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God's Pharmacy God  left us a great  clue  as to what  foods  help what part of  our  body! A sliced Carrot looks like the human eye. The pupil, iris and radiating lines look just like the human eye... and YES, science now shows carrots greatly enhance blood flow to and function of the eyes. A Tomato has four  chambers and is red. The heart has four  chambers and is red. All of the research shows tomatoes are loaded with lycopine and are indeed pure heart and blood food. Grapes hang in a cluster that has the shape of the heart. Each grape looks like a blood cell and all of the research today shows grapes are also profound heart and blood vitalizing food. A Walnut looks like a little brain, a left and right hemisphere, upper cerebrums and lower cerebellums. Even the wrinkles or folds on the nut are just like the neo-cortex. We now know walnuts help develop more than three (3) dozen neuron-transmitters for brain function. Kidney Beans actually heal and help maintain kidney function and yes, they look exactly like the human kidneys. Celery, Bok Choy, Rhubarb and many more look just like bones. These foods specifically target bone strength. Bones are 23% sodium and these foods are 23% sodium. If you don't have enough sodium in your diet, the body pulls it from the bones, thus making them weak. These foods replenish the skeletal needs of the body. Avocadoes, Eggplant and Pears target the health and function of the womb and cervix of the female - they look just like these organs. Today's research shows that when a woman eats one avocado a week, it balances hormones, sheds unwanted birth weight, and prevents cervical cancers. And how profound is this? It takes exactly nine (9) months to grow an avocado from blossom to ripened fruit. There are over 14,000 photolytic chemical constituents of nutrition in each one of these foods (modern science has only studied and named about 141 of them). Figs are full of seeds and hang in twos when they grow. Figs increase the mobility of male sperm and increase the numbers of Sperm as well to overcome male sterility. Sweet Potatoes look like the pancreas and actually balance the glycemic index of diabetics. Olives assist the health and function of the ovaries. Oranges,Grapefruits,and other Citrus fruits look just l ike the mammary glands of the female and actually assist the health of the breasts and the movement of lymph in and out of the breasts. Onions look like the body's cells. Today's research shows onions help clear waste materials from all of the body cells. They even produce tears which wash the epithelial layers of the eyes. A working companion, Garlic, also helps eliminate waste materials and dangerous free radicals from the body.

Staying healthy and feeling great

Antioxidants:
• Vitamin A Beta Carotene protects mucous membranes of the mouth, nose, throat, and lungs. Our health, our very life, is dependent upon the integrity of this vital lining which resists and destroys invading germs and bacteria.
• Vitamin C fights bacterial infections and reduces the effects of allergy-producing substances.
• Vitamin E like vitamin C, a lack of vitamin E allows cells to break down because essential fatty acids, forming part of the cell structure, are destroyed by oxygen in its absence, hence clots can form rapidly.
• Selenium and Vitamin E must both be present to correct a deficiency in either.

Vitamins:
• Vitamin D properly utilizes calcium and phosphorous necessary for strong bones and teeth. Deficiency can cause tooth decay, soft bones, leg cramps and arthritis.
• B-Vitamins are needed in every one of the billions of cells in the human body. They prevent fatigue, mental depression, nervousness, and an almost endless array of diseases. Deficiencies of B-Vitamins result from eating processed de-vitaminized foods. We need an abundance of B-Vitamins to eliminate stress.
• Biotin deficiencies, which can be caused by antibiotics, may produce eczema, dermatitis, heart trouble, lung infection, baldness, muscular soreness, fatigue, and mental depression.
• Niacin is essential for proper assimilation of starch, sugar, and B-1 and B-2. A niacin deficiency may cause serious mental depression, insanity, dermatitis, diarrhea, tender gums, nausea, sleeplessness, coated tongue, sore mouth, tension, and nervousness.
• Pantothenic Acid is necessary for every cell in the human body. A mother's milk is rich in Pantothenic Acid. But there is none in canned or pasteurized milk. Pantothenic Acid greatly increases strength and endurance. It helps to prevent aging.
• Folic Acid deficiency may cause fatigue, dizziness, mental depression, over pigmentation, and shortness of breath. Nothing - not even a fingernail or hair - can grow without Folic Acid. There are more deficiencies of Folic Acid than any other vitamin.
• Choline helps promote healthy circulation, strengthens the walls of the blood vessels, and helps to prevent cancer of the liver. It is a vital factor in making a strong, healthy liver.
• Inositol prevents and helps constipation, eczema, dermatitis, eye weakness, heart trouble, gas pains, and poor appetite, Inositol and Choline combine in the liver to form Lecithin which helps to dissolve clots and prevent hardening of the arteries, strokes, heart attacks, and multiple sclerosis.
• Paba helps correct both over and under pigmentation.
• Bioflavonoid strengthen blood vessels by increasing capillary strength. Aids in preventing bleeding gums and hemorrhoids.

Minerals: Minerals are absolutely essential to the utilization of all nutrients.
• Calcium is needed for strong teeth and bones.
• Magnesium is needed for healthy nerves and a strong heart.
• Potassium deficiency can injure the adrenals and raise blood pressure. A lack of Potassium also causes muscle spasms.
• Phosphorous contributes to the continuous regeneration of the brain, nerves, arteries, blood vessels, organs, and cells of the body.
• Zinc deficiency may cause prostitis, infertility, and low resistance to infections.
• Manganese deficiency has a tendency to cause muscle weakness and poor nerve responses.
• Iodine from kelp helps make a healthy thyroid upon which our very lives depend.
• Chromium works with insulin in the metabolism of sugar.
• Copper with other nutrients helps in the healing of wounds.
• Boron is needed in trace amounts for calcium uptake and healthy bones.

Protein:
• Protein is what we are made of. It repairs every organ, gland, tissue, and cell of the entire body. It makes us youthful, vigorous, confident and enthusiastic.

Enzymes:
• Enzymes are vitally important for maintaining proper function of the body, digesting food, and aiding in the repair of tissue.


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

 

 

 

              

 

 

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

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

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

PUBLISHED DATA: How does the pouch make you feel full? The nerves tell the brain the pouch is distended and that cuts off hunger with a feeling of fullness.

What is the fate of the pouch? Does it enlarge? If it does, is it because the operation was bad, or the patient is overstuffing themselves, or does the pouch actually re-grow in a healing attempt to get back to normal? For ten years, I had patients eat until full with cottage cheese every three months, and report the amount of cottage cheese they were able to eat before feeling full. This gave me an idea of the size of their pouch at three month intervals. I found there was a regular growth in the amount of intake of every single pouch. The average date the pouch stopped growing was two years. After the second year, all pouches stopped growing. Most pouches ended at 6 oz., with some as large at 9-10 ozs.

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

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

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

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

HOW DO WE INTERPRET THESE OBSERVATIONS?

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

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

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

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

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

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

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

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

PREVENTION OF VOMITING: Vomiting should be prevented as much as possible. Right after surgery, the patient should sip out of 1 oz cups and only 1/3 of that cup at a time until
the patient learns the size of his/her pouch to avoid being sick.

It is extremely difficult to learn to deal with a small pouch. For the first 6 months, the patient's mouth will literally be bigger than his/her stomach, which does not exist in any living animal on earth.

In the first six weeks the patient should slowly transfer from a liquid diet to a blenderized or soft food diet only, to reduce the chance of vomiting.

Vomiting will occur only after eating of solid foods begins. Rice, pasta, granola, etc., will swell in time and overload the pouch, which will cause vomiting. If the patient is having trouble with vomiting, he/she needs to get 1 oz cups and literally eat 1 oz of food at a time and wait a few minutes before eating another 1 oz of food. Stop when "comfortably satisfied," until the patient learns the size of his/her pouch.

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

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

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

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

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

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

THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SUMMARY:

1. The patient needs to understand how the new pouch physically works.
2. The patient needs to be able to evaluate their use of the tool, compare it to the ideal and see where they need to make changes.
3. Instruct your patient in all ways (through their eyes with visual aids, ears with lectures and emotions with stories and feelings) not only on how but why they need to learn to use their pouch. The goal is for the patient to become an expert on how to use the pouch.

EVALUATION FOR WEIGHT LOSS FAILURE: The first thing that needs to be ruled out in patients who regain their weight is how the pouch is set up.

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

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

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

3) To assess pouch volume, an upper GI doesn't work as it is a liquid. The cottage cheese test is useful - eating as much cottage cheese as possible in five to 15 minutes to find out how much food the pouch will hold. It shouldn't be able to hold more than 1 ½ cups in 5 - 15 minutes of quick eating. (*note, not part of the article... but, after a couple of years out, this test should be done with lean steak such as round steak rather than cottage cheese)

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

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

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

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

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

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

     THE FELLOWSHIP OF THE UNASHAMED! 


 I`m part of the fellowship of the unashamed. I have stepped over the line. The decision has been made_ I am a disciple of His. I won`t look back, let up, slow down, back away, or be still. My past is redeemed, my present makes sense, my future is secure. I`m finished and done with low living, sight walking, smooth talking and smooth knees, colorless dreams, tamed visions, worldy talking, cheap giving, cheap thrills and dwarfted goals.

I no longer need preeminence, prosperity, position, promotion, plaudits, or popularity. I don`t have to be right, first, tops, recognized, praised, regarded, or rewarded. I now live by faith, lean on His presence,
walk by patience ,am uplifted by prayer ,and I labor with power. My face is set, my mind made up, my gait is fast, my goal is heaven, my road is narrow, my way is rough, my companions are few, my Guide is reliable, my mission is clear. 
I cannot be bought, compromised,detoured, lured away, turned back, deluded, or delayed!

I will not flinch in the face of sacrifice, hesitate in the presence of the enemy, pander at the pool of popularity, or meander in the maze of mediocrity. 
I won`t give up, shut up, let up, until I have stayed up, soared up ,prayed up, and preached up for the cause of Christ. I am a disciple of Jesus. I must go till He
comes, give till I drop, preach till all know, and work till He stops me. And when He comes for His own, He will have no problem recognizing me...My banner will be clear!  

Will you join me? 

                                                            Dr. M Marshall Woodard
       
WE ARE SO BLESSED!
                 

If you woke up this morning with more health than illness, you are more blessed than the million who will not survive the week. 

If you have never experienced the danger of battle, the loneliness of imprisonment, the agony of torture or the pains of starvation, you are ahead of 500 million people around the world. 

If you can express your beliefs without fear of harassment, arrest, torture, or death, you are more blessed that almost three billion people in the world.

If you have food in your refrigerator, clothes on your back, a roof over your head and a place to sleep, you are richer than 75% of this world. 

If you have money in the bank, in your wallet, and spare change in a dish someplace, you are among the top 8% of the worlds wealthiest.

If your parents are still married and alive, you are very, very rare.

If you hold up your head with a smile on your face and are truly thankful, you are blessed because the majority can, but most do not.

If you can hold someone`s hand, hug them or even touch them on the shoulder, you are blessed because you can offer God`s healing touch.

If you own just one Bible, you are abundantly blessed. 1/3 of the world does not have access to even one. If you can read this message, you are more blessed than over two billion people in the world that cannot read anything at all.

 

 

 

 

 

 

 

 

 

 

 Staying healthy and feeling great

Antioxidants:
• Vitamin A Beta Carotene protects mucous membranes of the mouth, nose, throat, and lungs. Our health, our very life, is dependent upon the integrity of this vital lining which resists and destroys invading germs and bacteria.
• Vitamin C fights bacterial infections and reduces the effects of allergy-producing substances.
• Vitamin E like vitamin C, a lack of vitamin E allows cells to break down because essential fatty acids, forming part of the cell structure, are destroyed by oxygen in its absence, hence clots can form rapidly.
• Selenium and Vitamin E must both be present to correct a deficiency in either.

Vitamins:
• Vitamin D properly utilizes calcium and phosphorous necessary for strong bones and teeth. Deficiency can cause tooth decay, soft bones, leg cramps and arthritis.
• B-Vitamins are needed in every one of the billions of cells in the human body. They prevent fatigue, mental depression, nervousness, and an almost endless array of diseases. Deficiencies of B-Vitamins result from eating processed de-vitaminized foods. We need an abundance of B-Vitamins to eliminate stress.
• Biotin deficiencies, which can be caused by antibiotics, may produce eczema, dermatitis, heart trouble, lung infection, baldness, muscular soreness, fatigue, and mental depression.
• Niacin is essential for proper assimilation of starch, sugar, and B-1 and B-2. A niacin deficiency may cause serious mental depression, insanity, dermatitis, diarrhea, tender gums, nausea, sleeplessness, coated tongue, sore mouth, tension, and nervousness.
• Pantothenic Acid is necessary for every cell in the human body. A mother's milk is rich in Pantothenic Acid. But there is none in canned or pasteurized milk. Pantothenic Acid greatly increases strength and endurance. It helps to prevent aging.
• Folic Acid deficiency may cause fatigue, dizziness, mental depression, over pigmentation, and shortness of breath. Nothing - not even a fingernail or hair - can grow without Folic Acid. There are more deficiencies of Folic Acid than any other vitamin.
• Choline helps promote healthy circulation, strengthens the walls of the blood vessels, and helps to prevent cancer of the liver. It is a vital factor in making a strong, healthy liver.
• Inositol prevents and helps constipation, eczema, dermatitis, eye weakness, heart trouble, gas pains, and poor appetite, Inositol and Choline combine in the liver to form Lecithin which helps to dissolve clots and prevent hardening of the arteries, strokes, heart attacks, and multiple sclerosis.
• Paba helps correct both over and under pigmentation.
• Bioflavonoid strengthen blood vessels by increasing capillary strength. Aids in preventing bleeding gums and hemorrhoids.

Minerals: Minerals are absolutely essential to the utilization of all nutrients.
• Calcium is needed for strong teeth and bones.
• Magnesium is needed for healthy nerves and a strong heart.
• Potassium deficiency can injure the adrenals and raise blood pressure. A lack of Potassium also causes muscle spasms.
• Phosphorous contributes to the continuous regeneration of the brain, nerves, arteries, blood vessels, organs, and cells of the body.
• Zinc deficiency may cause prostitis, infertility, and low resistance to infections.
• Manganese deficiency has a tendency to cause muscle weakness and poor nerve responses.
• Iodine from kelp helps make a healthy thyroid upon which our very lives depend.
• Chromium works with insulin in the metabolism of sugar.
• Copper with other nutrients helps in the healing of wounds.
• Boron is needed in trace amounts for calcium uptake and healthy bones.

Protein:
• Protein is what we are made of. It repairs every organ, gland, tissue, and cell of the entire body. It makes us youthful, vigorous, confident and enthusiastic.

Enzymes:
• Enzymes are vitally important for maintaining proper function of the body, digesting food, and aiding in the repair of tissue.


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

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

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

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

PUBLISHED DATA: How does the pouch make you feel full? The nerves tell the brain the pouch is distended and that cuts off hunger with a feeling of fullness.

What is the fate of the pouch? Does it enlarge? If it does, is it because the operation was bad, or the patient is overstuffing themselves, or does the pouch actually re-grow in a healing attempt to get back to normal? For ten years, I had patients eat until full with cottage cheese every three months, and report the amount of cottage cheese they were able to eat before feeling full. This gave me an idea of the size of their pouch at three month intervals. I found there was a regular growth in the amount of intake of every single pouch. The average date the pouch stopped growing was two years. After the second year, all pouches stopped growing. Most pouches ended at 6 oz., with some as large at 9-10 ozs.

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

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

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

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

HOW DO WE INTERPRET THESE OBSERVATIONS?

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

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

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

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

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

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

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

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

PREVENTION OF VOMITING: Vomiting should be prevented as much as possible. Right after surgery, the patient should sip out of 1 oz cups and only 1/3 of that cup at a time until
the patient learns the size of his/her pouch to avoid being sick.

It is extremely difficult to learn to deal with a small pouch. For the first 6 months, the patient's mouth will literally be bigger than his/her stomach, which does not exist in any living animal on earth.

In the first six weeks the patient should slowly transfer from a liquid diet to a blenderized or soft food diet only, to reduce the chance of vomiting.

Vomiting will occur only after eating of solid foods begins. Rice, pasta, granola, etc., will swell in time and overload the pouch, which will cause vomiting. If the patient is having trouble with vomiting, he/she needs to get 1 oz cups and literally eat 1 oz of food at a time and wait a few minutes before eating another 1 oz of food. Stop when "comfortably satisfied," until the patient learns the size of his/her pouch.

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

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

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

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

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

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

THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SUMMARY:

1. The patient needs to understand how the new pouch physically works.
2. The patient needs to be able to evaluate their use of the tool, compare it to the ideal and see where they need to make changes.
3. Instruct your patient in all ways (through their eyes with visual aids, ears with lectures and emotions with stories and feelings) not only on how but why they need to learn to use their pouch. The goal is for the patient to become an expert on how to use the pouch.

EVALUATION FOR WEIGHT LOSS FAILURE: The first thing that needs to be ruled out in patients who regain their weight is how the pouch is set up.

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

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

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

3) To assess pouch volume, an upper GI doesn't work as it is a liquid. The cottage cheese test is useful - eating as much cottage cheese as possible in five to 15 minutes to find out how much food the pouch will hold. It shouldn't be able to hold more than 1 ½ cups in 5 - 15 minutes of quick eating. (*note, not part of the article... but, after a couple of years out, this test should be done with lean steak such as round steak rather than cottage cheese)

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

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

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

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

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

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

 

 

              

 

                                 *Art Graphic created by me Dreamz*aka 
                                                             ©TwoDreams

Question:  Where does the fat go when you lose weight? How does it leave the body?

Answer:  When you consume fewer calories than your body needs, your body turns to fat for energy. Body fat is broken down through a series of complex metabolic processes. Your body uses the energy produced by these processes. The waste products from these processes are water and carbon dioxide. You excrete water primarily through urine and sweat, and carbon dioxide by exhaling.

Drink Plenty of Water
Exercise & Breeeeaaatthhhee Deep! 


My Home Equipment (No Excuses)

Calories and Weight Lost

A calorie is a unit of energy. When your body needs energy, your body burns  calories from the food you eat or from the calories stored in your body in fat, glucose (or glycogen) and/or protein. Foods provide calories. Whenever you eat or drink, the calories you take in are used or stored for later use.
Weight loss all boils down to what is known as the energy equation: To lose weight you need to create a caloric deficit by eating less, or burning more, than your daily energy requirements. So, you need to take in fewer calories from food (and it doesn't matter if you eat fewer carb, fat or protein calories, as long as you meet your daily nutrient needs.) Or you need to use up more calories by burning more from physical activity. Over time, the caloric deficit you create will result in fat loss and/or pounds lost on the scale."

There are different types of calories that provide energy. These are known as the macronutrients: protein, carbohydrates and fat. (Alcohol also provides some energy but is not considered a main fuel source.) At the same given amount, each of these substances provides a slightly different number of calories:

    •   One gram of protein equals four calories

    •   One gram of carbs equals four calories

    •   One gram of fat equals nine calories



GET YOUR MIND RIGHT!

YeaYea sometimes you have to do the Mind Control Thing, but Work It! because its so Rewarding and Worth it in the End!

I Love Spending Time @ My Althetic Club

 Free Weights, Weight Machines, Treadmills Heated Pool(My Personal Favorites!)Cycling and Elipicals 
Also, Spin Classes are the Bomb! 
Outdoor Running for Fresh Air on Beautiful Days...
Swimming Laps @ least 25 
(I just Love the Water...Hey, I'm a Water Bearer)
followed by the Hot Tub and/or Sauna(so soothing)




DONT BE A PACMAN! (eating everything in sight)
Eat To Live!...
(With small rewards in between)
...and you will Feel So Undeprived!
Do your best to meet at least the minimum recommendations for calories, carbohydrates, fat and protein as outlined on your Nutrition Tracker. The table below converts these percentages into grams needed each day based on calorie intake:

Nutrient	Carbohydrates	Fat	Protein (Women)	Protein (Men)
Healthy Range	45%-65%	20%-35%	10%-35%	10%-35%
1200 calories	135-195 g	27-47 g	*60-105 g	N/A
1500 calories	169-244 g	33-58 g	*60-131 g	*75-131 g
1800 calories	203-293 g	40-70 g	*60-158 g	*75-158 g
2100 calories	236-341 g	47-82 g	*60-184 g	*75-184 g
2400 calories	270-390 g	53-93 g	*60-210 g	*75-210 g

 

 

 Be a BAD Muther....SHUT YO MOUTH!
         
                                              

               *Art Graphic created by me TwoDreams*aka 
                                    ©Dreamz
This Time!

Another diet we're about to endure,
but this time we'll do it, of that we are sure.
We've tried all the others without much success,
but this is the one to get into That Dress

For  years we've tried hard to lose excess weight,and we now have the answer  to looking  just great.For us no more 'Chips' or 'Big Mac' on a whim,We want to look good and we'd love to be Slim. 

We joined all these clubs where we'd regularly meet,We read all the can't haves but, we still go home and cheat. They said don't have this and they said don't have that,So now we've paid all that money just to stay Fat We all have a wardrobe from size 12 up to 20,and big, baggy jumpers of which there are plenty. A drawer of small undies is a dream we all know, so those big ugly knickers really must go!

 
With time passing quickly and teenage years gone,We have no more excuses to rely upon,
The one about "Babyfat" ran out long ago, So this time it's  Business, Let's Give it a Go!

 

 

        Happy New Year!

                                   



 

*Art Graphic created by me TwoDreams*aka 
©Dreamz

December 3, 2007

Sitting Over Here on the Losers Bench, and...
 I Cant Wait to Play

Oh Well, Soon Soon i hope, dont get me wrong i'm not complaining...i am just ready to get my game started! and i know i have to have  everything... my mind, my body and all the senses of my soul in tack to give my game the best of my ability...and as of yet i am still in a very recupertive stage.

But,i just wanted to let everyone know that i'm home and still hanging in here...its been a really wild ride...one i didnt expect, but i guess i wasnt one of the lucky ones who breezed through easier...the blessed thing is i have not had any complications Praise God...i am just really sore and in pain but,i can see it continually diminishing as the days are passing...now all i have to do is get rid of this nausea and sick of the stomach feeling all the time...i would like to say Thank you to everyone who had supported me so much and for all the prayers that have been sent my way...
 am so grateful always, Dreamz








December 7, 2007
I'M A FIRST STRING PLAYER!!!

OMG Thank You Everyone for your Prayers and Support...it is because of you & them i was able to find my way towards the light>>>THANK YOU MY AWESOME GOD!!!...i'd like to let every one know that i am doing really good now by keeping myself feeling Blessed & Strong... and doing what is  not only needed but mandantory...no matter how bad i felt i walked on my treadmill (just a bit at first @1.5 for 10 minutes)...and now accomplishing daily a 35-40 minute walk currently @ 2.6 (i'm getting there!)... i am now getting in All My Fluids Daily including 3 protien drinks a day mixed with a tolerence of 8oz skim milk...so i am getting in well over 100 grams daily...i am still a bit sore but i not longer take pains meds..i feel strong and happy and have plenty of entergy too!...You Guys who have been my rock, My Support Group Buddies...Brenie, Tag, Adelida, Rozzy, CarrieO, Dianna_Lynn, Jenn & Thank you so much for your prayers Hidy...and many others who do not post here like Karen and Sam from our support group who called my butt  everyday...i got Sooo Much Love for you all and cant wait to see you guys on the 18th
Blessings, Dreamz

NO ONE BY ALICIA KEYS...deplicts my feelings for
My Father God

I just want you close
Where you can stay forever
You can be sure
That it will only get better
You and me together
Through the days and nights
I dont worry cause
Everythings gonna be alright
People keep talking
They can say what they like
But all I know is everything's gonna be alright

No one no one no one
Can get in the way of what I'm feeling
No one no one no one
Can get in the way of what I feel for you
You you
Can get in the way of what I feel for you

When the rain is pouring down
And my heart is hurting
You will always be around
This I know for certain

You and me together
Through the days and nights
 I dont worry cause
Everythings gonna be alright
People keep talking
They can say what they like
But all I know is everything's gonna be alright

No one no one no one
Can get in the way of what I'm feeling
No one no one no one
Can get in the way of what I feel for you
You you
Can get in the way of what I feel for you

I know some people search the world
To find something like what we have
I know people will try
Try to divide
Something so real
So till the end of time
Im telling you that

No one no one no one
Can get in the way of what I'm feeling
No one no one no one
Can get in the way of what I feel for you
oh oh oh




December 13, 2007
MY POST-OP APPOINTMENT WENT GREAT!

Everything went really fantastic with my post-op today...i had all my surgical tape taken off, at least the last few that hadnt fallen off. All the sites did really good no trace of any infection and healed perfectly. i didnt have anything to report to Dr. Richardson because all is well. i was told i was doing really good with my protiens and fluid intakes and that i could now move on to pureed food,Yeaaa!, because i am so weary now of doing the fluid thing, i really dont think i could go on another day with another sweet protien drink. Neways i was so excited to eat but i wanted to still eat the right thing so yes i did pureed beans and i swear i feel like i am about to "POP" i am so tight...i was careful though...i weight out exactly 3 ounces in my little baby bowl and, OMG! i swear next time i will only have 2 ounces, because i dont need this feeling. i didnt dump, but i boderlined it for sure. Well, as soon as i can move i'm going to go get the perscription filled that Doc gave me for to take to keep my Gall bladder good. i'm trying so hard to do all the right things because i want my journey to be extra extrodinary sucessful!


December 28, 2007
 Now One Month Out, And Food and I Do NOT Get Along!

Well, i guess that really sounds pretty bad but i really just dont have much desire for eating. Besides sometimes when i eat it hurts my pouch. I had my One Month Post-Op with my Doctor yesterday and everything was great, even all my labs because thats one thing i am on top of everyday is taking all my vitamins. I told Dr. Richardson how i felt and he told me that was a good thing and that i would lose a lot of weight. He told me i was on point with my weight loss and he didnt see a problem since i was still doing my protien shakes twice a day with skim milk and acheiving 66 grams of protien from that. Even though food is of no interest i do pick at little protien things here and there, so i do get in a little bit more protien that way too. i was worried at first because i didnt want to eat, but i guess its ok if he seems to think so. Well, i will continue to make sure i get in enough protien, take my vitamins, drink plenty of water and do my exercise then i'll and see what happens.

                         

                *Art Graphic created by me TwoDreams*aka 
                                       ©Dreamz

After randomingly checking with my insurance company to make sure that all my paperwork had been submitted from my doctors office i was told that it was received on Oct.22nd and was on the Medical Directors desk for review ...Well,
            THREE DAYS PASSED AND...

I Was Approved on October 25th, 2007

....and i now have my surgery date of November 28th


OK Here We Go!
November 5th,2007

Dr. Ricardson's nurse called me today to set up my Pre-Surgery consult on Nov. 15th with Laura my Nut and with the appointment  with the Doc to finalize everything and to sign the all the necessary paperwork for the surgery. It will be two days after i start my liquid diet so i quess if i have any questions concerning that venture i can bring them up then...well, its all very real now!

 November 13, 2007

I started my liquid diet yesterday which is a 2 week liquid liver shrinking diet and i did pretty good all day long until around 5:00 my stomach started hurting really bad. Of course it wasnt long before i had to do a mad dash to the OMG, what in the hell? is happening...Ok i'm thinking that its the rapid onsought of protien and my body needs to adjust but please tell me why did it have to kill me all and i mean alllllllllnight and all the next day...i thought i was going to die...i had really bad headaches and nausea to no end...Yep i was balling like a baby...it was horrible, but mostly i think i was balling because i was like so concerned how in the world am i going to tolorate feeling like this for an entire 2 weeks...i need to call the Docs office right now!, Well i actually felt like i needed to go to the ER...LOL...but i decided to try to hold on and give it a chance since i was going in for my pre-op surgery appointment the next day... i just prayed on it and the Lord  helped me through.



SoOoOoOoOoOoOOOo, i'M OFF TO SEE MY WONDERFUL WIZARD! 
Behond the Yellow Brick Road~~~~
                    
               It Only Takes... 
          Brains, Courage, and Heart!  

 Just Follow the Golden Road Rules!                                       
 
                               
                    Triumph Over Evil

                             ~Love God~
              Stay Blessed&U,Stay Strong 
                      Click Your Heels!
                                
                                        (being healthy & Alive!)
                                         there is no place like it!
                            there is no place like it!!
            ...THERE'S NO PLACE LIKE IT!!!
            >>>there's no feeling like OZ<<<
                        Obesity Zapped!

 

 

 

 

 

 "Far better is it to dare mighty things, to win glorious triumphs, even though checkered by failure,than to rank with those poor spirits who neither enjoy much nor suffer much, because they live in a Gray Twilight that knows not victory nor defeat.  - Theodore Roosevelt 

                                                                          
                                                                      

 

 

 

 

 

My Nutrition Consult

Well i had my consult with Laura on Friday October 5th and she talked to me concerning my Pre-op and Post-op diets. She gave me a booklet with all the information i will need for my nutritional guidance and where i could pretty much find everything. That helped out a lot. Other than that it all went very smoothly and it was a very nice conversation and we got to know each other pretty good. Well, that was my final phase and now all my information is being submitted to my insurance company, so its time for the waiting game now. I'm just praying and hoping that i get a speedy reply. thats all i need because i already know i'm going to be approved because i have faith.

October 25, 2007
After a random check with my insurance company on the 23rd of Oct. to make sure that all my paperwork had been submitted from my doctors office i was told that it was received on Oct.22nd  and was on the Medical Directors desk for review ...Well,
THREE DAYS PASSED AND...

I Was Approved Today October 25th, 2007
 


What Did I Say About Faith!
 Solid, Undeniable, Completely Released Faith

Faith in our Lord is all anyone ever needs and following God's example in being the kind of person that he wants all of us to be by having genuine care and love for others no matter who they are,  how much or how little they have, what they do, or especially what COLOR the skin, because it is an insult to God who, Lovingly and Deliberately made all of us different but same. Its just that Simple! When we have this embedded within our heart, and practiced everyday, it automatically Guides Us into Goodness in Every Aspect concerning our Everyday Lives.
BELIEVE THAT!


All God Wants Us To do Is Love Each Other!





LIFE IS A GIFT 
There was a blind girl who hated herself
just because she was blind.
She hated everyone, except her loving boyfriend. He was always there for her.
She said that if she could only see the world,
she would marry her boyfriend.

One day, someone donated a pair of eyes to her. She was then able to see everything,
including her boyfriend.

Her boyfriend asked her,
" Now that you can see the world,
will you marry me?"
The girl was shocked when she saw
that her boyfriend was blind.
She then refused to marry him.

Her boyfriend walked away in tears
and later wrote a letter to her saying:
"Just take care of my eyes dear,
for I loved you so much
that it was I who was the donor of your gift. "

This is how the human brain changes
when our status changes.
Only few remember what life was before,
and who's always been there
even in the most painful situations.

"Life Is A Gift"

Today before you say an unkind word -
Think of someone who can't speak.

Before you complain about the taste of your food - Think of someone who has nothing to eat.

Before you complain about your husband or wife - Think of someone who's crying out to GOD
for a companion.

Today before you complain about life -
Th ink of someone who went too early to heaven.

Before you complain about your children -
Think of someone who desires children
but they're barren.

Before you argue about your dirty house
someone didn't clean or sweep -
Think of the people who are living in the streets.

Before whining about the distance you drive –
Think of someone who walks the same distance with their feet.

And when you are tired
and complain about your job -
Think of the unemployed, the disabled,
and those who wish they had your job.

But before you think of pointing the finger
or condemning another -
Remember that not one of us are without sin
and we all answer to one MAKER.

And when depressing thoughts
seem to get you down -
Put a smile on your face
and thank GOD you're alive and still around.

Life is a gift, Live it, Enjoy it, Celebrate it,
And Fulfill it.

We Serve an AWESOME GOD !!! 

 

 

  

"Far better is it to dare mighty things, to win glorious triumphs, even though checkered by failure,than to rank with those poor spirits who neither enjoy much nor suffer much, because they live in a Gray Twilight that knows not victory nor defeat."
                                                                                     
  - Theodore Roosevelt 
Hi My Name is...


It Really Is Finally Finally Happening!

All the Blessings and Goodness in my life 
internal and external are testimonies to our Lord and Savior ...i love him so much...he is my life!...and he will continue to always deliver me and show me the WAY with all endeavors...it is so admazing how much he has done and showed  me in my life...and i know he will continue to do so...i give him all Praise and Glory... So Please Pray for me and with me for continued Blessings from God for all of us ...as you can read on my blog that i was having insurance issues due to everything being turned upside down here in  New Orleans since the Katrina storm...and still all original Tenet facilities have not been able to get up and running as of yet ...Well Neways, Praise God, my insurance have been working to get a New contract with the Ochsner Hospital Facility here (which is/was a completely seperate entity from my insurance Tenet Choice...but is also a "Center Of Excellence" (and a necessary requirement for me)...i have prayed so hard for this and i now have been authorized to have my/yet another consult with Dr. William Richardson within their Bariatric Unit on Sept.20th...Yeaaa!!!...Thank You so much God!...
Well, i have all my testing already done so i am hopeful all runs smoothly and expedited...and that i really and truly am approved...i am so excited!...this time, God say the same, i really am on my way Woopie!....Thank You in advance for all your prayers  Much Love!


MY September 20th Consult

Well, i had my consult with Dr. Richardson and everything went really well. Dr. Richardson is very easy going and reserved, but you know what...to me it just showed that he is very cool, and i like that calm attitude about him...while i was in the waiting room i started making one of my Roseries and the particular Twine i was using is called 
"All God's Children" because the string coloring is (Red, Black,White &Yellow) Well, Neways when i went in it caught his attention and he thought it was so cool...even called me an expert. Well, i dont know about all that Doc, but thank you. I asked him which color (i just used colors for the moment) he would like to have and he actually selected the one i was actually working on so, i told him that it would belong to him before i left his office...Well, i think he liked them very much...Naw, Doc is not Catholic but he knew the Rosery and i told him that my Roseries are Indeed Blessed, and are Spiritual Prayer Beads that guides us through prayers to and for our Savior...Praying for nothing but Goodness and  Love for Jesus and his Mother... it made him smile...which in turn make me smile too!







NeHows, back to the consult, Well, i had already made my decision to have the Lap RNY so Dr.Richardson said that everything looked good and that i was good to go... just needed to do my consult with the Nutritionist, which is scheduled for October the 5th, and if my insurance cooperates smoothly with my approval i could get my surgery date by the end of October, OHWowZwow!





The Only Rules to Forever Abide By!

 
This is something I read on the general forum message board...don't know who wrote it but it sounds like it is good info to know.


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

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

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

Keep in mind, too, that some conditions cannot be reversed!

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

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

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

3rd Mistake:  Drinking with Meals

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

4^th Mistake:  Not Eating Right

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

5^th Mistake:  Not Drinking Enough Water

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

6^th Mistake:  Grazing

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

 7th Mistake Not Exercising Regularly

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

 8^th Mistakes:  Eating the Wrong Carb (or Eating Too Much)

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

 9^th Mistake:  Going Back to Drinking Soda

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

 10th Mistake: Drinking Alcohol

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

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

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