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I'm a whiskey guy. I started to drink occasionally at 6 weeks, even though my plan called for one year of no alcohol. This is not advice. I'm just posting what I did. For me, I needed as much normal as I could have, without jeopardizing my progress. I have been very successful so far.

Here is the medical policy. The link was open one day so I copied it Does anyone understand D.....preprinted, check off forms are not acceptable. Does that mean my WW Book for the weekly weigh ins? E-Mail Us Medical_Policy@Horizon-bcbsnj.com Horizon BCBSNJ Uniform Medical Policy Manual Section: Surgery Policy Number: 022 Effective Date: 06/10/2008 Original Policy Date: 06/22/2001 Last Review Date: 11/25/2008 Date Published to Web: 08/11/2008 Subject: Surgery for Morbid Obesity Description: _______________________________________________________________________________________ IMPORTANT NOTE: The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member. Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment. __________________________________________________________________________________________________________________________ As indicated by its name, morbid obesity is defined as an increase in weight over optimal weight, which results in significant complications and a shortened life span. For example, morbid obesity has a significant impact on cardiac risk factors, incidence of diabetes, obstructive sleep apnea, and various types of cancers (for men: colon, rectum, and prostate; for women: breast, uterus, and ovaries). The first treatment of morbid obesity is obviously dietary and life style changes. Although this strategy may be effective in some patients, frequently the weight loss is not durable with only 5%-10% of patients maintaining the weight loss for more than a few years. When conservative measures fail, some patients may consider surgical approaches. A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those patients with a body mass index (BMI) of greater than 40 kg/m2, or greater than 35 kg/m2 in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes. Super obesity has been described as a BMI greater than 50 kg/m2. Surgery for morbid obesity, termed bariatric surgery, falls into three general categories; (1) gastric restrictive procedures that create a small gastric pouch, resulting in weight loss by producing early satiety and thus decreasing dietary intake; (2) malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the intestinal tract; and (3) combination of both restrictive and malabsorptive components. There are multiple variants of malabsorptive procedures, which differ in the lengths of the alimentary limb, the biliopancreatic limb, and the common limb, where the alimentary and biliopancreatic limbs are anastomosed. The degree of malabsorption is related to the length of the alimentary and common limbs. For example, a shorter alimentary limb (i.e., the greater the amount of intestine that is excluded from the nutrient flow) will be associated with malabsorption of a variety of nutrients, while a short common limb (i.e., the biliopancreatic juices are allowed to mix with nutrients for only a short segment) will primarily limit absorption of fat. The following summarizes the different bariatric procedures. 1. Vertical Banded Gastroplasty The stomach is segmented along its vertical axis. To create a durable reinforced and rate-limiting stoma at the distal end of the pouch, a plug of stomach is removed and a propylene collar is placed through this hole and then stapled to itself. Because the normal flow of food is preserved, metabolic complications are rare. Complications include esophageal reflux, dilation or obstruction of the stoma, with the latter two requiring reoperation. Dilation of the stoma is a common reason for weight regain. Vertical-banded gastroplasty may be performed using an open or laparoscopic approach. 2. Adjustable Gastric Banding This is the most commonly performed restrictive procedure. Adjustable gastric banding involves placing a gastric band around the exterior of the stomach. The band is attached to a reservoir that is implanted subcutaneously in the rectus sheath. Injecting the reservoir with saline will alter the diameter of the gastric band; therefore the rate limiting stoma in the stomach can be progressively narrowed to induce greater weight loss, or expanded if complications develop. Because the stomach is not entered, the surgery and any revisions, if necessary, are relatively simple. Complications include slippage of the external band or band erosion through the gastric wall. Adjustable gastric banding has been widely used in Europe. Currently, the Lap-Band Adjustable Gastric Banding System made by BioEnterics Corporation is an approved device by the U.S. Food and Drug Administration (FDA) for marketing in the United States. Another FDA-approved device is the REALIZE Adjustable Gastric Band For Morbid Obesity which is manufactured by Ethicon-Endo-Surgery, Inc. [Please refer to specific benefit coverage under the Federal Employees Health Benefits Program (FEHBP).] 3. Gastric Bypass with Short-Limb (150 cm or less) Roux-en-Y Anastomosis The original gastric bypass surgeries were based on the observation that post-gastrectomy patients tended to lose weight. The current procedure involves division of the stomach into a smaller upper (called the pouch) and larger lower sections in association with a Roux-en-Y procedure (i.e., a gastrojejunal and a jejujejunal anastomoses). Thus the flow of food bypasses the duodenum and proximal small bowel. The procedure may also be associated with an unpleasant "dumping syndrome," in which a large osmotic load delivered directly to the jejunum from the stomach produces abdominal pain and/or vomiting. The dumping syndrome may further reduce intake, particularly in "sweets eaters." Operative complications include leakage and marginal ulceration at the anastomotic site. Because the normal flow of food is disrupted, there are more metabolic complications compared to other gastric restrictive procedures, including Iron deficiency anemia, Vitamin B-12 deficiency, and hypocalcemia, all of which can be corrected by oral supplementation. Another concern is the ability to evaluate the "blind" bypassed portion of the stomach. Gastric bypass may be performed with either an open or laparoscopic technique. 4. Mini-Gastric Bypass Recently, a variant of the gastric bypass, called the mini-gastric bypass, has been popularized. Using a laparoscopic approach, the stomach is segmented, similar to a traditional gastric bypass, but instead of creating a Roux-en-Y anastomosis, the jejunum is anastomosed directly to the stomach, similar to a Billroth II procedure. This unique aspect of this procedure is not based on its laparoscopic approach but rather the type of anastomosis used. 5. Sleeve Gastrectomy A sleeve gastrectomy has been proposed to be an alternative approach that can be performed on its own, or in combination with malabsorptive procedures (most commonly biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of HIS to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the dumping syndrome (overly rapid transport of food through the stomach into the intestines) that is seen with distal gastrectomy. This procedure is relatively simple to perform, and can be done by the open or laparoscopic technique. Some surgeons have proposed this procedure as the first in a 2-stage procedure for very high-risk patients including those who are “super” obese (BMI>50). Weight loss following sleeve gastrectomy may improve a patient’s overall medical status, and thus, reduce the risk of a subsequent more extensive malabsorptive procedure, such as biliopancreatic diversion. 6. Endoscopic Gastric Reduction or Transoral Endoluminal Gastroplasty The EndoGastric Solutions StomaphyX endoluminal fastener and delivery system was approved by the FDA on March 3, 2007 through the 510(k) marketing clearance as substantially equivalent to its predicate device, the Bard EndoCinch Suturing System. It is specifically indicated for use in endoluminal trans-oral tissue approximation and ligation of the GI Tract. The device uses vacuum to invaginate tissue through a port into a chamber and fasten it using H shaped polypropylene fasteners. It has been investigated as a possible minimally-invasive endoscopic procedure for patients who gain weight after bariatric surgery (e.g., due to a dilated gastrojejunal anastomoses after a Roux-en-Y procedure). 7. Biliopancreatic Bypass Procedure (also known as the Scopinaro procedure) The biliopancreatic bypass (BPB) procedure, developed and used extensively in Italy, was designed to address some of the drawbacks of the original intestinal bypass procedures that have been abandoned due to unacceptable metabolic complications. Many of the complications were thought to be related to bacterial overgrowth and toxin production in the blind, bypassed segment. In contrast, BPB consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure. The procedure consists of the following components. A. A distal gastrectomy functions to induce a temporary early satiety and/or the dumping syndrome in the early postoperative period, both of which limit food intake. B. A 200-cm long "alimentary tract" consists of 200 cm of ileum connecting the stomach to a common distal segment. C. A 300- to 400-cm "biliary tract," which connects the duodenum, jejunum, and remaining ileum to the common distal segment. D. A 50- to 100-cm "common tract," where food from the alimentary tract mixes with biliopancreatic juices from the biliary tract. Food digestion and absorption, particularly of fats and starches, are therefore limited to this small segment of bowel, i.e., creating a selective malabsorption. The length of the common segment will influence the degree of malabsorption. E. Because of the high incidence of cholelithiasis associated with the procedure, patients typically undergo an associated cholecystectomy. There are many potential metabolic complications related to biliopancreatic bypass, including most prominently iron deficiency anemia, Protein malnutrition, hypocalcemia, and bone demineralization. Protein malnutrition may require treatment with total parenteral nutrition. In addition, there have been several case reports of liver failure resulting in death or liver transplant. 8. Biliopancreatic Bypass with Duodenal Switch The duodenal switch procedure is essentially a variant of the biliopancreatic bypass described above. However, instead of performing a distal gastrectomy, a "sleeve" gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum, similar to the above procedure, to create the alimentary segment. Preservation of the pyloric sphincter is designed to be more physiologic. The sleeve gastrectomy decreases the volume of the stomach and also decreases the parietal cell mass, with the intent of decreasing the incidence of ulcers at the duodenoileal anastomosis. However, the basic principle of the procedure is similar to that of the biliopancreatic bypass; i.e., producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment. 9. Long Limb Gastric Bypass (i.e., >150 cm) Recently, variations of gastric bypass procedures have been described, consisting primarily of long limb Roux-en-Y procedures. For example, the stomach may be divided with a long segment of the jejunum (instead of ileum) anastomosed to the proximal gastric stump, creating the alimentary limb. The remaining pancreaticobiliary limb, consisting of stomach remnant, duodenum, and length of proximal jejunum is then anastomosed to the ileum, creating a common limb of variable length in which the ingested food mixes with the pancreaticobiliary juices. The stomach may be bypassed in a variety of ways, i.e., either by resection/division or stapling along the horizontal or vertical axis. Unlike the traditional gastric bypass, which is essentially a gastric restrictive procedure, these very long limb Roux-en-Y gastric bypasses combine gastric restriction with some degree of malabsorption, depending on the location of the anastomoses. Policy: [iNFORMATIONAL NOTE: When significant weight loss is achieved such as is typically the case after bariatric procedures for morbid obesity, it is not uncommon for the patients to be left with a significant amount of redundant skin (e.g., in the abdomen, breasts, thighs and arms). Procedures to remove the redundant skin are typically considered to be cosmetic. The eligibility of procedures and/or services related to, or resulting from, a prior surgical procedure for morbid obesity is determined by the patient’s specific contract benefits. When the patient’s contract does not specifically exclude such procedures and/or services, they are subject to review for medical necessity. Medical policies pertaining to the covered person’s condition should be consulted, as applicable (e.g., Policy #025 on Abdominoplasty, Policy #028 on Reduction Mammaplasty, and Policy #001 on Cosmetic Procedures including excision of excessive skin and subcutaneous tissue and suction assisted lipectomy, under the Surgery Section). The approval of a bariatric procedure for medical necessity should not be interpreted to be an automatic approval for procedures that address the sequelae of significant weight loss, nor should it create the expectation that such procedures will be approved.] I. Contract exclusions and/or limitations for surgery for morbid obesity (bariatric surgery) will determine the available benefit. [iNFORMATIONAL NOTE: Some contracts specifically exclude surgery for morbid obesity (bariatric surgery). Please refer to the group’s or individual member’s contract benefit language to determine benefit availability.] II. If it is NOT specifically excluded by the member's contract, surgery for morbid obesity (bariatric surgery) is considered medically necessary when all of the following lettered criteria are met: A. The surgical procedure is one of the following types: Laparoscopic adjustable gastric banding; [iNFORMATIONAL NOTE: Please refer to specific benefit coverage for adjustable gastric banding under the Federal Employees Health Benefits Program (FEHBP).] Vertical-banded gastroplasty; Gastric bypass with short-limb (i.e., 150 cm or less) or long-limb (i.e., greater than 150 cm) Roux-en-Y anastomosis; Biliopancreatic diversion and duodenal switch. [iNFORMATIONAL NOTE: According to the Consensus Conference Panel Statement presented at the Georgetown University Conference Center, Washington, DC, May 2004, "Standard of care for bariatric surgery includes use of laparoscopic and open techniques.] B. The member is at least 18 years of age and/or has reached full skeletal growth. Bariatric surgery is considered NOT medically necessary for members under 18 years of age unless the member has already achieved full skeletal growth and has a life threatening co-morbidity (i.e., pseudotumor cerebri, severe sleep apnea, uncontrollable hypertension, incapacitating musculoskeletal disease, etc.). [iNFORMATIONAL NOTE: According to published medical literature, bone age can be objectively assessed with radiographs of the hand and wrist.] C. The member has morbid obesity. Morbid obesity is defined as either: 1. A body mass index (BMI) greater than 40 kg/m2; or 2. A BMI between 35 kg/m2 and 40 kg/m2 with one or more of the following life-threatening, obesity-related co-morbidities which is (are) being treated or managed, and is (are) generally expected to be improved, curtailed, or reversed by obesity surgical management: coronary artery disease obesity-related cardiomyopathy congestive heart failure obstructive sleep apnea Pickwickian syndrome insulin resistance or frank diabetes mellitus clinically significant asthma chronic venous insufficiency of the lower extremities gastroesophageal reflux disease (GERD) pain and limitation of motion in any weight-bearing joint or the spine hypertension pseudotumor cerebri polycystic ovarian syndrome metabolic syndrome hyperlipidemia (hypercholesterolemia and/or hypertriglyceridemia) non-alcoholic fatty liver (NASH) osteoarthritis depression. [iNFORMATIONAL NOTE: BMI is calculated by dividing a patient’s weight (in kilograms) by height (in meters) squared. To convert pounds to kilograms, multiply pounds by 0.45 To convert inches to meters, multiply inches by .0254] D. Within the 12 months prior to the time of surgery, the member must meet all of the following requirements: 1. Documentation of successful completion of at least 6 consecutive months of supervised conservative weight loss program, diet programs/plans (e.g., Weight Watchers, Jenny Craig), or the Horizon Obesity Disease Management Program. Successful completion means formal documentation or photocopies/print-outs of progress notes of at least monthly follow-up by the supervising physician, other health care provider, or program coordinator including the patient’s weight and progress relative to the goals set at the start of the program. (NOTE: Pre-printed check-off forms and summary letters are NOT acceptable documentation for this requirement.) [iNFORMATIONAL NOTE: Programs supervised by a registered dietitian may not be a covered service under a member's contract.] 2. Documentation of participation in an organized multidisciplinary surgical preparatory regimen in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions. The regimen should provide guidance on diet, physical activity, and behavioral and social support prior to and after the surgery. Documentation should include physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen. 3.Documentation of pre-operative psychological evaluation provided by a licensed mental health care professional familiar with the implications of weight reduction surgery. (Please note that psychological testing is NOT included in this requirement.) [iNFORMATIONAL NOTE: It should be noted that all bariatric surgeries require a high degree of patient compliance. For gastric restrictive procedures the weight loss is primarily due to reduced caloric intake, and thus the patient must be committed to eating small meals, reinforced by early satiety. For example, gastric restrictive surgery will not be successful in patients who consume high volumes of calorie rich liquids. In addition, patients must adhere to a balanced diet, including proper micronutrient supplementation, to avoid metabolic complications. (Micronutrients are defined as Vitamins, minerals, and trace elements.) The high potential for metabolic complications requires life-long follow-up. Therefore, patient selection is a critical process, often requiring psychiatric evaluation and a multidisciplinary team approach.] III. The following procedures are considered investigational: Mini-gastric bypass Sleeve gastrectomy (either as a sole procedure or as one step in a staged procedure); Endoscopic Gastric Reduction (also known as transoral endoluminal gastroplasty). [iNFORMATIONAL NOTE: There is limited data published in the medical literature to evaluate outcomes of sleeve gastrectomy as a stand-alone procedure and to compare its efficacy with other procedures. Furthermore, the published data on outcomes following completion of both stages of a 2-stage operation are limited to case reports and case series with very small number of patients. According to the ECRI Health Technology Assessment Information Service Custom Hotline Response on Laparoscopic Sleeve Gastrectomy for Morbid Obesity (last updated 01/22/2007), “None of the studies reported weight loss at three years or more after the operation, which we consider the most important outcome measure for these studies to report. Earlier follow-up periods may not provide data indicative of the eventual results of the surgery and do not provide sufficient time to assess the possible long-term complications of this surgery”.] IV. Repeat bariatric surgery or any subsequent modification should be handled on an individual case basis and reviewed by the medical director. Supporting documentation should at least include a clear explanation of the clinical circumstances as to why the procedure failed, the member’s BMI, and the results of any diagnostic tests or studies performed. Since members are expected to be compliant with the postoperative requirements, members who have failed bariatric surgery because of noncompliance and wish to be considered for revision surgery must be actively reintegrated into an established multidisciplinary bariatric program. These patients must demonstrate compliance to the bariatric surgeon through enrollment in a multidisciplinary bariatric program including psychological intervention nutritional counseling, and support group attendance. A distinction between clinical failure and technical failure must be established. A. A clinical failure is defined as weight regain, inspite of an intact, functional operation. In these instances, reintegration into a multidisciplinary bariatric program and psychological re-evaluation are required. If the member is able to demonstrate the probability of complying with the postoperative requirements (e.g., diet , physical activity, etc.), repeat bariatric surgery or any subsequent modification of the original bariatric surgery may be considered medically necessary. Otherwise, any further surgical intervention is considered not medically necessary. B. A technical failure is defined as a breakdown of the operation itself (i.e., staple line disruption, fistula formation, dilatation of the pouch, marginal ulceration, band slippage, anastomotic dilatation, etc.). In these instances, psychological re-assessment of the patient is not mandatory. [iNFORMATIONAL NOTE: Band adjustment is a regular part of follow-up for adjustable gastric banding. All adjustments done within 90 days from band implantation are considered part of the global surgical service. Any subsequent adjustment beyond this period is eligible for separate reimbursement if the band implantation was deemed medically necessary.] ________________________________________________________________________________________ Horizon BCBSNJ Medical Policy Development Process: This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations. ___________________________________________________________________________________________________________________________ Index: Surgery for Morbid Obesity Adjustable Gastric Banding Banding, Gastric Bariatric Surgery Biliopancreatic Bypass Procedure Biliopancreatic Diversion Bypass, Biliopancreatic Bypass, Gastric Duodenal Switch, Biliopancreatic Bypass with Endoluminal Gastroplasty, Transoral Endoscopic Gastric Reduction Gastrectomy, Sleeve Gastric Banding Gastric Bypass Gastric Reduction, Endoscopic Gastric Restrictive Surgery Gastroplasty Lap-Band Adjustable Gastric Banding System Laparoscopic Adjustable Gastric Banding Laparoscopic Gastric Bypass Laparoscopic Mini-Gastric Bypass Laparoscopic Sleeve Gastrectomy Long Limb Gastric Bypass Malabsorptive Procedures Morbid Obesity, Surgery for Mini-Gastric Bypass Obesity, Morbid, Surgery for Scopinaro Procedure Sleeve Gastrectomy Transoral Endoluminal Gastroplasty Vertical Banded Procedures References: 1. Blue Cross and Blue Shield Association. Medical Policy Reference Manual: Surgery for Morbid Obesity. 5:2006: Policy #7.01.47 (and its associated references). 2. ECRI. Health Technology Trends. FDA clears stomach band for obesity. Vol.13 No.7. July 2001. 3. Weiner R, Bockhorn H, Rosenthal R, et al. A prospective randomized trial of different laparoscopic gastric banding techniques for morbid obesity. Surg Endosc. 2001 Jan;15(1):63-68. 4. Cadiere G, Himpens J, Vertruyen M, et al. Laparoscopic Gastroplasty (Adjustable Gastric Banding). Semin Laparosc Surg. 2000 Mar;7(1):55-65. 5. Fielding GA, Rhodes M, Nathanson LK. Laparoscopic gastric banding for morbid obesity. Surgical outcomes in 335 cases. Surg Endosc. 1999 Jun;13(6):550-554. 6. Dargent J. Laparoscopic Adjustable Gastric Banding: Lessons from the First 500 Patients in a Single Institution. Obes Surg. 1999 Oct;9(5):446-452. 7. Belachew M, Legrand M, Vincent V, et al. Laparoscopic Adjustable Gastric Banding. World J Surg. 1998 Sep;22:955-963. 8. Improvement of physical functioning of morbidly obese patients who have undergone a Lap-Band operation: one-year study. Obes Surg. 1999 Aug;9(4):399-402. 9. Furbetta F, Gambinotti G, Robortella EM. 28-month experience with the lap-band technique; results and critical points of the method. Obes Surg. 1999 Feb;9(1):56-58. 10. DeMaria EJ, Sugerman HJ, Meador JG, et al. High Failure Rate After Laparoscopic Adjustable Silicone Gastric Banding for Treatment of Morbid Obesity. Annals of Surgery. 2001 Jun;233(6):809-818. 11. National Institutes of Health. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Int Med 1991;115:956-61. 12. MacLean LD, Rhode BM, Forse RA. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990;107:20-27. 13. Willbanks OL. Long term results of silicone elastomer ring vertical gastroplasty for the treatment of morbid obesity. Surgery 1987;101:606-10. 14. Brolin RE. Results of obesity surgery. Gastroenterol Clin North Am 1987;16:317-35. 15. Kolanowski J. Gastroplasty for morbid obesity: The internist’s view. Int J Obesity 1995;19(suppl):S61-S65. 16. Melissas J, Christodoulakis M, Spyridakis et al. Disorders with clinically severe obesity: Significant improvement after surgical weight loss. Sout Med J 1998;91:1143-48. 17. Griffen WO, Printen KJ eds. Gastric bypass in surgical management of surgical obesity. New York, NY. Marcel Dekker, Inc, 1987:27-45. 18. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann Surg 1995;222:339-52. 19. Flickinger EG, Sinar DR, Swanson M. Gastric bypass. Gastroenterol Clin North Am 1987;16:283-92. 20. Cowan GSM, Buffington CK. Significant changes in blood pressure, glucose and lipids with gastric bypass surgery. World J Surg 1998;22:987-92. 21. Sugarman HJ, Starkey JV, Birkenhauer R. A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweet eaters. Ann Surg 1987;205:618-24. 22. Fobi MA, Fleming AW. Vertical banded gastroplasty vs. gastric bypass in the treatment of obesity. J Natl Med Assoc 1988;78:1091-98. 23. Doherty C, Maher JW, Heitshusen DS. Prospective investigation of complications, reoperations and sustained weight loss with an adjustable gastric banding device for treatment of morbid obesity. J Gastrointest Surg 1998;2:102-08. 24. Doherty C, Maher JW, Heitshusen DS. An interval report on prospective investigations of adjustable silicone gastric banding devices for the treatment of severe obesity. Eur J Gastroenterol Hepatol 1999;11:115-19. 25. Miller K, Hell E. Laparoscopic adjustable gastric banding: a prospective 4 year follow up study. Obesity Surg 1999;9:183-87. 26. Suter M, Giusti V, Heraief E, et al. Eary results of laparoscopic gastric banding compared with open vertical banded gastroplasty. Obesity Surg 1999;9:374-80. 27. Scopinaro N, Gianetta E, Adami GF. Biliopancreatic diversion for treatment of morbid obesity: Experience in 180 consecutive cases. Obesity Surg 1999;9:161-65. 28. Nanni G, Balduzzi GF, Capuluongo R, et al. Biliopancreatic diversion: Clinical experience. Obesity Surg 1997;7:26-29. 29. Murr MM, Balsiger BM, Kennedy FP, et al. Malabsorptive procedures for severe obesity; Comparison of pancreaticobiliary bypass and very long limb Roux-en-Y gastric bypass. J Gastrointest Surg 1999;3:607-12. 30. Grimm IS, Schindler W, Halusza O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1992;87:775-79. 31. Langdon DE, Leffingwell T, Rank D. Hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1993;88:321. 32. Sugarman HJ, Kellum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg 1997;1:517-25. 33. Marceau P, Hould FD, Simrad S, et al. Biliopancreatic diversion with duodenal switch. Word J Surg 1998;22:947-54. 34. Hess DS, Hess DW. Biliopancreatic bypass with a duodenal switch. Obes Surg 1998;8:267. 35. Baltasar A, Del Rio J, Excriva C, et al. Preliminary results of the duodenal switch. Obesity Surg 1997;7:500-04. 36. Mason EE, Doherty C, Maher JW, et al. Super obesity and gastric reduction procedures. Gastroenterol Clin North Am 1997;16:495-502. 37. Brolin RE. Results of obesity surgery. Gastroenterol Clin North Am 1987;16:317-336. 38. Angrisani L, Furbetta F, Doldi SB et al. Lap Band adjustable gastric banding system. Surg Endosc 2002 Dec 4;[epub ahead of print]. 39. Vertruyen M. Experience with Lap-band System up to 7 years. Obes Surg 2002 Aug;12(4):569-72. 40. Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002 Aug;12(4):564-8. 41. Rubensteing RB. Laparoscopic adjustable gastric banding at a U.S. center with up to 3-year follow-up. Obes Surg

Whoa there Green. Calm down. I know that you're very worried and right now you're very uncomfortable and anything you eat causes you grief. But trust me, it can get better and if you play your cards right, it will! The very first thing you should to TONIGHT is to elevate the head of your bed. You will probably be told to take some kind of medication that will calm down the cough and reflux (making your throat burn) and the pain in your chest. That will take some time to get resolved because yours is in such an inflamed and angry state. I have had a hiatal hernia for 20 years. At least I did until I had the LB surgery. When my doc did the surgery, he repaired my hiatus hernia. Many of the people who post at LBT, have one too or did until they had theirs repaired. It is usually diagnosed with an upper G.I. series of x-rays. I didn't consider the surgery sooner because the surgery for many years was not all that successful and many times made the situation worse. That was before doctors became so proficient at laparoscopic surgery. My LB doctor was chosen by me because for years he has been a leader in the laparoscopic surgery for correction of a hiatal hernia. He has taught many other doctors how to do the procedure and has done thousands himself over the years. He decided to start doing the LB surgery because with his exposure to so many overweight people who he treated for their hiatal hernias; he knew how difficult it was for them to lose weight and keep it off. He felt that the Lap Band was the first thing with a relatively low risk and high success rating, and since he'd been working in the "neighborhood" for so many years, with a laparoscope, it was a natural transition. You have to understand though that I lived for over 20 years with my hiatus hernia. Gaviscon was the drug of choice back then, but I just couldn't gag the stuff down. Nowadays, they have Prilosec and Prevacid which are much more effective. The one that worked the best for me was Prevacid. When I took it and elevated the head of our bed, it was almost like I didn't have a hiatal hernia anymore. Sweet relief!!! So don't worry too much. It is definitely treatable. Personally, I wouldn't recommend a repair since you already have the LB, but of course I'm not a doctor, much less YOUR doctor. If you can get a medication to work for you, long enough for it to calm the area down, and you stay really aware of what you eat and drink, and smoke... you can whip this into submission. Now for the not fun part. You really do have to quit drinking coffee or tea for a while. You have to quit drinking Scotch (or other alcohol) for a while. You really do have to not eat chocolate. And smoking really aggravates it. You need to stop that too. You just have to baby it until you get the thing under control. Spicy foods are out. You can forget chicken fried steak or barbeque, at least for the time being. Yeah I know, for a while it's going to be a huge, seemingly impossible way to live. But when you have as many problems as you're having, you just have to give it a chance to heal as much as possible and then baby it for a longer period of time. The Prevacid takes about 3 weeks to really kick in, but you'll find yourself not coughing and uncomfortable after a meal. Any other wisdom out there for Green on this topic? Who loves ya, baby?

"When I make the changes and I'm still FAT, what the hell am I suppose to do then?" LOL I'm right there with you! I guess that is the million dollar question isn't it. I see successes with the band. That keeps me going. I think this whole procedure is just screaming for a book to be written about what really happens. As it becomes more popular, someone is going to pull the trigger and make a million bucks. Would I have had this surgery if I had known that I would have to go back to WW to lose weight? No. This was a last chance option for me. I have tried and failed on all of the diets ten times each. I knew that I had a decent diet--I don't eat fast food, I don't eat out much, I don't drink cokes, I don't drink alcohol, I like all fruits and veggies. I just ate WAY too much. In my mind, I thought the band would be perfect for me. My dietician told me that I was the perfect candidate because portion control was my biggest problem. So, what do I do? I can't stay on an 800 cal/day diet with no restriction. It isn't going to happen. The hunger thing is a deal breaker. I went 3 weeks being so hungry that I couldn't sit through church because my stomach was growling so badly. I woke up at 2:00 a.m. STARVING. I was extremely irritable, had a throbbing headache and a bad case of "what have I done to myself?" I realized on my last fill that it is really a crap shot. She told me that they only fill 1 cc at a time. That was the rule. Well, starting at 0 cc's in a 10 cc band, it could take a while at fills every 14 days. She put in 1 cc. I asked "do you think that is going to be enough?" I didn't know. I was seriously asking a question. She said, "Okay, you talked me into it. I will give you another cc." So I doubled the amount of saline my just asking a simple question. I would like to think there is some clinical reason for the slow rate of fills. I have this nagging thought that it is more about insurance and copays. Every time I step foot into that office for a fill, my insurance pays $712, and I pay $30. Wouldn't it make sense to drag it out half a cc at a time if you were the clinic?

I have had gas off and on since surgery and sometimes it is bad and I feel very bloated. I swear by Gas-x I carry it with me everywhere. There are sometimes I may take it several times a day and I can go weeks and never need it. I prefer the strips that are mint or cinnamin that you place under your tongue and I also take Prilocex daily. I tried to stop taking the Prilocex but had to add it back. I also notice if I eat protein bars with sugar alcohols or just protein drinks that sometimes I have more gas. I honestly think it is due to the size of our stomachs and the slower rate that the food passes through but have nothing to back that up. Good luck and I wish I could say the gas went away but I am 1 year out (almost) and it is still there.

I am a 21 year old girl who had the surgery 10/22/14. It is the best decision. I have ever made in my life and I would never ever take it back. So far I am 130 pounds down and I feel amazing. Some things I wish I knew? Well, I knew what would happen physically, there would be pain, less eating, weight loss, loose skin. On my clear liquid diet I was very week I could barely make it up the stairs and I passed out from trying, so we started my full liquids a couple of days earlier. That was the only thing physically that I wasn't expecting g was how week I would be from the liquid diet. What I wasn't prepared for was the mental issues. I wear a size 16 now and when I look in the mirror I still feel like I wear a size 30. It breaks my heart. Your self esteem grows but not as fast as you lose the weight and I wasn't expecting to feel like this. It's hard to see yourself as beautiful. I also struggle with losing my food addiction. And not putting it toward something else like shopping, alcohol, sex. It's been so rough mentally. Just know when you lose the weight it is good to have a good support group and you won't yourself immediatly but you will with time

Here is a short but good article..... http://health.yahoo....mFQ2ySsY.mailto Also check out the link immediately below called testosterone shortage. A testosterone shortage could cost you your life. As if losing muscle mass, bone density, and your sex drive to low T levels wasn't bad enough, new research shows the decline can also increase your risk of prostate cancer, heart disease, and even death. Follow these steps to lift your levels and lengthen your life. 1. Uncover Your Abs As your waist size goes up, your testosterone goes down. In fact, a 4-point increase in your body mass index, about 30 extra pounds on a 5'10" guy, can accelerate your age-related T decline by 10 years. For a diet that'll help keep your gut in check, try the all-new Men's Health e-book, The Six-Pack Secret. You'll learn how to sculpt rock-solid abs in 4 weeks. We believe it's the most effective muscle-up weight loss program ever. 2. Build Your Biceps Finnish researchers recently found that men who lifted weights regularly experienced a 49 percent boost in their free testosterone levels. "As you strengthen your muscles, the amount of testosterone your body produces increases," says David Zava, Ph.D., CEO of ZRT Laboratory. You need to push Iron only twice a week to see the benefit. 3. Fill Up On Fat Trimming lard from your diet can help you stay lean, but eliminating all fat can cause your T levels to plummet. A study published in the International Journal of Sports Medicine reveals that men who consumed the most fat also had the highest T levels. To protect your heart and preserve your T, eat foods high in monounsaturated fats, food such as fish and nuts. A Fat MORE Dangerous than Trans Fat? 4. Push Away From The Bar Happy hour can wreak havoc on your manly hormones. In a recent Dutch study, men who drank moderate amounts of alcohol daily for 3 weeks experienced a 7 percent decrease in their testosterone levels. Limit your drinking to one or two glasses of beer or wine a night to avoid a drop in T. 5. Stop Stress Mental or physical stress can quickly depress your T levels. Stress causes cortisol to surge, which "suppresses the body's ability to make testosterone and utilize it within tissues," says Zava. Cardio can be a great tension tamer, unless you overdo it. Injuries and fatigue are signs that your workout is more likely to lower T than raise it.

I made up my mind that I needed help following my 10 year class reunion and my dad having stents(sp) put in the arteries around his heart. I feel so much better everyday and "stable" is another word that comes to mind. I hit a point about two weeks ago where I realized I was no longer climbing the "weight-loss" mountain...I just feel like I've conquered it. My diet Mon-Fri gives me between 900 and 1200 calories a day and appr. 100g of protein: Breakfast I have 1/2 cup of steel cut oats with a tsp of vallina and 8oz of reduced cal and sugar oj...280cal. I eat 12-14 Reduced fat Triscuits throughout a day...240 cals. 3oz of albacore tuna or chicken breast (smallest can) and 8.5oz can of peas/green beans/baby lima Beans for lunch...120-200cal with 20-30 grams of Protein. Cardio workout after work I have a Myoplex lite packet (choc., van., or strawberry), 1 scoop of whey protein (choc.), 1 tbls of phyllium seed husk (excellent natural fiber) blending with 12oz of skim milk...380cal with 60g of protein Cardio plus strength training days I switch the Myoplex lite with Myoplex orginal and it gives the shake 440cal and 80g of protein. I do cardio 5 days a week and strentgh train every other day. On the weekend I change it up and stay under 1300 calories and little hicups (like BBQ but keep it reasonable) once every ten days keep your body guessing. Ex: Two weeks ago, I did my Mon-Fri regimen exactly and lost 3lbs. I went to an out of town wedding for the weekend with no work-out and BBQ twice and lost 5lbs...wierd. But I haven't drank alcohol or had white carbs since the surgery and that is key for me! Good Luck!

I drink beer often. I have no problems with it but I count my calories. Having the surgery has not changed the way how fast alcohol affects me. I think it's different for everyone just make sure you account for your calories and take it slow when you have your first drink until you know how it will affect you. And also don't drink until you are fully healed (6-8 wks after surgery).

Start keeping a list to keep your sanity! Like the bumper sticker KILL THEM ALL; GOD CAN SORT THEM OUT LATER! Keep muttering This Too Shall Pass! And it will! I knew I had NASH, let's see, non alcoholic Steatohepatitis, is what it really means, in lay terms a Fat Liver, so I did a Liver-shrink the entire month of August 2018, for every week you do it your liver shrinks 4%, so mine was between 12-16% smaller for my surgery. It worked, it worked, and my surgeon complimented me on my mini-liver, told me it was as smooth, small and healthy as a new-born calf, once I was certain he didn't plan to sell me for veal, I was complimented for my hard work. But you do turn into a Stormin' Norma foe awhile. Tomkitten, my son, said like the lepers in the Bible he should have been in front of me carrying a sign" DANGER-STARVING MAMA-BEWARE EVERYONE! But it worked, I lost 15 pounds, felt I had done something to be prepared, and it ended well on Surgery Day! And those are lofty goals.

Hi Bchas, this journey is all about the mind/emotions. It is because we have not been able to cope with events or reactions to life that we have eaten the pain away. Your body will become healthy with the weight loss and your confidence will increase BUT you will still have the issues which caused this food addiction. Some people swap addictions and go from food to alcohol for instance so you really need to seek help in addressing the triggers for your eating patterns. Your parents sound wonderful. It can be scary facing your issues but it can also be surprisingly easy to let go whe you face your demons. Eating became an overwhelming focus in my life, I still obsess that I am eating too much, it takes up time that could be spent living your life. Deal with it now honey, you have a wonderful future ahead of you.

Bourbon Congratulations! You're 123 proof, with specific scores in beer (60) , wine (50), and liquor (104). Screw all that namby-pamby chick stuff, you're going straight for the bottle and a shot glass! It'll take more than a few shots of Wild Turkey or 99 Bananas before you start seeing pink elephants. You know how to handle your alcohol, and yourself at parties.

<p>I too empathize with you...I have been over weight my whole life. I have tried so many diets over the years only to take it off and put more back on. This last time, I swore I would never gain it back! Guess what...I did and gained even more again! I too feel like a failure some times. I feel defeated by this monster. But you know what? Alcoholics and drug addicts don't get better by themselves. People who are sick with other things take medication or have surgeries all the time to get well. What make this any different? I am tired! I'm just 32 but I have wasted it being fat and miserable. I always say if I'm not on a diet then I'm gaining. I can't stay on a diet the rest of my life relying on my own will all the time. I get tired! Why not get some help. </p> <p> </p> <p>I have made my decision...I am saving my $$$ and I should have enough by March. I will not have anouther fat summer for real this time!!!!</p> <p>I want to be free! We are not failures! We just need some help along the way. </p> <p> </p> <p>Keep us posted on your decision and progress...</p> <p> </p> <p>Kat</p>

These ladies are correct in that the band does not keep you from making bad choices. However, I disagree that it will not help you with your eating disorder. I am a compulsive overeater/food addict. I have been for many many years, and have tried all sorts of diets that didn't work. I've even been to Overeaters Anonymous (which I do recommend if you are suffering from the same disorder), which helped but I needed more. I was banded in August 2009, and have since lost almost 160 pounds. Because I could not physically eat as much, the band forced me to find other ways to deal with my emotions. It is only recently that my compulsions have returned, but now I know how to deal with them and will not relapse as badly as I would have pre-band. Yes, you will have to learn how to control your addiction and compulsions, otherwise you will be in a tremendous pain. And the band is not full-proof and it will take a while to get to good restriction. After surgery you will probably be very motivated and will follow the rules to a T, which will help while you are in "bandster hell" (not having full restriction yet). I am a firm believer that the band can help you overcome compulsive overeating/food addiction. It is a disease you will live with the rest of your life (just like being an alcoholic or drug addict...our drug of choice is food), but if you have the right tools you can learn to live without food controlling you. As long as you stay focused and follow your doctor's directions, the band WILL work for you. It is very freeing when food no longer controls your life!

Girl, I feel your pain. I just made an appointment with a counselor because I'm about to lose my mind. My husband is an alcoholic. Every night is him bitching about everything wrong in the world. I try really hard to keep a positive attitude. I know things in the world are shitty but I don't focus on what I can't control. My work life is stressful as we are getting ready to go through a merger and realistically don't know if we will have jobs or if we do, what they will be. I just hit my 20 years with this company so I am feeling a little sad. Then I have to go home and listen to him until he goes to bed. I'm frustrated to say the least. Rant over.

I was in a relationship (married 4 yrs) with an alcoholic & addict for 14 years. I wouldn't wish that lifestyle on anyone. Last January dropped 150 lbs (officially divorced my ex-husband), Best decision I ever made. Have you ever gone to any Al-Anon group meetings? I found them really helpful.

This hits home for me so much. My husband is also an alcoholic, with severe OCD. He works, he does all he should, but once 5:30 hits, he has to (in his mind) be sitting with his first drink of the night. He does the same thing, listing all the things I do wrong, and how I make him miserable. And ever since the day I set my surgery date, he has made a point to accuse me of cheating or that I will cheat because I will think I am better than him. He is not over weight, so I am not sure why he thinks that. Sometimes I want to throw my hands up. Instead I just rearrange my life to accommodate his insecurities, and taking away from my own success. It sucks...

If you're able to maintain that kind of starvation lifestyle for 2 or 3 years and beyond - kudos to you! I'm terrified of having to eat 1000-1200 cals a day while needing to exercise 4-5 days 45 min a day. Find a sustainable lifestyle early on. Like a really sustainable lifestyle. One that fits your needs and not that of somebody else or a lifestyle that blows to pieces the very moment "life hits you". I know a lot of users on here throw a fit the very moment there is talk about "moderation" - however, I think our whole life is about "moderation", not only this eating stuff. Or maybe I should rather use the word "regulation" instead? You need to learn how to regulate yourself, the amount you eat, drink, use alcohol or caffeine, have sex, exercise, express your emotions etc. Too little of these things and life might be miserable, too much of these things and life might be miserable, too.

I am just over a month post op - but my diet is not really restricted at all. The only things that are tough are thick, doughy white bread. Also, if she drinks alcohol - I'll let you know that after one drink I am drunk - so make sure you are there to drive her. I wouldn't worry about the vacation or cooking - just try to make healthy meals and support her new eating habits. We bandsters can eat about anything in moderation. The best thing you can do for her is to be supportive, and try not to tempt her with delicious, high fat foods.

When I was a baby, my father remarked to my mother: 'She's going to have problems with her weight in the future.' Apparently I was physically very similar to his mother. It turned out he was right but not for the reasons he believed. Ironically, it was his life choices that set me on the road to super morbid obesity. Whenever I want to imagine myself as slim and fit I have to go way back through the photo albums to the age of twelve or so. My thighs were so muscular, tanned and slim then! I ate normally, felt normally, behaved normally. I had friends at school, worked hard, and as the daughter of a vicar, was expected to behave impeccably. At the age of twelve my father abruptly left his children, his job and his wife for another woman and we had to vacate the vicarage quickly. We moved to a small, moldering terraced house in a rough part of Manchester. Our diet changed to extremely poor quality food as my mother struggled to care for her three children without the assistance of Child Support (I don't think it had been invented then). I ate to comfort myself, to choke down my feelings of abandonment and sadness. I stole change from my mother to buy sweets, I sneaked out of school at lunchtimes to go home and eat chips and cry on my own. My weight gain and my obvious differences in life experiences from my new classmates meant I was bullied, not only by the 'in crowd' of girls in their smart clothes, but also by my sadistic PE teacher, who on one occasion brought a tape measure into the girls' changing rooms and measured everyone's vital statistics. The closer to the fabled 36-24-36 they were, the more they were congratulated upon for being 'nearly right'. My home life didn't improve. My mother met a man who was an alcoholic and he moved in after their second date. Years of drink, violence, abuse and other horrors took its toll on my mental health and I began self-harming in secret. How is a fourteen year old schoolgirl, already reeling from changes in her life supposed to react when she comes home from school to find her stepfather passed out in the garden, his trousers to his knees, fully exposed and wet from urinating on himself? Worse still was later on when he had come round, expected to sit around the dinner table as if nothing had happened. My weight climbed and my self-esteem plummeted. At fifteen I went on my first ever diet. A quarter of a glass of grapefruit juice for breakfast, half a slice of dry toast for lunch and a quarter of a tin of mushroom soup for dinner. I lost weight, I obsessed about food constantly and my yo-yo had begun its lifelong twirling. I dieted several times in my life - sure to lose many stones then just as surely putting them back on and some. One does not simply wake up at 27 stone, it is the peak of years of food use, abuse and denial. My last big loss was in 2008 when I lost almost eight stone through strict diet and increased exercise. Four years later ... every stone is back and they, as always, brought a couple of friends back with them. I know this would have been the pattern for my almost certainly truncated life had I not had the incredible good fortune to have a mother about to receive a hefty inheritance along with a deep sense of guilt and regret for some of her life choices. I asked her several months ago if she would consider releasing some of the funds that she intended leaving to her children in the future early, enabling me to have private WLS. She said yes. It has happened very, very quickly. A medical screen by a bariatric nurse yesterday, followed by a consultation with a surgeon booked for next Tuesday. As soon as the funds come through (early December) I will have a date for a sleeve gastrectomy booked. The WLS is only ever going to be an aid, not a cure for my weight. I know I have years of poor eating habits and psychological difficulties to work on. But I have never been in a happier place personally than I am now. A husband (blimey!), a sense of direction (future children and employment) and a maturity of self set me in good stead for this undertaking. Bring it on.

I am having my surgery on January 12th. Sounds like I'll be sharing my date with Betsygirl, LisaRT and sherrie sosa . . .WOW!!!! How many others are out there??? I am having my surgery at Genesis Medical Center in Davenport, IA and my surgeon is Dr. David Aanastad. I start my pre-op diet on Monday, Dec 29th. It pretty much limits sugar, fat, caffeine, grains and alcohol. Guess I won't be drinking for New Year's Eve :cool2: Oh well, it'll be worth it!!!! Yesterday I had an afternoon of many appointments which made it all seem very real for me. I'm very anxious and nervous at the same time. I'm nervous about the actual surgery but think I'm also afraid of feeling hungry afterwards. I know that sounds CRAZY, but I know that when I'm really hungry I feel tired and cranky and I feel sorry for anyone near me :eek: :thumbup:

As long as your in weight loss mode your shouldnt drink. Alcohol reduces an enzime in your body required to breakdown the fat you want to lose for 3 days. That's right one drinks significantly reduces your weight loss for 3 days. In essence, slows your weight loss down to half. Personally I dont think 20 year olds have enough experience in life to handle the mental pressure of bariatric surgery. I know I would not have for exactly what your concerned about, drinking. Good luck on your journey. Also leaving your comfort zone 3 days after surgery would not be my first choice.

When looking for a Protein supplement I look for less than 200 cals (but really not more than 175) 23g of whey protein or more very little fat, less the better and no more than 2 sugars, including sugar alcohols

I think that the whole situation is sad. I personally think Nick should use this as an opportunity to educate kids. My stepdaughter lived with us until she was 12. However, when she turned 12 she decided she wanted to live with her mother, who was able to gain custody of her simply because the judge thought a girl of that age should be with her mother. Never mind the mother has a history of drug and alcohol abuse and frequent calls to her home for domestic violence. Basically, his daughter didn't want to live with us because we have rules. We are parents first, friends second. Her mother is friends only. She immediately allowed her to start smoking and would purchase cigs for her. She went from being an all A student to dropping out. Her mother allowed her 19 year old boyfrind to move in with them when she was 14. By the time she was 15, big surprise, she was pregnant. She is now 20 and already has 3 kids, no education and no money. My son is 17 and my daughter turned 15 today. I make a point of having a very open relationship with them. I think that is key to parenting. Don't be naive and do educate and talk to your children. My husband and I have made a point of openly talking to them about sex, drugs and alcohol since they were small children. I am not dumb, I had sex for the first time when I was 16. We encourage our kids to not have sex, to wait until they are older, more mature and ready. However, we also know that their hormones are raging. Therefore, they understand that if they do decide to have sex, they are encouraged to come to us first so we can make sure they are protected against pregnancy and sexually transmitted diseases. They know I won't condem them because they will do it whether or not I offer my blessing. Therefore, if they are going to be sexually active, I want them protected!!

I'm cruising in a month. Here is a thread I posted - some excellent responses on it. I do plan to drink alcohol, maybe one a day. I do expect to eat off plan, but I'll stick with Protein first so that it will fill me up and limit the sliders and sweets. I'm going to try and avoid grazing. I will do shipboard exercise classes and hit the gym, walk the ship (and ashore) and get in my normal 10,000 steps a day. It's OK if I don't lose, I don't expect to. But, I don't want to gain, either. Have fun, everyone!