death. I'd better use my last store of energy (the remaining fat and muscles in our body) to hunt up some food'. At this point, our body will switch from getting energy from food, to getting energy from our fat (and muscle too if we don't eat enough protein) and that is what we want.
In order to deal with this difficult transition period, tell yourself that you're right on track; this is exactly what is normal and to be expected.
Tell yourself that, in a few weeks, this will pass, and you will feel like a completely new person. We all seem to turn the corner about 4-6 weeks post op. Then, your mood will lighten and, with your weight loss starting to add up, you'll feel more positive and have a better outlook on life. Just keep telling yourself that you will not always feel this way! You WILL be back to feeling like your old self. Just give it time!
I copied this from Princess Splenda's website.
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 over-stuffing 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 ozs., 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 1.5 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 sends 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 one 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 1.5 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 one 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 1.5 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 1.5 hours to two hours after each meal.
5. After 1.5 to two hours, begin sipping water and over the next three hours, slowly increase water intake.
6. Three hours after last meal, begin drinking LOTS of water/fluids.
7. Fifteen 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. Practicing 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 six 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 1.5 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 protein 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 ozs. 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 out on 3000-5000 calories and with the pouch, the patient can only pig out on 600-1000 calories, maximum. The patient needs to just get back to the rules and not beat himself/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 calories/gram; peanut butter is 24 calories/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 1.5 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 1.5 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 15-25 minutes. The patient needs to gulp about 80% of his/her maximum amount of liquid in 15-30 SECONDS. Then just take swallows until fullness is reached. The patient will quickly learn his/her maximum tolerance, which is usually between 8-12 ozs.
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 re-grow.
URGENCY:
The first six months is the fastest, easiest time to lose weight. By the end of the six months, 2/3 of the re-growth 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 anti-depressant 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 5-15 minutes to find out how much food the pouch will hold. It shouldn’t be able to hold more than 1.5 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 re-focusing 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 re-focus 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 that 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.
THE GASTRIC BYPASS DIET
~~McFarland Clinic, PC
~~
Gastric Bypass surgery assists in weight lo by restricting the amount of food that can be eaten at one time. In order for this procedure to be a success, you must abide by the limits of the amount of food allowed per hour, coupled with good nutritious choices. Because you are limiting the amount of food and fluids you have at a time, it is important to drink enough water to prevent dehydration, by having some every hour you are awake.
Following surgery, no oral intake is allowed until bowel activity resumes and some healing of the pouch occurs. During this time, your fluid requirements are met with I.V. fluids.
GUIDE FOR MEASURING FOODS:
1 Cup = 240 cc = 8 ounces
1/2 Cup = 120 cc = 4 ounces
1/4 Cup = 60 cc = 2 ounces
2 Tablespoons = 30 cc = 1 ounce
1 Tablespoon = 15 cc = 1/2 ounce
THE FIRST STEP IS WATER
About day 3-4 post surgery, you will begin taking water in sips of 50 cc per hour.
Sip this 50 cc slowly, and stop if you feel uncomfortable. Limits are placed on the hourly amounts taken to avoid stretching or rupturing the small gastric pouch. Early after surgery, the emptying of the pouch may be slow. The feeling of fullness may be different from the feeling you had before surgery. Get to know what this feels like. A sheet for recording your water intake will be provided. Record the amount you take accurately to help gauge your tolerance.
CLEAR LIQUIDS
After tolerating 24 hours of water, the diet is advanced to clear liquids, at a rate of 75 cc per hour.
The following foods are provided on a clear liquid tray in the hospital.
~~Water
~~Broth
~~Diet Gelatin
~~Tea
~~Coffee (caffeine-free)
~~Clear juice (diluted)
You may have the clear liquid tray for two hours. Choose foods from the tray so that you can eat 75 cc each hour for the two hours. The tray will have more on it than you can finish. Once the two hours are up, put the food tray away and switch back to having water at the rate of 75 cc per hour.
FULL LIQUIDS
After a day of tolerating clear liquids, the diet is advanced to full liquids at the rate of 100 cc per hour. Once again, meals last two hours, with water taken in between meals.
The following foods are provided on a full liquid tray at the hospital:
~~Cream of Wheat
~~Soups (strained, creamed soup, broth)
~~Desserts (custard, diet gelatin, sugar-free frozen yogurt, sugar-free pudding)
~~Beverages (coffee, tea {caffeine-free})
~~Seasonings (salt and flavorings in moderation)
~~Pureed fruits
~~Sugar substitutes
~~Skim milk
~~Juices (diluted)
**********By now you should be tolerating 100 cc per hour of full liquids.
**********Patients usually go home after tolerating a day of full liquids.
**********Be sure you plan ahead and think of foods in this category that you can have at home.
**********Again, be sure to drink 100 cc per hour of water in between meals. Do not exceed the 100 cc per hour limit. If you take sips of water during mealtimes, count the amount sipped in your 100 cc per hour total.
SAMPLE MENU FOR TWO WEEKS AT HOME:
Breakfast:
~~100 cc NSA Carnation Instant Breakfast (made with Double Milk) (OR)
~~1/4 Cup SF/NSA yogurt (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk)
Lunch:
~~1/4 Cup cream soup (made with Double Milk) (OR)
~~100 cc NSA Carnation Instant Breakfst (made with Double Milk) (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk)
Supper:
~~1/4 Cup cream soup (made with Double Milk) (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk) (OR)
~~2 Tbsp. puree fruit
**********Double Milk Recipe**********
1 Cup FF Skim milk
1/3 Cup non-fat powdered milk
Drink a total of at least 1000 cc (4 cups) of water, broth, diet soda, unsweetened tea or coffee during the day, between meals. Stick to the restriction of 100 cc per hour of full liquids for three weeks after surgery.
PUREED DIET
This diet begins three weeks after your operation.
Take 15-20 minutes to eat one ounce of food. STOP DRINKING 30 MINUTES BEFORE EATING AND WAIT 45 MINUTES AFTER EATING THE MEAL BEFORE HAVING WATER AGAIN. Chew foods well. Be sure to have protein foods at each meal.
PUREED MENU EXAMPLES:
Breakfast:
~~1 scrambled egg (OR)
~~1/4 Cup cereal (OR)
~~1/4 Cup yogurt
Lunch:
~~1/4 Cup pureed meat (OR)
~~1/4 Cup mashed potatoes (OR)
~~1/2 Cup cream soup (made with Double Milk)
Supper:
~~1/4 Cup pureed meat (OR)
~~1/4 Cup pudding (made with Double Milk) (OR)
~~100 cc NSA Carnation Instant Breakfast (made with Double Milk)
To puree meat:
1/4 Cup broth
1/4 Cup meat, poultry or fish, cut against the grain
Blend in this small amount to achieve desired consistency.
Clean blender after each use to avoid food borne illness. (Use within 24 hours, unless frozen.)
Freeze:
Place extra blended food in plastic freezer ice cube trays. When frozen, transfer to freezer bags and write date on the bag. Use within two months, or throw away.
MECHANICAL SOFT DIET
This diet begins four weeks after surgery. Be sure to chew well and take 15-20 minutes to eat one ounce of food.
Begin to slowly add soft foods, such as:
~~Fat free or 1% cottage cheese
~~Low-fat cheese
~~Scrambled eggs
~~Hard cooked eggs
~~Unsweetened dry cereals
~~Crisp toast
~~Non-fat crackers
~~Tuna salad (water packed)
~~Baked fish
~~Ground chicken or turkey
~~Low-fat refried beans
~~Canned vegetables
~~Baked potato
~~Watermelon
~~Bananas
~~Low-fat casseroles
SOFT DIET MENU EXAMPLES
Breakfast:
~~1 scrambled egg (OR)
~~1/4 Cup cooked cereal (OR)
~~1/4 Cup low calorie yogurt
Lunch:
~~1/4 Cup baked fish (OR)
~~100 cc NSA Carnation Instant Breakfast (made with Double Milk) (OR)
~~1/4 baked potato
Supper:
~~1/4 Cup ground meat (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk) (OR)
~~1/4 Cup fruit
GENERAL DIET
Begin this diet after tolerating a soft diet. Add foods gradually and remember to chew well.
GENERAL MENU EXAMPLES:
Breakfast:
~~1 scrambled egg (OR)
~~1/4 Cup fresh fruit (OR)
~~1/2 slice toast, SF jelly
Lunch:
~~1/4 Cup tender meat (OR)
~~1/4 Cup yogurt (OR)
~~1/4 Cup cooked vegetable
Supper:
~~1/4 Cup tender meat (OR)
~~1/4 Cup raw vegetables or salad (OR)
~~1/4 Cup SF/FF pudding (made with Double Milk)
DO NOT EAT BETWEEN MEALS. DRINK ONLY NON-CALORIC FLUIDS.
THINGS TO REMEMBER:
Be careful eating red meat for the first four months.
Be careful with white bread for the first four months, unless toasted.
PROBLEM FOODS TO TRY WITH CAUTION:
Beef, orange membranes, skins and seeds of fruit and vegetables, corn, celery, sweet potatoes and fresh breads.
PROBLEM FOODS
The ability to tolerate certain foods depends on teeth condition and thoroughly chewing the food. Keep a written (or mental) list of foods difficult to eat.
Some problem foods are:
**********Tough meats, especially beef. Buy lean hamburger, marinate meats, use a tenderizer.
**********Membranes of oranges. Remove membrane, used canned sections or canned mandarin oranges.
**********Skins and seeds of some fruits and vegetables. Peel and seed fruits and vegetables.
**********Fibrous vegetables (corn, celery and sweet potatoes). Blend, puree, mince or strain to break down fiber.
**********Fresh bread. Toast white bread; use day-old whole grain wheat bread.
FLUID INTAKE
**********Fluids will be provided through an I.V. (intravenous feeding) after surgery. The I.V. will be continued until adequate fluids are taken by mouth.
**********Do not drink fluids with meals. Avoid drinking fluids 30 minutes before meals and 45 minutes after meals.
**********Sip beverages slowly. Let them linger in your mouth before swallowing.
**********Select no-calorie beverages, such as water, tea, SF Kool-Aid or SF lemonade.
**********Limit use of fruit juices to 1/2-1 cup per week.
**********Pay attention to signals of fullness.
**********Drink 4-6 cups of no-calorie fluids daily.
**********Drink a total of 7-9 cups of fluid per day.
**********Drink enough water to urinate four cups per day.
PROTEIN INTAKE
It is important to eat protein at each meal. In order to get 40-60 grams of protein each day, eat the protein foods first, and have skim milk or yogurt daily.
SIGNS OF INADEQUATE PROTEIN:
~~Hair loss
~~Brittle nails
~~Slow healing
INCREASING PROTEIN
**********Use Double Milk
**********Add low-calorie Nestle Quik, low-calorie cocoa, Alba or low-calorie instant breakfast to skim milk.
**********For Lactose intolerance~~~Put Lactaid or Dairy Ease in milk or use soy milk if lactose intolerance is a problem.~~~Choose lactose-free low-fat milk available in the dairy case of most grocery stores, If not available, ask for it to be stocked.
**********Eat an omelet, scrambled egg or low-calorie fruit-flavored yogurt.
**********Combine cottage cheese with canned fruit.
**********Spread tuna or chicken salad, made with low-calorie mayonnaise, on low-fat crackers.
FAT INTAKE
Keep total fat intake below 30-40 grams per day.
**********Read labels~~~To identify hidden fats.~~~To identify unrealistic portion sizes.
**********FAT-FREE is not CALORIE-FREE.
**********Too many calories, no matter the energy source, will slow weight loss.
Calorie per gram of energy nutrients comparison:
Carbohydrate = 4 calories/gram
Protein = 4 calories/gram
Alcohol = 7 calories/gram
Fat = 9 calories/gram
CHEWING
Swallowing food without chewing adequately causes pain, discomfort, nausea, or vomiting. It is possible to stretch the pouch and disrupt the staple line.
Guidelines are:
**********Do not skip meals.
**********Take 30-60 minutes to eat every meal. At first, take longer.
**********Chew each bite 20-30 times until the food is of pureed consistency.
**********Use a dessert spoon or long-handled baby spoon to better control bite size and speed of eating.
**********Savor the flavor and texture of each bite of food.
**********See the dentist, if your teeth are in poor condition.
**********Explain the reason for eating slowly if asked.
VITAMIN AND MINERAL SUPPLEMENTS
Vitamin and mineral deficiencies of iron, calcium and B-12 can occur following a gastric bypass surgery (Roux-en-Y). To avoid this complication, discharge recommendations are chewable Tums to provide 1000 mg elemental calcium (2-5 tablets, depending on amount per tablet) and chewable multiple vitamins daily. Daily supplements of B-12 (500 mcg) and iron are necessary after your first post-op visit. Tums will be replaced with Calcium Citrate at your six week post-op visit.
Calcium and iron should not be taken at the same time (at least four hours apart). Take iron with high vitamin C foods (citrus fruits, strawberries, tomatoes, mango and papaya, kiwi, cantaloupe and cabbage family vegetables), but not with milk or antacids. Do not take with yogurt, cheese, tea or coffee. Do not crush or chew extended release iron preparations. If a dose is missed, do not double the dose.
Use one bottle of chewable multiple vitamins with iron, then use any brand multiple vitamin with iron. If using large Centrum-type, break in half.
Do not eat rhubarb and spinach, or bran and whole grain cereals, when taking a calcium supplement. These foods contain oxalic acid or phytic acid and may interfere with calcium absorption.
CONSTIPATION
It is typical to have a bowel movement every 2-3 days following a gastric restriction procedure. Constipation sometimes occurs after surgery. If constipation occurs, include high fiber foods in your diet.
Additionally, increase no calorie fluids from six to eight 8-ounce glasses daily. Colace, an over-the-counter stool softener, is available if high-fiber foods and fluids do not relieve constipation. Metamucil may be used to increase finer intake.
High Fiber Food Examples:
~~1/4 Cup Kellogg's All Bran (with extra fiber)~~7 fiber grams
~~1/4 Cup Fiber One~~7 fiber grams
~~1/4 Cup Nabisco 100% Bran~~5 fiber grams
~~1/2 Cup Prune juice~~3 fiber grams
~~2 Tbsp. Mashed Peas, Pinto beans or Kidney beans~~1 fiber gram
~~2 Tbsp. Fresh fruits/Vegetables~~
How to break a plateau
#1 - Do this for 10 days to break a plateau
#2 - Drink 2 quarts of water a day
#3 - You must have 45 grams of protein supplement and all your vitamins/minerals supplements each day
#4 - You may consume up to 3 oz of the following high protein foods, 5x a day
beef
pork
chicken
turkey
lamb
fish
eggs
low fat cheese
cottage cheese
plain yogurt or artificially sweetened (?)
peanut butter
beans/legumes
You may also have:
sugar free popsicles
tea or coffee
sugar free soda
sugar free jello
broths/bullion (sp?)
crystal light drinks
#5 - If it's not on the list, you can't have it for 10 days!!!!
#6 - Keep a food diary and try to get up to 30 mins of exercise daily
First Stage of Post Op
HIBERNATION SYNDROME
After WLS, you may be feeling tired and become depressed. When you are several weeks post op, and are either on a liquid diet or you are eating many fewer calories than you were pre op, this depression and inactivity can become more pronounced.
All you want to do is sleep, you may have crying spells, you may begin to believe that the surgery was a mistake, or you may think 'what in the world have I done to myself?
All these feelings are completely normal and, to a certain extent, are to be expected. The low number of calories you are eating produces what many of us call the 'hibernation syndrome' and your depression and feelings of despair,are a direct result.
During the weeks immediately following surgery, our body starts to notice that we are not taking in enough calories. It doesn't know we've had WLS, or that it's the year 2004. Our body is missing food, thinks this is a famine, and struggles to conserve our energy. The human body reacts like it always has in a famine; it makes us depressed--so we don't have the motivation to do anything, and it makes us tired--so we don't have the energy to do anything. In this way, we will conserve as many calories as possible and remain alive.
You can see the practical value of this as our bodies have been living through famines, snowstorms, and other periods of unstable food supply for centuries.
This stage can last several weeks. Our discomfort is compounded as we are, at this same time, trying to recover from major surgery, adopt new eating habits, and deal with a liquid or soft diet. To get out of this stage, our body has to say to itself 'gee, this famine is lasting a bit too long. If I keep conserving my energy with inactivity, I will starve to death. I'd better use my last store of energy (the remaining fat and muscles in our body) to hunt up some food'. At this point, our body will switch from getting energy from food, to getting energy from our fat (and muscle too if we don't eat enough protein) and that is what we want.
In order to deal with this difficult transition period, tell yourself that you're right on track; this is exactly what is normal and to be expected.
Tell yourself that, in a few weeks, this will pass, and you will feel like a completely new person. We all seem to turn the corner about 4-6 weeks post op. Then, your mood will lighten and, with your weight loss starting to add up, you'll feel more positive and have a better outlook on life. Just keep telling yourself that you will not always feel this way! You WILL be back to feeling like your old self. Just give it time!
Recipes
Nov 05, 2006
AWARD WINNING CHILI!I
Chop finely and brown in a large skillet:
1 red pepper
1 green pepper
1 yellow pepper
1 orange pepper
if desired 3-4 medium jalapeno peppers
1 medium onion
1 1/2 to 2 lb of lean ground beef, pork or ground turkey
Cook thoroughly until peppers and onions are soft and drain.
Put this mixture into a large cooking pot.
Add 3 - 40 oz cans of any combination of light and dark kidney beans.
Drain 2 - 28 oz cans of whole tomatoes, squash until they have all water removed, and stir into the meat/onion, kidney bean mixture.
Add 1 - 1 lb jar of salsa, hot or medium.
Stir in 3 lb (48 oz) of ragu or any other plain tomato sauce.
Mix thoroughly. Add 1/2 cup splenda and chili power to taste. I start with 2 tablespoons of chili power and as chili mixture cooks, I add accordingly. As the chili cooks, the flavors will come out so allow to cook for a few minutes before test tasting and adding chili power.
Cook 1-2 hours on low/simmer heat, and enjoy! This chili is great right after cooking but is even better after it cools and refrigerates for a day, and even delicous after freezing and reheating also!
**********************
OTHER RECIPES
Fabulous Pecan Pie
3 large eggs
1/4 cup Steel's Nature's Sweet White Crystals
1/2 cup Steel's Nature's Sweet Brown Crystals
pinch of salt
teaspoon vanilla
4 tablespoons melted butter
3/4 cup Steel's Sugar Free Country Syrup
1/2 c Chopped Pecans, plus 10 halves
One 9 inch unbaked pie crust
1/2 teaspoon corn starch
Preheat to 350. Beat eggs in large bowl, then stir in everything else, except for the pecan halves. Pour filling into crust. Arrange halves on top. Bake 30-35 minutes. Cool. Keep refrigerated or this pie will spoil.
********************************
Joanne from Boston's Meatballs and Gravy
For the gravy, get a onion-- chop it up and brown it with 1/2 cup of olive oil
Take from heat-- cool it off because it splatters you
Put 3 cans of kitchen ready tomatoes in pan with oil
1/4 cup of the following
oregano
basil
rosemary
salt
red pepper flakes
black pepper
and T of sugar
Put on stove and simmer for at least 1 hour before you put meatballs in-- then cook at least 3 hours
1 and a half pounds of lean hamburger
2 pieces of bread soaked in milk
handful of bread crumbs
garlic cloves
sprinkle parsley over bread crumbs
handful of grated cheese
squeeze bread--get excess milk up; crumble into mixture and add 2 eggs
Mix. Put oven on 350 degrees.
Form balls, then bake for half hour.
Take out and give one to the dog and hubby. Put rest in gravy.
Go out, come home, and 4 more meatballs are missing. lol..
***********************************************
Cath's Tortilla Soup
Ingredients
4 large or 5 small chicken breasts
2 Tbsp Olive Oil
1 Small chopped onion
1 small can chopped green chiles
1 16 oz. can chopped tomatoes (Rotel is good)
1 package Taco seasoning
4 cans chicken broth
2 cups frozen corn
cilantro (chopped to taste)
1 avocado
Monterrey Jack cheese
Directions
Saute onion in olive oil
Add all ingredients EXCEPT for the avocado & cheese.
Cook over a medium heat until chicken is fully cooked.
Serve with tortilla chips. Top with cheese & avocado.
**Note – if you like a thicker soup, masa flour may be added. Also, sour cream topping is a favorite of some.
****************************
Traci's Taco Soup
1 1/2 lbs ground beef
1 sm. onion, chopped
1 sm. pkg Hidden Valley Ranch dressing mix
1 can Rotel, diced
1 can diced tomatoes
1 can plain ranch beans
1 can pinto beans
1 can white hominy
1 can yellow hominy
1 can red kidney beans
1 can ranch style beans
2 tsp. chili powder (optional)
2 Tbs. sugar
1 1/2 C. water (add more if needed)
Brown meat with onion and drain. Using a large pot, add all of ingredients together. Adding water as needed. Cook 30 minutes. Serve with tortilla chips & top with grated cheese.
NOTE: all cans are 15 oz size and the only one you do drain is the hominy cans...do not drain the others. It is very easy to double this recipe.
***********************
Melissa's Award-Winning Chili Recipe--thanks!
1 lb of ground sirloin
2 med. size cans of Ranch Style Beans (1 reg & 1 with japs)
1 can of steawed tomatoes
1 can pinto beans
1 can kidney beans
1 pkg of Chili Mild Seasonings
1/2 chopped onion
1 block cheedar cheese
In a med/lg pot brown mean and onions together, drain off fat, return to the stove on med heat.
Add Chili Seasoning (NO WATER JUST THE MIX) stir the seasonings into the meat
Drain your pinto and kidney beans ONLY
Add the Ranch Style beans and tomatoes and stir into the meat mixture
Add the pinto beans and kidney beans and stir into the mixture
Turn heat down, to simmer and simmer for about 30 minutes~ You want to stir the chili every 10 minutes.
grate your cheese, and on each serving add cheese on top.
*************************
About Me
Cedar Park, TX
Location
41.2
BMI
Surgery
11/25/2003
Surgery Date
Sep 12, 2002
Member Since
Before & After
rollover to see after photo
I've lost over 100 pounds! In the first photo, I weigh 350 pounds; in the last photo, I weigh 250 pounds.
