Weight Loss Surgery Blog

It’s a very common question, “After weight loss surgery, when can I start to eat normally again?” Those of us who have had weight loss surgery a few years ago know the answer - never! But of course it depends on what the definition of “normal eating” is.

My surgery was almost 12 years ago. I was fearful as I approached surgery that my eating days would be over. I love eating and I wondered if I would be able to enjoy a meal ever again. There is an incident that I talk about in my book, Weight Loss Surgery; Finding the Thin Person Hiding Inside You, in which I was sitting in the middle of a restaurant about three weeks before my surgery, eating a quesadilla, and I burst into tears. “I will never be able to eat a quesadilla again,” I wailed! Well I have eaten quesadillas since my surgery. But it comes down to how often and how much.

If “normal eating” means that you will resume your normal life and way of eating prior to surgery, you don’t want to go there. You don’t want to resume your normal life, because you don’t want to go right back to where you were prior to surgery. It is important to always remember your “bariatric roots.” You want to remember how bad you felt physically, how embarrassed you were to be seen in public, how low your self-esteem was as you failed one diet after another, how long your list of medications was, and all of the activities that you wanted to do and just couldn’t. All of those can help you to not go back to the way you ate before.

Anyone going through surgery must be willing to commit to living a healthy lifestyle – eating more sensibly and exercising. You may not be able to exercise prior to surgery, but as you lose weight, exercising should become more possible.  The first six months following surgery are not happy months in terms of eating. You start with a liquid diet and progress over a couple of weeks to full liquids, soft foods and then regular food.  There will be foods that you aren’t able to eat, because they won’t agree with you. They might feel like they are stuck when you eat them, or they might make you feel nauseated. For the most part that will pass.  Personally, being 12 years post-op, I eat out about two times per week.  If you saw me eating you would not know that I had surgery except for two things – I eat smaller meals and I chew food very thoroughly. I really don’t like chicken anymore. With the exception of chicken thighs, I find it too dry. If I eat too fast, I still will throw up. I cannot tolerate too many sweets. I can have a small piece of cake or pie or a cookie or two. More than that and I will get sick. 

There are rules that I have to follow (eat small meals, eat protein first, avoid carbohydrates, don’t drink while eating, minimal sweets, chew your food very well). If I follow these rules, I enjoy eating and it is much easier to maintain my weight.  It is the way I should be eating whether I had surgery or not. 
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I received an email recently asking a question about hunger, and the question sounded so familiar. What the reader stated was that she has a history of going on a diet, losing 50 or 60 pounds and then experiencing overwhelming, uncontrollable hunger that would cause her to go off her diet and regain weight. Yes, I remember that uncontrollable hunger all too well. It eventually wrecked almost every diet I ever tried. So where does that hunger come from?

The culprit is ghrelin, a hormone secreted in the  stomach and a small part of the small intestines that induces hunger. Research studies have found that the more ghrelin that is produced, the higher the body mass index (BMI) of the individual. So people who are obese have higher levels of ghrelin than those who are of normal weight.

Some studies have also found that ghrelin levels in those patients who have had gastric bypass surgery are lower than in those of the same weight that have not had surgery. Part of the reason may be that after gastric bypass surgery, there is less surface area in the stomach, therefore fewer cells in the working stomach to produce ghrelin.

You would think that there would be a vaccine that could be given to those who are overweight that would just block the production of ghrelin. Unfortunately it is not that simple.  Because eating and hunger are necessary for survival, the body seems to find other ways to induce hunger when ghrelin is blocked. So for now, we are stuck with it.

After gastric bypass surgery, those feelings of hunger are gone - at least for a few years. For many patients, the hunger returns, but generally it is not the overwhelming variety that plagued us before surgery. So if you are considering dieting because you over-indulged during the holidays, remember the following two points:

1. Don’t try a starvation diet.  That is a sure way for the extreme form of ghrelin-induced hunger to rear its ugly head. Your body’s instinct is to keep you from starving, so if you eat too small an amount, your body will rebel in many ways. One of them is to give you a jolt of real hunger.

2. A much better way to drop weight is to do it slowly through a lifestyle change. You will have a much better chance of long-lasting success. 

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My Mom died two years ago at the age of 95.  She lived with us the last nine years of her life, and all of us miss her terribly. So when I heard about the Presents for Patients Program here in Pittsburgh, I thought this would be a wonderful way to bring a little bit of my Mom’s presence back into our Christmas.

The program works by pairing people in the community with those who are in nursing homes.  You buy presents for them from a list that they have designated and deliver them during the Christmas season. I called immediately and asked for a female patients at a nursing home in my area.

My assignment arrived in the mail, and I was excited as I opened the instructions. I thought I could buy slippers like I would for my Mom or a nightgown or a book or a bright red amaryllis. My first clue that this was not going to be what I thought was the patient’s name - Megan. What older woman is named Megan? The suggested presents were a sweat shirt, pajamas, or stuffed animals. The instructions specified “no food.”

I called the nursing home to get a little more information, and I discovered that the patient indeed was not like my mother. Megan was a woman in her early 30’s. Although the nurse could not give me any details because of privacy laws, I did surmise that Megan had sustained a very serious head injury from an accident, was non-communicative, had a feeding tube, and would be living in a home for the rest of her life.

I was a little disappointed. I couldn’t go to the nursing home pretending  I was giving a gift to my Mom, but I was committed to going ahead with what I had promised. I talked further to the nurse and learned that Megan loves dogs. She suggested that I might want to bring her a poster of dogs. I then got an idea!

I have the most adorable dog, a little all white Maltese with big black eyes and a bouncy disposition. Munchkin is his name and he weighs only three pounds. He is not a teacup dog; he just never grew. He brings smiles to the faces of everyone who sees him.  So I asked if I could take Munchkin with me when I visited Megan. The nurse said she thought that Megan would like that.

So two days before Christmas, we visited Megan. As soon as we entered the nursing home, everyone started making a fuss over Munchie like they always do. We made our way to Megan’s room and there she was- lying there, not moving, staring in the direction of a window. We crossed the room and she didn’t make eye contact, even as we started to talk to her. I sat down on the side of the bed and lifted Munchie up on the bed to show her.

Although Megan didn’t really seem like anything registered with her, as soon as Munchie was on her bed, she started to glow. I looked down and somehow, in her curled fist, she had his leash and she was holding on. Munchie started to lick her fist and I told her that he was giving her kisses. That glow on her misshapen face spread over her and washed over me.  I felt such overwhelming happiness. And I understood.

This wasn’t my plan. My idea for this exercise was a somewhat selfish one, I admit it. I was doing this to make me feel good. But God had his own plan that was much different than mine. And when I saw that glow on Megan’s face, I understood God’s plan and appreciated his wisdom.

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I am often asked about revision surgery by people who have regained weight years after their original weight loss surgery. Revision surgery is a type of “do over” surgery that will either build upon the existing surgery or be an entirely new procedure that will help the patient lose the weight they have regained. If this is something you are thinking about, here are some things to think about. 

Before jumping into revision surgery, you should find out what caused your weight regain. If you originally lost a lot of weight, yet after years the weight returned, you are actually a good candidate for revision surgery. Those people who were never successful following weight loss surgery are much harder to find a successful path for. 

Facing the cause of your weight regain is a hard thing to do, but necessary so that you don’t keep repeating the same mistakes. You were able to maintain a weight loss for a number of years, so you should feel very proud of that, but what caused the weight to come back?  Let’s look at some of the possible factors:
1. Have you become lax and stopped following the basic rules of high protein, few carbohydrates,  and little snacking?
2. Is someone or some environment sabotaging your efforts?
3. Are there emotional issues that might be contributing to the weight regain that need to be addressed through counseling?
4. Are you more hungry than before? 

All of these need to be considered and taken very seriously.  If you are more hungry, your stoma (the opening between the pouch and the small intestines) might have stretched.  Revision surgery is not usually as effective as the first surgery that you had. Here are some of the revision surgeries that are done.
1. Assuming that you had gastric bypass surgery, a gastric band can be placed around the pouch to help you feel full and satisfied longer. This method has had some success. 
2. There is also surgery that will make the stoma smaller. One method is called the Stomaphyx in which a device is used that makes pleats to make the pouch smaller.  Another method is called scleroderma in which acid is used to form scar tissue on the stoma to make it smaller. Both of those methods have had limited success. 

There is also the issue of cost to consider. Revision surgery is about as expensive as the original surgery, about $15,000 to $25,000.  Insurance will not cover revision surgery unless your BMI is again over 40, making you severely obese. And even then, some insurance companies won’t cover revision surgery since it is a second surgery.  

Many surgeons won’t do revision surgery, because it is much more complicated to do. The surgeon must deal with the internal scar tissue that has been formed from the original surgery. It is not an easy thing to do. 

What you may want to consider rather than surgery is to try to control your weight on your own. Remember that diets don’t work. Years of dieting, losing weight and regaining the weight has taught us that. However, a change in your lifestyle by cutting out food that you know is not healthy and increasing your exercise does work.. It is a very slow process, but apart from surgery, is the most effective way to deal with weight regain.  

I would love to hear from anyone who has had revision surgery or from those who are thinking about it. 

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The gastric sleeve is a relatively new weight loss surgery procedure that is gaining in popularity. In the sleeve surgery, about 85% of the stomach is removed leaving the curved part of the stomach, that looks like a banana, intact. 

Food enters the stomach normally and exits normally as well. The patient is successful in their weight loss because with only 15% of the stomach remaining, the patient becomes full with less food.

The procedure has two important advantages:

1. There is no malabsorption. The intestines remain with no rerouting. therefore there is less chance of nutritional deficiencies than there is with the gastric bypass.

2. The pyloric valve remains. This valve is at the base of the stomach and regulates how fast food passes from the stomach into the intestines. With gastric bypass surgery, the surgeon tries to recreate a pyloric valve of sorts by making the stoma. The stoma is a narrow opening which keeps food in the pouch before it enters the small intestines. This stoma starts out the size of a dime, but can stretch over time making the gastric bypass surgery less effective because food leaves the pouch before the patient feels full and satisfied. With the gastric sleeve, there is no chance of stretching the pyloric valve.

There are two disadvantages:

1. Because 85% of the stomach is actually removed, the surgery is not reversible. Once you have the surgery, there is no going back.

2. Patients lose less weight with the gastric sleeve than they do with the gastric bypass.

There is a research trial being conducted at Northwest Weight Loss Center in Everett, WA currently concerning the gastric sleeve. Instead of removing 85% f the stomach, surgeons are folding the stomach over and stapling it, rather than removing it. This may eventually make the surgery reversible.

It is important to understand that no one surgery is the best weight loss surgery. Each one has advantages and disadvantages. However, choices are important. The more choices we have so that we can select the best surgery for ourselves, the more successful we will be.

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“Say it ain’t so, Joe.” A school child could lament, not about the fix of the 1919 World Series, but that Congress in their infinite wisdom has made a decision that would make pizza count as a vegetable.

November 16th Congress passed a revised agriculture bill that made it easier to count pizza sauce as a serving of vegetables. Apparently the reasoning is that 1/2 cup of tomatoes equals 1/8th cup of tomato paste. Therefore pizza can then be counted as a vegetable in our school cafeterias. A 1/2 cup of tomato paste should be counted as a 1/2 cup of any vegetable, but this bill gives tomato paste an outsized credit, consequently paving the way for that pizza sauce to be slapped on a carbohydrate laden crust and topped with fat laden cheese.

These consideration are serious because 31 million students receive free or low-cost lunches. These students need schools to not only provide them with, but teach them health eating options. Only 20 percent of schools follow the US Department of Agriculture’s guidelines for the limit of fat content in school lunches.

And then we wonder why we have an obesity epidemic in this country and why our children have diabetes!

Let me know your thoughts.

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It was bound to happen. I heard two stories recently and they are frightening related. They involve what we are doing to our children, how we feed them and the consequences of the pressure regarding obesity that society puts on us. In the end, 2 children were harmed. 

The examples are at both ends of the scale - so to speak, and in both situations the children were taken away from their parents. In one case the child was fed too much, and in the other case the child was fed too little. Both are tragic!

The first case involves an Ohio mother whose 8-year old child was removed from her care for being too obese  and was placed in a foster home. At the time the child was removed from the home, he weighed 200 pounds. County officials in Cleveland Heights complained that the mother was not doing enough to control his weight, which officials said should be about 60 pounds. They further said that he was at risk for developing diabetes and high blood pressure.  He has shown no symptoms, however, therefore is not in any imminent danger . Health officials termed the mother’s behavior to control her son’s weight as medical neglect. Officials said they worked for 20 months with the mother before making the decision. Yet there is no guarantee that foster care will improve the boy’s weight.

This is very much a case of a lack of understanding of the complexity of obesity. County officials clearly do not understand that it takes more than diet and exercise to control obesity. There are hormonal issues and psychological factors that also play a huge part.

There are roughly 2 million children who are categorized as severely obese. Will all of them be placed in foster care? Currently there are no guidelines for how to deal with issues such as this.

On the other hand, a Wisconsin couple were arrested recently because they were starving their baby daughter to death because they feared she would become obese. The baby girl gained only 5 pounds in the 14 months since her birth. At the age of 14 months, she weighed 13 pounds. Doctors said she would have to weigh 22 pounds to even appear on the growth charts. She had no subcutaneous fat and was literally starving.

Their doctor convinced the couple to place the baby in the hospital where she was fed normally and gained 8 ounces per day. The father was upset because, as he told a doctor, “I don’t want to have obese children,” and insisted the baby would “get fat” at the hospital.

Our attitudes toward obesity have reached the danger level, when families are broken apart and children are placed in foster care because of their weight, and other children are starved to death. What is wrong with us?

I would love to hear your thoughts.

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I have heard from a number of weight loss surgery patients that they have experienced increased tooth decay following weight loss surgery. I always attributed this to a lack of calcium. However, a study in the journal, Obesity Surgery, vol. 16, #9, “Dental Complications Following Gastric Restrictive Bariatric Surgery” found other reasons for increased tooth decay that have no relation to calcium.

Reasons for increased decay reported in the Obesity Surgery article include patients reporting that they are eating more sweets than before surgery, and a decrease in dental cleanings and checkups. No reasons directly related to weight loss surgery were cited as a cause for an increase in decay and sensitivity. While I find it odd that patients would be eating more sweets following surgery considering dumping syndrome, that is what patients reported.

However a new study from Case Western Reserve shows that periodontal (or gum) problems improve after weight loss surgery. The study concludes that there are two reasons for this

1. Insulin resistance drops as a result of weight loss surgery. This improves gum problems.

2. The hormone leptin is reduced. Leptin is known to cause inflammation. 

The full study can found at: http://www.healthjockey.com/2011/11/14/losing-weight-helps-fight-gum-problems-says-study/.There are so many reasons to have weight loss surgery, and although having better gums was probably not on the top of your list of reasons, it is nice to know that a problem with gum disease just might improve. On the other hand, be sure to watch your consumption of sweets and remember to get those checkups! 

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Over the years I have heard many women say that they did not want to have weight loss surgery because they want to have children. There is a mistaken idea that weight loss surgery prevents women from having children, and nothing can be further from the truth. A woman is at a much lower risk after having had surgery, and is also often more fertile. Although there is a decreased  risk, there are some important points to remember:

1. How soon after surgery can I get pregnant?
It is important to wait until one to two years after having weight loss surgery before becoming pregnant. During that one to two years post-op is a time when you are losing weight rapidly, and are able to eat smaller amounts; certainly not enough to sustain yourself plus a growing fetus. This is also the time when you want to concentrate on losing as much weight as you can to resolve co-morbidities, so that you will have a healthier pregnancy.

Until after the one to two year mark, be sure to use contraception. Many women who had thought they were infertile, suddenly find themselves pregnant. Don’t take for granted that your infertility will continue as you lose weight.

2. What nutrition considerations are there?
Pre-natal labs and glucose tests for those with a history of diabetes should be conducted. The following should be monitored: Vitamins B-1 (thiamin), B-12, folate, Vitamin D, albumin and pre-albumin, and iron, including ferritan.

3. How about my diet?
Be sure to eat large amounts of protein, 60 to 95 grams per day. A protein deficiency can lead to low birth weight and length, and can cause serious conditions in  the baby, such as respiratory, neurological, circulatory, and intestinal disorders.

Eat at least 100 to 150 grams of complex carbohydrates per day, such as vegetables and 100% grains.

Eat 25 to 35 grams of mono and polyunsaturated fats per day. This is important for the development of nerve sheaths in the fetus.

4. When should I start pre-natal care?
Start as early as possible.  Most women begin at two months, however  a woman who has had weight loss surgery should begin pre-natal care at five weeks. Ultrasounds should be conducted  at weeks 5, 11, and 18, and then every 4 to 6 weeks. Diabetic screening should be done in the first or early second trimester and again in the third.

For more information on this topic, visit Delamont, Kim, “Clinical Considerations and Recommendations for Pregnancy after Bariatric Surgery.” Bariatric Times, Oct 2011.

Additional topics include pregnancy consideration for each type of surgery, how frequently to eat, exercise, vitamins, weight gain, medication, delivery considerations, exercise, and breastfeeding. 

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I attended my husband’s family reunion yesterday. It happens every other year – the last Sunday in July. There are 3 people that I really look forward to talking with at these reunions. They are my sister-in-law, my husband’s one Aunt, and her daughter-in-law, Patty (not her real name).

Patty is fun and interesting, has the greatest smile, is pretty and is heavy. During the picnic when I was sitting with my daughter, we heard a loud crash, turned to look at what had happened, and there was Patty lying on the floor. She had broken the chair that she was sitting on.

We were all concerned that she was all right. She was, but I knew that she was dying on the inside. She had a half smile on her face the rest of the day, her chin was up, and she wouldn’t look anyone in the eyes. I have never broken a chair, but that was always a fear of mine.

After it happened, I couldn’t think what to say to Patty, and I did want to say something. But everything that I thought to say, I felt she could have ended my sentence with, “But look at me now.” I could have said, “Patty, before my surgery, I always had a fear of breaking a chair….but look at me now.”  “Patty, that was an old chair and that could have happened to anyone, ….but it wouldn’t have happened to me because look at me now.”

I can’t seem to get Patty off my mind. I did give her a big hug when we left, but I just felt there were unspoken words. If this has ever happened to you, was there anything that someone said that made you feel better? Please leave your comments.

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