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Forgot to ask this question of my doctor so thought I would throw it out here. Does anyone know when the new AP band expires? Has anyone had one long enough to know when it should be removed? Is the price less if you need to replace it due to just everyday wear? I am guessing weight gain would be a symptom of it starting to errode or just not work any longer? I know nothing lasts forever just wondering if I will be up for it to be removed when I'm 75?

I am not banded yet however I just got off of Depo and was on it for 6 years. And a lot of people complain of weight gain when you first start it but it is supposed to pretty much stabilize after the second shot. I know I gained like 15 lbs between the first and second shot and lost all of it between the second and third. And at the time I wasn't really doing anything to try to loose weight. Lots of my friends who are on it had similar weight changes when they first started.

I watched a good M. Knight Sham. movie so I'm handling the weight gain much better now that I'm chilled. L.A. how are you feeling? My girls... I miss you. Thinking of that FIRST Red Robin gathering and how great it was. I hold you all dear to my heart and that moment in time. .......................... Mona you are funny and I love that you write with emoticons like I do. The drool one is my fav.

Janet, I can feel for you on that liquid thing. I too get fills every 2 months or so and this last time when he filled me, I had been complaining about being able to eat anything, including the kitchen sink, so he put .6cc in my band this time (was averaging .2cc at a time) and OMG was I tight. I bet I did not eat more than 300 calories a day and nearly nothing to drink from that Monday till that Friday. I was kinda getting worried but suddenly on Friday it eased up a bit. I am still tight but no where near as tight as I was. I like where I am right now so this may be my sweet spot (if Doc agrees that is...I lost 6 lbs that week alone and cont. to loose a bit faster than I was). The protein power I was talking about is Smoothie King's signature protein powder. Do they have Smoothie Kings where you live? They are like a "coffee shop" for nutrition shakes. It is actually officially a juice bar. So kinda like going to GNC where you can find all kinds of nutrition powders, going to Smoothie King you actually buy the shakes themselves. They have a huge assortment of different types of nutrition shakes from shakes specifically for weight gain, muscle bulking, protien specific shakes and of course their wonderful low carb, high protein shakes which are awsome meal replacements. They can put all kinds of different flavoring and fruits in them. I crave those things sometimes. If you are currious, you can look them up online at Smoothie King Look specifically for the Gladiator Low Carb Meal Replacement under supplements. It is so YUMMY! My doctor is kinda picky about protein shakes and suppliments but he absolutely LOVES Smoothie King. I am sooo weighing every day now. I have got to be present the second I drop below 200. As much as I have lost the last 2 weeks, I have suddenly come to a screeching halt just before hitting "onderland" and am pouting greatly. I will be yelling from these mountaintops the second it happens :hurray: Ok, bedtime for me...you all have a great weekend...

At 16 months out i consider myself to have been quite successful and have been a consistant loser. For me thus far moderation has always been the key as far as food is concerned. I still eat what i want (with the exception of bread and beef) only FAR FAR FAR FAR less. I find that if i keep in tune to my sense of restriction and try and head in for fills when that feeling is lost that my pattern of losing remains consistant. Ive had minor set backs along the way (10 lb vacation gain in ONE WEEK!), holliday weight gains and so forth but i always GET RIGHT BACK ON TRACK. I weigh my self every day at the same time each day and very rarely does a day go by when i dont drink a minimum of 50oz of water. I would probably be further along then i am if i was more of an avid exerciser, but i try an do what i can when i can. Ive never had one problem with my band thus far and IM LOVING IT! I still have a ways to go but im in it for the long haul. Good luck to you.

This is the start to my journey back to a former life. Yesterday I complete the six month doctor visits that is required by my insurance company (BCBS). I am now waiting for the insurance companies OK stamp on my paperwork. I know how slow paperwork can creep through the system, so I am a month or more from surgery. I am starting off a 365lbs at 5'11" and BMI about 50. I am borderline with a few medical issues that haven't cropped up yet, so I better do something. Yes, I have tried the diet plans from A to Z and a few I have tried a few more than once. Part of my problem is a bad back problem I recieved for a car accident in May 1990. At that time I was a 210, six foot military man in good shape. Since, it has been a downward spiral of weight gain and pain... Now, is the time for me to turn this around before medical issues crop up or death replaces this life. If you care to read my journey, I plan on posting at each event while going through this change of life. Since, my goal is 210, I might be writing for awhile. If you care to comment I would love to hear from you. -Bill

This is the start to my journey back to a former life. Yesterday I complete the six month doctor visits that is required by my insurance company (BCBS). I am now waiting for the insurance companies OK stamp on my paperwork. I know how slow paperwork can creep through the system, so I am a month or more from surgery. I am starting off a 365lbs at 5'11" and BMI about 50. I am borderline with a few medical issues that haven't cropped up yet, so I better do something. Yes, I have tried the diet plans from A to Z and a few I have tried a few more than once. Part of my problem is a bad back problem I recieved for a car accident in May 1990. At that time I was a 210, six foot military man in good shape. Since, it has been a downward spiral of weight gain and pain... Now, is the time for me to turn this around before medical issues crop up or death replaces this life. If you care to read my journey, I plan on posting at each event while going through this change of life. Since, my goal is 210, I might be writing for awhile. If you care to comment I would love to hear from you. -Bill

Hi, my name is Chris - I was just banded on Wed 1/23 by Dr. James Davidson in Dallas. I'm 44 and have been fighting my weight since college. it has been a slow upward spiral with lots of weight loss followed by even more weight gain. I finally decided to do something about it as I hit an all time high of 304 and a BMI of 40+. My insurance excludes bariatric surgery so I had to go the self-pay route, fortunately Dr. Davidson was running a $9500 special and I decided to go for it. I lost 18 pounds on the pre-op diet (but have my expectations set a lot lower for the next few weeks based on all the posts about stagnant weight during the post-surgery period). anyway, just wanted to say hello to everyone. I'm looking forward to the journey! Chris

I know what you mean regarding control. I think that was a significant factor in my weight gain. When I got married at age 23, I was slim and fit - @125lb, 38-23-34. I made the mistake of marrying a man I didn't know as well as I thought I did and he turned out to be an incredible control freak as well as a violent drunk (he's now an EX ). Our lifestyle changed drastically after the wedding (no more going out dancing all night, full meals every night, etc) and I started to gain a little weight. He used to berate and belittle me every time I ate, so of course I rebelled by eating more and even sneaking food when he wasn't watching. Within a few years, I had gained about 20-30lb and his favourite refrain when slapping me about was "You FAT UGLY PIG!!" (This was at about 140lb!) With my self-esteem crushed, I turned to food for comfort (yeah I know, lots of other issues there, but that was significant). By the time I got out of the marriage 8 years later, I was about 160lb - overweight but not huge. I can clearly remember the first four years of being single again, when I did things like hang out in the refrigerator at night saying things like "Haha! Watch me eat this!! You can't stop me now!!" I deliberately put on the fat suit, partly because of that "defiance" aspect and partly because I wanted to keep men away - both were desperate attempts at taking a measure of control in my life. By the end of 4 years of single life, I had put on another 60lb and was around 220lb. At that stage, I sought therapy for my issues with self-esteem, the marriage and how I had managed to get myself into that situation. The therapy helped a lot and I really came to terms with who I was and how I had arrived there, but unfortunately the fat suit wasn't as easy to take off as it was to put on. Since then, I went through various stages of dieting and failure, and thinking I had accepted the weight and settled for being a "fat person" forever. I slowly yo-yoed my way up another 55lb until I hit my all time high of 275lb last year (15 years post-marriage). Now that I have made the change and been banded, I realise that I had never really accepted it and I am now finding comfort in having the control to be able to take the weight off. I'm looking forward to finding the "real me" under this fat suit.

Hi I am Shirley from Kansas. I am thinking about having the Lapband surgery. I weigh 235 lbs., 68 years old. Does this help with the desire to want food. I also did the FenPhen and had great results. Since I have retired, it has been hard to keep the weight off. I am very depressed about my weight gain.

It is really important to move to mushies then solids. Its not a good idea to eat all liquids. Maybe one protein shake a day but not all day long. It deafeats the purpose of the band to consume too many liquids. You may see a slight weight gain when you move your diet to mushies then solids. That will come off when you start getting fills. Good luck.

I just wanted to chime in on the 'too-young' comment. I am 23, and banded shortly after turning 23... And I wish I had done it earlier!! Just because we're young, doesn't mean we haven't been there and done that. I've been fat since I came outta my momma. At 8 years old I cried about having to pick up the golf ball out of the hole because it hurt my back too much. At 19-20 I had crippling.. and not ow it hurts, but crippling back pain. I could not walk anymore. I was too proud, my doc told me to start using those scooters when I go in public. I wasn't going to be caught dead doing that, I was only 20... that shouldn't happen to me!! So I just didn't go anywhere. And I was gaining weight even more rapidly from not doing anything. My great-grandmother was diabetic. Looking at pictures of she and I at the same age, we looked identical. By 30 she was bed-ridden and weighing 700+lbs. At 35 she died in her bed, and was one of those people that became a spectacle when her body was removed from the home. I did WW and failed. I did Atkins, lost a lot of weight, gained it all back + some. Atkins was the best success I had, until the band. I officially passed my Atkins success a month ago. I now have no back problems when I walk. I feel like I have been given a new life, I feel youthful (FINALLY). So.. as for being too young, if I 'just tried dieting some more', I might have ended up like my g'gma.

Yes, Suzanne, it was divine intervention!!! :wink2: Anyway, I had a thought and was just wondering... do y'all think maybe, just maybe, or bodies are holding everything they get because it thinks we're trying to starve ourselves and our bodies need to adjust to this new way of life and realize we're ok... like protecting us? Sounds corny, I know, but with Weight Watchers you're told "Eat your points, even if you're full, eat your points" and kind of for this very reason. And, if we were doing WW, for most of us, we're in NO WAY eating our daily allowance of points and therefore our bodies are rebelling against us...? Holding what we're putting in? I'm doing a poor job of forming words around my thoughts, but if any of you can read my mind... do you see what I'm saying? Make sense to anyone but me? I guess I'm trying to rationalize this weight gain thing, if only temporary... because it seems common among most of us.

Well, likely you WILL be restricted to a small amount of food forever or suffer painful consequences, or one would hope so, the other side of that coin in rebound weight gain. Two and a bit years on, I find this tiresome sometimes, not at home, but out, like sometimes I think "I wish I could take this darn thing out and just eat easily this once". Not that I have many problems, I can eat anything, but I tire of being "aware" of it all the time to avoid blockages and PB, particularly in social situations where I am talking (dangerous for me!). Other than that, I dont count Protein, dont count calories, dont obsess over drinking Water and never did. I find maintenance eating IS easier than losing weight eating, I'm much less stringent these days and enjoy a very normal lifestyle, but you do have to think about long term health. You can maintain your weight on crap food if you eat small amounts, and that's not ideal. As to exercise, well, where there's a will there's a way. I run regularly but do suffer from sciatica, a heavy and aching right leg and chronic heel bursitis on the right side, it really makes life misery sometimes, but I can run strangely enough where I cant walk fast. Its more the day to day drudgery of this condition and not actual pain or discomfort while I am exercising that bothers me and I'm still doing the rounds of various therapies to try to find something that will a) identify what the problem actually is after more than five years and :biggrin: relieve the problem. I've had GREAT success with acupuncture lately. But I keep on running because I'd rather run, stay thin and fit and have discomfort (not bad pain usually) than stop running, mimise my symptoms, get fat again and get the symptoms back due to obesity anyway. And every single professional I've seen has advised me to remain active. But its a matter of finding an activity you can tolerate - swimming for example?

I just saw a "Biggest Loser" type list involving some people I know. I was SHOCKED to see I weighed the same or a little less than 2 of the girls involved! These are 2 girls I have never thought of as being very heavy or significantly over weight, as I view myself! I'm also within 5lbs of my younger sister for the first time EVER! I get the impression it bothers her. She's about 25lbs over her normal weight right now. Even with her recent weight gain, I feel waaaaaaaaay bigger than her.

I was too busy doing the pre-op liquid diet to do any last meal stuff. Glad I didn't cause it's really silly. There is nothing "off limits" to me and my band. But it's usually a huge waste of money because I don't eat much of it anyways. Just everyone please relax and not go into a panic that you are not going to eat your favorite food ever again. I just don't think that's true. It's really not worth the extra weight gain that your going to have to do either. Take care..happy losing. Di

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

I was banded March 2007. I have not only not lost any weight, I've gained 3lbs over the past 10 months. I have been filled to the max. I don't eat much, let's be honest, I can't. I can't even eat the 4 oz portions suggested. Yes, I'm eating the right foods. I work out 3 to 5 days a week at least 1 hour to 2 hours each time. I was considered a low BMI on the lapband scale but still enough of a BMI to get the surgery covered by insurance. I'm frustrated and disappointed. Isn't there anyone out there that has had this happen? What's wrong with me?

perhaps the single-most predictable (and universal) weightloss pattern is a stall-out between weeks 2 - 3, sometimes as late as week 5. I've seen it time and time again (not just my personal experiences, but as a witness to medical study data, as an observer in weightloss therapy sessions, case studies, etc.) ESPECIALLY if you've had a loss of more than 1 - 2 lbs during the preceding weeks, but absolutely not required. Looking at your dates, you're smack dab in this timeline. It doesn't matter what "diet" someone is on, this happens enough to be almost guaranteeable. The short and non-scientific explanation is that there's a point where your body realizes it's losing fat and freaks out, kicks out a bunch of chemicals, lots of things are rearranged and redistributed, released, reserved, and a temporary reduction or cessation of weightloss results, or weight gain. NOT fat gain. Weight gain. Too many people are oblivious to the difference between WEIGHT and FAT. In non-banded folks, this body process often leads to a physiological urge to binge -- and is probably the #1 or #2 killer of sincere diet efforts. People do well week 1, and "suck" week 2 and say "F--- it, I'm not giving up all those goodies for <no weightloss> <weight gain>... I'm eating cupcakes!" Stick it out. It rarely lasts longer than 2 weeks. You may be able to help it on with increased exercise and hydration, but this is one of very few times where we can legitimately blame it on our bodies.

I remeber seeing a bumper sticker that said "I may be fat but your Ugly and I can Diet", think I was around 16 at the time. I always broached the subject of my weight gain before someone else had the chance too - always in a humorous way, I was the thin one until I got married. So, in becoming the "Fat" one - I could not let someone else feel uncomfortable with having to mention what I already knew since I do own mirrors, so I would quash the topic fast, have a laugh and move on. I gladly take any and all compliments that come my way, I try not to be sensitive with the imperfections that accompanied the weight gain...rather work to be a healthy person - Who, can get PS and fix the "fat" issue rather than the "ugly".

My pcp letter was awesome! He detailed my weight history, and determined future problems I am guaranteed to develop based on family history and current rate of weight gain. He also included documentation of all my records I provided him where he explained I have had sucess on self paid medically supervised programs the last 5 years....lost all my excess weight and reached normal even close to being underweight.....but never was able to maintain. All depends on the letters & reports your physicians make. Oh and my psychologist even thought he did not put his license number on the report and delayed me-I must say his report was excellent. He covered alot of ground as to current underlying conditions that we go thru being overweight that my pcp was not able to include. Have you submitted to insurance yet?

Brandy – Congrats on NORMAL weight… That’s so Great:biggrin: Karri – Congrats on RUNNING – that a BIG accomplishment… I have my love/hate relationship with the gym – I hate being hot and right now they don’t always have the fans going. I am a BIG head sweater – On Tuesday they had the fans going and I was only going to do 2 miles as I was feeling a little tired – well ended up doing 3.5 – cuz with the fans on I stay cooler and can workout longer – yesterday felt strong – but the fan’s weren’t on – after the 1st mile I was hot – 2nd mile dieing and really wanted to quit - and when I ck’d mileage is was 2.5 so I figured I could do ½ more mile – that’s only 2 songs. By the time I finished my head looked like I just got out of the shower. Blue Eyedbaby – The Secret – Well watched that show (oprah) and said to omg – That’s how I have been living my life – so for me it wasn’t a secret – I thought it was my original idea. I truly have always thought that there is a lesson to be learned from our life experiences and all the other stuff she wrote about – I guess I could have written this book in 92 and made a mint… #1 – I weighed 3.12 lbs at birth – I was a preemie – I was a chubby kid during grade school – 8th grade weighed 165 and was considered the fat girl – looking back at pic’s I wasn’t that fat – but had 40 lbs on all my friends. High School 130 then in my mid 20’s started with the weight gain – 140 -160 – 180 by 29 206 – did various diets /drugs 200 – 180 – by 92 after parents died went to 230 – lost 30 – then for the last few years – got to 190 – 200 – 220 – 230 – 240 then 250 – alas lapband As a child my family looked like Ozzie & Harriett – but it really wasn’t – My Mom always made the comment – such a pretty face – infact I was like in 4th grade and they had me on a diet (liquid diet meds) – all that did was make me a closet eater. My rebellious side comes out – tell me not to eat – I will eat ten times more.. #2 – Yes today I see my self thinner – as I have my size 12 jeans on – but 188 isn’t thin – ya it’s thinner than 250 – but not thin enough – so yes some days I do - some days I don’t – but heck look at the skinny chicks who are always saying “I’m so Fat” and they weigh 120 lbs and are 5’7.. Peaches – we aren’t in a contest here and really – it’s not about how fast it comes off but how long we keep it off – That will be the proof that this thing works – or should I say helps me keep it off – then I will know I am a success.. Linda – You may not need any more in your band – since it was a slight unfill – maybe you will be at your sweet spot.. Ok gang - I wrote this all this morning - but it didnt post for whatever that reason is - just like the dryer always eats that one sock :rose: Hope everyone is having a good Friday .... Will Ck back later...

ok, i feel different than a lot of people i see on here. i am exactly 3 months out today, and i have lost 2 lbs, and i just lost that 2 lbs, in the last 2 weeks. however, i had lost about 10 after my 2nd fill and then gained back 8 in the next week ---didn't think that was possible, but i'm having major fluctuations. so, i have good restriction right now, but it loosens up in a week or so. i do not want sweets or treats or anything really when i am tight. i am perfectly satisfied with some meat and veggies. it is just keeping that restriction that is the problem. i'm scheduled for a 4th fill already in 2 weeks. i have felt true restriction and i know that it helps with my cravings, my problem is keeping it there. (i have around 7 cc's in my ap small band). i need to exercise.. and let me just say about the food tracking, that i think we should all track our food even at restriction. my doc really stresses this. it is the only way to tell if you are getting adequate protien and it is a definate way to tell if you need a fill. you will see a pattern of more eating and can schedule a fill before you gain weight from it. also, my doctor says as a general rule, if you can eat more than 1/2 of a sandwich with bread then you need a fill. you should only be able to take about 10 bites. i'm not quite there yet, and i'm not stopping until i am. i'm a slow loser, and i need all the help i can get. funny thing is i drop the lbs fast. 4 weeks after surgery down 12 lbs, 6 weeks after surgery down 4 lbs (gained 9), 10 weeks after surgery 2 lbs over presurgery weight (gained 6), 12 weeks down 2 lbs (but i had lost 10 the first week..so igained back 8)...wth?

Bebers, I started on Nutrisystem a year ago, that was my highest weight. I was 220 at surgery, so I've lost 21 since surgery. Cyndi, I got fill number two on 1/14. I asked for a total of 6. He looked at me over his glasses and said don't be a hero. So we played around with the numbers a little, he put in the 6 MY GOD The Water backed up, he totally openend it and I felt it all go down...swoosh...I said MAN that was fun! So I ended up with 5.5. I am just now starting to eat solids, tried to eat a 3 oz bag of tuna today, OMG I felt the tightness in the chest, and the pain, I had to stop. Couldn't do it, I figure I better work up to it slowly, but I think I have some great restriction as I am not hungry at all. Did you get your fill?. Any way, the thread is about how many cc's do they put in your fill. I think it's really based on how your hunger is and how your weight gain/loss is. I would rather move it up slowly than to feel like I did with 6cc in there. That was brutal.

I believe I've been on Actos and Met for about 6 months. There's been a marked improvement when it comes to my glucose levels. When testing my sugar, I'm usually in the range of 90-115, which is wonderful for me. I'd been testing at 200ish for such a long time that my PCP almost jumped for joy when they did my first A1C after taking the Actos for 3 months. As far as the PCOS and its symptoms - there's been no real change that I can see. My cycle is still incredibly irregular and my cravings and PMS are insane. I have to admit that I've been apprehensive about Actos since it is a relative of Avandia. I read recently that it "may be less effective than other drugs for diabetes and cause liver damage, weight gain, anemia and heart failure". Fortunately, it has worked for me as far as the blood sugars go...but my weight is still a problem. PS Thank you all for the warm welcome. I really appreciate it!