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Hi girls, I'm up in the middle of the night, too.... Went to sleep about 11:00 in my chair, but woke up at 12:30 with pain... I thought I was going to get off easy tonight, but no such luck...... I took an easy day today.. Went with DD and Mimi for a little shopping in Bismarck this morning... Was looking for a black slip and bra to go under my MOB dress... We went into Dress Barn and DD started looking at black dresses for me... I already bought my dress a while back and she approved of it then, but now she isn't sure it's fancy enough.... MOB is to be fancy like the bride she says!! Well now I'm not sure what to do.... Thought I had it all under control.. I didn't find anything I wanted today.... So now I can add that back on my list.... And I didn't find a bra or slip.. Lane Bryant had no slips... Told be to go to Herberger..... Anyway, Janet it is 9/9 for my Mayo appointment... A week and a half to go..... I'm starting to fear that they won't help me either and I'm doomed to do this forever.... Gotta keep a positive thought but it gets hard when this happens every day..... Love the before and afters............... what you wrote sounds just fine... and just like you.... Good luck.... I'm sure you'll be a great spokesperson..... Cheri, hugs on your niece.... Gosh I hope they can figure things out.... I love the way you describe yourself...... I would love to be talk and regal rather than tall and misshapen....... You take a break this weekend and rest up now..... Melissa, glad to hear you are on the mend.... just stick with it so you don't have a relapse... You need that rafting party... sounds fun..... Laura K, sounds like a fune weekend again with your family...... I have never made salsa.... Well, once, and it was too watery.. do you can yours then or just have it fresh in the fridge?? Those darn chips... I have found that I like those little flavored rice cakes.... dont' care for the big ones, but these little ones that come in a bag are very good... and low on calories... I try to keep these around, but I did buy some crunchie cheezies one day and had to have some..... Didn't hurt, just didn't help either.... gotta do some of that occassionally just to feel normal..... I'm eating a grape popsicle right now.. It feels so good on my mouth that is still so ucky these days... I think it might be getting a bit better since that Flexeril is getting out of my system... No more dreams and no more weight gain... Actually have lost a few that I got a while back... Hope to be back to my norm by Vegas.... Linda, gosh I hear you about kids..... some days it seems like they will never not be our responsiblity.... If I took all the money we have spent in the last 3 years on our 3 kids, DH and I could have one helluva month long vacation abroad someplace..... And he wouldn't have to work 15 hour days like he has been lately just for some extra cash....... He has worked 77 1/2hours this week.... At least he doesn't have to work tomorrow and they are about done with wheat which is the big push right now.... Yeah..... I could use having him around home more...... I've spent some very alone days and would rather have him around moe.... Merry's pictures look great.... DH I presume????? He looked good, too... Merry will be running like a pup soon..... that is wonderful for all of you. Good luck with the hip replacement parts... Hope it turns out to not be an issue for you. Phyll, you and DH look so nice... glad you are having a great day.... Dance a little for me... Pretty baby... but aren't they all.. enjoy.... Eva, I hate the accumulations of cat hair...... It gets into everything.. And I try so hard to keep a clean house... I hate to see what comes out in the dryer lint trap when I was blanket/throws that we keep by our chairs in the living room...... But that's the breaks when you have cats..... Off you go to Baltimore... you are the travelors... and not afraid to just go any old time.. Wish my DH was a bit more like that.... I have to work on him for a while to get him to decide to do something fun... Have a great time... See you back here with a report on Tuesday..... Arlene, sorry your local boys didn't make it to the finals..., but what an accomplishment anyway... Walking with a 2 year old will be a challenge... Do you have one of those cute little backpack leashes??? They have them at Walmart... I tried that with Mimi a couple times, but since I couldn't lift her I was at her mercy if she wanted to stop... Had a terrible time getting her off the playground... and pulling on the lease was harder on my than lifting her... Good luck and let us know when that baby arrives.... Well our other girls must all be out enjoying life... I want that !!!! Instead of sitting awake at night with pain... I'm wondering about Judy and her puppy.... She seems to be pretty busy these days...... Do you suppose she'll want to "foster" this one???? time will tell... Well I should try to get back to sleep... Mimi is staying over and she asked to go to bed in my bed with Papa...... This is just fine.. I spend so much time up stairs in my recliner that a night without my bed is no big deal.....Today is DF's birthday so DD and some friends drove down to Bismarack to meet him after work for a nice little celebrations... I'm so happy with the life my daughter and fiancee are leading right now... I prayed and prayed that life would give her good things one day... I think that day has arrived and I couldn't be happier......Aside from the piercings and tatoees, we couldn't have picked a finer young man.... So we just look past the piercings and tatoos and see the good man and father that he is.... What a blessing... Night ladies..... Hope we all can get some rest ..... so we can enjoy our Sunday... Love you all very much, oh and welcome to the new gal.... You'll love it here... Just jump in and share about yourself... We are very open and honest around here... Hugs and prayers............ Julie

Got an e-mail from Kaye Bailey who is the nurse practitioner whoo works with bariatric patients and who developed the 5 day pouch test. I have found a lot of her information very helpful and when I read this I thought it might help some of you. If you want to read more you can click on the link "5 day pouch test" below and you'll find her site. I hope it's okay to re-post it --- it's such good information. <P done13="5">Three Keys to Lasting Weight Loss Surgery Success Nearly a quarter-million people in the United States will undergo weight loss surgery this year to arrest their morbid obesity and lose weight. In spite of the drastic nature of gastric surgeries not all patients will reach a healthy weight and some may eventually regain weight they lost initially with surgery. 5 Day Pouch Test Store By Kaye Bailey Nearly a quarter-million people in the United States will undergo weight loss surgery this year to arrest their morbid obesity and lose weight. In spite of the drastic nature of gastric surgeries not all patients will reach a healthy weight and some may eventually regain weight they lost initially with surgery. Obesity is not a simple cosmetic problem of excess body weight than can be corrected with surgery. It is a metabolic disorder where the body stores an abnormal amount of body fat. Bariatric surgeries help arrest the disease by reducing the amount of calories a person may eat and some surgeries reduce the amount of nutrients the body absorbs and stores as fat. The surgery does not remove the disease but with patient compliance weight is lost and obesity can be put in remission. Chances for healthy weight loss and weight maintenance with surgery can improve with patient commitment to recovery. Patients must accept that the burden of treatment for their disease obesity is with them. Bariatric counselors tell patients the surgery is only a tool and it is up to the patient to use it correctly. This applies to all procedures including gastric bypass, gastric sleeve, and adjustable gastric banding (lap-band). There are three pro-active things patients can do to use their tool wisely: Use the Tool Wisely. Lifestyle: Accept that bariatric surgery brings with it an entirely different lifestyle that you must adopt for the rest of your life. Unlike conventional diets there is no finish line: surgery requires an almost religious-like lifestyle change. Patients must follow a high Protein, low carbohydrate diet every day for the rest of their life in order to lose weight and maintain that weight loss. Patients will need to avoid simple carbohydrates including sugary snack foods and fried food. Snacking, when allowed, must be mindful including lean protein and low-glycemic fruits and vegetables. liquid restrictions mean no beverages before or after meals and no drinking with meals: this helps the surgical pouch work correctly. Patients learn and accept that some things will make them sick, smells will affect them differently, and sometimes they will feel emotionally blue because of the irreversible restrictions of surgery. We have this life-changing surgery with all its restrictions and then return to the very environment in which we became obese: of course we suffer feelings of sadness at times. Support: As with other life-changing disease, patients seeking treatment and recovery from morbid obesity with surgery benefit from support. While no one can understand another persons exact journey we can certainly share the collective experience of obesity, life long dieting and weight gain, and finally the somber decision to undergo treatment with surgery. While patients are likely to cluster to support groups both live and online before surgery and in the first year following surgery, there is a tendency to drift away from support groups as time passes. Evidence suggests, however, that solid support relationships are a key in sustaining personal efforts for health, weight control and wellness with bariatric surgery. Activity: The inclusion of physical activity as part of lifestyle change with surgery will make a difference in the long term successful weight management of bariatric patients. Early post-operative patients are directed to get 150 minutes of exercise a week, that is about 20 minutes a day. Patients who do this and more will successfully manage their weight loss and weight maintenance. Patients who regain weight often admit they never really got around to including physical activity in their new lifestyle. Studies indicate exercise need not be strenuous or exhausting. Physical activity simply must move us beyond the normal motion required of daily life. Weight loss surgery patients tend to idolize their surgeons and bariatric teams crediting them with restoring their health. But long after the surgical wounds have healed and the routine checkups are simply annual office visits it is up to the patient to own their surgical tool and manage it in a way that keeps their disease in remission. Janet, glad to hear from you -- sorry about the computer problems - it's hard without it. Apples, yes, go buy one of the readers and let me know which one you decided to buy - I'm interested in them also - I just know for sure you want to be sure to get one that you can download books from anywhere (like Amazon) -- some of the ones sold at the bookstores are limited to buying only books from them (or so I've heard). Glad you're having a good time - lol I wouldn't go back to the winter either after spending time away -- that's why I don't plan to go until I don't have to come back. Gotta run -- ultrasounds went well this a.m. Hoping to hear results today. Love your new pic LauraK-- you look fabulous!!! Love you all. Linda

Hello everyone! It's been quite some time. This thread is pretty much dead. But if any of you are still around, I thought I'd share... My second LapBand placed in Feb 2009 became disconnected!! I mean really?? How many LapBands should one girl have to mess with? LOL....so, I started gaining weight pretty fast and had to bicker quite a bit with the insurance company. But ultimately I was approved to have the Band removed and get the Vertical Sleeve. I had surgery almost 2 weeks ago and so glad it's over. I am so frustrated with the weight gain, but so glad that there won't be any more fills/unfills or getting stuck!! I'm on the mend and tired of mushies....for the third time! hahaha I hope all is going well for the rest of you!!! Best to all, Carol

It makes sense to me as a woman that there would be a double standard. Reproduction is such an unbalanced bit of business. The male's contribution is a spasm of pleasure and then he is out of there. The female's contribution, on the other hand, is enduring the pregnancy itself, the steadily deforming body, morning nausea, weight gain, the expense of needing to eat more nutrients in order to feed the growing foetus as well as her own body, the expense of buying garments which will accomodate her new body, and of course the medical expenses. These costs do not end here, much later in life, she may suffer from a prolapsed uterus, incontinence - why, the poor woman may dread sneezing - all because of that pregnancy. There is the considerable pain of childbirth. In earlier eras, before the current advances in medicine, childbearing itself was a risky business. My brother was told in his first year of med school that historically more women died in childbirth or of its complications than men in war. One of the major birthing bed killers was puerperal fever. Then antibiotics were discovered and that put paid to childbed fever. Fortunately this was a killer bacterium and thus vulnerable to death by antibiotics. Because pregnancy leaves women so very much wide-open and vulnerable to a whole bunch of nasty consequences, I believe that when it comes to the women's right to choose, it really is that; women get to call the shots and if she is anxious to have a baby or feels that killing the foetus sits badly with her particular moral compass then the man should have no say in this matter. I chose to have an abortion even though the man involved wanted to have the baby and wanted to settle down with me. I simply do not like children and was creeped out big time by pregnancy and its effects on the body both long term and short term. You may call this a phobia, if you like. I also think that if a man wishes to avoid the consequences of having a child to support he would be wise to wear a welly on his willy whenever he enters.........! That is called taking care of business!

I have to start my liquid diet now, even before I have a surgery date because I gained 3 pounds since April. I think mostly from quitting smoking. I have everything done, just an ultrasound because they found gallstones when they did my upper GI. I am really dreading it, but hopefully I can get through it. I am waiting my doctor is sending my paperwork to get approval from the ins company, BCBS of Mass. Does anyone have experience with being denied because of a weight gain? Even just 3 pounds? Dr. Didn't seem to be too concerned, but I have to go to the nutritionist to start my liquid diet now, even before getting a surgery date, who she said could be November!! Don't think I can last that long on a liquid diet!!!

Awww...Thanks Leigha...and an FYI...from Dictionary.com Bulimia: An eating disorder, common especially among young women of normal or nearly normal weight, that is characterized by episodic binge eating and followed by feelings of guilt, depression, and self-condemnation. It is often associated with measures taken to prevent weight gain, such as self-induced vomiting, the use of laxatives, dieting, or fasting. Also called bulimarexia , bulimia nervosa . I don't think that applies to trying to get unstuck. Never felt guilty, nor have I condemned myself!

elcee, I hope they get your BP figured out. Whooo Hooo on having a great time with no weight gain! Stacie, OMG! I would be crying too. It's hard to say when I'm not walking in your shoes, but I think I would tell them to put in a new band and make sure they stitch it in place well so it doesn't slip. Hugs to you. I hope you get it figured out.

In one of the books I've been reading to prepare for surgery, they talk about not weighing yourself for the first couple of weeks after surgery because of the water weight gain that can happen during surgery/hospital with the IVs. And weighing yourself can end up being disappointing and discouraging because of it. So, be patient, it will resolve. [emoji178]

Anyone else doing the 2 week preop diet feeling like they are failing? And might fail after surgery? Idk if its all in my mind or what but I just feel like if I have this much trouble staying on liquids now then maybe I will after aswell :-( plus ive been on the preop diet since last Wednesday and havent lost any weight....what the H is up with that crap? This has me worried that maybe my surgeon wont trust that ive done the diet and he will cancel. Im paranoid. They have a 10 lb weight gain rule...I havent gain 10 lbs...so I think im ok....but I havent lost anything either even though ive really tried! Feeling very discouraged.

Congrats to everyone! I have not had the time to do my fills and I guess that is my big problem. I went from 220 to 172 in about 6 months and didn't get a fill until I started to gain back weight. The fill didn't really do much. I gained more weight and went up to 194. Granted, I only had 2 fills this whole time and I am in the VG band which I understand you have to be a little more aggressive. I was embarrassed to go back to the doctor b/c of the weight gain, so I lost 14 pounds in the last month on a low carb/low calorie diet. I have an appointment to get an adjustment next Friday and hopefully I can get back on track. Currently, I have 5 cc in the large VG band and have little restriction right now. So, hopefully I will be re-committing myself to the band once again next week. I wish I could be a success story (by now) like everyone else here!

Hi all! Well My MIL is still in alot pain but no major organs damaged as I mentioned yesterday. I had alot of fun yesterday picking out new linoleum for my apartment- it looks like wood so it gives the look of wooden floors. It should be installed sometime this week ! What a difference a weekend makes, here in New York this weekend its low 70's and beautiful, compared to the Nor-eater that destroyed my basement apartment carpets and some furniture last week. On the negative side my psychiatrist has changed my Bipolar medication once again ! The Depakote was not working that well so now he has me on Tegretol and I have to go back to him in two weeks to see if he wants to keep me on this new medication. I hate when my medication gets changed since these medications have side effects and weight gain is one of them. Its been so hard to say on track lately I go up and down. I have gone as far up as 240 and back down to 225 in one month. Righ now Iam at 235 but Iam not changing the ticker until I go see the Nurse NP. My cravings when on these medications have been Sweets! Iam trying not go over board, but its so dam hard:think ! I have to for my next appointment on April 25th but, Iam not looking foward to it since I have been really terrible with my eating over the past month! It been because of the continued medication changes and my depression. I was a Complusive Overeater before I had the surgery and Emotional eater. I turn to food for comfort, being in a depressed state from my Bipolar this month with the medication, I have been turning to my old food choices.:think Its so hard for me having Bipolar1 and having my band, but Iam trying the best I can to work through it all. Thanks to this board and my friends here, I know I can post my feelings and know Iam not alone ! Lisa

Genn So sorry to hear of your injury. Take care. Barbara4 Time of day, amount of clothing, etc. have a lot to do with how much is on the scale. Surgi-Center scale is also digital and they do sometimes go off. My only logged number is what I weigh in the morning sans clothing on my own scale. I hope for a low number at doc's but don't get too jazzed if it's off from mine. You're buying smaller clothing, getting compliments and feeling good--that doesn't sound like a true weight gain. Even the digital scale at my former Weight Watcher's meeting was off. Talk about some unhappy weigh-ins until they announced the malfunction. My advice to anyone who will listen--claim the lowest number you've seen on your scale. Don't get discouraged when larger numbers come back. New numbers are shy, but they always come back with another smaller friend. If I post a gain, it will be because I know beyond a shadow of a doubt that I messed up (more than just one meal). So far the band doesn't let me stray too far. Socalgal3--Congrats on being anonymous. Would love a comment on your experience being anonymous. Chuckle--A darling cousin of mine had WLS several years back. Her Mother and Dad announced the news prior to a family reunion. Saw her at a wedding and asked her about WLS. She said "don't know how that rumor got started--it was lo carb diet". I can't go back in the closet, but I do intend to keep any more info to myself.

Hey guys! Remember me?? I was banded on July 5th 2006.. OMG what a roller coaster I have gone thru.. I have only lost 20 lbs. First thing is, I was my Doc's guinea pig. I was his first band. (of course he had a specialist with him to do the surgery) Filling was new to him and he thought he was filling me up but in actuality, he wasn't. I also have a wiggler port. It takes 2 people to fill me. One to stabilize it and another to inject. Doc says I might have to get that stabilized in the future but it is okay for now. That was the first problem. Second problem was me. I totally BLEW it over the holidays. I got a mixer (Artisan) for christmas from my fiance and was "going to bake for the family and friends".. well, apparently that means for myself too.. UGH.. When I went for my January check up, I gained 6.. thats right 6 pounds!! Boy did the nurse ream me out.. whew.. she made me cry but then felt bad and hugged me.. she said I had to get some "tough love" .. I then went home and went thru my kitchen. I got rid of the crackers, pretzels, bread, micro popcorn etc. (just like Dr. Phil says, get rid of the triggers) And then I did the unthinkable... I JOINED THE GYM! ME! wow.. If you would have asked me if I would join a gym a year ago, I would have laughed in your face! And it is a regular gym.. not curves or a gym geared towards "fat people".. do you know it was sooooo hard to walk in there the first time.. My friend couldnt make it so I went alone! I went alone!.. I got there, scanned in, went to the locker room and even struck up a conversation with a young girl (24ish) who was all thin and trim.. she said to me, "comon! lets grab a treadmill before they are gone!".. So there I was.. working out with a stranger.. a nice one at that! Me, Ms. Low Selfesteem.. I walked on that thing for 30 mins and then rode a recumbant bike for 15 mins. WOW.. and I actually liked it! I go every other day now. Last thing that inhibited rapid weight loss is that I suffer from "seasonal" depression so I am on wellbutrin. My doc says wellbutrin can cause weight gain. yay.. but I will be off that shortly.. Fast forward to this past Friday... I went for a check up and lost 7 lbs!! and Doc gave me a 2cc fill.. aggressive I know but I tell you.. I feel restriction now.. for the first time in 8 months!!! So with my new exercise routine and FINALLY getting restriction.. my ticker better show some loss! I have given up some comfort foods and what not and that is very hard.. things like pizza, rice, regular pasta (I do still eat wheat pasta but only once a week or so) That is my update and I am so glad to be back. So sorry this was so long but I really wanted to get stuff off my chest. Love and loss (weight loss that is!), Donnamarie

Hello Sleevetobers!!!! I was sleeved 10/25 and weighed in at 349 day of surgery. My weekly weigh in last Thursday had me at 303 pounds. Doctor has moved me onto puréed and select soft foods. I did have another surgery to remove a large keloid and skin tags on 11/15 and I had a hard time with the recovery from the surgery because of the fasting required before surgery. When I got home I felt weak and was ready to pass out. Before my wife called 911 I urged her to wait til my food got into my system. Once that happened I felt much better. This morning i was scheduled to have surgery to open my sinus passage ways so I can finally breathe through my nose again. It's gonna be nice to not be the 'fat heavy breathing' guy. So when I had surgery this morning I made sure to get my nutrition the previous two days before surgery and upped my calorie intake each day. It worked and my recovery today was fantastic. But when I stepped on the scale this morning I noticed my first weight gain since surgery of 1 pound. I just pray I didn't stunt my metabolism and will be able to continue with my weight loss. This is my last surgery that I will be having, I hope. I haven't hit any stalls yet, but I have been sticking to a low calorie intake. However, food has been so boring for me and since I'm home on disability for probably the next month, I have been playing Mr Mom. The kids love it cause I get down in the kitchen and on the grill. They've been feasting like some kings. I have cheated here and there because the stuff I've been cooking is insane. I've taken a bite a couple times, but spit it out after chewing a little bit and getting the flavor. No beef or pork yet. Does anyone else do this? It's helped but I caught myself actually swallowing a piece of biscuit I made. And the fried Jalapeño with cheese poppers I fried, well I peeled the breading off and ate the jalapeño and cheese. I felt like I had to go to confession and say 10 hail Mary's and our fathers afterwards. It's nice to read about others going through the same things that I'm going through because of the sleeve. It's tough especially since my wife is petite, skinny, and eats whatever she wants. She has a freaky metabolism. I just hope my kids have her metabolism cause they are all skinny and athletic. We don't allow them to drink soda or eat candy and have been raised like that because I didn't want obesity to become an issue in their life like it has mine. My flexibility has increased and now I can finally bend over and tie my shoes without my stomach being in the way. That is amazing cause I had to loosely tie my shoes to slip them on and always had to tie my work boots on a step or curb. I never shared this with anyone because of the embarrassment. But I wanted to yell out kinda like the kid from Big Daddy when he wiped his own arse. It took me back to that simple joy. Hope everyone else is finding these little things that are improving their quality of life like I have recently. Good luck on your journey in weight loss everyone!!! My kids and me at the MLS Cup watching LA Galaxy win back to back titles! Also Beckham's last game with the LA Galaxy. Good times!!! And I didn't have to argue with security regarding the protein shakes and yogurt I took into the stadium for my special diet. Great day!!!

I ran accross this today. I found it good information for those of us considering/waiting for WlS. Pouch Rules for Dummies INTRODUCTION: A common misunderstanding of gastric bypass surgery is that the pouch causes weight loss because it is so small, the patient eats less. Although that is true for the first six months, that is not how it works. Some doctors have assumed that poor weight loss in some patients is because they aren’t really trying to lose weight. The truth is it may be because they haven’t learned how to get the satisfied feeling of being full to last long enough. HYPOTHESIS OF POUCH FUNCTION: We have four educated guesses as to how the pouch works: 1. Weight loss occurs by actually slightly stretching the pouch with food at each meal or; 2. Weight loss occurs by keeping the pouch tiny through never ever overstuffing or; 3. Weight loss occurs until the pouch gets worn out and regular eating begins or; 4 Weight loss occurs with education on the use of the pouch. PUBLISHED DATA: How does the pouch make you feel full? The nerves tell the brain the pouch is distended and that cuts off hunger with a feeling of fullness. What is the fate of the pouch? Does it enlarge? If it does, is it because the operation was bad, or the patient is overstuffing themselves, or does the pouch actually re-grow in a healing attempt to get back to normal? For ten years, I had patients eat until full with cottage cheese every three months, and report the amount of cottage cheese they were able to eat before feeling full. This gave me an idea of the size of their pouch at three month intervals. I found there was a regular growth in the amount of intake of every single pouch. The average date the pouch stopped growing was two years. After the second year, all pouches stopped growing. Most pouches ended at 6 oz., with some as large at 9-10 ozs. We then compared the weight loss of people with the known pouch size of each person, to see if the pouch size made a difference. In comparing the large pouches to the small pouches, THERE WAS NO DIFFERENCE IN PERCENTAGE OF WEIGHT LOSS AMONG THE PATIENTS. This important fact essentially shows that it is NOT the size of the pouch but how it is used that makes weight loss maintenance possible. OBSERVATIONAL BASED MEDICINE: The information here is taken from surgeon’s “observations” as opposed to “blind” or “double blind” studies, but it IS based on 33 years of physician observation. Due to lack of insurance coverage for WLS, what originally seemed like a serious lack of patients to observe, turned into an advantage as I was able to follow my patients closely. The following are what I found to effect how the pouch works: 1. Getting a sense of fullness is the basis of successful WLS. 2. Success requires that a small pouch is created with a small outlet. 3. Regular meals larger than 1 ½ cups will result in eventual weight gain. 4. Using the thick, hard to stretch part of the stomach in making the pouch is important. 5. By lightly stretching the pouch with each meal, the pouch send signals to the brain that you need no more food. 6. Maintaining that feeling of fullness requires keeping the pouch stretched for awhile. 7. Almost all patients always feel full 24/7 for the first months, then that feeling disappears. 8. Incredible hunger will develop if there is no food or drink for eight hours. 9. After 1 year, heavier food makes the feeling of fullness last longer. 10. By drinking water as much as possible as fast as possible (“water loading”), the patient will get a feeling of fullness that lasts 15-25 minutes. 11. By eating “soft foods” patients will get hungry too soon and be hungry before their next meal, which can cause snacking, thus poor weight loss or weight gain. 12. The patients that follow “the rules of the pouch” lose their extra weight and keep it off. 13. The patients that lose too much weight can maintain their weight by doing the reverse of the “rules of the pouch.” HOW DO WE INTERPRET THESE OBSERVATIONS? POUCH SIZE: By following the “rules of the pouch”, it doesn’t matter what size the pouch ends up. The feeling of fullness with 1 ½ cups of food can be achieved. OUTLET SIZE: Regardless of the outlet size, liquidy foods empty faster than solid foods. High calorie liquids will create weight gain. EARLY PROFOUND SATIETY: Before six months, patients much sip water constantly to get in enough water each day, which causes them to always feel full. After six months, about 2/3 of the pouch has grown larger due to the natural healing process. At this time, the patient can drink 1 cup of water at a time. OPTIMUM MATURE POUCH: The pouch works best when the outlet is not too small or too large and the pouch itself holds about 1 ½ cups at a time. IDEAL MEAL PROCESS (rules of the pouch): 1. The patient must time meals five hours apart or the patient will get too hungry in between. 2. The patient needs to eat finely cut meat and raw or slightly cooked veggies with each meal. 3. The patient must eat the entire meal in 5-15 minutes. A 30-45 minute meal will cause failure. 4. No liquids for 1 ½ hours to 2 hours after each meal. 5. After 1 ½ to 2 hours, begin sipping water and over the next three hours slowly increase water intake. 6. 3 hours after last meal, begin drinking LOTS of water/fluids. 7. 15 minutes before the next meal, drink as much as possible as fast as possible. This is called “water loading.” IF YOU HAVEN’T BEEN DRINKING OVER THE LAST FEW HOURS, THIS ‘WATER LOADING’ WILL NOT WORK. 8. You can water load at any time 2-3 hours before your next meal if you get hungry, which will cause a strong feeling of fullness. THE MANAGEMENT OF PATIENT TEACHING AND TRAINING: You must provide information to the patient pre-operatively regarding the fact that the pouch is only a tool: a tool is something that is used to perform a task but is useless if left on a shelf unused. Practice working with a tool makes the tool more effective. NECESSITY FOR LONG TERM FOLLOW-UP: Trying to practice the “rules of the pouch” before six to 12 months is a waste. Learning how to delay hunger if the patient is never hungry just doesn’t work. The real work of learning the “rules of the pouch” begins after healing has caused hunger to return. PREVENTION OF VOMITING: Vomiting should be prevented as much as possible. Right after surgery, the patient should sip out of 1 oz cups and only 1/3 of that cup at a time until the patient learns the size of his/her pouch to avoid being sick. It is extremely difficult to learn to deal with a small pouch. For the first 6 months, the patient’s mouth will literally be bigger than his/her stomach, which does not exist in any living animal on earth. In the first six weeks the patient should slowly transfer from a liquid diet to a blenderized or soft food diet only, to reduce the chance of vomiting. Vomiting will occur only after eating of solid foods begins. Rice, pasta, granola, etc. will swell in time and overload the pouch, which will cause vomiting. If the patient is having trouble with vomiting, he/she needs to get 1 oz cups and literally eat 1 oz of food at a time and wait a few minutes before eating another 1 oz of food. Stop when “comfortably satisfied,” until the patient learns the size of his/her pouch. SIX WEEKS After six weeks, the patient can move from soft foods to heavy solids. At this time, they should use three or more different types of foods at each sitting. Each bite should be no larger than the size of a pinkie fingernail bed. The patient should choose a different food with each bite to prevent the same solids from lumping together. No liquids 15 minutes before or 1 ½ hours after meals. REASSURANCE OF ADEQUATE NUTRITION By taking vitamins everyday, the patient has no reason to worry about getting enough nutrition. Focus should be on proteins and vegetables at each meal. MEAL SKIPPING Regardless of lack of hunger, patient should eat three meals a day. In the beginning, one half or more of each meal should be protein, until the patient can eat at least two oz of protein at each meal. ARTIFICIAL SWEETENERS In our study, we noticed some patients had intense hunger cravings which stopped when they eliminated artificial sweeteners from their diets. AVOIDING ABSOLUTES Rules are made to be broken. No biggie if the patient drinks with one meal – as long as the patient knows he/she is breaking a rule and will get hungry early. Also if the patient pigs out at a party – that’s OK because before surgery, the patient would have pigged on 3000 to 5000 calories and with the pouch, the patient can only pig on 600-1000 calories max. The patient needs to just get back to the rules and not beat him/herself up. THREE MONTHS At three months, the patient needs to become aware of the calories per gram of different foods to be aware of “the cost” of each gram. (cheddar cheese is 16 cal/gram; peanut butter is 24 cals/gram). As soon as hunger returns between three to six months, begin water loading procedures. THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY 1. Fill pouch full quickly at each meal. 2. Stay full by slowing the emptying of the pouch. (Eat solids. No liquids 15 minutes before and none until 1 ½ hours after the meal). A scientific test showed that a meal of egg/toast/milk had almost all emptied out of the pouch after 45 minutes. Without milk, just egg and toast, more than ½ of the meal still remained in the pouch after 1 ½ hours. 3. Protein, protein, protein. Three meals a day. No high calorie liquids. FLUID LOADING Fluid loading is drinking water/liquids as quickly as possible to fill the pouch which provides the feeling of fullness for about 15 to 25 minutes. The patient needs to gulp about 80% of his/her maximum amount of liquid in 15 to 30 SECONDS. Then just take swallows until fullness is reached. The patient will quickly learn his/her maximum tolerance, which is usually between 8-12 oz. Fluid loading works because the roux limb of the intestine swells up, contracting and backing up any future food to come into the pouch. The pouch is very sensitive to this and the feeling of fullness will last much longer than the reality of how long the pouch was actually full. Fluid load before each meal to prevent thirst after the meal as well as to create that feeling of fullness whenever suddenly hungry before meal time. POST PRANDIAL THIRST It is important that the patient be filled with water before his/her next meal as the meal will come with salt and will cause thirst afterwards. Being too thirsty, just like being too hungry will make a patient nauseous. While the pouch is still real small, it won’t make sense to the patient to do this because salt intake will be low, but it is a good habit to get into because it will make all the difference once the pouch begins to regrow. URGENCY The first six months is the fastest, easiest time to lose weight. By the end of the six months, 2/3 of the regrowth of the pouch will have been done. That means that each present day, after surgery you will be satisfied with less calories than you will the very next day. Another way to put it is that every day that you are healing, you will be able to eat more. So exercise as much as you can during that first six months as you will never be able to lose weight as fast as you can during this time. SIX MONTHS Around this time, our patients begin to get hungry between meals. THEY NEED TO BATTLE THE EXTRA SALT INTAKE WITH DRINKING LOTS OF FLUIDS IN THE TWO TO THREE HOURS BEFORE THEIR NEXT MEAL. Their pouch needs to be well watered before they do the last gulping of water as fast as possible to fill the pouch 15 minutes before they eat. INTAKE INFORMATION SHEET AS A TEACHING TOOL I have found that having the patients fill out a quiz every time they visit reminds them of the rules of the pouch and helps to get them “back on track.” Most patients have no problems with the rules, some patients really struggle to follow them and need a lot of support to “get it”, and a small percentage never quite understand these rules, even though they are quite intelligent people. HONEYMOON SYNDROME The lack of hunger and quick weight loss patients have in the first six months sometimes leads them to think they don’t need to exercise as much and can eat treats and extra calories as they still lose weight anyway. We call this the “honeymoon syndrome” and they need to be counseled that this is the only time they will lose this much weight this fast and this easy and not to waste it by losing less than they actually could. If the patient’s weight loss slows in the first six months, remind them of the rules of water intake and encourage them to increase their exercise and drink more water. You can compare their weight loss to a graph showing the average drop of weight if it will help them to get back on track. EXERCISE In addition to exercise helping to increase the weight loss, it is important for the patient to understand that exercise is a natural antidepressant and will help them from falling into a depression cycle. In addition, exercise jacks up their metabolic rate during a time when their metabolism after the shock of surgery tends to want to slow down. THE IDEAL MEAL FOR WEIGHT LOSS The ideal meal is one that is made up of the following: ½ of your meal to be low fat protein, ¼ of your meal low starch vegetables and ¼ of your meal solid fruits. This type of meal will stay in your pouch a long time and is good for your health. VOLUME VS. CALORIES The gastric bypass patient needs to be aware of the length of time it takes to digest different foods and to focus on those that take up the most space and take time to digest so as to stay in the pouch the longest, don’t worry about calories. This is the easiest way to “count your calories.” For example, a regular stomach person could gag down two whole sticks of butter at one sitting and be starved all day long, although they more than have enough calories for the day. But you take the same amount of calories in vegetables, and that same person simply would not be able to eat that much food at three sittings – it would stuff them way too much. ISSUES FOR LONG TERM WEIGHT MAINTENANCE Although everything stated in this report deals with the first year after surgery, it should be a lifestyle that will benefit the gastric bypass patient for years to come, and help keep the extra weight off. COUNTER-INTUITIVENESS OF FLUID MANAGEMENT I admit that avoiding fluids at meal time and then pushing hard to drink fluids between meals is against everything normal in nature and not a natural thing to be doing. Regardless of that fact, it is the best way to stay full the longest between meals and not accidentally create a “soup” in the stomach that is easily digested. SUPPORT GROUPS It is natural for quite a few people to use the rules of the pouch and then to tire of it and stop going by the rules. Others “get it” and adhere to the rules as a way of life to avoid ever regaining extra weight. Having a support group makes all the difference to help those that go astray to be reminded of the importance of the rules of the pouch and to get back on track and keep that extra weight off. Support groups create a “peer pressure” to stick to the rules that the staff at the physician’s office simply can’t create. TEETER TOTTER EFFECT Think of a teeter totter suspended in mid air in front of you. Now on the left end is exercise that you do and the right end is the foods that you eat. The more exercise you do on the left, the less you need to worry about the amount of foods you eat on the right. In exact reverse, the more you worry about the foods you eat and keep it healthy on the right, the less exercise you need on the left. Now if you don’t concern yourself with either side, the higher the teeter totter goes, which is your weight. The more you focus on one side or the other, or even both sides of the teeter totter, the lower it goes, and the less you weigh. TOO MUCH WEIGHT LOSS I have found that about 15% of the patients which exercise well and had between 100 to 150 lbs to lose, begin to lose way too much weight. I encourage them to keep up the exercise (which is great for their health) and to essentially “break the rules” of the pouch. Drink with meals so they can eat snacks between without feeling full and increase their fat content as well take a longer time to eat at meals, thus taking in more calories. A small but significant amount of gastric bypass patients actually go underweight because they have experienced (as all of our patients have experienced) the ravenous hunger after being on a diet with an out of control appetite once the diet is broken. They are afraid of eating again. They don’t “get” that this situation is literally, physically different and that they can control their appetite this time by using the rules of the pouch to eliminate hunger. BARIATRIC MEDICINE A much more common problem is patients who after a year or two plateau at a level above their goal weight and don’t lose as much weight as they want. Be careful that they are not given the “regular” advice given to any average overweight individual. Several small meals or skipping a meal with a liquid protein substitute is not the way to go for gastric bypass patients. They must follow the rules, fill themselves quickly with hard to digest foods, water load between, increase their exercise and the weight should come off much easier than with regular people diets. SUMMARY 1. The patient needs to understand how the new pouch physically works. 2. The patient needs to be able to evaluate their use of the tool, compare it to the ideal and see where they need to make changes. 3. Instruct your patient in all ways (through their eyes with visual aids, ears with lectures and emotions with stories and feelings) not only on how but why they need to learn to use their pouch. The goal is for the patient to become an expert on how to use the pouch. EVALUATION FOR WEIGHT LOSS FAILURE The first thing that needs to be ruled out in patients who regain their weight is how the pouch is set up. 1. the staple line needs to be intact; 2. same with the outlet and; 3. the pouch is reasonably small. 1) Use thick barium to confirm the staple line is intact. If it isn’t, then the food will go into the large stomach, from there into the intestines and the patient will be hungry all the time. Check for a little ulcer at the staple line. A tiny ulcer may occur with no real opening at the line, which can be dealt with as you would any ulcer. Sometimes, though, the ulcer is there because of a break in the staple line. This will cause pain for the patient after the patient has eaten because the food rubs the little opening of the ulcer. If there is a tiny opening at the staple line, then a reoperation must be done to actually separate the pouch and the stomach completely and seal each shut. 2) If the outlet is smaller than 7-8 mill, the patient will have problems eating solid foods and will little by little begin eating only easy-to-digest foods, which we call “soft calorie syndrome.” This causes frequent hunger and grazing, which leads to weight regain. 3) To assess pouch volume, an upper GI doesn’t work as it is a liquid. The cottage cheese test is useful – eating as much cottage cheese as possible in five to 15 minutes to find out how much food the pouch will hold. It shouldn’t be able to hold more than 1 ½ cups in 5 – 15 minutes of quick eating. If everything is intact then there are four problems that it may be: 1) The patient has never been taught the rules; 2) The patient is depressed; 3) The patient has a loss of peer support and eventual forgetting of rules, or 4) The patient simply refuses to follow the rules. LACK OF TEACHING An excellent example is a female patient who is 62 years old. She had the operation when she was 47 years old. She had a total regain of her weight. She stated that she had not seen her surgeon after the six week follow up 15 years ago. She never knew of the rules of the pouch. She had initially lost 50 lbs and then with a commercial weight program lost another 40 lbs. After that, she yo-yoed up and down, each time gaining a little more back. She then developed a disease (with no connection to bariatric surgery) which weakened her muscles, at which time she gained all of her weight back. At the time she came to me, she was treated for her disease, which helped her to begin walking one mile per day. I checked her pouch with barium and the cottage cheese test which showed the pouch to be a small size and that there was no leakage. She was then given the rules of the pouch. She has begun an impressive and continuing weight loss, and is not focused on food as she was, and feeling the best she has felt since the first months after her operation 15 years ago. DEPRESSION Depression is a strong force for stopping weight loss or causing weight gain. A small number of patients, who do well at the beginning, disappear for awhile only to return having gained a lot of weight. It seems that they almost on purpose do exactly opposite of everything they have learned about their pouch: they graze during the day, drink high calorie beverages, drink with meals and stop exercising, even though they know exercise helps stop depression. A 46 year-old woman, one year out of her surgery had been doing fine when her life was turned upside down with divorce and severe teenager behavior problems. Her weight skyrocketed. Once she got her depression under control and began refocusing on the rules of the pouch, added a little exercise, the weight came off quickly. If your patient begins weight gain due to depression, get him/her into counseling quickly. Encourage your patient to refocus on the pouch rules and try to add a little exercise every day. Reassure your patient that he/she did not ruin the pouch, that it is still there, waiting to be used to help with weight control. When they are ready the pouch can be used once again to lose weight without being hungry. EROSION OF THE USE OF PRINCIPLES: Some patients who are compliant, who are not depressed and have intact pouches, will begin to gain weight. These patients are struggling with their weight, have usually stopped connecting with their support groups, and have begun living their “new” life surrounded by those who have not had bariatric surgery. Everything around them encourages them to live life “normal” like their new peers: they begin taking little sips with their meals, and eating quick and easy-to-eat foods. The patient will not usually call their physician’s office because they KNOW what they are doing is wrong and KNOW that they just need to get back on track. Even if you offer “refresher courses” for your patients on a yearly basis, they may not attend because they KNOW what the course is going to say, they know the rules and how they are breaking them. You need to identify these patients and somehow get them back into your office or back to interacting with their support group again. Once these patients return to their support group, and keep in contact with their WLS peers, it makes it much easier to return to the rules of the pouch and get their weight under control once again. TRUE NON-COMPLIANCE: The most difficult problem is a patient who is truly non-compliant. This patient usually leaves your care, complains that there is no ‘connection’ between your staff and themselves and that they were not given the time and attention they needed. Most of the time, it is depression underlying the non-compliance that causes this attitude. A truly non-compliant patient will usually end up with revisions and/or reversal of the surgery due to weight gain or complications. This patient is usually quite resistant to counseling. There is not a whole lot that can be done for these patients as they will find a reason to be unhappy with their situation. It is easier to identify these patients BEFORE surgery than to help them afterwards, although I really haven’t figured out how to do that yet… Besides having a psychological exam done before surgery, there is no real way to find them before surgery and I usually tend toward the side of offering patients the surgery with education in hopes they can live a good and healthy life.

I am sooo scared that I won't lose any weight at all .......... I have to take a cocktail of drugs for a neurological condition - which started my weight gain in the first place !!! That would be my worst nightmare - to go through surgery and gain nothing ........

Chimboree--you're beautiful. I used to think I was pretty, just fat, but I got a "pregnancy mask" with my last pregnancy that never went away, and now my face is all blotchy and sun damaged. Yuck! (I'm thinking about getting something done w/that while I'm in TJ to get the band!) Dini--What you were saying about pampering yourself reminds me of my sister--she's always been a big girl, but she has also always changed her hairsyle, bought cute clothes, and never thought she was too fat to dance at a night club. Ironically, I've always weighed less that she does, and I don't do any of those things. Although I do wish she would get the weight loss surgery with me, I also admire that she accepts herself the way that she is. Weight Gain: I don't have nearly as good an excuse as some of what I've been reading. I have never been small, but I did not get really fat until the summer between jr. high and high school, which I spent eating with my best friend. I was fat all through high school, lost a little, got pregnant (at 18), got HUGE again! Lost 130 and slowly gained some of it back until I had my second baby when I got HUGE again. I kept gaining after the second baby until I got pregnant a third time and continued my HUGE streak!!! I have gained about 70 pounds with each baby and did not take it off w/either of the last two.

food has been sucky for me lately. I have really good restriction but I have way too much of a sweet tooth (and that is rare for me). I am being really strict about my diet right now but I am hungry almost all the time. I think it is my anti-anxiety/depression meds. This is what happened the last time I was on it before I was banded. I was hungry all the time and made really poor food choices. I am going to hold off going to the doctor until I can start running again and see if it goes away. If not we are going to have to change the medication. This is true hunger feelings. My stomach growls and I get nauseated if I don't eat. However when I feel it I wait for at least an hour to see if it will go away. I drink during that time to make sure that I am not thirsty. I didn't have these feelings before I was on the meds so I am begining to think that perhaps this is the problem. I haven't been under too much stress (except yesterday and this morning with the class numbers!) so I am not sure what is going on. My weight is fluctuating like crazy depending on what I eat. If I eat very many carbs I retain Water and the scale jumps up 5-7 pounds. If I don't eat any carbs then I lose the water weight and it drops back down. My clothes still fit just like they did when I bought them so frankly I don't khow what the heck is going on. I finally told DH to take the scale out of the bathroom and I am back to just weighing 1 time per week. The PS wanted me weighing everyday after surgery so that we could monitor swelling. But I think the swelling is pretty good now so I can safely go back to 1 time per week. Hopefully that way I wont see the wide swings. Serious on Saturday I was at 148 and then Sunday morning I was at 141. Go figure!! I try not to read the side effects of medications until I start feeling something being off and then I will go check them out after I have tried to eliminate everything else. Lots of people claim to have serious hunger issues and weight gain on Effexor as well as water retention. So it could be a possibility that it is the meds. But like I said I am going to hold off and see if the running helps. I don't want to go back to the obssessive/anxious feelings that I had before, but I certainly don't want to start gaining weight. I am going to be working 2 jobs for the first part of the school year so I am not going to have the time to frantically count calories and be as obsessive as I was at the end of last school year so I need to find a happy medium. Well best get back to test writing. I have 1 and 1/2 tests to write and then I am done with the crappy part. The fun part is putting together the lessons and activities. Test writing...not so much fun!

gurlygirl - I had surgery on Tues morn. and flew back to Alaska Thurs night. I had an EXCELLENT recovery (I was at Health South Surgical Center and I thought it was top notch too.) and could've left Wed, but I'm glad I had the extra day. I saw Dr. K on Thurs morning before I left. He did no pre-op testing for me and gave me a prescription for some anti-nausea suppositories (which I didn't need, but good to have just in case). I also had an anti-nausea (scolpamine) patch that was placed behind my ear prior to surgery- gave me dry-mouth, but I was not nauseated at all! I've had 3 c-sections and I recovered from them fast and well...this was NOTHING compared to those! Good luck! Three weeks now and last night I got totally nervous about my first fill (on the 16th). I'm worried about the needle pain. I was more worried about the doc finding my port...I hadn't felt it until last night when I did some "pushing around"...boy did Dr. K bury it! I had an "incident" with steak the other night, but other than that have been doing well. I have yet to lose any weight, but I'm sure things will start moving when I get that fill. Hey, did any of you have to go on liquids or anything for a day or two following the fill? What's the best protocol to follow? Woofay - about the weight gain...have you considered that it's "new food" or at least a new diet and your body isn't used to it. Your colon can hold 30 lbs of crap (pun is totally intended!). Give it a few days and see if you have a really good poo. I would bet this is the issue. Not a pleasant thought, but it DOES give some hope! I'm totally with you on the "why not eat what I want if I'm just going to gain" it's in my head...working on getting it out! Mal - I hope your son is doing better. It's been a while since I read the thread and I was wondering how he's doing. Michelle - thanks for your positive support and attitude! I'm sorry that I will not be able to make it to Denver...maybe next summer when I can get my MIL out here again to watch the kids. Then we'll all be skinny!

Hello all, hope you had a Merry Christmas! Mini, I am down 2. Amazing, can't remember another x-mas week ever in my life that did not involve a weight gain. I was at the store today and saw all the vitamins, powders, and various diet stuff for sale. Isn't it nice not to have to start the year with yet another resolution about losing weight? yeah bandsters!

JDKbsgirl, I don't worry about the weight gain in that phase. Right now I'm only consuming around 650 calories a day. This is from 6- 4 oz meals. Even if we have these other foods, I can't see going up in calories enough to make a weight gain.

Me too! Oct 15th. Very nervous. Hoping I made the right decision for getting the sleeve over the bypass. I've been reading about people who are struggling with weight gain after a few years with the sleeve and that makes me nervous. Maybe everything makes me nervous at this point. LOL. Excited though. I'd just like it to be done already so maybe I can quit stressing. Can't wait to hear how our Oct group progresses. This is an exciting journey we are undertaking. I admire you all for your courage.

My surgery will be on Oct. 28th. I have 2 more nutrition appointments, upper GI series, pre-op testing and appt with my surgeon and primary care doctor. Oct. 3rd is when my paper work will be submitted to my insurance for prior authorization. I'm just trying to stick to the diet a weight gain is the only thing that can postpone my surgery. Good luck!!

Tina, sounds like things are going wonderfully! I'm so thrilled. Good for you for getting an attorney! "Serves" him right! LOL! Okay it wasn't THAT funny! :thumbup: Good job nipping the weight gain in the bud and getting back on track! WTG! Take good care and enjoy! Hugs!!!

I am officially banded as of yesterday and came home from the hospital today. Everything went smooth according to the surgeon but I am quiet sore around the cuts, of which there are 5. The most pain is on the left side where the port is. I haven't had much of an appetite yet so am trying to drink. I'm supposed to be on clear liquids for 2 weeks and then pureed mushies for 2 weeks. I didn't ask about when the first fill will be but I go back to the Dr. in two weeks and will ask then. From what everyone is saying you are able to eat quiet a bit until that fill. Hopefully there will be no weight gain. HAPPY NEW YEAR!!