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Coping with Stress During COVID-19: What Bariatric Patients Need to Know May 1, 2020 by Harold Bays, MD, FOMA, and Lydia C. Alexander, MD, FOMA Dr. Bays is Medical Director and President of the Louisville Metabolic and Atherosclerosis Research Center in Louisville, Kentucky. Dr. Alexander practices obesity medicine at Kaiser Permanente Medical Weight Management Group in San Francisco, California. Funding: No funding was provided. Disclosures: Harold Bays, MD, FOMA is Trustee, Chief Science Officer, and Lydia C. Alexander, MD, FOMA, is Secretary/Treasurer for the Obesity Medicine Association. During this most unique of times, as frontline healthcare workers and hospital staff, we frequently face difficulties when treating patients threatened by a rapidly increasing pandemic. This is made even more difficult with the stress of limited essential medical supplies. Among all the turmoil and disruption, the emergence of COVID-19 has created special challenges for patients with obesity. Many patients with obesity have impaired immunity, impaired lung function, sleep apnea, and hypoxia, making a virulent upper respiratory tract infection especially perilous. Added to this are obesity-related debilitation, immobility, orthopedic changes, polypharmacy, more limited access to medical/preventive care, and adiposopathic complications of diabetes mellitus, and cardiovascular disease.1 Collectively, patients with obesity are more susceptible to COVID-19 disease and have worse outcomes once infection occurs. For many bariatric patients, the rise of the novel coronavirus has created additional challenges, such as the effect of mental stress on their lives. Increased mental stress can worsen complications from obesity, such as hyperglycemia, high blood pressure, dyslipidemia, and might also worsen obesity itself. The good news is that if clinicians are attuned to the physical impacts of mental stress, then proactive measures can be taken to mitigate the potential adverse consequences of mental stress. Acute Stress, Chronic Stress and COVID-19 Acute, or short-term, stress is a function of the natural “fight or flight” response. One of the systems activated by the stress response is the sympathetic nervous system, which increases production of hormones epinephrine and norepinephrine. The acute stress response can be beneficial—it can increase visual acuity, decrease pain, increase blood flow, and boost the immune system. This complex sequence of hormonal changes and physiological responses helps people when they need to fight or flee to safety. Conversely, chronic, or long-term “submit and stay” stress has the potential to worsen health outcomes. Chronic stress can increase cortisol production, which might promote visceral fat accumulation.2,3 Symptomatically, chronic stress can cause decreased cognitive ability, diminished healthful decision-making, and more pronounced pain. Physiologically, chronic stress can impair immune function, impair sleep patterns and increase blood sugar, high blood pressure, and body weight.4 The Toll of Chronic Stress on Patients with Obesity During COVID-19 Stress and anxiety are understandable during the COVID-19 situation. We are living in a time of an unprecedented global pandemic crisis. Doom and gloom are everywhere. Good news is rarely reported. Stress is to be expected. However, clinicians can assist patients with proactive stress management techniques, especially for people living with obesity. Many patients are staying home to keep themselves and others safe and limit the spread of the novel coronavirus. Other patients are staying home because of governmental mandates. But while “distancing” from others could have potential benefits in preventing viral spread, staying home might result in less healthful nutrition and reduced physical activity. As we navigate the unparalleled COVID-19 crisis, it is critical that clinicians, including bariatric surgeons, counsel patients to recognize the signs of mental stress, as well as its potential negative impact to health. This would include increased blood sugar, high blood pressure, increased body weight, and challenges fighting viral respiratory infections. Bariatric patients should receive specific and actionable guidance on safely optimizing nutrition and physical activity during periods of shelter-in-place orders.5 Coping with Stress During COVID-19 As we await a cure or vaccine for the novel coronavirus, one of the most important measures clinicians can take in the interim is to address potential mental stress head-on, as one of the first topics of discussion during patient encounters (e.g., via telemedicine or otherwise). When appropriate, clinicians can then recommend patient-centered stress management techniques that might prove helpful. Here are some ways to get started: Feel your feelings. While it might seem intuitively obvious, many patients might not truly recognize the degree by which mental stress is altering their behavior, lives, and overall health or might be avoiding addressing feelings of sadness or loss of previous routines and lifestyle. This should be a prime topic to discuss during any patient encounter. Patients should be educated to become in touch with their feelings and recognize how those feelings might be affecting their behavior. Negative or unproductive feelings and the potential adverse effect on behavior cannot be resolved until it is first acknowledged. Take it one moment at a time. At this time, no one knows how or when the COVID-19 crisis will end. It is likely nothing will ever go back to “normal.” This might be a daunting notion to patients with obesity, who might already have a sense of hopelessness. Thus, instead of focusing on the seemingly unending days of isolation ahead, patients should be encouraged to focus on manageable, demonstrable, and accountable healthful measures that can be accomplished today. Behavior changes that are doable, accountable, and sustainable represent the mainstays of a behavior modification plan. Perform a food inventory. It is common that patients with increased mental stress resort to “comfort food,” which is often energy dense and highly processed. Temptation to consume these foods is increased if these nutrition-deficient foods are in the location where people live. Thus, patients might best be advised to perform an inventory on the nutritional quality of food where they live. When ordering food or grocery delivery, patients should virtually shop when they are not hungry or exceptionally stressed. Having friends or family review the list might also be helpful for some to ensure healthy foods are chosen. Stay physically active. When shelter-in-place regulations prevent leaving the house, patients can be advised to look for novel ways to keep moving. Pacing while on the phone, putting the laundry away one item at a time, listening to music and dancing, and taking a lap around the house or backyard are all ways to remain physically active while sheltering in place. Passive stress relievers, such as surfing the internet, watching television, and playing video games might seem like an ideal way to pass the time. But these do not contribute much to energy expenditure and might worsen anxiety. Too much time spent with passive screen activities can have a negative impact on health. It is a good idea for clinicians to specifically talk to their patients with obesity about limiting screen time. Stick to routines and care plans. Now is not the time for patients to fall out of previous healthful routines and self-care that was either promoting health, or helping with health maintenance. Patients should be encouraged to think beyond COVID-19. They should avoid having these few months negate years of potential progress that were so hard to achieve. Patients should especially be advised to monitor their sleep patterns. Poor sleep can contribute to worsening metabolic disease, cardiovascular disease, and obesity. Closer clinician contact with bariatric patients at this time is critical to identifying early maladaptive behaviors and routines and ensure continued long-term success Practice active stress reduction. Patients should be encouraged to explore activities, such as walks (where permissible), puzzles, books, yoga, meditation, and other hobbies. Maintaining social connection via phone and video calls while physically distancing can be an important method of stress reduction. These pastimes can have a soothing effect during this stressful time. Look for the helpers. Fred Rogers said it best, “Look for the helpers. You will always find people who are helping.” During times of crisis, finding a way to join the helpers can be gratifying not just for the one being helped, but also the one doing the helping. Participating in community efforts to improve the lives of those affected by the COVID-19 crisis can have a relieving impact for everyone. Maintain social connectivity. While the recommended jargon of “social distancing” is prevalent, perhaps the implication of this approach is not what was intended. Perhaps a better term is “physical distancing.” Remaining socially distant is not always the best plan, especially for patients with obesity who are already stressed and who might already feel isolated. For many patients, it might be best to recommend to seek and maintain social connection via a simple phone call, or FaceTime, Zoom, Google Hangouts, or any of the myriad digital communication solutions available. As clinicians continue to look for ways to help their patients during these stressful and uncertain times, bariatric surgeons can empower patients via implementing simple techniques, such as the ones described here. The Obesity Medicine Association (OMA) offers a trove of resources for clinicians and health care professionals, including continuing medical education, American Board of Obesity Medicine (ABOM) exam preparation, Obesity Treatment Proficiency Badges™, and The Obesity Algorithm®, which offers comprehensive clinical guidance on the latest obesity management trends and evidence-based medical approaches to treatment.6–8 To become an OMA member, visit: https://obesitymedicine.org/join/. For more obesity medicine resources, visit: www.obesitymedicine.org. References Scott KA, Melhorn SJ, Sakai RR. Effects of chronic social stress on obesity. Curr Obes Rep. 2012;1(1):16–25. Joseph JJ, Golden SH. Cortisol dysregulation: the bidirectional link between stress, depression and type-2 diabetes mellitus. Ann N Y Acad Sci. 2017;1391(1):20–34. Kyrou I, Tsigos C. Chronic stress, obesity and gonadal function. Hormones (Athens). 2008;7(4):287–293. Yaribeygi H, Panahi Y, Sahraei H, et al. The impact of stress on body function: a review. EXCLI J. 2017;16:1057–1072. Bergmann N, Gyntelberg F, Faber J. The appraisal of chronic stress and the development of metabolic syndrome: a systematic review of cohort studies. Endocr Connect. 2014;3(2):R55–80 Obesity Medicine Association. https://obesitymedicine.org/badges/. Accessed March 24, 2020. Obesity Medicine Association. https://obesitymedicine.org/. Accessed March 24, 2020. Obesity Medicine Association. https://obesitymedicine.org/obesity-algorithm/. Accessed March 24, 2020

Don't give up on your dream, 25 pounds can be done. 😊 Take it one day at a time. Years out, your surgery still works. Find your old discipline. Your weight loss may be slower but it still comes off. After the honey moon is over, what motivates you now? Dig deep to find your reasons to stay the course and be healthy. Work your program. Log food, hydrate and get exercise in. Join an online weight loss challenge. MyfitnessPal *JUST GIVE ME TEN DAYS WEIGHT LOSS CHALLENGE* https://community.myfitnesspal.com/en/discussion/10793433/just-give-me-10-days-round-112#latest

40 pounds is actually pretty good. My surgery was on 2/19 and I have lost only 25 pounds.I know it is discouraging but be patient. You are learning a better way to eat a slow weight is healthier. I concentrate how I am feeling rather the numbers.

I’m worried about the same thing. I’m scheduled for sgy next month and I find myself panicking sometimes about if I’m making the right decision or not. One reason being the loose skin factor. I’m 37, 5’3, 275 lbs and have been over 200 lbs for the past 10 years. Does anyone have similar stats who’s post op? How did you guys fair with loose skin? Do you regret the surgery? Did you see major improvements to your health long-term?

For those of you that didn’t reach your goal weight during the honeymoon phase (18-24 months after surgery), were any of you able to kickstart your weight loss later and drop the pounds? I lost lots of weight initially (100lbs.), but mostly maintained (or went up and down the same 5-10 lbs.) for the past year. I definitely haven’t been as strict with my diet and exercise during that time. I’m still about 25 pounds from my goal weight and don't want to give up on the dream. . Has anyone successfully met their goal later in the process? What made the difference for you to get it going again?

Yeah...i was soooooo cold ALL. THE. TIME. Some people report this as lasting quite long. For me, I stopped feeling I was unnaturally freezing to death around the 9-10 month mark (a couple months after my weight stabilized). At 1.5 years post op, i *think* I feel cold and hot like normal people now...

Thanks for the encouragement me. My wife created this account for me, and made my first post while I was in the hospital ( I am actually only 34). I was fine by day two, but they had convinced me that I was going to in surgery at 10:00 AM and out the door by 2:30 PM, and I would not have made it the first day without the IV. I had unfortunately only review this forum for peoples results at 6 months and 12 months, and didn't bother to look into the immediate after effects. I am 9 days into my diet and down 20 lbs (had a 5 lbs spike post surgery). Surely I can hit 40 lbs down by the end of May.

First of all congratulations on your 62 pound weight loss! I was a slow loser also. I had surgery 8/13/18. I was 204 when I had surgery and in February of 2019 I was 162 which was a loss of 42 pounds. (same time frame I believe). I was tracking everything I ate and averaged 700 calories a day. It was super frustrating and it felt like a turning point for me. I joined a gym through my hospital that provided me with a personal trainer and went to the gym 4-5 days a week. I tightened up my diet and ate more protein and fewer carbs . I made the decision that 40-50 pounds was not going to be good enough for me personally. Don’t get me wrong, I was pissed that I had to work “harder” than other people to get results, but that wasn’t going to change my situation. Once I let that go and just accepted that I wasn’t doing anything wrong and that my slow metabolism wasn’t a character flaw, I found it easier to dig deep and work hard to reach my goal weight. On the positive side: I had more time to adjust my lifestyle and eating habits and I never take a pound for granted. I maintain my weight on 1300 calories a day, so you can see why it took me longer, I just can’t eat a lot without gaining. I have tons of tricks and tips and I don’t feel deprived... ok, sometimes I do....But it’s ok, I’d rather grab an apple or a kind bar than be overweight again. You aren’t done losing weight, it might come off slower but you can do it. Track 100% of what you eat hydrate the best you can (your boss sounds like a gem) Move, walk, workout if you can as much as possible. Wear a Fitbit or device that monitors your steps, set a goal and meet it everyday. Best of luck and wtg with your loss so far!

I started my preop diet on 5 May 2019 and tend to think of this date as my anniversary, rather than my actual surgery date of 15 Oct 2019. Since May 2019 I've lost about 140lbs; 90lbs of this was after being sleeved. I lead a very busy, very active life and my goal weight is within sight, but it's more important to me to be fit, strong, and healthy, which I now am. Before becoming MO, I was a competitive athlete, and am again able to participate in sports and fitness the way I used to. There have been dozens of NSV's, and I'm grateful for every one of them. My focus continues to be on the psychological adjustments and actions required to permanently change my habits and behaviors. Since the coronavirus lockdown, I've continued to strictly follow an eating and exercise schedule so that I remain on track. With so much uncertainty at this time, what I put in my mouth and do with my body are one of the few things within my control right now. Congrats and well done to all my fellow Oct sleevers.

Hey there! I had gastric sleeve surgery on 1/31/2020 and here's my story. I attended the free 12 week orientation classes June 2019 thru Sept 2019 at Kaiser. My insurance paid for everything and I had no issues getting approved. My only out of pocket expense was a $100 co-pay for the hospital stay. Wonderful insurance, I know. Luckily, I had no medical issues making me very low risk for the surgery. My surgeon recommended that I get the Bypass and I changed my mind on procedure the day of surgery and switched to the Sleeve. My reasoning is simple...I didn't want to reroute my intestines and I didn't want to chance vitamin deficiencies or dumping syndrome. I fasted on clear liquids the day prior to surgery and it was hell. I had an interview on fasting day and wanted so badly to stuff my face, being an emotional eater (i did get the job!). I went to bed super early the night before surgery because I had a massive headache and mood swings from fasting. My surgery was at 1pm and because of the fasting... I wish I scheduled a morning surgery. The nurse that prepped me for surgery was an idiot. Why on earth would I be able to pee for a pregnancy test after having no fluids since the day before?! I could barely pee and what I did pee didn't make it in the cup lol I got 2 tiny drops of pee in the cup and guess what? It was enough for the pregnancy test. The nurse stuck me 7 times looking for a vein. 7 times. Not just a poke either, like she was really digging. She tried my forearm, the top of my arm, and both hands before calling for help. I woke up in recovery in extreme pain, nausea and was thirsty. I said "I'm thirsty and my stomach hurts really bad" and the nurse said yeah you just had stomach surgery. I wanted to sock her in the face. They made me wait 6 hours for pain medication and water. The night nurses sucked and the day nurses were great. I used the call button every 1-2 hours for more pain meds which they could only give me every two hours. I called after 45 mins and said "did you give me a full or half dose?" lmao but I was serious. The built up gas hurt and my throat was sore. I tried really hard to push the gas out and ended up sharting in my bed. I walked often because I badly wanted to go home. Coming home was nice and I wasn't hungry but still thought about food a lot. I followed the rules and sipped my water and protein shakes and jello. I only took a week off from work because I wanted my routine back. The doctor told me it was too soon because of brain function is usually low this early on. He said "do you want to go back because you're bored or because it's a money thing" and I said "I'm bored as hell" and he said "then no, you can't go back yet." I didn't listen and have no regrets. I started taking the pill form of multivitamin early on because the the ones you eat made me gag. I slowly introduce foods as instructed and my staples are yogurt, protein shakes, salmon, cottage cheese, and veggies. I keep my meals simple. I had my 3 month check up today and I'm on track. I've lost 50 lbs total since surgery. I'm aware that weight loss with the sleeve is slower but I'm okay with it. Each week I can physically feel and see my body changing for the better. I exercise daily by walking 1-2 miles, I feel great, and I have more energy. This is the one and only time that I've had surgery. It was rough at times but overall a good experience. I am happy that I did it and have a long road ahead

I know that every journey is different, but I feel very discouraged with my numbers. I was sleeved October 1, 2019 and my surgery weight was 229. I am now 178 and I feel that I have not lost enough and am in a stall. I have had problems with my water intake, partially due to my employer freaking out about additional bathroom breaks-I had to get an ADA accommodation, but it has expired, they want to hear from the doctor, who feels that it is ridiculous (he's not wrong). I am embarking on an effort to try to pick up the pace , 2 30 minute exercise periods per day ad diet modification. I am 4'11 and feel that i should lose a minimum of 50 more, nd it seems impossible. I know that part of it is mind set, but I just don't know what to do, other than discuss it with people who get it. Grrrrrr.😟

I had VSG surgery December 17 2019 and I’m wondering is it too early to have a glass of wine

So my surgery was 2/25. I started on the day of surgery at 345. I am now down to 306. I feel a little discouraged almost 10 weeks in and having lost only about 40lbs. I am slowly, SLOWWWLLLYY losing weight. I do not feel very thirsty ever, and initally I was not very hungry. But now I do get hungry. I don't even feel that much different.

Hey all! I haven't been as active on the site recently, due to the virus and just focusing more on life. But i'm coming up on 10 months and i did some transformation pictures. I hit my goal in month 7 and since then ive been trying to maintain a balanced diet that helps me put some muscle on. ive been getting in 1500-2000 cals a day, but that means im eating pretty much every hour or two and still drinking my 2 protein shakes a day. But i'm starting to see results so im really happy with that. I still have not had bread, and honestly i dont see why ill ever need it again. I do treat myself here and there. Once a week i will have ice cream, (its my favorite and i dont want to deprive completely) and i allow myself one meal where its kind of a free for all as far as not worrying about protein, but i naturally finding myself not wanting junk anymore. I crave veggies and fruit more then ever. I hope everyone is staying safe and continues to fight the good fight. I hope you all have a great Friday.

I completely understand your frustration. However, I can tell you from personal experience that this is real and the area you were in, may not have Covid-19 patients. My best friend is a nurse and we talk daily about this pandemic and how scary it is. Now I can say, the hospital where I’m scheduled for my bypass was quiet and dead at my last appointment a few weeks ago. But when my husband severed his finger about three weeks ago, there were constant Covid-19 patients arriving at the ER. It was unreal. But again, I understand. My surgery would’ve been this past Monday, April 27th and now I’m still scheduled for May 15th, but I’m in TN where they’ve decided to reopen the economy, and our numbers are shooting up as more testing becomes available. I just want to have this surgery and be happy. I’m two, almost three years into my journey due to insurance changes, and the practice switching over where I lost my advocate. Just stick in there and keep your fingers crossed. And feel free to contact me directly if you just want to vent. I’m really struggling right now not to eat everything in sight, and I’m supposed to start the liver shrink diet AGAIN, tomorrow. Don’t give up, just keep checking in and hopefully people will continue to social distance long enough for us to make our surgery dates!

I am so pissed right now. I have done everything and the only thing left is 3 months dietician and nutrition. smh no one is taking patient therapy and I have tried to do Telehealth but they won't accept that insurance won't. I am so f**king over this covid 19 everyone is getting their surgery and I am literally sitting her stuck. wtf so close in a minute I'm just going to go to Mexico and get my surgery cash

Hello all so yesterday I weighed myself and I.T look like I have gain weight instead of losing .. went from 193 on April 24 to 198 on April 30th . My nurse friend told me could be water weight or the fact I haven’t poop ? I’m not gonna lie feel like I’m failing and I’m a bit paranoid .. this COVID -19 has made me stressed eat only at work . Btw I work at a hospital on a covid floor.. Help ! I need some encouraging words

I told 5 people: the Mr., the Kid, my Mom, my sister & my BFF. Of course, as the weight started falling off, others would ask how I was doing it; I told them I was severely restricting calories & carbs, as well as exercised daily. All of which was true. After about 9-10 months, people just got used to seeing me smaller and eating differently and they stopped asking questions/commenting. It's been 1.5 years now, and me and my weight are old news. P.S., I did, however, tell people I had plastic surgery to remove excess skin. I had PS over Christmas, and I had to explain to friends and fam why I was all hunched over and unable to lift my arms. Plus they would see the scars on my arms/tummy eventually (sleeveless tops!), so I couldn't really hide it anyway.

I had my surgery March 2019. When I got home from the hospital I could barely choke down 2 oz of water or protein and my doctors office would yell at me during check in calls because I wasn’t being “compliant.” I cried so many times in that first week and wondered why I purposefully did this to myself. By the next week, I was a new person. Most of the pain subsided and even though it was still an effort to get the water and protein down, I was doing it and feeling much, much better. Each day/week got better. Sometimes there were setbacks but mostly good days. Learning to eat again was a challenge then and is still a challenge now. One year post op I was down 115 lbs and beyond my goal weight. My whole life has changed. My health and numbers are really good and I would go through all that again without a doubt. You took such an amazing step having the surgery and you will get through this and you will be glad you did. Hang in there and keep us posted on your progress.

Well hell..... husband tested positive for convid 19. Karma is coming for a bite of my ass. I have to go get tested tomorrow. we are doing fine. will keep y’all posted

I’m having so many mixed thoughts swirling around my head. I hesitate to post this today. I am grateful for having gastric bypass to have the tool to combat metabolic disorders and inability to exercise due to disability (post exertional malaise) and I was at the point it was all or nothing. All my fight was getting me nowhere fast. I know I’ve come a long way, I’ve also paid a hefty price physically and am still dealing with many health challenges. But I also know my body could not carry the burden of all that weight. And I will do everything in my power to maintain the weight loss. i reached goal Sometime last month. I overshot it a little. Although based on my height of 5’ I’m within my goal range. I haven’t been actively trying to lose for a few weeks. I raised my calories somewhat but not drastically. I started out at 208lbs with a BMI of 40.6 and today am 102.4 and a BMI of 20. its Funny though, I write my weight on a calendar daily, and write Daily log of my weight, meals, calories and protein to Track and plan what I will eat the best I can based on what’s available in the fridge, freezer, pantry. I haven’t given solid thought to my progress, I’ve just taken it one moment at a time. My weight fluctuates slightly and that’s ok. Other things weigh on my mind though. I hesitate to call it a celebration when even my birthday this month went unmentioned and Covid-19 will be around for the foreseeable future. It’s not impacted my odd daily routines of living with lifelong chronic illness and disability. I’m homebound much of the time as is. It’s risky going to get groceries but a necessity. But It’s had more of an impact on healthcare. i Had an early one year follow up with my surgeon February 11 and discussed continuing severe pain and spasms in left side under ribs along with other symptoms along with my history of ulcers in the remnant stomach and small intestine, they said I needed a double balloon enteroscopy. But I had to see a different doctor for the test. I couldn’t get an appointment until March 12 to see that doctor, I asked if they could schedule the test since it takes a while but no I had to wait to see the doctor first, who of course ordered the test. Which was then scheduled for April 27. And what happened, of course no one called until the last minute and it was then canceled indefinitely. And I’m left in pain, I sent them a message and they tell me I could go to the ER to be evaluated. First of all how is that a good idea? And evaluated for what? That’s why I saw the doctor and he ordered the test (actually both doctors did) I’m at a loss as to what to do and meanwhile I’m just trying to move ahead. i don’t even want to discuss this. I’ve other health issues that I’ve been waiting months to deal with. My doctor gives me attitude. Even things are obviously a problem. I saw my general doctor February after waiting a few weeks. I had sudden severe pain just lightly touching the front of my throat. I had a thyroid ultrasound. I also saw an endocrinologist. I was supposed to go to the hospital for further tests. But this was cancelled indefinitely. I’ve also been having nosebleeds and I don’t know why ... but it’s all been put on hold and none of the doctors care to follow up. I have been making plans about having skin removal surgery. Since it’s the only thing I can manage to do right now. The excess sagging skin is very problematic especially my thighs. A thigh lift, and Having a Belt lipectomy/Butterfly lift to remove excess skin might also help benefit strengthening my core which I can’t do with exercise. I’ve been working on this with Hospital BC that is part of BariatricPal and they are so helpful in the process. I’m trying to think of it as a vacation in Mexico with benefits. I’ll need financing of course. I’m far away from rich. It’s a goal to have a body I haven’t as long as I can remember. I haven’t been this weight as long as I can remember either. I could never reach this goal on my own before even as hard as I tried with strict low carb and calorie counting. I only managed 124lbs and it didn’t stay there long. So taking that last step of getting rid of ugly sagging, rashy problematic skin feels like part of the journey to finish. A crazy thing in times like these. I’ll be pinching pennies as hard as I can. But part of me is determined. And also ... trying to ignore the rest. I had wanted to deal with the other health issues first but looks like that won’t happen so I’m going to try to roll with it and see what happens. maybe it’s dumb for me to write this. I don’t know anymore. I’m exhausted. But I think that I want others to know that if I can do this with my chronic illness and disability And despite how hard it has been for me ... that others can succeed and reach their weight loss goal.

I’ve bought the enchiladas locally at Publix grocery, but recently placed an order online since they had a special offer to get free choczero syrups. Also if anyone uses the link I posted they get $10 off. It’s free shipping with $50. It seems like a lot but I shopped the flash sale and the special deal. I got chicken enchiladas, beef enchiladas and breakfast sandwiches. Plus You do earn rewards buying online. I’m trying to avoid the grocery too often. Check out their Facebook page they have a ongoing contest to win a gift card. I haven’t tried their ice cream yet. But it’s got great ingredients that I know wouldn’t bother my pouch. I just wish it were less calories. It would be more of a meal for me. Then again my dinners are plain Fage Greek yogurt with protein powder, a baby banana and some sf whipped cream.

Some people do a variation of ice cream with frozen bananas...(if you google no doubt there will be a few different recipes...I have seen some with banana, peanut butter and a little cashew milk. But simply...peel and chop a couple of bananas, freeze them, and then blend. Here are a couple of recipes I copied yesterday from the pound of cure website with the intention of trying them somewhere down the track. Chocolate Peanut Butter Nice Cream Serves: 1-2 Ingredients: 4 ripe Bananas, peeled 2 ounces Peanut Butter 2 Tablespoons Unsweetened Cocoa Powder Directions: Peel 4 ripe bananas and place them into the freezer for 2 hours. Add all ingredients into a food processor or blender and blend until smooth. Scrape down the bowl if necessary. Enjoy! NOTES: Depending on your blender/food processor, your nice cream may become too soft. If that happens, just pop it in the freezer for 10 minutes. If you have a hard time creating a creamy consistency, you can add 1-2 tablespoons of cashew milk. Peanut Butter and Banana Nice Cream Serves: 1-2 Ingredients: 3 ripe Bananas, peeled 2 ounces Peanut Butter Directions: Peel 3 ripe bananas and place them into the freezer for 2 hours. Add all ingredients into a food processor or blender and blend until smooth. Scrape down the bowl if necessary. Enjoy! NOTES: Depending on your blender/food processor, your nice cream may become too soft. If that happens, just pop it in the freezer for 10 minutes. If you have a hard time creating a creamy consistency, you can add 1-2 tablespoons of cashew milk.

The ASMBS held a webinar yesterday for bariatric surgeons discussing the topic of how and when to resume bariatric surgery in the COVID-19 era. You can watch the webinar at https://asmbs.org/resources/restarting-surgery-issues-to-consider If your surgeon called you tomorrow to schedule surgery within the next 1-2 months, are you comfortable having your surgery?