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I just went through this entire thread, because I have Aetna as well, which is sponsored through my employer. I have read through all the documents on the requirements, and I am not seeing anywhere that is states there can not be weight gain through the process. Is this something that your surgeon advised you of? I just don't want any suprises:)

Wow, in reading the replies there ARE a lot of different times. My Doc / Bariatric Center said it was 15 and 30. They said for gastric bypass it was 30 and 30. I would just go with your doctors recommendation though. I would take it seriously though, because my nutritionist said it is the number 1 reason for re-weight gain after weight-loss surgery. Best of luck!

"my nutritionist said it is the number 1 reason for re-weight gain after weight-loss surgery." I would love to see some research to back this up.

Surg wt 300...wt last week 277. Then no loss. Today, i am up to 281!!!! Help!! I'm on purees but only eating 1/4c or less, and it's very basic stuff. My plan doesn't allow tomatoes, cheese or "anything" you can puree. I dont eat canned soups. Normally i take a fluid pill for BP but have not since sleeved. Surgeon says not to. I wonder if this is just water wt?? Can't see how it could be real weight gain!! What should i do? Thank you.

I am so glad all of you had such a WONDERFUL experience w/ FEP BCBS. Here's my story: I had a lap band in 2005 that I paid cash for here in the US. I LOST a 132 pounds I kept my wait off even after my port broke. I had some weight gain and had my port repaired in 2012. It has not been right since that time and last April I suffered my first slip....So in April of last year my doc scoped me and unfilled my band. In a month my band returned to position and a way I went. I haven't felt well since April and in November I went and saw my surgeon and decided to go for a sleeve as I am now having on going issues w/my band. When I feel I slip I go back on Clear liquids and my band calms down(I am 3 hours from surgeon and am a nurse), So they submitted everything to my primary Insurance the end of November and I was approved on 12/5....However here is the catch My doctor was approved but not the hospital. So now here I sit 2 doctors later and a surgery date coming up on March 1st about 5.5 hours away from home. So now please realize I have 2 insurance and BCBS is not my primary. So I literally saw the doctor on the 2/2/15 and was approved on 2/3/15 by my primary. So when they went to submit it to FEPBCBS. Which most offices and Insurance companies here is the 21st century accept electronic records or faxes. FEP BCBS said...OH NO HUH-UH, you have to go to the post office and mail those records to us.(Ya know????SNAIL MAIL). People, the government if fining hospitals who are not getting on board with ELECTRONIC MEDICAL RECORDS and FEP BCBS won't accept a PRE-DETERMINATION electronically or fax??????????? Wouldn't you think this would be important as I AM having a serious complication from my device???????? REALIZE the codes for bariatric surgery are all ELECTIVE procedures no matter WTH is going on with a person. So the representative asked when my surgery date was and she assured my coordinator that they would NOT get to my approval that soon since it is a PREDETERMINATION and they don't have to give a time frame since it is a PRE DETERMINATION! Plus, she wanted to make sure the coordinator is familiar with the FEP BCBS guidelines and that they more than likely would want to meet all of FEPBCBS criteria again. THERE GUIDELINES ARE BS. They have no clause in there GUIDELINES for complications of a bariatric surgery....SO I have to meet the same criteria of someone who is either a failed Bariatric surgery(even though I lost 132 pounds) or a new Bariatric surgery....My BMI is 35 - 39 this year. They don't consider my comps complications(plantar fasciitis) or I would have to have a BMI over 40!(FORGET THAT!) In my H&P due to my intermittent lap band slippage I am at risk for necrosis and other life threatening issues. I feel like CRAP! My primary insurance recognizes this and approved me, ( I walked out of the office at 3:30 and got an email the next morning at 7:00 that I was approved) within 14 hours! I am really glad you all feel really supported by the FEP BCBS because the gals answering the phones won't do anything but quote the damn manual and I don't fall into any of there categories and they won't put a RUSH on anything or for anyone. So my primary insurance is covering it but I have a 5000/copay. So hopefully I will be feeling better in a couple of weeks....if you are curious or care Medicare, VA and multiple other insurances have a provision in there GUIDES for complications arising from a prior surgery. God forbid any of you experience a complication and need a revision of your bariatric surgery! Because when the office calls to get pre-auth they are going to be quoted the manual and you will be expected to meet all of that criteria again(Seems ludicrous to me) then they will have to MAIL your records for your pre determination!......Good LUCK everyone and GOD BLESS! Sorry for the NOVEL but I am angry! I know I know at least I have insurance!

Cheri, that is great that you had some bounce back in your skin. I can tell by your picture and the fact that you are pregnant that you are much, much younger than some of us. And that probably helped with your skin bouncing back. And some folks just have more elasticity in their skin than others. I've never had any! I carried twins, not even to full term, when I was just a teenager, and my tummy skin never recovered, although I very quickly returned to my former weight, and was quite fit back in those days. And I was large breasted and the boobs were just ruined from no elasticity in the skin envelope. I later had a breast lift/reduction to fix that mess, and the boobs have somehow survived the weight loss fairly intact for an old girl. I can remember being in my early 30s and working out with weights, just fit and firm all over, except for my loose skin. And of course, the later weight gain made it worse. I'll probably get the tummy fixed because I can see it clothed. To heck with the rest.

i read that thread as well - but this one is more relatable, as i'm living the changes - not wishing for them.....both are great inspirations! * i like feeling the air between my legs when i walk. no more rubbing together * i love that my activity level is off the hook. i work out often, run & it does not feel like a chore... * love the fact i'll look better in my 40's than i did in my 30's * in changing my diet; i pay attention a whole lot more as to what i put in my mouth. i read labels, shop for fresh food, & all around make healthier choices regarding food. that too is not a chore. * clothes just look a lot better when you purchase them to "fit" - not hide. * getting my social groove back. sorta went into seclusion after the weight gain & now i can't wait to get out & about these days. * hubby is a FT gropper. everday he tells me how "great i look" - the smile is back & i am more confident and it shows.... could keep going...the band has just been a positive thing for me!!

That first drop is so exciting but there is the leveling off and even sometimes a gain prior to getting fill right and adopting to new lifestyle. I lost 10 pre-op, 10 immediately post-op, then another 4-5 which I then regained. Just got that off again following my first fill. I recognize there will be ups and downs, water weight gain and loss, etc., but I know I'm on my way to good health no matter what. You are, too!

I haven't had any weight gains but a couple of slow weeks where I lost only a pound or maybe 1/2 pound. I seem to average about 1&1/2 lb a week. I battle head hunger a lot too but I seem to have better self-control most of the time now than I ever had before surgery. I do eat things occasionally that are less than helpful choices for weight loss but I can't eat very much so it hasn't hurt me do far. Very sugary foods make me nauseous so I don't want that stuff as much, LOL! I crave a bowl of cereal sometimes so I have a little 1/2 cup custard bowl for that. Cracks me up when I think how much I used to eat. I suggest you try upping your daily calories to 1000 and add in some more protein and also a little omega 3 fats like avocado, egg, olive oil and see if that helps with the head hunger. The omega 3 fats are very important for the sense of satiation and for your overall health. pre-surgery weight 325; surgery date 2/28/2013; surgery weight 307; 8 weeks past-op weight 281.4; 12 weeks post-op 274

Everyone posting on this thread have been my biggest motivators. I'm just shy of 2 years out, made my very modest goal at 9 months post op. It's hard sometimes to come to the site now because I always feel everyone besides me is satisfied on eating low carb, 800 cals, and 1/4 cup max per meal. I'm embarrassed, I feel like the anomaly almost... Luckily I'm 6 pounds from my low weight currently. I'm ok with that, but not HAPPY with that. I'm also kind of pissed I have to "diet" to get those stupid 6 pounds off. I could gain back all of my weight easily, but I won't. I won't go back. But it does take effort. I still have restriction with some foods but I could seriously eat 3/4 box of Cheezits in an evening, I have! Basically, I am so so happy with my sleeve but its hard to lose weight gained. The 6 pounds I'm trying to lose have been haunting me for months. All we can do is keep trying!!!

Hi Simba, you sound just like I was. My Dr. told me to drink as much as I needed to. Not to worry about weight gain during this time. I did'nt gain any, I lost. One thing that helped me was I would take regular soups blend them with extra broth. It was really thin, but it filled me up longer. You want it as thin as you can get it. Also gatorade helps. Good luck. Hope this helps you.

I had a 5 lb weight gain after week 4.. And it's finally back down.. When I eat I'm now making sure it weighs 4-5 oz in total. I'm trying to get all my water and protein in but it gets a little confusing at how much I should have .. Well with the protein any ways

Hi yall... Im almost 6 weeks post op for my gastric sleeve.. My highest weight (right before liquid diet) was 255, day of surgery weight was 244, and my current weight is 231.5. I am loosing very slow.. In the 6 weeks post op I have only lost 12.5 lbs. I am able to tolerate all foods with no problems what so ever.. I was scared I was over eating and a friend of mine that has also had the surgery suggested a weighing my food out before eating (4-5 oz per meal). I started doing that as well... There are times that i feel i can eat more than what i have weighed out but I dont. I am also a type 2 diabetic. I retain water badly. I have been walking 2-3 miles 4 times a week. I have a bad shoulder and have limited movement with it.. On week 4 i had a 5 lb weight GAIN.. i about freaked.. I know it was water.. But it really stirred up a lot of emotions.. I am drinking my Total soy protein shake every morning.. and sometimes will drink a protein shot.. and the rest of the day i drink water (around 3-4 20 ounce cups per day with lemon and lime and stevia in the raw) And have 2 sensible weighed out meals. Now with all that said i also have PCOS.. Poly cystic ovarian syndrome.. Im fixing to turn 42 this month.. Is it normal for weight gains, stalls, Am I doing something wrong.. I am really at my wits end on what I should do to get the weight moving. I had my sleeve done in Mexico.. due to costs and all.. I dont have a nutritionist here.. But talk to several people that have had the surgery as questions arise... Any suggestions would be helpful.. Oh and I still feel hungry.... Is this all normal?? Im just CONFUSED !!!!!!!!

I am really nervous. I am not eating that much, but have gained 5 pounds in the last week. Am I doing something terribly wrong? I'm not eating bad stuff - carbs, pasta, rice or anything. I have sausage or eggs for breakfast. Tuna, turkey, chicken salad for lunch or dinner. If I have a late breakfast, I won't be hungry for lunch so I'll have the salad for dinner. This weight gain has me worried. Any advice?

I think we have all been there-those feelings! Unless I am reading your profile wrong - haven't you lost 19 pounds since surgery? If so...that is awesome - you may just be in a bit of a stall as your system tries to straighten out - that happened to almost everyone - I went back and checked and I was down 20 lbs 6 weeks out from surgery - where i had a week stall at the same weight (and a weight gain) even when following the program to a t - Now I know there is no way I could gain weight based on what I ate so It had to be Water weight etc - my recommendation (which you will see in many many posts) put the scale away or use it sparingly the first few months. I am 4 months out so still very new and weigh twice a week - fridays and mondays as i am able to eat more foods and I am exercising more - I want to see what the impact is on my weight in general. I want to make sure now that i am increasing my exercise and increasing my calories because the exercise is making me hhhuuunnngggrrryyyy that it is all still in line. so far so good. And I am sure it will all come in line for you as well - Countless posts are found here where the poster (me included) was second guessing or worried "if it is working" and by month 3 it is starting to make sense. Good luck to you!

I had my follow up with the surgeon and discovered I as having an allergic reaction to the glue. I am happy to say @AceBlaque you were right. I am now 6lbs down from my presurgery weight. So all the surgery weight gain is gone plus another 6 lbs. Thanks again for your response. 💕

I was admitted to the hospital via the ER on Sunday January 21st in excruciating pain. By that Wednesday evening I was in surgery having my gallbladder removed. Since then I have gained 7lbs. Sunday - Wednesday I was restricted and couldn't, nor did I want to, eat anything. I was being pumped with antibiotics and fluids. Since being home I have watched my fat intake and sodium. Other than that, I am not eating things that I feel would cause weight gain. Being almost 1 year out from having my sleeve surgery this is scary to see my weight jump this much so quickly. This coming Wednesday would mark 2 wks post op and I have a follow up with the surgeon. Has anyone experienced this? I am hoping it is due to the trauma my body experienced and as I heal my weight would normalize again and not keep going up. I was also due to have my menstrual cycle the week of the attack but that has not happened either, again, I believe it is due to the experience and surgery. Anyone went through this and can tell me what to look forward to on the other side of healing, your comments would be greatly appreciated. I have been doing extremely well after sleeve surgery and I don't want my body to go backwards.

morning gals sorry was distracted and my computer was freaking out from all my facebook stuff. Haydee, i got kicked off facebook from everything i got trying to load all at one time. i'm drinking coffee and getting ready for my dr appt, primary, who i hope will give me something to mellow me out without the weight gain, and adjust my water pill, which does not seem to be working anymore then home to tile the bathroom seat, so tomorrow i can tile the wall around it. I have a week to get it all done

Amy-- I am a PA....but don't do tons of women's health...have never had an IUD....I didn't think IUD's did much for anything but prevention of pregnancy.....but here's what I got when I googled "IUD": Health Risks: Getting any vaginal infection while using an IUD can increase the risk of developing a serious pelvic infection. This can result in a loss of fertility. For this reason, women need to assess their own risk for infection. If you have multiple partners or if your partner has multiple partners, your chance of infection is much higher. Piercing or perforation of the uterine wall may occur during insertion of the IUD. Over time, an IUD may become imbedded in the uterine wall. An Imbedded IUD is still effective, but it can be painful and may need to be removed. There is a risk of surgery and/or sterility if an IUD becomes imbedded. If a woman becomes pregnant while using an IUD, it is highly recommended that she have the IUD removed, whether or not she wants to carry the pregnancy to term. An IUD increases the risk of having a miscarriage or premature birth. A woman who becomes pregnant while using an IUD is also more likely to have an ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg attaches and grows outside the uterus. This can be very dangerous and requires emergency medical attention. Side Effects back to top Both the ParaGard and the Mirena IUDs can cause longer, heavier, and more painful menstrual periods, but this is much less common with the Mirena. The increased blood flow may cause anemia. Spotting may occur without serious cause or as a sign of infection. The Mirena IUD can cause ovarian cysts. Some women using the Mirena stop bleeding altogether. Usually their menstrual periods return when the IUD is removed. Mirena can cause weight gain, headaches, increased blood pressure, acne, depression, and decrease in sex drive. HOpefully, this helps....Personally would ask more questions..... GOd Bless, Melody Banded 3/20/06 -47lbs

When you go to the Bariatrics doc and you keep gaining weight is that bad and what will they do to you will they cancel your surgery

I copied this post from an old post I found on the site from 2013. What do you think? I kind of a long read, but I has a lot of good information I thought. I was most interested about the parts that talk about the importance of making the most in the first 6 months and not to take them for granted. I am 4 1/2 month out, so It has given me a renewed sense of urgency to make the most of my "honeymoon" period. As my weight loss starts to slow more, the more worried I get about actually meeting my goal. 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 � cups will result in eventual weight gain. 4. Using the thick, hard to stretch part of the stomach in making the pouch is important. 5. By lightly stretching the pouch with each meal, the pouch send signals to the brain that you need no more food. 6. Maintaining that feeling of fullness requires keeping the pouch stretched for awhile. 7. Almost all patients always feel full 24/7 for the first months, then that feeling disappears. 8. Incredible hunger will develop if there is no food or drink for eight hours. 9. After 1 year, heavier food makes the feeling of fullness last longer. 10. By drinking Water as much as possible as fast as possible (“water loading”), the patient will get a feeling of fullness that lasts 15-25 minutes. 11. By eating “soft foods” patients will get hungry too soon and be hungry before their next meal, which can cause snacking, thus poor weight loss or weight gain. 12. The patients that follow “the rules of the pouch” lose their extra weight and keep it off. 13. The patients that lose too much weight can maintain their weight by doing the reverse of the “rules of the pouch.” HOW DO WE INTERPRET THESE OBSERVATIONS? POUCH SIZE: By following the “rules of the pouch”, it doesn’t matter what size the pouch ends up. The feeling of fullness with 1 � cups of food can be achieved. OUTLET SIZE: Regardless of the outlet size, liquidy foods empty faster than solid foods. High calorie liquids will create weight gain. EARLY PROFOUND SATIETY: Before six months, patients much sip water constantly to get in enough water each day, which causes them to always feel full. After six months, about 2/3 of the pouch has grown larger due to the natural healing process. At this time, the patient can drink 1 cup of water at a time. OPTIMUM MATURE POUCH: The pouch works best when the outlet is not too small or too large and the pouch itself holds about 1 � cups at a time. IDEAL MEAL PROCESS (rules of the pouch): 1. The patient must time meals five hours apart or the patient will get too hungry in between. 2. The patient needs to eat finely cut meat and raw or slightly cooked veggies with each meal. 3. The patient must eat the entire meal in 5-15 minutes. A 30-45 minute meal will cause failure. 4. No liquids for 1 � hours to 2 hours after each meal. 5. After 1 � to 2 hours, begin sipping water and over the next three hours slowly increase water intake. 6. 3 hours after last meal, begin drinking LOTS of water/fluids. 7. 15 minutes before the next meal, drink as much as possible as fast as possible. This is called “water loading.” IF YOU HAVEN’T BEEN DRINKING OVER THE LAST FEW HOURS, THIS ‘WATER LOADING’ WILL NOT WORK. 8. You can water load at any time 2-3 hours before your next meal if you get hungry, which will cause a strong feeling of fullness. THE MANAGEMENT OF PATIENT TEACHING AND TRAINING: You must provide information to the patient pre-operatively regarding the fact that the pouch is only a tool: a tool is something that is used to perform a task but is useless if left on a shelf unused. Practice working with a tool makes the tool more effective. NECESSITY FOR LONG TERM FOLLOW-UP: Trying to practice the “rules of the pouch” before six to 12 months is a waste. Learning how to delay hunger if the patient is never hungry just doesn’t work. The real work of learning the “rules of the pouch” begins after healing has caused hunger to return. PREVENTION OF VOMITING: Vomiting should be prevented as much as possible. Right after surgery, the patient should sip out of 1 oz cups and only 1/3 of that cup at a time until the patient learns the size of his/her pouch to avoid being sick. It is extremely difficult to learn to deal with a small pouch. For the first 6 months, the patient’s mouth will literally be bigger than his/her stomach, which does not exist in any living animal on earth. In the first six weeks the patient should slowly transfer from a liquid diet to a blenderized or soft food diet only, to reduce the chance of vomiting. Vomiting will occur only after eating of solid foods begins. Rice, Pasta, granola, etc. will swell in time and overload the pouch, which will cause vomiting. If the patient is having trouble with vomiting, he/she needs to get 1 oz cups and literally eat 1 oz of food at a time and wait a few minutes before eating another 1 oz of food. Stop when “comfortably satisfied,” until the patient learns the size of his/her pouch. SIX WEEKS After six weeks, the patient can move from soft foods to heavy solids. At this time, they should use three or more different types of foods at each sitting. Each bite should be no larger than the size of a pinkie fingernail bed. The patient should choose a different food with each bite to prevent the same solids from lumping together. No liquids 15 minutes before or 1 � hours after meals. REASSURANCE OF ADEQUATE NUTRITION By taking Vitamins everyday, the patient has no reason to worry about getting enough nutrition. Focus should be on Proteins and vegetables at each meal. MEAL SKIPPING Regardless of lack of hunger, patient should eat three meals a day. In the beginning, one half or more of each meal should be Protein, until the patient can eat at least two oz of protein at each meal. ARTIFICIAL SWEETENERS In our study, we noticed some patients had intense hunger cravings which stopped when they eliminated artificial sweeteners from their diets. AVOIDING ABSOLUTES Rules are made to be broken. No biggie if the patient drinks with one meal – as long as the patient knows he/she is breaking a rule and will get hungry early. Also if the patient pigs out at a party – that’s OK because before surgery, the patient would have pigged on 3000 to 5000 calories and with the pouch, the patient can only pig on 600-1000 calories max. The patient needs to just get back to the rules and not beat him/herself up. THREE MONTHS At three months, the patient needs to become aware of the calories per gram of different foods to be aware of “the cost” of each gram. (cheddar cheese is 16 cal/gram; Peanut Butter is 24 cals/gram). As soon as hunger returns between three to six months, begin water loading procedures. THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY 1. Fill pouch full quickly at each meal. 2. Stay full by slowing the emptying of the pouch. (Eat solids. No liquids 15 minutes before and none until 1 � hours after the meal). A scientific test showed that a meal of egg/toast/milk had almost all emptied out of the pouch after 45 minutes. Without milk, just egg and toast, more than � of the meal still remained in the pouch after 1 � hours. 3. Protein, protein, protein. Three meals a day. No high calorie liquids. Fluid LOADING Fluid loading is drinking water/liquids as quickly as possible to fill the pouch which provides the feeling of fullness for about 15 to 25 minutes. The patient needs to gulp about 80% of his/her maximum amount of liquid in 15 to 30 SECONDS. Then just take swallows until fullness is reached. The patient will quickly learn his/her maximum tolerance, which is usually between 8-12 oz. Fluid loading works because the roux limb of the intestine swells up, contracting and backing up any future food to come into the pouch. The pouch is very sensitive to this and the feeling of fullness will last much longer than the reality of how long the pouch was actually full. Fluid load before each meal to prevent thirst after the meal as well as to create that feeling of fullness whenever suddenly hungry before meal time. POST PRANDIAL THIRST It is important that the patient be filled with water before his/her next meal as the meal will come with salt and will cause thirst afterwards. Being too thirsty, just like being too hungry will make a patient nauseous. While the pouch is still real small, it won’t make sense to the patient to do this because salt intake will be low, but it is a good habit to get into because it will make all the difference once the pouch begins to regrow. URGENCY The first six months is the fastest, easiest time to lose weight. By the end of the six months, 2/3 of the regrowth of the pouch will have been done. That means that each present day, after surgery you will be satisfied with less calories than you will the very next day. Another way to put it is that every day that you are healing, you will be able to eat more. So exercise as much as you can during that first six months as you will never be able to lose weight as fast as you can during this time. SIX MONTHS Around this time, our patients begin to get hungry between meals. THEY NEED TO BATTLE THE EXTRA SALT INTAKE WITH DRINKING LOTS OF FLUIDS IN THE TWO TO THREE HOURS BEFORE THEIR NEXT MEAL. Their pouch needs to be well watered before they do the last gulping of water as fast as possible to fill the pouch 15 minutes before they eat. INTAKE INFORMATION SHEET AS A TEACHING TOOL I have found that having the patients fill out a quiz every time they visit reminds them of the rules of the pouch and helps to get them “back on track.” Most patients have no problems with the rules, some patients really struggle to follow them and need a lot of support to “get it”, and a small percentage never quite understand these rules, even though they are quite intelligent people. HONEYMOON SYNDROME The lack of hunger and quick weight loss patients have in the first six months sometimes leads them to think they don’t need to exercise as much and can eat treats and extra calories as they still lose weight anyway. We call this the “honeymoon syndrome” and they need to be counseled that this is the only time they will lose this much weight this fast and this easy and not to waste it by losing less than they actually could. If the patient’s weight loss slows in the first six months, remind them of the rules of water intake and encourage them to increase their exercise and drink more water. You can compare their weight loss to a graph showing the average drop of weight if it will help them to get back on track. EXERCISE In addition to exercise helping to increase the weight loss, it is important for the patient to understand that exercise is a natural antidepressant and will help them from falling into a depression cycle. In addition, exercise jacks up their metabolic rate during a time when their metabolism after the shock of surgery tends to want to slow down. THE IDEAL MEAL FOR WEIGHT LOSS The ideal meal is one that is made up of the following: � of your meal to be low fat protein, � of your meal low starch vegetables and � of your meal solid fruits. This type of meal will stay in your pouch a long time and is good for your health. VOLUME VS. CALORIES The gastric bypass patient needs to be aware of the length of time it takes to digest different foods and to focus on those that take up the most space and take time to digest so as to stay in the pouch the longest, don’t worry about calories. This is the easiest way to “count your calories.” For example, a regular stomach person could gag down two whole sticks of butter at one sitting and be starved all day long, although they more than have enough calories for the day. But you take the same amount of calories in vegetables, and that same person simply would not be able to eat that much food at three sittings – it would stuff them way too much. ISSUES FOR LONG TERM WEIGHT MAINTENANCE Although everything stated in this report deals with the first year after surgery, it should be a lifestyle that will benefit the gastric bypass patient for years to come, and help keep the extra weight off. COUNTER-INTUITIVENESS OF FLUID MANAGEMENT I admit that avoiding fluids at meal time and then pushing hard to drink fluids between meals is against everything normal in nature and not a natural thing to be doing. Regardless of that fact, it is the best way to stay full the longest between meals and not accidentally create a “soup” in the stomach that is easily digested. SUPPORT GROUPS It is natural for quite a few people to use the rules of the pouch and then to tire of it and stop going by the rules. Others “get it” and adhere to the rules as a way of life to avoid ever regaining extra weight. Having a support group makes all the difference to help those that go astray to be reminded of the importance of the rules of the pouch and to get back on track and keep that extra weight off. Support groups create a “peer pressure” to stick to the rules that the staff at the physician’s office simply can’t create. TEETER TOTTER EFFECT Think of a teeter totter suspended in mid air in front of you. Now on the left end is exercise that you do and the right end is the foods that you eat. The more exercise you do on the left, the less you need to worry about the amount of foods you eat on the right. In exact reverse, the more you worry about the foods you eat and keep it healthy on the right, the less exercise you need on the left. Now if you don’t concern yourself with either side, the higher the teeter totter goes, which is your weight. The more you focus on one side or the other, or even both sides of the teeter totter, the lower it goes, and the less you weigh. TOO MUCH WEIGHT LOSS I have found that about 15% of the patients which exercise well and had between 100 to 150 lbs to lose, begin to lose way too much weight. I encourage them to keep up the exercise (which is great for their health) and to essentially “break the rules” of the pouch. Drink with meals so they can eat Snacks between without feeling full and increase their fat content as well take a longer time to eat at meals, thus taking in more calories. A small but significant amount of gastric bypass patients actually go underweight because they have experienced (as all of our patients have experienced) the ravenous hunger after being on a diet with an out of control appetite once the diet is broken. They are afraid of eating again. They don’t “get” that this situation is literally, physically different and that they can control their appetite this time by using the rules of the pouch to eliminate hunger. BARIATRIC MEDICINE A much more common problem is patients who after a year or two plateau at a level above their goal weight and don’t lose as much weight as they want. Be careful that they are not given the “regular” advice given to any average overweight individual. Several small meals or skipping a meal with a Liquid Protein substitute is not the way to go for gastric bypass patients. They must follow the rules, fill themselves quickly with hard to digest foods, water load between, increase their exercise and the weight should come off much easier than with regular people diets. SUMMARY 1. The patient needs to understand how the new pouch physically works. 2. The patient needs to be able to evaluate their use of the tool, compare it to the ideal and see where they need to make changes. 3. Instruct your patient in all ways (through their eyes with visual aids, ears with lectures and emotions with stories and feelings) not only on how but why they need to learn to use their pouch. The goal is for the patient to become an expert on how to use the pouch. EVALUATION FOR WEIGHT LOSS FAILURE The first thing that needs to be ruled out in patients who regain their weight is how the pouch is set up. 1. the staple line needs to be intact; 2. same with the outlet and; 3. the pouch is reasonably small. 1) Use thick barium to confirm the staple line is intact. If it isn’t, then the food will go into the large stomach, from there into the intestines and the patient will be hungry all the time. Check for a little ulcer at the staple line. A tiny ulcer may occur with no real opening at the line, which can be dealt with as you would any ulcer. Sometimes, though, the ulcer is there because of a break in the staple line. This will cause pain for the patient after the patient has eaten because the food rubs the little opening of the ulcer. If there is a tiny opening at the staple line, then a reoperation must be done to actually separate the pouch and the stomach completely and seal each shut. 2) If the outlet is smaller than 7-8 mill, the patient will have problems eating solid foods and will little by little begin eating only easy-to-digest foods, which we call “soft calorie syndrome.” This causes frequent hunger and grazing, which leads to weight regain. 3) To assess pouch volume, an upper GI doesn’t work as it is a liquid. The cottage cheese test is useful – eating as much cottage cheese as possible in five to 15 minutes to find out how much food the pouch will hold. It shouldn’t be able to hold more than 1 � cups in 5 – 15 minutes of quick eating. If everything is intact then there are four problems that it may be: 1) The patient has never been taught the rules; 2) The patient is depressed; 3) The patient has a loss of peer support and eventual forgetting of rules, or 4) The patient simply refuses to follow the rules. LACK OF TEACHING An excellent example is a female patient who is 62 years old. She had the operation when she was 47 years old. She had a total regain of her weight. She stated that she had not seen her surgeon after the six week follow up 15 years ago. She never knew of the rules of the pouch. She had initially lost 50 lbs and then with a commercial weight program lost another 40 lbs. After that, she yo-yoed up and down, each time gaining a little more back. She then developed a disease (with no connection to bariatric surgery) which weakened her muscles, at which time she gained all of her weight back. At the time she came to me, she was treated for her disease, which helped her to begin walking one mile per day. I checked her pouch with barium and the cottage cheese test which showed the pouch to be a small size and that there was no leakage. She was then given the rules of the pouch. She has begun an impressive and continuing weight loss, and is not focused on food as she was, and feeling the best she has felt since the first months after her operation 15 years ago. DEPRESSION Depression is a strong force for stopping weight loss or causing weight gain. A small number of patients, who do well at the beginning, disappear for awhile only to return having gained a lot of weight. It seems that they almost on purpose do exactly opposite of everything they have learned about their pouch: they graze during the day, drink high calorie beverages, drink with meals and stop exercising, even though they know exercise helps stop depression. A 46 year-old woman, one year out of her surgery had been doing fine when her life was turned upside down with divorce and severe teenager behavior problems. Her weight skyrocketed. Once she got her depression under control and began refocusing on the rules of the pouch, added a little exercise, the weight came off quickly. If your patient begins weight gain due to depression, get him/her into counseling quickly. Encourage your patient to refocus on the pouch rules and try to add a little exercise every day. Reassure your patient that he/she did not ruin the pouch, that it is still there, waiting to be used to help with weight control. When they are ready the pouch can be used once again to lose weight without being hungry. EROSION OF THE USE OF PRINCIPLES: Some patients who are compliant, who are not depressed and have intact pouches, will begin to gain weight. These patients are struggling with their weight, have usually stopped connecting with their support groups, and have begun living their “new” life surrounded by those who have not had bariatric surgery. Everything around them encourages them to live life “normal” like their new peers: they begin taking little sips with their meals, and eating quick and easy-to-eat foods. The patient will not usually call their physician’s office because they KNOW what they are doing is wrong and KNOW that they just need to get back on track. Even if you offer “refresher courses” for your patients on a yearly basis, they may not attend because they KNOW what the course is going to say, they know the rules and how they are breaking them. You need to identify these patients and somehow get them back into your office or back to interacting with their support group again. Once these patients return to their support group, and keep in contact with their WLS peers, it makes it much easier to return to the rules of the pouch and get their weight under control once again. TRUE NON-COMPLIANCE: The most difficult problem is a patient who is truly non-compliant. This patient usually leaves your care, complains that there is no ‘connection’ between your staff and themselves and that they were not given the time and attention they needed. Most of the time, it is depression underlying the non-compliance that causes this attitude. A truly non-compliant patient will usually end up with revisions and/or reversal of the surgery due to weight gain or complications. This patient is usually quite resistant to counseling. There is not a whole lot that can be done for these patients as they will find a reason to be unhappy with their situation. It is easier to identify these patients BEFORE surgery than to help them afterwards, although I really haven’t figured out how to do that yet… Besides having a psychological exam done before surgery, there is no real way to find them before surgery and I usually tend toward the side of offering patients the surgery with education in hopes they can live a good and healthy life.

Currently experiencing the same thing. I hear this is very common at the time. My doctor advised I up my activity (I'm only clear to walk until week 6) and increase water intake, but that this stall is normal. Weight gain could potentially be bloating, water, hormones, a whole slew of things. As someone who militantly believed in CICO and that hormones were a cop out, this has been a tough pill to swallow but following my doctors advice has been yielding more results than my previous beliefs and efforts.

@@redfire_angel75, for me it has been easier exercising now then before surgery, my only hiccup has been my gout but it seems to have subsided... Thank God!! I'm not sure if my age had anything to do with it but I had a lot of fatigue and not much energy, especially with in the first 2 months. I found my stride soon after and now I've been told it's hard to keep up lol I'm so excited for you, this was a life changer for me and I'm sure it will be the same for you too!!! Take lots of pics along your journey, you will be shocked and encouraged by the changes. Here's a before and after pic of my face, as much as my before pic embarrasses me it just shows how much my weight gain aged me... http://pic-collage.com/_rlycISx7 Your going to do awesome and please post pics so we can share in your success Sent from my iPhone using the BariatricPal App

Been with my husband for 23 yrs, married for almost 19. We've always been known to be extremely physically attracted to each other, even with our weight gain over the yrs. my husband has no problem dropping pounds, where it was never easy for me. But sex has always been great. NOW, after the sleeve is a different incredible experience. While hubbie was very supportive during my struggle to get healthy, surgery or not, I think he's happier than I am now. I think he thinks he has a new wife. I laugh & tell him I'm new & improved. Lol... Everything has gotten smaller, not worried about that because I was a size 3/4 when I met my husband & a 5/6 when we married. So not worried about him seeing my small boobs, smaller bottom, or my very very small scars. Yes, I feel more confident that I no long look like I am pregnant. No longer have to spend hundreds of $$$$ on body magic garments to tuck stomach. Everything has shrunk to both our liking & appreciation. And still shrinking. When I say everything has shrunk, it's left one thing exposed quite often. "Not being shy, right?" So when I walk or sit, I'm turned on. Incredible!!!!!! So you can only imagine what happens by the time I meet up with my husband thoughtful the days. Funny that we do stuff now that I don't recall doing years ago when I was a size 7-8. We laugh now only saying I was still being "conservative" then, now that we really really now & respect each other, the things we do, WOW!!!! I new found attraction. Oh so happy!!!!!

I posted the question for just this reason...I wasn't sure what I was noticing was real, and I guess there are so many different ways to look at it. At first it perplexed me because I have always been a very confident person. I couldn't really put my finger on it, but it seemed like over time I met with much more resistance than in the past. Then it just started becoming more clear that this all has happened gradually over time and there seems to be a correlation between the weight gain and the poor attitudes I am noticing.:thumbup: