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Muscle Milk has several formulas. There is one for people who are trying to bulk up. ( A weight gain type) There is one for regular Protein intake with good fats. Read the label. If it's the type that is 150 calories a scoop (or 300 for two scoops), with 30+ grams of protein, it's great stuff. They also have the light version (available premixed at Costco). Great to grab for Breakfast.

Hi All, Just wanted to know what others have experienced. For some reason I am having daily anxiety. I absolutely can't stand it as it hits out of nowhere at all. I am only 17 days Post-Op, take my vitamins daily, and still taking my Metformin until I am blood tested again. I do not want to go on an anti anxiety medication. I had been on Lexapro for 4 years at which point I put on a lot of weight going from a size 4 to 1-2X. I lost all motivation on working out as well. I went off the Lexapro completely 2 months before surgery and started actually caring about myself which is why I decided to do this surgery so I could get my health back on track. Following my weight gain, I developed diabetes, Apnea (now using a C-Pap for a year) and NASH of the liver. I notice exercise helps with the anxiety for sure but I cant seem to get a decent response from the medical community to help me feel better about this. I asked my surgeon why this sudden onset of anxiety that hits for what seems like no reason at all and his response was if I am eating right and exercising that this could be the cause because of sudden change and that maybe people are treating me differently and all of this is causing anxiety. I then told him no - people are not treating me differently. My family is amazing with all of this and I am working out of the house so have not been around others for them to treat me differently. In my case this is absolutely not the case at all. I pressed on asking if chemical changes in the body could be happening due to the surgery that may be causing this and he said yes. Wondering why I had to keep poking to get that response at all and yet because that was not the first response I am even doubting that. Why not just tell me that since I made it clear I am having these spikes out of nowhere and can't figure out why. I am finding myself overthinking everything right now honestly. Wondering how I will tolerate eating anything at this point or will I ever be able to. My doctor keeps his patients on a 5 week post-op liquid diet before you go on to a pureed / soft food diet for another 3 weeks. So unsure of myself right now and considered I made a huge mistake and so very much want to get passed this feeling more than anything in the world. Part of me is happy I did the surgery for my health and the results of weight loss I have seen thus far but another part wonders why I could not get back on track on my own and worried about long term complications. Like once I start eating will I have a sudden stomach leak, will I have no ability to hold down food or end up on liquids for the rest of my life? Will I ever be able to enjoy a glass of wine again and comfortably get on with life in a better more healthy way. Will I end up with Gallstones that cause another surgery or will I have stomach blockage in the future and how will I know if I do? I want to celebrate my choice to have done this and enjoy the weight loss but instead I am having so much self doubt and it's making me miserable. My liver health alone was cause to do this along with the diabetes so what is my damn problem? It is really hard to deal with this and I'm frankly pissed at myself for letting the anxiety get to me. I am considering going back on a lower dose of Lexapro again at least until this simmers down as I am hoping this is a chemical change in my body due to part of the stomach being removed and all the dietary changes just concerned it will make me not give a crap again and go lazy. IDK, if I knew factually this was all going to be a temporary reality then I would do it until the body goes back to normal.

Mine fit my thumb now!! I'm going to wait til I get to goal to get them resized. I had to resize them because of my weight gain, so I will probably have to get the stones reset instead!!! KInda cool thought, a new band for a new me!!!! ~cheri

Getting down I keep going up and down two pounds. I started at 210. Now I'm at 214. I always gain about 5 pounds right around my period. has anyone been denied for weight gain. It's a small amount but I'm working to get off.

Hello all. So I have Lupis as well as Fibromyalgia! I have been trying not to think of it in regards to my surgery. However, in the back of my mind, there is the fear that having surgery will cause a flare up! I had to go off of my Plaquinil for a month, until after my surgery, which is July 10th. Its been about two weeks and I've been good until last night!!! I could feel the rain coming, my joints have been aching. And my hips are absolutely killing me! Like to the point of tears, and it takes a LOT to make me cry. My hands and arms/elbows are hurting not from typing, I have to keep stopping. I stopped taking the Plaquinil once before for a week, and it felt like I hit a wall going 90mph! That time it affected my hands and elbows and shoulders first, then I was curled up in the fetal position in so much pain I could barely think! And now its started again! Calling the doctor in the morning. And I guess they will increase pain meds, but I have done that for the last two nights and it hasn't helped! And I can't even take motrin! I want to pull my hair out! I am afraid if the increase my meds now, will they be able to control my pain after surgery? I have two little boys to take care of!! I will be staying at my parents after surgery for the first two weeks, but I can't let them do everything! My guys can wear the most entergetic people out! Getting a little upset about this tonight! I told my surgeon that nothing about the surgery scared me at all, the only thing that scared me was coming off my Plaquinil! And he said "for good reason"! AAAHHHHHHHH anyone else dealing with these issues? I could really use some support! Can't wait to get it over with and go back on my meds!!!!! And scared they will try to put me back on steroids, which have contributed to my weight gain over the last two years! Hurting, nervous, upset!

@@SWEETTEA I don't want to derail the thread, but yes, I had a doctor explain it to me that way. We have the disease obesity. And like any disease, there are treatments and there are cures. WLS is a treatment for the disease, not the cure. Eating right, exercising, tracking calories etc is the treatment, not the cure. That's why if you stop the treatment, the symptoms of the disease return (weight gain). Made total sense to me.

Had my sugery in Aug. 2008 @ 353 and at my lowest weight I was 225!!! But then I got a piece of food stuck and had to have all of the Fluid taken out. I've felt like I've lost control since then and can't get back on track. I've put off going back to the doctor because they've changed how they code the adjustments and it will cost at least $300 to have an adjustment. Finances are really tight right now. The other factor, and probably the most severe one for me, is that I'm embarrassed. I've been embarrassed to talk to my doctor about my recent weight gain of at least 50 lbs!!!! And I'm lost. I've tried dieting to get it off without success. That's how I've gained so much...binging. So I googled 'getting back on track with Lap-Band' and found this site. I'm just now deciding to get on track and I'm feeling overwhelmed and defeated. I am just now starting nursing school and time is limited which leads to emotional eating, poor food choices, and excuses to eat bad and not exercise.These are just a few. I'm hoping I can get back on this wagon. It's not my doctor's fault but I just am so nervous to admit/face him...I don't know how to do it...and even worse, facing the nurse; getting on that scale...her writing it down and telling me I've gain 58 lbs...then the questions 'have you been drinking with your meals? Eating between meals?'... Please, any advice is helpful!!!! Jess

Well, I would agree with you. I dont think I quite have the metabolism of a snail, but something sure doesnt add up and I'm glad I have my band. I weigh 140lb at 5ft 10, quite slim, yeah, but a healthy weight, near the bottom of my range. I eat about 1800 calories a day to maintain that weight - so I'm not complaining,that's an OK deal. But I need a lapband to stay within that calorie range. I also run an hour some days or do a spin class and a body pump class the other days. I'm very active. All the charts say I shoudl be eating 2,500 to 2800 calories a day! At the very least, you'd think I coudl eat the 2000 to 2200 recommended for the average woman. But there's no way I can eat that much and not gain. I'm not sure where the weight gain would stop, whether I'd be heavier but still in the healthy range or whether I'd become overweight again, but I dont care to find out either. I certainly know I got obese on somethign like 2,500 a day - I wasnt a binge eater, didnt eat amounts that seemed huge compared to other peple by any stretch of the imagination. What I wonder though is which came first? Did I get fat because my metabolism was slower than it shoudl be or am do I now need to stick to a fairly limited, low calorie diet to maintain my weight precisely BECAUSE I have lost a lot of weight through long standing calorie deprivation? I suspect it is the latter. Once you've cut calories as low as we tend to do for a long time, you cant eat like a normal person ever again. Your body is just conditioned to run on much less. I certainly eat less and do more than my 120lb sister.

Well here I am wow my 1 year anniversary today I had sleeve surgery this day last year And what a ride it's been! This was the best decision I have ever made ! I had done every diet known to man kind and failed time and time again my rheumatoid was out of control my prescriptions where growing by the month and diabetes and heart disease where just around the corner and I was deeply unhappy within myself desperate to be healthy but unwilling to make the necessary changes and sacrifices to get there it was all just too hard. steroids played a large role in my weight gain and lack of exercise due to the pain in my feet and hands it was a downward spiral at my heaviest I was 115kgs so 230 pounds Some would say not that big but to me it was huge. I followed a blogger in nz who had the surgery and an idea was born she looked amazing so off I went to her surgeon next step to come up with $20,000 as I was self pay I saw the surgeon in December and in March I had the surgery. Looking back at times I felt defeated like this weight won't come off it's so slow couldn't imagine myself smaller and it took a long time for my mind to catch up with my body I still felt big up until recently. Basically this journey has been the best decision of my life I am so happy within myself I feel alive,confident,beautiful,healthy these are things I've not felt in a very long time I am now 71kgs and I'm happy at this weight I know maintaining this will be a life long commitment and sometimes I eat bad things I'm human but it's not often and I always think of where I've come from and where I'm going and I can't go back I've come to far and it's true nothing tastes as good as skinny feels I will keep these comparison photos and look at them when I need to be reminded of where I've been in this journey For anyone considering surgery don't put it off you won't look back a new you is possible you just have to want it !! the surgery itself and recovery was fine sure at times I hated it but looking back for me it was easy. Good luck to everyone on this journey it sure is an amazing one this app has been so helpful and I'm truly thankful for it.

Hey Dimples58, Soooooooo.....drinking after wls is truly different for every person. I was also advised by my medical crew that I would not be able to tolerate much alcohol, BUT this was not true for me. I can drink a sailor under the table. Lol! This is not good though because it's a lot of calories and causes weight gain. My first attempt was a shot of whiskey about 6 months post op and I felt nothing. The only time I feel it quickly is if I don't eat first.

I find out today if the surgeon will let me do three months instead of six for preop. I'm so nervous. I would LOVE to have this by the end of the year. I have a plane trip next week and I'm tired of the anxiety and being the biggest person at my new job. But I blessed the insurance does not excluded it. If it is six it will be ok but I'll be afraid holiday weight gain. Fingers crossed!! Thanks.

Here's a little more info. I lifted this from a post I made on 7/12 in answer to the same question: A PB is a bandster term for "productive burp" which happens thusly: Usually once you have good restriction, but possible any time, if you eat too large a bite, don't chew well enough, or are overfull, the bite of food can't fit through your stoma (hole formed by the band between your "pouch" or upper stomach and your lower stomach) and it has to go somewhere, so it comes back up. The esophagus isn't built to have things just sit there, it's a conveyor belt that likes to move things along. So it will spasm...and if the food doesn't go on through, the body produces a lot of mucous (called slime here) which lubricates the esophagus and offending bolus of food and helps move it up and out. it is different from vomiting in that there are usually no stomach spasms involved, and there is no stomach bile/acid expelled. It can be dangerous if you PB too strongly or too much at first, before your band is healed, and later on even if healed, if you PB a lot (some do it daily as a way of life) it is very hard on your innards and can cause the band to slip. An occasional misstep/PB, however, especially if it happens after you've healed from surgery, isn't really a cause for concern but it should be a lesson to be learned. They are almost always caused by "operator error"...not chewing well, bite too big, or overeating. Occasionally, though, a PB is caused by being too tight (too much fill) and if that's the case, you need to get a little saline removed quickly or risk poor weight loss/weight gain, problems with your band, etc.

I had surgery eight years ago at age 55. No diabetes, though - just obesity. SUPER obesity. Also, borderline sleep apnea that I didn't know about until I did a sleep test for surgery. I lost 235 lbs and gained back about 20 lbs in year 3 post op (a 10-20 lb rebound weight gain after you hit your lowest weight is very common). Maintained ever since, but it's work. On the other hand, before I had surgery, the most I could lose was about 50-60 lbs, and every ounce of it would come back. Happened dozens of times. So yes - weight loss is sustainable after bariatric surgery as long as you monitor yourself. I had strictures at two months out and four months out. Very easy fix. The PA at our bariatric clinic told me it was the most common complication, and that they happen to 5% of gastric bypass patients (and if they're going to happen, it'll be during the first three months post-surgery - they're very rare after that). I personally wouldn't call something that happens to 5% of people "common", but that does give you an idea of how common complications are. Basically - they're not very common. about 30% of bypass patients have dumping syndrome. I've never had it and most of the people I know haven't had it, but some of us do. It's caused by eating too much sugar at one sitting (or for some, too much fat at one sitting seems to set it off). It's because food passes through to your small intestine much more quickly once you've had bypass, and your intestines go into overdrive trying to deal with the sugar (or...fat). It can be prevented by limiting the amount of sugar you eat at one sitting (which we should be doing regardless, even us non-dumpers). good luck in your decision. Honestly, I should have done it years ago. My only regret is that I waited that long to have it done. My life has changed dramatically for the good. I'd go back and have the surgery done every year if I had to - it's been terrific!

Hello, I'm almost four months post op. I was having issues with BM's as well which caused weight gain or stagnation. I purchased some fiber one bars and brownies only 90 calories. You eat as a snack. The pounds started flying off again I've lost 60 lbs thus far. I hope this helps you. Good luck on your new journey

I was banded on Monday too! The gas pain is just awful, more than I expected. I'm taking pain pills just for that pain - the incisions don't hurt a bit. Walking helps but not as much as I had hoped. I generally have a heating pad on my left shoulder, and it helps some. With that being said, I would do this again in a heartbeat. As for the hernia, I did as much reading on that as I could before surgery because I knew I had a big one. My doctor said that most people have small hernias, but mine was the biggest he'd seen in 30 years of medical practice. Anyway, with all the reading I did, no one seemed to have a reason for hiatal hernias, just that they happen quite commonly. And I am so happy that this is now fixed - none of the weird symptoms I had before are there. That part of the experience is just wonderful. I'm also not very hungry and find it a bit difficult to get in all the Protein shakes. Takes me a while to drink a whole shake, and if I add anything to it for flavor or texture (like frozen strawberries), I can't finish it. I did that in the diet before surgery, but can't manage it now. That's a good thing, I've started losing weight again after a couple of days of slight weight gain. Anyway, happy to join you and the other folks in Bandland!

I can't begin to describe how blessed I have been this year. Before I was banded, I was lost. I would wake up most mornings and just say to myself "where do I even begin to dig myself out of this hole". Yes I was referring to the massive weight gain that I had in the past 2.5/3 years. I was falling into a depression but no one knew about it because I was putting up this front that I was the most confidence "fat chick", because I had to...it was my defense mechanism. May of 2009 rolls around and I am desperately searching on the internet for a surgeon to finance my surgery because I am a part time employee and full time student with no health insurance. That's a different story though! The angels sent to me Dr. Webber at Harper Hospital in Detroit MI. This was the start of a new life for me, it was the end of my sorrows, the beginning of a lifetime of happiness. I wasn't going to be overweight for all of my 20's, I will enjoy the last 5 years of my 20's shopping in the same stores as my girlfriends...going to a party and not cry because I have nothing to wear, attract guys with my real confidence and not just a pretty face. More importantly I was going to live to get married and have children w/o any complications. So this Thanksgiving I want to give the greatest Thanks to my Dr. Webber, who without him, I would still be lost and in the deepest hole that I wouldn't be able to get out of. I want to give thanks to him for convincing me to have the surgery and reassuring me that it was going to be OK when I was scared and crying the morning of surgery and about to change my mind. I want to give thanks to him for keeping me safe when my life was in his hands for the 2 hours of surgery. I want to give thanks to him for being the person that saved my mind, body and soul! So thank you Dr. Webber I love you! I was banded May 22nd 2009 and 6 months later I am down almost 70 lbs!! I am happier than ever, and I wish that everyone reading this is as happy as I am and has the greatest success as I have had so far. Goodluck to everyone....and God Bless!

I gained 14 lbs since surgery day I am too bloated too eat or drink anything ((

Welcome to the forums! You'll get tons of support here :] I'm just curious what has been your history with weight gain or loss?

So true, but the Band does help. I would do it again, even though all my family members think the Lap-Band has been a failure. Losing 95 pounds when you want to lose 150 is like the old half-full/half-empty debate. I still love to eat. Food has been my companion (though not my friend) ever since I was a child. I used to be skinny (my nick-name in high-school) until I hurt my leg playing football in college, then my calorie output dropped, but my calorie input rose. Result: 80 pound weight gain in 8 months. Since the Lap-Band surgery, I have grieved like I lost a friend, but it was only a companion, no make that an acquaintance. Sometimes when I got stuck at a weight and just could not lose, it was because I wasn't eating enough and my (prehistoric) thermostat drove my metabolism to protect me from starving. Instead of cutting back, I ate a little more including fat. I did not eat huge amounts of fat, but I stopped avoiding fat. Someday, I hope to start losing again. I seem to be in a stuck situation again, but I seem to keep injuring myself every time I start back to the gym. My body doesn't respond to training the way it used to. Hope my rant helped.

Remembr that you are healing. I had surgery on the 9th and I still get tired at times and have to know when to slow down and even tell myself to stop. As far as the gas it will be there for a while. Walk walk and walk is the best medicine. The pain in the left shoulder lasted about 1 week in a half and that was the worst part of it all. The intake will gradually come just do not get dehydrated. The week after surgery I lost 5 pounds now I fluctuate between 1-2 pounds weight gain over the last two weeks. I think it is time to step up my exercise. At first when walking on the treadmill I would get exhausted. Now I think I can walk a little more. The good thing is I can see a big difference in my clothes. So just hang in there it will get better.

I think yes cash pay. That’s what my situation is as I’m still considered low BMI despite significant weight gain after my band was removed.

I had an early menopause brought on by cancer treatment - OMG it was HORRIBLE. The hot flashes, I would get major panic attacks with them, and want to rip my clothes off. At home, I did rip my clothes off! It upset my sleep markedly too I was absolutely bug eyed, totally depressed, having major sugar cravings, etc. I went onto HRT. I know the risks, but I'm only 44, have early osteoporosis, was miserable and not coping with the menopause symptoms. HRT has been an absolutely life saver for me, I will be on it for a long time yet. I also had to start testosterone treatment and THAT was incredible. That's the fountain of youth. It took away all the aches and pains, the belly weight gain, the declining libido, the mood issues. The little break you had might just be a coincidence, I think a more natural menopause can sort of come and go, cant it?

Here is an academic overview of the various bariatric procedures with a bit of excess 'science stuff' thrown in. No opinion. No bias. Published 2012 by the UK Royal College of Physicians. If anyone requires further clarification to the sources contained (hopefully its been copied successfully), please see the reference list at the end. This will provide you (licensing permitting) with a link to those original source documents so you can do your own further research/analysis. Any questions or queries, please do not hesitate to ask. Revs x Overview of bariatric surgery for the physician Keng Ngee Hng, Specialty registrar in gastroenterology1⇓ and Yeng S Ang, Consultant gastroenterologist and honorary lecturer2 + Author Affiliations 1Salford Royal NHS Foundation Trust 2Faculty of Medicine, University of Manchester, Oxford Road, Manchester Address for correspondence: Dr KN Hng, 4 Fern Close, Shevington, Wigan WN6 8BL. Email:keng_ngee@hotmail.com Abstract The worldwide pandemic of obesity carries alarming health and socioeconomic implications. Bariatric surgery is currently the only effective treatment for severe obesity. It is safe, with mortality comparable to that of cholecystectomy, and effective in producing substantial and sustainable weight loss, along with high rates of resolution of associated comorbidities, including type 2 diabetes. For this reason, indications for bariatric surgery are being widened. In addition to volume restriction and malabsorption, bariatric surgery brings about neurohormonal changes that affect satiety and glucose homeostasis. Increased understanding of these mechanisms will help realise therapeutic benefits by pharmacological means. Bariatric surgery improves long-term mortality but can cause long-term nutritional deficiencies. The safety of pregnancy after bariatric surgery is still being elucidated. Introduction Obesity is a worldwide pandemic,1–4 with the number of obese children and adolescents increasing alarmingly.5 This has serious health and socioeconomic implications due to the attendant increase in related comorbidities.1,2,4,6 Obesity causes type 2 diabetes, hypertension, dyslipidaemia, cardiovascular disease, obstructive sleep apnoea, obesity hypoventilation syndrome, cancer, steatohepatitis, gastro-oesophageal reflux, gallstones, pseudotumour cerebri, osteoarthritis, infertility and urinary incontinence.1–6 Severe obesity reduces life expectancy by 5–20 years.1 Diet, exercise and drug treatments for severe obesity have been disappointing.1–3,5–12 At the present time, bariatric surgery is the only treatment that reliably produces substantial and sustainable weight loss.1–7,9,13 It is indicated in people with BMI >40 kg/m2 or with BMI >35 kg/m2 in the presence of significant comorbidity.3,5,7,14 Bariatric surgery is cost effective,3,6,15 achieving weight loss, as well as improvement or resolution of associated comorbidities.1,2,5,6,9,15,16 In the past decade, the development of centres of excellence,5,6laparoscopic techniques,2,5,6 improved safety profiles2,6,9 and better documentation of clinical effectiveness2,6,15 have fuelled an increase in the number of procedures performed. Types of surgery Bariatric surgical procedures are traditionally classified as restrictive, malabsorptive or combined according to their mechanism of action. The procedures most commonly performed are laparoscopic adjustable gastric banding and roux-en-y gastric bypass.3,13 Sleeve gastrectomy is increasingly performed.2,6,7 Biliopancreatic diversion and biliopancreatic diversion with duodenal switch are much more complex and performed infrequently.2,5,17,22 Other historical procedures are no longer in common use. In addition to restriction and malabsorption, recent evidence suggests that neurohormonal changes are an important effect of bariatric surgery.2,6,7,17,18 Bariatric surgery is only part of the management of severe obesity. Careful patient selection and preparation are extremely important, as are long-term compliance with diet, nutritional supplementation and follow up.2,5,6,19 Laparoscopic adjustable gastric banding2 A purely restrictive procedure, laparoscopic adjustable gastric banding (LABG) is the least invasive procedure, is completely reversible and has the lowest mortality.19 A silicone inflatable band is placed around the stomach cardia immediately below the gastrooesophageal junction (Fig 1). This is connected to a subcutaneous port that is used for band adjustment.5,6 The band compresses the cardia to generate a sense of satiety and reduced appetite, which is thought to be mediated via vagal afferents.2 Roux-en-Y gastric bypass (RYGB) is a combined procedure that is also performed laparoscopically. A 20–30-ml gastric pouch connected to the jejunum forms the Roux limb (Fig 2). The disconnected duodenal limb is anastomosed 75–150 cm along the Roux limb, forming a Y configuration. The distal stomach, duodenum and part of the proximal jejunum are thus bypassed.5–7,20 Despite the traditional classification of the this procedure, malabsorption is not significant with the standard RYGB surgery.7 In an extended gastric bypass, the Roux limb is lengthened to increase the malabsorptive component.6,20 In sleeve gastrectomy, 60–80% of the stomach is removed along the greater curvature to leave a restricting ‘sleeve’ of stomach along the lesser curve (Fig 3).5,20,21 Originally the first step of the biliopancreatic diversion with duodenal switch (see below), sleeve gastrectomy has evolved into a staging procedure for super obese or high-risk patients.2,5–7,20 It is also increasingly used as a standalone procedure.2,6,7 Biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPD/DS) are malabsorptive operations that result in bypass of most of the small intestine. With BPD/DS, a sleeve gastrectomy is performed, leaving the pylorus intact. The duodenum is then disconnected and the stomach anastomosed to the distal small bowel (the ‘duodenal switch’), creating a short alimentary limb. The long biliopancreatic limb is then anastomosed to the ileum 75–100 cm proximal to the ileocaecal valve, so digestion and absorption occurs only in the short common channel.5,6,20 With BPD, a partial gastrectomy leaves a 400 ml gastric pouch and the common channel is shortened to just 50 cm.5 Safety profile and complications Bariatric surgery is safe.2,5,6,9,22–24 High-volume centres of excellence deliver bariatric surgery with inhospital mortality of 0.14% and 90-day mortality of 0.35%, which is comparable to that for cholecystectomy.6 Acute complications, including haemorrhage, obstruction, anastomotic leak, wound infection, cardiac arrhythmias, pulmonary emboli, respiratory failure and rhabdomyolysis, occur in 5–10% of patients.5,6,9,10,25 Long-term complications include internal hernias, anastomotic stenoses, marginal ulceration, fistulae, diarrhoea, dumping syndrome, gallstones, emotional disorders and nutritional deficiencies.5,6,13,15,20,25–27 Patients with LAGB can experience port problems, stomal obstruction, band slippage/erosion, pouch dilation, gastro-oesophageal reflux and oesophageal dilation.5,13,19,25 Malnutrition is a concern with BPD with or without DS.1,17 Long-term risks for sleeve gastrectomy are unknown.5 The Longitudinal Assessment of Bariatric Surgery22 reported overall 30-day mortality of 0.3% for 4,610 patients having LAGB or RYGB for the first time, with 4.3% of patients having a major adverse outcome within 30 days. This was most frequent among patients having open RYGB (7.8%). A meta-analysis involving 85,048 patients reported a total 30-day mortality of 0.28% and a two-year mortality of a further 0.35%.24 The most complex malabsorptive procedures had the highest perioperative mortality at 1.11%. Mortality for gastric banding is between one in 2,000 and one in 5,700.2 Effects on weight, comorbidities and long-term mortality After RYGB, patients lose 60–70% of their excess weight over two years, and this is largely durable.1,2,6,9,15,16,28 Weight loss is dependent on long-term compliance with dietary recommendations.2,5,6 Sugary, energy-dense foods and drinks can ‘bypass the bypass’. After gastric banding, patients lose about 50% (range 39%–59%) of their excess weight at a slower rate, often continuing into the fifth year.1,2,5,6,9,19 Regular band adjustment is necessary.16 The Swedish Obese Subjects (SOS) study reported a reoperation or conversion rate of 31% for gastric banding and 17% for gastric bypass among patients followed for ≥10 years, excluding operations for postoperative complications.16 However, at the centre in Melbourne, only about 10% of patients after LAGB need some revisional procedure, including band replacement, in the following 10 years.2 Biliopancreatic diversion with or without DS produces excess weight loss of 70.1%9sleeve gastrectomy produces initial excess weight loss of 55%, but this may not be durable.2 Bariatric surgery also produces significant improvement in obesity-related comorbidities, with the most remarkable effect being resolution of type 2 diabetes (T2DM). A meta-analysis encompassing 22,094 patients reported complete remission of T2DM in 76.8% of patients,9 and a registry from the UK with data on 8,710 patients reported resolution of T2DM in 85.5% of patients.29 Major improvement often occurs within days after RYGB, before significant weight loss is achieved.5–7,17,18 After LAGB, improvement in T2DM occurs more slowly as a result of weight loss.2,7,19 Combined or malabsorptive procedures produce greater improvement than purely restrictive procedures.1,2,5,9,18 Diabetes less than three years in duration, no insulin requirement, milder obesity with BMI <40 kg/m2 and weight loss ≥10% predict complete resolution of T2DM.18,19 Bariatric surgery is now advocated by some for the treatment of T2DM in patients with BMI <35 kg/m2.4,7,30,31 Bariatic surgery effectively treats all other associated comorbidities: from steatohepatitis and pseudotumour cerebri to urinary incontinence.1–3,5,6,15 Meta-analysis showed that hyperlipidaemia improved in ≥70% of patients, hypertension resolved in 61.7% (and resolved or improved in 78.5%) and obstructive sleep apnoea resolved in 83.6%.9 At five years, the risk of cardiovascular disease had decreased by 72%.3 The incidence of cancer also reduced markedly,6,15,16 as did the risk of developing new comorbid conditions.15 Long-term efficacy is well documented.5,6,28 At follow up after 10 years, the Swedish Obese Subjects (SOS) study showed a 29% reduction in adjusted all-cause mortality, primarily because of decreases in cancer and myocardial infarction.16A retrospective cohort study of 7,925 patients after RYGB reported a 40% reduction in all-cause mortality during mean follow up of 7.1 years.23 Specific mortality decreased by 56% for coronary artery disease, by 92% for diabetes and by 60% for cancer. A large observational study, in which the vast majority of patients had undergone RYGB, reported an 89% risk reduction in five-year mortality.15 Energy homeostasis and hormonal changes Weight loss after bariatric surgery is not explained by volume restriction and malabsorption alone.17 Indeed malabsorption is estimated to account for only 5% of the weight loss following standard RYGB.17 Bariatric surgery causes significant changes in the neurohormonal profile, which contributes to sustained weight loss through changes in appetite, satiety, food preferences and eating patterns and explains the remarkable effect on T2DM.2,5–7,17,18 The hypothalamus32 Hormonal signals provide information about energy status to the hypothalamus. Adipokines are secreted by adipose tissue and enterokines by the gut. Incretins are enterokines that stimulate release of insulin after food intake.18 Two hypothalamic circuits influence food intake, and both contribute to acquisition and storage of nutrient energy. The homeostatic circuit increases appetite and locomotion in response to energy shortage. The hedonic circuit is engaged at stable weight plateaus in association with increases in body fat. It heightens finickiness to taste of food. Obese animals overeat palatable food but undereat bland foods and lose weight. In our current obesogenic environment, the hedonic circuit facilitates the seeking of energy-dense foods uncoupled from energy status. Enterokines Ghrelin,33 which is mostly synthesised in the stomach, is a potent appetite stimulator involved in hunger and meal initiation. Circulating levels are inversely proportional to BMI and respond to changes in body weight. Ghrelin enhances gut motility and speeds gastric emptying.17 It promotes lipid accumulation and weight gain, favouring glucose utilisation. It also inhibits insulin secretion and impairs glucose tolerance.18 Levels of ghrelin reported after bariatric surgery have been variable, which may be due to differences in surgical techniques and research methods.7,18Overall, the trend is for a decrease in ghrelin levels after RYGB and an increase after gastric banding.7,17 Sleeve gastrectomy, which removes most of the ghrelin-producing stomach, reduces levels of ghrelin. Peptide YY (PYY)34 is secreted postprandially by L cells in the pancreas, small intestine and colon. It suppresses appetite and promotes satiety via signalling actions in the brain. It also delays gastric emptying (the ileal brake) and enhances insulin sensitivity.7 Secretion of PYY generally corresponds to the energy ingested, although it may vary depending on the macronutrient content.17Interestingly, levels also correlate positively with exercise intensity, with resulting decreases in food intake. Glucagon-like peptide 1 (GLP-1) is co-secreted postprandially with PYY in the distal intestine.17 A powerful incretin, GLP-1 potentiates glucose-stimulated insulin secretion, enhances β-cell growth and survival, inhibits glucagon release and enhances all steps of insulin biosynthesis.7,17 It also slows gastric emptying to produce greater gastric distension and helps regulate appetite and body weight.7,17 Obese individuals have lower levels of PYY and GLP-1, and levels are decreased further in patients with diabetes.5,17,18 Two hypotheses exist to explain the hormonal and metabolic effects of the RYGB: the hindgut hypothesis the foregut exclusion theory. The hindgut hypothesis postulates that after RYGB and malabsorptive procedures, rapid nutrient delivery to the distal gut L cells and their increased exposure to incompletely digested nutrients lead to an early and exaggerated PYY and GLP-1 response, contributing to early satiety, reduced meal size and early resolution of T2DM.7,17,18 Ileal transposition studies provide strong evidence for this. Interposition of an ileal segment into the proximal gut in rodents produced exaggerated PYY, GLP-1 and enteroglucagon responses, reduced food intake, weight loss, improved insulin sensitivity and overall improved glucose homeostasis.7 The foregut exclusion theory proposes that exclusion of the duodenum and proximal jejunum after RYGB is the mechanism that mediates the effects of bariatric surgery.7,18 However, duodenal–jejunal bypass experiments in rats supporting this theory are compounded by the accompanying pyloric disruption that results in accelerated gastric emptying and rapid nutrient delivery to the hindgut.7 The endoluminal duodenal–jejunal sleeve also accelerates gastric emptying by abolishing duodenal osmoreceptor control of pyloric contraction.7 This 60 cm-long sleeve prevents nutrient contact with the duodenum and proximal jejunum, while biliary and pancreatic secretions flow outside the sleeve, delaying digestion.35 A possible mediator of the foregut exclusion theory is the gastric inhibitory polypeptide or glucose-dependent insulinotropic polypeptide (GIP), which is secreted by K cells in the duodenum in response to nutrient absorption.18,39,40 In addition to its incretin action, GIP promotes lipogenesis,41 with GIP receptor knockout mice protected against diet-induced obesity and insulin resistance,39 while antagonism of the GIP receptor improves glucose tolerance and insulin sensitivity and partially corrects pancreatic islet hypertrophy and β-cell hyperplasia.40 Levels of GIP are suppressed after malabsorptive procedures.18,41 Adipokines Adiponectin17,36,37 is synthesised primarily in adipose tissue, with levels inversely correlated with BMI. It is an important insulin sensitiser, and hypoadiponectinaemia causes insulin resistance and T2DM. Adiponectin also possesses antiatherogenic, anti-inflammatory and cardioprotective properties and may act centrally to modulate food intake and energy expenditure. Weight loss following bariatic surgery increases levels of adiponectin. Leptin38,32 is secreted by adipose tissue and regulates body weight via its action on the hypothalamus. It increases nocturnally to stimulate lipolysis but also increases postprandially to induce anorexia. In addition, leptin plays an important role in glucose homeostasis. Levels of leptin are proportional to body fat, with starvation or energy shortage activating the homeostatic mechanism in the hypothalamus to restore energy balance. However, leptin resistance develops in obesity. Weight loss from bariatic surgery reduces leptin levels.17 Many other enterokines and adipokines exist, some of which may also play a part in producing and sustaining weight loss or diabetes remission after bariatric surgery.17,18 Understanding the mechanisms of action of bariatric surgery will help realise therapeutic benefits by pharmacological means.6,7,19 Nutritional deficiencies Nutritional deficiency is common after bariatric surgery and the risk increases from LAGB through SG and RYGB to BPD with or without DS.20,26,31 The problem is heightened by the fact that micronutrient deficiencies are already highly prevalent in obese patients before surgery.21 After surgery, patients are at particular risk of deficiencies in Vitamins B1, B12, C, A and D and folic acid, as well as Iron, Calcium and Protein.20,26 Lifelong prophylactic supplementation is often necessary, and regular monitoring is essential.26 Investigation of clinical syndromes resulting from malnutrition can be challenging. Anaemia20,27 After bariatric surgery, patients are prone to iron deficiency because of intestinal bypass, pouch hypoacidity and intolerance of red meat. Obesity creates a state of chronic inflammation that can contribute to anaemia. Anaemia can also be caused by deficiencies in folate, Vitamin B12, vitamin E (haemolytic anaemia), copper (anaemia and neutropenia), Vitamin A and zinc. In refractory anaemia, gastrointestinal blood loss must be considered. Bleeding in the excluded stomach, duodenum or biliopancreatic limb is problematic as the usual endoscopic access route is no longer available. Neurological problems6,20 Neurological symptoms can result from deficiencies in thiamine, vitamin B12, niacin, vitamin E and copper or from hypocalcaemia secondary to Vitamin D deficiency. Clinical syndromes includes Wernicke's encephalopathy, peripheral neuropathy, dry beriberi, neuropsychiatric beriberi, pellagra, ataxia, spasticity, myelopathy, muscle weakness, posterior column signs and ptosis. Oedema6,20 Patients with oedema may have underlying heart failure, which can also be due to wet beriberi (thiamine deficiency) or selenium deficiency. Hypoalbuminaemia may be caused by liver cirrhosis secondary to steatohepatitis; severe protein/calorie malnutrition; kwashiorkor; and diarrhoea secondary to bacterial overgrowth, malabsorption of bile salts and niacin deficiency. Eye, skin and hair problems20 Vitamin A deficiency causes difficulties with nocturnal vision and reduced visual acuity. Vitamin E deficiency can cause retinopathy. Thiamine deficiency can present with blurred or double vision. Dry skin, pruritus and rash can be caused by deficiencies in vitamin A, niacin, riboflavin, zinc and essential fatty acids. Hair changes can be due to zinc deficiency or protein malnutrition. Pregnancy after bariatric surgery About half of patients undergoing bariatric surgery are women of childbearing age,8 which introduces specific concerns. Obesity is strongly associated with infertility8 and increases the risk of obstetric complications.8 Yet the effects of rapid weight loss and potential malnutrition in pregnant patients are of concern. Bariatric surgery improves fertility42,43 and reduces the incidence of obesity-related complications such as gestational hypertension, gestational diabetes, pre-eclampsia and foetal macrosomia when compared with obese controls. The effect on premature delivery, miscarriage, intrauterine growth retardation, low birth weight and neural tube defects and the need for caesarean section are unclear.8,43 Maternal surgical weight loss reduces the prevalence of obesity and cardiometabolic risk factors in offspring until the adolescent years.42 Pregnancy seems to have little effect on the surgically induced weight loss.8 Patients are generally advised to delay pregnancy until after the period of maximal weight loss (12–18 months).8 Extra vigilance in preconception, antenatal and obstetric care is required. Conclusion In summary, bariatric surgery is a safe and effective treatment for severe obesity and its associated comorbidities. It is particularly effective in the treatment of T2DM. Neurohormonal changes that affect appetite, satiety, glucose homeostasis and long-term energy balance contribute to its long-term efficacy. Two hypotheses exist to explain how hormonal changes produce these effects, and both may contribute. Patient adherence to postsurgical aspects of management is very important. Pregnancy after bariatric surgery brings additional considerations. Finally, the indications for bariatric surgery are being widened. Acknowledgements Dr Keng Ngee Hng is a specialty registrar in gastroenterology and has previously submitted part of this work for her Master of Science in gastroenterology (Salford University). Dr Yeng S Ang is the educational supervisor for Dr Hng and has refined the ideas, concepts and layout of the previous work. Recent updates are also included within this paper. © 2012 Royal College of Physicians

A nine pound weight gain in two years isn't too bad Now it's time to work it off. Remember it's a lot easier to lose nine pounds than 20. Make it your goal to lose three pounds a week. In less than a month you'll be back to 185. From there you can work off more of you want.How is your restriction after 2years? One piece of advice I get from my nutritionist and doctors is to stay away from the carbs. They slide right through your restriction and you can over eat them. Instead stay with the proteins. i know as time goes by we tend to get back into the bad eating behaviors. Now is the time to reverse your weight gain while it's still manageable.

I had surgery September 15th and the last two days I’ve gained weight. Please tell me this has happened to other ppl?? That it will go away?? I’m so upset!