GETTING BACK ON TRACK

I'm writing this because it seems to be a constant theme of my one year out support group. Yes, even folks this far out often need to be reassured they are on track. Many patients look at this as a magical surgery that makes them thin and some do not do the work that comes after the surgery because it is so easy to lose weight during the first year. Unfortunately in life, most of us cannot have our cake and eat it to.

I tell our patients the pain of surgery goes away but changing eating and lifestyle behaviors is very difficult and takes a lot of focus the first six months out of surgery. Many complain it feels like they are eating or drinking something all the time. I'm sure it feels like that with such a small stomach and having to sip constantly to get in enough fluids in at first. Fortunately, this changes with time. The goal is to make it become second nature and not awkward like it feels at first.

Probably the biggest fears patients have are regaining the weight and stretching the pouch. If you goals become that of health and not weight loss and size, life will become much more rewarding. Following the basic principles of bariatric surgery and being physically active everyday for at least 30 minutes will make you successful for the rest of your life. However, this must be done 95% of the time, not just occasionally or when you start regaining weight. Below are the basic tenets of gastric bypass surgery:

1. Eat slowly. It takes 30 minutes for those hormones to signal the brain you are getting full. I know patients who can eat in 15 minutes after a year out and have no ill effects. If they overeat, by the time they can tell, it's too late and they are working on overstretching their pouch. Put the food or utensil down between bites. Leave about a minute between bites. Make meals pleasant and a time to relax. Play music, light candles, set an attractive table. Make it an event. Stop eating at the first sign of fullness. This is an important concept to figure out. If you can't tell, just stick with 6 to 8 ounce portions at meals for long term maintenance. When a patient is eating more than I do with a big stomach, there are some other issues that need to be resolved.
2. Do not drink with meals. I've seen a patient regain 120 pounds drinking a liter of fluid with meals. Drinking a lot of fluids with meals once you are 6 months out or so will liquify the food allowing it to go through faster and allowing you to eat more. Keep the fluids between meals, not with. This will differ with something like BPD/DS but is certainly true of the RNY.
3. Eat protein at every meal forever. You need to eat protein at your meals to get enough in your day. Protein will fill you up and help kill those carbohydrate cravings. Long term, strive for 2 to 4 ounces of protein at each meal. Round out the meal with a fruit or vegetables and ¼ cup of starch or a slice of bread. This is not a starchy diet. Breads still tend to swell and fill people up.
4. Take your vitamins and supplements everyday forever. We've had patients decide they feel good and stop taking them. Bad idea! Many will become deficient in B vitamins within 2 months. Without calcium, osteoporosis will be your friend. Keep in mind that 1 out of 2 women in the U.S. over age 50 have osteoporosis and that is without a gastric operation. Remember, you are not eating enough calories to get all the nutrients from your food or you are malabsorbing so badly that you have to take them even if you are eating a lot of food. If you are having trouble tolerating protein foods, you may need a protein supplement to get enough. Go to something like www.dietwatch.com and figure out how much you are consuming. Even the minimum world standard is 40 grams per day. The proteins you eat should come from animal sources like fish, eggs, milk, cheese, yogurt, beef, chicken, or pork. The only plant source that is a complete protein is soy.
5. Drink water. Your body uses 2 quarts a day. That means you should be drinking at least 8 to 10 glasses per day to replace all those fluids, more if you are exercising. An easy way to figure out how much you need if you exercise a lot, is weigh yourself before you exercise, then weigh yourself after. You should drink 1 cup of water for every pound you lose to replace those fluids. If you exercise more than 90 minutes, drink something like Cytomax or Gatorade. Water quenches thirst better than any other drink. Add lemon, lime, or orange to give it some zing.
6. Do all of your follow-up visits and have your labs checked every year forever. Keep track of your serum ferritin, B12, and folate as well as your albumin (protein indicator). See if they are going up or down. Try to keep them at levels previous to surgery unless those levels were too low. Have a dexascan (x-ray) of your hip and spine to evaluate your bone status. I highly recommend having Vitamin D levels checked before surgery as a study that came out from Tufts this year indicated many overweight people have low levels of this vitamin. You need Vitamin D to absorb calcium. Having low levels could indicate a bone problem. My girlfriend drank milk all her life and exercised and found out at age 43 she had osteoporosis. Her Vitamin D level was extremely low.
7. Be physically active daily. It only takes 30 minutes. Dance, swim, bike, hike, try something new. Take tennis lessons. Strength train 3 times per week. This will build muscle mass and give you shape and tone as well as help keep those bones dense. Check out this site to see what weight training can do for a body: www.joycevedral.com. Make sure to stretch after weight training or cardio work and always warm up for 5 to 10 minutes before to get that blood flowing to the muscles. We lose ½ pound of muscle per year after age 27, that's why folks get that middle age bulge. With the loss of muscle mass, the need for calories goes down about 25%. Just eating well doesn't cut it. Maintaining takes some work but make it fun and mix it up. Find a friend or try a video tape. A great place to find tapes when you are just starting out is: www.kellybliss.com. Her book is also excellent for those head issues.
8. Fine tune your diet with a Registered Dietitian. Once you are a year out, go see a dietitian and optimize your diet for maximum benefit.
9. Develop a healthy relationship with food. Throw out the old ideas of food being good or bad and making you good or bad. A better way to look at it is some foods are more nutritious than others. We all eat things because they look and smell good, not because we're hungry. If you get a craving, have a few bites and be done with it. It may not even taste good to you anymore or may not make you feel good. If you cannot control how much you can eat of a food (I call these trigger foods), keep it out of the house until you are ready to deal with this issue. This may take professional guidance.
10. Take cooking classes. Learn how to cook tasty and nutritious foods in 15 minutes so you don't have to rely on frozen foods or take out. Who knows, you might actually find it fun. It will give you something to do with all that energy you've gained from weight loss and exercise. There are many cookbooks on cooking for one. Just go to Amazon.com and type in cooking for one in the search box. Voila! Books on marinating and spices are helpful too!
11. Have realistic goals. Success with these surgeries is defined as 60 to 80% of your excess weight being lost. If you do better than that, it is gravy. Write a list of all the thing you could not or would not do before your surgery because of your weight including medical problems. These are now your goals. As you reach them or they go away or improve, check them off. By then end of the year, reflect on all your successes. Wow!
    
    
    I hope this helps some of you on your journey to the new, healthier you! I wish everyone the best. I know you can do it. The mind is the most powerful tool you have. Be the best YOU can be, that will always be good enough. There will always be smarter or better looking people. Find and develop the gifts that God gave you. Find your passion in life and pursue it!
    
    Yours in health,
    
    Sally Myers, RD, CPT