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A lot of threads recently on telling/not telling friends and family about our surgeries. I posted a lengthy article several weeks ago by Bariatric Surgeon Dr. Mitchell Roslin. He makes some excellent points about how we as a society view this disease so I've excerpted two paragraphs that help me see the issue clearly: "Besides surgery, there is absolutely no documented or successful treatment option. Laymen watch popular television shows like the Biggest Loser or daytime talk shows and think that weight loss is easy. Unfortunately, the majority of people that lose large sums of weight – regardless of whatever method – suffer cataclysmic recidivism. Intuitively, most believe that we can be trained or be taught to change our behavior and maintain weight loss. However, science contradicts these widely-held beliefs. The body resists weight loss. When caloric intake is curtailed, we respond by becoming more efficient and reducing our metabolic rate. A registry is kept of people that have lost substantial sums of weight and maintained the weight loss for five or more years. On average, to preserve their weight, at the new loss state, they eat less than 1200 calories and exercise more than an hour per day. We must realize that behavioral modification techniques that have not even succeeded in halting the rise in the prevalence of obesity are unlikely to be successful as a treatment for morbid obesity. Stated succinctly, prevention and treatment are different. We prevent bacterial infections by washing hands and avoiding contact with infected sources. We treat people, de rigeur, with surgical debridement and medications such as antibiotics. It is possible that if Vice President Cheney never smoked, he would not have had a heart attack at 37 years of age. However, no one would treat his heart disease by only having him stop smoking and change his diet. While an important component, such efforts would be combined with medications. Yet, in obesity, we still want to believe that the same techniques that are used to prevent weight gain will result in successful treatment."

thank you for your input. as I said, I live with someone who just had this surgery. what I've seen is that he would go on a diet, and if he didn't get these super results of 10 lbs a week, which is unrealistic, he'd just quit. right now, he's only 2.5 weeks out, and in a stall. I guess I can see that if this happened with "just" a regular diet, he'd quit and just eat. but right now he can't do that. Having never had this huge weight problem as he does, I guess I'm trying to understand. for me, I would have never let myself get to the point he is at. for me, my "omg I weigh that much???" number is far far lower then his. I struggle daily with losing 30 lbs. but that's all I've ever let myself go. and yes, being female who BEARS the kids, I've always felt that female who have had children have a slightly different disadvantage on weight gain then those who haven't had kids. be it male or female. I'm hoping desperately that this time he succeeds, but whenever I try to talk to him about this, he just snaps at me. I'm hoping he'd never see this post because he hates Oprah. I do know that if he were on a regular good ole fashioned diet, and not lost weight for 5 days, he'd say heck with it, and just binge on food. I live with him, I've SEEN this. right now, he's not losing, but unable to do any binge type eating. I tell him, don't be ridiculous, you will lose weight, how can you not on 800 calories a day? I believe that in 6 months or so, he'll have that huge WL that he seems to need, and be able to go forth and succeed when he's past this "honeymoon" period. no, to be blunt and completely honest, I don't think anyone "needs" WLS, I think people want instant gratification with huge WL's whenever they diet. so this was the point of my question. does this huge wl within such a short time, change your way of thinking so much that you do succeed? listen, I don't mean to criticize, please don't take it that way. but I myself have found, that it's super easy, and quite enjoyable, to eat whatever you want and gain weight seemingly overnight; but way hard to lose it. but let's face it, most of us are just not built in such a way, that we can indulge in Cheeto's every night of the week, and be thin. what makes you change you bad habits after surgery? what is it that does this, that regular dieting doesn't do for you?

I’ve been lurking around these forums for over 2 yrs and decided it was finally time to post something. This coming July will make two years for me and I’m down 78 pounds, 8 pounds under my original goal. The last time I felt that I was losing control was when I made the decision to see a doctor about weight loss surgery. I had always been an extremely active (hyperactive) skinny kid and adult through my 20s and most of my 30s. My mother called me “Skinny Malink” when I was a kid. Then in my late 30s I suffered a serious knee injury from a soccer accident that led to gradual weight gain to 245lbs!!! (I’m 5’10”). As soon as I was able to start eating solid foods (14 days), I began tracking every morsel of food that enters my mouth on MyFitnessPal.com. I mean I track everything, from the 6 grams of coffee creamer I put in my morning coffee every day to the half serving of hash browns and ¾ portion of the Sausage McMuffin I have once a week at McDonald’s with the guys (a 10 year tradition for us that I wasn’t about to break). (I used to eat 2 orders of Sausage McMuffins without egg, 2 orders with egg, and 2 orders of hash browns in one sitting.) If my wife asks me to try a sample of a cake batter she is about to put in the oven, I figure out a way of entering that too. Everything. Strict monitoring is the key to successful weight loss and weight loss maintenance. I wear one of those body monitors that they use on The Biggest Loser. I track every calorie I burn 23 hours a day. Everyday my goal is to eat just under or around the calories I expend, which for me is around 2200 to 2400 calories a day. That’s with some light exercise meaning a 30 to 40 minute slow walk every day (I had corrective knee surgery about a year ago and today I can walk slowly, like 2mph). For the past six months I have also been following that British “Fast Diet” by Dr. Mosley. Basically you eat 600 calories of mostly Protein for two days out of the week (500 for women) and then anything you want on non-fasting days. This a very easy way to maintain weight loss for sleevers and the health benefits are truly amazing. Intermittent fasting lowers your chances of getting cancer and Alzheimer’s disease. I have a lot more energy now since fasting than I ever did. (I do track my food intake on non-fasting days even though you’re not supposed to). You can look up the Fast Diet on the internet or on Amazon.com. There is a U.S. version of the book and it’s available for Kindle. Because I’ve been using intermittent fasting for half a year, I guarantee that the hunger I feel is not just “head hunger” (if by head hunger you mean purely psychological). It is true that the docs remove a part of the stomach that produces the majority of one of the hunger hormones, ghrelin, but there are many chemicals in the body that cause the sensation of hunger, not just one. Besides, not all the ghrelin is eliminated from your system because 15% of it is produced in other parts of the body. When you have some free time, look up a protein called neuropeptide-Y. It plays a major role in hunger sensation and regulation and it increases during periods of stress. It is true that the hunger pangs I feel today are different in intensity and quality from what I used to feel before the surgery but not all sensations of hunger that I feel are in my head. Even after a vertical sleeve gastrectomy, there is a chemical basis for hunger, it’s just that the chemical composition is different for VSG patients. I eat exactly the same foods today that I ate before the surgery except just a lot less of them. That includes pizza, my famous homemade Texas chili, Red Lobster’s lobster bisque, and spaghetti with meat sauce. I don’t think of any food as “bad”, not even candy bars like Baby Ruth, my favorite. I just monitor everything I eat on MyFitnessPal.com and force myself to stay within my daily maintenance calorie intake of 2200 to 2400 calories. What is different for me today than from two years ago is that because I am tracking all my food, I am aware of how many carbs, Proteins, and fats I am eating for the first time in my life. I follow the nutritional guidelines recommended by MyFitnessPal.com (just select "guided" goals). If you’re in a stall or having trouble losing those few extra pounds, I encourage you to try the Fast Diet by Dr. Michael Mosley. It’s also called the 5:2 Diet. Especially for people who have had 75 to 80% of their stomachs removed, it’s a very easy way to lose and maintain weight and the long-term health benefits from intermittent fasting are awesome. IMHO, stick with the counseling and try to allow yourself to enjoy your comfort foods in moderation without guilt. The more you beat yourself up for eating foods you enjoy, the more stress you feel, the more your hunger proteins will surge, and the more you will crave those foods you are trying to avoid. That’s why will power alone never works over the long haul. I have more will power than anyone I know and I still got uncomfortably fat. Instead of seeing yourself as losing control whenever you eat comfort foods, try to turn that around so that you are gaining control. What I do is I take out one portion of candy or cake or whatever it is I feel like eating for that day and then deliberately plan on eating it at my usual snack time. For me, I take out my Baby Ruth bar and leave it on the end table for when I am watching TV at night. Every time I pass it, I smile in anticipation. I also make allowances during the day for that snack by monitoring everything I eat and by exercising so I know I have enough calories to “spend”. This way, I am gaining full control over these food choices instead of feeling like I am losing control every time I eat them. Anyway, this approach has worked beautifully for me. Everyone has a different history with weight and health issues so I don’t know if this method will work for everyone. I’ve been able to comfortably stay under goal for over eight straight months by using this system of intermittent fasting combined with strict monitoring of all the calories I eat and use. I wanted to share my experience with it in case others can benefit too. Best of luck.

Hello my peeps! It feels like FOOOOOREVER since I've posted here. I haven't weighed in a looooooong time :-(...the last time I weighed myself I was 147 which would be a 3 lb. gain from my lowest of 144. I fear I may be at least 155 now, but not sure. I'm still wearing 6-8 however some of the 6's feel snug and I FEEL BLOATED :-(...I have not been eating the way I should and not drinking enough Water (water has always been a problem for me). I really need to up my exercise back to 5x a week. I have been going to 1 hour Zumba classes Tues, Wed, but I just bought Zumba Fitness Rush for Xbox Kinect and I really LOVE IT! I can do it at home YAY! SOOOOO with that said I have decided to join weight watchers TOMORROW...I have always loved their program and want to learn about the new 360. I heard fruit is 0 points now LOL! And I really really really need to be accountable to a weekly weigh in. I know I'm gonna get what the heck is this girl doing here looks... but I gotta do, what I gotta do I will probably have to change my weight gain vote from 1-5 lbs to more :-( ....but praying I can get back to that level, I CAN DO IT...Stay tuned...

Im happy for all of you, but remember this thread is: Weight Gained Since Having Gastric Sleeve Surgery. Thanks gals!

I can say that mine started off as a medical problem. I have PCOS and I KNOW ppl will think I blame that a lot. BUT I've had it since I started my period. If you look up the side effects of PCOS I have every single one of them. Most importantly is easy weight gain and it's really hard to get the weight off. I'm not like some of the posters who have done weight watchers and lost a hundred pounds and then gained it back. I would kill myself eating very few calories and going to the gym doing cardio for an hour at a time sometimes twice a day and would only see a pound gone in a month. It was extremely frustrating. I've battled weight my entire life without even trying. Ok that being said, I think a part if me gave up and just embraced food as a friend and gave in. I was one of those who said "but I don't eat very much" well after surgery, I'm seeing how much I really did eat and it makes me ill! I am so thankful for this surgery! For the first time in my life going to the gym and eating healthy is paying off! I've lost 60lbs!! I've never been able to do that on my own! I see and realize now that I'm a total food addict! But i am working on it! Every day! My name is Michelle and I am a food addict!

What great pics. And what a special journey to take together. I have a thin hubby who has never said a negative thing about my weight gain during 46 years together. Having surgery in July. He is so supportive. Has attended all appointments and support group meetings with me. He's the best!

Never did I ever think when I got banded in 2010 I would be getting my band out and revising to the sleeve...Everything went so well. For 2 1/2 years everything was wonderful. I did my homework, I did what was expected of me and dropped about 70 pounds.. Talk about a new me. I still had like 50 pounds to go but I was on a roll and wasn't going to stop. I was on top of the world. Went back to school and found that confident person I once was before becoming obese. Unfortunetally after an unsuccessful fill due to the port twisting, everything went to crap. I had my port fixed and never found my green zone again. I am a 46 year old woman that knows her body and when something is wrong, something is wrong....after numerous attempts ( seven long months of trying to convince my doc something was wrong, like weight gain, starving all the time and horrible pain after my fills) he finally listened and sure enough I had a leak and my port lies right where my pant belt lies. Why would you put a port there in the first place? So not only did I go through physical and emotional pain. I went through a lot of financial pain. All those fills that never worked and the horrible pain I faced. I just never understood why a doctor would let a patient continue to feel this way...and yes, I have gained all my weight back and more. Talk about ashamed and feeling like a failure for the millionth time....The good news is..I fired my doctor and hired a new one (same practice, awkward, but its my body!. He is awesome, kind, very sensitive to your needs, caring and listens to you, Not like the doctors that ask you the question that you just answered to him. One time I had the doctor ask me the same question three times that I had answered. Talk about wanting to get up and walk out...So I have been blessed for a second chance per insurance. They are paying for the band removal and the sleeve. I am scared right now, but I have faith in my doctor and staff. My life will be for the better and I have much support. I have three young boys and wonderful husband supporting me and believing in me. I am not bashing the band, I am bashing the doctor that would not listen to me. He should have never let it get this bad. If I won the lottery, I would help set up a foundation for those that could not afford this surgery. It is life changing and I would want everyone to have that opportunity....obesity is just an awful disease to live with..So my new journey begins MAY 1 and I am so blessed. I think about a year from now how much healthier I will be. Plus I will finish up my schooling and be ready to conquer the world. Best wishes to everyone for whatever choice of surgery you chose...I commend all of you for taking that step. Surely a life long journey.

I know I may be accused of being in denial but I'm not addicted to food. I have always joked that I wish someone would invent people kibbles so I could just munch on a handful of something crunchy and move on. Moreover, anyone who has lived with me will confirm that I rarely overeat. So how the H...LL did I put on so much weight and have so much trouble losing and keeping it off? Unrelenting hunger. I don't eat much at one time but I am famished in an hour or 90 minutes. Headache, nausea inducing hunger. And if I do not have healthy food when that hits, I will eat anything to make it quit. And in this obesegenic world that is a very risky place to be. I did not have this problem until about 15 years ago after my daughter was born and I went into gestational diabetes for the second time. I have been told I have "borderline" hypoglycemia but I never bothered with testing as it is time-consuming, expensive, not covered by insurance, and inconclusive. One way I kept weight gain under control was lots of physical activity. But bad feet run in my family and my activities gradually became more and more limited until I needed foot surgery and the forced inactivity really blew my weight up. As my BMI approached 40, I decided screw it, I don't want to fight this battle anymore and with the blessing of my PCP, podiatrist, and Gyn, started looking at surgical solutions. So you could say that for me, the surgery was truly a metabolic surgical fix. And I am already amazed at the difference. I feel so great it's almost unreal for me. So that's how it feels from the standpoint of someone who is not a food addict. It does happen.

So do you guys know someone with a completely healthy relationship with food and what does it look like? By this I mean they rarely over eat, they eat healthy, they don't snack when they are bored or sad and they can say no to their favorite foods? Are alllll skinny people not addicted to food and we are the only ones? I doubt that. I do think some people have more will power, better genetics or exercise way more so they balance out. My activity level has contributed to my weight gain along with my need to like big quantities of food I enjoy.

I've had the same primary care physician for 20+ years (rare in this day and age). I have an uncle who is a world renowned geneticist whose specialty is diabetes and obesity. I've managed to get the two of them in the same room on several occasions and the discussion and debate on this very issue is always evolving and ongoing. One of the things my PCP realized that kind of swayed him away from the "it's all diet and exercise" opinion was a lunch he had with one of the trainers for the Seattle Seahawks. As he pointed out there are 300+ pound NFL linemen that spend 5 to 8 hours a day in the gym 300 days a year. They eat relatively healthy and far less calories than the average Olympic swimmer. Yet they remain technically, morbidly obese. The diet and exercise argument wouldn't put them that large if entirely true. Yes some people have a very unhealthy relationship with food, it's one of many causes, but not the only cause. I think the reality is more of a blended issue. Many people fall into the category of not always eating the best, not always exercising optimally and having genetic issues and or a metabolism that is seriously dysfunctional. No one cause and no one solution outside more drastic measures like surgery. I was one of those people that didn't battle weight most of my life. I graduated high school at 145lbs at 6'1". I was teased for being too skinny. I graduated high school and started going to the gym daily while taking weight gain shakes. I was working as a grocery store meat cutter which was a very, very physically intensive job throwing around 200lb boxes of meat all day. We worked in shirt sleeves in a 35 degree room. I think that cold temperature and the calories we needed to stay warm is what messed me up. But it didn't help that I got myself from 145lbs to 250lbs in 2 years. It was all muscle and I was built like a professional gym rat. But 6 days a week in those work conditions played a role. Went to back to school, got a degree in technology and a desk job, wife and kids and went to the gym once a week instead of twice a day. Weight crept up, muscle disappeared and a few years later found myself getting sleeved and turning this around. But then I look at my wife. 5'10" 135 lbs, size 6. She has out eaten me every single day we've been married (20+ years) and is within 5lbs of the size she was when we got married. Never exercises ever, eats crap, candy etc. If it were all diet and exercise she'd be 500lbs.

Hello Stephanie, Welcome! I'm 45 and very excited for you. Take advantage of the best time for losing the weight, the first year. I lost 70 pounds during that time. Unfortunately, I had some medical issues (not band related) and have gained back 35. I'm now back on track and following all the rules again. The post above me, by Tom from Toronto, was great, he basically said it all and gave some great advice. I wish you the best of luck with surgery, it was the easiest surgery I've had to tell you the truth. My only complaint was the gas pains 1-2 days following surgery. I can eat anything, though I did have a slight problem with turkey last Sunday because I tried white meat. I can only eat the dark or I get stuck. Other than that, it's all in moderation. My weight gain occurred when the band was completely unfilled due to the medical issue. It's now refilled and I'm feeling restriction and confident I'll lose the weight again, fast! Well, best of luck as you begin this exciting journey!

I have had weight gain for a few days then it suddenly drops

In the loss phase I ate no more than 900 calories a day. In maintenance I aimed for 1,100-1,300 a day. While pregnant, I aimed for 1,400-1,600 calories a day. I'll be honest, there were times when that was a real challenge due to either restriction or morning sickness. And there were times when the hormones were flooding my body and I felt like I could eat all day long. But overall, that's the window I tried to stick with throughout. I gained 32 pounds, a perfectly normal weight gain that actually worried my OB. This is the same OB that saw me during my twin pregnancy and the fact that I gained so little this time had them worried. However, my daughter was born at a normal weight (for our family) - right in between the weights of my previous children at 6 pounds, 7 ounces. She was born perfectly healthy, at 39 weeks, 3 days so there were no problems with her size or health due to my surgery or my diet. A huge thing to consider is Vitamin supplements, though. I had very real issues with both lactose intolerance (it reared it's ugly head again with my pregnancy) and morning sickness every time I consumed meat. I had to find ways to make up the difference, and I turned to Protein shakes for a while. I also took a number of Vitamins to help ensure the baby was getting enough of what she needed, too. By one week postpartum I had already lost more than half the weight, so try to shelve any concerns about a normal pregnancy gain and focus on the baby. Good luck, and wishes for a healthy pregnancy! ~Cheri

Thanks guys, so helpful... Not worried about slight weight gain from Water retention. I am going to try out the AST micronized creatine for 30 days and see what impact it has on my lifting. I have already noticed catalyst making a huge difference in speed, weight and reps in my cross fit sessions. Almost 2 x improvement for my WOD from 1 session to the next where I added catalyst in between. My goal is to transform into a good athletic build in 6 weeks. I am already noticing improvements from waist up. My PT says it can be done.

Suzie, I'm sorry to hear about your job. That's lousy news. Hopefully, though, you can enjoy the extra time off and find a new one you like even better as soon as you're ready. Lela, I'm glad to hear you're doing well. Keep up the good work. Anna, you can always start again. We're living proof of that. I think a visit to your doctor is a good place to start. It sucks to have to go in and confess that you haven't been doing well, but I promise that the doctor has heard it before. By going in and having a consultation, you can make sure your band is still properly placed, verify how much fill you have, and either get some added or taken away. If you're getting stuck on scrambled eggs , you might actually have been a little bit too tight, which can actually cause weight gain. Once you're ready to start again, you just need to go back to the beginning and follow all the rules. ALL of them, ALL the time. Measure and weigh your portions, keep track of your calories, take tiny bits, and chew chew chew until your jaw is about to fall off! You can do it, you just have too want it enough to work for it. I'm still going crazy with allergies, which is helping neither my work nor my eating. I'm not doing badly, but it's harder at the moment. I think that because I spent so long using food to soothe myself, I'm still having trouble not doing that when I'm not feeling well. But I'll get through this, just like everything else. Hope everyone 's having a good day.

Hello I wanted to respond to you mostly to validate what you are saying. I have worked for over 20 years with juveniles with mental health issues. I have seen first hand the weight gain with the psych meds. I really commend you for staying on your meds to deal with your bi polar. I know this must be very difficult for a young lady such as yourself. I think if your doctor believes it will be ok then why not? I would just make sure your meds come in liquid form or can be dissolved. I know many of those meds are very large and time released. Great job on your journey to wellness.

Thanks. And it's not like i have to stay with this doctor. If he see's weight gain, it he is annoyed. I told him the lap-band is not the magic cure all to weight loss. Thanks again.

I have been using Nuva Ring for 7 years. I didn't notice any weight gain when I started and over the years I don't think it's contributed much to my weight gain, mostly that's been caused by eating too much. You're most likely going to have to try a few different kinds to see what works best for you, we all have a different reaction. This works best for me since I can't seem to remember to take a pill everyday. I also tried the patch before the ring but it was always ripping off the top layer of skin every month when I changed it out. Another benefit of the ring is very minimal bleeding, sometimes I don't even get my period before I start the next ring.

Is anyone on NuvaRing or has used it? My PCP prescribed it and knows i have The sleeve. She said NuvaRing does not cause weight gain but im still worried about gaining. Anybody has experince with this BC?

Pouch Rules for DummiesINTRODUCTION: 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 � 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 � 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 � 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 � hours to 2 hours after each meal. 5. After 1 � 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 � 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 � 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 � of the meal still remained in the pouch after 1 � 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: � of your meal to be low fat protein, � of your meal low starch vegetables and � 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 � 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 a 40 year old former college athlete. Prior to 2010, I was 6ft 3 1/2 inches weighing approximately 315...which was 85lbs heavier than my college playing weigh 20 years ago. Nonetheless I was pretty active and never really had any issues maintaining or losing weight whenever necessary. In 2009, I was starting to experience problems sleeping (night sweats, light sleeping), fatigue, and weight loss. After seeing my primary care doctor, I was diagnosed with Grave's Disease which is basically an overactive thyroid. I was taking medicine for this until July of 2010 when my life would change forever. In July 2010, I had an episode called a "thyroid storm" where my thyroid went all out wack causing me to be hospitalized in the ICU for 2 weeks. This was actually a life threating dilemma as my blood pressure and heart rate shot through the roof and I was dealing with severe dehydration, diarrhea, and a few other things. Needless to say, I made it out of the woods and recovered but in October of 2010, I had a total thyroidectomy (removed my thyroid). One of the main things that your thyroid controls is your metabolism and prior to having it removed the endocrinologist told me that some patients experience weight gain but as long they get the correct dosage of thyroid replacement meds and as long as I workout regularly, I should be fine. Being that I was a former college athlete and I was still semi active, working out was not an issue for me. Little did I know what was in store for me... Shortly after recovering from my thyroidectomy, I was down to 302lbs and remembering what the doctors had told me, I began working out 4 times a week for a least an hour each time (cardio). I was also advised by my endocrinologist that I should maintain a 2500 calorie a day diet that I was pretty strict about rarely going over 2500 calories...maybe 3000 calories on a few ocassions. Despite my efforts I was noticing that I was beginning to gain weight...slowly. I would do quarterly visits with my endocrinologist and they would up my doses of levothyroxine (thyroid replacement) and she would tell me to "push away from the table more". I told her that I was following her advise to no avail. After a few more visits (6 month's time). I was still gaining weight at an alarming rate. I was starting to experience fatigue and several other issues associate with weight gain. Finally the endocrinologist upped my dosage to 200 mcg (from 100 mcg). At this point I was extremely frustrated with this endo and decided to get another doctor. The second doctor that I started seeing was no better than the first, she offered no solution to sudden weight gain despite working out and despite monitoring my diet. When I explained to her that I was considering weight loss surgery as a last resort she said well maybe you should...that was the last time that I saw her. In January of 2012, I made the decision to have weight loss surgery. At this point, I've gained 100 + pounds and it wasn't until recently that the weight gain had really stopped. I am now 425lbs...the heaviest I've ever been. I now have issues getting around without being tired or my back hurting, my desire to workout is pretty non existant, sex life is bad, sleeping is an issue, and the list goes on. I went through Dr. Fullom's 6 month program and was approved for surgery. My first surgery was scheduled for October of 2012 but was cancelled due to some blood work that came back. Since then my surgery has been cancelled 3 times for the same reason...they thought that my blood was too thin. Since then I've seen the hemotologist and I now have my clearance letter from him and I'm scheduled to have my surgery on April 11, 2013. I am extremely excited about this new chapter in my life and I'm ready to go "All In". I am somewhat nervous because of the whole thyroidectomy/slow metabolism issue.

I had surgery on the 2nd of April I was just wanting to know if the scale says I gained 2.4 lbs is that normal

i'm in a similiar boat, where i only have half my restriction right now. i'm a 10cc band i've got roughly 3cc. i have some restriction (though not much), but i'm able to eat whatever i want without getting stuck typically. it's an odd feeling because prior to getting pregnant bread was out, steak was out, etc, not that being unable to eat bread was a bad thing. i don't know of doctor's who actually put fills in during pregnancy though. i know someone else was talking about it above, but my doc personally wouldn't. he wanted to take it all out but i fought him on it. i may end up with more being taken out before the end but i'll cross the bridge when i get to it. the weight gain is hard to watch, at least it's been hard for me to watch. i was within 100 pounds of my goal weight (i hadn't been this small in over a decade...it was quite the feat) and to watch it start creeping back the other direction at the pace it was was very very difficult. it did eventually level off though. instead of watching the weight jumps between doctor visits, i'm back to 1 or 2 pounds (thank goodness). be mindful of what you're eating. a food journal really helped during that time when i was visiting my nutritionist. we were able to look at what i was eating and determine there really wasn't much to change and that my portions were fine. my body was adjusting to pregnancy, though if i don't watch what i eat like a hawk, i can eat too much food in one sitting =/ hang in there.

It is not a good idea to "snack all day". That is considered grazing and is one of the ways around this surgery to cause weight gain. At the stage you are now at, I was eating (and still am) 3 meals a day and 1 snack. Around 1000 calories a day. You need to write down every single thing you are putting in your mouth and figure out how many calories you are getting a day and if you are getting in the correct amount of protein. Exercise is also very important and can knock your metabolism into high gear. You might want to think about talking with your nutritionist to get her advice as well. Good luck and let us know how you are doing. Lina12 - I know it is frustrating but I would give the same advice to you as to Canadianchick. Sometimes just because we have the surgery we think it should fall off, (I'm including myself in that ) but it still takes work and good habits, tracking, and exercising. Praying for you!