SOME COMMON QUESTIONS & ANSWERS AFTER RNY GASTRIC BYPASS
~~ (c) 9/2003-2005, Caroline Ann Martin
2 Years PostOp, -225 lbs and at goal!

My WLS & PS Journey: http://AButterflyEmerges.com
ObesityHelp.com Profile: http://tinyurl.com/bkld
Photos including Must Haves for PostOps: http://picturetrail.com/carolineam (password is ps)
GastricBypass-PostOp Group: http://groups.yahoo.com/group/gastricbypass-postop

GastricBypass-PlasticSurgery Group: http://groups.yahoo.com/group/gastricbypass-plasticsurgery
Bariatric Advantage Vitamins: http://tinyurl.com/2ludv

The following are common questions that I've seen come up regularly in my GastricBypass-PostOp YahooGroup. I hope this is of help to those on a WLS and PS Journey!  I continue to add to this document, so please feel free to check back from time to time.

Q: I haven't lost anything for a week (or 2 or 3) and I am only (fill in the
blank) month(s)/week(s) post-op - is this where my weight loss will stop? Will
I fail at this too?
A: The weight does not just drop off most of us. We do not wake up out of our
surgeries thin. LOL Patience with the WLS/weight loss process is key here :)
Some people weigh only once a week or even once a month to avoid falling into
the disappointment that comes when one doesn't see a change in the scale every
day. Fluctuations in weight are NORMAL, and it is not uncommon to see the
scale stay stagnant (or even go up a couple pounds). What helps many is to
measure their bodies (chest, waist, hips, thighs, arms, neck, etc.) weekly as
you will most often find that while the scale is the same, you are still
losing inches.

Also, try to focus on the bigger picture. At 3 months postop, I was down
"only" 60 lbs. I was very scared - ok, terrified that I wasn't losing fast
enough and that the majority of the weight loss was in the first 2 months),
but my fears have since gone unfounded - very unfounded. At 8 1/2 months
postop, I'm now down 140 lbs and look back and realize that for some of us the
weight APPEARS to come off slowly (and we expect that it will just drop off
us), when in reality it doesn't.

My advise to anyone feeling like they are losing slowly is to keep doing the
right things. If you are doing all the right things, eventually the weight
WILL come off. Take photos (full body photos), take your measurements, note
all that you can do that you couldn't before your surgery, and probably most
important, note how your relationship with food (and your taking care of
yourself) is changing - it's these things that will help you remain committed
to your success.

Q: Why can I eat so much? Have I already stretched my pouch?
A: Ask yourself how much you are really eating. Check to see if you have
unrealistic expectations of what you should be able to eat. Many of us think
"2 tablespoons and we should be full", and this is simply untrue. Perhaps it
is true for a small minority of people and for those who are only a few days
post-op, but as time goes on, you WILL be able to eat more. But you will never
be able to eat like you used to before your surgery. Likewise, many use the
"we should be eating no more than 2 oz" rule in the beginning, but what is
rarely mentioned is that the 2 oz should be measured by volume and not weight.
As for the pouch stretching, this is normal. It is said that the average size
pouch a year out from surgery is about 8 or 9 oz (a cup of food). Also, know
that soft or liquid foods/drinks go through our pouch faster (because we no
longer have the pyloric valve that holds the food inside our stomachs), so we
will be able to eat a lot more soft foods/liquids than solids. After the first
couple months post-op, it is very important that we be eating solid,
protein-dense foods as this will help to keep us full longer.

Q: Can the pouch ever stretch to the point where I can eat normally again?
A: Yes, the pouch stretches over time but it doesn't go back to the size it
was before surgery. When it is said that it stretches to where you can eat a
"normal" meal, this means a meal about the size of a lean cuisine, perhaps a
tiny bit larger. It doesn't mean being able to eat what we used to eat before
surgery which for the great majority of us was never "normal" to begin with.

Q: Why is it that I'm not supposed to drink during or after meals?
A: I try to think of the stoma and pouch as a funnel... The area where you
pour the food into is the pouch, and then it takes time for the food to funnel
through the stoma and into the intestine. By drinking during or soon after our
meals, you are just washing the food out of your pouch and creating more room
to keep eating which is in direct conflict to using your pouch as a tool to
limit the amount you can eat. The end result is that you will be able to eat
more and you will be hungry again faster (and thus eat more). Also, if you add
food/liquid faster than it is funneling through the stoma, everything will
just back up and you'll end up vomiting.

Q: How do I know when I am full? Why do I never get that full/satisfied
feeling anymore?
A: Once we have the RNY Gastric Bypass, we experience being full differently.
This is especially true for the first several months when the pouch (and all
the nerve endings that send the message that we're full) is still healing. It
used to be that full meant that feeling we got after sitting down to a big
turkey dinner. It doesn't mean this anymore - now full means "feeling a ball
(or knot) in your chest" just under the breastbone (where your pouch is) or
"feeling as though food is stuck in your throat". If you continue eating past
this point, chances are you will vomit as the food backs up. Also, those old
eating until you are full/satisfied days are now history. (It's my theory that
that is the true reason why the great majority of us were morbidly obese and
super morbidly obese to begin with - because we were eating to feel
satisfied/full, and for whatever reason, our bodies/minds didn't register
"full".) Full does NOT equal satisfaction anymore. Early on post-op, chances
are that you will be full before you are satisfied. As time goes on, you will
begin to experience being satisfied early on and before being full. Further
out, you may begin to experience what you remember as being full before you
had your surgery. I recommend measuring out your food into about 1/4 cup as an
early-out post-op and focus on being aware how your body feels after having
eaten that amount. That new feeling is what satisfied should feel like.

Q: I had my surgery and weighed the same amount as (name person), yet he/she
has lost so much more than me. What am I doing wrong?
A: It is common for most of us to question our weight loss and compare
ourselves with others. But this doesn't really help us. We all lose at our own
rate according to our bodies and our metabolism and how we use the tool we
have been given. It is important that we remember that we are not in a race,
and providing we are eating healthy, exercising, taking our vitamins, etc., we
WILL reach the finish line (in our own time). If we are eating like a 150
(name your own goal) lb person eats, eventually, we will get to our goal.
Again, patience is key.

Q: I am (fill in the blank) years post-op and am gaining weight. I am so
scared and never want to go back to being MO again! What should I do?
A: It is very important that we understand that some weight regain is NORMAL.
Statistically speaking, 90% of people who've had the RNY Gastric Bypass are
able to drop on average 85% of their excess body weight within the first 18 to
24 months of surgery. Long-term, however, the average weight loss maintained
is 65% of their excess body weight. While weight regain is not inevitable (as
shown by the many people who have been able to keep the weight off), it is not
uncommon. If you find yourself gaining weight, it is important that you not
beat yourself up about this. Simply "go back to basics" - protein first, no
drinking with or until 1/2 hour after meals, no snacking, exercise, etc. Don't
worry about whether you've stretched your pouch out or not. Again, this is to
be expected. Our pouches will never be the size that our old stomach once was,
and all it takes is for us to start using the tool we've been given yet again.


Q: I feel hungry all the time. How do I deal with the physical hunger and head
hunger/cravings?
A: Many people find that once they begin to experiment with high carbohydrate
& high glycemic index foods, they begin to experience (often intense)
cravings. Even if you are able to eat things like bread, rice, pasta and other
high glycemic index foods without dumping, doesn't mean you should be eating
these things. As long as you are eating high carbohydrate foods, chances are
that you will continue to feel both physically hungry and experience head
hunger/cravings. I regularly remind myself that just because I CAN do
something, doesn't mean I SHOULD do it. This is a very important thing to
remember when it comes to our successes following WLS, and it doesn't only
apply to high carb foods; it also applies to high fat foods, alcohol,
carbonated drinks, caffeine, soft foods (for the longer term post-op), etc.
Please don't mistake this as my saying that we should rid of all carbohydrates
from our diets. Surely, we need carbohydrates, but as with everything, they
should be in moderation.

Also, in dealing with head hunger, as easy as it is to say why we shouldn't
eat such and such, it is more effective to ask ourselves what the payoff is of
eating such and such (name "off limit" food here). When we know what the
payoff is for our unhealthy behaviors, we can find heathy substitutes that
offer a similar payoff - then the "need" for the unhealthy behavior is
decreased. (ie: I used to eat chocolate whenever I was stressed. Now I write
or drink decaf coffee or decaf tea to destress myself.)

To add to the question of hunger, while most new postops do not experience
hunger, there are some (including myself) who experienced true physical hunger
soon after surgery. (I actually woke from surgery hungry - physically hungry!)
Over time, I found that this resolved itself, and since about 3 months postop,
I only experience physical hunger when I haven't eaten for several hours or I
haven't been drinking my water (thirst is often disguised as hunger).

Q: Will I still lose weight if I eat vegetables and fruit?
A: Yes... As much as some will push the super low carb diets, the reality is
is that our bodies NEED carbohydrates! Granted sugar, white breads and rice
and pasta, potatoes and corn may not be the best choices (see above Q&A), but
lower carb and low glycemic index veggies and fruits ARE very important. For
one thing, we need carbs to utilize protein and for another, the fiber found
in veggies/fruits is necessary for gastrointestinal health and to ward off
certain cancers.

As for whether or not you will lose weight as fast with or without the carbs,
while I am sure some will swear otherwise, I have NEVER had a problem losing
weight providing my carb grams were equal to or less than my protein grams.
And yes, this means that when my protein was 70 grams/day, I could have as
much as 70 grams of carbs and still lose weight VERY rapidly (125 lbs in 8
months prior to surgery).

DO try to get in protein first but a few bites of vegetables are absolutely
fine! BTW, zucchini is my all time favorite!

Q: Why am I cold so often since I've had WLS?
A: Believe it or not, that cold feeling is NOT because we are losing our
insulation. I am sure losing body fat may account for a small part of it, but
the major reason this happens is because of a low fat diet. The fat we eat is
very important in our daily diet - it is responsible for keeping the skin,
organs and other tissues of our body well moisturized and lubricated so to
say. It also helps us to stay warm. When we eat very low fat diets, we can
experience being cold. This is true even for people who start out super obese
who are still morbidly obese. And it is true whether or not we've had WLS. As
long as one is eating a VERY low fat diet, chances are one will experience
feeling cold (regardless of how much weight one has lost or has yet to lose).
Similarly, low iron can make on feel cold, so it is very important to for WLS
postops to take supplemental iron (check with your dr. as to how much as iron
is stored in our bodies and too much of it can lead to toxicity).

Q: Shortly after my surgery, my tailbone started hurting especially when
sitting for long periods of time. Why is this and what can I do to help it?
A: Even at over 20 months postop, by tailbone hurts like h^ll and back again
anytime I sit for more than 5 minutes. And my experience isn't mine alone - go
into the OH chat room or my gastricbypass-postop group and you'll find the
great majority of us complaining about the pain...

I, too, started experiencing the pain when I was early out and still weighed
over 300 lbs, so at least in my case, I don't think it has anything to do with
"losing padding" as I still had ample padding back then. Also, I've lost LOTS
of weight before and never experienced the tailbone pain in prior weight loss
attempts. More likely, it might have to do with my needing to learn how to sit
properly. Also, the pain is worst when sitting on a cushioned chair or sofa as
compared to a wood chair - perhaps because I sit differently (and more
properly) in a hard chair?

Now, when I sit, I find myself sitting more on one of my hips. It's the only
way that I can sit without being in excruciating pain. I've also gotten a
number of coccyx pillows and use them all the time. Duromed makes a good
"donut pillow" that can be bought for less than $20 (see my picturetrail for a
photo and a link at
http://www.picturetrail.com/gallery/view?p=999&gid=2874285&uid=1444166 - you
will want the 18" cushion), and I am currently considering buying the
Backsaver Ergo Sit-Rite cushion (and pull out the coccyx insert) from Relax
the Back though it is $70.

There are also websites for people who deal with coccydynia. The most
informative, in my opinion, can be found at
http://www.coccyx.org/ .

Q: I hate to exercise. Can I lose weight without exercising?
A: Yes, absolutely you can. Exercise will NOT make a huge difference in the
weight we lose. We CAN and WILL lose weight just by our very restricted diets.
To clarify, to lose just 1 lb via exercise alone, a 250 lb person would have
to walk over 15 miles or do vigorous swimming for over 6 miles! That's a lot
of exercise!

Exercise is not responsible for how much we will lose. HOWEVER, what it IS
responsible for is helping to improve and maintain our muscle to fat ratio and
our metabolism as we lose our weight. It's important to remember that with
rapid weight loss, we will lose muscle and not only fat. If we lose too much
muscle, we can face heart problems (as the heart is a muscle), increased
sagging skin, lowered metabolism and thus slower weight loss, increased chance
of weight regain, etc. While exercise will not in and of itself lead to large
amounts of weight loss, it is nonetheless a VITAL component to our commitment
to get healthier and to keep the weight off.

This all being said, what I've found to help most is to do physical activities
that I enjoy doing. While I do a lot of swimming, hiking, roller skating,
etc., I don't think of my doing these things as being exercise (but they most
certainly are :).

Q: Do I really need one of those MedicAlert Bracelets?
A: It's my opinion that EVERYONE, surgery or no surgery would benefit from
having one of these bracelets. Please visit www.MedicAlert.com to join and get
your bracelet/emblem today. I don't recommend the ID's where you only get the
bracelet/emblem and that's it. MedicAlert is by far the best company to go
with not only in the quality of the emblem/bracelet, but also because
emergency personnel can call MedicAlert with the number on your emblem and
find out LOTS of info about you such as who you are, your insurance info, your
emergency contact person, as much medical info as you provide (way more than
what can be included on the emblem), who your doctors are, what medications
you take, etc. You will want "Gastric Bypass, No Blind NG Tube, No NSAIDS,
Call Immediately" on the emblem and can call MedicAlert to ensure they put
these on the emblem. You can order online at www.MedicAlert.com. Annual
membership fee is only $35 and includes a basic emblem/bracelet. They also
have some REALLY nice styles of bracelets in both sterling silver and gold. I
have one of the silver ones and can't be happier with it. It brings me peace
of mind knowing that God forbid there is an emergency where I am not conscious
or fully aware, my MedicAlert bracelet will allow me to communicate the vital
information emergency staff will need.

To make my MedicAlert bracelet prettier (and fun), I've added sterling silver
charms around the bracelet (making it into a charm bracelet) and added a
swarovski crystal/sterling silver bracelet that hooks onto the sides of the
emblem. My angelette (and angel), Krista, made this for me :) (You can visit
Krista's Profile at http://tinyurl.com/vd32 and email her if you want her to
make you one :)

Q: I eat a meal and an hour later, I am hungry again! Why is this and what
should I do about this?
A: Are you drinking with your meals or soon afterwards? If so, this could be
the culprit. Also, when you do eat your meals, are you eating until satiated
or are you limiting yourself to a certain amount of food and stopping even if
you still could eat more?

The trick in using our pouch to it's greatest extent is to reach a point of
satiation with each meal and then staying this way as long as possible. It
means not drinking with meals, eating until satiated and then not drinking for
at least 30 minutes (some say 1 1/2 hours) after the meal. Water loading (as
opposed to snacking) between meals can also help to keep us feeling satiated
between meals.

Q: How do I deal with hunger in between meals? Is snacking ok?
A: I basically do 3 meals a day and lots of water loading. I will allow myself
up to 2 snacks per day only if I am needing (or REALLY wanting) to eat more.
For snacks, I will do protein drinks, non-fat cheese, beef jerky, SF
popsicles/fudgesicles or a couple frozen grapes, Atkins Crunchers, or
sugar-free, non-fat decaf latte/coffee. Notice how each of these fills a
"need" - protein for energy, cheese for creamy, jerky for chewy,
popsicles/fudgesicles or grapes for sweet, Crunchers for crunching, and lattes
for warmth & comfort. Generally, I make it a rule that I will not give in to
snacks, but if I am physically hungry and it is before 9 pm, I may have a
small snack as stated above.

Also, be sure that you are drinking at least 64 oz of clear, non-caloric
liquids (preferably water) each day. Often thirst is disguised as hunger. I
follow a personal rule that if I am hungry between meals, I will drink water
first. If I am still hungry 15 minutes later, than I will allow myself a
small, high protein snack.

Q: I am only a few weeks/months post-op and am having a very hard time getting
in at least 64 oz of water per day. How do I increase what I am drinking?
A: The first couple of weeks are the toughest in getting in enough liquid. For
me (and I've heard from others who this was true for also), plain water sat
heavy in the pouch and brought on nausea. What I've found works best was to
experiment with the temperature of the liquids I was drinking. I've found I do
best with either hot or room temperature liquids - ice cold liquid was (and
still is) harder for me to get down. Each person is different in this respect
and you may find that you do best with ice cold drinks.

I also found that mixing in a little Crystal Light with my water (about 1 part
Crystal Light to 3 parts water) helped to make the water "lighter" and easier
to swallow and keep down. It is important to remember that the required 64 oz
of liquid need not be just plain water (although this IS prefered). Most
clear, non-caloric (very low calorie), no caffeine liquids are fair game when
it comes to getting in your daily 8 cups of water.

One of my absolute must haves on my "Must Haves for Post-Ops" list is a 32 oz
water bottle that one can keep nearby and sip from throughout the day. I have
one from Starbucks that I simply love and Naglene's narrow necked 32 oz water
bottle is similar and equally as wonderful.

Q: Ever since my surgery, I've been dealing with severe constipation. What can
I do about this?
A: Some people take Colace daily to help although this does not help me at
all. Using Benefiber in my drinks DOES help although figuring out how much to
take per day so that it helps (but not too much) is tricky. I like the
Benefiber as it does not swell and has no taste, color or texture so it does
not alter my drinks. When the constipation get's so bad to the point that I am
straining (which is NOT a good thing to be doing as one can rupture the bowel
this way), I take Philips Milk of Magnesia and that helps tremendously. I tend
to use the Milk of Magnesia as a last resort as it impacts my activity level
for a day or two. Also, be sure to be getting in a MINIMUM of 64 oz of water
per day and even with all the low carb craze, it is super important to be
eating high fiber vegetables and fruits (as they are important for
gastrointestinal health). Too much calcium (over 2000 mg) can also cause
constipation, so be sure to be taking only what your surgeon recommends
(usually between 1200 and 1600 mg).

Q: I am a recent postop and am experiencing terrible gas regardless of the
foods I eat. Why is this, will it go away, and will anything help?
A: Excessive gas following WLS (especially if done laparoscopically) is the
norm. It is worst right after surgery and resolves over time, and occurs
primarily because of the gasses pumped into your belly during laparoscopic
surgery. Simply stated, it takes time for all this gas to leave your body.
When I was an early out postop with this problem, I found that taking OTC
Phyzeme helped a great deal. Also, walking and physical activity helped
enormously. At 8 months postop, I still experience gas from time to time
although it is no different or more than it was prior to my surgery.

Q: I am early out postop and nothing tastes or smells good. I find that I have
no appetite and could care less about eating. Is this normal and what can I do
about it?
A: Yes, this is absolutely normal for many if not most early out postops. If
you are like most who experience this, you'll find that things start tasting
(and smelling) more like they used to the further out you become postop. And
while it may seem like a bad thing that you have no interest in foods right
now, this is really is a GOOD thing! Consider this to be part of the "tool"
we've been given to change our relationship with food.

Q: I am between 1 month and 3 months postop and am having a very hard time
keeping any food down. What am I doing wrong?
A: Most postops (at least those who've had the RNY) find that this happens
when they start adding solid foods into their diet. It DOES get better as one
learns what foods are agreeable to them and new eating behaviors become habit,
but in the meantime, here are a few helpful hints:
- use baby spoons and forks to limit how much you put in your mouth at any one
time
- take a small bite, wait a couple of minutes and then if you are ok, take
another small bite.
- be sure to chew chew and chew some more everything to a pulp. You can't chew
too much!
- if you feel the slightest pressure/heaviness in your pouch area or food in
your throat/chest, then stop. Even a TEENY TINY bit of too much food can push
you over the limit to the point that everything comes up. Before WLS, we could
eat past full. Now, one small bite too much will cause you to get sick.
- going along with the above, if you feel that food in your throat feeling or
heaviness or pressure in your pouch area while having food in your mouth that
you're chewing on, then spit the food out. If you swallow it, there's a good
chance you will get sick.
- measure out your food before you start eating. Using measuring
cups (not weighing ounces on a scale), figure on eating about 1/4 to 1/2 cup
of food per meal.
- do not drink anything for at least 15 minutes before your meals, with your
meals or for at least 30 minutes after your meals. Either the liquid will
force the food through your pouch
allowing you to eat more than you need to (and negating the purpose of the
pouch) or the food will block the liquid from going down and it will all back
up and you'll vomit.
- avoid any and all things with sugar in it, especially refined
sugars. If your vomiting includes sweating, nausea or other symptoms, chances
are you may be dumping.
- avoid dry foods and bread/rice/pasta as these tend to get "stuck" easily
and/or swell and will make us feel very uncomfortable especially during the
early postop days.

Q: Are protein shakes really necessary? Can't I just get my protein from food?
A: Protein supplements definitely have their place in a diet for one who
doesn't get in the necessary protein per day (whether they are newly post-op,
vegetarian, not able to tolerate meats or dairy, etc.). If one CAN get all
their protein from regular foods without having to consume more than they want
or are able to, then by all means that is wonderful. But protein supplements
CAN be a wonderful tool in one's daily diet.

For example, my hubby and I are going to a dinner party tonight for his job. I
do not know exactly what will be served or if (and how much) I will be able to
eat. For a late breakfast, I had a little of my ham, cheese and corn bake that
I'd made last night in my crock pot. I ate probably about 1/2 cup and focused
primarily on the ham (about 20 grams protein). Then for lunch, I wanted to
avoid carbs and make this a super high protein "meal" that was still low
calorie and low fat (assuming I will eat more tonight), so I decided to have
one of my VHT protein shakes (35 grams protein). I plan to stop at Starbucks
on the way there for a SF vanilla latte which will give me an added 15 to 18
grams of protein. Because of the protein shake being so high in protein and
low in carbs and calories, I won't have to worry so much about what I eat
tonight. I have already gotten in my necessary protein for the day, not many
calories and not many carbs so it will all balance out with whatever I eat
tonight. There is NOTHING else outside a can of tuna fish that I know of that
would give me 35 grams of protein and less than 5 grams of carbs and 0 grams
of fat. And being that I can't even eat a whole can of tuna (it sits VERY
heavy in my pouch and the most I can do is 1/3 of the can at a time), the
protein shake is the way to go.

This is not to say that one should drink protein shakes ONLY throughout the
day. Rather, when used strategically to ward off hunger and increase daily
protein, while keeping calories, carbs and fat down, protein drinks can be a
wonderful tool towards one's weight loss and weight maintenance.

Q: So many people talk about the Nectar protein shakes being great, but when I
make it, it tastes nasty! Any recommendations?
A: A few things with Nectar (and other shakes that this might apply to):
- Always put in the water first, then the powder.
- Be sure to shake it well (I use a Tupperware Quick Shaker which I love)
- Add extra water if it's too sweet or too thick
- Try it at least two to three times before making a decision as to whether or
not you like it (some tastes "grow" on people). When I first tried the Nectar
Fuzzy Navel, I hated it. Now I love it.
- Allow enough time after shaking it to rid of the foam, but drink it as soon
as you can. With the Lemonade flavor especially, I found that that it tastes
nasty if left sitting.
- You can try mixing the Nectars with Crystal Light instead of water. Though
they are made even sweeter, they are really tasty this way - ie: Caribean
Cooler with CL Pinapple-Orange and Fuzzy Navel with CL Classic Orange. I would
think that the Lemonade would mix well with CL Lemonade.
- Also remember that as with anything, tastes change follow surgery. Sweet
tends to be sweeter and chemical tasting, etc. This improved for me the
further I got out, and I learned to not assume I won't like something because
I didn't like it early out. The Zero Carb Isopure is a perfect example - I
HATED it when I first tried it (about 4 weeks out) but now it's actually not
bad. I don't love it but it's not bad either.

Q: Does carbonation really stretch the pouch? Do I really need to avoid it?
A: Whether the pouch is stretched or not is not the only part of our new
anatomy that is in question - so too is the stoma. And while the jury is still
out for me as to whether or not carbonation stretches the pouch/stoma, I
figure, "why chance it?" Also, what IS known is that carbonation does affect
calcium levels, and that increased calcium is related to increased weight
loss. Given that there is no harm done in avoiding carbonated drinks, my
feeling is that we should just avoid them altogether. What many do not mention
is that drinking carbonated drinks can also physically hurt. For many, it
literally hurts to drink them.

Q: When will I be able to start taking pills again without having to cut them
into pieces or crush them?
A: It is my understanding that we will never be able to take large pills again
(anything larger than a pencil eraser). Part of the reason is due to the stoma
being small and if the pill gets stuck in our stoma, it could either cause a
blockage or can stay stuck in our pouch and when it dissolves cause an ulcer.
The other reason is that some meds will have a hard time dissolving or being
absorbed without stomach enzymes.

For capsules (liquid or powdered), we can take these from the start (assuming
it isn't a medication we shouldn't have as a post-op such as ibuprofen), but
some people have a really hard time keeping them down especially if they are
the larger ones (ie: Trinsicon, potassium, antibiotics, etc.). To make them go
(and stay) down easier, one should take them with hot liquids as the hot
temperature will help the capsule dissolve much faster.

Also, don't be mislead by "gel tabs" or "gel caps" (as put out by Tylenol).
These are NOT capsules that will dissolve at body temperature. Rather, gel
tabs/caps are simply solid pills with a gel coating.

Q: What about vitamins? What should I be taking, how often, and when?
A: What I'd recommend doing is going to www.BariatricAdvantage.com and
ordering their chewable multivitamin, chewable chocolate (or cinnamon calcium
citrate, chewable iron, and sublingual B12.

I've been taking these vitamins since 2 months postop and LOVE them. They give
us all the necessary vitamins we need with out giving us too much of any
vitamin (which could be toxic depending on the vitamin). All are chelated
which helps with absorption, and all are sized (and created) specifically with
the bariatric patient in mind making it easier to take them (and better for
us).

Here's what I take and when:
Morning when I wake: 1 multi-vitamin and 2 calcium
Afternoon: Iron & B12
Evening: 2 calcium
Bedtime: 1 multi-vitamin and 2 calcium

It's important to not take iron and calcium together as they negate each
other.

While some complain of the cost (around $40 per month), honestly, the price is
comparable to any quality vitamins on the market. I figure if I spent that
much every two days on fast food as a preop, I can certainly spend this once
per month towards something that is SOOOOO necessary and vital towards my
health!

Thank you for letting them know I referred you :)

Q: What's with all the talk about protein? Is it really all that important and
how much do I need?
A: The great majority of us are advised (by our bariatric surgeons,
nutritionists, PCP's, etc.) to always eat "protein first" following surgery,
and to eat vegetables only after we've eaten our protein for the meal and only
if we still have room left. Then if we still have room, we can eat fruit and
then if there's still room left, we can have bread. It is similar to the
Adkins diet (and some shy away from carbohydrates all together), but minus the
fat. Specifically, most are advised to eat high protein, low carb, low fat for
all our meals and snacks.

The reasoning behind this is that a low carb lifestyle (specifically with high
glycemic index foods being avoided) amounts to regulation of blood sugar and
therefore appetite. Also when the body runs out of carbs to burn, it breaks
down the fat stores for energy. When carbs are high, the body burns the carbs
first (as carbs are most easily converted to sugar) and while fat will still
be burned but to a lesser extent, muscle will also be burned.

High amounts of protein also helps promote faster healing (especially
important for new postops), helps preserve muscle (especially important during
the weight loss process), and helps to the body to have a lower body fat
percentage (important for metabolism among other things).

Most are advised to eat 60 to 70 grams of protein per day (hard to do
especially for newer postops unless protein is the primary focus throughout
the day) and some are advised to eat 1 gram of protein for ever lb of lean
body tissue (which can mean as much as 120 grams of protein on up per day).

Every now and then you might hear of a "protein train" within various online
and in person support groups. In a nutshell, a "protein train" is a set period
of time where a person will focus on going back to liquids and getting in a
high amount of protein for a set number of days. This is usually done through
protein drinks and/or meal replacements and is not unlike a liquid fast. The
reason for it is to help people "get back to basics" when eating habits start
to go awry (as happens over the holidays for many) and to jump start weight
loss for those who've been "stuck". Likewise, back in my HMR days, falling
back on shakes was a tool in maintenance to help balance out "bad" eating
days.

Q: I can't stand protein shakes, but like protein bars. Are the bars ok to
eat?
A: First, when you say you can't stand protein shakes, which have you tried?
There are some really nasty ones on the market and then there are some that
are outstanding tasting. As everyone's tastes are different, be sure to visit
Vitalady, Bariatric Eating, or similar online source and order some samples to
find the ones YOU like best. The ones I keep finding myself turning to are
Labrada's Proplete Gold, Labrada’s Pro V-60, Syntrax's Nectar Fuzzy Navel, and
VHT (Van Horn Technologies) Extreme Smoothies. Also, if you are early out
postop, remember that sweet may taste too sweet and chemical. If you find you
don't like a shake, it may be your taste and not the shake itself. This will
change the further you become postop and sweet will start tasting good again.
So be sure not to give up on shakes without trying them at a later stage.

As for protein bars, I RARELY eat them. The reasons are:
- way too much sugar and/or sugar alcohol - most have anywhere from 15 to 30 g
sugar/sugar alcohol (I dump from either and they are just empty calories
anyway)
- way too much fat (most have about 9 g or more of fat)
- the protein is lower in most bars (10 to 20 g protein in most bars as
compared to 25 to 30 g from most protein shakes)
- the protein source found in most protein bars is soy which is not as nearly
well absorbed as whey protein or whey protein isolate which is what is found
in most protein shakes.
- Why have a 200 to 300 calorie protein bar to get in 20 g protein, when for
the same amount of calories, I can get in 50 to 75 g protein from protein
shakes?

This being said, probably the best protein bar I've found that I can tolerate
a little of at a time are the Avid bars found at Costco. They are moderate in
fat, moderate in sugar with no sugar alcohol, and have 20 g protein (primarily whey).

The Power Crunch bars are also amazing and are, by far, my favorite, though

they offer only 14 g protein and still a bit of fat.

Q: Are the candies with sugar alcohols and "low impact carbs" ok to snack on?
While true that sugar alcohols do not affect blood sugar/insulin levels as
much as regular sugar, we can most definitely still dump from them. I can
tolerate more sugar alcohol (about 15 gms) than I can sugar (about 10 gms) per
sitting, but I am still limited in my intake of them. Besides still being able
to dump from them, sugar alcohol can also cause symptoms similar to lactose
intolerance (cramping, diarrhea, etc.) - not pleasant at all.

Also, most of these candies still have calories - lots of them... Given that
they also have little to no protein, it's my opinion that it's best to stay
away from them. When I DO snack, I try to always make it a healthy, high
protein snack (such as non-fat cheese, beef jerky, etc.)

And with this said, I try my best to avoid snacking altogether. Rather than
giving in to snacking, I will drink some decaf hot tea, exercise, read, watch
a movie, draw, etc.
 

Q: Many of my WLS peers say that all postops should avoid milk. Is this true?  Also is it ok to make my protein shakes with milk instead of water?

A: Some postops avoid milk for a variety of reasons, but not all do. You need to do what works for you... Personally, I drink milk regularly (lattes - yum) and have about 2 to 4 cups a day since my first month out. I have never had a problem with losing weight.
 

Also, research indicates that a calcium rich diet (including milk) is linked to lower body weight and increased weight loss. As for calcium absorption, calcium is better absorbed when accompanied by a small amount of fat.
 

If you are making your protein shakes with milk and not water, just be aware that the calories for your shake will increase by about 100 calories (assuming you are using skin milk).

Q: Help! I am a few months post-op and am losing my hair! Will I go bald and
how can I stop this?!
A: Welcome to the club! Hair loss is COMMON between months 3 and 8 & most
often starts around the 3rd/4th and becoming noticeable in the 5th/6th month.
If you are like the great majority of us, your hair loss will slow down a few
months after it starts and your hair WILL grow back (sometimes even fuller
than it started out).

Vitamins/supplements and protein are VERY important and too few/little are
thought to be one of the reasons for the hair loss, although I have seen MANY
people lose hair on very low calorie/low fat diets even when protein and
nutrients were very high. To be on the safe side, make sure to increase your
protein (at least 60 to 70 grams per day), and it is said that Zinc and Biotin
will help to prevent excess hair loss. Both of these can be found in Bariatric
Advantage's Multivitamins I mentioned just above.

Also, I have been using Nioxin products and really like them. I'm not sure
they have made a huge difference in my hair loss or regrowth, but I figure it
can't hurt to use them. Many swear by the Nioxin line (especially their
cleanser shampoo and scalp therapy conditioner).

Q: Even though I've been doing great weight-wise, I am having a really hard
time with depression. How do I best cope with this?
A: Anti-depressant medications may certainly help, but they may not completely
rid of the depression. Chances are that if you dealt with depression before
your surgery, you will deal with it after your surgery as well. Some may
experience depression even more following surgery since food is no longer
being used to cope and stuff feeling, memories, etc. inside.

Counseling can be of benefit in terms of learning alternative ways to cope,
and being able to nurture and be gentle with ourselves is VITAL if we are to
find peace and calm in our lives. For myself, I've come to realize that
sometime it's ok to give in to a day (or even a few) at home and just take
care of me. I think of myself as a turtle - sometimes I hide in my shell and
sometimes I venture out to explore, some days I move fast and other days I
crawl... And on the days that I crawl, I try to accept this and not be too
hard on myself.

Q: I deal with dissociation which has been a major contributor to my being
morbidly obese to begin with. Will I be able to succeed with WLS considering
this?
A: While I can't answer for everyone who dissociates, speaking for myself,
having had the RNY is the BEST thing I could have done. The surgery made it so
that my body gives me instant feedback and consequences about what I
eat/drink, and it is now MUCH harder to dissociate while eating. A couple
things to consider though for those with DID - everyone in your system should
agree to the surgery as everyone needs to "follow the rules", and following
surgery, it is possible that other means of coping/dissociating (such as SI)
might come more into play. Also, it is not uncommon for flashbacks to start
surfacing or surface more as one is no longer turning to food to keep the
memories at bay. If you are like me and have DID, I think it is most important
to have a good therapist (who is more than familiar with DID) to help you work
through issues, memories, etc. as they arise.

Q: Even though I've lost (fill in) lbs, I am having trouble seeing the weight
I've lost. Is this normal, and how do I deal with this?
A: When I was thin (130 lbs), I thought I was fat. When I was 210 lbs at age
19, I thought I was the biggest person in the world (at my heaviest, I’d have
been happy to be “just” 210 lbs LOL). When I was 370 lbs, I thought I looked
like I weighed 250 lbs. I knew I looked big, but never did I realize just how
big I really was (the width of a door - not exaggerating here). Now that I am
losing the weight, some days I see myself as thinner than I am. Some days I
still feel huge. This experience is not unique to us and occurs for many
people following losing a huge amount of weight especially for those who've
lost it in a short period of time.

It seems the only time I can TRULY see my size is when I look at photos taken
of me. Thus is the reason for all the photos I've taken or have had taken of
me since my WLS. I wish I'd taken photos of me at my heaviest before surgery,
but I rarely let photos be taken - I was always the photographer, only allowed
photos from my shoulders up, or I stood between people hiding behind them.

I SOOOOOO recommend that everyone take full body photos every month as this
will help your mind "see" your progress. And if you are reading this and are
preop, take as many photos as you can now before you start losing weight.
While you may cringe at the thought of it, these photos will be more valuable
than your "thin pictures" ever could be as it allows you to see just how far
you've come...

Q: I had my surgery but am still extremely heavy and still require a seatbelt
extender when on a plane. How do I ask for one without drawing attention to
myself?
A: Nothing personal, but when I was over 300 lbs, the least of my concerns was
needing a seatbelt extender. Whether I asked for an extender or not, it was
OBVIOUS to others that I was extremely overweight. At 370 lbs with over 70
inch hips, I've no doubt my peers already realized the fact that I was very
heavy. If they were to cast judgment on me, I am sure they had already done so
before my asking for an extender. Thinking that I could hide my obesity by not
asking for a seatbelt extender was similar to my thinking that wearing black
clothing made me look thin. LOL

Being so heavy, the greater concerns for me were being able to walk through
the aisle, making sure I wouldn't have to use the restroom during the flight
(because I couldn't get down the aisle because I was wider than the aisle and
bathroom), making sure I ate something before the flight (because I couldn't
use the pull down tray from the seat in front of me), taking some pain
reliever before hand (to help ease the pain from the bruising that always
occurred on my hips), etc.

One thing that I always found DID help me was to preboard the plane (usually
occurs before or at the same time 1st class boards). I've never been asked why
I needed to preboard, and I was always able to get the extender before many
other passengers were even on the plane. Also, be sure to get an aisle seat
(as they tend to be a little bigger) and never get the seats by the emergency
exits (as they are smaller on most airlines).

When all else fails, keep remembering that this too will be another bad memory
of what it's like to be MO/SMO as you become closer to your goal. Let the
memory keep you honest with yourself and let it help you stick to your
resolutions towards continuing your weight loss and keeping the weight off...

Q: How do I choose a goal weight? or I still have (name number) lbs to lose to
reach my goal (name weight). Everyone's been telling me I am getting too thin
and that I shouldn't lose any more. Should I continue trying to lose to my
goal weight?
A: Even for myself, I go back and forth as to what my goal (pounds-wise)
should be. I'd LOVE to be 135 lbs and a size 3/5 which is what I was in high
school (age 18) before weight was ever an issue for me. And being that 134 is
the "ideal weight" for someone my height (according to the medical charts),
perhaps this is a reasonable goal.

But to make sure my goal is reachable, I say it is to be 150 lbs or less...

Then again, what is my goal, really? Is it to be 150 lbs (or other arbitrary
number on the scale?) Is it to get back to wearing a size 3/5? Honestly, no...
Rather, my goal is to not have my weight limit me in the things I want to do
in life. I want to be active and be able to fully participate in life. I want
to be able to roller skate, do gymnastics (if my since-aged-15-years body will
allow me), cross country ski, horseback ride, bike, do yoga, etc. I want to be
completely free of the addiction to food, and I want to be as healthy as I can
possibly be along with have a healthy lifestyle. Of course, I want to look
good as well, but who says a size 3/5 looks better than a 10/12?

If I can do all the things I want to do, then how can I say that I haven't
reached my goal? Can I say that I haven't reached my goal because the number
on the scale is more than that arbitrary number I "pulled from a hat" when I
was still MO? Of course not... If I can do all the things I want to do, then I
HAVE reached my goal, and rather than obsess about some arbitrary number on
the scale, I will choose to take full advantage of the new life I've been
given :)

To add to this, the closer and closer I get the that ever elusive "135" on the
scale (at 16 months postop I am 155 lbs), the more I realize how important it
is to take into account other factors that account for weight - excess skin,
increased bone density, increased muscle, etc. all from when I was heavier.
Weight looks MUCH different on the way down than it does on the way up. At 155
lbs, I wear all size 6's, but as I was gaining, I was wearing size 10's.

Also, to add, eventually the weight loss WILL end at whatever number on the
scale and we will need to start maintaining.... We no longer need to play the
weight loss game - not that it was ever a game to begin with - the issue was
NEVER REALLY needing to lose the weight but rather taking care of ourselves on
a daily basis. If we live a healthy lifestyle, a healthy weight will follow.

Q: Why does the weight loss slow down the further out from surgery one
becomes? What about the window of opportunity?
A: There are many who talk about "the window of opportunity" which is stated
to be the period of the first 6 up to the first 18 months postop where the
weight seems to just "fall off". The truth of the matter is that the "window"
will stay open for as long as one needs to still lose weight and one keeps
doing the right things in terms of their eating/exercise. As for weight loss
slowing down the further one is out from surgery, there are a few things that
account for this:
- the lower the weight one gets to, the less calories required to maintain
body weight so the less the caloric deficit and the less the weight loss
- the lower the weight, the lower the number of calories burned with weight
bearing activities, the lower the caloric deficit and the less the weight loss
- the further out postop one becomes, the more volume one is physically able
to eat, the higher the calories taken in, the less the caloric deficit the
slower the weight loss
- the further out postop one becomes, the more types of food
(including more sugar and fats, breads, etc.) one is able to tolerate and eat,
the higher the calories taken in, the less the caloric deficit the slower the
weight loss
- there is a return of appetite for many people somewhere between months 6 and
12 postop. If not diligent in healthy eating patterns, old behaviors (such as
grazing, night-time eating, eating sugary foods, etc.) can resurface, food
intake will be higher, calories will be higher, the lower the caloric deficit
will be and the less the weight loss will be
- finally, there has been some research indicating that the common channel of
the intestine grows more cilia to make up for some of the bypass and therefore
the malabsorption component to the surgery (RNY) decreases. This would explain
why distal patients have better chance of keeping the weight off.

Q: I have stopped losing weight at ___ lbs. I am a longer term postop and
don't understand why I am still not at goal when others seem to have lost more
than me and have lost faster.
A: Everyone is different... It's hard to not compare yourself to others but
everyone's body is different, metabolism, diet, exercise, etc. Men tend to
lose faster than women, younger people tend to lose faster than older people,
those with less weight to lose starting out tend to lose a higher percentage
of their excess weight and they reach goal faster, etc.

This all being said, if you are not losing anymore and still need to (check
with your dr and go by body fat percentage - not the number on the scale),
then you need to change something in terms of your calories in vs calories out
- ie: decrease the calories you take in each day and/or increase the amount of
exercise you do. Sometimes we get "stuck" at a certain weight because that is
the weight that we are most comfortable maintaining. (our eating pattern
supports maintaining a certain weight.) The lower one goes on the scale, the
less calories needed each day to maintain the weight. Also, exercise doesn't
burn as many calories the lower you get, so you would need to bump up the
intensity and time spent exercising as well.

Q: How much does malabsorption (from my RNY surgery) play a role in the number
of calories I can eat per day?
A: From all that I've read, there is no way for surgeons (or anyone) to know
exactly how much malabsorption takes place in terms of its impact on the
absorption of calories. What I can say is that even with 150 cm bypassed, I
did not lose any faster than I could have expected to lose had I not had
surgery and had just been taking in the same number of calories as I've been
since WLS. I would venture to say that my weight loss was more dependent on
restriction of food intake and calories as opposed to any malabsorptive
factor.

This being said, there ARE people who've had distal RNY or DS who have needed
to go in for revisions or reversals due to not being able to stop losing
weight. The purpose of the revision in this case would be to lengthen the
common channel and thus decrease the malabsorptive component of their original
surgery.

For myself, I don't use malabsorption in the equation. I use only my basal
metabolic rate (BMR) in figuring the number of calories I need per day to
maintain (or lose or gain). BMR, by the way, is the number of calories your
body requires per day to maintain its weight. The multiplying factor for BMR
is 11 calories per lb for the great majority of women and 12 calories per lb
per day for the great majority of men. To get a more exact BMR, I would advise
having a body composition test done through your surgeon or PCP.

Q: What's the difference between distal and proximal gastric bypass? Is one better

than the other?

A: Proximal and Distal refer to the amount of small intestine bypassed
with the RNY gastric bypass surgery. Most surgeries are done proximal
with approx 75 cm of small intestine bypassed. For those with BMI's
over 60, it's not uncommon to see 150 cm (5 ft) bypassed (considered
long-limb proximal) or more bypassed. It is believed that because
there is a greater degree of malabsorption with more intestine
bypassed, that those who are distal will have more and faster weight
loss and be able to keep more of the weight off long term. But
research indicates that proximals can do just as well as distals, and
that at 2 years out and beyond, there really isn't much difference.
There is more risk involved with distal bypasses for malnutrition and
other problems so it's one of the reasons many surgeons will try to
avoid it. Also, insurance companies are less likely to pay for distal
surgeries as they are considered more experimental.

Q: What about excess skin following massive weight loss?
A: I am not going to lie to you... For me, the excess skin is frightening.
People are always commenting on how wonderful I look, but all I can think of
is, "you've no idea what is hidden underneath the clothing!" (Don't believe
me? Visit my picturetrail at http://picturetrail.com/carolineam - password is ps) The amount
of excess skin will vary from person to person depending on many different
factors including but not limited to age, starting weight, amount of weight
lost, dieting history, whether one smokes and/or drinks, amount of muscle/lean
tissue, whether one exercised "on the way down", race, condition of skin prior
to and after WLS, race, etc..

In mild cases of excess skin, the person may decide to "live with it." In
moderate cases, cosmetic plastic surgery might be sought after, and in severe
cases (as is with my case), reconstructive plastic surgery may be required. As
you are losing, be sure to take photos of any rash, boil, infection, etc. that
develops due to the excess skin. Be followed by a medical dr. and raise any
concerns to him/her, and keep receipts for any medications you may need to
treat such medical issues. Documenting the medical need for PS may provide
very helpful in getting any future plastic surgery covered by insurance.

In the meantime, what can one do to help make better the situation? I've found
that wearing supportive, well-fitting undergarments helps to not only make the
excess skin less obvious, but it also supports the skin, making movement
easier. There's a specific undergarment made for women that I've heard only
wonderful things about (and wore for months prior to my reconstructive
surgery) called "Lipo in a Box." The site can be found at: http://lipoinabox.com. 

Q: I am female and wondering where my breasts went after losing a substantial
amount of weight!!! How do I figure out what size bra I should be wearing?
A: I started out wearing about a 58H (yes, you read right) and after losing
218 lbs, am now a 32G (DDDD). While a G cup sounds huge, it isn't as big as it
sounds - it's the same as a 40C. My favorite bras are made by Chantelle,
although previously when I was still a 36 back and above, I wore Glamorise
bras. Sadly, what's left of my breasts is pretty much excess skin at this
point (who knew I stored so much fat in my breasts) and are looking far from
good outside a bra. Getting a good fitting bra is absolutely paramount to
having a good shape when wearing clothing.

Cup size is determined by the difference between the measurement of your back
(where the bra band goes around you) and the fullest point of your breasts
while wearing your best fitting bra.

An A cup means there is a 1 inch difference, B cup is 2 inches, C is 3 inches,
D is 4 inches, DD is 5 inches, DDD is 6 inches, G is 7 inches, H is 8 inches,
etc. etc. Cup sizes stop at a J cup and these are super hard to find. To
figure your back size for the bra, take your back measurement and add 4 inches
if your back measurement is an even number of inches, and 5 inches if your
back measurement is an odd number of inches.

So, for example, my back is 28 inches around and the fullest point of my
breasts (wearing my best fitting bra) is 35 inches around. So the back would
be a 32 (28+4=32) and the cup size would be a G (35-28=7).

As a general rule, as you go down in back size, assuming your breast
measurement doesn't change, you will go up in cup size... So a 34DDD is the
same as a 36DD is the same as a 38D is the same as a 40C, etc.

Q: I have been experiencing dizzy spells since my WLS. What could be causing
this and what should I do about them?
A: MANY postops report this dizziness, including myself. I've even passed out
once when I wasn't able to sit down fast enough and have had several very
close calls.

During gastric bypass, sometimes the Vagus nerve (one of the 12
cranial nerves) is affected (especially if it is nicked or severed during
surgery). There is something called vago-vagal syncope (VVS) and what this is
is as a sudden onset reaction to physical pain/stress, emotional upset,
standing too long, or change in bodily position from horizontal to vertical
whereby blood pressure drops suddenly and the person will experience
dizzyness, sweating (more clamminess), loss of hearing, loss of vision, and
eventual fainting.

The symptoms come on very fast and unless the person can sit down immediately
and put there head between their knees or lay down again, there is a risk of
fainting (and falling). I would follow up with your PCP and request to see a
cardiologist. The cardiologist will most likely order a tilt table test though
know that one can show a false negative for VVS on this test (which I did).

Differential diagnoses include anemia/iron or B12 deficiency (which could also
account for the cold and/or numb feeling in the extremities), hypoglycemia
(also not uncommon for RNY postops), dehydration, and orthostatic hypotension.

Treatment for VVS includes avoiding situations that could bring on an attack,
staying well hydrated, sitting down and putting your head between your knees
when the dizziness first starts, making sure to get up from a laying down or
sitting position slowly, medication (usually steroidal meds from my
understanding which is definately not something most postops want).

I am not a doctor or nurse, btw - just someone whose MA degree and past work
experience required a bit of medical background and someone whose been
experiencing these dizzy spells almost daily since 8 months postop.

Q: I am _______ months postop and am scared that I can now eat more than I
used to be able to when I was newly postop. Have I stretched my pouch and/or
stoma too much and will I fail?
A: In terms of how much the pouch/stoma stretch, at about 1 year to 1 1/2
years postop, most postops are able to eat about 1 cup of solid food per meal
(about 8 ounces). If you did primarily protein shakes and liquids, you
wouldn't be stretching your pouch as your would by eating food, and chances
are you'd be able to tolerate much less food.

While I know a lot of people get worried about the pouch/stoma stretching,
this is a good thing that needs to happen. Eventually you will not want to
lose any more weight and the only way to stop the weight loss is to take in as
many calories as you expend each day. For the typical woman weighing 150 lbs,
she'd need to take in at least 1600 calories per day to maintain her weight.
While this doesn't sound like a lot (and it's not, really), it is a lot for
someone who can only get and keep in a 1/4 cup of food per meal.

Q: Before I had this surgery my entire life revolved around food. I "counted"
everything that I could to lose weight -calories, protein, carbs, portions,
servings, physical activity, etc... the whole bit. When I read posts by other
postops, it seems that one still has to count protein, carbs, calories, etc.,
but for me, this surgery was a release from all that. Do I really still need
to be counting?
A: No, because if you stick to the basic rules of protein first, 3 meals (or 5
small meals) per day without snacking, no eating at night, no drinking with or
for up to 1/2 hour after meals, no more than 20 to 30 g fat per day, etc. it
will be virtually impossible to overeat and not lose weight.

BUT just to add that even though one shouldn't need to count anything anymore,
one still should be very aware of what he/she is getting in each day.

A "normal" person who's never had a food issue or weight issue instinctively
knows how much, what, when to eat, etc. I would venture to say that the great
majority of us who've had WLS were not normal in this respect. For whatever
reasons, we didn't instinctively know when to eat or stop eating, etc.

There's the old saying that WLS did surgery on on stomachs, not our brains,
and this is so the truth. When one is still needing to lose weight, providing
you are following some of the basic rules like "protein first", "eat when
hungry, stop when satiated", etc. you are more or less assured that you will
be getting in what's needed (without having to worry about counting calories
or anything else).

BUT, when one reaches goal weight, and in terms of maintaining one's weight,
these rules change, and they change fast... All of a sudden, you will find
that you can't depend on your instincts as your instincts were never normal to
begin with. Prior to WLS, our instinct was to eat abnormal portions of foods,
the "wrong" foods, etc... After WLS, our instinct is to eat super small
portions of food and to steer clear of unhealthy and/or high sugar/fat/calorie
foods (which is still not a "normal" instinct that people who've never dealt
with a weight or food issue seem to have been born with). Further out postop
(1 1/2 to 2 years out and beyond), one's instinct might be to return to old
behaviors around food.

So, when one is at goal and is looking to maintain weight, one can't rely on
his/her instinct as it never was and still is not normal. How do we then
figure out when, how much, etc. to eat? Yup, you got it! By turning back to
counting... Granted, I am not talking about counting every little calorie and
doing complex mathmatical equations to figure out how much we should or
shouldn't be eating, but it is vital that we have a general idea as to how
little or much we are eating each day.

It comes down to accountability and the ability to assure one's self that
he/she is getting in "enough" but not "too much". At 21 months postop, there
are days when I feel like I am eating WAY too much and expect to start
regaining my weight. Then there are other days where I have little to no
interest in food. Having a general idea as to the calories I am taking in
throughout the day is what allows me to decide what and how much I will eat
(or not eat) the remainder of the day. This is how I maintain my weight of 144
lbs and a weight loss of 223 lbs.

Q: I am only a few months postop and gained 1/2 lb this week!  What am I doing wrong and will I fail?  I am finding that I am returning to my "old" habits fast because I feel like a failure!

A: Hi Jodie,
A few things, yes, PLEASE don't worry over 1/2 lb. You lost 6 1/2 lbs the week prior. Part of that was probably a loss in water. This week, you probably lost more fat but gained back some of the water you lost the week before. It is absolutely NORMAL to have fluctuations in weight.

Also, when I started my WLS journey, I thought I had 240 lbs to lose. I lost 225 lbs, and even at 140 to 155 lbs (my weight fluctuates between these numbers) I am in a size 2/4 (a smaller size than I was at age 17 when I weighed 125 lbs). Weight looks different coming off than going on...

Out of everything I learned in the early out months, the most important lesson was that getting to a healthy weight and maintaining it is not a game that one wins or loses. Likewise, if one thinks her/himself to be "losing" (failing), it doesn't mean one should throw in the towel. If you want to be successful in the long run, it is VERY important to learn how to view postop life as a lifestyle change - NOT just another diet.

At some point in time, you will reach goal and when this happens, that's when things get tough. Maintaining one's weight loss is MUCH harder than losing the weight. For me, the reason this is true is because when I was still in the losing stage, the downward progression of the numbers on the scale kept me motivated to stay on track and do all the right things. Once I reached goal, I had the excess skin to contend with and this played havoc on my mind (I was thin but the skin made me feel heavy still). Worse was that I no longer had an immediate motivator to keep me on track (weight loss). I had to learn other reasons to continue to do the right things....

As for calorie counting, when you are in the early out months, it is hard to get in enough calories to even maintain weight let alone gain weight. Further on down the line (usually beginning around 18+ months postop), while you may not have to count calorie for calorie, you should have an idea as to how many calories you are taking in each day as well as burning. In the end, weight maintenance (as well as losing or gaining for that matter) comes down to calories in/calories out). How many calories you require each day to maintain weight is known as Basal Metabolic Rate (BMR). The average woman burns 10 to 11 calories per lb of body weight per day and the average man burns 12 calories per lb of body weight. So if you weigh 300 lbs right now, assuming you have a normal metabolism, you would require 3,000 calories per day. To burn 1 lb of fat, one needs to have a caloric deficit of 3,500 calories. So for every 500 calories per day that you deficit, you can expect to lose 1 lb per week. Knowing how many calories you are taking in/burning and your BMR will become more crucial the further out postop you become.

Q: I haven't had my surgery but am afraid of having the excess skin as you
have! Is there anything I can do to prevent it? Should I rethink my having
WLS?
A: Yes, the excess skin I have wax (and still is but to a MUCH lesser extent)
unreal. But I would ABSOLUTELY have WLS again, in a heartbeat, even knowing
the amount of skin I'd be left with...

As for exercising, I exercised and weight trained my entire way down in weight
but unfortunately it didn't stop me from having so much excess skin. If you
look at my reconstructive photos in my picturetrail, you will see that
underneath the skin is an extremely toned body. In my case, it has nothing to
do with the amount of muscle I have... Some people are more prone to excess
skin than others despite the amount of exercising or toning one does.

Speaking of my own situation, I was never heavy as a kid or teen, and when I
started gaining weight it came on FAST. From age 18 to 19, I gained almost 100
lbs and then for the next 15 years became super super morbidly obese (with a
BMI of over 61) with several massive yoyo dieting weight losses and regains
(lose 80 gain 100, lose 125 gain 123, lose 60 gain 70, etc. etc.). Also,
genetics plays a part in this no doubt. My dad's mom has never had a weight
problem, yet at age 45 she had batwings that could rival most postop's arms.

Also, please know that I started out HUGE.... My hips were 72" around, my bra
size was a 58H (yes, a 58DDDDD!), my waist was 57", each thigh was 40", etc.
And not only did I start out huge, but I lost 100+% of my excess weight (going
from 367 lbs to 144 lbs) and over 200" with my body fat dropping from 57% to
less than 15%. (to give you an idea of just how much my body has changed my
upper arm used to be the same size that my waist is now... Part of the reason
there was sooooo much excess skin on me is because I lost ALL of the fat
underneath the skin.

If you are like most WLS patients, you are more likely to be around 100 to 150
lbs overweight, not the 230 lbs overweight that I was. You also probably
aren't starting out wearing a Women's Plus Size 6X and 7X or a Men's 6X.

And even if you are or even past that, then even MORE reason to get your
weight under control.... You can deal with any skin issues if and when you
cross that bridge. Did you see my other photos? The one's where I am clothed?
If so, you'll see how easy it was for me to hide all the skin! I always said,
if I can't get PS, at least I look good in clothing!!! LOL

Sure hope this helps and yes, PLEASE, don't let any skin issue discourage you
from getting on a path to health!

Q: I've lost ___ amount of weight and am having trouble with excess skin.  I've seen a plastic surgeon who says that I shouldn't even bother trying to ask that plastic surgery be covered by my insurance as they will deny it saying it's only cosmetic. Is this true? Are some insurance carries better at approving plastic surgery than others?

A: I've been there done that dealing with insurance and plastic surgery. Frustratingly enough, the dr's are right in that most of the time, PS is automatically deemed cosmetic and is therefore considered an exclusion under most insurance policies. Furthermore, many plastic surgeons don't want to deal with the insurance companies as it is time consuming and usually without positive results.

This is not to say that one can't appeal the insurance company's decision or that insurance never approves PS. I had fought for 5 months for Blue Shield of CA to cover my needed reconstructive surgeries and after all my battling and appeals, the only procedures they covered were my abdominoplasty (wound up only needing panniculectomy without muscle tightening) and breast lift. I wound up paying 3K out of pocket to turn the panniculectomy into a lower body lift/belt lipectomy. Round 2 of my surgeries included extended brachioplasty and breast implants which I paid for in full out of pocket to the tune of $8K.... Then I moved here to PA and my plastic surgeon (in CA) submitted requests to my new insurance company (Aetna). I was told by Aetna and my PS that they've NEVER seen a thighplasty nor buttock lift covered by Aetna, but within 2 weeks, Aetna approved my 3rd round of surgery. (I had to pay a $500 copay.)

The thing is, without an official request (from your plastic surgeon) to your insurance company for approval, there is no official denial of which you can appeal.  So even knowing the chances are good that your insurance company  will deny the needed plastic surgery, you should still have your dr. submit the authorization request(s).  Then, once you have an official denial, you can fight it via appeals.  I can tell you that PS does appear to be covered in certain states more than others, and whether it is approved or not doesn't only have to do with the specific insurance company you have, but also your specific situation.

For many if not most, PS following massive weight loss IS cosmetic. Unless you are having ongoing medical issues such as yeast infections, skin breakdown, functional impairments, etc. that are not relieved by other more conservative treatments, getting it covered will be very difficult. This being said, abdominoplasty seems to be the easiest to get approved. If you have a hernia or have lost enough weight to where the panni hangs past the pubic area, usually it is covered.

Q: I am a female and am having trouble finding a good fitting bra as I lose weight.  How do I measure for my bra size and any recommendations for bras for larger breasted women?

A: Here's how you measure for bra size - (there are several versions of this but this is what I've found works best):

Measure the area around your ribcage/back just below your breasts (this is your back size). Then, in your best fitting bra, measure the widest point around your breasts. Subtract this from your back measurement. A 1" difference is an A cup, 2" difference is B cup, 3" difference is C cup, etc. Here's how the cup sizes go - A = 1" difference, B=2", C=3", D=4", DD=5", DDD (or F)=6", G=7", H=8", I=9", J=10". This is standard for most bra manufacturers with the exception of Goddess who offers a DD=5", E=6", F (or DDD)=8", G=9", etc. Also, if you have excess skin on the sides of your breasts, be sure to get a "full coverage" bra (which means that the band along the sides is wider and therefor holds more skin in).
 

Just to add, if you have very large breasts as I do, be weary of any measurements done in a store. Using Victoria's Secret as an example, the largest size cup they offer is a DD and this is only offered in a few styles (more styles can be found through their catalog). As back size goes down, cup size goes up so a 32 DD = a 34 D = a 36 C = a 38 B, etc., and if the store doesn't carry your cup size (such as a DDD), the staff may up your back size to get the correct cup. Trust me, you DON'T want to do this as the band of the bra will ride up your back and won't offer the correct support. Also, the cups will extend to closer to your back, and if underwire, it can be painful.

For smaller backs/large cups, the best place I've found for bras has been JC Penny's catalog. It's easy to find bras as high as H cups there (while keeping the back smaller). Glamorise makes some wonderful bras for large breasted women that give a natural shape.

Q: What about the window of opportunity and weight regain? Can I gain all of
my weight back?
A: Yes, it is true that there is a window of opportunity (somewhere between 6
months and 18 months), but I would argue that the window never really closes
until we decide to shut it. The rules of weight loss (and weight gain) are the
same no matter where we are in the process of WLS and even whether we've had
WLS or not. It all comes down to calories in/calories out. The further one
becomes out, the more volume of food that can be eaten per meal, the greater
the tolerance for sugars and fats, some old habits may return especially if
you haven't used the window to develop a new relationship with food, etc.

In terms of weight regain, it is VERY common for postops to have a "bounce
back" of about 10% of the weight they lost beginning around 2 years postop.
This doesn't have to be the case, and surely isn't the case for everyone,
though for many it does happen.

For myself, I will be 2 years postop come May 2nd. I reached goal back in
August, lost to my all time low in November, and then bounced back 5 lbs since
then. For the past 3 1/2 months, I have been stable at my current weight,
fluctuating between 144 and 152 (minus some swelling from recent
reconstructive surgeries). For me to stay here, it is important that I stick
to protein first, no grazing, and continued healthy eating. The grazing part
is the one I will forever have to be vigilant with I think. Since I reached
goal in August, it's as though something went off in my head saying eat eat
eat... I still eat healthy, don't drink my calories (the exception being
protein shakes and non-fat, sugar free lattes), eat protein first (the great
majority of the time), etc., but I do find myself grazing from time to time
and this scares me as it is the one thing that will get me in trouble later
on.

But, I am the one with the power to control what goes into my body these days.
For days when I find myself grazing, I graze on SF popsicles, non-caloric
liquids, fruit and similar, healthy foods that I can do damage control with.

******There are more common questions, and as I hear them, I will add to this list :)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

(c) 9/2003-2005, Caroline Ann Martin
2 Years PostOp, -225 lbs and at goal!

My WLS & PS Journey: http://AButterflyEmerges.com
ObesityHelp.com Profile: http://tinyurl.com/bkld
Photos including Must Haves for PostOps: http://picturetrail.com/carolineam (password is ps)
GastricBypass-PostOp Group: http://groups.yahoo.com/group/gastricbypass-postop

GastricBypass-PlasticSurgery Group: http://groups.yahoo.com/group/gastricbypass-plasticsurgery
Bariatric Advantage Vitamins: http://tinyurl.com/2ludv

10 SIMPLE BUT CRITICAL RULES TO ENSURE YOUR SUCCESS

1. EAT THREE SMALL MEALS PER DAY.
Supplement between meal cravings with a protein shake.

2. EAT ONLY GOOD SOLID FOOD.
Healthy foods will fill you up faster than junk food. Likewise, solid, dense
foods will keep you full longer than soft foods.

3. EAT SLOWLY, SENSE FULLNESS AND THEN STOP.
Remember this is a tool. Let it work for you.

4. THERE MUST BE NO EATING BETWEEN MEALS.
Grazing behavior can add over 1000 calories a day to your intake.

5. TAKE NO LIQUIDS WITH THE MEAL.
Liquids will empty solids from your pouch quickly and you will feel hungry
sooner. It may also induce vomiting. Water loading 15 minutes before is
helpful to longer term post-ops and no drinking until at least half-hour after
the meal.

6. ALL LIQUIDS MUST BE ZERO CALORIES (except protein supplements).
Liquids pass right through the small stomach and do not produce a feeling of
fullness. It is easy to consume several hundred to a thousand calories a day
by drinking alcohol, fruit juice or other non-diet beverages.

7. EXERCISE FOR AT LEAST 30 MINUTES EVERY DAY.
Regular physical activity will keep your weight loss going, reduce stress and
help you feel better all around. It will also help you maintain your weight
loss in the long run (because it helps to rebuild muscle which has a positive
affect on metabolism). It may even help a little with the excess skin.

8. CONSUME YOUR PROTEIN.
We encourage you to get at least 80 grams of protein a day. Some specialists
in nutrition suggest you get a minimum of 100 grams of protein per day. Taking
in adequate amounts of protein will aid in preventing fluid retention, muscle
loss and will definitely slow down hunger pangs. Patients who consume adequate
amounts of protein for their body size will enjoy a much greater weight loss.

9. DRINK PLENTY OF WATER.
This may by taken in the form of any non-calorie, non-carbonated, non-caffeine
beverages. Try Crystal Light, Snapple diet drinks or decaffeinated coffee or
tea. Aim for a MINIMUM of 64 oz of water per day. I've found that keeping a 32
oz water bottle with me throughout the day helps me get in this amount easily.

10. TAKE YOUR VITAMINS/SUPPLEMENTS RELIGIOUSLY. This includes a multivitamin,
calcium (not carbonate), iron and B12. These are vital to your staying healthy
in the long term. Bariatric Advantage makes some wonderful vitamins that make
take your vitamins a pleasure rather than a chore. Feel free to visit
http://tinyurl.com/2ludv .

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
(c) 2003 - 2005, Caroline Ann Martin, M.A.
2 Years PostOp, -225 lbs and at goal!
http://groups.yahoo.com/group/gastricbypass-postop

http://groups.yahoo.com/group/gastricbypass-plasticsurgery

Caroline's WLS "Rules" rg food when losing weight:

A few people have asked me what my rules are... Here they are in a nutshell and more or less in order of importance...

Keep in mind that these may not apply for the first couple of months postop as the ability to get and keep down food is different. Also, in terms of maintaining weight, I have since ammend some of them (mostly the 3 meals, no snacking rule by including planned, healthy snacks to up my calories to meet my BMR).


- 3 planned meals per day and no snacking that is unplanned (the exception to this is if I am being very active and I'll have some beef jerky, NF cheese, a NF/SF latte, etc.) (Also, when I was early out, in order to get in enough calories for the day, I added in 2 high protein snacks.
- Eat until satisfied/satiated, do not measure food out and stop eating after a certain amount. This is what allows me to stay satisfied with my 3 meals per day. (early out I did measure my food into 1/4 to 1/2 cup servings as I wasn't able to sense fullness until the third or fourth month postop).
- The more "solid" the food the better as this helps me become satiated faster and stay satiated longer.
- No drinking while eating or for a minimum of 30 minutes after eating soft or solid foods.
- Each meal should take no more than 20 to 30 minutes - otherwise it becomes grazing. (If I go out to dinner with friends, I don't pay as much attention to this. I am more watchful of the time at home where I'm more likely to graze and eat for emotional reasons.)
- Minimum of 70 g protein per day (I have a protein shake most days for breakfast which helps me get in my protein, and most days I take in more along the lines of 100 g or more protein.)
- Maximum of 20 g of fat per day (most days I have much less than this in my diet)
- No more than 10 g sugar (and/or sugar alcohol) per meal unless the sugar is from milk, fruit or veggies)
- Minimum of 64 oz of non-caloric (very low cal), clear liquids per day (ie: water, Crystal Light, Propel, Fuze, decaf coffee or tea, etc.)
- No chips, rice, pasta, potatoes or bread (as time has gone on, I've added a few bites of bread and potatoes into my meals. I don't buy them and bring them home though as I've been known to eat them inlui of anything else.)
- No fried foods
- No nuts (way too high in fat and I never get full from them) unless they are in VERY limited supply forcing me to stop after just a few.
- Each meal's nutritional breakdown should include about equal protein and carbs or more protein than carbs. (ie: protein first...)
- No eating after 9 pm (unless I wasn't able to have dinner and obviously need to eat).
- Absolutely no carbonated drinks (besides concern over whether drinking carbonated drinks may or may not stretch the pouch, carbonated drinks are know to pull calcium from the bones. Also, it hurts to drink for me to drink them and they aren't necessary for a healthy diet, so why bother?)
- Do NOT give in to cravings - I tend to "push the limit" with high carb/high fat foods even though I get sick from them. For me, it's MUCH easier to avoid the 1st bite than it is to stop after several bites. (This is different for everyone, and for many, what works better is to have a couple bites of whatever one wants and be satisfied with it. For me, however, I am RARELY satisfied with just a bite or two of a craved food. Rather, I am very compulsive around food and once I open the door to the craving, it's very hard for me to stop. I've been known to take a few bites, and another and another and another, etc. until I find myself sick :( So I just don't open some doors. It's like an alcoholic who follows a personal rule of not allowing him/herself to have "just one drink" as he/she know's it's impossible to have "just one" and that serves as a trigger to relapse. (now, all this being said, food is all around us and it's not quite the same as alcohol for a variety of reasons, and there are times I will have "just a bite" if the situation is that the quantity available is "just a bite". For example, a few weeks ago I was at the San Diego Zoo with some friends. One of my friends had Pringles potato chips with her and offered all of us some. Keeping in mind that one of my all time favorite foods prior to surgery was Pringles, I soooooo wanted those chips. But it breaks the "rule" of no chips and don't give into cravings.... But given that I was with people, being very active that day, the chips were in limited supply so that I could only have "just a few", I took a few and ate them. Was I satisfied after eating the 5 chips or so that I had? No... But fortunately, that time, it didn't open a door to further chip eating.)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
(c) 8/04, Caroline Ann Martin
http://groups.yahoo.com/group/gastricbypass-postop