Judith Meeks-Hakim

Bariatric Realities – Medical Professionals’ Guidelines about Alcohol Use & WLS
I know I said my next article was going to be on causes of obesity, but I got carried away tonight doing some investigating about the professional medical guidelines for alcohol use after weight loss surgery. In summary, the gist of the recommendations are: “Patients undergoing bariatric surgery should be screened and educated regarding alcohol intake both before and after surgery… patients should be made aware that alcohol use disorders (AUD) can occur in the long term after bariatric surgery.” (From: http://asmbs.org/resources/alcohol-use-before-and-after-bariatric-surgery.)
Well, now. Those are some non-specific medical recommendations by medical professionals who are the predominant leaders and caregivers of the surgical weight loss population. Education and awareness. Hey – I am all about education and awareness. Great things, education and awareness.
And yet, I’m gonna say that as a recommendation, that is a very “PC” non-recommendation recommendation, when one considers that we are talking about 1) ALCOHOL and 2) WEIGHT LOSS SURGERY patients.
Consider these educational nuggets and facts I found that WLS patients really ought to be aware of:
Psychologist Stanton Peele, writes, “readers now know that scientifically, it's not alcohol that causes people to live longer, but it is simply being with others and that they are less socially isolated when they drink that prolongs their lives. After all, alcohol is a toxin.” (italics and bold added) (From https://www.psychologytoday.com/blog/addiction-in-society/201011/science-is-what-society-says-it-is-alcohols-poison.
My comments: Yes – alcohol is a toxin, and that means POISON. Those of us in the medical field really ought to know that people are not supposed to ingest poison. But the recommendations do not say, “Do NOT ingest the toxin, alcohol.” No, no, no… they say be educated and aware.
Dr. Charles S. Lieber, M.D., M.A.C.P., in a publication for the National Institute on Alcohol Abuse and Alcoholism, writes, ““A complex interplay exists between a person’s alcohol consumption and nutritional status,” and … alcohol and its metabolism prevent the body from properly absorbing, digesting, and using essential nutrients” (italics added.) Dr. Lieber does indeed, educate us about the nutritional value of alcohol: “Alcohol would not fall under the category of an essential nutrient because not having it in your diet does not lead to any sort of deficiency. Alcoholic beverages primarily consist of water, pure alcohol (chemically known as ethanol), and variable amounts of sugars (i.e., carbohydrates); their content of other nutrients (e.g., proteins, vitamins, or minerals) is usually negligible. Because they provide almost no nutrients, alcoholic beverages are considered ‘empty calories.’ Therefore, any calories provided by alcoholic beverages are derived from the carbohydrates and alcohol they contain.” (italics added)
My comments: People who have weight loss surgery (other than the band) experience absorption issues to one degree or another. Nutritional deficiency is one of the concerns the medical professionals monitor in the months and years following WLS. We stress to patients the importance of taking vitamin supplements for the rest of their lives to help ensure proper nutritional balance.
And yet, rather than saying, “Alcohol use is unwise after WLS,” or “Don’t drink alcohol after WLS,” the governing body of health professionals for bariatric surgery recommends being “educated” and “aware.”
Is that happening? Are the physicians and surgeons and nutritionists and mental health professionals educating patients and making patients aware that ALCOHOL IS A TOXIN THAT CAN INTERFERE WITH VITAMIN ABSORPTION – and it should not be consumed after weight loss surgery? I can’t answer that, although I know we do this at the programs I work with. If it’s not happening, why not?
Having a background in direct sales, which, ironically, was incredible education for my later career as a psychologist, I was taught to “anticipate the objections.” Many health care professionals may be pooh-pooh’ing the vitamin deficiency issue associated with alcohol, stating it’s only those who drink heavily who are at risk for this type of vitamin deficiency. That information, to the best of my knowledge, is relevant for persons who have not had weight loss surgery. What’s more, we don’t know the extent to which people are drinking many years after WLS. Most of the research, as noted in the ASMBS Guidelines/Statements entitled ASMBS position statement on alcohol use before and after bariatric surgery, states, “The existing studies do not present a uniform picture regarding the overall prevalence of lifetime or current alcohol use disorders (AUD) in patients seeking bariatric surgery. The vast majority of the existing literature is retrospective, with small sample sizes, lack of control groups, and low response rates. There are also varying definitions of alcohol disorders (“high-risk” versus “misuse” versus “abuse/dependence”) in the bariatric surgery literature.” In other words, this research does provide some information, but remember, we don’t really know that much because there isn’t enough research on enough people over a long enough period of time. We don’t then, know the actual affect that alcohol use has on vitamin absorption for WLS patients. We DO know that vitamin deficiency is a concern, so WHY aren’t we telling people not to drink?
Not only is alcohol a toxin for our bodies, “Alcohol is actually classified as a drug and is a known depressant. Under this category, it is the most widely used drug in the world. According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA)” (italics and underling added). http://www.medicinenet.com/alcohol_and_nutrition/article.htm
My comments: I am literally chuckling now at the absurdity of this situation. The situation being the medical professionals, all having a code of ethics that reflects the “do no harm” sentiment, ignoring potential harm for their patients. Please note that we would all consider alcohol as being “empty calories” and having sugar/carbohydrates and certainly no protein.
PLEASE let it be the case that the mental health practitioners around the world who deal with surgical weight loss patients are telling them, “Don’t eat empty calories. Eat a lot of protein. Limit the simple carbs and sugar. And refrain from consuming your calories from liquids. NO STARBUCKS. BUT, HEY - GO AHEAD AND DRINK THOSE SUGAR/CARB LADEN, EMPTY, NUTRITION-ROBBING TOXIC CALORIES IN ALCOHOL, THAT ARE, BY THE WAY, THE MOST WIDELY ABUSED DRUG IN THE WORLD.”
Honestly, that sentence should be the entire article.
But WAIT! There’s MORE!
I really love this last tidbit I’ll share with you. It’s so much nicer for me when I can find it online so it’s not that mean, alcohol-hating Dr. Stapleton being the one to blame!
“The truth is that no one needs alcohol to live, so regardless of what you've heard or want to believe, alcohol is not essential in our diets. Did you know that a glass of wine can have the same calories as four cookies? How about a pint of lager – surprised to hear it’s often the caloric equivalent of a slice of pizza? You do not need to be an alcoholic for alcohol to interfere with your health and life.”
https://www.drinkaware.co.uk/check-the-facts/health-effects-of-alcohol/appearance/calories-in-alcohol
Do you hear this, people in the medical profession? Are you giving the OK for your patients to eat four cookies “now and then,” or “in moderation,” or “not for the first six months, or year after surgery?” Do you realize that you may be DOING HARM by giving your patients “permission” to drink alcohol?
“But our job is not to be the watchdog or decision-maker for people.” Another potential objection to my dismay about the recommendations being for “education” and “awareness,” rather than a direct, “SAY NO TO ALCOHOL” stance. I agree that no one can make the decisions about what people can or cannot do, or what they will or will not do. People in the medical field do tell people things like, “Don’t get that wet or you could get an infection,” “Keep the splint on for the next six weeks if you want to heal properly.” There ARE dos and don’ts that are educational and increase awareness. What’s the real issue that medical professionals don’t take a hard stance on alcohol after WLS? I don’t know. I do know that I did my dissertation on medical doctor’s attitudes toward addiction. Turns out it is much like that of their attitudes toward obesity: many don’t know that much about it, very many do not feel comfortable working with it, and most don’t care about/understand it.
To top it all off, HERE’s the real kicker… Not only do the medical AND some of the WLS organizations not tell people, “Don’t drink alcohol,” THEY PROVIDE ALCOHOL AT THEIR EVENTS!
I can’t say any more.
Connie Stapleton, PhD
connie@conniestapletonphd.com
Facebook: Connie Stapleton
Twitter: @cstapletonphd
LinkedIn: Connie Stapleton, Ph.D.

Having a smaller stomach pouch after surgery makes it a challenge to get in more veggies. Veggies you can sip instead of chewing to applesauce will make it easier to get in your vegetables. Think about blending veggies with protein powder to help increase your protein intake. Focus on non-starchy veggies. There are several ways you can sip your veggies.
One way is to experiment with blended smoothies. A blended smoothie has 3 main parts: fresh or frozen produce, ice cubes, and a base. The base can be water, milk or yogurt. For bariatric patients, a base can also be protein powder or ready to drink protein shakes. You’ll need a good blending machine like NutriBullet, Ninja or Vitamix. Look for a blender with at least 1000 Watts for best results. Next time you make a protein smoothie, throw in a handful of raw spinach or kale, cucumbers, shredded purple cabbage, frozen veggie blend, fresh herbs or something from your garden. Fruits are often a part of a smoothie, but you will need to calculate the carbs to stay in your carbohydrate goal.
Another idea is to make a non-alcoholic Bloody Mary. Stir a tablespoon of unflavored protein powder into 6 ounces low sodium V8 vegetable juice. This V8 is a blend of several vegetable juices. Throw in dashes of lemon juice and Worcestershire sauce, stir again and the pour over ice. Unflavored protein powder can be added to vegetable soups. Sprout’s has unflavored whey protein powder in the bulk bins, which is a way you can test taste this protein without buying a large canister. One tablespoon provides 10 grams of protein. If you use whey protein isolate, remember to keep it under 140o F. to prevent the protein from curdling. Healthy sipping!

Every time you deny you inner knowing, that small still voice within, you suffer and chip away at your self esteem, your self worth. Release the need to please others, to fit in, to go along with the crowd. Lovingly, assertively, and respectfully speak up for your self, speak your truth. When you deny your truth and ignore your feelings you can’t help but suffer: you may feel angry, sad, victimized, depressed, anxious, or overwhelmed, which often leads to engaging in unhealthy behaviors (overeating, drinking, smoking, shopping, etc) to numb the pain of these feelings. Life is so much simpler when you are authentic. You DO have the power to change your experience of your life. Don't complain. Instead FOCUS on what you DO want in your life, how you WANT to feel and what ALREADY IS GOOD... See yourself as being happy, fulfilled and loved… Keeping this vision/feeling in your heart notice the signs and follow your instincts as they will lead you to living an abundant joy-filled life… All day long check in with yourself to be sure your actions are GROUNDED IN THE ENERGY OF LOVE not fear, anger, or anxiety.

Know this: WHEN YOU LIVE IN LOVE ALL IS WELL! XO


Live in Love,
Louisa

How do you know whether weight loss surgery is for you? Will it be the weight control solution you have been searching for for years? Or will it be a decision you regret? Nobody can answer that for you, but here are some considerations as you think about whether weight loss surgery is for you.
The Qualifying Criteria
You are not a candidate for bariatric surgery unless you meet certain criteria set by your surgeon or, if applicable, your healthcare coverage plan. The standard criteria are:
Body Mass Index (BMI) over 40 or BMI 35 with an obesity-related comorbidity, such as type 2 diabetes, high cholesterol, or sleep apnea. Confirmation that your obesity is not caused by an underlying condition that would make weight loss surgery ineffective. A psychological exam to show that you are capable of sticking to the post-op diet and lifestyle changes that are necessary. Previous documented attempts at losing weight with diet and exercise. Ineffectiveness of Previous Efforts
Weight loss surgery is a last resort, not a first try at losing weight. It is for patients who have been obese for years and who have tried to lose weight using lifestyle changes, such as a modified diet plan and a formal exercise program. Many weight loss surgery patients try “every diet under the sun” before deciding that it is time for WLS. They may have had trouble losing any weight at all, or may have lost weight initially but been unable to keep it off.
Readiness to Change
Weight loss surgery is just the beginning. The way you eat after weight loss surgery determines how well you will be able to control your weight for the rest of your life. You need to be ready to change if you want to be successful with weight loss surgery. No longer will you be able to down a pizza or hit the drive-through on a whim.
Are you ready to possibly:
Give up coffee and regular and diet soda? Cut sugary treats and fried foods, especially with gastric bypass? Pass on the alcoholic offerings at home, parties, and restaurants? Count protein, slash carbs, and measure portions? Addressing Other Issues
Weight gain does not always take place in a vacuum, and weight loss does not solve other problems you might have in your life. First, identify why you became overweight in the first place, and what is keeping you from losing the weight. Is weight loss surgery the answer, or do you need to first deal with an abusive relationship or lack of self-confidence, for example?
Emotional eating is a common reason for weight gain. If you tend to eat your feelings away, you are best off figuring out other ways to handle your feelings before you get surgery. Can you use walking as a form of therapy? Maybe you can join an in-person or online support group to turn to when you feel sad, lonely, or angry.
If your emotional eating is related to a specific problem, such as stress at work, your best bet may be to handle the problem before getting WLS. That could mean finding a healthy coping mechanism, or it could mean getting counseling to help you work through the source of stress. It could even mean finding a new job, as scary as that sounds.
Consider Replacement Addictions
Replacement addictions are common after weight loss surgery. They happen when you give up food – which can be an addiction – for a different addiction. Instead of turning to food for comfort, entertainment, or companionship, some weight loss surgery patients turn to “replacement addictions” or “cross addictions” They may take up smoking, or start to abuse alcohol. Replacement addictions can also be healthier than eating; some weight loss surgery patients become gym rats or take up gardening, sewing, or other hobbies.
As you consider weight-loss surgery, think about the possibility of food addiction being replaced by replacement addictions. What role does food play in your life now? What do you see replacing that emotional or physical role after surgery?
The decision to get weight loss surgery requires a lot of soul searching for most candidates. These points can help you work through some of the doubts you may have as you try to decide what is best for yourself.

Ask Questions
Your advocate should get the information you need. Ask your surgeon how you can best prepare for surgery, what you can do to recover faster, and which mistakes he or she sees most often so you can avoid them. Find out how to contact your surgeon for post-op questions, and learn where you can go for support group meetings.
You will need to ask plenty of other questions, too! As your own advocate, don’t be shy about asking anyone about anything. Read everything you can online and on BariatricPal, then use the forums to ask about anything you’re not sure about. You are sure to get all kinds of helpful hints that you never expected!
Provide for Your Needs
Life does throw curve balls, but your basic needs stay predictable. You know which foods and fluids you will need in any given day, so make sure you have them. Plan your menu for each day and go grocery shopping for the week so you are sure to always have the food you need around.
Always keep a stash of “extras” in case of unplanned circumstances. Have instant protein meals and other staples in your pantry for last-minute meals. Keep protein bars and nuts in your car, your gym bag, and at work. Have different flavors of protein powder for whenever you find yourself hungry and without other options.
You can also help yourself out by planning ahead. For example, if you’re going to a party, make sure you will have the foods that you will need for that time without needing to wait until after the party to eat or depending on the host to provide healthy proteins. Stick a protein bar or some nuts in your pocket or purse, or bring a healthy dish to share and nibble on yourself.
Be Your Own Planner
If you were taking care of a child with certain needs, you would schedule them in, make sure your child had the materials needed, and get your child to where he needed to go. If you have children, you may keep track of their homework, take them to after-school activities, and make sure they get the nutritious meals and proper sleep that they need. You would keep healthy foods around and provide them with the pencils and sports equipment that they need for school and extracurricular activities.
Why wouldn’t you be just as good to yourself? Provide the same level of self-care for yourself as you do for your family. Keep healthy foods on hand, and schedule your own exercise and meal planning in and keep your commitment just like it was school.
Prioritize your commitments, just like you would do for your children. Your meal prep and workout time is important, but so is relaxation time with your family or friends, or by yourself. Over the long term, balancing work and play can keep you on track but satisfied.
Speak up When Necessary
Keeping quiet can sometimes seem easier or more considerate to others, but keeping a low profile can work against you sometimes. Learn when it makes sense to speak up for yourself. For example, at restaurants, the server may be willing to bring you what you ask for (like a slab of plain chicken breast or the kids’ meal), but will not even know that is what you want (and need) if you do not say something out loud. You may find that you need to explain your weight loss surgery as a medical condition to get your server to honor your request.
These are some other times when you should not keep your mouth shut:
When someone pressures you to eat something that's not on your diet. When you do not understand your surgeon’s or nutritionist’s instructions. When you need help around the house or preparing your food. Learning to be your own best advocate can pay off in a big way, as you will always have someone looking out for your best interests. It is one more thing you can do to help yourself succeed in your WLS journey.

I have worked as a psychologist, providing psychological evaluations prior to bariatric weight loss surgery for the past eight years. For the most part, people need a power tool to help them lose and keep off the weight they have lost over and over again in their lives. The gastric sleeve, bypass, and now balloon are those tools. However, every once in a while, I will encounter someone who believes these procedures are the magic bullet.
I can pick this up in five seconds when I learn that:
this person has no exercise plan to maintain their weight loss a barrage of excuses as to why they can't exercise anymore zero insight into why they are overweight ("I don't know why I am overweight, I just eat steamed vegetables and grilled chicken mostly.") a lack of motivation or understanding for why they also have to engage in behavioral modification in addition to the surgery "Why would you reveal all of this?" you ask. Aren't I giving away the keys to the kingdom to anyone who reads this and wants to pass a psychological evaluation? Perhaps- but who are you really cheating if you don't go within and face the real demons that got you here in the first place?
When I ask people about their eating styles, I tend to group them into four categories:
1) emotional eater- someone who uses food when they are bored, stressed, tired, lonely, sad, or even happy in addition to eating when they are hungry
2) skip and binger- someone who fails to think about food until it is too late, and when they are ravenous end up going for whatever is available which is usually some type of carb and calorie laden fast food
3) miscellaneous- someone who just recognizes that they eat too large of portion sizes and/or the wrong types of food
4) food addict- usually someone with a history of other addictions, trauma, and a significant amount of weight to lose. They usually have comorbid psychological diagnoses that have been unaddressed or ill-addressed.
Out of the four categories, the 4th is the most troubling for a psychologist. This particular person is most correlated with the patient who fails to address their core issues, eats "around the sleeve," or bypass, experiences dumping syndrome, comes back a year later and asks for the bypass, or a different procedure.
This is the person who, ironically, is usually the most resistant to my recommendation that they seek therapeutic support prior to the surgery. They want it done YESTERDAY. They want it NOW. It is this type of thinking that got them into trouble in the first place. The impulsivity and lack of emotional regulation.
I've witnessed people fail to address their maladaptive eating patterns and never quite get to their goal weight. I had a male that would buy a bag of pepperonis at the grocery store and snack on them all day and couldn't understand why he wasn't losing weight. This daily "snack," which was a mental security blanket, served as a veritable IV drip of fat and calories throughout the day.
I've had a woman who figured out how to ground up her favorite foods into a liquid form because she never quite let go of her attachment to "comfort foods." One of her most notable liquid concoctions consisted of chicken and Cheetos. I'll just leave that for you to chew...er swallow.
They say with drug and alcohol recovery- you "slay the dragon," but with food addiction recovery, you have to take it for a walk three times a day. If you don't fundamentally shift your relationship with this dragon, you're going to get burnt when you are walking it.
My number one tip for transforming your relationship with food is to start looking at eating the same way you do as brushing and flossing: You don't necessarily salivate at the idea of what type of toothpaste you will use, where you will do it, who you will do it with, right? You just do it twice a day because you don't want to lose your teeth and you want to maintain healthy gums.
Food has to be thought of in the same way. You fuel up. You don't use food as a place to define your quality of life. You don't use food to celebrate. You don't use food to demarcate the end of a long day. You don't use food to help you feel less alone. You figure out healthier coping alternatives to meet these needs.
Loneliness-call a friend for support
Celebrate- get a massage
Demarcate the end of a long day- start a tea ritual and use essential oils
Another reason you must say goodbye to comfort food is that it triggers the pleasure center of the brain, which ignites our dopamine, which perpetuates the addiction. Many people think we are just telling them to get rid of the comfort food because of the carbs or calories, but there are unique and harmful chemical consequences to ingesting these types of food we know are bad for us.
If you are ready to take a modern approach to weight loss and stop dieting for good- check out my wls/vsg psychological support course here for free.

Clients who regain weight after bariatric/weight loss surgery often ask us about the ‘5 day pouch test’. This much debated ‘test’ promises to ‘reset’ your stomach and help you lose more weight. It’s so popular in fact, it has its own acronym – the ‘5DPT’. So what’s the deal, is it too good to be true?

Let’s start with a bit of background
The pouch test was ‘created’ in 2007 by a fellow gastric bypass-er named Kaye. She struggled, like many, with discouraging and disheartening weight regain after bariatric/weight loss surgery. In an attempt to recreate that ‘tight newbie feeling’ again, she developed the pouch test.

To start off the 5 day pouch test, she instructs you to ‘get back to the basics’. Or in other words, she wants you to return to the post-op liquid phase that is required in the first few days after surgery. She then recommends that you progress slowly from soft/puree protein, to firm protein and then lastly to solid protein (what’s the difference between firm and solid protein? We don’t know either...). Following this, you are supposed to feel a renewed sense of self.

MYTH...
The 5 day pouch test WILL NOT...
- shrink your stomach
- reduce hunger and increase satiety (feeling of fullness)
- ‘reset’ your body
- cut your cravings for carbs and sweet/salty foods

FACT...
We do however agree with some of Kaye’s suggestions.

1. Always delay your fluids from your solids foods.
--> Stop drinking 15 minutes before your meals/snacks and wait at least 30 minutes after eating to start drinking again. WHY? - Drinking and eating at the same time ‘flushes’ the food out of your stomach too quickly. This causes you to feel hungry soon after eating.

2. Take your time to eat.
--> Eating slowly and savouring your food without distractions increases satiety at meal times. WHY? - This gives your brain time to process that you are eating and lets you get the flavor fix you’re looking for.

3. Ask yourself if liquid protein snacks (aka ‘slider foods’) keep you full long enough (Ex. milk, yogurt, soft cheeses, cereal).
--> While these foods are nutritious and provide good quality protein, they may not help you feel as full as you felt in the first few months after surgery. WHY? - These liquid foods spend less time in your stomach which is why you maybe feel hungry soon after eating.

4. Include a high protein food at every meal and snack.
--> WHY? – High protein foods help keep you full longer.

In our opinion, the ‘5 day pouch test’ is just another diet in disguise. Anything that promises to ‘reset your system’, ‘boost your weight loss’, ‘cut cravings’, ‘kick start your metabolism’, ‘burn fat’, etc. is unfortunately wishful thinking.

There are no short cuts to healthy eating and lasting weight loss. There is only you, your pouch (i.e. your little stomach) and knowing how to use it!

How do I know if my pouch is still small?
Believe it or not, the majority of weight regain after bariatric/weight loss surgery is NOT related to having stretched your stomach. This is good news! In our experience, weight regain is more related to what you eat, the timing of your meals and snacks, and how you are eating. For example, if you feel comfortably full for 2-3 hours after eating the amount of food that fits on a bread plate, which includes a combination of protein, a small amount of grains, and some vegetables, your pouch is likely perfectly fine.

We even asked one of our favourite bariatric/weight loss surgeons about the 5 day pouch test! Here is what he said:
Need help?
If you are looking to get back on track with your weight loss and healthy eating, sign up for our Get Me Back on Track package. Whatever the cause of your weight gain, we will give you realistic strategies and tips to tackle your triggers and barriers to healthy eating. Even simple changes to your home and office environments can make a big difference.