Sara Kelly Keenan LC

Making the decision to have weight loss surgery is a very big deal. It seems obvious to say that when someone agrees to weight-loss surgery they're desperate for help to change the way they're living, or not fully living their lives. Everyone goes into the procedure ready and willing to surgically alter their anatomy hoping for a better future. So why is it that so many will fall short of losing the optimal amount of weight for their health and will actually regain within 3 years much if not all of the weight they lost? Some studies say 1/3 of patients will regain most of their weight post-surgery. I think the number is actually higher because many people who regain simply fall out of contact with their bariatric surgeon and support staff because they feel ashamed, so the statistics do not include these people. So, why do most people regain the weight? What can you do to help insure that you will be one of the successful long-term losers of your excess weight? By examining why people fail you can create a plan for how you will succeed. The government agency, National Institutes for Health (NIH) defines weight-loss surgery as "merely a tool that helps people get a new start toward maintaining long-term good health. The surgery alone will not help someone lose weight and keep it off. Together with a reduced-calorie and low-fat diet and daily exercise, surgery will help an individual lose weight and maintain the weight loss.” Please read that a few times. That is how important this quote is! The surgery alone will not help someone lose weight and keep it off. We as weight-loss surgery patients have a history of seeking comfort, happiness and pleasure through food. We wouldn't be here if that weren't true. Me included. The process of surgically altering our anatomies does nothing to remove from us the tendency to seek comfort in familiar ways but assures there will be physical suffering if we do. Post-surgery we will still have the same brain that is used to comforting us with food, and we will still have the fingers and the arms that are used to lifting food to the same mouth to find comfort and pleasure. It is critically important that the WLS patient seek out new ways to soothe, comfort, and find pleasure in their world other than by eating. ONE main reason patients regain their weight is they search for ways to get around the surgery, still thinking of food as primarily a source of pleasure, not a source of fuel that can be pleasurable. This is often done relying on liquid calories, which may pass more easily, like high calorie coffee or juice bar drinks or alcohol. This is also done post-operatively by trying to maintain the presence of “trigger foods” in their lives. “Trigger foods” are often foods from the patient's past that helped cause obesity, do not satisfy hunger but instead create a craving. Many are high-calorie and highly processed, not nutritious. Trigger foods can include chocolate, chips, crackers, bread, cookies, ice cream, pudding, lattes, frapuccinos and alcoholic beverages. Really, any food can be a “trigger food” if there is so much pleasure in the “mouth-feel” or taste that repeating the pleasurable experience takes on more importance than actually feeding hunger. Very successful patients cultivate a mostly trigger-free post- surgical life. Bariatric surgeons and the NIH know the most common reason for regain and the most common post- surgical complication is “noncompliance.” Non-compliance is a fancy word that means the patient is not eating and exercising the way he/she agreed to before surgery. These people “talk the talk.” The successful patient “walks the walk” after surgery and changes how they eat and move. A SECOND reason people often regain beginning in the second or third year post-op is that the “honeymoon” is over. The “honeymoon” generally encompasses the first 12 to 18 months post- surgery. During this time many patients will say, "I could eat all the chocolate and ice cream I wanted and still lose weight. I didn't have to try and the weight just came off.” This is often true because the body has been through such a shock after surgery that it takes months for the body to reset itself and learn to function with its' new physiology. Patients who regain their weight often believe that this “honeymoon period” is the new way that it will always be and don't adopt healthy eating patterns. So when their “honeymoon period” ends as it will they believe that the surgery has somehow failed them. In reality they have failed their surgery! During the first 12-18 months post-op it is essential to develop healthy patterns around food and exercise. This is the time when it is actually easiest to do and to not do so wastes a once-in-a-lifetime opportunity to begin a great new life with positive momentum. A THIRD reason many patients regain much of their lost weight is a lack of support. Humans are social animals and we desire and need the support of each other throughout our lives. For thousands, if not tens of thousands, of years people coming together as a family or a community over food has been a way we connect with each other. Post-surgery, when the patient isn't able to eat what others are eating or in the quantities others are eating, or others are eating their 'trigger foods”, life can feel very stressful and lonely. This can be compounded by being around unsupportive people or people who want to be supportive but don't know how. Patients fail by not surrounding themselves with supportive people in a safe environment where they also must be accountable for their actions and behavior with food and their bodies. It is key to have a community of professionals and non-professionals who understand the challenges and hardships faced by those carving a new life with a new anatomical structure. There are online and in-person support groups. Even patients who've gone abroad for weight loss surgery can often use the support services available with their local medical group's Bariatric department. Creating relationships that support and assist you in becoming a healthier person and that hold you accountable for making healthy choices are key. These are my top three. What would you add to this list? What plan will you create to deal with the items you add to this list? Who will support you on this journey of your life.....for your life?

I love the link to the Gretchen Rubin article too. When I wrote in my article above that one of the ways people regain is to try to keep "trigger" or "comfort " foods in their lives in moderation I was trying to express what Gretchen Rubin is also saying. Many find abstaining easier and more freeing long term and more conducive to weight loss and a healthier relationship with food than trying to keep these foods in our lives in moderation. The "sex on a plate" reference struck me as so helpful because when I and others I have worked with try to keep "comfort" foods in our lives in moderation it is easy to slide into a sensual relationship with the experience of intaking that food that takes on almost a sexual quality. The ingesting of it can become a rhythmic form of self-pleasuring that could almost benefit from a Barry White album playing in the background!

Yvonne, I love your "sex on a plate" comment. There's a lot of truth in that for me.

MBM1Forever: "I am wondering out loud if the focus would not get so off track after the "honeymoon" period if the focus was always to eat a healthy diet." RIGHT ON!!

Ro, I sent you a private message.

So why is it that so many will fall short of losing the optimal amount of weight for their health and will actually regain within 3 years much if not all of the weight they lost? Some studies say 1/3 of patients will regain most of their weight post-surgery. I think the number is actually higher because many people who regain simply fall out of contact with their bariatric surgeon and support staff because they feel ashamed, so the statistics do not include these people. So, why do most people regain the weight? What can you do to help insure that you will be one of the successful long-term losers of your excess weight? By examining why people fail you can create a plan for how you will succeed. The government agency, National Institutes for Health (NIH) defines weight-loss surgery as "merely a tool that helps people get a new start toward maintaining long-term good health. The surgery alone will not help someone lose weight and keep it off. Together with a reduced-calorie and low-fat diet and daily exercise, surgery will help an individual lose weight and maintain the weight loss.” Please read that a few times. That is how important this quote is! The surgery alone will not help someone lose weight and keep it off. We as weight-loss surgery patients have a history of seeking comfort, happiness and pleasure through food. We wouldn't be here if that weren't true. Me included. The process of surgically altering our anatomies does nothing to remove from us the tendency to seek comfort in familiar ways but assures there will be physical suffering if we do. Post-surgery we will still have the same brain that is used to comforting us with food, and we will still have the fingers and the arms that are used to lifting food to the same mouth to find comfort and pleasure. It is critically important that the WLS patient seek out new ways to soothe, comfort, and find pleasure in their world other than by eating. ONE main reason patients regain their weight is they search for ways to get around the surgery, still thinking of food as primarily a source of pleasure, not a source of fuel that can be pleasurable. This is often done relying on liquid calories, which may pass more easily, like high calorie coffee or juice bar drinks or alcohol. This is also done post-operatively by trying to maintain the presence of “trigger foods” in their lives. “Trigger foods” are often foods from the patient's past that helped cause obesity, do not satisfy hunger but instead create a craving. Many are high-calorie and highly processed, not nutritious. Trigger foods can include chocolate, chips, crackers, bread, cookies, ice cream, pudding, lattes, frapuccinos and alcoholic beverages. Really, any food can be a “trigger food” if there is so much pleasure in the “mouth-feel” or taste that repeating the pleasurable experience takes on more importance than actually feeding hunger. Very successful patients cultivate a mostly trigger-free post- surgical life. Bariatric surgeons and the NIH know the most common reason for regain and the most common post- surgical complication is “noncompliance.” Non-compliance is a fancy word that means the patient is not eating and exercising the way he/she agreed to before surgery. These people “talk the talk.” The successful patient “walks the walk” after surgery and changes how they eat and move. A SECOND reason people often regain beginning in the second or third year post-op is that the “honeymoon” is over. The “honeymoon” generally encompasses the first 12 to 18 months post- surgery. During this time many patients will say, "I could eat all the chocolate and ice cream I wanted and still lose weight. I didn't have to try and the weight just came off.” This is often true because the body has been through such a shock after surgery that it takes months for the body to reset itself and learn to function with its' new physiology. Patients who regain their weight often believe that this “honeymoon period” is the new way that it will always be and don't adopt healthy eating patterns. So when their “honeymoon period” ends as it will they believe that the surgery has somehow failed them. In reality they have failed their surgery! During the first 12-18 months post-op it is essential to develop healthy patterns around food and exercise. This is the time when it is actually easiest to do and to not do so wastes a once-in-a-lifetime opportunity to begin a great new life with positive momentum. A THIRD reason many patients regain much of their lost weight is a lack of support. Humans are social animals and we desire and need the support of each other throughout our lives. For thousands, if not tens of thousands, of years people coming together as a family or a community over food has been a way we connect with each other. Post-surgery, when the patient isn't able to eat what others are eating or in the quantities others are eating, or others are eating their 'trigger foods”, life can feel very stressful and lonely. This can be compounded by being around unsupportive people or people who want to be supportive but don't know how. Patients fail by not surrounding themselves with supportive people in a safe environment where they also must be accountable for their actions and behavior with food and their bodies. It is key to have a community of professionals and non-professionals who understand the challenges and hardships faced by those carving a new life with a new anatomical structure. There are online and in-person support groups. Even patients who've gone abroad for weight loss surgery can often use the support services available with their local medical group's Bariatric department. Creating relationships that support and assist you in becoming a healthier person and that hold you accountable for making healthy choices are key. These are my top three. What would you add to this list? What plan will you create to deal with the items you add to this list? Who will support you on this journey of your life.....for your life?

I see what you are saying Stevehud and I have a similar "personal definition" of success. I think it is important to differentiate between "personal success" (the amount of weight loss I personally want to experience in order for the surgery to feel successful to me) and "success" as defined by the medical studies. They are overly broad for my purposes but I'm sure they have their reasons. That said, as a coach I help my clients figure out what "success" measure is meaningful for them, keeping in mind that definition can change over time as the process of losing weight and getting healthier occurs and goals that seemed impossible become possible. So I revisit with my clients their definition of success throughout the (generally) 3-6 month coaching process.

Thank you for your comments Reeger, They are detailed, informative and add a lot to this discussion. You are right that the physiology of obesity is a complicated and still mysterious area of medicine, that we are in the early stages of understanding the science of obesity medicine and the shortcomings of the procedures. You are much better trained and informed than I to have that discussion with our clients. The word "non compliance" comes from the National Institutes for Health (NIH) research materials I quoted. I did not intend any blame in the use of that word. For me, it is a statement of fact and I took it as such from the NIH. For example, in my first 3 years post-op (2004-2007) when I lived on caffeine and high-calorie liquids (as I wrote about in my article "Vulnerability, Weight Loss Surgery and Cross-Addictions" last August) I was in "non-compliance" with my doctor's care plan for me and my pre-surgery plan and promise to myself. I am acknowledging the fact. You, as a medical professional, and I, as a coach, have a common goal I believe which is to help our clients become the healthier people they desire to be. I believe our roles are different but complimentary. You have outlined very well the shortcomings of the procedures and how medical science is in many ways in its' infancy in understanding the biological issues that come into play with obesity. That is your area of expertise and I leave that to you and the bariatric surgeons who refer people to me to discuss that with our clients. I, as a coach, have a different role. My role is to help our clients figure out "where" they are with regard to their health, "where" they want to be, what incremental steps they can take and are willing to take to move that direction and then support them in moving that direction with a intentional plan. I wrote this article to highlight how people struggle and what steps they can take to positively affect their own outcomes more. I tried to provide strategies for moving through these struggles toward that outcome through patient-driven change. I don't minimize the science. I am glad you are there for our patients to work with them on the science. I am here to help them get focused on their desired, healthier life and break down the achievement of that into incremental, manageable tasks that can be built upon to improve their health and the quality of their lives as they define "quality."

MBM1Forever, You are right about it not always feeling like a Honeymoom. It's only a Honeymoon in that many people find losing weight in the first year is easier than losing it after the first year or maintaining the loss. But the first 6-12 months for me were closer to a Hell than a Honeymoon. I do want to offer you some hope and tell you that for me the first year was the worst and it was not a "new normal" I was living but was a hard-time of adjustment. The new normal that I settled into in the years after was more pleasant and easier to live with. 13 years later I can tell you that in the first year I couldn't have imagined what is normal for me now! I think it is likely that your "damn difficult" time is part of the early phase of recovery and it will get better. "New Normal" is likely a kinder place and further down the road.

VSGAnn, I agree with you that there isn't enough (I'd say any) rigorous research around the regain issue and I wish there was more of it too. NWLR's study is good for learning what "works" but not great since becoming a member of their study requires successful, maintained weight loss. It's a study of what "works" in weight loss generally and is not a study of Weight Loss Surgery. Unlike other "disease recovery studies" there is shame and stigma involved in regain of weight so the patient is more likely to disconnect from medical resources and "fall of the radar." Regarding those people you mentioned who are regaining on 1200 calories per day, I work with people like that to speed-up their metabolisms very gradually so they can eat up to 2300-2800 calories per day and burn it all. But it tests most people's self-discipline to be able to do that. It involves very intentional daily exercise and very precise nutritional macros which are both ramped up slowly over a period of months. It takes a tremendous amount of focus and dedication for 4-6 months, like the focus required for professional athletics, but it is possible. Using this approach I took my metabolism from burning 1200 calories per day (after weight-loss) to maintaining my current weight eating 2800 calories per day. My calorie consumption is higher than the average because I am over six feet tall.

Hi FocusOnMeNow, One of the things i do in my practice is help people create and live a list like the one you refer to. What I've learned over time is that it is a very personal list and needs to be revisited over and over again. It also helps to break the list down into small, achievable tasks. Everyone finds comfort in different ways or combinations of ways and those ways change over time. The list can also broaden as you lose weight and work on fitness as well. For instance, my first list included walking my dogs 20 minutes per day up a 300 foot hill. That, over several years, morphed into a passion for hiking, then ultra-distance hiking, then mountain-climbing. I could not have known at 333 pounds what my list would become! My best advice to you is create a flexible list that you revisit often to add activities that provide comfort, but more importantly passion. When we live passionate, vision-filled lives things like the cake are less tempting because they don't advance us on our paths towards our vision of the future-life we desire.

Lisa, What can you do/say to yourself in the early moments of the downward spiral to end the free-fall into self-sabotage? If you had to create a manual for you to use at those moments what would it say? Really sit with that question. You might benefit from writing that manual and keeping it handy. We all have such moments. No one is more qualified than you to write that manual for you to end the free-fall and return to the light of your potential!

When we honor and nurture our bodies we keep the possibility of a purposeful, healthy present and future alive within us. When we enrich our bodies with rest, create movement that challenges us while inviting gentleness and provide our bodies natural, quality foods the possibility for living meaningful, vision-filled lives opens before us. When we abuse our bodies with substances, judgment, criticism or cruelty we darken the places where light is required to move us toward our vision of a purposeful, fulfilling life. Consider, what would it mean to be your body's best friend? If you were your body's best friend what would you say to it? What would it say to you? What does it need to hear? How would you reassure it? Support it? It is not an accident that our bodies are ALWAYS present and ALWAYS available for connection with our spirits and our minds. You can be your body's best friend. You are THE ONE it has been waiting for! When I consider what I would say to my body it goes something like this: "You are not what your parents and friends said you were...ugly, lazy, slobbish, in need of a tent-maker for clothing, undisciplined. You are a precious being who, in total innocence in a traumatic, unsafe environment turned on yourself when you turned to food in an attempt to find some comfort, calmness, and affection. You are the very opposite of lazy and undisciplined. You have searched for decades without resting for comfort, affection, tenderness and love. You never gave up searching! You kept searching. But while you were searching with food I have been here all along and I have now learned how to give you what you crave and I have the support to continue to give you what you crave...a love and comfort that "comfort" food can never deliver. " When I consider what my body would say to me it goes something like this: "Don't leave me! Don't turn your back on me and trash me the way all the others have and the way you used to! The means don't trash me (disparage me) and don't treat me like a trash can to fill with unhealthy food in unhealthy quantities. Post-surgery, don't deny me the nutrition I need for health and don't continue to use food primarily as a source of comfort. If you can't see me and treat me well and love me then who will? I need you! Now that you can see me please do not turn your back on me again." With an open-hearted, internal dialog such as this food can take its rightful place as a source of fuel rather than as a fleeting, unsustainable source of pseudo-love. How are you moving beyond food addiction, beyond the nuts and bolts of surgery and becoming available for the purposeful, vision-filled living of the rest of your life?

When we abuse our bodies with substances, judgment, criticism or cruelty we darken the places where light is required to move us toward our vision of a purposeful, fulfilling life. Consider, what would it mean to be your body's best friend? If you were your body's best friend what would you say to it? What would it say to you? What does it need to hear? How would you reassure it? Support it? It is not an accident that our bodies are ALWAYS present and ALWAYS available for connection with our spirits and our minds. You can be your body's best friend. You are THE ONE it has been waiting for! When I consider what I would say to my body it goes something like this: "You are not what your parents and friends said you were...ugly, lazy, slobbish, in need of a tent-maker for clothing, undisciplined. You are a precious being who, in total innocence in a traumatic, unsafe environment turned on yourself when you turned to food in an attempt to find some comfort, calmness, and affection. You are the very opposite of lazy and undisciplined. You have searched for decades without resting for comfort, affection, tenderness and love. You never gave up searching! You kept searching. But while you were searching with food I have been here all along and I have now learned how to give you what you crave and I have the support to continue to give you what you crave...a love and comfort that "comfort" food can never deliver. " When I consider what my body would say to me it goes something like this: "Don't leave me! Don't turn your back on me and trash me the way all the others have and the way you used to! The means don't trash me (disparage me) and don't treat me like a trash can to fill with unhealthy food in unhealthy quantities. Post-surgery, don't deny me the nutrition I need for health and don't continue to use food primarily as a source of comfort. If you can't see me and treat me well and love me then who will? I need you! Now that you can see me please do not turn your back on me again." With an open-hearted, internal dialog such as this food can take its rightful place as a source of fuel rather than as a fleeting, unsustainable source of pseudo-love. How are you moving beyond food addiction, beyond the nuts and bolts of surgery and becoming available for the purposeful, vision-filled living of the rest of your life?

The magic of transformation really isn't very magical. Transformation is found in the daily practice of kindly, lovingly stretching ourselves and reaching for more in our lives and in our bodies . That's what I'm doing in this 5 year old photo...when a disabled woman with chronic pain, opiate addiction and 170 pounds of excess weight bravely took a chance on a yoga class for the disabled. I love this "me" from 5 years ago, I see her inner beauty shining and am so grateful to her for taking the leap of faith, in the absence of evidence, that things could be better. WLS is a leap of faith, a big one! It can be a wonderful spring-board to transformation from un-wellness to health but additional leaps are required to get there. What leaps of faith towards further wellness, happiness and fulfillment can YOU take today?

I've been at goal weight for years, I am 11 years post-WLS and food is often still a struggle. Although my weight doesn't fluctuate more than 5 or so pounds from goal weight, which I maintain, it is always a struggle. I was on a cruise last week and the buffet was like a mermaid singing her siren's song enticing me to shipwreck myself on her fattening rocks. So tempting. And for the entire week she never shut-up! What I'm beginning to accept is that I will ALWAYS be a food addict and need to remain vigilant at all times. I won't be permanently free of this addiction and there will always be struggle involved. It seems my only choice is whether I struggle at a healthy weight able to participate in active sporting and life endeavors or whether I will struggle while I return to morbid obesity at 333 pounds and live out my days sitting in a chair in front of the tv gorging myself. I choose to struggle while healthy and active. I have tools and support for continuing to choose the healthy, active path. Maybe that's as good as it gets...and that's enough!

I echo everything you wrote, My Bariatric Life. BRAVA!! "Introducing NLP" and "NLP For Beginners" are both good choices for you.

@@CowgirlJane Yes, I have reviews there as beaglemama and beaglemamasara.

The magic of transformation really isn't very magical. Transformation is found in the daily practice of kindly, lovingly stretching ourselves and reaching for more in our lives and in our bodies . That's what I'm doing in this 5 year old photo...when a disabled woman with chronic pain, opiate addiction and 170 pounds of excess weight bravely took a chance on a yoga class for the disabled. I love this "me" from 5 years ago, I see her inner beauty shining and am so grateful to her for taking the leap of faith, in the absence of evidence, that things could be better. WLS is a leap of faith, a big one! It can be a wonderful spring-board to transformation from un-wellness to health but additional leaps are required to get there. What leaps of faith towards further wellness, happiness and fulfillment can YOU take today?

LOL @@MichiganChic Oh, if only money and pain were not issues!! :-)

That price was just for the body surgery in May of 2013. I paid almost $9000 for the facelift, browlift and neck lift 3 months ago and that included a week at Cosmed. I wouldn't have returned there twice if I wasn't happy but surgery is always risky and surgery across a foreign border is even more so. There were also terrifying moments during recovery when I was vulnerable and felt alone and longed for caregivers whose native tongue was English. If I'd had complications I knew I'd have to be driven across the border to a US hospital through a long US Immigration line for treatment and that is a risk I assumed. I'm just lucky I didn't have complications. I don't think it happens often but if it happens to YOU it can be VERY serious. I am done with plastics work but I will be going back there in a few months for Fraxel.

It's the best $17,000 I've spent in my entire life in terms of return on my investment in happiness and improved quality of life.

For all of the procedures I listed in the body surgery part of the post I paid $16k, which included 10 days of care in the doctor's own 9-bed hospital with round the clock nursing...and I needed it!! The cash price for just a basic tummy tuck here in the SF Bay Area was going to be that much as an outpatient. The cost for the services I recieved if I paid for them in the US would have been close to $100,000.

I went to Cosmed Clinic in Tijuana. It's a modern, state-of-the-art, 2 year old private hospital with US board certified Mexican docs.

I'm 54 and in very good shape. I have a strict, intense fitness plan. I had the skin removed several months after getting within 10 pounds of goal weight. I knew from yo-yoing for 20 years the skin was permanently stretched. I couldn't afford it in the US so I went to Mexico for an arm lift, breast lift, lower body lift and inverted-t tummy tuck. That was several years ago. Then I returned 3 months ago for a facelift. Best money I ever spent and got excellent care and results.