Search the Community

Let me drop my two cents into the bucket... ching ching. So coming from an old woman that had ran the gauntlet when it comes to BC .... Lets see.... First of all i got pregnant the first time at the age of 16 and im 47 now... so oblivious.. i have had many years to do some trial and error.... First was the pill... ONova 150ies... for those young woman, these were the best but were taken off the market. So the dr tried me on many diff strengths....all had issues. Plus im terrible at remembering. Then at 18 i got divorced and opted to do Condoms. this worked... no unwanted kids and no STD's win win. Then i met my husband and we dated for a few years and decided we were going to get married and stopped the condoms.... BAM. Jason... After Jason, i gave pill another try.. nope, so then came the Diaphragm... Oh Holy hell... anyone who has used them will tell you... the UTI's because you have to leave it in place for a while after sex... NOT GOOD. Then came the Depo shots.... I gained 50lbs in Three months on them and said... oh hell no..... THEN cam the IUD... I liked the IUD. Mine was inserted during my cycle and i thought the insertion was Not terrible. I had cramps worse then that... But i do have a high tolerance for pain. My issue was the heavy bleeding... it was bad... not going to lie. Then upon an ultra sound my GYN discovered that my IUD was implanted (not by her) wrong and i could have gotten preg at anytime.... OMG... Thank you Lord for knowing that giving me another kid would not have been good..... So then we did the Nuvaring, I don't care what anyone says. This one, for me, worked the best, this was the lesser of all the Evils..... I didn't have to remember to take a pill, didn't have to hope it didn't break, NO Uti's, No weight gain. I could control when my cycle started.... During sex (how little there was) i would remove and then reinsert after. The Bleeding still happened, as i had always been a 7 full day heavy bleeder.... But it worked. and after a few years on that we, my dr. and i decided on a partial Hysterectomy... Due to the bleeding. So i still have my ovaries .... Just no more babies... no bleeding.... Can you say HEAVEN.... Truth is i didn't know what kind of pain i was putting up with until the pain was gone. Now im home free..... yes LORD and thank you Jesus... Free at last free at last, thank God oh mighty im free.... at last...

Don't be ashamed. We're human. And that's what we're here for to listen and support and encourage each other. I did the exact same thing. I gained 30 lbs during COVID. Just got them off over the last 3 months. It IS possible to still lose after WLS and after a weight-gain. The tool still works, you just have to use it. Go back to the basics of tracking every single thing you eat and drink. Get your 60g protein, 64 oz water daily. It'll come back off. It won't be fast, but it'll be reliable. You can do it!

I had my surgery (sleeve) on 2/14 and recovery is going relatively smoothly. I’ve been following the dietitians guidelines and starting to walk 30 minutes a day. Over the last few days the scale has been going UP not DOWN 😫. Has anyone experienced this? My thought is that I didn’t get enough protein in the first week following surgery and my body is balancing that out. Thoughts?

Yeah I like everything - I'm a foodie (hence the weight gain!) - I'll get some cod.

Marfar, I have often thought the same thing.....was wondering if I was the only one thinking it LOL And for those of us with a round face, it just keeps getting rounder with weight gain LOL

I wish I could have done it in one surgery too. I had to wait 18 months and go through countless endoscopic procedures before I could be cleared for sleeve. Hence my 75lb weight gain!?!! As long as I was getting sleeved I didn't care what size my stomach was going to be.. And I'm ecstatic with what ever it is..

I made the decision to have the surgery to stop my binge and volume eating. My plan is to use this tool to end the behavior. I know that in the beginning the fast weight loss will keep me motivated. I've already lost and regained hundreds of pounds in the past and I don't ever want to have to lose the SAME pounds again. This is a last resort for me. In the past I went from 272 to 127 with diet and exercise. I broke my foot teaching a Zumba class and that was the beginning of my weight gain (again). As I watched the scale go up 3, down 2, up 5, down 3, I slowly gained 70 pounds back over the next 7 years. I saw 200 quickly approaching and decided diet and exercise just wasn't going to do it for me again. At 60 years old, the weight doesn't fall off anymore. I didn't want to be 272 ever again. So.... before my fear became my reality I made the decision to have the surgery. I'm scheduled for Aug. 1st, and it can't come fast enough.

Per what everyone else is saying: You are too tight. If you can't eat solids by lunch and are throwing up more than once a week (we all take bigger bites sometimes) then you are too tight. Get half of your last fill taken out. Your teeth are changing because of the vomiting and lack of nutrition. You will need to see a dentist to get that addressed - if you can't go for a few months do four things: 1) sign up for Groupon wherever you are, they often have dentist deals 2) use sensodyne whitening toothpaste and brush three times a day and floss but never brush after throwing up for at least 30 minutes 3) after throwing up rinse with Water only, generally you won't get much stomach acid with the band, more food from the pouch 4) start taking Prilosec OTC (you can use the generic too) and take that until you get to see a dentist because it will reduce the amount of acid you are producing to reduce the negative impact on your teeth. The biggest thing is to go get a partial unfill. Fills are expensive. I've paid for mine since day 1 and they cost me between $280-560 each time. But being too full has much greater consequences (band slip, swollen stomach and esophagus, teeth issues, band erosion, etc.). Once you get the unfill go back to your post surgery diet. Two to four days of liquids, two to four days of mushies, two to four days of soft food, then start with the normal food. That will give your system time to settle down. You'll get through it, due to issues I've had I've stalled with weight loss as well. You may also want to fit in a blood test and get your ANA level checked specifically. If it's elevated you may have Lupus - which can cause weight gain, hair loss, changes in teeth, and more.

Yes it is... because the scale wasent moving for me either, but once i did that I noticed that i was having movements like 3-4 times a day and i was eating the mushies also.. and i was really shocked... but i only weigh in once a month due to the pre menst.thing and the water weight gain and crap like that so monday will be my weigh n day and I know it has moved...lol.. I have more inches coming off and it really feels good... but things will move for u soon trust me.. and when u drink the fiber stuff do that for about a week and see if things get back to normal..

This cannot be sugar coated so here it goes. First forum post in my life but seriously need to talk about this. My short story first. Had the band, lost 110 pounds. Got down to 117 and felt amazing. Then it sucked. Irritated my stomach and the let out and fills and throwing up and weight gain got old. So transitioned to sleeve on 12/12/16. Started at 162, 155 day of surgery and down 143 and stalled. Ok no problem. Stomach feels great. BUT tonight had the most horrible experience going to the bathroom. I have no kids but I'm pretty sure this was similar to giving birth. Hard. Stuck. Extremely large. After an enema , and drinking a laxative and three long camp outs in the bathroom and very loud grunts and screams, I was relieved. My friend had the bypass and the same thing happened to her and I took her to the ER. I was never told it would be this bad by my staff???!!! This should be in bold letters on all paperwork! I've read some places on different things to do but would like advice on best intake regime to keep this from happening. I take a probiotic but should I take a daily Fiber or laxative and what is best? Anyone else go through this??? Sent from my iPhone using the BariatricPal App

I had gastric bypass surgery 5 years ago. I was incredibly determined and managed to lose 180 lbs. in a year's time. I'm 5' 9.5" and I went from a size 28 to a size 10. Now, I've regained a lot of weight and I'm starting over. I thought it might be helpful to list the steps that caused my weight gain. My goal is to tackle these 6 and starting moving in the right direction. Does anyone else have additional things that contributed to regaining weight? Stop weighing yourself Stop tracking your food intake Stop exercising Drink liquids with meals and ignore the 15 minutes before/30 minutes after rule Start eating your old favorite foods Stop visiting Bariatric Pal forums

Yes. Before the weight gain I was a size 7. I went up to 8 1/2 - 9 . I’m 7 months post op and I’m in 7 1/2-8 now. It will go down.

Boy, that was dramatic. Maybe if you hurry, you can get your old stomach back. Seriously ... in less than a month post-op you lost 15 pounds. FYI, my surgery weight 8 weeks ago was 216. One month (30 days) later, I'd lost 10.4 pounds. And I was thrilled. Thrilled! I cannot remember (decades ago?) the last time I lost 10.4 pounds in 30 days. Also consider this: About a month ago, I gained four pounds in two days. And then two days after that I stepped on the scales and had suddenly lost 8 pounds, for a net loss of four pounds in four days. It's not typical. But it happens. I would suggest that with the purees you've taken in some salt and maybe also have some constipation that's causing a temporary weight gain. Don't go off the deep end every time you get on the scales and see they've gone up or haven't gone down--especially if you're eating/drinking what's recommended by your surgeon. Give yourself a break and appreciate that you / we will NOT lose our overweight in a straight downward path. (Also google "three week stall" if you don't know about that. Happens to almost everyone.)

@Doubletruble - I hope they can get your levels in control! I am sure they will level out by the time they submit. 2 days of liquid diet only ? wow your surgeon is being good to you lol I will have a week! I don't know how some others have to do 2 weeks, that's craziness!!! @@auntitraci - I can understand how frustrating it is. One of the side effects of Steroids are weight gain. The NUT has no idea about medication side effects. I am sorry that it was a waste of time. It sounds like she has the mentatlity like most when their comments are what you mentioned. Will you be off of them before time for surgery? What does your surgeon say?

Coke (any soda) is a HUGE source of weight gain and retension. Not to mention other bad things it does to your body. The biggest thing about soda is it helps to retain water especially coke. Now I am no doctor just going on what doctors have told me in the past. I started Hot tea day of surgery on my way home from the hospital. i waited 2 days to start regular coffee in moderation and made sure i got enough other liquids so that TMI i know my urine was clear. In the end Coffee should not hurt you if taken in moderation and you make sure to stay hydrated. Obviously you should steer clear of milk or cream unless its fat free and use a sweetner like agave or equal etc... Like i said im not a doctor just offering my honest humble opinion.

I don't know if this will help any of you waiting for Aetna approval. This is their policy on Bariatric Surgery: Clinical Policy Bulletin: Obesity Surgery Number: 0157 Policy Note: Most Aetna *** and QPOS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna. Some Aetna plans entirely exclude coverage of surgical treatment of obesity. Please check benefit plan descriptions for details. Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Sleeve Gastrectomy, Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures: Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic sleeve gastrectomy, open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met. Selection criteria: Must meet either 1 (adults) or 2 (adolescents): For adults aged 18 years or older, presence of severe obesity that has persisted for at least the last 2 years (24 months), documented in contemporaneous clinical records, defined as any of the following: Body mass index (BMI) (see appendix) exceeding 40; or BMI greater than 35 in conjunction with any of the following severe co-morbidities: Clinically significant obstructive sleep apnea (i.e., person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults); or Coronary heart disease; or Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or Type 2 diabetes mellitus [*] For adolescents who have completed bone growth (generally age of 13 in girls and age of 15 in boys), presence of obesity with severe co-morbidities: BMI exceeding 40 with one or more of the following serious co-morbidities: [*] BMI exceeding 50 with one or more of the following less serious co-morbidities: Medically refractory hypertension; or Hypertension; or Dyslipidemias; or Nonalcoholic steatohepatitis; or Venous stasis disease; or Significant impairment in activities of daily living; or Intertriginous soft-tissue infections; or Stress urinary incontinence; or Gastroesophageal reflux disease; or Weight-related arthropathies that impair physical activity; or Obesity-related psychosocial distress. [*]Member has attempted weight loss in the past without successful long-term weight reduction; and [*] Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multi-disciplinary surgical preparatory regimen): Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria: or [*] Multi-disciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multi-disciplinary surgical preparatory regimen of at least 3 months (90 days) duration meeting all of the following criteria, 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: Behavior modification program supervised by qualified professional; and Consultation with a dietician or nutritionist; and Documentation in the medical record of the member's participation in the multi-disciplinary surgical preparatory regimen at each visit. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multi-disciplinary surgical preparatory regimen.); and Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and Program must have a substantial face-to-face component (must not be entirely delivered remotely); and Reduced-calorie diet program supervised by dietician or nutritionist. and [*] For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, pre-operative psychological clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and post-operative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery. [*] Vertical Banded Gastroplasty (VBG): Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following co-morbid medical conditions: Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or Hepatic cirrhosis with elevated liver function tests; or Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix); or Radiation enteritis. Aetna considers VBG experimental and investigational when medical necessity criteria are not met. [*] Repeat Bariatric Surgery: Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction, stricture, erosion, or band slippage. Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet any of the following medical necessity criteria: Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 % of excess body weight) 2 years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch or dilation of the gastrojejunostomy anastomosis is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the dilation of the pouch or GJ anastomosis, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that can not be corrected with band manipulation or adjustments. [*] Experimental and Investigational Bariatric Surgical Procedures: Aetna considers each of the following procedures experimental and investigational because the peer reviewed medical literature shows them to be either unsafe or inadequately studied: Bariatric surgery as a treatment for idiopathic intracranial hypertension Gastroplasty, more commonly known as “stomach stapling” (see below for clarification from vertical band gastroplasty) Intragastric balloon Laparoscopic gastric plication LASGB, RYGB, and BPD/DS procedures not meeting the medical necessity criteria above Loop gastric bypass Mini gastric bypass Roux-en-Y gastric bypass as a treatment for gastroesophageal reflux in non-obese persons Silastic ring vertical gastric bypass (Fobi pouch) Transoral endoscopic surgery (e.g., the StomaphyX device/procedure) VBG, except in limited circumstances noted above. Cholecystectomy: As a high incidence of gallbladder disease (28 %) has been documented after surgery for morbid obesity, Aetna considers routine cholecystectomy medically necessary when performed in concert with elective bariatric procedures. Note: Bariatric surgery is considered experimental and investigational as a treatment for infertility (ACOG, 2009). See also CPB 0039 - Weight Reduction Medications and Programs. Background These criteria were adapted from the NIH Consensus Conference on Surgical Treatment of Morbid Obesity (1998) which state that obesity surgery should be reserved only for patients who have first attempted medical therapy: “Weight loss surgery should be reserved for patients in whom efforts at medical therapy have failed and who are suffering from the complications of extreme obesity.” Rationale for Pre-surgical Preparatory Regimen: The patient’s ability to lose weight prior to surgery makes surgical intervention easier and also provides an indication of the likelihood of compliance with the severe dietary restriction imposed on patients following surgery. Given the importance of patient compliance on diet and self-care in improving patient outcomes after surgery, the patient’s refusal to even attempt to comply with a nutrition and exercise regimen prior to surgery portends poor compliance with nutritional and self-care requirements after surgery. Therefore, the appropriateness of obesity surgery in non-compliant patients should be questioned. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term post-operative medical management, and must understand and be adequately prepared for the potential complications of the procedure. There is rarely a good reason why obese patients (even super obese patients) can not delay surgery in order to undergo behavioral modification to improve their dietary and exercise habits in order to reduce surgical risks and improve surgical outcomes. The patient may be able to lose significant weight prior to surgery in order to improve the outcome of surgery. An individual’s understanding of the procedure and ability to comply with life-long follow-up and life-style changes (e.g., as exemplified by compliance with previous medical care) are necessary for the success of the procedure. Obesity makes many types of surgery more technically difficult to perform and hazardous. Weight loss prior to surgery makes the procedure easier to perform. Weight reduction reduces the size of the liver, making surgical access to the stomach easier. By contrast, the liver enlarges and becomes increasingly infiltrated with fat when weight is gained prior to surgery. A fatty liver is heavy, brittle, and more likely to suffer injury during surgery. Moreover, following surgery, patients have to follow a careful diet of nutritious, high-fiber foods in order to avoid nutritional deficiencies, dumping syndrome, and other complications. The total weight loss from surgery can be enhanced if it is combined with a low-calorie diet. For these reasons, it is therefore best for patients to develop good eating and exercise habits before they undergo surgery. The pre-operative surgical preparatory regimen should include cessation counseling for smokers. The National Institutes of Health Consensus Statement (1998) states that all smokers should be encouraged to quit, regardless of weight. Smoking cessation is especially important in obese persons, as obesity places them at increased risk for cardiovascular disease. Severely obese persons are at increased risk of surgical complications. Smoking cessation reduces the risk of pulmonary complications from surgery. Ideally, the surgical center where surgery is to be performed should be accomplished in bariatric surgery with a demonstrated commitment to provide adequate facilities and equipment, as well as a properly trained and funded appropriate bariatric surgery support staff. Minimal standards in these areas are set by the institution and maintained under the direction of a qualified surgeon who is in charge of an experienced and comprehensive bariatric surgery team. This team should include experienced surgeons and physicians, skilled nurses, specialty-educated nutritionists, experienced anesthesiologists, and, as needed, cardiologists, pulmonologists, rehabilitation therapists, and psychiatric staff. The American College of Surgeons (ACS) has stated that the surgeon performing the bariatric surgery be committed to the multidisciplinary management of the patient, both before and after surgery. The ACS recommended: "They develop skills in patient education and selection and are committed to long-term patient management and follow-up. There is active collaboration with multiple patient care disciplines including nutrition, anesthesiology, cardiology, pulmonary medicine, orthopedic surgery, diabetology, psychiatry, and rehabilitation medicine. Appropriate technical skills in the performance of bariatric surgical procedures are acquired." Although not a requirement for coverage, ideally, the bariatric surgeon should be board certified by the American Board of Surgery or in the process of certification within 5 years after completion of an accredited residency program in general or gastrointestinal surgery, and recertification has been obtained by the American Board of Surgery on an every 10-year basis, if applicable. Appropriate qualifications for a bariatric surgeon include either fellowship training or extended mentoring by an experienced surgeon, preferably by members of international/national bariatric societies, in all aspects of bariatric surgery, advanced laparoscopic techniques, and additional training in re-operative techniques. A number of studies have demonstrated a relationship between surgical volumes and outcomes of obesity surgery. Most recently, an assessment by the Canadian Agency for Drugs and Technologies in Health (CADTH) (Klarenbach et al, 2010) stated that their volume-outcome review found that higher surgical volumes were associated with better clinical outcomes. CADTH was not, however, able to identify specific thresholds for surgical volume that were associated with better clinical outcomes. A Multidisciplinary Care Task Group (Saltzman et al, 2005) conducted a systematic review of the literature to to provide evidence-based guidelines for patient selection and to recommend the medical and nutritional aspects of multi-disciplinary care required to minimize peri-operative and post-operative risks in patients with severe obesity who undergo weight loss surgery. The Task Group recommended multi-disciplinary screening of weight loss surgery patients to ensure appropriate selection; pre-operative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity-related diseases associated with increased risk for complications or mortality; pre-operative weight loss and cessation of smoking; peri-operative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); pre-operative and post-operative education and counseling by a registered dietitian; and a well-defined post-surgical diet progression. The authors explained that obesity-related diseases are often undiagnosed before weight loss surgery, putting patients at increased risk for complications and/or early mortality. Multi-disciplinary assessment and care to minimize short- and long-term risks include: comprehensive medical screening; appropriate pre-, peri-, and post-operative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long-term nutrition education/counseling. A Multidisciplinary Care Task Group (Saltzman et al, 2005) recommended that operative candidates must be committed to the appropriate work-up for the procedure and to continued long-term post-operative medical management. They must also be able to understand, and be adequately prepared for, potential complications. The Multidisciplinary Care Task Group recommended the use of patient selection criteria from the NIH Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity, which are consistent with those of other organizations. These include: BMI greater than or equal to 40 kg/m2 or BMI greater than or equal to 35 kg/m2 in the presence of significant co-morbidities, a well-informed and motivated patient with a strong desire for substantial weight loss, failure of non-surgical approaches to long-term weight loss, and acceptable operative risks. The Task Group recommended that all weight loss surgery patients be encouraged to lose weight before surgery, and to promote 5 to 10 % pre-operative weight loss in patients with a BMI greater than 50 kg/m2 or obesity-related comorbidities (Saltzman et al, 2005). The Task Group recommended to decide on a case-by-case basis whether to proceed with surgery in patients who are unable to lose weight. The Task Group stated that registered dietitians are best qualified to provide nutritional care, including pre-operative assessment and post-operative education, counseling, and follow-up. Weight loss surgery patients need to learn important new skills, including self-monitoring and meal planning. Many forms of weight loss surgery require patients to take lifelong nutritional supplements and to have lifelong medical monitoring. Dedicated dietitians can help patients during their pre-operative education on new dietary requirements and stipulations and their post-surgical adjustment to those requirements. The Task Group also recommended a pre-operative assessment for micronutrient deficiencies. The Task Group recommended that smokers should be encouraged to stop, preferably at least 6 to 8 weeks before surgery (Saltzman et al, 2005). Bupropion and/or nicotine replacements are recommended to help minimize weight gain associated with smoking cessation. Patients should be encouraged to remain non-smokers after weight loss surgery to reduce the negative long-term health effects of smoking. Body Mass Index as a Criterion for Candidacy for Obesity Surgery: Surgery for severe obesity is usually considered an intervention of last resort with patients having attempted other forms of medical management (such as behavior change, increased physical activity and drug therapy) but without achieving permanent weight loss (Colquitt et al, 2002; NIH, 1995). Surgery is indicated for persons with severe obesity (body mass index (BMI) of 40 kg/m2 or more) or for persons with a BMI of 35 kg/m2 or more and serious co-morbidities such as diabetes, coronary heart disease, or obstructive sleep apnea. Ideally patients selected for surgery should have no major perioperative risk factors, a stable personality, no eating disorders, and have lost some weight prior to surgery. The patient's ability to lose weight prior to surgery makes surgical intervention easier and also provides an indication of the likelihood of compliance with the severe dietary restriction imposed on patients following surgery. Rationale for Six-Month Nutrition and Exercise Program Prior to Surgery: The NIH Consensus Conference on Surgical Treatment of Morbid Obesity (1998) states that obesity surgery should be reserved only for patients who have first attempted medical therapy: “Weight loss surgery should be reserved for patients in whom efforts at medical therapy have failed and who are suffering from the complications of extreme obesity.” The NIH Consensus Conference states that the initial goal of medical therapy is a 10 % reduction in weight, and that a reasonable duration for medical therapy is 6 months. The Consensus Conference stated: “The initial goal of weight loss therapy is to reduce body weight by approximately 10 % from baseline. If this goal is achieved, further weight loss can be attempted, if indicated through further evaluation. A reasonable time line for a 10 % reduction in body weight is 6 months of therapy.” The NIH Consensus Conference Statement (1998) explained "The rationale for this initial goal is that even moderate weight loss, i.e., 10 % of initial body weight, can significantly decrease the severity of obesity-associated risk factors." The NIH Consensus Conference (1998) states that the combination of a reduced calorie diet and increased physical activity can result in substantial improvements in blood pressure, glucose tolerance, lipid profile, and cardiorespiratory fitness. The NIH Consensus Conference (1998) has stated that the patient should begin a nutrition and exercise program prior to surgery: “An integrated program must be in place to provide guidance on diet, physical activity, and behavioral and social support both prior to and after the surgery.” The American Dietetic Association (1997), in their position statement obesity surgery, recommends dietetic counseling and behavioral modification commencing prior to, not after, surgery: “Careful dietetics evaluation is needed to determine if the patient will be able to comply with the postoperative diet. A preoperative behavior change program with psychological evaluation should be required.” More recently, evidence-based guidelines from the Scottish Intercollegiate Guidelines Network (2010) have stated that bariatric surgery should be considered on an individual case basis following assessment of risk/benefit in obese patients with "evidence of completion of a structured weight management programme involving diet, physical activity, psychological and drug interventions, not resulting in significant and sustained improvement in the comorbidities." Candidates for obesity surgery should begin a weight reduction diet prior to surgery. The purpose of a pre-operative nutrition program prior to obesity surgery are to test patient motivation, to reduce perioperative morbidity, to accustom patients to the restriction of food intake after surgery, and to increase total weight loss (van de Weijgert et al,1999; Jung and Cusciheri, 2000; Pekkarinen et al, 1997; Martin et al, 1995). Even super obese patients (BMI greater than 50) may benefit from initiating a nutrition and exercise program prior to surgery. Obesity itself increases the likelihood of pulmonary complications and wound infections (Choban et al, 1995; Abdel-Moneim, 1985; Holley et al, 1990; Myles et al, 2002; Nair et al, 2002; Bumgardner et al, 1995; Perez et al, 2001; Chang et al, 2000; Printken et al, 1975). The higher the patient's BMI, the higher the surgical risk, and the highest risks occur among patients with a BMI over 50 (Gonzalez et al, 2003; Oelschlager and Pellegrini, 2003). Even relatively modest weight loss prior to surgery can result in substantial improvements in pulmonary function, blood glucose control, blood pressure, and other physiological parameters (Anderson et al, 2000; Hakala et al, 1995; Kansanen et al, 1998; Pekkarinen et al, 1998). Factors such as blood glucose control, hypertension, etc., affect surgical risk. Garza (2003) explained that the patient should lose weight prior to surgery to reduce surgical risks. "The overall health of patients should be optimized prior to surgery to reduce the potential for complications. Patients ought to be encouraged to lose as much weight as possible before surgery" (Garza, 2003). Although the long-term effectiveness of weight reduction programs has been questioned, the Institute of Medicine (1995) has reported the substantial short-term effectiveness of certain organized physician-supervised weight reduction programs. For maximal benefit, dieting should occur proximal to the time of surgery, and not in the remote past to reduce surgical risks and improve outcomes. Even if the patient has not been able to keep weight off long-term with prior dieting, the patient may be able to lose significant weight short term prior to surgery in order to improve the outcome of surgery. Given the importance of patient compliance in diet and self-care in improving patient outcomes after surgery, the appropriateness of obesity surgery in noncompliant patients should be questioned. The American College of Surgeons has stated: “Not all persons who are obese or who consider themselves overweight are candidates for bariatric surgery. These procedures are not for cosmesis but for prevention of the pathologic consequences of morbid obesity. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term postoperative medical management, and understand and be adequately prepared for the potential complications of the procedure. Screening of the patients to ensure appropriate selection is a critical responsibility of the surgeon and the supporting health care team.” A Multidisciplinary Care Task Group (Saltzman et al, 2005) conducted a systematic review of the literature and recommended an attempt at modest weight loss before obesity surgery, citing evidence that modest reductions in weight (5 to 10 % of initial weight) reduce factors known to increase surgical risk (e.g., sleep disordered breathing, hypertension, hyperglycemia), and that with weight loss, obese patients had significantly shorter operating room times and length of stay. The Task Group stated that registered dietitians are best qualified to provide nutritional care, including pre-operative assessment and nutritional education and counseling. Contraindications to Obesity Surgery: Surgery for severe obesity is a major surgical intervention with a risk of significant early and late morbidity and of perioperative mortality (Colquitt, 2002; Oelschlager and Pellegrini, 2003). Contraindications for these surgical procedures include peri-operative risk of cardiac complications, poor myocardial reserve, significant chronic obstructive airways disease or respiratory dysfunction, non-compliance of medical treatment, psychological disorders of a significant degree that a psychologist/psychiatrist would have thought would be exacerbated or interfere with the long-term management of the patient after the operation, significant eating disorders, or severe hiatal hernia/gastroesophageal reflux. A Multidisciplinary Care Task Group (Saltzman et al, 2005) identified contraindications to weight loss surgery, including unstable or severe coronary artery disease, severe pulmonary disease, portal hypertension with gastric or intestinal varices, and/or other conditions thought to seriously compromise anesthesia or wound healing. The Task Group also noted that weight loss surgery is contraindicated in those who are unable to comprehend basic principles of weight loss surgery or follow operative instructions. The Task Group stated that any combination of the following factors -- revisional surgery, male, greater than 50 years of age, BMI greater than 50 kg/m2, and obstructive sleep apnea, hypertension, and type 2 diabetes -- indicates high risk. Requirement that Obesity be Longstanding (Present for 2 or More Years): Obesity surgery is not indicated for persons with transient increases in weight (Collazo-Clavell, 1999). According to the Guidelines of the American Association of Clinical Endocrinologists and the American College of Endocrinology (1998), “Surgical treatment of obesity may be considered only in carefully selected patients [where] … obesity has been present for at least 5 years.” Obesity Surgery in Children and Adolescents: According to available guidelines, obesity surgery is generally indicated for persons age 18 and older (AACE, 1998). Children and adolescents are rapidly growing, and are therefore especially susceptible to adverse long-term consequences of nutritional deficiencies from the reduced nutrient intake and malabsorption that is induced by obesity surgery. It is not known whether the benefits of obesity surgery in children and adolescents outweigh the increased risks. According to a panel of experts (Inge et al, 2004; Lawson et al, 2006), bariatric surgery may be an appropriate treatment for severe obesity in adolescents who have completed bone growth. According to the recommendations by the expert panel, potential candidates for bariatric surgery should be referred to centers with multi-disciplinary weight management teams that have expertise in meeting the unique needs of overweight adolescents. Consideration for bariatric surgery is generally warranted only when adolescents have experienced failure of 6 months of organized weight loss attempts and have met certain criteria: severe obesity (a BMI of 40) and severe co-morbidities, or super obesity (BMI of 50) and less severe co-morbidities that may be remedied with weight loss; and have attained a majority of skeletal maturity (generally 13 years of age for girls and 15 years of age for boys). Surgery should only be performed at facilities that are equipped to collect long-term data on clinical outcomes. The panel recommended the Roux-en-Y gastric bypass method of surgery over the simpler, newer technique of implanting an adjustable gastric band since gastric bands are less effective and younger patients would probably need replacement as they age. Requirement for Physician Supervision of Program Documented in Medical Record: Aetna’s policy states that the patient should participate in a medically supervised nutrition and exercise program and/or a comprehensive multidisciplinary preoperative preparatory regimen, and that this participation be documented in the medical record. As is true generally, physicians should document their assessment of the patient, what health interventions are prescribed, and their assessment of the patient’s progress. There is established evidence that medical supervision of a nutrition and exercise program increases the likelihood of success (Blackburn, 1993). The American Medical Association Council on Scientific Affairs recommends that “any person considering a weight loss program first consult a physician for a physical examination and an objective evaluation of the proposed weight loss program as it relates to the individual’s physical condition … Various health organizations recommend that physicians assess their patients for overweight and that patients receive appropriate counseling about safe weight management and the benefits of physical activity and a healthy diet [citing guidelines from the National Heart, Lung and Blood Institute, the AACE/ACE, the Institute of Medicine of the National Academy of Sciences, the U.S. Preventive Services Task Force, the American Obesity Association, the American Medical Association, and an expert committee of pediatric experts convened by the Health Resources and Services Administration]” (Lyznicki et al, 2001). “If treatment is indicated, physicians can help patients develop weight loss or management plans tailored to individual needs; this includes setting reasonable weight loss goals; selecting appropriate weight loss programs; referring patients to ancillary personnel when appropriate; and providing monitoring, support and encouragement” (Lyznicki et al, 2001). Requirement for Psychological Evaluation: Candidates for obesity surgery who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications should undergo a comprehensive evaluation by a licensed psychologist or psychiatrist to assess the patient’s suitability for surgery, the absence of significant psychopathology that can limit an individual’s understanding of the procedure or ability to comply with life-long follow-up (e.g., defined noncompliance with previous medical care, active substance abuse, schizophrenia, borderline personality disorder, uncontrolled depression). Roux-en-Y Gastric Bypass (RYGB) and Vertical Banded Gastroplasty (VBG): Surgery for obesity, termed bariatric surgery, includes gastric restrictive procedures and gastric bypass. The gastric restrictive procedures include vertical banded gastroplasty accompanied by gastric banding which attempt to induce weight loss by creating an intake-limiting gastric pouch by segmenting the stomach along its vertical axis. The process of digestion is more or less normal. In the United States, the primary operative choice for severely obese patients has recently shifted from vertical banded gastroplasty (VBG) to the Roux-en-Y gastric bypass (RYGB) (Fisher and Schauer, 2002; Mason et al, 1997). Vertical banded gastroplasty (VBG), a purely restrictive procedure, has fallen into disfavor because of inadequate long-term weight loss. Roux-en-Y gastric bypass (RYGB) combines restriction and malabsorption principles, and combines gastric segmentation along its vertical axis with a Roux-en-Y procedure, such that the food bypasses the duodenum and proximal small bowel. Because the normal flow of food is disrupted, available literature indicates that there is a greater potential for metabolic complications compared to gastric restrictive surgeries, including Iron deficiency anemia, Vitamin B-12 deficiency and hypocalcemia, all of which can be corrected by oral supplementation. Several studies have suggested that RYGB is a more effective weight loss procedure than VBG, offering the best combination of maximum weight control and minimum nutritional risk (Sugerman et al, 1989; Howard et al, 1995). Pories et al (1995) reported 57.7 %, 54.7 %, and 49.2 % excess weight loss with RYGB at 5, 10, and 14 years, respectively, in a large series with 95 % follow-up. Thus, the RYGB is "the current procedure of choice for patients requiring surgery for morbid obesity" (Barrow; 2002). An assessment conducted by the French National Technology Assessment Agency (ANAES, 2001; Msika, 2003) found that surgical mortality for RYGB and VBG is about the same. However, RYGB is associated with significantly more weight loss, and has become the procedure of choice for obesity surgery. Gentileschi et al (2002) systematically reviewed the published literature on open and bariatric laparoscopic obesity surgery and concluded that the available evidence indicates that laparoscopic VBG and laparoscopic RYGB are as effective as their open counterparts. An assessment of laparoscopic RYGB by the BlueCross BlueShield Association Technology Evaluation Center (BCBSA, 2005) stated that among available bariatric surgical procedures, RYGB appears to have the most favorable risk-to-benefit ratio, and that the overall risk-to-benefit ratio of laparoscopic RGBY is similar to that of open RGBY. The assessment found that open and laparoscopic RYGB induces similar amounts of weight loss. However, the assessment found that the profile of adverse events differs between the two approaches. Laparoscopic RYGB is a less invasive approach that results in a shorter hospital stay and earlier return to usual activities. The assessment found that the estimated mortality rate was low for both procedures, but somewhat lower for laparoscopic surgery than open surgery (0.3 % versus 1.1 %). Laparoscopic RGBY had a higher rate of postoperative anastomotic leaks than open RGBY (3.7 % versus 1.9 %), and a somewhat higher rate of bleeding (4.1 % versus 2.4 %). The report found, on the other hand, that open surgery had higher rates of cardiopulmonary complications (2.6 % versus 1.0 %) and wound infections (11.0 % versus 4.7 %). Regarding long-term adverse events, the rates of reoperation (9.9 %) and anastomotic problems (8.0 %) may be higher for laparoscopic RGBY than for open RGBY (6.0 % and 2.0 %, respectively), while the rate of incisional hernia is higher for open RGBY than laparoscopic RGBY (9.0 % versus 0 %). An assessment by the Institute for Clinical Systems Improvement (ICSI, 2005) found that large studies have shown that RYGB may result in weight loss of 60 % to 70 % of excess weight. It also found that VBG shows substantial weight loss efficacy but less than that for RYGB. In addition, VBG has a high rate of serious morbidity, including a re-operation rate of up to 30 % from stoma obstruction and staple-line disruption. Therefore, the evidence supports the overall superiority of RYGB over VBG in safety and efficacy for bariatric surgery. A decision memorandum from the Centers for Medicare and Medicaid Services (CMS, 2006) concluded that the evidence is sufficient that open and laparoscopic RYGB is reasonable and necessary for Medicare beneficiaries who have a BMI greater than 35 and have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. The assessment concluded that the evidence is not adequate to conclude that open or laparoscopic vertical banded gastroplasty is reasonable and necessary and they are therefore non-covered for all Medicare beneficiaries. A systematic evidence review by the Canadian Agency for Drugs and Technologies in Health (CADTH) (Klarenbach et al, 2010) found that, although data from large, adequately powered, long-term randomized controlled trials are lacking, bariatric surgery seems to be more effective than standard care for the treatment of severe obesity in adults. Procedures that are mainly diversionary (e.g., biliopancreatic diversion (BPD)) result in the greatest amounts of weight loss, hybrid procedures are of intermediate effectiveness (e.g., RYGB), and restrictive procedures (e.g., adjustable gastric banding) result in the least amounts of weight loss. RYGB and adjustable gastric banding tended to lead to trade-offs between the risk of adverse events and the need for procedure conversion or reversals. Biliopancreatic Diversion (BPD) (Jejunoilieal Bypass, Scorpinaro Procedure) and Duodenal Switch (DS) Procedures: While appropriate surgical procedures for severe obesity primarily produce weight loss by restricting intake, intestinal bypass procedures produce weight loss by inducing a malabsorptive effect. Biliopancreatic bypass or diversion (BPD) (also called jejunoileal bypass or the Scopinaro procedure) consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure; the result is a 200-cm long alimentary tract, a 300- to 400-cm biliary tract, and after these 2 tracts are joined at the distal anastomosis, there is a 50-cm common absorptive alimentary tract. The BPD was designed to address some of the drawbacks of the original intestinal bypass procedures, which resulted in unacceptable metabolic complications of diarrhea, hyperoxaluria, nephrolithiasis, cholelithiasis and liver failure. The duodenal switch (DS) is a variant of the BPD procedure with a vertical subtotal gastrectomy and pylorus preservation, which eliminates the "dumping syndrome". The duodenum is divided just beyond the pylorus. The small bowel is then divided, and the end going to the cecum of the colon is connected to the short stump of the duodenum. This becomes the "enteral limb". The other end, leading from the gallbladder and pancreatic ducts, is connected onto the enteral limb at about 75 to 100 cm from the iliocecal valve. This limb is the "biliopancreatic limb". The last 75-100 cm then becomes the "common channel", measuring about 10 % of the total small bowel length and is the only portion that can absorb fat. Some have advocated use of the DS procedure in the super-obese (i.e., persons with BMI greater than 50) because of the substantial weight loss induced by this procedure. Patients who have this operation must have lifelong medical follow-up, since the side effects can be subtle, and can appear months to years after the surgery. A decision memorandum from the Centers for Medicare and Medicaid Services (CMS, 2006) concluded that open or laparoscopic BPD with or without DS are reasonable and necessary for Medicare beneficiaries. Gastroplasty (“Stomach Stapling”): Gastroplasty, more commonly known as "stomach stapling" and not to be confused with vertical banded gastroplasty (VBG), is a technically simple operation, accomplished by stapling the upper stomach to create a small pouch into which food flows after it is swallowed. The outlet of this pouch is restricted by a band of synthetic mesh, which slows its emptying, so that the person having it feels full after only a few bites of food. According to the available literature, patients who have this procedure seldom experience any satisfaction from eating, and tend to seek ways to get around the operation by eating more. This causes vomiting, which can tear out the staple line and destroy the operation. Overall, clinical studies have shown that about 40 % of persons who have this operation do not achieve loss of more than half of their excess body weight. In the long-term, 5 or more years after surgery, only about 30 % of patients have maintained a successful weight loss. Studies have reported that many patients must undergo another revisional operation to obtain the results they seek. Sleeve Gastrectomy: Sleeve gastrectomy is a 70 to 80 % greater curvature gastrectomy (sleeve resection of the stomach) with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume (CMS, 2005). It is often the first step in a 2-stage procedure when performing RYGB or duodenal switch. A decision memorandum from the Centers for Medicare and Medicaid Services (CMS) found that the data supporting open or laparoscopic sleeve gastrectomy are generally sparse and not adequate to draw conclusions. The CMS concluded, therefore, that these procedures are not reasonable and necessary for Medicare beneficiaries. The CMS decision memorandum stated that their conclusions about the lack of clinical data for sleeve gastrectomy applied, not only to the Medicare-aged population, but also to persons under 65 years of age. More recently, a systematic evidence review prepared for Clinical Evidence concluded that the effectiveness of sleeve gastrectomy for morbid obesity is unknown (DeLaet and Schauer, 2009). The evidence review found no clinically important results from randomized controlled clinical trials about sleeve gastrectomy compared with non-surgical treatment, or compared with vertical banded gastroplasty or biliopancreatic diversion. They found low quality evidence that sleeve gastrectomy may be more effective than gastric banding at increasing weight loss at 1 and 3 years, and moderate quality evidence that sleeve gastrectomy seems more effective than gastric bypass at increasing mean excess-weight loss at 1 to 2 years. A systematic evidence review of sleeve gastrectomy by the Australia and New Zealand Horizon Scanning Network (ANZHSN) (Lee, 2007) found that the evidence showed that laparoscopic sleeve gastrectomy can induce substantial excess weight loss at least as effectively as LASGB (in one study up to 3-years post surgery) but less effectively than gastric bypass and duodenal switch in the short-term. The report noted, however, that these results should be viewed in light of the ease and simplicity of laparoscopic sleeve gastrectomy relative to the other more invasive procedures. The report found a comparable reduction in co-morbidities in patients who underwent laparoscopic sleeve gastrectomy or RYGB, most notably in resolution rates of diabetes within 4 months after surgery despite laparoscopic gastric banding patients being significantly more obese than the RYGB patients in the study. Evidence suggested that, compared to LASGB, laparoscopic sleeve gastrectomy had lower complication rates but more severe complications. The report found laparoscopic sleeve gastrectomy safer than laparoscopic RYGB or intragastric balloon implantation. The report stated that evidence of the safety of laparoscopic sleeve gastrectomy compared with duodenal switch is conflicting possibly because of differences in baseline patient characteristics. The report stated that the incidence of gastric sleeve dilatation appears to be an uncommon event, but the evidence is far from conclusive at this point. The report noted that one study found that laparoscopic sleeve gastrectomy and LASGB had significantly shorter operative times compared to RYGB and duodenal switch. Laparoscopic sleeve gastrectomy had a significantly longer length of stay compared to LASGB, but a significantly shorter length of stay compared to RYGB and duodenal switch. The report found that knowledge gaps include: comparing the effectiveness of laparoscopic sleeve gastrectomy to established bariatric procedures in super-obese (BMI greater than or equal to 50) as a stand alone procedure; long-term (greater than 5 years) safety, durability of weight loss and comorbidity data for laparoscopic sleeve gastrectomy relative to existing bariatric procedures; and effects of laparoscopic sleeve gastrectomy on plasma ghrelin levels and subsequent effect on appetite. More recently, a review of the literature by the Veterans Health Administration Technology Assessment Program (Adams, 2008) found no new literature that would not alter the conclusions of the ANZHSN review. A randomized controlled clinical trial comparing short-term (1-year) outcomes of laparoscopic sleeve gastrectomy to laparoscopic RYGB found comparable reductions in body weight and BMI (Karamanakos et al, 2008). However, power calculations were not reported, and the study (n = 32) was likely under-powered to detect clinically signficant differences in effectiveness between the 2 procedures. This study was poorly reported, failing to discuss inclusion criteria for the trial and adverse events associated with the procedures. An earlier retrospective study by Lee et al (2007) (n = 846) found similar rates of short-term weight loss in persons who elected sleeve gastrectomy and persons who elected RYGB or duodenal switch procedures. However, the lack of randomization and retrospective nature of the study results in a substantial risk of bias in the results. The strongest arguments for sleeve gastrectomy relate to the comparatively poor outcomes of LASGB, which is the competing option for persons wishing to undergo a restrictive (non-malabsorptive) procedure. A randomized clinical study by Himpens et al (2006) compared laparoscopic sleeve gastrectomy to LASGB (n = 80). Although median weight loss was significantly greater after 1 and 3 years with sleeve gastrectomy (65 lbs) than with LASGB (37.5 lbs), the total weight loss with either procedure was insufficient for most potential candidates. The study also found that sleeve gastrectomy was associated with more severe complications than LASGB. The study was also poorly reported, including failure to discuss randomization and blinding procedures, and whether any subjects did not comply with randomization or were lost to follow-up. Clinical studies have reported long-term reoperation rates with LASGB of up to 60 % (see, e.g., Scozzari et al, 2009; Camerini et al, 2004; Tweddle et al, 2004; Morino et al, 2002). Australia has reported that the costs of band adjustments with LASGB has exceeded the costs of the primary LASGB procedure. A Cochrane review of the evidence for bariatric surgical procedures (Colquitt et al, 2009) found that, although the effects of the available bariatric procedures compared with medical management and with each other are uncertain, "limited" evidence suggests that sleeve gastrectomy results in weight loss similar to RYGB and greater than with LASGB. The assessment stated that information from the included trials did not allow the authors to reach any conclusions about the safety of these procedures compared with each other. The assessment noted that, due to limited evidence and poor quality of the trials comparing each pair of procedures, these conclusions should be viewed with caution. In a position statement, the American Society for Metabolic and Bariatric Surgery (2009) determined that sleeve gastrectomy is an "approved bariatric surgical procedure" despite finding only "limited" intermediate term data and a lack of long-term data on the effectiveness of the procedure. The ASMBS position statement explained that the Society has accepted sleeve gastrectomy as an approved bariatric surgical procedure primarily because of its potential value as a first-stage operation for high-risk patients, primarily super-obese patients with an average BMI of 60 kg/m2. The ASMBS reached this conclusion despite not knowing what proportion of super-obese patients will achieve satisfactory outcomes with sleeve gastrectomy alone without conversion to RYGB or duodenal switch, and despite a lack of evidence that accomplishing RYGB or duodenal switch as a staged procedure results in better outcomes (fewer risks) than accomplishing these procedures as a single surgery. An assessment by the California Technology Assessment Forum (CTAF) (Walsh, 2010) concluded that sleeve gastrectomy does not meet CTAF technology assessment criteria for improvement in health outcomes for the treatment of obesity. The CTAF assessment reported that the results of multiple case series and retrospective studies have suggested that sleeve gastrectomy as a primary procedure is associated with a significant reduction in excess weight loss. The CTAF assessment reported that the complication rate from sleeve gastrectomy ranged from 0 % to 4.1 % and complications included leaks, bleeding, strictures and mortality. The CTAF assessment found few comparative studies of sleeve gastrectomy. CTAF identified only 2 randomized controlled trials that have compared sleeve gastrectomy to another surgical procedure (citing Himpens et al, 2006; Karamanakos et al, 2008). These trials included a total of 112 participants who were followed from 1 to 3 years. Among the 80 subjects followed for 3 years, there were a similar number of complications in the sleeve gastrectomy and the RYGB groups, although the complications in the sleeve gastrectomy group were more severe. The CTAF assessment stated that, "[t]o date, long term outcomes from registry studies are relatively limited, but longer term follow-up will provide additional important information." An assessment of surgical treatment for obesity from the Canadian Agency for Drugs and Technologies in Health (CADTH) (Klarenbach et al, 2010) also concluded that the evidence base for sleeve gastrectomy is limited. Loop Gastric Bypass: Although the basic concept of gastric bypass remains intact, numerous variations are being performed at this time. Recent data demonstrate that surgeons are moving from simple gastroplasty procedures, favoring the more complex gastric bypass procedures as the surgical treatment of choice for the severely obese patient. The gastric bypass operation can be modified, to alter absorption of food, by moving the Roux-en-Y-connection distally down the jejunum, effectively shortening the bowel available for absorption of food. The weight loss effect is then a combination of the very small stomach, which limits intake of food, with malabsorption of the nutrients, which are eaten, reducing caloric intake even further. In a sense, this procedure combines the least desirable features of the gastric bypass with the most troublesome aspects of the biliopancreatic diversion. Although patients can have increased frequency of bowel movements, increased fat in their stools, and impaired absorption of Vitamins, recent studies have reported good results. The loop gastric bypass developed years ago has generally been abandoned by most bariatric surgeons as unsafe. Although easier to perform than the RYGB, it has been shown to create a severe hazard in the event of any leakage after surgery, and seriously increases the risk of ulcer forrmation, and irritation of the stomach pouch by bile. Laparoscopic Adjustable Silicone Gastric Banding (LASGB): Recent advances in laparoscopy have renewed the interest in gastric banding techniques for the control of severe obesity. Laparoscopic adjustable silicone gastric banding (LASGB) has become an attractive method because it is minimally invasive and allows modulation of weight loss. Available brands of LASGB include the Lap-Band System (Allergan, Inc., Irvine, CA) and the Realize Adjustable Gastric Band (Ethicon Endo-Surgery, Cincinnati, OH). The claimed advantage of LASGB is the adjustability of the band, which can be inflated or deflated percutaneously according to weight loss without altering the anatomy of the stomach. This method entails encircling the upper part of the stomach using bands made of synthetic materials, creating a small upper pouch that empties into the lower stomach through a narrow, non-stretchable stoma. The reduced capacity of the pouch and the restriction caused by the band diminish caloric intake, depending on important technical details, thus producing weight loss comparable to vertical gastroplasties, without the possibility of staple-line disruption and lesser incidence of infectious complications. However, distension of the pouch, slippage of the band and entrapment of the foreign material by the stomach have been described and are worrisome. A decision memorandum from the CMS (2006) found that there was sufficient evidence to support LASGB as reasonable and necessary for Medicare beneficiaries with a BMI greater than 35 and co-morbid medical conditions. Sustained weight loss was well documented, ranging from an approximate mean of 30 to 50 % excess weight loss in LASGB, compared to an approximate mean of 50 % excess weight loss in RYGB. The CMS decision memorandum found that short-and-long-term mortality associated with both LASGB and RYGB were low (less than 2 %) in this younger age group. Regarding performing adjustable gastric banding as an open procedure, the CMS decision memorandum (2006) concluded that the evidence is not adequate to conclude that open adjustable gastric banding is reasonable and necessary and therefore this procedure remains noncovered for Medicare beneficiaries. Mini Gastric Bypass: The "mini gastric bypass" has been promoted as a new surgical treatment for severe obesity. It involves laparoscopic construction of a large and elongated gastric pouch and a loop gastric bypass with distal diversion (200 cm or up to 50 % of the small bowel) to reduce food absorption. While the name mini gastric bypass implies "small" and "simple", this is a major surgical procedure. The mini-gastric bypass uses a jejunal loop directly connected to a small gastric pouch, instead of a Roux-en-Y anastomosis. In this way, the mini-gastric bypass is similar to the loop gastric bypass; the latter procedure that has been abandoned by bariatric surgeons because of its inherent risks. Specifically, performing a loop, rather than a Roux-en-Y, anastomosis to a small gastric pouch in the stomach may permit reflux of bile and digestive juice into the esophagus where it can cause esophagitis and ulceration, and may thus increase the risk of esophageal cancer. The Roux-en-Y modification of the loop bypass was designed to divert bile downstream, several feet below the gastric pouch and esophagus to minimize the risk of reflux. The trend towards use of Roux-en-Y and away from loop gastric bypass was based on sound surgical experience of multiple surgeons with large series of patients. The published evidence supporting the mini-gastric bypass comes from descriptive reports and case series; the potential biases inherent in reports of case series are well known in clinical epidemiology. The evidence for the mini gastric bypass has come from a single investigator, thus raising questions about the generalization and validity of the reported findings. The mini-gastric bypass has not been subjected to a prospective clinical outcome study in peer-reviewed publication. Silastic Ring Vertical Gastric Bypass (Fobi Pouch): The Fobi pouch, developed by California surgeon Mathias A.L. Fobi, is a modification of gastric bypass surgery. The modifications to gastric bypass surgery are designed to prevent post-surgical enlargement of the gastric pouch and stoma. In a traditional gastric bypass procedure, surgeons create a smaller stomach by stapling off a large section. A problem with the traditional procedure is that the staples can break down, causing the stomach to regain its original shape -- and patients to start gaining weight again. Also, the stomach opening that leads into the intestines, which in surgery is made smaller to allow less food to pass through, often stretches as the years go by. With the Fobi pouch, there is no use of staples; rather, the stomach is bisected and hand-sewn them to maintain the separation. A synthetic band is placed around the stomach opening to keep it from stretching. However, there is a paucity of direct comparative studies of the Fobi pouch to traditional gastric bypass surgery, causing colleagues to "question whether his technique is really an improvement on the traditional procedure" (Davis, 2000). All of the published literature has been limited to descriptive articles, case series, and a prospective non-randomized controlled study. These studies were from a single group of investigators, raising questions about the generalization of the findings. Intragastric Balloon: The intragastric balloon (also known as the silicone intragastric balloon or SIB) has been developed as a temporary aid for obese patients who have had unsatisfactory results in their clinical treatment for obesity and super obese patients with higher surgical (Fernandes et al, 2004). Intragastric balloon is intended to reduce gastric capacity, causing satiety, making it easier for patients to take smaller amounts of food. Randomized, controlled clinical studies, however, have found no increase in weight loss with the intragastric balloon plus dieting versus dieting alone (Rigaud et al, 1995; Geliebter et al, 1991; Mathus-Vliegen et al, 1990; Lindor et al, 1987). One non-randomized controlled clinical study that reported positive results reported that results were not maintained after gastric balloon removal (Ramhamadany et al, 1989). In addition, the intragastric balloon has been associated with potentially severe adverse effects, including gastric erosion, reflux, and obstruction. An assessment of the intragastric balloon from the Canadian Coordinating Office for Health Technology Assessment (2006) concluded that “[m]ore data on the benefits, harms, and cost-effectiveness are required before the intragastric balloon can be compared with other short-term weight loss interventions, including low-calorie diets.” StomaphyX: In March 2007, the FDA granted 510(k) pre-marketing clearance to the StomaphyX (EndoGastric Solutions, Inc.), an endoluminal fastener and delivery system used to tighten esophageal tissue. There is only limited evidence on the effectiveness of the StomaphyX in bariatric surgery repair/revision. Overcash (2008) reported 2 cases of the safe and successful use of the StomaphyX device to alter the flow of gastric contents and repair gastric leaks resulting from bariatric revision surgery. Both patients were at a high risk and could not undergo another open or laparoscopic surgery to correct the leaks that were not healing. The author reported that the StomaphyX procedures lasted approximately 30 mins, were performed without any complications, and resulted in the resolution of the gastric leaks in both patients. The findings of these cases needs to be validated by well-designed clinical studies. Bariatric Surgery and Pregnancy: The American College of Obstetricians and Gynecologists' practice bulletin on bariatric surgery and pregnancy (ACOG, 2009) stated that bariatric surgery should not be considered a treatment for infertility. Bariatric Surgery for the Treatment of Idiopathic Intracranial Hypertension: Fridley et al (2011) reviewed the literature on the effectiveness of bariatric surgery for obese patients with idiopathic intracranial hypertension (IIH) with regard to both symptom resolution and resolution of visual deficits. The published literature was reviewed using manual and electronic search techniques. Data from each relevant manuscript were gathered, analyzed, and compared. These included demographic data, pre- and post-operative symptoms, pre- and post-operative visual field deficits, bariatric procedure type, absolute weight loss, changes in body mass index, and changes in cerebrospinal Fluid (CSF) opening pressure. A total of 11 relevant publications (including 6 individual case reports) were found, reporting on a total of 62 patients. The Roux-en-Y gastric bypass was the most common bariatric procedure performed. Fifty-six (92 %) of 61 patients with recorded post-operative clinical history had resolution of their presenting IIH symptoms following bariatric surgery. Thirty-four (97 %) of 35 patients who had undergone pre- and post-operative funduscopy were found to have resolution of papilledema post-operatively. Eleven (92 %) of 12 patients who had undergone pre- and post-operative formal visual field testing had complete or nearly complete resolution of visual field deficits, and the remaining patient had stabilization of previously progressive vision loss. In 13 patients both pre- and post-operative CSF pressures were recorded, with an average post-operative pressure decrease of 254 mm H(2)O. Changes in weight loss and body mass index varied depending on the reported post-operative follow-up interval. The authors concluded that the published Class IV evidence suggested that bariatric surgery may be an effective treatment for IIH in obese patients, both in terms of symptom resolution and visual outcome. They stated that prospective, controlled studies are needed for better elucidation of its role. Laparoscopic Gastric Plication: Pujol Gebelli et al (20110 stated that laparoscopic gastric plication is a new technique derived from sleeve gastrectomy. Plication of the greater curvature produces a restrictive mechanism that causes weight loss. The results of the first cases where this technique has been applied in this hospital were presented. A review was made of patients operated on in the authors' hospital between November 2009 and December 2010. Plication of the gastric greater curvature was performed under general anesthetic and by laparoscopy using 3 lines of sutures and with an orogastric probe as a guide. Results of the morbidity, mortality and weight loss were presented. A total of 13 patients were operated on (7 women). The maximum BMI varied between 37.11 kg/m² and 51.22 kg/m² at the time of the operation. The most frequently found morbidity was nausea and vomiting. Two patients required further surgery due intractable vomiting and total dysphagia; in 1 the plication unfolded, and in the 2nd it was converted into vertical gastrectomy. The authors concluded that laparoscopic gastric plication is a new surgical technique which gives equivalent short-term results as vertical gastrectomy. It is a reproducible and reversible technique with results and indications still to be validated. Brethauer et al (2011) presented the results of a feasibility study using laparoscopic gastric plication for weight loss achieved without stapling or banding. After institutional review board approval, 2 methods were used to achieve laparoscopic gastric volume reduction. In the 1st group (anterior plication [AP]), the anterior gastric wall was folded inward from the fundus to the antrum using 2 rows of running sutures. The greater and lesser curvatures were approximated to create an intraluminal fold of the stomach. In the 2nd group (greater curvature plication [GCP]), the short gastric vessels were divided, and the greater curvature was folded inward, with 2 suture lines to reduce the gastric capacity by a large intraluminal gastric fold. The average pre-operative body mass index was 43.3 kg/m(2) (range of 36.9 to 49.0), and 3 patients were men. Of the 15 patients, 9 underwent AP. For the 9 patients who underwent AP, the 6- and 12-month endoscopic evaluations demonstrated comparable-size plications over time, except for in 1 patient, who had a partially disrupted fold. Of the 6 patients who underwent GCP, the 6- and 12-month follow-up endoscopic examinations demonstrated a durable intraluminal fold, except for in 1 patient, with a partial disruption at the distal fold owing to a broken suture. For patients completing 1 year of follow-up, the percentage of excess weight loss was 23.3 % +/- 24.8 % in the AP group (n = 5) and 53.4 % +/- 22.7 % in the GCP group (n = 6). No bleeding or infectious complications developed. The 1st patient in the GCP group required re-operation and plication reduction owing to gastric obstruction. The authors concluded that their initial experience has suggested that a reduction in gastric capacity can be achieved by way of plication of the anterior stomach and greater curvature. The early weight loss results have been encouraging, with better weight loss in patients who underwent GCP. They stated that the use of laparoscopic GCP warrants additional investigation as a primary bariatric procedure. Huang et al (2012) noted that the laparoscopic adjustable gastric band has been widely accepted as 1 of the safest bariatric procedures to treat morbid obesity. However, because of variations in the results and the complications that tend to arise from port adjustment, alternative procedures are needed. These researchers have demonstrated, in a university hospital setting, the safety and feasibility of a novel technique, laparoscopic adjustable gastric banded plication, designed to improve the weight loss effect and decrease gastric band adjustment frequency. These investigators enrolled 26 patients from May 2009 to August 2010. Laparoscopic adjustable gastric banded plication was performed using 5-port surgery. They placed Swedish bands using the pars flaccida method, divided the greater omentum, and performed gastric plication below the band to 3 cm from the pylorus using a single-row continuous suture. The data were collected and analyzed pre- and post-operatively. The mean operative time was 87.3 mins without any intra-operative complications. The average post-operative hospitalization was 1.33 days. The mean excess weight loss at 1, 3, 6, 9, and 12 months after surgery was 21.9 %, 31.9 %, 41.3 %, 55.2 %, and 59.5 %, respectively. The mean follow-up time was 8.1 months (range of 2 to 15), and the gastric band adjustment rate was 1.1 times per patient during this period. Two complications developed: (i) gastrogastric intussusception and (ii) tube kinking at the subcutaneous layer. Both cases were corrected by reoperation. No mortality was observed. The authors concluded that laparoscopic adjustable gastric banded plication provides both restrictive and reductive effects and is reversible. The technique is safe, feasible, and reproducible and can be used as an alternative bariatric procedure. Moreover, the authors stated that comparative studies and long-term follow-up are needed to confirm their findings. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records; and Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote);and Nutrition and exercise program(s) must be for a cumulative total of 6 months (180 days) or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least 3 consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of 6 months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.) Clinically significant obstructive sleep apnea; or Type 2 diabetes mellitus; or Pseudotumor comorbidities

Hi, I am back online to this site. I started about a year ago but did not care for the doctors or their set up so it's taken me a year later to get it together enough to try other doctor's. Anyway, I have my paperwork in but have not heard anything yet. I am 53 years old, married to my best friend for almost 30 years. Two children, two grandchildren and one granddog. My family is very important and love spending time with them. I have a great support network with family, friends and church family. I have severe arthritis and have been disabled for 5 years. Unable to walk, work and everyday mobility has brought me close to 300 lbs. My life took a total change when I could no longer walk, I have to use a walker and a scooter to get around. I am tired of not being able to live my life to the fullest and sitting on the sidelines. That's why I have resorted to Lap Band surgery. When I am able to lose 75 lbs. I hope to be able to have my knees replaced and then get back to a normal life style. I need a lot of help if anyone wants to contact me, I also would like to have recipes and figure out what to expect after surgery. I love to cook, sew, play with my grandchildren , attend church activities and was pretty active prior to the health problems after the 100 pound weight gain these last 5 years.

:omg: at 2 Philly steak sandwiches a month out!! That is crazy!!! :confused: Warning: Tough love coming.... Re: drinking during meals. We all CAN do it. We choose NOT to do it for maximum results. Re: eating everything.... The band does not make healthy choices for you. If you choose to shove carbs and crap down there, the weight will keep coming and you have wasted your time, money and energy. You have to make healthy choices!! If you can eat eat eat a lot.... then fine. Eat 4 boiled chicken breasts if you want to. Eat a whole package of steamed carrots. For munching, grab a plain yogurt or a banana. I think you were seriously misled if your surgeon told you that the band will do all the work and choices for you. The band is NOT bypass and is a dual partnership in which you must diet and exercise and use the band as a tool for weightloss. It will not be a catch all and it will not stop you from eating stuff that causes weight gain. Re: a month post op.... When did you start eating hard solids like that? What week? What were your post op instructions? Who is your surgeon? Where were you banded? Take your small bites slowly, chew well and rest between each bite, about 15 full seconds. DON'T drink before, during meals or after meals. Eat for maximum of 20 minutes and stop. Give it time to settle in your pouch first. The band WILL work and do its job. You have to work with it. :hungry: Once you deal with the head hunger, life will start getting better, I promise. Just hang in there!:clap2:

I originally posted this on the message boards and I thought I could reuse for my first blog: Hello everyone, So this is my first post here and here is my story… I am 29 years and I will hit the dreaded 30 next month. Not that I think 30 is old, I just can't believe that I am gonna be thirty and after all these years I have not be able to successfully manage my weight. Right now my scale is tipping at about 250. I haven't always been this fat. I would say that back in my high school days I was a little chubby. The last lowest weight I can last remember was 165 lbs in 2001. So I have gained 85 lbs in 8 years…wow. I have been happily married to my high school sweet heart for 6 years now and he is absolutely wonderful to me. He loves me as I am, no matter what. We have a awesome 18 month old son, who is the center of our universe. I was diagnosed with a under active thyroid (hypothyroid) when I was 16 years old. Both my mother and grandmother were also hypothyroid and overweight as well, so my all of issues are definitely built into my genetic make up. But I will admit that I have contributed to my 85lb weight gain by eating improperly and being lazy. We moved away from our family and friends right after we got married, so I have spent the last six years some what isolated from our loved ones. We happily spend every weekend lazy, in love and alone on our sofa. Fortunately my husband has been blessed with a amazing metabolism, and he is the same 160 lbs that he weighed on the day we got married. Now I will admit that I do have a food problem. But I am not a emotional eater. I actually lose my appetite when I am really upset. I am a 'bored' and 'lonely' eater. I snack when my husband isn't around. And I have no shame when it comes to making poor food choices…buffalo chicken, cheese burger, fries, pizza, chinese food…none of them any good. I have tried to lose weight in the past but always became easily discouraged and distracted when I didn't see any immediate results. I have always simply blamed my failed thyroid for holding me back. Although I know that is not 100% true. My life style certainly contributes. I saw a new endocrinologist a few years back and asked him if he had any insight on how I can approach weight loss while living with hypothyroidism. I mean, obviously he has seen plenty of patients with my condition…he must know someone who has had success. I just wanted him to share their secret with me. Should I give weight watchers another try…should I try jenny craig…should I see a nutritionist…can he give me a magic pill?!?!?! And then he gave me the old diet and exercise talk…as if I was stupid and never heard of it before. Ugh, whatever…thanks for nothing! I then decided to start seeing a new endocrinologist just because his office was closer to work and it was convenient. I asked him if he knew what the secret to weight loss was. Now before I tell you what he told me, I want to paint this visual for you. My endo is a 5 ft tall chinese man. He is straight from china and I really have to focus when he talks so I can understand his words clearly through his accent. He speaks very abrubtly and to the point. So when I told him that I don't believe I eat a lot but I just wanted know what he thinks I need to do, he told me…"it doesn't matter what you eat, just eat half! If the only thing you eat all day is a peanut, then only eat HALF a peanut the next day!" What?!?! As if that was even possible. I felt defeated again. But he actually seemed to take more interest in the health of my thyroid. He gave attention to a 2 cm nodule that my last endo identified and did nothing with. My new endo conducted ultra sounds and a biopsy. The biopsy results revealed that my nodule is non-cancerous but it was also not begin. My nodule cells are just irregular. They could remain irregular for the rest of my life or there is also the potential that they can become cancer at some point. Thyroid cancer is very, very slow growing. Regardless of what they are or would be, the option of having surgery to remove that part of my thyroid was completely in my hands. I could chose to monitor to the grow or I could choose to cut it out. So this is the part of my story that brings me here today...the whole idea of any type of surgery scares me. I don't want to be put to sleep and I know it is vain but don't want the scar on my neck. But I know that I want to live the rest of my life free and clear of the potential of cancer. My thyroid is sick to begin with and hasn't been working probably since I was 16 years old. I already take 224 mcg of synthetic thyroid replacement medication. I came to the conclusion that my thyroid is useless and they may as well remove the whole thing. My total thyroidectomy is scheduled for Feb 3rd. So I have been thinking about my endo's "half a peanut" theory and began to seriously consider lap band surgery. My mom has gastric bypass surgery a few years back and it has given her a new life. She has no regrets other than not doing it sooner. I want to live the next 30 years of my life differently from the way that I currently do. I want to run and play with my son. I want to look good standing next to my hubby. This posting is long enough, I am sure I don't need tell you guys everything that I want because I am sure they are same things that you want from life. So spoke to my husband, my mom and friend and I think I feel good about pursuing this. I am going to attend a Introductory Bariatric Meeting on 2/13. I know that this isn't the going to be the final resolution I was searching for. It is not a magic pill. But I believe that it a tool that will put me in the rigth direction. Thanks for your time!

I think the amount you consume depends on how far out you are from surgery. I personally feel you must remove the triggers to get some kind of control. If you are truly hungry feed your body some type of protein- I have tried drinking skim milk and waiting to see if that helps. 3 meals is what my NUT told me to aim for- since grazing will lead to weight gain. As you can tell that hasn't been what I've done lately! On a good day a Protein shake made with milk for breakfast- lunch about 2oz chicken breast chopped up in lettuce tomato carrots, with regular salad dressing- dinner 3oz pork chop with green Beans and about 1/4c of mashed pot. If hungry in between some Greek yogurt! I think I feel hungry when I am truly just thirsty... I have read that if you have all of your protein in for the day and you still feel hungry, drinking something will help. Be prepared have high protein food in your house. So when you go for something it will satisfy you longer. The sugar craving are getting better for me with each day I avoid them!

16 December 2010 Suddenly, I'm one week away from undergoing a vertical sleeve gastrectomy. It is almost too much to digest that this truly is the beginning of the end of my 15-year battle of the bulge? The long-and-short of my story is that I was a chubby kid, athletic high-schooler, super-athletic collegiate (squash team) and, league player in my twenties and early thirties. A back injury (herniated disc) whilst training for a tournament spelt the end of competitive squash and any form of athletic activity. A job for a bachelor that involves numerous lunch meetings and after-hours cocktail functions is a recipe for disastrously rapid weight-gain. The trouble with athletes who suddenly quit working out is that they retain their appetites and eat with the same care-free abandon as they did when they were burning it up in the gym. Thus began my long addiction to food. A 10-year marriage-to-date to a wonderful wife and excellent cook fuelled the addiction. Despite sporadic forays into the gym and some tennis, I went from 85 kg (187 lbs) in my playing heyday to my current 160 kg (351 lbs). I've gained the equivalent in weight of another entire adult human being. Interspersed in this 15-year saga were numerous efforts to lose the weight, the likes of which are all too familiar: cabbage Soup, Exchange, Atkins, X-Diet, etc. There was one time that I managed to stick to a so-called 'detox' eating programme that caused me to lose weight possibly at the same rate as many bariatric post-ops. I actually fought through the back pain and starting playing squash again. It was tremendously gratifying to fit into my college clothing once more. The diet itself, though, was tantamount to starvation and led to my becoming incredibly sad. Although not diagnosed as such, I came about as close as I can imagine to being chemically depressed. It makes sense, I suppose, that if you deprive yourself of fat and not take supplements, plus cut out salt and sugar without electrolyte replacement, you're not going to absorb fat-soluble Vitamins which has to affect one's sense of well-being. Short-lived was my renewed thinness because at the end of the two-month crash diet, my resolve came crashing down too. So pleased was I with reaching my goal that I celebrated with a hearty double cheeseburger from the world's greatest supplier of lard disguised as food and have been supersizing ever since. Five years ago when my doctor noticed the increase in my blood sugar levels and expressed alarm at my increasing size, I took notice but was sure I had the strength of mind to return to my athletic ways. I didn't count on the severity of my backache nor the added damage that must have been caused to my back lugging all this weight around over the years. When he asked his assistant to find out who did bariatric surgery in Canada, I really froze in my tracks. A failed business contract, the commencement of accounting studies towards a different career and a home relocation found me in the offices of a new personal care provider. I discussed my weight with my new doctor and told him what the previous one had suggested. This time, I assured him, I wanted it too. That was two years ago. The wheels of the Canadian public healthcare system grind slowly. It took about a year to first see one of only three bariatric surgeons serving our entire province. At the time, the wait-list to have surgery here for free was around 3 years. I had two visits with the surgeon spaced six months apart. In that time, the only hospital where bariatric surgery is performed in our province announced a 60% cut in the budget for the procedure. This further clogged the bottleneck and increased the wait-time for surgery to 5 years. I couldn't afford to self-pay abroad so explored a not-so-well-published option of out-of-country-funding by our provincial health insurance for elective surgery. When I was approved, it felt like I had won the lottery (indeed I may have in terms of longevity). In fact, the first time I knew the outcome of my application was when I checked my voice-mail one evening early in November. There was a cheerful message from Virginia Mason Medical Center in Seattle regarding a referral. There was no mistaking then that funding had been approved. Until a few weeks ago, I was working nights as a security guard whilst studying accounting through night classes. I kept playing phone tag with the administrator of the bariatric office until we eventually connected and set the ball in motion. Since her first voice-mail on Nov 5, I have been scheduled for surgery on Dec 23 and am seeing my new, American surgeon for the first time this coming Monday. The pace of things South of the 49th parallel is at lightning speed by comparison. I had two final exams to distract me these past weeks but can now fully concentrate on preparing for surgery. I'm an irreligious, sceptical 46-year-old so there's some irony in getting a gift of sorts (we actually pay a sizable premium for health insurance so it's a right rather than privilege) when the rest of the Western world is exchanging trinkets and electronic gadgets in State-mandated spending sprees. I'm deliberately trivializing the arbitrary commercialization of the Winter solstice against what in my case will amount to better health and possibly, longer life. ------------------------------------------------------------------------------ 19 December 2010 With not a little trepidation, I pointed the car South and put pedal to the metal. It must have been the fatigue after a late night at Mark and Stacey's party rather than a hangover--I was careful not to overdo the Jägermeister and spiked punch--that made me want to get this journey over with. Testing a new pair of progressive lens glasses from behind the wheel for the first time, I made a beeline to Dave's house in Tacoma where I would be spending the night. Everything seemed a little clearer on the drive down. I have known Dave since I first started playing squash at the YMCA in the centre of Tacoma, WA. In 1990, I was wrapping up the penultimate year of my economics degree and Dave was a high-risk options broker. A substitute for one of two older brothers that I never had, Dave was a mentor and friend. In fact, it was on a trip that Dave sponsored to a squash tournament in Vancouver that sparked my love for the city that my wife and I now make our home. Cut back to a year earlier when I met fellow ex-South African, Claude where we played squash at the same club in Los Angeles. Claude had had his full of LA and when he heard that I was heading to the Pacific Northwest to complete my studies, he and his wife, Lynelle contemplated selling up and following suite. After a few visits to me in Tacoma, both were sold on the idea and moved. From being an only son with two sisters, I was privileged to now have two brothers in the same town. Needless to say, over the years, both these guys have watched anxiously as my weight practically doubled after my return to South Africa and subsequent emigration to Canada. They were always classy enough not to chide me but often asked how my squash was, as if to prod and propel me back onto the courts. Dave's wife, Rasha had prepared a magnificent prawn dinner with Pasta which we washed down with red wine followed by sliced kiwi fruit and pumpkin pie. Over several rounds of backgammon, we dissected and analysed the American economy. It was indeed a last supper of sorts. Having solved the problems of the world, we all turned in for the night. The next morning would be quite eventful for me. Dave had pancakes on the stove and heaps of bacon sizzling in a pan. The last Breakfast, he said. With a mouthful of pork, I told him this felt like taking a drink before meeting one's parole officer. When Dr. Jeffrey Hunter walked into the room with a beaming smile and firm handshake, I knew immediately that my surgery next Thursday would be in safe hands. During the 20-minute drive from Dave's house to the hospital, I didn't once doubt my decision to pursue the surgical path to wellness. This surgeon and his staff reinforced it. Everything at my first visit to the man who will next week be removing the greater curvature of my stomach, representing 85% of it's current size, went swimmingly. My visit included a lengthy stint with the nutritionist who walked me through the diet plan that will be the mantra that I chant over the next several weeks. With my sights set firmly on Protein shakes and lean cuts of meat with heaps of spinach leaves, I made tracks to Claude's in the hamlet of Woodinville a few kilometers Northeast of Seattle. Claude owns a house with a veritable park for a backyard complete with flowing stream all nestled amongst giant douglas firs. I love going there. With the clock ticking to get back to Canada to fetch Shamin at work, Claude and I barely had time to do a deep analysis of what Obama and the Democrats are doing to fix the problems of America before we spirited ourselves off to a Mexican restaurant. The last lunch, Claude called it. Faced with a two-hour drive, I declined any liquid nourishment and stuck to a black bean soup plus a quarter of Claude's chicken enchilada. Not only had my brothers treated me to some pretty amazing meals, but Shamin had ideas of her own when I fetched her. We made tracks to our favourite sushi spot in our hometown of White Rock and indulged as only convicts facing the gallows can, with the maki 18-piece combo, miso soup, agadashi tofu and mugs of green tea. Shamin said that this was our last supper. Since Saturday, I have had three last suppers, one last breakfast and one last lunch. And thanks to Mark and Stacey, one last party. -------------------------------------------------------------- 6 January 2011 It's 11h30 and two weeks to the hour that I was being wheeled into surgery. What Shamin expected to be a 45-minute routine procedure like a visit to the dentist, an impression I had created, turned out to be a 2-hr major operation that resulted in yanking out 80% of my stomach. Mostly the upper curvature, the stretchy part of the stomach, was removed leaving me with a pouch about 4-6 oz in volume, the size of a small banana or 2/3 of a cup. This new pouch does not stretch. I chose this particular version of bariatric surgery to avoid some of the malabsorptive issues related to Roux n Y (a.k.a. RnY or gastric bypass), the current gold standard of WLS, and to be able to take anti-inflammatories as and when I become lighter on my feet and engage in more sport. The sleeve gastrectomy went quite well and there were no complications. My first night post-surgery though, was rough. I was in a lot of pain from the surgery and kept burping which caused quite a bit of discomfort. The staff at Virginia Mason Medical Center in Seattle is absolutely top-drawer and took excellent care of me. The next day, the barium drink during the x-ray in order to check for leaks and make sure that Fluid was passing through the stomach via. the pyloric valve into the small intestine, ranks amongst the most vile stuff I've ever drunk. It was all I could do to keep from throwing up. Isn't it remarkable how attuned you become to everyone's expressions when you're a patient? Why is the nurse frowning at my chart and how come the doctor is gesturing so animatedly? When the surgeon and the radiation team relaxed as the barium made it's way successfully through my tract, I also breathed a sigh of relief. Later, one of the nurses explained to me that they medicate the stomach to near-lifelessness in order to operate on it, then it becomes of paramount importance to revive it as soon as possible the next day. So they're constantly listening through the stethoscope for signs of activity. You'll never see from polite company or one's wife quite the kind of elation when you tell them that you've farted than erupts from the nursing staff when you inform them after bariatric surgery that you've passed gas. In fact, after your first bowel movement if indeed you have one, they're ready to hand you a trophy and send you home. Two days after surgery on the 2010th birthday of our lord Jesus, I was desperate for a shower. After I accidentally yanked out my glucose supply line, they deemed me fit to be discharged. Shamin helped me get my things back to the hotel room. No sooner did we set them down than we were in the car heading to Kirkland for lunch. Shamin drove. On the menu was medium rare sirloin, baked potato, crumbed shrimp and salad, with cheescake and chocolate for dessert. I pigged out on soup broth and sugar-free jelly. Wine flowed liberally so two days after surgery, high on oxycodon, it fell to me to drive back to the hotel. In fact, the next day, I took the wheel to blaze a trail out of Seattle and made it half-way back to Canada before succumbing to fatigue. Things went a little pear-shaped the next morning, my first back in Canada. I chewed on my gummy bear Multivitamin, followed by some flavoured Water with a crushed metformin. Later, a bit of cream of wheat fortified with whey protein isolate seemed to be competing for limited space. In the middle of a Skype chat with my sister in South Africa, the cream of wheat wanted out and I hurled for the first time. How on earth am I going to get in 70 - 100 g of protein with this little stomach volume? The summary of my food intake is protein and more protein, very, very little carbohydrates and almost no fats and sugars. I'm also on a cocktail of Multivitamins, Iron, B12 and Calcium supplements to compensate for the limitations of the new diet. Modern multivitamins and supplements are chewable and tasty so, incorporated as Snacks, you don't even feel like being medicated. Combating dehydration is now a way of life. I have to walk around with a bottle of water and sip constantly between meals. As it is early days yet and I'm only now graduating to pureed foods, I have to space out my spoonfuls in order to avoid an extreme sensation of fullness and subsequent pain. Recently, I was able to finish a whole cup of veggie soup over two hours whilst watching a movie. It now takes about 4-or-5 teaspoons of food to achieve a feeling of fullnes whereupon I start to belch. Any more hurts like hell. One more bite is like trying to stuff one more marble into an already full jar. There’s no give whatsoever. The greater curvature of the stomach is where your stretchy material resides. Mine has been removed and sealed shut with three lines of staples. My very compact stomach pouch has a valve on both it's entrance from the oesophagus and exit into the small intestine, respectively. Therefore, it is a closed container under pressure, implying no more fizzy drinks that could release carbon dioxide and cause immense discomfort. Adios beer, hello wine, vodka and whiskey on the rocks. I’m currently paying lip service to six meals a day; I can barely manage one, and two Protein Shakes. Yesterday morning, I bravely scrambled a single egg with a tiny amount of spinach and a sliver of cheese. I got through half of it, then ate the rest several hours later. Interspersed between meals, I’m supposed to sip about 2 litres of water. What a bloody joke! I’m averaging about a litre. The only things I’m making sure I consume are the multivitamins, iron supplement and chewable calcium sweets. They’re like dessert. Oh, I do get to enjoy as much sugar-free jelly that I can handle and I never seem to tire of it. Within a few weeks, there will be little external sign that I had any surgery. As the whole affair was done laparoscopically, I’m left with 5 little scars on my belly that is already mostly healed. Once fully-healed, I'm heading to the swimming pool to start exercising. I hate walking at the best of times. Oh yes, the million dollar question; I first met the surgeon on 13 Dec and went on a pre-op diet for 10 days. I lost 10 lbs (4.5 kg) in that time. In the 24 days since, I have shed a total of 36 lbs (16.3 kg). I have been told by my dietician that it is not unrealistic to expect to shed around 75% of my excess weight over the next six months. When I started out, I was 351 lbs (160 kg). I'm now 315 lbs (143 kg). The next milestone is to break the 300 lb mark, a weight I haven't been in over a decade. --------------------------------------------------------------------------- 13 January 2011 If there's one thing that I've discovered post-op, it is precisely that old habits can die easily and very, very quickly at that. There is nothing quite as drastic as once being able to virtually inhale a three-egg omelette with cheese, green pepper, mushroom and bacon and, sausage and hash browns on the side, followed by a cup of coffee, to hoping-upon-hope that the single boiled egg you're just about to tackle for breakfast won't fill you after just three bites. Such is the drastic nature of this procedure. The sense of fullness isn't the same satisfactory one as before. Rather, it takes you by surprise. One minute you're savouring the taste of just your third spoonful, then you feel a slight burp and know you ought to stop right there-and-then. But being a man, you bravely go for the fourth and the pain hits from nowhere. The tightness in your stomach is indescribable. It feels like your chest is going to explode and you wonder why-oh-why you were ever so greedy as to dare to eat a whole fourth spoonful. This surgery is like having an electric shock device around your ankle when you're on parole. Any deviance in the eating department and you're very quickly zapped into line. All went well the first two weeks post-op with a little heartburn to contend with. These past few days, I thought I was going to meet an untimely demise from acid reflux. How embarrassing is that? Even in my drinking heyday, I had never felt anything quite like this. Back in the day, you puked, you rinsed, you slept (not necessarily in that order) then got up, nursed the hangover and picked up where you left off. This time, the reflux was a whole new kettle of fish. Anything short of standing bolt upright had acid gurgling at the back of my throat. sleep was almost impossible. Yesterday, I finally collected from the pharmacist in capsule form a potent antacid which has proven to be the elixir for which I had been waiting. Last night for the first time in days, I got a full night's sleep and am feeling very refreshed finally. The surgery is doing its work. I have shed 17 kg in 30 days. The last three days, there's been a slight lull from my average loss of a pound-a-day. It might be because I have been struggling to get in the dietitian's requirement of 70 - 100 g of protein per day. A single egg has just 8 g of protein. Given the minimal volume of my stomach of around 130 ml, it would be impossible to meet the protein requirement from food consumption, the equivalent of 9 - 12 eggs. The solution to the dilemma is whey protein isolate shakes that body builders use. I mix it with something called enriched milk (skim milk fortified with powdered milk for the extra protein) and knock them back in 15 g slugs. Even that requires about 5 drinks a day. As tasty as vanilla and chocolate flavour is, after a while you just want to gag. Interspersed in all this protein intake is a requirement to rehydrate constantly. Water, jelly, electrolyte drinks and more water, 2 litres minimum of the stuff per day, is what is required. There just isn't enough room for it all. To combat the potential for malnutrition, for the rest of my life I have to take a multivitamin and iron supplement with breakfast, then three doses of calcium supplements the rest of the day. They're all in chewable form so it feels like snacking on sweets for dessert. Also, once-a-month, I have to get a Vitamin B-12 injection. On the plus side, I've kicked the type II diabetes that required two metformin pills a day. Which would one rather have, is the big question. There's no telling what the consequences of diabetes is, ranging anywhere from gangrene and the amputation of a foot to a stroke from high blood pressure. Yikes! By far, the nuances of bariatric surgery are a nuisance I'd rather have. --------------------------------------------- 13 February 2011 It has been so long ago that I was last under 300 lbs, I have kind of forgotten which era of my life that was. There is a selection of still-new clothing in my closet that is too tight for me so I obviously bought them when I was thinner than I am now. I have to try to recall when I bought--and almost immediately outgrew--them. Did I buy them in Canada at my favourite fashion store, Walmart, or in South Africa at my similarly popular source of bulk thread, Makro? If memory serves me right, I don't think I ever felt this 'trim' since arriving in Canada in 2004, and I certainly had one hell of a paunch during my wedding in 2000, so we may well be looking at the late 90's. I would be lying if I didn't admit that my latest stall was getting the psychological better of me. I mean, here I am post-major-surgical-procedure to lose weight, barely able to imbibe half-a-cup of food per meal that fills me for hours, and getting nowhere near the required amount of protein, only to hover tantalizingly above 300 lbs for the last few weeks. Like everyone, I went dramatically from 351 lbs pre-op to around 305 lbs. The expectation that this kind of rate would be sustainable is rich to say the least, yet it becomes a pipe-dream for the morbidly obese. Luckily, I didn't go into the kind of depression that resulted in starvation to achieve this milestone. I stuck with the programme, sucked down protein shakes to make up the deficit, ate the soy sausages and even relished the chocolate-coated Protein Bars that 10 years ago would have made me gag. My exercise regimen has included some very basic exercises because I still feel a little too weak to go for lengthy walks, let alone jog or play squash. I timed my exercise routine. It took me exactly 13 minutes (12h00 to 12h13) to do 20 reps each of the following: squats (feet shoulder-width apart, only squatted as far as was comfortable) crunches (lying on back, hands clasped behind head, tried bringing up head to knees, could barely get my head off the ground) leg lifts (lying on back, palms face down under buttocks, just lift feet off ground) cheat pushups (on my knees instead of the traditional way) left bicep curl (using a shopping bag filled with our new duvet as a weight) right bicep curl (ditto) left tricep extension (ditto) right tricep extension (ditto) bench press (lay on bed and pushed the 'weight' towards the ceiling) shoulder press (shopping bag as weight, standing legs slightly apart, raised 'weight' to ceiling) left side bends (standing feet slightly apart, hands clasped behind head, lean twice to the left, then back upright, will use make-shift weight in future) right side bends I did these 12 exercises (so a little over a minute each on average) on a mat in the small space between the bed and the wall. My gym outfit was my boxer shorts and I went barefeet. I will continue to use my make-shift dumbbell until we find that ideal duvet cover. Who needs a gym, eh? It has now taken me longer to describe my exercise than the workout itself took. How did I find the excuses to avoid exercise in the past? Which brings me to the topic of constipation. What is up with that? I guess the minimal food intake is as much to blame as the lack of hydration. I have struggled to drink the suggested amount of water and am hoping that the protein shakes count as both nutrition and fluids. No doubt, the body tries to absorb as much of whatever little it is now getting and often tempers the metabolism in anticipation of famine rather than feast. So, as much as toilet humour provides endless hours of mirth in slapstick comedy, it is a serious topic when it comes to diet and weight-loss. Not having a bowel movement for two-to-three days is discomforting to say the least. The medical team knows about this and is ready to prescribe suitable 'stool softeners'. Instead, I've re-discovered prune juice. "What does all this have to do with the scale," one wonders? Well, when you're desperate to reach certain weight milestones, like lose 50 lbs or 100 lbs, or achieve a specific weight, 300 lbs in my case, you start to become very particular about what exactly it is that you're weighing. In my mind, any food or liquid in my intestine is not part of my body weight, hence has to be expunged before the weigh-in. How ridiculous is it that I was careful not to swallow any water whilst brushing my teeth in the morning? Sometimes, the mind concocts ideas that descend rapidly from the sublime to ridiculous. To cut to the chase, after yet another morning leaving the toilet tissue undisturbed, I stepped trepidly onto the scale and weighed in at 298.4 lbs. The sensation was overwhelming. For all intents and purposes at 05h30 on a Sunday morning, I ought still to have been in bed. But an early night and a full bladder resulted in an early morning and my usual interlude with the scale. My wife was still fast asleep so it took enormous restraint to squelch my desire to yelp. With an enormous weight off my shoulders, no pun intended, I have a spring in my step today. At last it feels like the programme is on track again. I have regained all of the confidence in the surgical procedure that I had going into it. The overwehlming evidence of its effectiveness just from the experiences of its alumni should have been convincing enough. However, it still requires one's own adventure with it to fully come to terms with its benefits. I look forward now to tackling the next 100 lbs. -------------------------------------------------------------- Tuesday, 22 March 2011 I love numbers because, unless manipulated by accountants and politicians, they tend not to lie (a bold statement from a would-be-accountant). When I first started exploring bariatric surgery as a solution to my morbid obesity, one of its wilder claims that attracted me to it was that a person could lose 75% of his excess weight within 6 months. At the time, I was 351 lb (160 kg) and felt that I needed to get down to 220 lb (100 kg). In total, that would imply a loss of 131 lb (60 kg). 3/4 of that is 98 lb (45 kg). Could I really lose 45 kg in 6 months, in other words, 7.5 kg per month? It seemed too good to be true. A 45 kg loss in weight would put me at 115 kg, a weight at which I once used to play a half-way decent game of league-level squash. As I read more about the effectiveness of the surgery, I became giddy in anticipation of becoming a veritable gazelle within just six months. At the 3 month mark since my vertical sleeve gastrectomy, I weigh 280.4 lb (127.5 kg). I have lost a whopping 71 lb (32 kg). This implies a rate of loss of just over 22 lb (10 kg) per month. If this is sustainable for another three months, I'm on track to blitz right past the projected 6-month, 45 kg loss. It even tickles a tantalizing fantasy of shedding the entire 60 kg within 6 months. Reality dictates otherwise, however, because the initial rate of loss post-op is staggeringly high versus what it's become, hence a much larger drop in weight immediately post-op. Still, a gander at my weight graph in the health tracker shows a fairly straight line with a constant slope. With some hesitation, I'm tempted to adjust downward my overall weight-loss expectation to around 187 lb (85 kg). Before my op, I asked the surgeon whether this was feasible and he said it certainly was. At the time I didn't believe him but now I'm not so sure. I remember very well when I was last 85 kg. It was in 1991 when I was at my fittest ever and about to play in the B Divison at the US Open Squash Tournament in Portland, OR. In the second round, I lost a 5-game marathon to the top-seed and shed 8 lbs of water weight for my effort. Back then, I was a fairly well-oiled machine and knew intimately the effects of food on my body. A diet on a student budget, comprising instant noodles with broccoli, tuna, pinto Beans and chicken kept me in trim. Toasted sandwiches with hotdogs, cheese and mayo inevitably translated into an upward tick of the scale. -------------------------------------------------------------- Sunday, 27 March 2011 More on the numbers, this time regarding my recent lab tests. In summary, they're all good and a reversal of where they've been the past decade. I've moved into the normal range in just about all the important categories. Even going back 10 years to my mid-30's, my blood sugar levels--as measured by Hemoglobin A1C and Fasting Glucose--were always a couple of points above normal though nothing worth calling out the cavalry for. Even the Urine Albumin or ACR (Albumin/Creatinine Ratio) which is a gage of the level of functioning of the kidneys, was just above normal. When my personal care physician (PCP) a.k.a. family doctor diagnosed me with Type II Diabetes, it was almost tongue-in-cheek. He said that each measure, on its own, was not worth a diagnosis of diabetes but, together, ooh, aah, maybe, why not? "Diabetes! Take a couple of Metformin daily and see me again in three months." At the time, it sounded more like he was obliged for ethical and liability reasons to come to a conclusion of diabetes rather than any concrete proof of the disease. Thus began three-monthly visits to the labs to test these two variables, as well as an annual visit to the optometrist to photograph the back of my eye. This was to see if excess blood sugar was causing the rupture of capillaries back there. The eyesight of diabetics deteriorates for this reason rather than from the normal decline around middle-age from retinal mal-function. Another ominous feature of my blood was elevated pressure and high levels of cholesterol, especially the abnormally high ratio of total cholesterol to bad (LDL) cholesterol. Neither was ever high-enough to warrant medication but required a change in diet that favoured fish and chicken over red meat and, an increase in leafy greens. My dietary approach was to ignore the advice. The PCP was vindicated in his diagnosis of diabetes. While the ocular capillaries were always intact, the blood sugar levels were not. I initially avoided the Metformin like the plague and it showed in the tests. As soon as I started taking them, the numbers came down though never into the normal range. It was plainly obvious that my body was not processing sugars normally. In fact, the endocrinologist to which my first bariatric surgeon had referred me emphatically increased my Metformin dosage from two- to three-a-day. There must have been something more compelling in the numbers that he saw leaving me feeling a little disingenuous for doubting my PCP. It's a coincidence that my three-monthly lab date was just before my VSG. It meant that I had fresh numbers for comparison and could attribute any changes in my digits directly to both the surgery and post-op dietary changes. Prior to those pre-op labs, I had been on a high-protein, leafy-green diet to shed some weight, get my body into ketosis mode and, reduce the size of the liver and rid it of fats and sugars. Despite that, my numbers were still off the charts. A tabular summary of the results are: Normal Early Immediately Post-op Range Dec '10 Pre-op Mar 2011 Glucose 3.6-5.5 mmol/l 7 (high) 6.4 (high) 5.3 (normal) A1C 4.8-6.2% 6.8 (high) 6.6 (high) 6.0 (normal) ACR < 2.0 2.1 (high) 0.8 (normal) Chol. 2.0-5.2 mmol/l 4.6 (normal) LDL 1.5-3.4 mmol/l 3.3 (normal) HDL >0.9 mmol/l 0.9 (low) Chol/HDL <5.0 5.1 (high) Triglyc. <2.3 mmol/l 0.9 (normal) BP 120/80 120/80 (normal) I'm reasonably pleased with the results though everything could come down a notch, especially the cholesterol level. -------------------------------------------------------------- Tuesday, 24 May 2011 Almost 21 weeks since surgery, I find myself still picking from the hors d'oeuvres or soup section of the menu while my short, slightly-built wife has her pick of the Entrees. It's an ironic reversal that is actually working quite well for our appetites and budget. For the wait staff, however, it's enormously confusing. The order taker has to first scowl at me for declining anything to drink, not even water, then frown harder at my minimal order. I don't always feel that it's necessary for me to explain why I cannot drink 30 minutes before a meal. There is usually a progression from amusement to bewilderment as the paltriness of the order registers. "Are you sure that would be all?" I get asked whilst being physically sized up against my order. As he turns to leave, you can almost read the, "What a cheapskate!" facial expression. Initially it might be understandable that I'm too cheap to order a beer or glass of wine. But for such a big fellow to cut costs with just the cup (not even the main-course-sized alternative) of clam chowder while the lady chooses the lamb shank with potatoes and gravy is just wrong. It doesn't end there. If a different person actually brings the meal to the table from the kitchen, there is the almost mandatory politically correct query about which meal is for whom. To avoid any question of ridicule as it's obvious that the mountainous lamb shank is for the big chap and the lady is watching her figure, I find the main course heading my way. At least the order taker had time to digest the information; this poor character shakes his head almost as if we the customer got our own order wrong. ------------------------------------------------------ Thursday, 26 May 2011 The converse of the non-surgical victory (NSV), something with which bariatric post-ops become quite familiar even only a few months post-op, has to be the non-surgical disappointment (NSD). In the wake of the breakneck speed at which we lose weight, start fitting into old clothes, get compliments from people and become more active, we run the danger of expecting too much too soon. Coupled with a stall at the 22-week mark, I experienced my first NSD when my scuba wetsuit proved two inches too tight. If you know these infernal things, the zipper is at the back, like those embarrassing surgical gowns. I guess if it had been wet which is when it is more stretchy, I might have been able to squeeze it shut until my blood stopped flowing. So rather than pass out, I go it the heck off and resolved to be patient a few more weeks. -------------------------------------------------------------- Thursday, 23 June 2011 Today is a weight-loss surgery (WLS) milestone for me. Exactly 6 months ago to the hour, I was in my ward at the Virginia Mason Medical Center in Seattle, WA recovering from my vertical sleeve gastrectomy earlier that morning. The six-month post-op period is significant in the WLS context because it is considered the 'honeymoon' period during which the most rapid rate of loss occurs, as much as 75% of the total weight needed to be reduced. Of the 70 kg (154 lb) that I needed to shed at surgery, I have kissed 49% away so my experience has been closer to average. I'm half-way there with the rest expected to take another year to come off. As a matter of fact, I reached my current weight about a month ago so my honeymoon may have ended prematurely. I seem to have entered the dreaded post honeymoon stall that is experienced by many WLS recipients. This is not the end of the loss because my caloric intake is still miniscule. It may be the body's response to what is essentially starvation (in relative terms, of course) in which it hangs on to whatever it is fed. That's all well-and-good and I'm not panicking. I continue to get full on tiny portions. I have pushed the envelope on a few occasions with one bite too many, and paid the price in the form of extreme pain and discomfort. It's a vast change in psyche compared to the heyday of binging with a stretchable stomach. That was when I could eat through any sensation of fullness whereas now I'm alert to any signal of fullness. Around three bites into a meal, I start to notice a slight churning in my stomach accompanied often by a tiny belch. Of course, this sensation is commonplace to anyone who hasn't had surgery. It is only unusual in my case because it occurs so much earlier. At that point, most normal people would be exlaiming that they have left just enough place for dessert. I, on the other hand am good for just one more bite which, if I reserved for dessert, would be depriving myself of a crucial opportunity to ingest protein. Most of this description in any event is pertinent to meals of dense protein comprising fish, chicken, red meat or soya. A small bag of popcorn goes a longer way in which I have to allocate an entire segment of about 3 hours to indulge. Cynics may be critical of the fear-driven disincentive to eat and they would be right. You should not be averse to food and certainly not terrified of getting full. That kind of mentality coupled with societal pressure to conform aesthetically spawns a whole range of eating disorders that include bulimia and anorexia. Overweight people such as I are often like petulant children who want our cake and want to eat it. The surgery is just the wooden spoon of discipline. So wish me luck as I tackle the next 50% over 12 months. -------------------------------------------------------------- Sunday, 26 June 2011 The irony of getting a question in a letter from someone named Ruth was enough to send me into paroxysms of laughter. She's not Dr. Ruth, just my friend's daughter whom I've known since the mid-80's. She wrote: "Wow, Neeven, you look so great! You must feel really good too! How has your weight loss changed your life? Ruth". To this I replied simply (yeah, right!), "Dear Ruth Thanks so much for the compliment. Indeed I feel good courtesy of numerous changes to my life, both psychological and physical. The most important of these has been a more optimistic outlook despite bleak circumstances. Just being able to leap out of bed with ten times more energy rather than dragging myself from under the covers is testimony to that. My mobility is vastly improved. I am walking everywhere now, back on the tennis courts with a vengeance and, after a few more lost pounds, even contemplating a squash membership. I played tennis this morning against a chap who 24 years ago used to play competitively. He tired after the first set while I was still good to go. It was a big boost to my confidence that my fitness has improved so much. I was chasing balls that I used to let fly past and taking the extra steps to better position myself without the fear of exhaustion. It is easier to get in-and-out of cars. I no longer have to shuffle in the aisles between restaurant tables and risk knocking over some poor diner’s beverage. I can see my shoelaces again and even bend down to tie them without needing a respirator afterward. From opting for the stairs, to sharing a bench with someone, to stepping aside in an elevator to allow one more person in, I’m considerably more self-confident. It’s taking some getting used to the attention I’m receiving from friends who are noticing the difference. Those who have been with me from the beginning have continued to be tremendously encouraging and supportive. Others who see me after a very long interval struggle with the awkwardness of commenting on my physique. They want to gush at how ‘good’ I now look but suddenly hesitate at the implied suggestion that I used to be a slob. Yesterday, at Shamin’s company’s annual Summer picnic, most of her colleagues had last seen me mere weeks before I had the surgery, squeezed into my suit and wolfing down chow at the Christmas function. This time, many targeted me for conversation to inquire how I felt, what I was eating and whether I had struggled. I’ve never been coy about talking about the surgery (and neither is Shamin at work, it appears) so I was flattered that they wanted to chat and heap praise on me. I soaked it all up Stephen Colbert style, like a seasoned celebrity. I made the mistake of not logging my body-dimensions pre-op but I guess my loosening clothing is measure-enough of what used to be. I say that tenuously because a lot of what is now too big for me, was actually once very tight for me. I used to bulge out of my jeans so my girth must have been a lot larger than the diameter of the trousers. Near the end, I couldn’t button my suit coat and the ski jacket that I wore during my Dec. ’09 visit to New York shows evidence of strain on more than a few seams. From shirt collars that used to choke me, to button holes that protested, to belts that didn’t even fit but now need new holes, there’s no shortage of evidence of my shrinkage in my wardrobe. Heck, even my feet slip into my shoes more comfortably. By far the biggest compliment I get is from Shamin who is highly critical of my aversion to spending instead of splurging on a few pants, shirts and jackets that actually fit. I sometimes catch her giggling at how much of a clown I look like in jeans with a crotch that hangs too low, or a favorite sweater that now reveals my clavicle. My logic is that I’m just a few inches from fitting into four brand new trousers that I outgrew the instant I bought them years ago. The reality is that as good as it has been, I’m only half-way down this journey with another 80 lb of loss still to navigate. I’m going to get much smaller (how many guys actually say that with a straight face?). It will now fall off slower but fall it will (hello, still talking about the weight here...!), so I’m biding my time before incurring the expense. We’re saving in other ways. I select from the appetizer section of restaurant menus and my share of the consumption of household groceries is negligible. That is partially offset by the introduction of pricey protein shakes, protein bars and a cocktail of nutritional supplements to the grocery list though there’s a net saving against breakfast Cereal, candy, soda and potato chips. My life was worsened for the sudden development of GERD post-op which persists intermittently but guaranteed to flare up by my favorite, curries. We used to prepare it spicily-enough to remove paint from a ship’s hull, whereas I can barely handle black pepper on my 4 oz steak now. I have become partial to fat-free, white-sauced foods rather than their tomato-based alternatives and, in general, just a whole lot more finicky about meals. I approach every meal with a certain trepidation. This selective eating is a two-edged sword that deprives me of the tastes I once savored, but further promotes my weight-loss. Now do you regret asking a simple question? Your friend Neeven"

What does everyone mean by supervised weight loss ?? I have to be weighed for 4 consecutive months with no weight gain , I can lose but not significantly. Is this considered my supervised weight loss ? I am required to meet with a nutritionist for clearance. Or is the nutritionist my supervised weight loss ? Sent from my iPhone using the BariatricPal App

Surgery was 4/23. I gained 18 pounds in 3 days while still in the hospital after my sleeve. I was readmitted to the hospital 8 hours after my initial discharge after it was found I had lost blood flow to 20% of my spleen, presumably from a blood clot. I received a large amount of IV fluid in that time which resulted in those 18 pounds. I lost that in 5 days plus an additional 9 pounds since, but to me, those 18 pounds of fluid "don't count". I was just wondering if anyone else had a large weight gain immediately post-op.

I have Anthem BC/BS. Our plan is called a POS (point of service) Don't know how that differs from PPO or HMO. I am in the early stages of this process. My doctor did a referral in Jan. and I will see the surgeon for the 1st time on March 13. Because I have read about such a variety of experiences w/ BC/BS I did a little investigating in regards to the policy I have through my employer. What I found is copied below. The caveat is that this is specific to the policy my employer subscribes to. If you go to the Anthem site (http://www.anthem.com/ ) and look up your state, you may be able to find out what the policy is re: WLS based upon the plan you subscribe to. Medical Policy Subject:Surgery for Clinically Severe ObesityPolicy #: SURG.00024Current Effective Date: 04/16/2008Status:RevisedLast Review Date: 02/21/2008 Description/Scope Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. There are a variety of surgical procedures intended for the treatment of clinically severe obesity. This document addresses those procedures. Policy Statement Medically Necessary: Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria: BMI of 40 or greater, or BMI of 35 or greater with co-morbid conditions including, but not limited to, life threatening cardio-pulmonary problems (severe sleep apnea, Pickwickian syndrome and obesity related cardiomyopathy), diabetes mellitus, cardiovascular disease or hypertension; AND The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND The physician requesting authorization for the surgery must confirm the following: The patient's psychiatric profile is such that the patient is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and The patient's post-operative expectations have been addressed; and The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and The patient has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and The patient's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and The patient's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed. Surgical repair following gastric bypass and gastric restrictive procedures is considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band hermiation, or pouch enlargement due to vomiting. Not Medically Necessary: Stretching of a stomach pouch formed by a previous gastric bypass/restrictive surgery, due to the patient overeating, does not constitute a surgical complication and the revision of this condition is considered not medically necessary.

I spoke with my doctor this morning. She said my thyroid is fine and that she's checked that evertime I've done blood which was done late September and we do it almost every other month. Doc says the weight gain is most likely from the limited mobility due to my fibromyalgia. I've definitely slowed down a lot...Ive never been an over eater, I just wasn't eating the proper foods and that coupled with lack of exercise and late night dinners has made me this way. My hate for food may be why I chose to eat less, I always knew it wasn't good food goin in so I never ate a lot.. For all those that say I'm not being honest with myself, understand this, I am not here to give a false image, I'm looking for advice and encouragement. Whatever u did to gain weight is what u did, I know how I got here...lets stop insinuating I am a liar. Thanks for all the advice. I now know its not my thyroid. My doc says that since I've started my meds for the fibromyalgia, it will allow me over time to be able to work out and that mixed with the surery and my new eating habits will help me get my life back..I jus hope she's right. Also it will prevent my family history diseases, and assist with infertility issues..weight loss is the cure for way too many things..lol.